AF447 report pledge must be honoured says Xenophon
The independent South Australian senator, Nick Xenophon, has called on the government to honor its promise to review the finding of the inquiry into the Air France AF447 disaster in relation to the Australian Senate inquiry into pilot training and airline safety.
When the Senate committee charged with that inquiry reported in June last year its recommendations included a review by CASA, Australia’s air safety regulator, and the ATSB, the country’s safety authority, of the then as yet to be finished inquiry by the French safety authority, the BEA, which reported last Thursday.
That recommendation was supported by the government, as well as the members of the committee that conducted the inquiry.
Senator Xenophon said the French report highlighted ‘weaknesses’ in the handling of the Air France A330-200 by the two co-pilots left in control of the jet while the captain took a rest break, which subsequently crashed into the mid Atlantic on a flight from Rio to Paris which killed at 228 people on board.
(The senator’s comment is an understatement, considering the events described and analysed in acute detail in the final report. )
“The Air France 447 tragedy shows how serious safety systems in aviation are. It would be an even bigger tragedy if we didn’t learn from the findings in the French report,” Senator Xenophon said.
A fair summary of the relevance of the French report to Australia is that inexperience, lack of appropriate training, and, after careful reading and re-reading, the risk of irrational responses to a crisis compounded by functional hysteria and helplessness on the flight deck has lethal potential in modern airliners.
The pilots on AF447 knew enough to fly an airliner in cruise using an autopilot system in much the same way that almost all jet airliner flights are flown using contemporary designs.
But they did not know enough to handle the unexpected. How pilot training needs to change to remedy some of the issues that helped destroy AF447 is now very much an area of acute concern to aircraft makers and safety authorities abroad.
There were events described in the report which could be considered unique to, as well as seriously negative for Air France, including its legal responsibility for the dysfunctional human relations factors in the piloting of AF447. But there are universal issues of concern as to the reasons for none of the pilots being able to understand the nature of the control crisis that overtook the jet, and thus unable to perform the appropriate recovery procedures to regain control of the jet, in the very short period of time they had left.
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Ben,
The fact that the mainstream Australian media has largely ignored the AF447 report pretty much sums up our complacency about these things. I suspect if it were not for Senator Xenophon, you would have been an even lonelier voice.
I smiled at your comment about understatement – after all, one is only allowed to squeeze the bubble of public complacency about flight standards, certainly not to burst it! Perhaps that is also why there has been no noise from the pilot associations – the reality may be a little too confronting for the passengers who believe that every pilot is trained to the standards of Qantas even when they are only prepared to pay half of the bus fare to fly somewhere!
But back to the point.
The problem can be described by the folowing three selective quotes from contributors to the PPRuNe forum:
“Angelorange” said: “…We know there were many factors aggravating the situation but responsibility lies with the pilots, the airline, the manufacturer, the training system and the regulators. How much will be judged to have the greater share will depend on honesty, openness and sadly politics. I hope we can learn from the mistakes made and ensure a safer flying future by improving pilot selection, training, and mentoring, developing CRM/SMS so it is of real value and not a box ticking , white-wash exercise. I hope AF447 will lead to a clarifying of systems, improvment to the automation/pilot interface, designing controls that keep all the flight crew in the loop.”
“Oakape” said: ” How many recent accidents have been caused by problems with the AFCS, whether it be failure, reversion or simply the pilot being unable to engage it in the first place?
I can immediately think of four – Kenyan, Ethiopian, Turkish & Air France. There may be more.
There seems to be a growing number of pilots these days who can’t actually fly & when the autopilot decides to have a rest they are left in control of a large aluminium tube full of unsuspecting & trusting people, with no idea of what to do next. Is the licencing scandal in India not exclusive to that country & more widespread than people think?
Airline flying is supposed to be the pinnacle of aviation, only reached after many years of study, training, experience & perseverance. This does not seem to be the case anymore. People obviously believe that as little as 250 hours is enough.
