Air France 447 - On topic only!

[Evan]

Hey, I just found this on Skybrary:

Autopilot, auto thrust, and flight directors can all contribute to loss of control in the event of unreliable speed.

Now how do we get line pilots to read Skybrary?

[3WE]

Originally Posted by Evan

How... (sorry, I had to cancel my geek warning)... How so?

Tell me, Jedi Master, how pitots blocked by ice crystals are going to result in an airspeed indication approaching overspeed?

(and no Jedi mind suggestion)

In some ways, we have one of those collisions of knowing fundamentals versus "the aircraft-specific memory checklist from the QRH".

Someone else on this forum and this thread asked how the increase in airspeed indications worked...very recently.

I explained.

Gabriel and Deadstick also contributed information.

For further reading, I would suggest a generic instrument training book, check the index for instrument failures, and icing.

Do not check the Airbus QRH and memory item checklists. It has nothing to do with programming the computer.

Repeating, planes (note that I used plural) have been stalled out and crashed because of this phenominon. Additionally, a number of planes (again plural) have been stalled out or almost stalled, but fortunately the pilots recovered, again because of the blocked pitot increasing airspeed indications with climb phenomenon. I did not make these incidents up!

By the way- the words "approaching overspeed" speak not did I. Your ability to discern fundamental airmanship from the procedural side of the force weak still it is.

[Evan]

Originally Posted by 3WE

By the way- the words "approaching overspeed" speak not did I. Your ability to discern fundamental airmanship from the procedural side of the force weak still it is.

No. You didn't speak those words. You spoke these words:

So you pull up some to slow down, but then your speed increases more, so you pull up more.

Using the Force, I translated this to mean they would have a reason to slow down, aka overspeed.

Normally I'd just let you off the hook 3WE, but since you made this into a personal attack on my supposed ignorance...

...explain to me why they would want to pull up to slow down from an indicated airspeed already far below the normal one.

[Black Ram]

Originally Posted by TeeVee

my gather from the report is that the investigators were NOT convinced the crew were in agreement over UAS. while they both mentioned "speeds" they never actually stated "UAS" or anything like this.

"The impression of an accumulation of failures created as a result probably did not incite the crew to link the anomaly with a particular procedure, in this case the “Vol avec IAS douteuse” procedure"

"The symptoms perceived may therefore have been considered by the crew as anomalies to add to the anomaly of the airspeed indication, and thus indicative of a much more complex overall problem than simply the loss of airspeed information."

"The PNF detected the climb based on observation and reasoning (“according to all three you’re climbing”), which indicates the beginning of a loss of confidence in the instrument readings."

I could go on quoting for a day or so, but the idea is that these guys were lost. Scared shitless and lost. The captain returned in the midst of absolute mayhem and he too became lost.

I agree they were lost. However, the other crews who experienced UAS didn't link it to the proper procedure either. But once again - and I think this is very important - none of them did what the pilots of AF 447 did. Also, they clearly knew they were in Alternate Law, so except if they were complete amateurs, they must have known the implications, namely the loss of flight envelope protections.

It is true the report sometimes seems to be trying to give the pilots the benefit of the doubt. However, this for me is a major let down, because it can be (and is sometimes) interpreted as exonerating AF and their training program, the real culprit here. Personally for me this is unacceptable and very dangerous. Just look at AF's history - they first crashed the A320, the A340 and the A330 (non-test flights), and the pilots' actions played a crucial role in all of those. I honestly get scared when I think what could be next... But, the good news is the recommendations and the summary of the causes of the tragedy in the end of the report talk over 90% about pilot training, interaction, overseeing, human factors. The only mention of the Bus is about the lack of a clear indication of UAS (no guarantee it would have had any effect) and a possible improvement of the cockpit ergonomics.

So I don't think Airbus failed big time. But since nothing can be perfect, I'm all for finding a way to make improvements (though it's not in the recommendations). I even thought, why can't the AP and AT carry out the UAS procedure on their own, instead of disengaging? Maybe more automation is the answer.

[Black Ram]

Originally Posted by Spectator

That said, I think the fault handling of the glass cockpit could be improved, but it is in no wise a "ten minute" upgrade! There is a lot of complex logic in there, and the ramifications of even the smallest change are big. There'll be testing and review and regulatory approval and and and and before it reaches a 'plane that one of us will ever board.

Yeah, but the first thing would be to announce plans for changes to the cockpit. I don't think I have heard even rumors.

[kris]

Originally Posted by 3WE

Repeating, planes (note that I used plural) have been stalled out and crashed because of this phenominon. Additionally, a number of planes (again plural) have been stalled out or almost stalled, but fortunately the pilots recovered, again because of the blocked pitot increasing airspeed indications with climb phenomenon. I did not make these incidents up!

Which ones?
AF447 is not one of them.

