Safety Forecast

Safety Forecasts More AF Mishaps

Safety Forecasts and Plans has determined that since AF has devoted so many resources towards trying to prove that they were not legally at fault for the deaths of their AF 447 passengers, that AF has not devoted sufficient resources to preventing future mishaps of all kinds, and therefor should plan on more mishaps for the future.

The statistical review of the past 10 years shows that AF mishaps were preventable, yet AF took steps insufficient to prevent them. Since AF has seemingly now devoted enormous resources to the trying to defend themselves, such as spending as much as $35 million to recover a DFDR by submarine, when all that they had to do was to walk into their own dispatch office and witness supervisory personnel not taking preventative steps to advise line captains about weather hazards in their path.

Example? AF 358 flew into a thunderstorm upon landing. Was the thunderstorm present prior to approach? Did dispatch, flight ops or anyone at AF have a thunderstorm avoidance policy? Did the policy undergo scrutiny, study or in anyway become part of flight operations procedures subsequent to AF 447 departing?

It appears that the thunderstorm avoidance procedures at AF was not change after AF 358 crashed in Toronto. Remember that this crash happened in August of 2005.

AF 447 occurred June 2009. So four years occurred and AF 447 flew into a thunderstorm. So once again the same mishap occurred all over again. And Why?

Very simply because no one in AF, or Canada or any other body determined that the cause of the mishap was flying into a thunderstorm. Blame was placed legally at the hands of the flight crew. Legal blame, legal blame was the product of the Canada Aircraft Safety Mishap Board. In fact it appears that the board didn’t complete the safety task at all.

Should not have the board instead of assigning blame, determined the cause to be an encounter with a thunderstorm? Who claims that the aircraft can fly in thunderstorms? Does the manufacturer? Who does?
And yet less than 4 years later, AF flies another aircraft into a thunderstorm and the various mishap boards are all focusing on the actions of the crew once inside the storm!!!!!!! How absolutely ridiculous and illogical can any attempt be?

The manufacturer of no commercial aircraft and the regulator of no civil aviation authority anywhere in the world builds or certifies any commercial aircraft to operate inside of a thunderstorm.

So why does AF continue to do so? Why does any board expect to find any differing result in the event of an encounter?

AF 447 again?

If no one at the AF Dispatch office is tasked with flight following, that is looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched AF flight and then tasked with coordinating a new and safer path diverting around the hazard, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.

The subsequent spending of tens of millions of dollars investigating any such mishap, will in the end not change the disastrous outcome, and in that sense will be money not spent to promote safety, but only rather to satisfy subsequent law suits. Remember, that is a legal function, not a safety function.

Safety’s goal is to PREVENT THE MISHAP FROM OCCURRING IN THE FIRST PLACE, FROM OCCURRING AT ALL.

The job of lawyers is to just pick up the broken pieces and dead bodies and sit around with a pile of money and dole it out to whom they determine is the victim. How does that bring back the dead? How does that make anyone whole? Where is the prevention of loss in all of that?

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AF 447, Safety Forecasting and Planning

Did the AF dispatch office fail to fulfill their duty to look at satellite data?
Did AF flight ops management have a procedure to get the information about recent bad weather enroute passed to transoceanic flight crews, especially those transiting the tropical convergence zone?

When you who are safety managers look at these questions, do you wonder why this lack of procedure was allowed to occur when so many lives are at stake?

If you who are safety managers are able to see that this could be a problem for your airline, then you have created e forecast of things to come.

Who Was at Fault & Who Pays versus How Did This Happen & How Can We Prevent a Recurrence

1. If you are investigating an aviation mishap and asking the question, “Who was at fault and who pays,” then you are doing a legal investigation.

2. If you are investigating an aviation mishap and asking the questions, “How did this happen and how can we prevent a recurrence?” then you are doing a safety investigation.

3. In either case, what is written on the door of your office, the door of your truck or car, the name tag you wear or the title of your agency is not as relevant as which set of these questions begins your investigation.

