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AF447: Human Factors  
User currently offlineKaiarahi From Canada, joined Jul 2009, 2806 posts, RR: 27
Posted (2 years 7 months 5 days 21 hours ago) and read 9361 times:

I tried to post this on the "AF447: Lessons Learned" thread, but the mods have already archived it, so the discussion can't be continued there.

Thanks to canoecarrier for noticing that the BEA has announced the composition of the Human Factors working group mentioned in the third interim report. From the BEA website:

"This working group’s objective is to analyze all aspects connected to the conduct of the flight:

* Crew actions and reactions during the last three phases of the flight described in the third Interim Report, in particular in relation to the stall warning;
* Cockpit ergonomics;
* Man-machine interfaces.

This working group is made up of seven experts:

* Three BEA investigators specializing in human factors;
* A psychiatrist specializing in risk analysis;
* A human factors aviation consultant;
* A type-rated A330 pilot;
* An A330 test pilot."

Work is expected to be completed by the end of December. The BEA note also indicates that the final report will be published in the first half of 2012.

I'm not going to speculate on the Working Group's lines of inquiry, but to me it's interesting that it includes a psychiatrist (médecin-psychiatre) - not a psychologist - specializing in risk analysis.


Note à moi-même - il faut respecter les cons.
48 replies: All unread, showing first 25:
 
User currently offlinercair1 From United States of America, joined Oct 2009, 1292 posts, RR: 52
Reply 1, posted (2 years 7 months 5 days 13 hours ago) and read 9045 times:
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Quoting Kaiarahi (Thread starter):
"This working group’s objective is to analyze all aspects connected to the conduct of the flight:

* Crew actions and reactions during the last three phases of the flight described in the third Interim Report, in particular in relation to the stall warning;
* Cockpit ergonomics;
* Man-machine interfaces.

I think this is a very positive development. We need to understand why 3 experienced pilots did not recognize and recover from the unusual attitude.



rcair1
User currently offlineJoeCanuck From Canada, joined Dec 2005, 5320 posts, RR: 30
Reply 2, posted (2 years 7 months 5 days 11 hours ago) and read 8893 times:

Quoting rcair1 (Reply 1):

Definitely a positive move. This accident could so easily been brushed aside as just another "pilot error" incident, and you hit the nail on the head; the failure to recognize the stall is the real mystery. Finding ways to help pilots maintain spacial awareness clearly, quickly and in a way that gives them confidence that what they are seeing is accurate will be the real trick.

Just another warning light or buzzer or warning won't do the job...especially if the pilots are already overloaded.

That they are drawing from professionals with a variety of expertise for their working group is also encouraging. An effective, reliable solution will probably take some outside of the box thinking.



What the...?
User currently offlinecanoecarrier From United States of America, joined Feb 2004, 2828 posts, RR: 12
Reply 3, posted (2 years 7 months 5 days 11 hours ago) and read 8857 times:

Quoting JoeCanuck (Reply 2):
That they are drawing from professionals with a variety of expertise for their working group is also encouraging. An effective, reliable solution will probably take some outside of the box thinking.

I mentioned this privately to Kaiarahi earlier. In my opinion BEA has done some very noble work related to increasing aviation safety since this aircraft went missing. Before they'd found the wreckage, at a time when a number of people here on A.net were screaming that FDR/CVR data should be transmitted real time they had already put together a working group to study the feasibility of triggered transmission of flight data.

http://www.bea.aero/en/enquetes/flig...ed.transmission.of.flight.data.pdf

As far back as 2009 they were studying, in the immediate aftermath of this crash, how to localize an FDR/CVR when a plane goes missing outside of radar coverage.

http://www.bea.aero/en/enquetes/flig...ery.working.group.final.report.pdf

And, here we are again, BEA is well ahead of us. I suggest they have been all along and have revealed themselves as a very professional accident investigation organization. We only needed to scroll a little further down the AF 447 page to see the technical documents beyond the press releases.



