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.......you still want to try to figure out what they might have been thinking......
Something like "Oh Shit" would about cover it I think ?
Can't claim to have read this entire thread but surely by now we've come to the conclusion that the aircraft was giving sufficient warnings to invoke a reasoned reaction but the pilots didn't react reasonably ?
If it 'ain't broken........ Don't try to mend it !
That's true, I didn't say they shouldn't have known they were stalled, I'm just saying they didn't. Once you get over the fact the pilots were out of their league, you still want to try to figure out what they might have been thinking.
Ok, valid point- if they couldn't figure it out when the stall warning was sounding, there's no reason to believe they could figure it out after the stall warning stopped.
Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.
Given that there will always be a stealthy factor of pilot error or even ineptitude, aviation safety is built upon redundancies and lines of defense, and I think we need to look at all of these.
Redundancies are easy here. Two of these clearly failed. All the pitots failed because they have a common vulnerability, and therefore so did the systems that depend upon redundant air data. All of the pilots failed because, it would seem, they all had a common lack of preparedness. Major flight systems redundancies did not fail and performed as designed.
Now, the six lines of defense as I see them:
1) Weather Avoidance - this is debatable. Some argue that the weather they flew into was not prohibitive and they had no reason to expect the danger they encountered. Others argue that concern for safety should have motivated them to divert further around the system, as other flights did that night. Whatever the case, defense level 1 was breached by pilot judgment. Fault: Pilot Judgment. This alone did not crash the plane because there were still five lines of defense left.
2) Pilot Manual Flight Skills and CRM for Abnormal Operations - Once the autoflight fails, the pilots are trained on how to fly the plane manually, and Airbus has designed their manual flight controls for this purpose. The Pilots should have been able to remain in a safe attitude and speed envelope until the autoflight could be reengaged. Airbus provides detailed checklist procedures indicating both actions and crew assignment. These were not referenced. Defense level 2 failed due to lack of practiced manual flight coordinative skills and CRM procedural training. Fault: Air France and the BEA. This alone did not crash the plane because there were still four lines of defense left.
3) Unreliable Airspeed Procedure - Once the airspeeds were recognized to be unreliable, the pilots had a secure procedure to deal with the situation, and maintain stable flight until the problem abated and the autoflight could be reengaged. This procedure was not performed. Defense level 3 failed due to a lack of procedural adherence, which in turn was due to an absence of practical procedural training. Fault: Air France and the BEA. This alone did not crash the plane because there were still three lines of defense left.
4) Airbus Flight Envelope Protections and ADIRU Redundancy - The aircraft has the ability to protect itself from dangerous pilot inputs by limiting those inputs. Defense level 4 failed because autoflight and flight protections need accurate air data to function and there is no redundancy for air data sensors when exposed to a common environment that exceeds their operational limits. Fault: An industrywide lack of technology needed to reliably withstand the environment they flew into. This alone did not cause the crash because there were still two lines of defense left.
5) Stall Avoidance Procedure - Once the pilots had caused the plane to reach an unsafe angle-of-attack, there are warnings to alert the pilots about the impending stall. These warnings functioned properly and sounded multiple times before the actual stall. Defense level 5 failed due to lack of Approach to Stall procedural training and/or a lack of respect for the stall warnings. Fault: The pilots, Air France and the BEA. This alone did not cause the crash because there was still one line of defense left.
6) Stall Recovery Procedure - Once in a stall, there are procedures to follow to recover airspeed, reduce angle-of-attack and restore lift and control. While these are not always possible, especially at low altitude, this crew had 35,000 ft to work with, and should have been able to recover HAD THEY BEEN AWARE OF THE SITUATION. Defense level 6 failed because the crew had apparently lost situational awareness and were not aware of the fully developed stall condition. They may also have lacked proper training for stall recovery. Fault: Pilots, possibly Air France and the BEA, and possibly Airbus for not providing a cockpit indication informing them of the stalled state they were in (although I'm not aware of any commercial aircraft that does this). Loss of situational awareness was the factor that seems to have ultimately doomed the flight.
With six solid lines of defense, this crash should not have been possible. It amazes me that none of these provisions had any effect on saving the aircraft. This is due in part to the interrelated effects of inadequate training that erode many of these lines of defense. If even one of these lines of defense had held, this would have been, at worst, a minor story, possibly a tale of a terrifying plunge, but everyone would have lived to tell it.
It also shows the improbability of this ever reoccurring, even with no modifications whatsoever to the aircraft, assuming that training standards have since been remediated and pilots more closely scrutinized.
Something like "Oh Shit" would about cover it I think ?
Can't claim to have read this entire thread but surely by now we've come to the conclusion that the aircraft was giving sufficient warnings to invoke a reasoned reaction but the pilots didn't react reasonably ?
Granted, confusion is the overriding state of mind, but I think there are plenty of clues in the transcript to suggest what these pilots were focused on (roll, thrust, pitch), which in turn may suggest why they lost touch with the big picture, even though they knew (through lack of control, unfamiliar noise and sensation I assume, and instrument readings) something was terribly wrong.
The BEA press release said:
This new working group, which will be made up of specialists in cognitive sciences, ergonomics and psychology will have to examine all aspects linked to man-machine interactions and to the pilots' actions in the last few minutes of the flight.
Only after all of this work has been completed and included in the Final Report will it be possible for a recommendation on the functioning of the stall warning to be made, based on reasoned scientific analysis, work in which EASA will participate...
