I’ve been dreading this summer … for the first time in my life though actually. That’s because next month the final French BEA report on the Air France 447 crash will be released.
Most professional pilots have a pretty good idea what it’s going to say though … pilot error. No big surprise there.
From the headlines lately, the need for one media outlet to trump the BEA to their final report is powerful. London’s Daily Telegraph decided that not only were the AF 447 pilots at fault, but that Airbus has been hiding behind a sidestick design flaw for two decades since the A330 was certified. In another, a writer claims that the angle of attack indicator was faulty. Then ABC’s Nightline claimed last week that Captain Marc Dubois had a lady friend — an Air France flight attendant — along for the ride that night, someone who kept him quite distracted after he departed the cockpit for a rest break.
Technical issues on the A330’s pitot tubes? That’s fact already. Fresh pitots just hadn’t found their way onto this airframe before the accident unfortunately. Major sidestick design flaw though, after 20 years … I don’t believe it.
These airplane stories become easily jumbled up when non-aviation types get too close though. I’m trying to do my part and keep the story straight for some of the mainstream media when I can. Fox News gave me another opportunity last week when the PIC’s girlfriend story began circulating. Fox News and other networks about Air France 447.But we as aviators need to be serious about the depth of what this accident represents.
It proves the point made again and again by experts that loss of control is now THE most critical shortcoming for many professional pilots today … not simply in recognizing the situation, but in their ability to fix the problem.
High-altitude stalls, for example, are much different than what we experience in any airplane down low where the air is a bit meatier. But even the big bazillion-dollar simulators can’t accurately represent how an A330 will react when it stops flying at FL360. So how do we train pilots to be ready?
AF 447 is also about responsibility. And there’s a difference to me between responsibility and blame.
Truth be told, all the pilots on 447 are responsible to some degree for the accident. They were, after all, the guys in the cockpit, confused by a dozen different warning lights and aural chimes and computer generated voices in the turbulence that night, weren’t they?
In all flying jobs though, there is always one person who must under all circumstances, accept all the responsibility. In this case, that man was the captain … 58-year old Marc Dubois, a pilot with 11,000 hours in his logbook. Despite other pilots handling the controls in those final four minutes, men like Pierre-Cedric Bonin, the young man most of the world seems to have pinned this accident on, as well as the more experienced aviator David Robert, Marc DuBois was in charge. He was the Pilot in Command. To non-aviation folks, that means the buck stopped with him.
It’s time to stop blaming Pierre-Cedric Bonin and David Robert for the crash of Air France 447. Yes they both handled the controls, but when the captain did return to the flight deck, the transcript proves one thing. Dubois did not act like any captain I’ve ever flown with, or even known.
Rather than take action, Dubois is heard to shout orders at Robert and Bonin. Dubois displayed no clear-headedness in those final moments. He seemed as confused as the other two pilots. And while he might have been to start since he just arrived in the cockpit (for whatever reason) the confusion about whether the airplane was flying or not should have evaporated pretty quickly when Dubois entered the cockpit.
But it didn’t.
Almost to the end, he told people what to do and nothing more. Clearly neither Robert or Bonin were capable of making that airplane fly, for whatever reason. The captain should have. But he never did.
When I made this statement at a pilot meeting a few weeks ago, someone asked what Dubois should have done. “Whatever it took to make the airplane fly,” I replied. Whether that meant grabbing one of the other pilots by the collar and dragging him out of the seat, telling the other two to let go of everything while he flew … or quite frankly, anything else it took to make that airplane fly.
But he never did.
So get ready for summer, because when that BEA report is released July 5, the fireworks are going to begin.
Rob Mark, publisher
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BTW, in case you missed a few of these interesting stories about AF 447, I’d pasted a few links below. I’m not endorsing them, just sharing.
http://www.telegraph.co.uk/technology/9231855/Air-France-Flight-447-Damn-it-were-going-to-crash.html
Hi Rob,
Nice article on PIC responsibilities as per Air France accident. Hopefully, folks like you can keep the lay media straight.
In our fear of flying classes in Houston, this crash is on the mind on quite of a few of our non-pilot clients. It is hard for us to correct erroneous info propagated by the mainstream press which most of our jittery passengers take as gospel!