The beatings will continue until morale improves
User currently offlinetdscanuck From Canada, joined Jan 2006, 12709 posts, RR: 80
Reply 4, posted (2 years 7 months 5 days 2 hours ago) and read 8583 times:

Quoting Kaiarahi (Thread starter):
to me it's interesting that it includes a psychiatrist (médecin-psychiatre) - not a psychologist - specializing in risk analysis.

This may be a translation thing...do psychiatrist/psychologist mean the same thing in France as they do in North America?

Tom.


User currently offlinejoelyboy911 From New Zealand, joined Oct 2009, 244 posts, RR: 0
Reply 5, posted (2 years 7 months 5 days 2 hours ago) and read 8542 times:

Quote:
médecin-psychiatre

While I have not encountered this exact term in my French study before, médecin is a doctor, so médecin-psychiatre is a psychiatric doctor in English, whereas the French term for a psychologist (scientist or clinician in the field of psychology) is psychologue.

I don't think psychologist and psychiatrists are ever the same thing (not being from North America, I don't know about there) - as I understand it a psychiatrist is a doctor, and thus able to prescribe medication, but that's going off on a pointless tangent.

At any rate, I'm sure the psychiatrist involved in this study will be sufficiently expert. I'm certainly glad the human factors will be analysed in-depth from this accident.



Flown: NZ, NY, SJ, QF, UA, AC, EI, BE, TP, AF
User currently offlinetguman From Canada, joined Apr 2001, 430 posts, RR: 2
Reply 6, posted (2 years 7 months 4 days 23 hours ago) and read 8033 times:

My own understanding of the physciatrist-psychologist differentiation is that a physciatrist is a psychologist that can perscribe medication and is a doctor of medicine not just a Ph. D. that is just my understanding and memory from 10th grade psychology.

As a pilot, I look forward to this report.

TGUman



Life is a Mine Field.
User currently offlineRuscoe From Australia, joined Aug 1999, 1517 posts, RR: 2
Reply 7, posted (2 years 7 months 4 days 23 hours ago) and read 7946 times:

The inclusion of a psychiatrist indicates to me that they are wanting to exclude mental illness. I think this is very unlikely, and the chances of having three with a mental illness at the same time is remote. If it was just for why normal people do particular things, then a psychologist may have been more appropriate.
Having said that the particular psychiatrist may have a special interest in this area.
Why not have them both?.

Cheers

Ruscoe


User currently offlinePu752 From Uruguay, joined Mar 2005, 584 posts, RR: 1
Reply 8, posted (2 years 7 months 4 days 23 hours ago) and read 7871 times:

We are talking about human factors in a plane crash investigation, when there are many unknown facts in the biology of the humans studies. No clear respons will ever come out.

User currently offlineAquila3 From Italy, joined Nov 2010, 243 posts, RR: 0
Reply 9, posted (2 years 7 months 4 days 22 hours ago) and read 7740 times:

Quoting canoecarrier (Reply 3):
at a time when a number of people here on A.net were screaming that FDR/CVR data should be transmitted real time they had already put together a working group to study the feasibility of triggered transmission of flight data.

BTW I was one of them, just I was not screaming, but politely put my opinion, that is still that way. "Black Boxes" are a relic of the past and should be replaced/integrated with something more up to date. When at that time I have encountered the fierce opposition of some eminent and very respected members of this fourm I just decided to shut up, keeping my opinion for me. But this is OT.

Then, returning to the human factors, it is not yet clear to me if the AF procedures for PF relieving are still in place as they were in that tragic night or they are now updated. The fact that the less experienced pilot relieves the Captain on a seat were he is not trained for had attracted some critics even from inside the AF environment. What about a complete double crew (two CPs and two FOs or anyway two trained left and two trained right)? I believe some American carriers do like that for such long-haul flights. I understand that this is a big cost issue for AF, but for such long flights it should be feasible. The alternative is to train at least one of the FO for left seat, this woulbe only a matter of anticipating something tha he likely will have to do for the future.



chi vola vale chi vale vola chi non vola è un vile
User currently offlineKaiarahi From Canada, joined Jul 2009, 2806 posts, RR: 27
Reply 10, posted (2 years 7 months 4 days 19 hours ago) and read 7310 times:

Quoting tdscanuck (Reply 4):
This may be a translation thing...do psychiatrist/psychologist mean the same thing in France as they do in North America?

