Independence76 From United States of America, joined Jul 2007, 256 posts, RR: 0
Reply 1, posted (2 years 3 months 2 weeks 3 days 16 hours ago) and read 29783 times:
I've waited for this day for 3 years.
Hopefully we can truly peer through the eyes of the pilots for the first time with all the answers in front of us. I do not mean to sound overdramatic (I apologize if I do), but this may go down as the landmark example of "the true danger of automation with an inexperienced flight crew" within the aviation community.
The Airbus Fly-By-Wire system is incredible and I admire it greatly. However, for this flight crew sitting in front of 200+ people not immediately realizing the first sign of trouble is, to me, a distressing scenario in the practice of pilot training. Alternate Law 1 & 2 are virtually "page 2" material of Airbus flight characteristics.
I'm somewhat indifferent on the proposition of altering the side stick and throttles to be backdriven, but it would be of a greater benefit to pilots in my honest opinion, and this accident potentially may not have happened if they were. One could argue that making them backdriven would assist in CRM awareness, but this is a debate I'm willing to let the BEA settle.
I will be eagerly awaiting the final report.
[Edited 2012-07-04 19:11:34]
[Edited 2012-07-04 19:12:27]
[Edited 2012-07-04 19:12:35]
"In general, pride is at the bottom of all great mistakes." - John Ruskin
justloveplanes From United States of America, joined Jul 2004, 1062 posts, RR: 1
Reply 2, posted (2 years 3 months 2 weeks 3 days 15 hours ago) and read 29706 times:
It is a tough call to make. The other side of the coin is how many crashes has the Airbus system avoided? Thousands of times more I am will to bet. So one must be careful about throwing out the baby with the bathwater.
Best solution is better training an pitot tubes that don't ice up IMHO.
LH707330 From United States of America, joined Jun 2012, 794 posts, RR: 0
Reply 3, posted (2 years 3 months 2 weeks 3 days 13 hours ago) and read 29552 times:
This will be an interesting read, I'm most curious to see what the human factors group comes up with. Hopefully they will have something more material than "pilot error: they failed to execute the checklist" as the probable cause. Maybe they will mention personality issues between flight crew members, etc. Who knows....
JoKeR From Serbia, joined Nov 2004, 2238 posts, RR: 9
Reply 4, posted (2 years 3 months 2 weeks 3 days 10 hours ago) and read 29244 times:
Quoting justloveplanes (Reply 2): It is a tough call to make. The other side of the coin is how many crashes has the Airbus system avoided? Thousands of times more I am will to bet. So one must be careful about throwing out the baby with the bathwater.
Exactly my thought! If there was a serious flaw, 330s would be dropping out of the sky at regular intervals, thank Lord that's not happening.
I suspect human factor, inadequate training and poor communication will be the main culprits, though fingers will probably be pointed left, right and backwards. Really hope that the families find peace and closure after this report - sadly nothing that this report says will bring back their loved ones or take away the pain they have endured.
PHX787 From Japan, joined Mar 2012, 7752 posts, RR: 18
Reply 5, posted (2 years 3 months 2 weeks 3 days 4 hours ago) and read 28565 times:
So I took a look at it, and it's a pretty interesting read, but it's pretty much confirming the initial report, with faulty airspeed readings causing pilot errors. I hope that this doesn't happen again.
Following that point, I saw that they made an additional 25 further recommendations on the top of the ones issued previously and are pursuing a manslaughter investigation against Airbus and Air France.
I cannot look too deep right now as I am working, but do you have any details on what the recommendations and accusations are?
PHX787 From Japan, joined Mar 2012, 7752 posts, RR: 18
Reply 13, posted (2 years 3 months 2 weeks 3 days 4 hours ago) and read 27983 times:
Quoting AirlineCritic (Reply 12): Quote:
The summary of final report will be summarized as soon as the report has been released a few hours after the end of the press conference and processed as usual.
Klaus From Germany, joined Jul 2001, 21484 posts, RR: 53
Reply 16, posted (2 years 3 months 2 weeks 3 days 3 hours ago) and read 27703 times:
Quoting Independence76 (Reply 1): Hopefully we can truly peer through the eyes of the pilots for the first time with all the answers in front of us. I do not mean to sound overdramatic (I apologize if I do), but this may go down as the landmark example of "the true danger of automation with an inexperienced flight crew" within the aviation community.
Is the problem any larger than an inexperienced crew without automation?
I would say no, even to the contrary.
A crucial lack of experience is always dangerous and unacceptable.
Quoting Independence76 (Reply 1): I'm somewhat indifferent on the proposition of altering the side stick and throttles to be backdriven, but it would be of a greater benefit to pilots in my honest opinion, and this accident potentially may not have happened if they were.
It would have changed absolutely nothing, since the pilots were made aware by the systems that they were going into a stall already and yet they reacted incorrectly to that.
