Tag Archives: AF447

Just Culture Arguments

IMG_6033Advocating for a Just Culture, without referencing the logic of a larger safety, legal and administrative contextual framework can take on the appearance of advocating for an exemption to all the laws of all the nations that have developed over all time with respect to one party doing harm to another party.

For example, let’s consider the Air France 447 case. For which party in this mishap should a Just Culture exemption to all law on harm be advocated?

Consider the pitot equipment manufacturer, the air frame builder, the air line certificate holder and the certificate holder CAA regulator government.
Did or did not all four of these parties know, and fully know, ahead of time , ahead of the time of operation of AF447, of the pitot equipment’s failure to perform on previous occasions? Were these four parties or were these parties not completely familiar with the certain likelihood that flight operations in the inter tropical convergence zone involved instrument meteorological conditions in icing at cruising flight levels? Were not these four parties, less the pitot manufacturer, completely familiar with flight operational standard procedures and training of the flight crew?

Nevertheless, did not the certificate holder, with the approval of various CAA regulators, propose to operate and receive approval for an operation into an area of known and well known hazardous weather, all the while with known defective equipment?

See, there is one strange part of the whole Just Culture argument that needs to be looked at very much more closer than, in my opinion, it has been looked at before. Think about this:
Under all the laws of all the nations, are the flight crew considered separate parties, separate certificate holders, separate parties from the airline certificate holders all the time, or at least during the time that they are operating?

Or are they considered agents of the operating, certificate-holding airline?

If they are legally considered agents of the operating certificate-holding airline, how would any flight crew legal exemption from liability for harm done during an operation, the Just Culture argument,  have a follow-on exemption from liability for the airline certificate holder?

Is this not a grey area, a not well defined legal area, an area where an argument for Just Culture for airline flight crews begins to grow dialectic from all other laws governing agents of companies, for example the captain of a ship in admiralty law, the CEO of a corporation under corporate law and similar company-agent relationship laws that exist all over the world? Is this a very large and complicated problem that Just Culture has addressed to the satisfaction of at least some of the countries of the world? In my opinion, even the countries in ICAO, have not fully considered that there really are many more layers to this issue as it relates to global commercial aviation safety mishap investigations.
In the case of AF447, the flight crew training by all appearances and by any analysis that has been published, was, in my opinion, not adequate for the known hazards to be faced and subsequently for the hazards actually faced by the flight crew of AF447,  again in my opinion.
But, in IFALPA’s opinion and policy view, is or is not flight crew training the responsibility of the airline certificate holder and under direct supervision of the CAA regulator? So, where does the Just Culture argument take us in terms of crew training, as far as who is responsible for a crew that, as I stated in my opinion, was not adequately trained?  Is training, such an absolute essential part and basis of safe commercial flight operations, intrinsically tied to the airline, the CAA regulator and the equipment manufacturer? If this is so, how can the crew’s position be lifted out of the events of a commercial aviation mishap?

Or maybe is that just what the Just Culture advocates are saying, that the crew was trained according to the standards of parties other than themselves?  But doesn’t that appear to create a huge legal problem for any party harmed by a commercial flight operation? If the Just Culture argument contends that the crew is not an agent of the company and thus should not be held, as agents, individually culpable, then who should be? If the non-operating and potentially non-flight certified corporate officers are to be held culpable for harm caused by a commercial operation, what is the relationship accountability between the crew and the corporate officers?  This can devolve into an extremely complex set of arguments, in my opinion.

May arguments of exemptions from laws addressing harm have a severe uphill challenge, when the argument is solidly based on a footing that training costs are minimized by airlines solely for economic arguments? The challenge grows even more severely uphill, when and if crew training documentation has a large gap in the area of operations in known and well known hazards of severe weather with defective equipment, weak supervision communications links and poor enroute supervisory oversight, as was the case of AF447, in my opinion. The training gap itself raises the classic liability negligence questions of who knew about the hazards, equipment limitations and weather and when did they know it?
If IFALPA’s Just Culture policy is aimed at thawing the safety channel into insight of human error (also known as human factors), now very often frozen solid by centuries old laws addressing harm, liabilities and negligence, then the Just Culture policy should very clearly state so.
If however, IFALPA’s Just Culture directly or indirectly attempts or even appears to attempt, to advocate an exemption by any party to harm, including flight crew, from all the laws of all the countries, this advocacy is more likely to look like a dodge from responsibility,  than a safety policy to quickly get to the bottom of the cause of a mishap, in my opinion, and thus not likely to enjoy widespread acceptance.
In the US Supreme Court case of Weber vs US Government, the nine justices clearly differentiated the separate safety function of the mishap investigation team from the parallel legal liability functions of lawyers representing various harmed parties and the third parallel regulatory administrative function occurring simultaneously as the result of an aircraft mishap.