Yes.

Quoting joelyboy911 (Reply 5):
I don't think psychologist and psychiatrists are ever the same thing

Psychiatry is a medical specialty focused on the diagnosis and treatment of mental disorders and pathologies. Psychology is the science of behavioural and mental processes. Obviously there's cross-over, but psychologists focus on why individuals or groups do things or think in a certain way (behavioural / cognitive science), while psychiatrists focus on mental disorder.

I find the inclusion of a psychiatrist "specializing in risk analysis" interesting. Are they looking at the risk that people with certain behavioural or cognitive *disorders* will act/react in a certain way? Are they looking at the risk that flight crew intake profiling does not disclose certain relevant *disorders*? All speculation, obviously, but the inclusion of a medical specialist rather than a behavioural/cognitive scientist could be considered a little surprising.

Quoting JoeCanuck (Reply 2):
Quoting canoecarrier (Reply 3):
Quoting rcair1 (Reply 1):

  



Note à moi-même - il faut respecter les cons.
User currently offlinecanoecarrier From United States of America, joined Feb 2004, 2828 posts, RR: 12
Reply 11, posted (2 years 7 months 4 days 5 hours ago) and read 6860 times:

Quoting Aquila3 (Reply 9):
BTW I was one of them, just I was not screaming, but politely put my opinion, that is still that way. "Black Boxes" are a relic of the past and should be replaced/integrated with something more up to date.

You should read their conclusions then. They looked at everything from real/full time transmittal of FDR/CVR data to what it would take to transmit that data only in an emergency. It's been a few months since I read the report, but I did find it not only comprehensive, but it answered most of the arguments that were being made here on a.net at the time.

Quoting Kaiarahi (Reply 10):
Are they looking at the risk that people with certain behavioural or cognitive *disorders* will act/react in a certain way?

This particular aspect was brought up in an earlier thread. Specifically, that the PF had the type of personality that AF and other carriers were trying to weed out. I suspect a number of human factors will be studied. The time that the handover to the relief pilot is made and how long the 3 crewmembers should be together before the Captain leaves, crew hiring practices based on personality profiles, and short term makeup of crews based on how they would be expected to work together in an emergency are a few that come to mind.



The beatings will continue until morale improves
User currently offlineholzmann From United States of America, joined Jan 2011, 178 posts, RR: 0
Reply 12, posted (2 years 7 months 4 days 4 hours ago) and read 6791 times:

From what little I've read, my impression is that the stall warning horn was somehow counter-intuitive? The horn would sound when exiting the stall and would stop when entering? Or am I totally off my rocker here? It apparently was not a logical warning giving the stress of the circumstances.

If this is somehow an Airbus "feature" then they should be at fault. Do Boeing horns work the same way? Is Airbus getting a free pass because this is all being debated in European courts? These are my questions.


User currently offlinetguman From Canada, joined Apr 2001, 430 posts, RR: 2
Reply 13, posted (2 years 7 months 4 days 4 hours ago) and read 6733 times:

Quoting holzmann (Reply 12):
my impression is that the stall warning horn was somehow counter-intuitive? The horn would sound when exiting the stall and would stop when entering? Or am I totally off my rocker here? It apparently was not a logical warning giving the stress of the circumstances.

Having read the third interim report, my understanding of what was happenning is that because of the initial pitot tube malfunctions, when the airspeed indicator's numbers were below the stall speed the stall horn would stop sounding as the computer believed it was a pitot tube malfunction. As the pilot's recovered from the stall, and the airspeed began to increase, the stall horn would activate as the airspeed would be passing through the stall range.

