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Colgan 3407, Feb 2009, Buffalo: Is "Safety Delayed" in reality "Safety Denied"?:Why is the FAA so Slow to do its own Work?

The Buffalo Feb, 2009, Colgan Air mishap killing more than 50 people occurred nearly 3 years ago. In the past few days the FAA has come out ...

Sunday, October 16, 2011

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More Questions Asked by Flight Crew Members Regarding AF 447


More questions have been raised by fellow safety minded pilots regarding AF Flight 447. Here are several:
1. Why were they flying through that nasty weather?
2. Why did the captain leave the cockpit just prior to the flight's arrival to this area?
With respect to the questions asked, here is my take.
1. The captain had at least a 2 hour old satellite pix by the time he started engines. The thunderstorm encounter occurred somewhere after about the 2nd or third hour of flight, meaning that the flight entered the thunderstorm area about four to five hours minimum after the sat shot was taken. This means that it is very possible that the sat pix that the captain received did not resemble the convective weather area that the flight eventually encountered. This is assuming of course that the crew got a satellite pix at all out of Rio. This is a very common problem for all airlines operating oceanic flights. Flight Control is not required to resend the latest satellite shots to the crew during the flight. Why is that???
A. Let's say that the captain was a cautious fellow and planned well. So he gets up a few hours before the hotel pickup, has a shower, checks his email, gets packed, dressed and meets the crew in the lobby. At the airport or maybe even at the hotel, he sees the sat shot prepared and sent by AF Flight Control Dispatch Offices.
I have not seen a satellite pix or a weather observation from the time from 4-5 hours before the mishap, but if I was investigating this incident, that is the first place that I would look. Why? Well that is the information that will inform the captain as to what lies ahead of him and will inform his game plan, sleep strategy, crew switch strategy for the flight. So my money is on a sat shot that shows widely scattered storms if any at all. He doesn't see a threat at this time and doesn't see any reason not to use his normal strategy of getting the oceanic clearance, getting the plane out onto the tracks and then retiring to get some rest and let the other crew members handle the routine of the crossing. This will allow him to get some sleep and be fresh when they get close to Europe and have to start their let down at CDG for landing. Maybe this is his normal routine.
B. Alternative scenario: The captain is a "show me" kind of guy- unless he sees the lightning flashes and is face to face with a thunderstorm, he doesn't worry about the metro stuff, because it is all 4-5 hours old data by the time they get out onto the tracks for crossing.
Either way, I do not think that the captain foresaw the 60,000 ft+ tropical convergence storms in his path as a real possibility.
Additionally, thunderstorms anywhere rise rapidly in height, developing at 2000-4000 feet per minute, even as much as 6000 feet per minute. Therefore, information such as “the previous flight got through this path” is not valid information for following flights, especially flights following by 10 to 15 minutes later. The fact that another flight transited this area 10-15 minutes prior is certainly and in my opinion most definitely not an endorsement for safe flight. Thunderstorms by their very nature are unstable. That is what makes them so dangerous to flight. Thunderstorms violate the very first principle of aerodynamics, which says, "assume a homogeneous airmass." For sure a thunderstorm is not a homogeneous airmass!
Thunderstorm development in the inter-tropical convergence zone (ITCZ) is even more dynamic than at other places on the globe, meaning that even more caution needs to be exercised in the ITCZ by commercial airline operations. This mishap occurred on a flight planned and operated regularly in the ITCZ.
C. Third scenario is this. This is the kind of fellow that does his own thing. He does the takeoff, then he does his nap, then he does his arrival. This is the way that he does things and this is his thing. This is how he does every oceanic flight and he figures the other crew can handle things. That is just the way he is.
D. Fourth possible scenario: The Air France Dispatch Office in CDG does not consider it their responsibility to update Air France flights with Air France passengers on board of dangerous weather that has developed and is now in the path of an Air France flight. They consider it their responsibility to get the preflight paper work prepared and delivered and then do no further duties other than to stay awake and answer any questions that come up during the flight.

My guess is that AF Dispatch Flight Control Standard Operating Procedure SOP is not to initiate any inflight communications unless directed to do so by "higher authority" or some similar version of that idea. The second place that I would look were I doing the BEA investigation would be the AF Flight Control Log for AF 447, the AF Flight Control SOP and all of the metro data that was available to AF Flight Control before the mishap.

I would further examine just exactly how AF Flight Control does business every day and night with respect to how much info is passed to airborne flights concerning dangerous weather occurring ahead of any AF flight.

Sorry to say this but more than a few commercial flight crew members are like B and C. I am even more sorry to say that more often than not, many flight control offices are like D. They send company flights on flight paths that intersect dangerous weather and do not change plans along the way. My guess is that this most likely remains "the way things are" at many airlines. How about yours?

So that is some thoughts on question one. But if you are a good captain and a good communicator, my guess is that you also have a few ideas and I would be very interested in hearing from you and reading your thoughts on this same question.

Now for question two, here is what I think. I do not think that the captain was fully aware of what was ahead of him. I also do not think that the captain expected a failure on the pitot static system due to icing to occur if the flight did go into clouds.

