TransAsia airplane crashes in Taipei (ATR 72)

[Gabriel]

Evan, I will not go in circles again. I certainly don't agree.

You know I am all for procedures. But don't tell me that a driver driving in rainy conditions in the interstate reacts to losing the speedometer by turning sharply to the left, and when the car overturns he turns the steering wheel to the left even further, because he was not trained in driving in rainy conditions, in rally techniques, and in the procedure for driving with the speedometer inop.

[Evan]

Evan, I will not go in circles again. I certainly don't agree.

You know I am all for procedures. But don't tell me that a driver driving in rainy conditions in the interstate reacts to losing the speedometer by turning sharply to the left, and when the car overturns he turns the steering wheel to the left even further, because he was not trained in driving in rainy conditions, in rally techniques, and in the procedure for driving with the speedometer inop.

I'm not saying that. Procedures are not about technique, they are about human error and the human mind. We don't know what went through this pilot's mind or Renslow's mind at the critical moment of unexpected failure. Both were flying along 'fat dumb and happy' at the moment prior to the event. Both had no reason to expect the event, but both were on edge about weather phenomena, expecting something other than what actually occurred. So, at the critical moment, was their situational awareness altered by their mental state? I think that's the only explanation. But we will never know with any certainty...

The phenomena of altered situational awareness due to human factors is not new to the industry and that is why pilot training includes memorized and practiced procedure to stabilize flight and establish SA—I realize you are not against these procedures but I insist that any commercial pilot must be uncompromisingly for them (with the caveats I have repeatedly mentioned).

You are correct to point out that a procedure must follow a pilot's understanding of why the procedure is applied, for instance, a pilot must first understand the effect of AoA in a stall situation before he ever learns the procedure for stall. I also think a pilot must know the psychological reason for the practiced, memorized procedure, that is, a pilot must first understand that he is surprisingly fallible under stressful circumstances and that perceived reality, being made of perception, can be radically altered when perception is confused by things like 'startle factor' and 'confirmation bias'.

If every pilot recognized both the effect of AoA on lift and the effect of the unexpected on the mind, we would have a much greater proficiency for procedure and a much lower accident rate.

I don't want to go around in circles either, but the industry seems to be doing just that, repeating the same mistakes. To me, the problem with pilot mentality can be summed up as follows:

Hubris on a good day, improvisation on a bad one.

That is a recipe for disaster. Only aggressive training can overcome that.

[Evan]

But don't tell me that a driver driving in rainy conditions in the interstate reacts to losing the speedometer by turning sharply to the left, and when the car overturns he turns the steering wheel to the left even further, because he was not trained in driving in rainy conditions, in rally techniques, and in the procedure for driving with the speedometer inop.

To directly address the driving analogy, in a lot of car crashes the the driver will accelerate into the other car rather than braking. Studies found that people who drive with one foot on the brake and one foot on the gas had a greater tendency to do this. Subsequently, drivers were taught to use the same foot alternatively for the brake and gas. Most of the accident drivers had years of experience and knew logically which foot was gas and which was brake. Under the 'startle factor' however, the mind would sometimes say 'right foot=brake' or the conscious mind would say left foot=brake and the central nervous system would answer by moving the right foot. The mental driving instinct was therefore changed—by changing the driving procedure—to 'alternate pedal means brake', eliminating the left-right confusion phenomena. This shows us how, when the brain has to improvise under extreme circumstances, very bizarre 'unthinkable' conclusions or actions can result. It also shows us how we can defend against it.

Some are more susceptible to this phenomena while others appear to be more immune from it. I suppose there might be a way to screen for this but I think the only way to really know how reliably a person will react is in the moment itself. We can't be finding that out with a planeload of passengers in the back. So instead we have trained procedures to minimize the effect and CRM to help offset it.

Also, there is the persistance of the error that baffles us. The pilot continues to pull up... The pilots do nothing for six minutes to arrest the stall... The driver continues to press on the gas or turn to the left... The moment that situational awareness is lost, that is the moment that confirmation bias takes over. Studies have shown that confirmation bias can be difficult-to-impossible to overcome while under the effects of stress. To regain situational awareness, a person must first suspend their present conviction—a conviction that, under the circumstances, might seem to be the only thing they have to cling onto. Yes, it blatantly defies common logic, but so does quantum physics, and so does the mind under extreme stress. Illogical realities exist in unusual circumstances. For six minutes, as AF-447 fell, nobody seemed to have a clear awareness of what was happening (the PIC might have had a vague idea) and I think this is because they had firmly replaced this with a flawed idea of what was happening. In my opinion, AF-447 was lost the moment situational awareness was lost and replaced by confirmation bias, and that moment was the moment improvisation was substituted for memorized CRM procedure.

[3WE]

Only aggressive training can overcome that.

Is being told vehemently to not lower the nose an example of aggressive training?

[guamainiac]

3WE, perhaps one of those devices that delivers voltage for the wrong response in a trainer or during briefings. There is some merit to negative reinforcement depending on who you talk to?

[Evan]

Is being told vehemently to not lower the nose an example of aggressive training?