I do not know how exactly an aerodynamic stall is measured in a large jet like the A330. Do they have a vane or opening on the wing to sense the movement of the centre of pressure as it moves too far forward in the stall?

TGUman



Life is a Mine Field.
User currently offlinercair1 From United States of America, joined Oct 2009, 1292 posts, RR: 52
Reply 14, posted (2 years 7 months 4 days 4 hours ago) and read 6700 times:
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Quoting tguman (Reply 13):
stall horn would stop sounding as the computer believed it was a pitot tube malfunction.

The stall warning is disabled if the measured airspeed falls below a certain point - otherwise you'd have the stall warning firing as you taxied around and also during the roll.

Quoting tguman (Reply 13):
I do not know how exactly an aerodynamic stall is measured in a large jet like the A330. Do they have a vane or opening on the wing to sense the movement of the centre of pressure as it moves too far forward in the stall?

It - like nearly all commercial airliners - has both pitot tubes which measure airspeed and angle of attack indicators which measure the angle between the relative wind and the wing chord (is it the chord that is the reference?) It's late and I forget

I believe the AB stall warning is actuated by pitot speed only - but I could be wrong - it may be a computed value from both. I don't think A and B are materially different in this regard.

Operation of the stall warning and these devices is covered in detail in other threads.



rcair1
User currently offlinerwessel From United States of America, joined Jan 2007, 2238 posts, RR: 2
Reply 15, posted (2 years 7 months 4 days 3 hours ago) and read 6634 times:
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Quoting rcair1 (Reply 14):
I believe the AB stall warning is actuated by pitot speed only - but I could be wrong - it may be a computed value from both. I don't think A and B are materially different in this regard.

The stall warning is almost wholly dependent on the alpha vanes, and *not* airspeed.


User currently offlineJoeCanuck From Canada, joined Dec 2005, 5320 posts, RR: 30
Reply 16, posted (2 years 7 months 4 days 2 hours ago) and read 6574 times:

It seems that for some time there was conflicting information coming from the flight instruments. When this happens, pilots are left with the unenviable and sometimes impossible task of having to choose what is true and what is errant information.

What can happen is time is wasted because it has to be a cautious process; a wrong move might make things worse.

Loss of spacial orientation is not uncommon and can effect and, has effected, pilots of any experience or training level...sometimes with tragic consequences.

In spacial orientation loss resulting in a loss of control of the aircraft, in situations where the plane was recovered, was when the plane came out of the clouds or otherwise could see the horizon. Once a pilot can see the ground, knowing your attitude and recovering is virtually automatic.

The current instruments are great navigational tools but sometimes fail at giving pilots the instant information often required to regain spacial orientation.

Giving pilots an easy to use device or technique, as instinctive as seeing the horizon without adding too much to the clutter of bells, buzzers and lights, would in my opinion, go a long way to reducing the dangers of loss of spacial orientation.

I look forward to the findings of the panel.



What the...?
User currently offlinetdscanuck From Canada, joined Jan 2006, 12709 posts, RR: 80
Reply 17, posted (2 years 7 months 4 days 2 hours ago) and read 6536 times:

Quoting rcair1 (Reply 14):

It - like nearly all commercial airliners - has both pitot tubes which measure airspeed and angle of attack indicators which measure the angle between the relative wind and the wing chord (is it the chord that is the reference?)

All modern airliners have wing twist so the chord line isn't fixed. The zero is somewhat arbitrary but, for convenience, it's often taken to be the AoA where the wing generates zero lift.

Tom.


User currently offlineRuscoe From Australia, joined Aug 1999, 1517 posts, RR: 2
Reply 18, posted (2 years 7 months 3 days 17 hours ago) and read 6173 times:

Quoting rcair1 (Reply 14):
The stall warning is disabled if the measured airspeed falls below a certain point - otherwise you'd have the stall warning firing as you taxied around and also during the roll

This can easily be handled by landing gear switches, which activate when there is weight on them

Quoting rcair1 (Reply 14):
Operation of the stall warning and these devices is covered in detail in other threads

True, but this is about human factors and in my opinion had the stall warning worked below 60kts, they may well have recovered.