Some of the comments here indicate that they believe that all airline pilots are created more or less equal. I have sat beside & behind enough of them to know that that is not the case. Some airline flight decks are populated by people who have no business being there. But they are cheap – just ask the accountants who put them there!
Some comments also indicate that people believe that the answer is more automation or a refinement in the current automation. I’m sorry, but I don’t agree. If you can’t tell when the automation is behaving incorrectly, or you have to rely totally on the aircraft to tell you what to do next with some verbal warning or instruction, then you have no place in an airline flight deck. Does anybody remember having to look ‘through’ the flight director on occasions & simply fly the aircraft?
The cost cutting mantra of modern business that has flowed into the airline industry is taking it’s toll. I have seen a drop in both quantity & quality of training in recent years. Reducing T & C’s is possibly reducing the quality of peolpe coming into the industry as well. Arguably we are no longer getting the brightest & best any more. The question is – is cost cutting winding back all the gains that have been made in aviation safety over the last 2 or 3 decades? Are we seeing the beginning of another era of increasing accident rates?
IMHO, the reaction by the PF on this flight to a loss of airspeed indication, followed by the A/P dropping out, is inexcusable. The decision by the more experienced PM to continue to let him fly after his initial reaction of excessively pitching up at that altitude in also inexcusable.
If we have a generation of pilots in flight decks who can’t actually fly, then it is going to get a whole lot worse before it gets better.”
and “Irish Steve” said: “… I am not sure it can be described as error in that they were not equipped to deal with the scenario they found themselves in. The reasons for that need to be laid bare and never allowed to happen again, and there is a clear requirement for significant extra training and awareness, but that’s post event hindsight, at the time, the relevant people saw nothing wrong with the way they were operating, and that may well be a false sense of security because the automation is usually so reliable.
If I had to put words to it, pilot inadequacy is closer to the mark than pilot error. They were never trained how to really fly the aircraft, they were trained to fly the automation, which is fine while all the systems work as designed, but if they don’t, this is the inevitable result. The reasons for that are much wider than just the pilots, they go right to the top, and fixing it will have to go to the top as well.”
I have quoted these folks because I believe that together they represent a fair summation of the problem – which is no less of a problem in our backyard as it may be elsewhere. I hope you and the good Senator get some coverage on this issue because the current Government in their “Alamo” moment and their insufferably arrogant replacements will not have the appetite to deal with the implications. David Learmount of Flight magazine refers to this accident report as a “wake-up call” – we absolutely cannot afford not to listen!
Wildsky makes some interesting points. But surely all the statistics say todays pilots ( and aircraft) are safer. Would anybody fly if planes crashed at the ‘same rate’ today as the 60s and 70s ?. And a command seat in an intercontinental jet required a long apprenticeship.
While it is true that media silence is apparent about AF447, there is another reason for this, and I can get a break in the routine, I’ll post on this.
Todays pilots are “captains” in the marine sense.
No longer is this a job for the reactive overconfident fighter jock.
Today you “command” the plane.
Naively viewed this is a workload reduction.
But only the pilots that invest this gained time into introspective
worrying, observing the system checking it for missmatch against
the predicted behaviour will avoid the real traps.
The discussion and commentary focusing on the pilots in some way obfuscates the BEA’s first paragraph of, 3.2 Causes of the Accident, on p.199,
“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.”
and, the first bullet point on p. 200,
“Thus, the accident resulted from the following succession of events:
- Temporary inconsistency between the airspeed measurements, likely following the obstruction of the Pitot probes by ice crystals…”
The pilots may have been incompetent; they may have had insufficient training, poor situational comprehension, and poor communication, et cetra. Yet, was there an expectation the aircraft’s systems were robust enough covering most situations outside its flight envelope? These aircraft are marketed as the most technologically advanced, fully automated, fly-by-wire systems leaving the impression the statistical odds of failure are almost nil.
If aircraft manufacturers and airlines believe more in the ability of their systems and prefer automation over humans an alternative to existing pitot tube technology is required.
But, is the statistical odds 228 die too low to justify the cost? Pitot tubes don’t fail that often in triplicate, and aircraft “alternate law” training is costly too.
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