[Peter Kesternich]

Originally Posted by kris

Which ones?
AF447 is not one of them.

Northwest Flight 6231

http://en.wikipedia.org/wiki/Northwe...es_Flight_6231

[Evan]

Ok, here's another bit o grasping speculation: It seems very obvious from the CVR that the crew never undertook the proper ECAM actions, which require verbal requests and confirmations between the two pilots as each item is processed and cleared. If not processed and cleared, the messages would present themselves as follows:

2:10:05 - The first ECAM item would have been: AUTO FLT AP OFF (loss of autoflight). This is a level 3 message, meaning it is displayed in red and remains at the top of the list because ECAM messages are displayed according to priority. It remains there throughout the crash sequence. Ok, fine.

2:10:08 - The next item would be an amber advisory message: F/CTL ALT LAW (PROT LOST) followed by a blue action message: MAX SPEED.......330/.82

I wonder if the PF, in a confused state of mind in IMC, was monitoring these messages and misinterpreted MAX SPEED.......330/.82 as an overspeed warning message... and initially pulled up to slow the aircraft.

Here's the thing: the ECAM only has so many lines and therefore displays the most important messages at the top based on priority, so other messages do not appear intil these messages are cleared by the crew (a green arrow indicates that more messages are waiting to be displayed). So, as a result...

2:10:10 - The amber message AUTO FLT A/THR OFF appears, along eith the blue action message THR LEVERS.......MOVE moving the existing message F/CTL ALT LAW (PROT LOST) down. The message MAX SPEED.......330/.82 is also pushed down the list BUT REMAINS DISPLAYED.

2:10:15 - The message ENG THRUST LOCKED appears along with a second crew action message THR LEVERS.......MOVE. Only now does the message MAX SPEED.......330/.82 momentarily scroll down off the display.

2:10:23 - the THR LK mode is deactivated

2:10:24 - As a result, the ENG THRUST LOCKED and both THR LEVERS......MOVE messages disappear, allowing room for the message MAX SPEED.......330/.82 to reappear!

2:10:24 - 2:12:?? - MAX SPEED.......330/.82 then likely remained on the ECAM until after 2:12:00 when the message NAV ADR DISAGREE and the related procedure for this replaced it on the ECAM.

Now look at the CVR. Pitch attitude begins to increase at 2:10:08, when the message MAX SPEED.......330/.82 first appears, and continues until reaching 12° at about 2:10:28 when the the PNF instructs the PF to watch his speed, and the PF replies that he is going back down.

The initial pull up and sustained pitch application almost exactly mirror the time that the message MAX SPEED.......330/.82 is initially displayed.

Ok, so it's just another food-for-thought theory, but the we have established that A) the crew was sufficiently disoriented, and B) the crew did not follow proper ECAM procedures or anything resembling CRM, so I don't find it that far-fetched to think they were this poorly acquainted with the meaning of the ECAM messages. And it would possibly explain both the initial pull and the duration of that pull. And C) the FD's (when available) might have been corroborating this action.

=========

Even if this is the reason for the pitch command, fault still lies with Air France for not training them on correct ECAM actions, and not with the ECAM itself. Yes, the messages can be—and hopefully will be—made clearer, but lets not forget that a dozen other A330 crews did not make this mistake and 767 pilots do just fine without any ECAM assistance. And, of course, Flight Directors need to be turned off (or at least disregarded) no matter what you are flying.

[3WE]

Originally Posted by Evan

an indicated airspeed already far below the normal one.

Where did I say that?

[3WE]

Originally Posted by Evan

If your pitots are blocked, your airspeed indication is very low to begin with.

This would conflict with general aeronautical knowledge.

I don't belive you will find this in generic training manuals, nor aircraft-specific manuals and memory checklists.

[Fear_of_Flying]

I think the final report allocated a significant and appropriate amount of responsibility for this accident on lack of training.

The recommendations for Airbus seemed to be more along the lines of "In an ideal situation, had this contingency been in place, the accident may have been prevented."

The analogy I look to is this. If someone backs up in their driveway and inadvertently hits a young child behind the car, that is the driver's responsibility. As a driver, you should always know what's behind you before you back up. But as a recommendation, to avoid similar future occurrences, one might recommend a rear view camera, without actually making such an improvement mandatory for all vehicles.

At the end of the day, a rear view camera should not be necessary for a driver who does what he or she is supposed to. In the case of this accident, had these pilots done what they were supposed to - in fact, had they just not done what they were not supposed to - then the additional recommendations pertaining to Airbus would never have come into play. Indeed, had the pilots done absolutely nothing but sit there and gape, they might well have come out of the situation unscathed.

The factor that does not get addressed in the report is that of pitot tubes, and the fact that they are the one critical system that lacks redundancy. Probably there is no way to include this in the report, but for aviation in general, I think we have now had enough crashes related to pitot tube malfunctions to insist on a redundant backup system.