Another key factor is the quality of the training itself. That also has to be addressed by CAA and ICAO oversight. All current approach-to-stall procedures I have seen include lowering pitch or at least not increasing it.

That aside, a pilot who already possesses good airmanship (a Gabriel for instance) is going to violate a bad procedure out of self-preservation. I've also said this many times: procedures do not trump airmanship, they are there to help preserve it. I don't expect any pilot to follow a procedure that he considers contradictory to airmanship. I also don't know of any instances where this has ever happened. Do you?

[Gabriel]

To directly address the driving analogy, in a lot of car crashes the the driver will accelerate into the other car rather than braking.

Yes, and the problem is that he didn't follow the crash avoidance procedure for the Ford Pinto R24-MK2 that said:

Driver driving: brake

And that the reason for that is that he didn't receive the proper training.

Evan, again, we agree. Know the procedures. Practice the procedures. Follow the procedures.

But why do you think that a pilot who fails to keep the plane straight and level because of startle factor, sheer terror, or whatever, will have the clarity of mind to follow the procedure?

What should be better known, better practiced and more natural to a pilot that flying straight and level?

Explain me EXACTLY why the pilot started to do aerobatics instead, and how you are so sure that the same factors would have not affected his abilities to follow the procedures (ASSUMING that he been trained on them).

[Gabriel]

In my opinion, AF-447 was lost the moment situational awareness was lost and replaced by confirmation bias, and that moment was the moment improvisation was substituted for memorized CRM procedure.

Let's take that. How this will not happen if they knew and trained the procedure?

[Evan]

Yes, and the problem is that he didn't follow the crash avoidance procedure for the Ford Pinto R24-MK2 that said:

Driver driving: brake

Brake how? By pressing the left foot or by releasing the right foot from the pedal and shifting it to the left pedal and pressing it. It's like you're not even reading my posts. Are you entirely reading them?

Let's take that. How this will not happen if they knew and trained the procedure?

I'll keep it short. Autopilot fails, master warning, Holy sh*t! Call-out for AP failure. Situational awareness intact. AP failure memory procedure (instilled to memory from solid, recurrent training). You are now stable on the flightpath. PNF: call out for lost airspeeds. Situational awareness intact. Memory items (as before), you are now stable in the speed envelope with slight deviation from flight path. ECAM action items. QRH items. Speeds are back. You are out of it.

I'm not saying it's foolproof but it is a hell of a lot less prone to error than improvisation between two pilots who are not speaking to each other or coordinating tasks:

Autopilot failure. Holy sh*t! Why? What does it mean? I have control. I should climb. I definitely should climb. What's happening? Stall warning. Must be part of this crazy system failure. Ignore it. I should definitely keep climbing, get above this situation. Meanwhile, PNF: what's happening? Lot's of messages on the ECAM, many alerts... what's it doing now! Oh, speeds are gone. Alternate law. THR LVR MOVE!!. Stall warning...? Hey, why are you climbing? Don't climb!

What?

Go back down!

Ok, I'm going back down.

No you're not, you're still climbing!

What?

Stall.

Chaos.

[3WE]

Brake how? By pressing the left foot or by releasing the right foot from the pedal and shifting it to the left pedal and pressing it. It's like you're not even reading my posts.

I promise you that my Subaru has no FCOM/QRH on various procedures to apply the brake...Procedure 200 If your foot is on the gas...Procedure 236A if your foot is on the brake pedal already, procedure 172M you are using cruise control...

I do not need special rainy-road training to work the brakes in all of those scenarios.

Similar to what Gabriel said earlier- I have no training whatsoever EXCEPT for low-altitude 172 hand maneuvering. I do not need A330 high-altitude hand flying and upset training to know to not pull up relentlessly.

[Gabriel]

Brake how? By pressing the left foot or by releasing the right foot from the pedal and shifting it to the left pedal and pressing it. It's like you're not even reading my posts. Are you entirely reading them?

Yes Evan. I am. You said that techniques are not explained in the procedure, and you are correct. If you have to do a fuck you, they don't say which finger to raise.

Reduce thrust, not "put your right hand on the thrust levers and pull back 2.73 inches".

I'll keep it short. Autopilot fails, master warning, Holy sh*t! Call-out for AP failure. Situational awareness intact. AP failure memory procedure (instilled to memory from solid, recurrent training). You are now stable on the flightpath.

AP off. I have the plane (that happened)
You are now stable on the flight path: That never happened. And no matter how many times you say it, it was NOT because they were not trained in nay specific procedure. There is no "straight and level" procedure so, according to your procedure for no procedure, they have to "revert" to airmanship.

[Evan]

AP off. I have the plane (that happened)

But there was no subsequent callout for the situation, no callout for the procedure, no communication between the crew aside from the command call which goes without saying since he was already PF. So... no stated situational awareness... Just improv time with no do-overs. Bonin never understood the situation and I think this was because of the eerie effects of mental stress.

And no matter how many times you say it, it was NOT because they were not trained in nay specific procedure. There is no "straight and level" procedure so, according to your procedure for no procedure, they have to "revert" to airmanship.