Ruscoe


User currently offlinetdscanuck From Canada, joined Jan 2006, 12709 posts, RR: 80
Reply 19, posted (2 years 7 months 3 days 17 hours ago) and read 6112 times:

Quoting Ruscoe (Reply 18):
Quoting rcair1 (Reply 14):
The stall warning is disabled if the measured airspeed falls below a certain point - otherwise you'd have the stall warning firing as you taxied around and also during the roll

This can easily be handled by landing gear switches, which activate when there is weight on them

That doesn't cover the other case, where certain dynamic maneuvers can put your airspeed lower than that without stalling the wing. The point is that you can't use AoA sensors as an input to a stall warning system when you're in flight regimes where the AoA sensors don't work.

Quoting Ruscoe (Reply 18):
True, but this is about human factors and in my opinion had the stall warning worked below 60kts, they may well have recovered.

They ignored/disbelieved the initial stall warning (which was correct) for *50 seconds*...at that point, it's pretty obvious the flight crew has discarded the stall warning horn as a valid source of information. Then proceeded to ignore/disbelieve the altimeter, the attitude indicator, and the VSI for the rest of the flight. Why do you think having one more warning in the mix would make any difference?

Tom.


User currently offlinercair1 From United States of America, joined Oct 2009, 1292 posts, RR: 52
Reply 20, posted (2 years 7 months 3 days 15 hours ago) and read 5959 times:
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Quoting Ruscoe (Reply 18):
True, but this is about human factors and in my opinion had the stall warning worked below 60kts, they may well have recovered.

Possibly - as I mentioned in earlier posts a long time ago - the fact that the stall warning _came on_ when they started to recover had to be confusing. Certainly in the calmness of our computer discussions - it is obvious they should have 'known' that this could happen - but frankly, I think that is overstating what a pilot will retain. These are very complex systems and system behaviour in the realm they were in are not well understood, because they are, well, in a flight realm they are not supposed to be in.

Quoting tdscanuck (Reply 19):
has discarded the stall warning horn as a valid source of information. Then proceeded to ignore/disbelieve the altimeter, the attitude indicator, and the VSI for the rest of the flight. Why do you think having one more warning in the mix would make any difference?

Agreed. More warnings are not the answer. I don't know what it is - but that is not it.



rcair1
User currently offlinetguman From Canada, joined Apr 2001, 430 posts, RR: 2
Reply 21, posted (2 years 7 months 3 days 13 hours ago) and read 5785 times:

Quoting rcair1 (Reply 20):
- the fact that the stall warning _came on_ when they started to recover had to be confusing.

Absolutely agree with you there. If the action you are doing is causing a stall warning, you undo that action.



Life is a Mine Field.
User currently offlineJoeCanuck From Canada, joined Dec 2005, 5320 posts, RR: 30
Reply 22, posted (2 years 7 months 3 days 13 hours ago) and read 5761 times:

Quoting tguman (Reply 21):

Absolutely agree with you there. If the action you are doing is causing a stall warning, you undo that action.

One of the problems was the pilots had conflicting information...so what do you believe, the stall warning or information which may be showing something other than a stall?

Pilots are taught right out of the box to rely on their instruments. In training, instruments are generally completely disabled or covered to simulate failure...not active giving inaccurate information.

Having conflicting instruments is significantly more difficult to deal with than instruments which have simply gone dark or otherwise shut down.

At the very least, training may have to be changed to include more practice on how to discern accurate information from faulty.



What the...?
User currently offlineLTC8K6 From United States of America, joined Jun 2009, 948 posts, RR: 0
Reply 23, posted (2 years 7 months 3 days 12 hours ago) and read 5729 times:

Quoting tguman (Reply 21):

Absolutely agree with you there. If the action you are doing is causing a stall warning, you undo that action.

