Air France 447 crash and the findings of the investigation board.

The Human Factor

Airline pilots were once the heroes of the skies. Today, in the quest for safety, airplanes are meant to largely fly themselves. Which is why the 2009 crash of Air France Flight 447, which killed 228 people, remains so perplexing and significant. William Langewiesche explores how a series of small errors turned a state-of-the-art cockpit into a death trap.

The article is a short 9 page read. Basically a design flaw in the side controller sticks which are used to manually fly the aircraft and having a new guy co-pilot who was afraid of weather and clouds (especially at night) all played their part in sitting up the accident. The final straw was when the pitot tubes iced over and they (the crew) started receiving erroneous readings..

Crew Resource and management was a big deal at our airlines. I actually participated in some of the flights that were used for the final report and study which started the whole concept.

I knew from experience even if you are capable of doing everything yourself (in a severe emergency) if you do not get your other crew members involved... when you really do need them they will either be frozen in fear or late to the party.

The other part of the article about automation is absolutely true. We have a generation of pilots who are great push button system monitors... but when it comes to basic stick and rudder they really have very little experience except in a simulator.

This was a terrible accident and as usual there was not one thing that lead to the aircraft crashing and loss of life.

www.vanityfair.com...#

a reply to: 727Sky

The fact that most pilots are not coming out of the Air Force is disturbing, and even more to the point its been about 20 years since pilots, air force or not have been made to fly manual in training. You can find a cut rate school, log your minimum hours, and boom you go to work.

The bigger problem is that airlines don't pay their pilots worth a damn anymore, a lot of them are fatigued and caffined out, and stressed out due to debt of being a pilot. Couple that in with basic human anxiety especially to people who shouldn't be in the captain's seat to begin with and you have crash city.

Most pilots as you say, are nothing more than button pushers. Flying for them is almost like flying Microsoft Flight Simulator. No one teaches real time and real life emergency procedures anymore.

Remember that flight in Canada that was underfueled - those 2 flew that plane I believe on a single little propeller fan and SAFELY landed it in an air field. No one was able to do that in the simulator. They were Air Force trained pilots.

Aviation these days is russian roulette. I would never fly again after the last flight (engine was on fire for most of the flight) and while we landed, I distinctly remember the captain yelling "what do you mean they forgot to put the screws back into the wing!!!!"

I'm done. Boat to Europe or nothing. At least if an iceberg hits I got 2 hours to get out.

a reply to: ArchPlayer

The commuter airlines and some of the start-ups do not pay the right seaters worth a darn the first year. Depending on the airline it does get a little better but not by much considering the amount of work and training it took to get their license.

However, the Majors in America pay very well for a captain. I have friends still working who make $25,000 a month on the 737 aircraft and 33 to 37,000 a month on the 75/767.. The 777 guys make more than that it just depends on the Bid and the route they are able to hold plus any trips they are able to pick up in open time.

I am very glad I retired when I did as it was not mandatory to turn on the auto-pilot at 1000 ft msl and turn it off on short final basically after the FMC shot the approach for you.. Many of my generation would still hand fly up to 18,000 ft and hand fly below 10,000 but.... even during my time it was evident we were training button pushers whose stick and rudder skills were never developed or were becoming very rusty . The topic of this thread and subsequent crash is horrible and as in many crashes it is not one thing but a multitude of little things that can lead one (the pilots) to wrong conclusions and actions. Plugged pitot tubes or an iced or taped over static port is a big deal, especially at night, (in the weather) due to the confusion and recognizing that is why the instruments you depend on are not reliable.

originally posted by: ArchPlayer
a reply to: 727Sky




Remember that flight in Canada that was underfueled - those 2 flew that plane I believe on a single little propeller fan and SAFELY landed it in an air field. No one was able to do that in the simulator. They were Air Force trained pilots.

the air canada flight, also called the "gimli glider", had some good fortune happen. The copilot was a canadian airforce reserve and had been stationed at gimli before it had been closed. i'm not sure the captain was ex military, but but he was a licensed glider pilot and flew his glider often on his days off. they also had the old fashion airspeed indicator and altimeter, plus Winnipeg atc happened to still have the old style radar.

commercial pilots should all have personal airplanes and if they don't want to own one the company should pay for membership in a flying club. then they will always have ample opportunity to fly without automation. and all pilots need to be glider licensed and maintain glider proficient.

originally posted by: 727Sky
....