100_4230Since all ICAO commercial aircraft mishaps are investigated by state agencies, I find the arguments for a differentiated government safety investigation, asking solely the questions, “How did this mishap occur?” and “How can we prevent this mishap from recurring?” are clearly warranted. In their rare unanimous 9-0 Supreme Court decision, upholding the arguments for keeping thawed the channels of investigation of human factors associated with aircraft mishaps and direct testimony of persons with first hand knowledge, the court at no time granted, suggested nor established any prohibition to any party for exemption to liability for harm or any independent investigation to determine the legal purpose questions of “Who was harmed?” and “Who Pays?”
Instead the court prevented lawyers seeking legal liability claims evidence from having access to safety investigation evidence, and in particular, personal testimony given on the promise of confidentiality, and solely for the Safety Purpose, in order to quickly fix the safety hazard, thereby preventing further harm in a subsequent flight operation.
At no time, however,  did the court prevent any harmed party from conducting their own separate legal liability investigation to determine who was harmed and who should pay for the damages.

There was absolutely every reason for lawyers representing Weber for conducting their own investigation. However, they saw the safety investigation as the only one possible, erroneously so in my opinion. In my opinion this was a mistake. Instead of Weber seeking an exemption to have access to the safety investigation, they should have gotten busy conducting their own investigation to ask, “Who was at fault for the damages and who should pay?” They should have interviewed their own witnesses, found their own evidence and determined their own facts through testimony they collected. Instead, they made a raid on the Safety Purpose investigation and were soundly rebuffed and rightfully so, by the unanimous decision of the US Supreme Court.
Nor, do I believe, should Just Culture arguments seek such exemptions from liability damage claims and from administrative regulatory laws related to flight crew certification.
The questions “Who was harmed?” and “Who is going to pay for the damages?” are rightful and powerful questions that will long remain part of the laws that define the operational limits of any commercial company. Additionally, the question of certification continuance, suspension, revocation or further training should be expected and rightfully so in the event of a commercial airline mishap.
I believe it is The Safety Purpose, or what Europeans label as Just Culture on the other hand, to separately advocate for mishap prevention, all the while giving the crew and any other related party, the opportunity to provide safety testimony into the human factors related to commercial flight operations. Safety and Safety alone should ask, “How did this happen and how do we keep this from happening again?” If we safety advocates stick with these questions, the Safety Purpose, then our efforts, the efforts to achieve a Just Culture for example in Europe and other parts of the world, will succeed, in my opinion.

At the same time, we must look at the laws governing agents of companies and determine whether moving forward, how do commercial flight crew members currently fit into the framework of centuries old shipping company agent laws.101_0241

More on AF 447 LOC: Stability, Vg/Vn Diagram and Recovery

There is another very important aerodynamic engineering issue that needs to be discussed when Loss of Control is the subject, and that is Stability, as it relates to high angle of attack flight. Transport category aircraft may not have the same “forgiving” stability as training aircraft, when it comes to bringing the aircraft back into the flight envelope, in the event that Loss of Control has taken the aircraft outside of the flight envelope.
Training aircraft are designed for students, so that they are designed to be easily recoverable from high angle of attack flight and out of controlled flight and flight outside of the flight envelope. The center of gravity, the aerodynamic center, the moment arms of the wings and fuselage, the control surfaces size, types, deploy-ability and locations, the aerodynamic and geometric wing twist, the wings’ angle of incidence on the fuselage and additional itens such as stall strips or other early stall initiation devices, are all assembled so as to make recovery from stalls, post stall gyrations and spins possible for students. This however is not how transport category aircraft are designed and assembled.

Rather, transport aircraft are commercial competitive aircraft, and as such, are optimized for L/D max  (lift/drag max) in cruise, that is the best lift for the cost of drag, for high coefficient of lift devices for take off and landing performance and for relatively good stability (In my opinion, slots, slats and similar devices are incorrectly called high-lift devices. Why? Because you really just want to get the same lift but at lower angles of attack.  They might be more properly be called high “coefficient of lift devices” where the coefficient of lift is maximized by camber and air channels, where the angle of attack is lowered).