Only to someone unfamiliar with how the stall warning works, which should not be the case here.


User currently offlinebonusonus From United States of America, joined Nov 2009, 403 posts, RR: 0
Reply 24, posted (2 years 7 months 3 days 8 hours ago) and read 5527 times:

Quoting LTC8K6 (Reply 23):
Only to someone unfamiliar with how the stall warning works, which should not be the case here

But the FDR showed that whenever the stall horn sounded, the PF reacted to it, usuallywith a nose-up input, which made the warning go away.


25 tdscanuck : The PF appears to have developed a serious case of confirmation bias at some time during the event...his actions are only consistent with a firm beli
26 canoecarrier : Well not only that, but he also consistently took command as evidenced by the FDR noting that the priority button was hit by the PNF, followed by a v
27 N14AZ : That's exactly what I thought when I saw this thread. After reading all the reports and the CVR transcripts one has the feeling that - speaking as a
28 tdscanuck : At the time AF447 went down it was the third A330 major incident (second with fatalities). It's still a fantastically safe aircraft but it's not accu
29 N14AZ : Are you refering to the accident with the A 330 prototype in Toulouse? I cannot think of any other major incident / accident. So what was the third i
30 liquidair : Had someone told me about this accident, and i hadn't read the previous 22 threads on this subject, I would've sworn blind the PF acted intentionally.
31 Viscount724 : At the time AF447 went down it was the second fatal A330 accident, including the early test crash. The third was a year after AF447 -- the 8U (Afriqi
32 tdscanuck : The dead-stick into the Azores...major incident, no fatalities. Tom.
33 Kaiarahi : I understand what you're trying to say, but: 1. It was intentional (i.e. not involuntary). 2. We don't know what he was trying to (intentionally) ach
34 liquidair : You make an interesting point. The PF's actions were intentional, yes- but we've all assumed the outcome was accidental. I personally think it unlikel
35 JoeCanuck : It's almost as if the PF's actions ended up being directed to shutting off the warnings as opposed to breaking the stall. In other words, if he pulled
36 canoecarrier : I've wondered this as well. Most of us can relate to having a coworker that they don't like or trust. Sometimes to the extent that we don't really li
37 liquidair : Not all actions are premeditated. But on the whole, I agree with you canoecarrier
38 tdscanuck : That's exactly what he was doing...he didn't know he was in a stall therefore there is no reason for him to try to break it. If he took an action tha
39 JoeCanuck : ...and once you get contradictory information from your instruments, deciding what is reliable and what isn't has the potential to overwhelm the most
40 canoecarrier : I seem to remember Pihero saying they had a bright moon at their eight o'clock that night, so they were close to a daylight flight. Not to rehash the
41 Post contains images rcair1 : In the steam gauges days - I used to carry little shower soap sticker holders that could be placed over the failed instruments to you would remember
42 gregarious119 : Maybe I'm being too elementary here, please take it easy as I only dream of being in the left seat some day. Is it too simple to affix a clear ball wi
43 Post contains links rwessel : The ball on the traditional turn-and-bank indicator is just that, although only in one dimension. See: http://en.wikipedia.org/wiki/Turn_and_bank_ind
44 Pihero : Yes, and that's where the group's study will concentrate on. That point towards more of an individual parameter thna group dynamics for the psychiatr
45 tdscanuck : Yes. That would not have provided any information the crew didn't already have and would not have shown them they were in a stall. None of the electr
46 AirlineCritic : It was accidental. I don't know if it was confirmation bias, inexperience, bad way of communicating among the three, but it was not done on purpose.
47 WingedMigrator : The seat of the pants might also have played the usual unwelcome role. Who could have predicted, least of all the pilots, that an airliner could "fly
48 Kaiarahi : You're missing the point. As far as we know, the PF's actions were intentional (i.e. not involuntary), but we don't know what his intention(s) were.
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