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Old 09-10-2017, 03:26 AM   #61
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Wait, ok, so...airplane is plummeting towards the ground, radar power, in the bars, still plummeting. We need to have a symposium to decide whether or not, you know, maybe they should be mildly criticized for not at least trying out lowering the nose? Is this for real? Is Alan Fundt hiding in the bushes?
IIRC, as they were descending with the stick back, the airspeed was less than 60, which is where the 'Bus cuts off the stall warning. Twice, again IIRC, they pushed the nose down, airspeed rose above 60 and the stall warning started, making the PF think he'd done the wrong thing, so he pulled back again to silence the alarm.
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Old 09-10-2017, 07:20 AM   #62
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IIRC, as they were descending with the stick back, the airspeed was less than 60, which is where the 'Bus cuts off the stall warning. Twice, again IIRC, they pushed the nose down, airspeed rose above 60 and the stall warning started, making the PF think he'd done the wrong thing, so he pulled back again to silence the alarm.
Appears he did. Cancelled a non-ignorable, non-cancellable warning by returning to well above normal pitch angles for phase of flight and stuck with it. Which isn't to say it's not possible to exceed critical AOA while staring straight at the ground. Entering stall/spin regimes almost exclusively the domain of GA or military training, an already identified but as yet not addressed aspect of the problem.
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Old 09-10-2017, 08:48 AM   #63
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I submit they did know. But for inability to shed a crippled FMS under extreme stress, couldn't get there soon enough. You worked in training, correct? Tell me you haven't observed crews in recurrent cling to flight director commands during stick shaker, unusual attitude or loss of situational awareness situations when they freely admit at de-brief they "knew" it couldn't help.

Came across a report from what I seem to recall was a Delta PI, many years ago. In it, he detailed using a raw data, hand flown, unfamiliar, non-precision IAP to minimums at a special airport (MGGT?) for both 757 & DC9 crews. As might be expected, while nearly all of the DC9 approaches resulted in a landing on the first attempt, a surprisingly high number of the 75 crews required another after going missed at some point. When Al Ueltschi traded his white cap at PAA for climbing the stairs to begin work at a characteristically Spartan hangar desk, making FlightSafety his legacy, he well understood the value in accurately & reliably prioritizing fundamentals of aircraft operations. Saved a lot of lives in the effort.
Several events where experienced crews did not recognize they have stalled. Look at AA 903, believe 1999, and also the C-5 crew into Diego Garcia. In both cases they did not recognize they were stalling until investigators told them later (although one member of the crew did recognize it in DG the aircraft commander still did not until they told him later as I recall).
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Old 09-10-2017, 10:00 AM   #64
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Several events where experienced crews did not recognize they had stalled.

Close to the same page here, I think? The crew in question more than proficient to standard, professionally expert even on approach to stall recovery, maneuver validation, textbook aerodynamic theory. They clearly knew enough about loss of lift due to relative wind/airfoil separation. What specific, panic classification blocked all three from working it out, given the time available, we can only guess at.

All I suggested was, a root cause of an accident may prove uncomplicated, examined in isolation. Drafting/approving a comprehensive fix that fits all sizes is, more often than not, complex as chit. Symposiums, sunshine meetings and white papers can serve a worthy function. As well a time and place for procedural revision based on clinical, human behavior discovery. Standardizing how we perceive, problem solve, advocate and correct for error, critical to all aspects of best practice operation. ASAP, SMS pillars, IOSA, all for it. But who better than you, line flight officers, to best determine if any of it really drives safety forward, out there day & night, slipping the surly bonds?
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Old 09-10-2017, 05:17 PM   #65
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Close to the same page here, I think? The crew in question more than proficient to standard, professionally expert even on approach to stall recovery, maneuver validation, textbook aerodynamic theory. They clearly knew enough about loss of lift due to relative wind/airfoil separation. What specific, panic classification blocked all three from working it out, given the time available, we can only guess at.

All I suggested was, a root cause of an accident may prove uncomplicated, examined in isolation. Drafting/approving a comprehensive fix that fits all sizes is, more often than not, complex as chit. Symposiums, sunshine meetings and white papers can serve a worthy function. As well a time and place for procedural revision based on clinical, human behavior discovery. Standardizing how we perceive, problem solve, advocate and correct for error, critical to all aspects of best practice operation. ASAP, SMS pillars, IOSA, all for it. But who better than you, line flight officers, to best determine if any of it really drives safety forward, out there day & night, slipping the surly bonds?
I would say that that the concept of "root cause" is entirely a human construct. Accidents these days are a complex interaction of many components that are not possible to separate out. They are also not linear event sequences (the idea that it is layers of cheese as Jim Reason once used, but even he disavowed later) is really just a domino model. With complex and highly coupled systems we see interactions that are very difficult to anticipate using conventional methods. This was actually the topic of a talk I co-presented at the ISASI annual seminar a few weeks ago. The conference paper is available on the ISASI website, here http://isasi.org/Documents/library/t...20Systems.docx
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Old 09-11-2017, 11:14 AM   #66
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I would say that that the concept of "root cause" is entirely a human construct. Accidents these days are a complex interaction of many components that are not possible to separate out. They are also not linear event sequences (the idea that it is layers of cheese as Jim Reason once used, but even he disavowed later) is really just a domino model. With complex and highly coupled systems we see interactions that are very difficult to anticipate using conventional methods. This was actually the topic of a talk I co-presented at the ISASI annual seminar a few weeks ago. The conference paper is available on the ISASI website, here http://isasi.org/Documents/library/t...20Systems.docx
Equipped to comment from but one guy's perspective. Can only to describe the analysis attached as…comprehensively excellent. Could go on to detail circumstances (LCA/ASAP board/Pt.142/Pt.119) where FLCH & A/T interface may be in conflict with stabilized visual approaches but, it's all there really.