The backdrive would have stopped as well when the systems lost forward speed again during the stall, so it would not have been of any use.
The crew was confused, beginning with their failure to execute the mandatory checklist on the loss of airspeed indication. And they made multiple crucial errors of judgment after that as well, actively keeping the aircraft stalled against aerodynamic forces.
nomadd22 From United States of America, joined Feb 2008, 1880 posts, RR: 0
Reply 17, posted (2 years 3 months 2 weeks 3 days 3 hours ago) and read 27519 times:
Quoting Klaus (Reply 16): Is the problem any larger than an inexperienced crew without automation?
The theory is that the inexperience was aggravated , or caused by a too automated flight system. The more planes go toward push button flying, the less experience pilot have at truly flying them. To put it in vague terms, they can lose the "feel" for the operation. It sounds like the AF crew had the indicators they needed, but failed to put them together into a coherent picture of what was happening, aggravated by a breakdown of cockpit discipline.
Automation has surely prevented more loss of life than it's caused. It just has it's downsides too.
It's not just flying planes. It's something that's happening in fields everywhere. Many people don't need to understand how machines work at the most basic levels anymore as they get more complex and automated. It's a problem when that automation fails.
Klaus From Germany, joined Jul 2001, 21484 posts, RR: 53
Reply 20, posted (2 years 3 months 2 weeks 3 days 1 hour ago) and read 26022 times:
Quoting nomadd22 (Reply 17): The theory is that the inexperience was aggravated , or caused by a too automated flight system. The more planes go toward push button flying, the less experience pilot have at truly flying them. To put it in vague terms, they can lose the "feel" for the operation. It sounds like the AF crew had the indicators they needed, but failed to put them together into a coherent picture of what was happening, aggravated by a breakdown of cockpit discipline.
They never had control of the situation right from the get-go: Failing to even execute the unreliable airspeed checklist leaves no doubt about it.
Automation or not was not the problem there.
Inexperience and a lack of competence in general has nothing to do with automation. That's mostly a phantom debate in this context.
Quoting Mir (Reply 19): The report references the CVR transcript in its list of appendices, but doesn't include it. Peculiar - anyone know if it's available?
AirlineCritic From Finland, joined Mar 2009, 728 posts, RR: 1
Reply 21, posted (2 years 3 months 2 weeks 3 days 1 hour ago) and read 25977 times:
Some interesting points as I keep reading through the report. This part is in 1.16.2, a study of previously happened unreliable speed incidents. The study found that:
With regard to the crews’ reactions, the following points are notable:
The variations in altitude were contained within about one thousand feet. There were five cases of deliberate descent, including one of 3,500 feet. These descents followed a stall warning;
Four crews did not identify the unreliable airspeed situation: in two cases, the crews concluded that there was an inconsistency between the angles of attack; in the two other cases, the crew considered that the speeds were erroneous rather than unreliable.
For the cases studied, the recorded flight parameters and the accounts given by the crews did not reveal any application of the memory items from the unreliable airspeed procedure, nor the procedure itself:
The reappearance of the indications of flight directors on the PFD suggests that no disconnection inputs were made into the FCU;
The durations of engagement of the thrust lock function indicate that no attempt was made to rapidly disconnect the autothrust followed by a manual adjustment of the thrust to the recommended value;
There was no attempt to command display a pitch attitude of 5°.
I find it amazing that other crews (not just AF447) often did not identify the unreliable speed situation. And more interestingly, apparently none of the crews performed the unreliable airspeed procedure.
Quoting Klaus (Reply 20): Quoting Mir (Reply 19):The report references the CVR transcript in its list of appendices, but doesn't include it. Peculiar - anyone know if it's available?
Wasn't it in the interim report already?
A more complete CVR transcript is available on the BEA page linked above - with many comments in different English words than the interim report version.
It appears to me that this translation does a better job of conveying the 'flavor' of the pilots words - based on the more accurate cultural translations from the French we've had on past threads.
This CVR transcript makes it clear that both the PF and the PNF felt they had to climb and were trying to make the aircraft climb as it fell in the deep stall.
But as cautioned in the CVR forward - the CVR transcript cannot viewed as a complete description of what happened in the cockpit - the FDR data has to be linked to the CVR to have a more complete view.
