compassion, collaboration & cooperation iN transistion
crash landing in Portland, that the Crew Resource Management System,
under development by NASA, was adopted by United Airlines as the very
first airline to address the issue of the 'cockpit culture of the time',
which had by then, been seen as responsible for several aircraft accidents,
including the world's worst fatal aircraft accident at Tenerife.
The job of flying a commercial aircraft would never be the same again,
as a result of the implementation of a fail-safe system which would ensure
THE transformation of INDIVIDUAL INTENTION to COLLECTIVE ACTION.
It would appear, however, in the context of the advanced state of pilots' use
of, and reliance on computer automated and controlled commercial aircraft,
that the 'cockpit culture of today ' is increasingly approaching the point
when yet another radical system upgrade of Cockpit Resource Management
is required - when the reality is that pilots DO NOT GET the appropriate
training to cope with manually flying a computer controlled aircraft,
when the computer controlled systems fail.
Unfortunately as the Daily Telegraph reported, on the 28 Apr 2012, nearly 3 years after the disappearance of Air France Flight 447 from Rio de Janeiro to Paris ... "The official report by French accident investigators is due in a month and seems likely to echo provisional verdicts suggesting human error. There is no doubt that at least one of AF447’s pilots made a fatal and sustained mistake, and the airline must bear responsibility for the actions of its crew. It will be a grievous blow for Air France, perhaps more damaging than the Concorde disaster of July 2000 " - the airlines and the plane-makers have still not learnt the lessons of the consequences of a lack of training on how to cope with an unexpected shutdown of the automatic pilot at cruising level, and associated cockpit management in this situation, as well as the design of the flying control systems of aircraft and more particularly the design of the control stick – the “side stick” – used in all Airbus cockpits.
The article goes on to conclude ...
"All the indications are that the final crash report will confirm the initial findings and call for better training and procedures. With the exception of Air France, which has a vested interest in avoiding culpability, no one has publicly challenged the Airbus cockpit design. And while Air France has modified the pitots on its fleet, it has said nothing about side sticks.
It is extremely unlikely that there will ever be another disaster quite like AF447. Crews have already had the lessons drummed into them and routine refresher courses on simulators have been upgraded to replicate AF447 high-level stalls. Airbus has an excellent safety record, at least as good as Boeing, and the A330 is an extremely trustworthy aircraft. Flying is easily the least dangerous way to travel, far safer than a car. But while more of us take to the air each year, a single crash is enough to damage confidence.
Critics of side sticks may now argue that Airbus should return to the drawing board. A feature designed to make things better for pilots has unintentionally made it harder for them to monitor colleagues in stressful situations. Yet there is no sign that the inquiry will call for changes to the sticks and Airbus remains confident about the safety of its technology. It will resist what it regards as a retrograde step to return to faux-mechanical controls. The company is unable to speak openly during the investigation, but a source close to the manufacturer says: “The ergonomic systems were absolutely not contrived by engineers and imposed on the pilot community. They were developed by pilots from many airlines, working closely with the engineers. What’s more, it has all been tested and certified by the European Aviation Safety Agency and regulators in the United States, and approved by lots of airlines.”
As Captain King points out, a belief in automation and the elegantly simple side sticks in particular, is integral to the Airbus design philosophy: “You would have to build in artificial feedback – that would be a huge modification.”
A defender of Airbus puts it thus: “When you drive you don’t look at the pedals to judge your speed, you look at the speedometer. It’s the same when flying: you don’t look at the stick, you look at the instruments.”
There is a problem with that analogy. Drivers manoeuvre by looking out of the window, physically steering and sensing pressure on the pedals. The speedometer is usually the only instrument a motorist needs to monitor. An airline pilot flying in zero visibility depends upon instruments for direction, pitch, altitude, angle of climb or descent, turn, yaw and thrust; and has to keep an eye on several dozen settings and lights. Flying a big airliner manually is a demanding task, especially if warnings are blaring and anxiety is growing.
Multimillion-euro lawsuits could follow any admission of liability and it is certainly preferable from Airbus’s point of view that Air France should shoulder the blame for the night when AF447 plunged into the void.
However, no one would suggest that, when it comes to the aircraft we all rely on every day, commercial considerations should come anything but a distant second to safety."
A precis of selected pieces of the final BEA Accident Investigation Report follows ...
3.2 Causes of the Accident
The obstruction of the Pitot probes by ice crystals during cruise was a phenomenon that was known but misunderstood by the aviation community at the time of the accident. From an operational perspective, the total loss of airspeed information that resulted from this was a failure that was classified in the safety model. After initial reactions that depend upon basic airmanship, it was expected that it would be rapidly diagnosed by pilots and managed where necessary by precautionary measures on the pitch attitude and the thrust, as indicated in the associated procedure.
The occurrence of the failure in the context of flight in cruise completely surprised the pilots of flight AF 447. The apparent difficulties with aeroplane handling at high altitude in turbulence led to excessive handling inputs in roll and a sharp nose-up input by the PF. The destabilisation that resulted from the climbing flight path and the evolution in the pitch attitude and vertical speed was added to the erroneous airspeed indications and ECAM messages, which did not help with the diagnosis. The crew, progressively becoming de-structured, likely never understood that it was faced with a “simple” loss of three sources of airspeed information.
In the minute that followed the autopilot disconnection, the failure of the attempts to understand the situation and the de-structuring of crew cooperation fed on each other until the total loss of cognitive control of the situation. The underlying behavioural hypotheses in classifying the loss of airspeed information as “major” were not validated in the context of this accident. Confirmation of this classification thus supposes additional work on operational feedback that would enable improvements, where required, in crew training, the ergonomics of information supplied to them and the design of procedures.
The aeroplane went into a sustained stall, signalled by the stall warning and strong buffet. Despite these persistent symptoms, the crew never understood that they were stalling and consequently never applied a recovery manoeuvre. The combination of the ergonomics of the warning design, the conditions in which airline pilots are trained and exposed to stalls during their professional training and the process of recurrent training does not generate the expected behaviour in any acceptable reliable way.
In its current form, recognizing the stall warning, even associated with buffet, supposes that the crew accords a minimum level of “legitimacy” to it. This then supposes sufficient previous experience of stalls, a minimum of cognitive availability and understanding of the situation, knowledge of the aeroplane (and its protection modes) and its flight physics. An examination of the current training for airline pilots does not, in general, provide convincing indications of the building and maintenance of the associated skills.
More generally, the double failure of the planned procedural responses shows the limits of the current safety model. When crew action is expected, it is always supposed that they will be capable of initial control of the flight path and of a rapid diagnosis that will allow them to identify the correct entry in the dictionary of procedures. A crew can be faced with an unexpected situation leading to a momentary but profound loss of comprehension. If, in this case, the supposed capacity for initial mastery and then diagnosis is lost, the safety model is then in “common failure mode”. During this event, the initial inability to master the flight path also made it impossible to understand the situation and to access the planned solution.
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