The other part of the article about automation is absolutely true. We have a generation of pilots who are great push button system monitors... but when it comes to basic stick and rudder they really have very little experience except in a simulator. ...

And yet the reason they are button pushers is because the machine has proven to be more reliable at the job than the man. Thats the other side of the same medal.

Considering the diametral development of air traffic versus crashes, the "ugly" truth is that the better button pusher has probably saved a lot more lives than hotshot stick pilots, and we never even know it

Yes, I know there are a lot more factors playing into the statistics, but still...

edit on 30/9/2014 by Lonestar24 because: (no reason given)

originally posted by: Lonestar24

originally posted by: 727Sky
....

The other part of the article about automation is absolutely true. We have a generation of pilots who are great push button system monitors... but when it comes to basic stick and rudder they really have very little experience except in a simulator. ...

And yet the reason they are button pushers is because the machine has proven to be more reliable at the job than the man. Thats the other side of the same medal.

Considering the diametral development of air traffic versus crashes, the "ugly" truth is that the better button pusher has probably saved a lot more lives than hotshot stick pilots, and we never even know it

Yes, I know there are a lot more factors playing into the statistics, but still...

that is until the machine cannot make sense of what its inputs are telling it, then it stops and expects humans to take over.

first you must come to the realization that no one will make a decision that they know will result in failure. then you must ignore the knowledge you have, that the outcome was a failure. once you understand those two things you can begin to see how the decisions were made and why they made sense to the pilots at that moment in time

while they still had enough altitude to recover they actually were trying to do the right thing. what happened when they started reducing the AOA? the stall warning horn began to sound, the pilot pulled back increasing the AOA and the stall warning horn quit, reinforcing the decision to continue to pull back on the stick.

the computers running the airplane could not make sense of the information because they were out of range for what it was programmed to ever expect.

a reply to: bigx001

There are so many stories of the flight deck automation going fubar either through pilot inputs or raw data inputs if the normal public knew they might consider the direction this is headed is the wrong direction. Someday due to cost and automation there will be people who reach their destination in a vehicle that from start to finish is controlled by a computer.

Go ride on one of the fully automated electric trains that travel from terminal to terminal at some of the airports.. notice the breaking and the acceleration which is controlled all by computer and supposedly monitored by a human off sight; enough to make a kid sick.

Once upon a time long ago I was an instructor pilot in both fixed wing and helicopters for the military. I could have just flown a helicopter during a check ride (which would have been stupid on my part) and been done with it. I had a rule that at least once a week I flew helicopters due to the type of training I had to give (instrument flight examiner and contact work to include autorotation's) the once a week kept me current in the machine and maybe saved my life and 3 others when the single engine quit and a real life autorotation was required.

You can (in todays world of training) put a pilot in a simulator blow an engine, have a fire and throw in some turbulence and for the most part they will be cool and ace of the base. They know it is a simulation...

Now take them and have a few of the same things happen in the real world.. A very large percentage will do just fine; they are professional pilots... But the ones who brain freeze or vapor lock will not be detected until the incidence actually happens..

The first time I ever personally landed a B727 was after three touch and goes during a night time training session (all simulator training before that) where I received the required 3 landings and take-offs. Two days later I landed with 152 passengers on a regularly scheduled trip... I was awake to say the least..... to be honest the way the training is done works and saves the airlines big bucks !

It is after one gets their airline wings that I have a problem with..... the lazy ones never hand fly and could not fly a hand flown ILS in actual weather with an engine out (normally hand flown procedure until the automation nerds took over) are the ones I have a problem with. They have no feel for the aircraft just as the first officer in this accident... With 25,000+ hours of airline flying I had 3 engine failures; two of which the passengers never even knew... stuff happens .. Not bragging as that is not my intent ... My intent is without feel (some call it seat of the pants) the first officer in the above accident was the major contributing factor for this accident. If he would have sat on his hands and looked at the airdata on the GPS/FMC he would have seen that they were still at speed and more or less at the proper altitude. Instead everything he did was wrong for the circumstances; he wanted to get in the clear or above the clouds and bumps... Easy to be lead down the wrong path in this situation....especially for him.