I've already said it so many times, it's not about straight and level, it's about level-headedness, clear thinking, that is what the procedures are there for. Yes, the logical thing to do is keep it straight and level, but logic and airmanship are nothing compared to the effects of the mind under stress. Maybe not in your case, maybe not in 9 out of 10 pilots, but in the airline business, those are lousy odds.

Yes Evan. I am. You said that techniques are not explained in the procedure...

The important message I was pointing out is that experienced drivers were pressing the wrong pedal under stress and thus the driving technique being taught was altered to minimize that threat. I was showing you how the mind disrupts logic under stress, and how procedure can help to defend against that.

Your entire argument assumes pilots will always perform logically under stress. This has been shown to be quite untrue. Bonin continued to pull back even after relinquishing control! His mind was locked in bias. Again and again pilots do bizarre things that (if they survive) even they can't explain. It doesn't matter if they know better. WIthout practiced procedures for reacting to these sudden situations—as a team, with two heads—there is only improvised airmanship and that is sometimes very convoluted by tricks of the mind.

I think degraded, illogical behavior is maybe something pilots don't imagine themselves capable of (you certainly don't). So they continue to fly fatigued without recognizing the danger in that. They continue to brush off procedural proficiency without seeing the value in it. It's all hubris. And they continue to fly into the ground, stall, shut down engines and crash 21st century aircraft in very bizarre ways.

****

Anyway, I can't make the point any clearer than this so I'm leaving it for now. I agree with the findings of the final report. 3WE is still ranting about type-vs-type procedure (having missed that point) and missing my point entirely about human factors. I was hoping at least you could understand the reasons why the undustry has deemed it necessary to create these pre-rehearsed CRM-oriented routines, following the findings and recommendations of investigative reports and collaborating with safety pilots, engineers and human factor experts. At least they understand. All that's needed now is a way to get pilots to recognize their own human limitations and embrace these things as the best way to stay AGL...

But we are going to have to explain what happened to AirAsia and TransAsia and what can be done to prevent this nonsense from continuing. Just saying the pilots (some with 10,000+ hours) were inept isn't going to solve anything.

[Gabriel]

Your entire argument assumes pilots will always perform logically under stress.

You are entirely missing my entire argument.

You've said that first stabilize the flight path. Then follow the procedure.

Even taking into account the memory items, you cannot expect the pilots to asses, recognize and correctly respond to the situation at once. It will take some seconds. In the mean time, the PF has to stabilize the flight path, or at least not destabilize it!

Well, in AF the stall warning was sounding like 2 seconds after otto disconnected. And not because the pilot failed to stabilize the flight path but because he actively destabilize it.

Your argument is that the pilot failed to stabilize the flight path because he was not familiar with the UAS procedure. My argument is that the pilot actively destabilized the flight path before a good pilot, very well trained in the UAS procedure, and fully willing to apply it, would have even recognized that it was a UAS situation, and hence I don't see how the procedure would have helped to avoid the active upset.

[Gabriel]

I think degraded, illogical behavior is maybe something pilots don't imagine themselves capable of (you certainly don't).

Again Evan. I'm not saying that.

It doesn't take much to imagine myself acting illogically due to startle and terror. I have good memory, unfortunately in this case.

What I'm saying, again, is that that knowing perfectly well the procedure that you didn't identify yet as the one to follow will not help you if your initial reaction is, using somebody's else words, pull up relentlessly.

We have no protection against a pilot reacting out of sheer terror. Not even procedures. Not even airmanship.

Now, although there is no guarantee, good airmanship and good procedural skills can help prevent terror. Not being familiar with the procedure, alone, doesn't explain this accident. Lack of good airmanship alone either.

But again, I don't put both components at the same level. One is a prerequisite for the other. It's very hard for me to understand Bonoin actions, procedure or not, because it's so against basic airmanship. It's very much the equivalent to turning hard left in response to the speedometer failing in your car. If it was just sheer terror and the pilot was simply in a state of complete inability to act rationally and reasonably, then knowing the procedures like a boss would not have helped, because he was not in a state of mind to apply them.

The only thing that might have helped would have been the other pilot, instead of saying "you are climbing too much /// stabilize //// lower the nose" had said "I've got the plane". He seems to have a better SA. Now, this is easy to say in hindsight.

[Evan]

Your argument is that the pilot failed to stabilize the flight path because he was not familiar with the UAS procedure. My argument is that the pilot actively destabilized the flight path before a good pilot, very well trained in the UAS procedure, and fully willing to apply it, would have even recognized that it was a UAS situation, and hence I don't see how the procedure would have helped to avoid the active upset.

No, my argument is that the crew failed to implement the AP failure procedure. The UAS was not recognized until 8-9 secs after that happened. But the sustained pull-up that resulted in the stall happened only after the UAS was recognized, after a couple of intermitant stall warnings but well before the stall, so applying the UAS procedure, a good span of time after the initial shock, would have also saved them. But again, I think the PF was locked out of rational thought by then. If CRM wasn't already out the window, the PNF could have still brought him into the UAS procedure, had he known it, and back to SA at that point (or taken command), before the fatal pull-up. But no procedures were performed and no CRM was present because Air France failed to train them for this scenario.