All the best,
Douglas
I don’t think you can ever underestimate the importance of the title of PIC, and you could just as easily interchange pilot in command with pilot in control.
It is imperative that the crew know who is actually flying the plane. Confusion in this area will always create problems. In tandem with control, it is equally important to understand who is in command, and maybe more important that that person actually take command. The old saying that, “indecision is worse than no decision” comes to mind.
Nice article. But, with the amount of time he had before the crash, I am not sure the Captain could have done anything but shout orders. He told them to to the correct thing, and they did. The only problem was, they didn’t have enough time and altitude. The guys flying crashed this plane. But was it their fault? They only knew what they knew. This is a training issue… and a potential problem with the future of aviation; Knowing how to fly our magic airplanes when the automation fails.
Thanks for a great article, and another perspective.
Hi Robert,
Love to hear your opinions, but this is one I have to disagree with. Your notions of captain as skygod is old fashioned and runs counter to good CRM. I’m contrasting the way you think he could/should have reacted with the way Capt. Richard de Crespigny did react when he lost an engine on his A380 on takeoff from Singapore. de Crespigny told me in a lengthy interview that he felt it was important to get the opinion of every man on the flight deck when dealing with the barrage of error messages. What Qantas 32 had that AF 447 did not was time.
Many things went wrong on AF 447, certainly crew training and automated cockpit are contributing factors. But the notion that the captain saves the the day with his superior judgment, pushing the other guys out of the way, harkens back to Pan AM KLM runway collision, another accident in which the left seat bossed the rest of the crew into submission.
First to Karlene’s note …
There’s a fine line at times between blame and responsibility Karlene.
Despite other opinions I’ve read here, the captain was responsible for the flight. If you read the AF447 transcript – albeit an edited version – there seems to be little sense of urgency for what was happening in the cockpit when Dubois did return.
You know as well as I do that a captain’s paid to be able to size things up quickly and lead the crew out of the situation safely.
I’ll rant you there wasn’t much time when you’re falling at 10-12,000 fpm, but within a few seconds of returning, the captain should have been able to figure out the basics of what the airplane needed to fly … not talk about it.
If he had to, yell, “Everyone let go of everything,” reach around the left seater and shove the stick forward.
As much as it looks like Monday-morning quarterbacking here, I’m really more interested in seeing the least-experienced guy removed the spotlight of blame.
In a crash with a CFI, do you blame the student because the instructor wasn’t able to talk him out of a situation?
Bravo Rob. Nicely written. Couldn’t have agreed with you more.
Karlene does have a point with time as a factor in recovery.
Christine Negroni, the captain is the PIC, not a skygod. He raised to that position because of his experience and expertise. Perhaps the captain did use CRM and that’s why he didn’t yank those two yahoos out of their seats. So one can argue that CRM was a contributing factor when old fashioned four stripe “get outta my seat” was required. Your comparison to the Pam AM vs. KLM is unfounded. There are times for diplomacy, and there are times to shoot first and ask questions later. A good captain knows the difference and when to execute the correct style.
Dear Christine —
I love you dear, but on this discussion, you are simply not thinking of this like a pilot. You’ll need to bare with me, I can’t remember if you are a pilot or if you just write about flying. No offense meant.
I am not talking about the captain as some sort of skygod.
As a professional pilot myself, I know that stuff went out years ago. But CRM is not always a cut-and-dried answer either.
Your example of how the Qantas 32 captain handled that mess is indeed one for the record books. They made it all up as they went along, just like the guys on UA 232 did on their crippled DC-10.
That’s not the same thing we’re talking about though on AF447.
There’s no other way to explain this other than to say that if you’ve never been responsible for a planeload of people in an emergency, what I’m going to say might not make much sense.
The reason it all worked aboard UA 232 and QA32, is that the captain WAS able to use those other pilots as resources to solve the problems they faced.
In the case of AF447 however, the story the transcripts tell – edited as they were – is that both David Robert and Pierre-Cedric Bonin were already so overwhelmed, so far in over their heads with confusion, that the only person who could and should have been able to walk in and offer a more clear-headed perspective was DuBois.
He should of, but for some reason, he quickly became as caught up in the state of confusion that overwhelmed the other two pilots.
If you think I’m asking for some crazy kind of skygod to save everyone here, then you read something into the story that was not intended.