Remember that the pitot static equipment manufacturer, France's CAA, Airbus and AF all denied that the equipment was faulty, even though there had be several incidents of failure previously of this same equipment in this same scenario and that it had been reported in the industry press.

So that captain may have allowed himself to be informed by the "authorities" in lieu of informing himself through reading industry incident reports.
Again, there are plenty of crew members who allow themselves to be informed this same way, at airlines all over the world, pilots who do the same thing.

Those of us who doubt "authority" are few.probably less than 1/3 of all. My guess is that real doubters are even fewer than 1/3, more like 1/10!

So, here is a third question: Why didn't the captain jump back into his seat and take control as soon as he arrived back up front? I know that I would have. You? Sure things were confusing, alarms going off, icing, thunderstorms, panic-what better time for the captain to be in charge of the flight deck and the controls?


I hope that this mishap is eventually re-investigated by some board other than the BEA, a board that knows that they are doing a Safety Investigation and not a Legal Investigation for some future court proceedings..

In the meantime, I am blogging my thoughts to allow local safety managers around the world to think deeper about keeping their operation safe. That is my intent.

Keep in touch.

Wednesday, October 12, 2011

AF 447: Are any Airbus Airliners Certified to Operate in 60,000 ft Thunderstorms?

Are any Airbus airliners certified to operate in 60,000 ft thunderstorms? If so, where is that test data available?

If not, why was Air France operating Airbus aircraft inside 60,000 ft thunderstorms as in the case of AF 447?

Was this question addressed by BEA? If not, why not?

Friday, October 7, 2011

AF 447 Investigation Missed Many Important Facts

The key to success in any investigation, in my opinion, is to be right, to be correct with your analysis of the facts and testimonies collected. You have to be correct and logical with your conclusions and you have to make recommendations, recommended corrective actions based solely on the conclusions. I would say that somewhere between 90-95% of the time that accident boards get the form of the investigation incorrect. They list conclusions without logically supported analysis, they come up with recommendations out of the clear blue sky with no support from the conclusions and they do not even collect all of the facts.
Case in point?
Take BEA's investigation of AF447. I have not read a single fact, analysis or conclusion so far that leads me to believe that BEA considered the role of AF Dispatch Office in the mishap.

However, consider this important information: it was AF Dispatch Office that had all of the latest metro satellite data at their disposal. That data showed massive thunderstorms in the flight path of AF447, thunderstorms rising to altitudes well above the Airbus operating ceiling. While AF Dispatch had this data, they did not connect having this data and their responsibility to minimize the safety risk to the Air France passengers onboard AF447, nor the crew nor their own asset, that is the aircraft. Air France Dispatch took no action to warn AF447 even though it was their specific regulatory requirement to do so since AF is a scheduled airline and AF447 was a dispatched flight.

If for an aeronautical experiment, a test crew were to be sent with any current airliner into a 60,000+ foot thunderstorm at night, I doubt any aircraft or test crew would escape the encounter unscathed.

In fact Airbus is not required to send any of their passenger aircraft into 60,000 foot thunderstorm in order to be certified by the FAA or any other airframe regulatory body.
Plus consider the idea that passenger injuries are likely to be sustained even if the airframe makes it out the other side of a 60,000 foot storm in one piece. Plus few passengers will speak well of the flight experience if they manage to live through being inside a 60,000+ ft thunderstorm. Many will vow to never fly again and of those, many will never fly again.

In my opinion, political pressure on an investigation is not really so much an issue as is the poorly handled investigation, collection of the facts, poor analysis, poor conclusions and poor tie in of recommendations. Political and party pressures are a fact of life. They are afraid, under stress, and will do anything to survive. But the truth can not be hidden. If it is not found, the board wasn't looking hard enough.

Thursday, October 6, 2011

AF 447 missed facts

The key to success in any of these investigations, in my opinion, is to be right, to be correct with your analysis of the facts and testimonies collected. You have to be correct and logical with your conclusions and you have to make recommendations, recommended corrective actions based solely on the conclusions. I would say that somewhere between 90-95% of the time that accident boards get the form of the investigation incorrect. They list conclusions without logically supported analysis, they come up with recommendations out of the clear blue sky with no support from the conclusions and they do not even collect all of the facts.
Case in point?
Take BEA's investigation of AF447. I have not read a single fact, analysis or conclusion so far that leads me to believe that BEA considered the role of AF Dispatch Office in the mishap. It was AF Dispatch Office that had all of the latest and current metro satellite data that showed massive thunderstorms in the flight path of AF447, rising to altitudes well above the Airbus operating ceiling. Even while AF Dispatch had this data, they took no action to warn AF447 even though it was their specific requirement to do so since AF is a scheduled airline and AF447 was a dispatched flight.

Send any current airliner into a 60,000+ foot thunderstorm at night and I doubt any will escape the encounter unscathed. Plus passenger injuries are sure to be sustained even if the airframe makes it out the other side.

So, in my mind, political pressure is not really so much an issue as is the poorly handled investigation, collection of the facts, poor analysis, poor conclusions and poor tie in of recommendations.