But with long wings and long fuselages, when there are very long moment arms with large weights such as passenger/cargo payloads and massive engines, transport aircraft may not perform in the same docile manner as trainer aircraft, acrobatic aircraft and military tactical jets. For line crew members to expect transport aircraft to be as nimble and recoverable as trainers would not be realistic.

Stability is more challenging to engineer when the moment arms and weights get larger.  Recovery from the edge of the flight envelope, that is the Vg/Vn diagram or the Velocity vs G Loading diagram, is possible and quite satisfactory with most transport category aircraft.

But when a flight’s excursion goes well outside of the flight envelope, of the Vg/Vn diagram, when the transition is larger and the aircraft passes well through and past the edge of the envelope, then recovery back into the flight envelop, may not be as easy.

It may still be possible, but testing during development may not have been investigated or engineered. Recovery from outside the envelope may require much more aerodynamic knowledge than a pilot that is qualified just by the requirements of training by regulation may posses.

And if crew members do not possess that knowledge, then there is a problem, because the plane is outside the advertised limits of operation and they may be at a loss on what procedures to use next. So, now what?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

In my opinion, when flight crew members get into the seat of a transport category aircraft, an aircraft  with dozens of people seated behind or into the captain’s seat of a jumbo transport category aircraft with hundreds of people seated behind, flight crew members should be prepared to focus 110% of their attention for the next eight to twelve hours on nothing but flying. Forget about casual conversation. Forget about big meals, you will not starve in 8-12 hours, a sandwich and coffee will do. Forget about all sorts of distractions. Flight crew members need to be focused on keeping the aircraft in the flight envelope by procedures and purely by procedures.

Flight crew members have to know the Vg.Vn diagram and know how to stay well inside of the envelop. Why? That reason is because it may be difficult, very challenging and for some and in some cases, impossible to get back into the envelope once having left the envelope! Is that what happened to Air France 447? I just don’t know, but many of the clues seem to point in that direction.

Flight crew members need to definitely keep the aircraft out of thunderstorms and out of harm’s way for any threat to control and stability. The commercial transport plane is not a trainer, it is not a jet fighter and it is not an acrobatic plane and it is most certainly not a test and development aircraft. It is a massive piece of machinery that has been designed to do one thing extremely well and that is carry large payloads over long distances at exceptionally efficient fuel costs. Attempting to do anything other than that with the aircraft just does not seem “like a good idea.”

As far as members of various boards of investigations are concerned, if board members do not know the aerodynamic principles and physics of large transport plane flight, then it would behoove the board to bring in people who do know these things, such as pilots. Investigations that do not cover this subject area, when part of the flight, especially the fatal last few minutes, occurs outside of the VgVn diagram, are incomplete and therefore as of yet,  little safety value.

These investigations in my opinion are not for the purpose of assigning blame and forming the basis for further legal actions such as dismissal, monetary damages and fines. Lawyers and courts do that kind of work and the case history for lawyer based investigations and court awarded compensation in the Western world goes back hundreds of years.

Instead, these safety investigations are supposed to be about what went wrong and how do we keep this from happening again. They should be about safety.

Whatever the SOP, whatever the aircraft hand-book, whatever the company training program, something was not right in this case and it was up to the board to find that out. But did they find out what was wrong and did they inform everyone else who conduct flight ops with this equipment, on these routes, with these aircraft, how to do so safely? Or did they leave more questions unanswered? Why is the interest in this subject still so high?

How many times have we been given reports of aircraft mishap board investigations stating that something went wrong, and then that they advise someone else, such as the operator, the regulator or the manufacturer to figure it out?

This is incorrect safety investigation theory and procedure. In my opinion it is the duty of the board to find out what went wrong first and then to recommend actions to correct that situation, those SOPs, the aircraft handbook and the training process.

So, to proceed, would not the board need to understand “what went wrong?”

To understand “what went wrong”, investigators would have to know the aerodynamics of high angle of attack flight, the subject of aerodynamic stability, the idea of the Vg Vn diagram  and flight envelop and the entire concept of controlled flight for jumbo transport aircraft.  They also would have to reaffirm that all flight crew members need to know this information through training with their report of the mishap.

Again, JMHO. What do you think? Hey, we are pilots, we have to know this stuff. Shouldn’t the investigators be required to know this stuff as well? How else can they unravel the mystery of a mishap investigation? How else can we move forward to make commercial aviation as safe as possible? How else can we climb into the captain’s seat and take on the responsibility of being a commercial airline captain?100_0306

AF 447 and AF Global Operations Center: Is there a Connection?