A good cockpit manager – like the CRM idea promotes – would have been just fine.
But AF 447 didn’t have one of those either from what I can tell.
Rob
Nice discussion here.
One thing about the airlines today… first officers are type-rated and we are the captains when the captain is resting. Because of our training and our experience, we are required by the FAA to have the same training and ability as the “captain” has. With that said, there is no reason that the captain should not be able to go to the bunk for his schedule break and not be 100% assured that we are making the right decisions in the flight deck during his absence.
Now… everything that happens begins with a chain of events. The element of responsibility that falls on the captain’s shoulders is his decision making to head into the storm.
Did he make an error and not know it was there because the radar was down? Did it grow more rapidly than he’s ever experienced? Had he flown in conditions so many times he didn’t expect there to be a problem? I’m not sure.
But… his part in this was the aircraft flying toward the storm. Then, if he knew it was there his leaving the flight deck at that time was a really bad decision.
With all that said, those pilots in the flight deck… had they been trained and known what to do if they lost their instruments… would have been fine. Had they sat on their hands and done nothing, would have been fine.
So… going toward was Captain’s responsibility. Not knowing what to do… “Airline’s training, or lack there of was at fault.”
When he came up, I was rather impressed at his rapid assessment when the pilot said, I’m holding the stick back. He knew. I actually flew this in the simulator. And, I knew what was happening. I was at altitude. And it took me 3000-4000 feet to get out of it. And I wasn’t falling at the rate and in the condition they were with the elevator trimmed full up (by the plane helping them) not knowing.
I had to run the trim forward to help get out. Granted this was a simulator, and not tested or certified outside the envelope. But, with all I knew It was not an intuitive task. I also had to cut the power on the engines to make my recovery a success, and slowly add it back.
But the point is… I knew. I had a plan. I reacted quickly. And I still ate up a lot of altitude.
Had I walked into that flight deck and looked at what they were looking at… the data presented would have been something I’d never seen. I’m not sure if you froze the visual and had 100 pilots analyze it, we’d be in a discussion for 15 minutes. Not until they added the side note: “One of the pilots has had the stick full aft this entire time” would we know.
And climbing over the seat and grabbing the stick. If they weren’t going to crash, that might have done them in. It’s not a mechanical stick like the Boeings. Bottom line, when the captain, or anyone, figured out what the problem was… at the “time” he entered, there was no way they could have saved that plane. Even if he’d been briefed before he went back up.
Someone has to sign for the flight. It’s the Captain. Yes… he/or she, is responsible. But they also should have the confidence that the FOs know what to do. If this isn’t the case, then we need to go back to augmented crews, with two captains and two first officers at every flight.
Might not be a bad idea. The captains should, in theory, have more experience. But that is not always the case.
This situation was the perfect storm.
Thank you so much for opening this great discussion.
Very interesting points here Karlene.
And you are correct that the other two pilots SHOULD have known what to do. The point is that they did not.
I also had an opportunity to try the recovery in an A330 simulator knowing full well what was coming. And once that descent rate hit 10,000 fpm, the recovery was a long process indeed. From what I saw, once they left 15,000 ft. still stalled, it was all over.
My concern is that the accident report will say something like “the probable cause was the pilots failure to maintain control of the aircraft,” or something equally inane (sorry, just my editorial opinion). I’ll be more interested in the recommendations.
As you said, if it is a training issue, let’s identify it and move on. But is there not also a systemic issue?
Training only occurs a few days each year. Unless someone is keeping an eye on things operationally, to be certain people are flying the way they are being trained it is also all for naught I think.
Let’s not forget that this was never supposed to be able to happen anyway. I wonder what other little aeronautical gremlins might by lying in wait, don’t you?
Industrial Hubris
The manufacturer and airlines have chosen to proceed down a path that increases the distance of the human from the Human Machine Interface, HMI, particularly involvement in the control loop, and the control feedback loop.
A significant number of recent upsets have included inappropriate inputs by the flight crew due to SA type I loss, and/or lack of training in the type of operation encountered, arguably a SA type II failure form inadequate knowledge.
In most accident events, it is generally far easier post event to perform more effectively than the event crew (not always… BA038, QF32…) as the re-enactment crew know that something is going to occur, even if they have no exact information, they know the potential aspects that can be encountered and are effectively pre primed for model recognition.
