Air France Flight 447 and CRM What went wrong

[Cliff_Chambliss]

fascinating read about automation and pilot skill in the October 2014 issue of Vanity Fair (of all places).

http://www.vanityfair.com/business/2014 ... -447-crash

Lots to learn here especially for crews. 

You have to fly the airplane
When you are a member of a crew you have to communicate.
When crew members start working against each other and stop communicating bad things happen.

[THRAWN]

Cliff,

Thanks. It's a good read, but one has to wonder if it really helps having lessons like this presented repeatedly. Incidents like this still keep happening, even with the outreach, and programs, and training, and retraining, and seminars, and.....A lot of the issue is just plain hubris on the part of each of the crew members. Each one thinks that they have the answer, and don't want to be told anything differently. It happened at Fairchild, at Tenerife, the Everglades....Fixing this issue, and the associated attitude that causes the incidents, might never happen.

[BFreemanMA]

I clicked on the link but received a 404 error. Did they pull the article?

[Cliff_Chambliss]

Fixed the link.

http://www.vanityfair.com/business/2014/10/air-france-flight-447-crash

Add to this a presentation by Airbus in July this year:

About two weeks ago in a speech given by a senior enginner at Airbus he stated that with the modern technologies there is no need for the pilots to be able to see outside the airplane. That the flight crew could be located in the tail of the airplane or even in a compartment in the cargo hold and monitor the airplane systems, sensors, and computers. Then yesterday this comes out:



Wow, who would have thought...
Airbus Shifts Pilot Training Focus to Emphasize Manual Flying

Change Is a Marked Shift From Traditional Principles That Relied on Automated Systems

By ANDY PASZTOR
BETHESDA, Md.- Airbus Group is significantly revising its pilot-training policies to focus more attention than ever before on manual flying skills.

Discussed at an international safety conference here on Wednesday, the change marks a marked shift from traditional Airbus principles that for decades relied heavily on automated aircraft systems and basically taught pilots to use them to fly out of trouble in nearly all circumstances.

But now, the European plane maker is emphasizing the importance of pilots practicing hand flying, and urging that they do so as early as possible when beginning to learn how to handle a new aircraft.

William Tauzin, director of international regulatory affairs for Airbus, told the conference those principles are an essential part of the training program under development for the A350 widebody jet, which is slated to begin service with lead customer Qatar Airways around the end of the year.

In proposing the training sequence for the A350, Mr. Tauzin said "we decided to put manual flying much earlier in the curriculum," before pilots are taught to perform normal procedures using automation. The program still must be approved by regulators on both sides of the Atlantic.

In an interview after his presentation, Mr. Tauzin said pilots will experience manual flying in the simulator after only a brief introduction to the A350. In the past, they would have spent more than a dozen sessions learning about the plane's various automated systems, and then started flying simulator sessions with the automation turned on.

The goal is to first "just have them feel the plane, and how it behaves without" turning on automation or presenting any complicated system failures or emergencies, according to Mr. Tauzin. Experts say it is a way to make pilots feel more comfortable and confident about their ability to revert to manual flying in an emergency.

Eventually, Airbus seeks to expand the revamped training approach to other models. "There is no reason why we wouldn't apply it to the rest of the fleet," Mr. Tauzin said.

The new focus is the strongest sign yet of industry wide concern about the hazards of excessive reliance on automated cockpits, and worries about pilots who may be reluctant to take over manual control when necessary. The result could be to accelerate the movement of airlines toward training programs highlighting manual flight maneuvers.

The A350 training changes are prompted by "the growing realization that pilots are losing their manual skills, and it's part of the industry's risk-management focus," according to Joachim Wirths, head of operations for Qatar's aviation regulator.

Increasingly sophisticated automation has played a big part in making flying safer than ever in the U.S. and globally, but more recently regulators, pilot unions and outside safety experts have highlighted potential downsides. A comprehensive study prepared for the FAA and released last November found that some pilots "lack sufficient or in-depth knowledge and skills" to properly control their plane's trajectory.

The study found that is partly because "current training methods, training devices and the time allotted for training" may be inadequate to fully master advanced automated systems.

Among the accidents and certain categories of incidents examined in that report, roughly two-thirds of the pilots either had difficulty manually flying planes or made mistakes using flight computers.

Airbus began making limited adjustments to its training philosophy in the wake of the 2009 crash of an Air France A330 in the Atlantic. The crew failed to recognize the plane was in a stall and was confused by cockpit instruments.

Initial changes Airbus introduced after that crash started training pilots how to avoid and recover from such high-altitude stalls. But the training program being developed for the A350 goes substantially further in explicitly emphasizing hand flying at various altitudes and across a wide range of maneuvers.

Some airlines already are far down that path. John Tovani, managing director of flight training for Delta Air Lines Inc., told the conference that pilots "are exploring this manual flight stuff in the simulator more and more," when instructors deliberately turn off computerized systems.

