Why AF447 crashed - fascinating analysis.

[Globalti]

http://www.popularmechanics.com/pri...ppened-aboard-air-france-447-6611877?page=all

Of special interest to me because I fly with AF almost all the time. Let's hope the aviation industry will learn from this.

 

[fossyant]

Very interesting

 

[Grizzly]

"The men are utterly failing to engage in an important process known as crew resource management, or CRM."

A note to anyone involved in complex high stress high risk occupations, invest in CRM training. It will change the way you work and reduce adverse events.

 

[beanzontoast]

Many years ago I read a book called 'Black Box - Last Words from the Cockpit' (looked for an Amazon link today, but not available at the moment) - a collection of transcripts and commentaries of some actual crashes and some flights where the plane landed safely after an emergency. Sobering, but fascinating.

 

[ColinJ]

Very interesting and scary!

Having witnessed some really stupid decisions made by some highly intelligent people in a variety of stressful situations, I'm afraid that it doesn't surprise me though ...

 

[Archie_tect]

Bonin was responsible for killing everyone because of his incompetence. Could he have done it deliberately....

 

[Flying_Monkey]

Bonin was responsible for killing everyone because of his incompetence. Could he have done it deliberately....

I really don't think that we need conspiracy theories or personal accusations.

More generally, as the report shows, 'human error' isn't something singular any more within complex systems, and in fact the systems are often too complex to deal with if several things go wrong within a very short time or are misinterpreted. What's interesting is that one of the questions that the article asks is whether we can design systems to compensate, but perhaps what we should be asking is whether in that trying to design in machine contingency for every possible outcome, we actually increase the probability of catastrophic outcomes in rare or imrobable cases like this.

This is an interesting pointer: http://boingboing.net/2011/12/08/disaster-book-club-what-you-n.html

 

[colly]

Reading that was gripping to say the least. Terrifying too that despite all of the safety and fail safe systems crashes can happen so relatively easy.
I wouldn't want to blame Bodin outright because clearly his lack of experience played a great part. Like most disasters it isn't just one thing that is the cause. Bodin's lack of experience, the Captain leaving the cockpit with the First Officer not clearly in command, the fact that each control operates completely independently with no feed back of the other, and other things. On another day given the same set of circumstances maybe Bodin would have realised what was needed and simple pushed the control forward.

 

[Globalti]

It just happens that our milkman is also a flying instructor so occasionally he and I have a chat and last year he took me out from Blackpool for a test flight. While discussing air crashes one day he said to me "It's usually human error in the maintenance or the idiot in the cockpit".

 

[dan_bo]

We have a similar turn of phrase to cover most problems on our kit: 'the problem lies somewhere between the chair and the monitor'. Although obviously the consequences are far far less serious.

 

[beanzontoast]

We have a similar turn of phrase to cover most problems on our kit: 'the problem lies somewhere between the chair and the monitor'. Although obviously the consequences are far far less serious.

Known by a variety of acronyms including PEBKAC. http://en.wikipedia.org/wiki/User_error

 

[Archie_tect]

I really don't think that we need conspiracy theories or personal accusations.

Sorry FM but when someone who was trained to react without further input fails in their duty the buck stops with them. It's not a conspiracy theory- he inexplicably continued to do the one incorrect thing which caused the crash and steadfastly failed to do what he was expected to do with his level of skill and knowledge, [even if that expectation should have been to stop what he was doing, raise his concern and simply transfer control to someone else].
Might seem a little unrealistic to expect calm analytical thought given the circumstances, but pilots are selected and trained to deal decisively with split second emergencies, not to panic.

 

[ColinJ]

I can just imagine the Airbus design meeting where somebody suggested that the two control columns should not be linked! I'm sure that somebody would have stuck his/her hand up and argued that it was a really bad idea and would then have been treated like an idiot for making that objection!

 

[Flying Dodo]

That account seems a little bit biased. It describes the co-pilot Bonin as "inexperienced" and implies he shouldn't have been left on the flight deck. Although he'd only been flying A330's for a year, he had over 3,000 flight hours in total.

The article goes on to quote in many places the book by Jean-Pierre Otelli and states "neither Bonin nor Roberts has ever received training in how to deal with an unreliable airspeed indicator at cruise altitude, or in flying the airplane by hand under such conditions". When I used to fly myself and did a basic instrument rating I was taught that - and that was just in a Cessna, so that sort of scenario would be tested regularly by the airlines.

Ultimately though the pilots didn't trust the information they had available and hadn't realised that over time the aircraft had slowly been pitched up. Coupled with the fact the captain didn't actively take command when back on the flight deck meant they weren't in a position to make the correct choices sadly.

 

[Bicycle]

Stress is a strange thing. many years ago I was involved in an investigation of Human Rights Abuses in a most bloody and sordid civil conflict.

One evening I and one other of our team were quite suddenly thrust into a very unpleasant situation. For reasons I will never understand, I took our travel-costs notes from my pocket and started to do some calculations. Any fool over the age of three would have advised us to leave the area at once, but I sat in my stupid coat and my stupid boots and did some maths.

Nothing bad came of it in the end, but the fellow I was with was quite short with me as we jogged back to safety.

To this day I am quite fascinated by what happened to my mind in that really very obviously dangerous situation.

That flight story is terribly sad. Half way through the transcript I found myself rooting for them even though I already knew the outcome.