Finally, it should be noted that the warning sounded uninterruptedly for 54 seconds after the beginning of the stall, without provoking any appropriate reaction from the crew. This fact must be analysed as a priority by the working group.
I think this is kind of interesting. In effect, this might be the first time an investigation truly has looked at what were the pilots thinking and why. While the findings may not be explicit in the final report, (which is more likely to say "The pilots did not act in a manner consistent with a stall" rather than "The pilots didn't realize they were stalled") they may be implicit in some of the recommendations.
I think this is kind of interesting. In effect, this might be the first time an investigation truly has looked at what were the pilots thinking and why.
Not true. Human psychology and flawed perception has been discussed at length in other accident and incident reports. One of them (possibly the Gimli Glider - can't recall exactly) devoted a section to the phenomenon of confirmation bias.
It also shows the improbability of this ever reoccurring
HeLLo
Thank you Evan for this complete post, I thank also the well named "Fear of Flying" for having talked about the psychology of the team which, in my opinion, led to this disaster. As a matter of fact, as soon as I've read the complete CVR I've felt something strange in the way they talk and communicate together.
@@++
I think one interpretation of the conversation would certainly have to be that, once stalled, no one understood that was the case. It seems that the pilot flying was intent on making sure they had plenty of thrust with the nose pointed up, which, in his mind, should have caused them to climb... he didn't understand why they continued to fall:
"What is… how come we’re continuing to go right down now?"
Then later, when the captain was advising against pitching up, the PF was insistent, saying "Well we need to we are at 4000 feet." He still wanted to use a combination of thrust and a nose-up attitude in order to climb.
The captain, upon entering the cockpit, asked what was happening, to which the answer basically was "I don't know", and he was unable to interpret what he saw, either. His focus seemed to be on keeping the wings of the aircraft level, and again he seemed unaware of the rate of descent, or perhaps not trusting the altimeter.
Two seconds after the pilot flying asks for the altitude, the captain says, "That's impossible..." which may or may not be in reference to the question. But it doesn't seem like he wants to avoid pitching up in order to increase speed or recover from a stall, he simply doesn't want to climb. Only when the automated warning said "Pull up" did the captain decide they should pull up, again, with the mistaken idea that they would gain altitude if they did so.
Then there was that whole confusing exchange of:
PNF You're climbing...you're going down down down
PF Am I going down now?
PNF Go down.
Capt. No you climb there.
PF I'm climbing ok, so we're going down.
To me, it just seems that there's a fundamental confusion, and perhaps disbelief, about how it is they're losing altitude while pointing nose-up with thrust.
Their focus then was on the inaccurate speed indicators rather that the altimeter or AoA instruments...perplexing.
Seeing a "Gamer Syndrome" identified here would not shock me one bit.
It sounds like there were violations of protocol with the Captain departing the flight deck without specific instructions or naming an "Interim Captain" or "Interim Pilot in Command", but what do the regs say about this.
Under stress, they may have just started to lapse into the video game mode.
But, we have no actual timeline and transcript to really read to determine who said what to whom and did what ... and when they did it.
I have never played a game on a box but some of you younger types may understand the logic or whatever.
Drizzit, they have always to my recall, looked at psychological and sociological factors. First I remember that stood out was the crash of a JAL freighter where the Captain was schizz-face fall down drunk and after being helped to the left seat of a DC-8, did a take off from a taxi way and turned turtle, creaming in. Back then (1977), a young Japanese individual totally deferred to an older person. So, yeah, cockpit "dynamics" are indeed on the checklist. The Captain had a blood alcohol of .298.
Gabe, where did you get the chart or extract the numbers from?
The official third interim report in English that we are all of us discussing about
Google "bea".
--- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
--- Defend what you say with arguments, not by imposing your credentials ---
But, we have no actual timeline and transcript to really read to determine who said what to whom and did what ... and when they did it.
We do, or what do you think we are all discussing about?
--- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
--- Defend what you say with arguments, not by imposing your credentials ---
Seeing a "Gamer Syndrome" identified here would not shock me one bit.
It sounds like there were violations of protocol with the Captain departing the flight deck without specific instructions or naming an "Interim Captain" or "Interim Pilot in Command", but what do the regs say about this.
Under stress, they may have just started to lapse into the video game mode.
But, we have no actual timeline and transcript to really read to determine who said what to whom and did what ... and when they did it.
I have never played a game on a box but some of you younger types may understand the logic or whatever.
Drizzit, they have always to my recall, looked at psychological and sociological factors. First I remember that stood out was the crash of a JAL freighter where the Captain was schizz-face fall down drunk and after being helped to the left seat of a DC-8, did a take off from a taxi way and turned turtle, creaming in. Back then (1977), a young Japanese individual totally deferred to an older person. So, yeah, cockpit "dynamics" are indeed on the checklist. The Captain had a blood alcohol of .298.
I dunno...While CRM might have contributed here, I'm thinking a much bigger contributor is double gross failure to understand that pointing the nose skyward with power limited by altitude and/or throttle is a reasonably good way to stall the plane.
If one dude was screaming- "nose down you are stalling", and the other dude was fighting him saying "no, nose up!", that's more of a CRM failure.
Good CRM would suggest that one pilot flies and the other monitors and points out problems. While they swapped too much, there was a lot of flying and monitoring that was a gross failure.
Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.
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