Airline Dispatch Office at the airline global operations center has current satellite imagery in real time of weather along the route of all flights.

I wonder if any manager at the home office has yet been able to put two and two together and say, “Ah HA!! So that is why we have all of these fantastic latest scientifically correct current actual satellite pictures from space, displayed in real time right in front of us on television screens.”

“I think it is so that if we see something dangerous out ahead of one of OUR flights, we can use these radios and other real-time telemetry data channels sitting here in the console right below the television screens to communicate with OUR captain of OUR flight to warn him or her of the danger, such as an area of 60,000ft to 70,000ft thunderstorms in their course ahead and recommend a safe course of action. Am I right or what?”

Hmmmmmmmmmmmmmm.

Actually in some cases, the display is on current LED screens and the communications function is fully integrated into the LED screen.

Is the airline dispatcher and the valuable weather information available at their finger tips being overlooked in the typical rush to find “pilot error?”

AF447 Pitot Tubes Issue

1. For many commercial aircraft, there is an emergency procedure for when pitot static based flight instruments become inoperable.
Pitot static based flight instruments include airspeed indications, altimeters and rate of climb instruments.

2. The scenarios encountered that might render these systems inoperative include a blocked pitot tube or a blocked static port.

A. In the past safety investigations found the following factors involved in pitot tube blockage:
1. loss of pitot tube heater allowing ice to build up or precipitation to clog the tube and/ or the associated plumbing.
2. a protective maintenance cover left on the pitot tube
3. insect, bird or other debris or object entering the pitot tube.

B. In the past, safety investigators have found the following factor most commonly involved in static port blockage:
1. Masking tape place over the static port by crews washing, waxing or painting the plane, where the tape was not removed prior to flight.

3. Since from what has been reported in the media that the flight was proceeding normally, it can be deduced that the problem with the pitot and static system was most likely due to the pitot tube icing over due to lack of heat.

A. Since most pitot heat systems are electrically powered, it is possible that there was some interruption in that electrical system.
B. When the loss of pitot static powered instrumentation occurs, the flight crew is directed by emergency procedures to use instruments which indicate flight attitude, that is pitch, roll and yaw.
C. The attitude instrument most often found in jet powered tranport aircraft is the attitude indicator. It will simultaneously indicate pitch, roll and yaw.
D. Attitude instruments are most often powered on commercial jet transport aircraft electrically and therefore will provide valid data in the event the pitot static system is inoperative. Their source is either laser ringed gyros, mechanical gyros or other similar systems.
E. Laws of aerodynamic performance state that pitch-attitude controls airspeed and engine power controls altitude. So as long as the flight crew maintains the cruise pitch attitude and the cruise power settings on the engine, the aircraft should stay relatively level in flight and the airspeed should remain at the speed required for cruise flight. The crew is often directed to seek an area of clear sky outside of icing conditions or precipitation in an attempt to regain use of the pitot-static system in the event icing caused the problem.

4. This is an emergency procedure which is successful and will allow the flight crew to maintain control of the aircraft through all flight regimes. I can speak from experience that this procedure works just fine. I can also state that this procedure is practiced in training simulators at many US airlines and I would suspect at many European airlines as well.

5. If the investigators state that the aircraft stalled, there are many scenarios by which this could have taken place. One common scenario is that the pitot tube ices up decreasing the dynamic pressure input to the airspeed indicator and rate of climb indicator. The static pressure port may not be blocked so it continues to show static pressure. If the crew does not cross check the pitch-attitude indicator, and only looks at pitot-static instruments, they may see an increasing airspeed and react by increasing pitch and reducing power. This could lead to as stall within a short time at altitude with an aircraft heavily laden with fuel, passengers and cargo.

6. To prevent this type of mishap, many airlines employ training in emergency procedures for the loss of pitot static instruments. The procedure includes disconnecting the auto pilot from control of the aircraft and hand flying the aircraft, again using pitch attitude and engine power settings from a chart. The charts carried on the aircraft include variables such as flight altitude and aircraft weight.

7. If the loss of pitot static system occurred while in a severe thunderstorm, the crew would have had to deal with both the severe turbulence, icing, possible lightning as well as the disconnecting of the autopilot. That would have been a handful for any crew to handle, but that is why most major airlines have strong training programs.