People,
Air France , after miraculously recovering the black boxes from the 3km deep Ocean floor nearly a year after the disaster, have now released their report, see
What really happened on board Air France 447 (Rio – Paris) http://www.popularmechanics.co...447-6611877?page=all
They have been diligent, honest and open in their inquiry, as this report shows. The Industry and the public owe them their gratitude – no doubt there will be lessons learned and issues addressed by the designers and operators.
Regards, V.Narayan (Vee) Lead Author, Case Studies in Maintenance and Reliability: A Wealth of Best Practices, 2012, Industrial Press.NY ISBN-13: 978-0831102210 Author, Effective Maintenance Management: Risk and Reliability Strategies for Optimizing Performance, Second Edition, 2011, Industrial Press NY ISBN-13: 978-0-8311-3444-0
Original Post
Thanks Vee for posting this.

Just this week I returned back from a visit home to Australia. Kinda glad I read this after, not before.

It would be interesting to know how often situations like this occur which don't result in a disaster, and whether these incidents are reported and corrective action taken to prevent reoccucrrence.
Richard,
You are welcome.
I believe Airlines have to report all such events to their National Regulators, and that this information is shared between other Regulators as well as Operators and equipment vendors, but I don't know this for a fact.
Airlines like BA measure pilot performance at every landing and provide feedback and training to those whose landings are not perfect. That of course does not relate to really high stress situations like this one. Swain and Guttman in their research on the Nuclear Industry published some startling results (NUREG/C-1278-FSAND80-200.3-34)1983. In a high stress situation, apparently the chances of a Control Room operators hitting the wrong button is as high as 10%. So pilots can go badly wrong in such situations. Against this, we have UA flight 232 or the USAIR flt landing on the Hudson to correct this impression.
Nobody would have faulted Air France if they had given up their search after 3 or 4 futile months – certainly everybody else seemed to back off as they saw it as a gone case. But AF persisted at great cost, full marks to them. Such exemplary diligence should give us all some cause to have faith in the Industry. in
quote:
Originally posted by Josh:
It seems the captain is taking things too easy by not studying weather conditions and letting a junior guys to fly the plane.


On long-haul flights, Airlines carry one or more extra pilots precisely to allow for one of them to rest, so that no one falls asleep at the controls. Even 'senior' pilots have to rest!

There are many studies on the behaviour of people in high-stress situations. In hindsight, it is easy to point fingers, but that does not prevent future incidents. The only way forward is to either prevent that combination of circumstances if possible, or redesign the hardware, software, procedures or offer different training.
All pilots know what to do when large storms are expected along the flight path, so a 'junior' pilot should not need 'babying'.

Aircraft designers will no doubt sort out the pitot tube freezing over issues; independent movement of joysticks on manual control is another such issue. Even after the pitot tubes started to respond, the pilot behaved irrationally – but that can happen to people under stress. After the UA 232 disaster, 40 crews went through a simulation of the incident. All 40 crashed, but the original crew did manage to reach the airport runway. That saved 189 lives.

Consider what that means in your own Control Room. In a real emergency, with dozens of alarms going off every minute, is it possible that the CRO does the wrong thing? The stats, according to Swain & Guttman, say there is a 10% chance that will happen. That is very high indeed, even I have seen it happen in my own experience.

RCA must always aim to prevent recurrence. That does not happen with a blame culture.
Perhaps my post sounds finger-pointing and blaming. However, is it possible flying too many hours cause the captain to be over-relaxed as if nothing bad would happen.

WHy did the captain not exercise more leadership by:
- avoiding the large storms,
- not taking a nap during the storm period or reschedule his nap and break or at least supervise his pilots through the storm for training purposes (not babying),
- directing senior pilot to take control in his absence if not by default and
- regaining control upon his return from the nap instead of sitting behind his pilots.

Of course, everybody is entittled to breaks and holidays!

If the large storm was avoided, then no freezing of pitot tubes. Why did the flight crew fail to avoid the storm and went straight into it? No checklist or not included in the flight path planning checklist?

Anyway, can the pitot tubes be heated to avoid freezing? Is this freezing identified in the aircraft RCM analysis?

Why did the pilots fail to respond the stall warning? Is it possible to interlock any actions that increase the stalling effect to double the loudness or frequency of the warning sound?

Is it possible to install another reserved pitot tube (s) which are insulated from freezing and possibly enclosed and only opened and used whenever necessary?
Josh,
Major disasters such as AF 447 occur due to an unusual combination of fairly common and usual events/situations. Very few are attributable to a single action (or inaction) by an individual. Hence the answers to you your questions are unlikely to solve future problems of this kind (why did he take a nap - this ia normal practice on all long flts; why did he not supervise – all pilots are well trained to react to storms in the flt path, so 'senior' pilots do not necessarily 'know more' and others less). Even Captains with several 000's of flying hours have crashed into mountains when under severe stress. So the issue is stress not competence.
As to the hardware/software issues such as pitot tubes, Airbus, Boeing and others are pretty sure to take care of the design changes required, and their urgency.
If Air France had given up, like everybody else, we would still be guessing as to why the disaster occurred. The facts are now clear, so the solutions must attack the root causes – some relate to hardware, some relate to people's behaviour. No doubt all this will be attended to in a systematic way by the Industry, as was done after the UA 232 disaster.
When it comes to safety, I think all of us can learna alot from teh airline Industry.

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