[Highkeas]

Originally Posted by Fear_of_Flying

...........
The factor that does not get addressed in the report is that of pitot tubes, and the fact that they are the one critical system that lacks redundancy. Probably there is no way to include this in the report, but for aviation in general, I think we have now had enough crashes related to pitot tube malfunctions to insist on a redundant backup system.

The pitot tubes are dual or triple redundant - it is unusual to have all of them freeze up. It was known that the pitot tubes were prone to problems and were being replaced fleet wide.

And as mentioned in previous posts there is a back-up procedure to follow if airspeed indication is lost thus adding another measure of redundancy.

[3WE]

Originally Posted by Fear_of_Flying

The factor that does not get addressed in the report is that of pitot tubes, and the fact that they are the one critical system that lacks redundancy. Probably there is no way to include this in the report, but for aviation in general, I think we have now had enough crashes related to pitot tube malfunctions to insist on a redundant backup system.

Cessna 172's have one pitot tube.

They also have heat to prevent icing.

(Ok, so does Air Bus, but it's interesting that they aren't more infallable)

[Myndee]

Originally Posted by Peter Kesternich

Northwest Flight 6231

http://en.wikipedia.org/wiki/Northwe...es_Flight_6231

Interesting that the last sentence is:

In that manner, this crash resembles the loss of Air France Flight 447 on June 1, 2009, where the pilots were warned of unreliable airspeed, but failed to perform the necessary procedures.

[TeeVee]

here's an interesting tidbit: was discussing this whole af447 deal with my buddy that flies the challenger 300. he is currently in dallas doing training on the sim. guess what is and has been part of his standard training? you guessed it! high altitude upset recovery INCLUDING STALLS.

so much for big airline training programs.

[3WE]

Originally Posted by TeeVee

...standard training? you guessed it! high altitude upset recovery INCLUDING STALLS...

I can't figure out why the recurrent training doesn't include a quick verbal review? (No expensive sim time, and it would not take all that long!)

Here's a good start:

1) Do you remember stalls from your initial training? (tell me about it?)
2) What causes a stall?, Flying too slow?
3) What attitudes and airspeeds can an airplane be stalled at?
4) That being said, what attitudes and airspeeds and situations are particularly good for stalling?
5) What's a good procedure for recovering from a near stall with minimal altitude loss?
6) What's a good procedure for recovering from a fully-developed stall?
7) What's the best way to avoid stalling?
If the speed is slow and the nose is high and the stall warning is going off, what might that mean, and what corrective actions might you consider?
9) Quickly review what happened in these crashes: Pinnacle, Colgan, Air France?
10) Please promise that you won't do stuff like that.

Then they can spend the rest of the day doing engine cuts at V1 +/- 1 knot, review weather minimums, deal with extreme cross winds and practice lots of memory checklists.

[TeeVee]

expensive sim time? yeah, it's expensive. but if my friend's boss can afford it, the airlines should be able to. if they can't, well, then maybe they shouldn't be in business.

[TeeVee]

Originally Posted by 3WE

9) Quickly review what happened in these crashes: Pinnacle, Colgan, Air France?
10) Please promise that you won't do stuff like that.

love it!

[Gabriel]

Originally Posted by TeeVee

here's an interesting tidbit: was discussing this whole af447 deal with my buddy that flies the challenger 300. he is currently in dallas doing training on the sim. guess what is and has been part of his standard training? you guessed it! high altitude upset recovery INCLUDING STALLS.

so much for big airline training programs.

After several accidents and incidents where a stall was mismanaged, there was a new birth of stall training. The manufacturers, the authorities and even the airlines made a group to study the problem, named crap the procedures that were current up to then (and they were crap, they even blamed them for confusing the pilots to produce a stall while attempting to minimize altitud loss, as mandated byt the procedures, in place of managinf AoA, which was not even mentioned and is what it takes to minimize altitude loss) and made a new one, and recomended training training training.

Air France was before this. I bet that, by 2009, you could find several pilots of several airlines that had not practiced high altitude stalls.

By the way, a good thing of the new procedure is that it is the same at any altitude. So, by all means do practice high altitude stalls, but practicing stalls at any altitudes will help at high altitudes too.

[Evan]

Originally Posted by Gabriel

After several accidents and incidents where a stall was mismanaged, there was a new birth of stall training. The manufacturers, the authorities and even the airlines made a group to study the problem, named crap the procedures that were current up to then (and they were crap, they even blamed them for confusing the pilots to produce a stall while attempting to minimize altitud loss, as mandated byt the procedures, in place of managinf AoA, which was not even mentioned and is what it takes to minimize altitude loss) and made a new one, and recomended training training training.

They have also recommended AoA instrumentation. The 737NG currently offer this as an option. 767? 777? 787? 748? A320NEO? A380? A350?