Returning to AF447 for a moment. Don't personally regard the known human factors as, a conclusion. Like so many others, just seek to better understand how what might have been for one crew, a readily solved anomaly yet for another, 7 mile dive into ghastly statistical record.
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Old 09-12-2017, 01:58 PM   #67
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Equipped to comment from but one guy's perspective. Can only to describe the analysis attached as…comprehensively excellent. Could go on to detail circumstances (LCA/ASAP board/Pt.142/Pt.119) where FLCH & A/T interface may be in conflict with stabilized visual approaches but, it's all there really.

Returning to AF447 for a moment. Don't personally regard the known human factors as, a conclusion. Like so many others, just seek to better understand how what might have been for one crew, a readily solved anomaly yet for another, 7 mile dive into ghastly statistical record.
Agree. It is one thing to solve problems from a system level, and quite another for those of us on the "sharp end" to have to deal with a poorly designed system. I have the "luxury" of working both ends of this. I have thought much about this and in the end, the reason others have survived comes down to a few issues:

1. Unfortunately, luck is involved to a certain extent. Some events just are not the same duration or involve quite the same set of circumstances. Like microburst events, there is just some random probability involved.;

2. In the cases where crews flew through without significant issue, in every case I am aware of there was at least one person at the controls with "legacy" experience, experience that came with years of flying prior to the introduction of augmented control systems and RVSM rules, where pilots still had to really hand fly a real airplane at altitude. No amount of hand-flying a FBW airplane will prepare a pilot for the handling qualities at higher altitudes without degrading it into direct law. It is just not the same animal.
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Old 09-13-2017, 06:45 AM   #68
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One of the benefits to risk withering criticism during give & take on these boards, is opportunity to identify a lurking bias, in yourself. Unrealistic, disingenuous, expectation next gen cockpit crews instantaneously snap back on mothballed or partially developed skills 1st gen crews exercised routinely? Happened back then too, lest one forget. Anybody remember Galaxy 203? How envious I was when a mutual friend mentioned the FO got hired there. And how stunned, some months later, by the ominous tone of statements alluding to how his background & training indicated possible contributing factor in a second segment stall that claimed 70 lives.

There looks sufficient grounds for at least deliberate consideration as to gaps where B787 & A350 level, automation failures, are trained & checked. Moreover, regulatory overseers, if a proposed AOA design/display improvement performs decisively effective in comparative testing, isn't that what retrofit is all about?
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Old 09-13-2017, 09:57 AM   #69
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One of the benefits to risk withering criticism during give & take on these boards, is opportunity to identify a lurking bias, in yourself. Unrealistic, disingenuous, expectation next gen cockpit crews instantaneously snap back on mothballed or partially developed skills 1st gen crews exercised routinely? Happened back then too, lest one forget. Anybody remember Galaxy 203? How envious I was when a mutual friend mentioned the FO got hired there. And how stunned, some months later, by the ominous tone of statements alluding to how his background & training indicated possible contributing factor in a second segment stall that claimed 70 lives.

There looks sufficient grounds for at least deliberate consideration as to gaps where B787 & A350 level, automation failures, are trained & checked. Moreover, regulatory overseers, if a proposed AOA design/display improvement performs decisively effective in comparative testing, isn't that what retrofit is all about?
Yes. I also invite people here to the newly resurrected Bluecoat Forum. We set it up on LinkedIn. It is meant for a direct interchange of ideas between pilots and engineers. https://www.linkedin.com/groups/12063236
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Old 09-14-2017, 06:53 PM   #70
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Been told of one operator having done just that. I know Boeing included stall recoveries from the landing configuration on coupled ILS approaches by disabling the A/T at low thrust. The maneuver, if satisfactory, ended with continuing to a landing on profile, combining events, which I didn't consider very realistic. Improved guidance on aerodynamic recoveries coming into its own of course after Colgan.

We need to do better.

One of the difficulties facing industry & accident investigators in particular, seems to me anyway, is pressure to produce big answers when the root cause of a big tragedy may reveal itself uncomfortably obvious or uncomplicated. As redundant & user friendly all the dreamy tech on new flight decks may be, it can and will fail somebody, somewhere, eventually.
We did a training scenario event like that last year.
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