The first officer in this incident was weak and to further complicate the situation obviously had no feel for the aircraft and what it was doing.. The joy stick controllers of this aircraft and the way they are not linked is beyond asinine IMO... But I was always a Boeing kinda guy..

a reply to: 727Sky

I think it comes down to philosophy on automation within the cockpit (flight deck). I remember a story from my cousin, a first officer for a major airline.

She flies Boeing and her boyfriend flies mainly Airbus for a competing airline. Her insight was that in a Boeing aircraft the view was automation was a tool, whereas in an Airbus, it was the flight controls within the acceptable flight envelope.

originally posted by: ownbestenemy
a reply to: 727Sky

I think it comes down to philosophy on automation within the cockpit (flight deck). I remember a story from my cousin, a first officer for a major airline.

She flies Boeing and her boyfriend flies mainly Airbus for a competing airline. Her insight was that in a Boeing aircraft the view was automation was a tool, whereas in an Airbus, it was the flight controls within the acceptable flight envelope.

Exactly. All the Boeings I have ever flown if I needed an 80 degree bank to miss a mountain peak or another aircraft without radar contact or mode C transponder the bird would do it. Airbus limits all that through the computers. Another way of saying it is in a Boeing the pilots are Number one. In the Airbus they are until the computer disagrees then it is #1..

I had a friend once tell me the old A, B, and C model Chinooks were the best helicopter the Army had.. He had never had anything go wrong... I just looked at him and said that is the only reason you are still alive.. He just blinked a few times laughed and said, "you may have a point"!. Those were the days when an engine could blow and kill the hydraulics which could then cause the bird to roll upside down and break open like an egg making an omelet.. Or the old C model which seemed to sling a blade off one of the rotor hubs... which again made everyone look like scrambled eggs after the incident.

The only reason I say this is because there is a syndrome .... I drive a Ford it is better than a Chevrolet kinda thing... Or I fly an airbus it is better than a Boeing etc... Whatever some people fly it is the best according to them..

I did fly the MD-80 for about 4 years.. it was not worthy of the lent, dirt, or grease in the wheel well of a Boeing IMO except for losing hydraulics and then it was actually superior in some ways to the B727.. I was getting off the aircraft about the time the Air Alaska MD-80's jack screw failed/stripped and killed everyone. No aircraft is perfect and stuff happens but may we all who have to travel hope the boys or girls up front know what to heck they are doing..Like fly the aircraft if the automation craps out.

originally posted by: 727Sky
... My intent is without feel (some call it seat of the pants) the first officer in the above accident was the major contributing factor for this accident. If he would have sat on his hands and looked at the airdata on the GPS/FMC he would have seen that they were still at speed and more or less at the proper altitude. Instead everything he did was wrong for the circumstances; he wanted to get in the clear or above the clouds and bumps... Easy to be lead down the wrong path in this situation....especially for him.

The first officer in this incident was weak and to further complicate the situation obviously had no feel for the aircraft and what it was doing.. The joy stick controllers of this aircraft and the way they are not linked is beyond asinine IMO... But I was always a Boeing kinda guy..

I´ll certainly not call your professional view on the events in question, but to me as an interested outsider, having read a bit over time about this flight, it more or less seems to me that core problem here was a panicking F.O., ineffective communication and cockpit vertigo by two somewhat inexperienced pilots.

I dont exactly see how a less automation-based education/flight would have helped the crew there. Even the least "hands-on" pilot certified for commercial driving knows in and out that pulling up continuously is probably a bad idea. Yet the F.O. panicked, and did. His curious fixation on climbing, and his impression that they were incredibly fast, is documented.

If the flight crew had at any point really just SAID what they were doing, the situation might have resolved itself amicably. The Pilot not flying had the right ideas. Yet we have two pilots constantly working AGAINST each other. One could make a case that the yoke disconnect on Airbuses played a part, but then again, the aircraft unmistakably screamed out "dual input".

All of these things and cockpit vertigo have happened often enough in older, more "analogue" times, with catastrophic results. My basic problem is, I can see where the aircrafts´ system might have been confusing on the fringes (like the stall warning giving out once the computer thought "This AOA is crazy, it must be wrong"), but I dont know yet how exactly a more "seat of the pants" crew of similar experience would have an automatic advantage in this situation.

originally posted by: Lonestar24
[quot
If the flight crew had at any point really just SAID what they were doing, the situation might have resolved itself amicably. The Pilot not flying had the right ideas. Yet we have two pilots constantly working AGAINST each other. One could make a case that the yoke disconnect on Airbuses played a part, but then again, the aircraft unmistakably screamed out "dual input".