: The passage you quoted emphasises the need for better, more focused training. We've wondered why this crew alone seemed to have failed to follow proc
: They were constantly pulling deep into a stall, but they were not in a deep stall![Edited 2012-07-05 10:51:48]
: As you say, the transcript in this final report is much more comprehensive than the one they released in the Interim Report. Previously there were ga
: With the 'zero tolerance' approach to failure in the industry, surely the replication of the similar reactions to similar situation suggests a wider
: Example of the CRM and decision procedures in the crew (Section 18.104.22.168): and choice of relief pilot (Section 22.214.171.124.2): [Edited 2012-07-05 11:56:36]
: This part is a little interesting. We've talked about how the crew ignored (or seemed to ignore because they didn't comment on it) the stall warning(s
: The initial BEA report was 'shocking' to the industry - in that about 3 dozen similar events were identified quickly. Such super-cooled icing at alti
: A long awaiterd document anrd really worth the wait . For those who don't understand french doc presentation, the final report in English is Here and
: Oh how I wished I did not have to learn the memory items for my flight training in the PA28. They were annoying, consumed valuable study time and I n
: I think Klaus has a good point here. More than automation the point is the lack of training, in many airlines this maneouvre is performed only until
: In section 126.96.36.199 the reports notes: "It would also seem unlikely that the PNF could have determined the PF’s flight path stabilisation targets. It
: One thing I noticed, and correct me if I'm wrong here ... but reading through the CVR transcript which included all the sounds, it was already pointed
: Airbus has flown test flights to determine buffeting levels in configurations corresponding to AF 447 (Section 1.16.5): Apparently, ECAM was not very
: Having read this report, one glaring issue seems to point to a lack of handling experience, both in non-normal operations and manual flight. It states
: If the crew believed the initial stall warning was faulty (and they certainly had reason to - we know it was driven by corrupted input from the air d
: .....an additional thought. Because the report says that recovery was unlikely once they fell back through 35,000 feet, I'm not sure they had time bet
: System complexity would go way up and reliability would take a significant hit (right down to canceled flights on malfunctions), which doesn't seem l
: If your in the cruise, all you need to do initially is to turn the flight directors off and manually maintain the pitch attitude and thrust setting i
: But it did sound, in conjunction with the loss of air data indications. That's enough to link the two in the back of your mind, and if you don't real
: And that makes a lot of sense. Thanks, Zeke. I also think that is the general idea with the unreliable speed procedure: Paraphrasing a bit, it essent
: Read the first line, "if the safe conduct of the flight is impacted", that is not the cruise. You are already level, above MSA. This is the problem w
: Ah, yes. Thanks. Question: Does this also cover not necessarily turning off PD/AP, if the crew can observe that they are not immediately causing a pr
: The checklist is 5 pages long, it is broken up in different phases of flight. The initial part of the checklist which you posted is designed for the
: The a.net discussions have often looked at the role of the stall warnings that were no longer continuous after some time had passed and the aircraft a
: I have a quick question. The report says that for low altitude stall recovery the suggested method is 12.5 deg and TOGA throttle. It goes on to say th
: You are connecting items that are not connected. The fact that a system, any system, works most of the time does not mean that it cannot be improved.
: Unbelievable. It's a testament to the plane there weren't more crashes, if there was such incompetence and lack of adherence to procedures.
: I would hope that this accident prompts Airbus to rethink its over-reliance on computerized flight control, which, consistent with the use of joy stic
: The information tells me that it is not incompetence. Rather there is a training, and systems issue, in properly identifying unreliable airspeed in m
: That's a prejudiced knee-jerk judgement which is simply not covered by the investigation. If anybody was "over-reliant" on anything, it was Air Franc
: In the english version, at page 201, the last in the list of factors believed to explain the (to me, still incredible) failure of the flight crew to t
: Former US Airways pilot Cpt. Sully Sullenberger, best known for the 'Hudson River Miracle', is now an aviation and safety advisor/commentator for the
: Given the amount of time and money that have gone into understanding what went wrong with AF447, it seems that even one accident like this is enough
: rfields, thanks for your great work on help on understanding the report and issues around the accident. To nitpick, though, the BEA does not believe
: The amount of concern is beyond doubt and directly related to the extent of the tragedy. Where I think you're going wrong is by leaping to a conclusi
: I'll have to go back and check our timeline from the previous threads, but didn't the Captain enter the cockpit just as the last stall warning was so
: You believe that even though the report identifies several Boeing aircraft accidents due to near identical source events, and very similar crew react
: Undoubtedly having tracking joysticks would add complexity to the Airbus control design. So does having multiple pitots, the ability to switch display
: I understand but disagree with your point, and I'm not offering an expert opinion. Notably, however, my lay-person's concerns about Airbus echo those
: In the B727 accident discussed in the report - both pilots held the yoke full aft and never realized the aircraft was stalling. Also mentioned in the
: Interesting, but undoubtedly they all work in different ways. Have the other heavily computerized systems caused the same type of spectacular catastr
: It does not stall the aircraft, exceeding the critical angle of attack does. A stall can occur in any attitude and at any speed. What your theory doe
: An interesting point. I would be interesting to know if the response to control inputs changes between the flight modes on the 777 as it seems to do
: There are several different things to remember about computerized aircraft systems. When most folks talk about fly-by-wire - that is not what they me
: I respect your opinion....and agree with the last part, but this would only require new joysticks capable of tracking and a controller to link the tw
: The PF appears to have been significantly focused on maintaining a wings level position. The aircraft continually wanted to roll to the right. The pl