On conventional aircraft, in inflight loss of control events including stalls, the speed (aoa) stability will tend to recover the aircraft if all the controls are returned to a neutral position, and power is reduced to minimum. (if the power is not reduced, the pitch couple form the thrust can shift the trim condition into an excessively high aoa condition, such as the A320 Perpignan event). For the FBW aircraft, the automatic trimming that can occur may result in an excessive trim case to allow the natural stability of the aircraft to result in a recovery. FBW control can also be affected by unexpected & uncommanded inputs due to sensor failures (QF072) or unrecognised software errors from unexpected configurations (HDA323).
Criticising the dead for not knowing any better is hardly ethical, particularly when they are the result of the confluence of the demands of regulators, shareholders, managers, manufacturers and instructors. It is also very easy to assume that the crews performance is exceptional to the general population of aircrew, which smacks of hubris. I personally am concerned that the crews performance is consistent with the outcome from a system that assumes that the aircraft has morphed into a nintendo game rather than a high energy close coupled machine that is operated in a dynamic environment that rather regularly encounters operating conditions that do not fall within the design expectations.
It is time that flying was returned to being a profession rather than the abysmal and parlous state of affairs that has resulted from the influences impinging on the system. To quote Shakespeare’s Romeo & Juliet, “…all are cursed,…” This is a systemic event, and not merely the outcome of the crew that were caught out on the day. Blaming the crew will not remove the risk that exists with the next LOC case that will occur, which is almost a daily occurrence.
regards
Robert, yes… this is a systemic problem. I wrote a blog about this and my company put a letter in my file and made me pull the post. Is there a problem? Yes. Will it get worse before it gets better? Yes. Is there a solution with the modern airplanes? Absolutely. But it will cost money. I am in the process of the sequel to Flight For Control…. Flight For Safety. This problem, these issues, and the current industry will all come out in the next fictional novel.
Will it stay fiction? Not when I’m ready to retire. But until this, I’m not sure how to create change unless we create awareness and do this slowly. We can’t make an impact if we’re not on the inside.
Culture really can’t change… it has to die. So this is a slow process. I’m not giving up, no matter how many times I do a rug dance.
Thanks for your concern in this very serious issue.
Rob, I think you’re right that this may be a systemic issue. And part of that problem is at the training level. How much time do we really spend training pilots in upset recovery? The generic power-off/power-on stalls that we do at the primary training level is marginally sufficient at best. Should we be training pilots until they are completely comfortable with any stall condition and be able to recovery it? Is it possible with the training equipment used? How much time do we allow for this type of training? How can we measure a student’s proficiency in upset recovery? As an instructor myself, I can tell you that most certificated pilots I have flown with do not like to take the stall to the full break point. And when they do, they panic, and apply incorrect flight control inputs to recover. How is it possible that certificated pilots can’t apply the correct flight control inputs immediately? You and I both know the answer to that. Another aspect of stall training is that often times, students show fear and anxiety with stalls, and I suspect instructors don’t push the issue too much as a result. Can’t blame them really. We certainly don’t want to scare the customer out of the air so to speak. I see a lot of pushing pilots through the system, especially at puppy mills. Just how much time do you think they spend on stalls when there are so many more maneuvers and flight operations needed to be accomplished in the limited exposure hours in training?
Take this same pilot, who now somehow passed the Private level, and go into Commercial and onward. How much more power-off/power-on stall training occurs at those higher levels? In the recently published PTS, stall recoveries are STILL more challenging at the Private level than at the Commercial level:
Private – Recognizes and recovers promptly after a fully developed stall occurs.
Commercial – Recognizes and recovers promptly at the “onset” (buffeting) stall condition.
What happens when the pilot missed the cues for the “onset”? Can they still recover efficiently and effectively after the “onset”? Do they even possess the experience and proficiency to be able to recover at any stage of a stall (and spin)? We don’t train pilots for upset recovery. This is a specialized package, that often comes with a very specialized (read: expensive) price tag; and it requires the pilot to take the initiative to procure. I wonder just how many pilots go out spending thousands a year just to get recurrent upset recovery training/practice.