That's the problem. It takes extra cognitive and psychological effort to linguistically form the words and say what you are doing. Think about driving a car---you would be much more distracted if you had to linguistically tell somebody else every physical action you were taking. Or even walking or any sport. You just do it by feel and eye---your linguistic brain is a co-processor running side by side and slower, and is not in control.

An alert "dual input" means additional linguistic processing and thinking and not instinctive feeling, right at the moment when everything is going wrong and people are cognitively overloaded. You need as much handled by the visual and movement trained non-linguistic part of the brain. The inexperienced pilot was panicking and didn't have presence of mind to talk---you need to engineer for those situations too. During emergencies, words often come out wrong. This is a property of biological brains and can't be ignored and say "you SHOULD do X".

There is only one aircraft. There should be only one control. The fact that there has to be an error message ("x and y are not in sync") is a major design flaw. If there were more physically tactile controls which cannot possibly ever get out of sync then this source of error wouldn't ever occur. Engineer it out. With one linked control the other pilot would have immediately known from physical feedback that something was wrong and ordered the other one to stop and let go.

I would consider linked controls with clear physical feedback, and specific lights visible when any pilot is applying force.

And I'm not convinced about yet another 'vocal' message for autopilot control mode---perhaps that should be a change in colored lighting near/on the control stick and the autopilot. Idea is to train people intuitively to look and know what things should be in any stage of flight and recognize instinctively when something looks "wrong" instead of having to remember and seek out a transient vocal reminder.

Sad, tragic and extremely annoying. 2 blue eyed boys of the company at the controls and neither doing things first time right.
Approach to stall was not correctly handled and recovery initiated even though asi, vsi and ai non functional, they still had the ah.
Damn inexplicable seesaw power changes and pulling back on the stick when all you need is a nose down attitude asap on stall warning or even stall buffet.
But how come both the pilots with 2500 + hrs could not decipher the flight condition by feel or seat of the pants
Did not know that airbus did not have syn. dual stick control.
My belated condolences to those affected

a reply to: 727Sky

you know the outcome, he didn't. put yourself in the tunnel with no knowledge of what the end will be. it's difficult to do because we always want to place blame and not understand why they made the choices they did. at some point you will find yourself making many of the same decisions, if you can maintain yourself inside the tunnel

many times we will throw out valid information because it does not support our beliefs and that is what they did, they ignored valid instrument readings because the information did not support what they believed. and that's confirmation bias

the whole idea is to actively train the confirmation bias out and it's not easy because we will readily grab what information supports what we believe we are seeing. simulator training needs to slightly change, in as much as you are trying to disprove what you are seeing.

you're right there was plenty of other indications as to the fact that the plane flying normal and would still have had they paused for several minutes.

i think all commercial pilots should have ga planes and fly them frequently or the company they work for should pay for them to be in a flying club so they can always have hours in a plane that has no automation/

in the end you can still do everything correct by procedures and still have a fatal accident. American Airlines Flight 191, the pilots followed the exact procedure for an engine failure, one i'm sure they practiced multiple times in a simulator so it was like second nature, and it still crashed.

the problem there was the procedure was wrong but no one had ever encountered a problem where the procedure would lead to failure, because we are taught what? if we follow procedures there should not be an accident

a reply to: bigx001

I don't know. As a passenger I would expect that the pilot and copilot are skilled enough not to panic in case of an unexpected event. Because that is how this article reads to me, both guys in the cockpit completely overwhelmed by the situation, failing to actually fly the plane.

originally posted by: moebius
a reply to: bigx001

I don't know. As a passenger I would expect that the pilot and copilot are skilled enough not to panic in case of an unexpected event. Because that is how this article reads to me, both guys in the cockpit completely overwhelmed by the situation, failing to actually fly the plane.