"There are times when you have to take over manually," according to Mr. Tovani, because even the most sophisticated automated systems can get planes into situations and "places from where the pilots are going to have to fly out."

[Cliff_Chambliss]

Cliff,

Thanks. It's a good read, but one has to wonder if it really helps having lessons like this presented repeatedly. Incidents like this still keep happening, even with the outreach, and programs, and training, and retraining, and seminars, and.....A lot of the issue is just plain hubris on the part of each of the crew members. Each one thinks that they have the answer, and don't want to be told anything differently. It happened at Fairchild, at Tenerife, the Everglades....Fixing this issue, and the associated attitude that causes the incidents, might never happen.

Well the incident at Fairchaild AFB I would not call as a breakdown of CRM.  Col Holland was not going to "play nice" with anyone.  He had made up his mind that he was going to do what he wanted and everyone else could play all the CRM they wanted but leave him out.  This was a breakdown on the command structure and discipline.  (search "Failed Leadership") on this site.  Sometime back I posted Anthony Kern's excellent analysis of this event "Darker Shades of Blue - a Study in Failed Leadership".

Eastern Flight 401 and the Everglades crash actually took place before the birth of CRM.  Still an excellent case study of an accident that should never have happened and most likely would not have had CRM been around.

Tenerife:  "What did he say"  "Was that for us?"  "oh **** (use your own expletive)".  Partly weather conditions, partly poor phraselogy, partly language problems, part ATC, Part Pan Am Crew, and a lot of KLM.  Had ATC used simple words like Stop, Wait, NO.
Had the Pan Am crew been listening and said NO WE ARE ON THE RUNWAY,  had the KLM Crew asked for a repeat.  if, if, if.  If anything the KLM crew was in a hurry.

But yes, CRM is still treated as a joke by too many flight crew members and all we can do is keep preaching, keep teaching, keep up with the seminars, etc.  We can't fix the grey hair attitudes but maybe we can salvage the young "peach fuzz cheeks".

Besides carrying a lead pipe and busting heads in flight for poor CRM will get you talked about. 

Old Story:
Long time aircraft commander straps into his seat and pulls his pistol and places it on the glareshield.  He looks to the navigator and says "This is what I use if my nav gets me lost".  The navigator sets up his flight station and puts his pistol on his desk.
What's that for? asks the aircraft commander.
The Navigator looks at the pilot and slowly drawls:  "I'll know we're lost before you do sir."

That is not how CRM Works.

[Eclipse]

You can emphasize hand flying, CRM, whatever you want, but the more and more flying becomes a cost-based commodity, up to the point
where pilots are no longer a factor, it's likely not going to get "better".

You can't take people trained at the minimum, paid the minimum, working the maximum, and expect then
to become artisans.  Pilots will increasingly become technicians and operators - running someone else's script.

The Sully's of the industry are aging out faster every year and not being replaced.

[AirAux]

What a great story and perspective.  The best pilots I have known have maintained their proficiency in anything from glider airobatics to small helicopters.  They love to fly and fly as much as possible.  It's almost like they fly for the airlines to have the money to support their addiction for real flying.  That crew was beyond belief, but oh so prevalent in todays skies...  Perhaps all pilots should have to spend 4 hours a month flying VFR in a single engine? 

[Eclipse]

Perhaps all pilots should have to spend 4 hours a month flying VFR in a single engine?

Probably a good idea - the craftsman who builds cabinets or carves puzzle boxes in his spare time is less likely to make silly
mistakes when hanging drywall or mounting a door during the week, and he's also more likely to have a ready knowledge of
experience for unusual situations, but...

Who pays for that?

The airlines are already asking me to fold my legs twice over, and ask for a credit card per peanut and they still cry poverty.

[Майор Хаткевич]

Perhaps all pilots should have to spend 4 hours a month flying VFR in a single engine?

Probably a good idea - the craftsman who builds cabinets or carves puzzle boxes in his spare time is less likely to make silly
mistakes when hanging drywall or mounting a door during the week, and he's also more likely to have a ready knowledge of
experience for unusual situations, but...

Who pays for that?

The airlines are already asking me to fold my legs twice over, and ask for a credit card per peanut and they still cry poverty.

As do the pilots who make nada.

[Eclipse]

Agreed - The business to be in is selling jet fuel or maybe a ramp rat?

[a2capt]

One of the days .. back when .. hanging around the long gone flight school .. about the time I had recently passed my check ride..

An older guy came in, indicated that he was a 747 pilot and decided that he was going to do is BFR "differently" this time, and wanted to go in a C150..

..so the did.

When they came back, the guy was saying "that is the hardest flying I have had to do in a long time. It's much more work. The view.. and it seems like it drags on forever .. "

But he was all grinning and appreciative.