Bring it to the jet world where stalls are not recovered, they’re powered through. How many sim sessions are allotted by the airlines to each pilots for this? Not a lot. Sim time is expensive. Flight training departments have limited budget, and time in sim equals time out of revenue generating flights.
This problem is easily solvable. And the answer to this is simple: quality and recurrent training.
High Altitude stalls are NOT much different that at low altitude – the underlining principles are exactly the same! It is the pilot folklore and poor teaching of stall recovery in almost every flight school that is to blame!
AoA and energy are fundamental. Adding power at the stall does NOT help matters – NASA tested a B757 at FL450 – held attitude and added TOGA power – the aircraft remained stalled and decended at over 5000fpm!
How does a glider pilot recover from a stall? Unload the wings!
ITCZ flying from Military hi alt pilots: Know your weight, fly at Va and unload at the stall.
William, you’re right… not much time in that training environment. And prior to these instances most airlines didn’t do high altitude stall recovery because in theory, in the Airbus, we would never be faced with that position. They never anticipated a pilot pulling the stick full aft. I think that would have been a fair assumption to make… why would they? But I always say, never say never.
Luke, stall recovery in high altitude and low altitude should be difference due to lack of performance at altitude because of density altitude. Procedurally yes. Performance no. So, unless you train for it, not sure if a practice down low, would prepare you for altitude. But… in this case, they just didn’t identify it. Why? We will never know.
In the airbus, under normal circumstances (everything working) we can’t make the plane stall. We pull back, and ALPHA floor kicks in. Without the automation, and protections to save them, these pilots did the wrong thing. They had the aural warnings but the plane couldn’t save itself.
I suppose this proves that man can overpower the magic machine of automated flying. Something that we all need to remember.
Doesn’t Airbus have a section in the QRH for unreliable airspeed? We have been training for this long before the AF447 crash. What was interesting is that crews don’t seem to understand the procedures laid out in the QRH. For example in level flight, it will give you an attitude in degrees with a certain thrust setting. Many crews just set the thrust and hope one day they’ll get to the required pitch setting.
The proper technique would be to reduce thrust to idle, hold altitude until reaching the required pitch attitude and then add thrust.
Martin, While I am unable to disclose confidential information, most QHR’s have unreliable airspeed. But some airlines are just a little delayed in training. It took an accident to make that happen. That’s great you guys are, and have been, training.
I wrote about this extensively. The basic flight skills were lacking: stall awareness and recovery. It doesn’t help that the Airbus is viewed as unstallable. As I noted in my post, there are no unstallable airplanes any more than there are unsinkable ships. Canards, Ercoupes, Airbuses, and anything else with an airfoil can be stalled.
High altitude stall recovery should be taught in the sim. That’s where jets spend most of their time, up high. If we don’t have the data to program the simulators, then we need to get it.
–Ron
there are two components to the problem, the first is the confusion as to the state of the aircraft, and then the inadequate recovery technique.
Simulator modelling is variable in validity in the post stall condition, although some are getting much better. For behaviour around stall aoa the majority of simulators have fair validity. The recovery technique in the QRH of Boeing and Airbus aircraft has changed, however the authorities have failed to respond as yet to change their expectation and PQS standards related to the checking of these manoeuvres, they will catch up someday, but for now are possibly an impediment.
A stall is a simple condition with a simple solution, whether you are at high or low altitude, the priority is simple; it is an aerodynamic condition, and requires an aerodynamic response, reducing the aoa. The fixation with altitude is an impediment to safe recovery, adding thrust above existing levels does not assist the reduction of aoa that is necessary, nor does it promote a control couple that would result in that outcome, it does the opposite.
Continued nose up elevator command is an indicator of loss of understanding of the condition of the aircraft, or lack of comprehension of the basic fundamentals of aircraft physics.
Ron, this is an excellent idea. All airlines train at altitude for rapid depressurization, engine failures, and perhaps a hydraulic problem. Something that could happen in flight, at altitude. Now we have one more thing to add to that list.
But in the course of fatal accidents,not many have happened at altitude. This was just something that nobody expected. As this pitot tube problem is not a first. Many, many incidents with it, but the other pilots have never had a problem, until now. All it takes is once. The perfect storm.
Training is the answer!