Yes they failed to realize a flat descent and really were novices for that discrepancy. But even the veteran captain did not realize this is hard to comprehend.
or for some reason this accident had to happen.

a reply to: bigx001

you know the outcome, he didn't. put yourself in the tunnel with no knowledge of what the end will be. it's difficult to do because we always want to place blame and not understand why they made the choices they did. at some point you will find yourself making many of the same decisions, if you can maintain yourself inside the tunnel

When we first got some of the 800 series 737s they would all of a sudden (but rarely) have the CRTs go black, nothing nadda would display. If you look just to the right of the captains CRT there is an analog altimeter and airspeed indicator plus artificial horizon all laid out for convenient viewing by both pilots..
At that stage of my airline career I was bringing one of the new birds back from Seattle at night and had just passed Junction when we lost both CRTs.THAT CAN''T happen just ask anyone at Boeing ! . We were not in the weather if I remember correctly but we were above 33,000.. We flew the standyby altimeter and airspeed for the next 100 miles until we could get the CRTS back on by doing nothing but switching power supplies to the units on an off one at a time. Not in the book to do that..... Switching the master slave (or whatever it was called, sorry been a long time) had no effect because both were out. . This was a ferry flight and we had no passengers on board. ATC was notified and as we were already just flying a heading for the arrival into Houston everything was just fine.. We got the CRTs back about Austin, Tx.. Long time ago but that is just about right from what I remember ?

I do not know what Boeing and the company did to fix the problem but there were some pilot bulletins published just incase the impossible were to ever happen again.. Like I said stuff happens.. My first on that flight was very senior and could have held Captain.. We tended to fly together more often than not.. An he was a great stick and is now a very senior Captain at United Airlines getting ready to retire ... Had enough... He feels like I did about the boys and girls who can push buttons but could not fly their way out of an unusual circumstance if they had to. See that is why us old grey hairs retire and go to that great grass strip in the sky.... bitchen all the way ! hahahah


youtu.be...

originally posted by: 727Sky--->I do not know what Boeing and the company did to fix the problem

First they improved the equipment cooling fans and ducts.
That didn't work so they replaced the CRT displays with plasma panels, later (february 2006 and on) LED. (even the standby instruments)

Well the problem went away and i haven't heard of that happening on the newer NG's.
One of those situations where pitch and power skills would be very useful.

Somebody should have advised Air France about that before the crash.

originally posted by: Ivar_Karlsen

originally posted by: 727Sky--->I do not know what Boeing and the company did to fix the problem

First they improved the equipment cooling fans and ducts.
That didn't work so they replaced the CRT displays with plasma panels, later (february 2006 and on) LED. (even the standby instruments)

Well the problem went away and i haven't heard of that happening on the newer NG's.
One of those situations where pitch and power skills would be very useful.

Somebody should have advised Air France about that before the crash.

Thank you for your reply ... I was starting to sound like an old crop duster, which was not the intent... Flying skills should never be second or third class due to laziness..... again IMO.. hahah I am retired now and other than getting on a bird and going someplace all that is no longer my concern except when some of my working friends start complaining... Then I just smile and say, "I told you so"!
Small pleasure on such a serious topic...

a reply to: 727Sky

even ga planes that have glass suites, still have steam gauges, but even steam gauges will give bad readings when instruments give bad information.

so what do you do, you have independent information that you can use as a reference to verify your main instruments are either functioning or have failed.

it is always easier to blame than to decipher why people made the choices they did. and I know it's not easy, but avoid these phrases "they should have known", "they didn't know" "if they would have" etc. these are defensive phrases and will always lead you to the wrong conclusion and thus the wrong solutions.

use these instead "they believed", "they thought" and then find the information they used to back up those statements. when you do you will start seeing what they saw and you will be able to come up with better solutions and training.


it's not an easy thing to change all our years of assigning blame to one of finding the cause. but it is the correct direction to move

originally posted by: moebius
a reply to: bigx001

I don't know. As a passenger I would expect that the pilot and copilot are skilled enough not to panic in case of an unexpected event. Because that is how this article reads to me, both guys in the cockpit completely overwhelmed by the situation, failing to actually fly the plane.

actually I expect airlines to ensure that a pilot can fly a plane without any autopilot or automation to assist them at all. this goes against the bean counters because this can cost hundreds of dollars per flight because automation is more profitable than a person. add that up over the course of a year and the cost will be more than the cost of an accident it's just the fact