Christine, I’ve been teaching CRM for many years, as well as threat and error management, and using it as well. I believe in these concepts more than you can imagine.
But, if I had been that captain, and there had been time, I would have done whatever it took to take control of that airplane. Knock the guy over the head and climb over to take the control if I had to. Unfortunately, the time wasn’t there.
Actually, I address this issue in my Novel Flight For control. CRM only goes so far, sometimes you have to take matters into your hand, even if it means knocking someone out. Hopefully “because” of good CRM skills, you won’t be faced with that option.
I recently was asked a “what if” the captain doesn’t listen, on my blog. What do you do?
http://karlenepetitt.blogspot.com/2012/06/friday-flyer-challenge.html
We had a lot of great feedback. Bottom line, do what it takes. Everything is situational. The skill comes in knowing when drastic measures are in order. Like the Jet Blue pilot locking the captain out of the flight deck. Good CRM would dictate to discuss, and work with. But not in this case.
CRM is essential to keep things safe. But when “things” have gone south… you do what it takes. This has nothing to do with being a Sky God. It has everything to do about saving yourself and your passengers.
This has been a great discussion from everyone. Thank you Rob, and everyone!
I read that the instructions for a crew in an Airbus A330 that loses airspeed indicators and autopilot are to immediately set thrust at 85% and pitch up at 5 degrees.
Why didnt the crew do that?
Sam… good question. Did AF have a procedure for doing that? Had they trained for it? Nobody has commented on their severe banking…up to 40 degrees. That’s very significant. Altitude. Turbulence. Storm. Fighting the plane. All of it added to their confusion.
First time reader/poster here, with all of only 315-odd hours in Cherokees and Cessnas. But the insight here is cross-disclipinary, and applicable in every endeavor.
Example: I never worked there (instead, working for four years on a US Naval nuclear powered cruiser and twenty-six years at a nuclear power plant in Missouri), but the ultimate cause of the Three-Mile Island nuclear accident was identical to the ultimate cause of AF447, as analyzed above: Failure to recognize.
A power-operated relief valve was manually opened several times (finally sticking open), because the downstream pipe’s temperature sensor was not reading what the operators expected; they were expecting a reading of somewhere over 400 deg. F, but were seeing only some 240*F. Why, because the temperature of the water in the system was >400; but the pipe opened to the atmosphere, and water flashes to steam at 29.92″Hg, no matter what temperature/pressure it may be at inside an otherwise closed system. That water, flashing to steam, loses a tremendous amount of energy, and by the time it exits the pipe to the atmosphere, it is at 212*F, period.
Training. If the operators *had* been trained to recognize this natural phenomenon, they forgot. Turns out they hadn’t. Consequently, they overrode the plant’s automatic protection systems, until the reactor core experienced a significant amount of fuel element failure and partial meltdown.
I won’t address design philosophy (auto-throttle vs. lever position, kinesthetic feedback of the side stick). I’m just looking at basic training. I spend what little time I can afford (my EBT card doesn’t allow for 100LL as an approved food) often flying with that red idiot light on steady, just holding altitude, making turns, &c. Perhaps I ought to go ahead and perform full, deep stalls, just for the sake of proficiency.
Jim: full stalls are a good thing to practice. If you haven’t tried a “falling leaf” stall you might find it instructive. Better yet would be spin training — the ultimate destination of many unintentional, prolonged stalls — and quality aerobatic instruction.
–Ron
All three of these guys failed to recognize THE most basic concept of flying? A stalled aircraft and recovery? Unbelievable.
All this talk of electronics and whiz bang training in simulators…blah blah blah.
Guys, go get out your basic flight school books and then get into a Cessna and LEARN TO FLY again! Stall buffetting and stick full back? It is, after all, just a big airplane.
Inexcusable and Unbelievable lack of awareness x 3 by pilots totally out of touch with their airplane and the basic concept of flight.
(At least the captain died a satisfied man?)
Lapsed PPL (373hrs). Once went to get checked out by the owner of a Grumman AA5 – as his hourly rental rates were good. His take off procedure/instructions (wet grass), full power, stick full back “into your gut, when it leaves the ground, ignore the stall warning, it’ll be fine”. Needless to say I never hired the aircraft!
Surely constant back pressure on stick/yoke without increasing thrust can only lead to a stall?