4. If the title of your agency says mishap investigation, but the purpose of your investigation is to find fault, then you are conducting a legal investigation and it is very likely that the safety purpose will go unfulfilled. The Safety Purpose is to ask, “How did this happen and how can we prevent a recurrence?”
5. A legal investigation is designed to determine, “Who was at fault and who pays?” In many, perhaps most ways, the legal investigation looks backwards.
6.The safety investigation however only works if it looks forward, because the investigators have to determine how to prevent a recurrence. How often do you think mishap safety investigators get this right?
7.Safety investigations are only complete when the cause is found and recommended procedure and training changes are determined that, had they been in place, would have prevented this mishap from occurring. Therefore, Probable Cause determination is not good enough, because you will not know what to fix to prevent a recurrence. You have to know the cause or causes, so that if they are indeed valid, you can then develop a recommendation for corrective action, that if all were to follow in the future, and had been in place before the mishap, would ensure that this mishap never happened and would never happens again.
If for example, no one at the Air France Dispatch Office is tasked with flight following, and looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched flight, and then tasked with coordinating a new and safer path diverting around the hazardous weather, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.

Why Did 44 Die in Russian TU 134 crash near Petrozavodsk

Again, why? Fog does not cause a plane to crash. If a plane is in fog and not able to descend to the runway, the procedure is for the crew to execute a missed approach and try another approach, hold for the weather to improve or divert to an alternate field nearby with better weather.

Sounds like this crew was quite a distance away from the field when they hit the ground. Nothing here in this report makes any sense. Did the crew try to get below the overcast and strike an obstacle? Did the crew miss-set the altimeter and go too low inadvertently? Did the crew set in the incorrect navigation radios and wind up somewhere other than their planned approach route?

There are so many questions that should be asked immediately but to wait 1-2 years to hear the answers seems to most people a very long time and somewhat counter intuitive for a safety investigation.

Did AF 447 use correct Turbulent Penetration Procedures?

The second issue seems to be flight crew training when in heavy turbulence and when the pitot-static system is not operating.
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.

Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.

The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.

I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?

Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.

Other procedures include all of the various heaters and engine ignition circuits should be placed on.

Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.

Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?

AF 447: Basic Instrument Training

Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.

I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?

Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.

Other procedures include all of the various heaters and engine ignition circuits should be placed on.

Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.

Does FAA even do safety correctly?

Why does the FAA not take immediate and rapid action on safety issues when a flight crew member, the NTSB or anyone else for that matter brings the issue and a solution to their attention? Quite a simple answer really: the FAA is run by lawyers and not safety professionals. Lawyers deny that there is a problem of their own origin, because to “admit a problem” ( lawyerspeak, not safetyspeak) would be to admit fault and therefore legal liability in a tort court.
Instead of safety resolutions, the FAA maintains deniablity until pressure from the press and the public is so great that they cannot deny “something has to be changed!”, usually the result of a press grabbing major air disaster, such as Continental/Colgan 3407.
A safety professional, on the otherhand, would have been looking at the problem, in this case, flight crew training, as soon as the first evidence of a problem was revealed.
The sad part about the lawyer approach of the FAA is that hundreds of innocent people have to die and grab headlines in order for a change to be made.
If the FAA were instead run by safety professionals, changes would occur without a lot of needless loss of life.
As far as comments such as, “Regulation created in a knee jerk reaction can do more damage to the commercial air industry than the industry (or passengers) can afford. Is it worthwhile to ground perfectly safe aircraft and aircraft operations on the basis that if there are no aircraft flying or no-one can afford to travel by air no crashes can happen…” frankly, I do not even know where to categorize this illogical line of reasoning.

As far as I know, there has never been a recommendation by a safety professional that said no aircraft should be flying or make flying so expensive that no one can travel. These kind of statements are known as “make up an outlandish course of action, pretend that a safety professional said it, and see how many people you can fool,” type of statement, also know as “red herrings.”
Safety on the other hand is good for business.

Paul

AF 447 Investigation Flawed itself?

1. Air France Flight Control Dispatcher in Paris should have been monitoring AF 447. Flight Control should have been monitoring all hazards impacting the flight such as severe convective weather and rerouted AF 447 around the hazard.

A. Scheduled passenger airlines that operate under both US and European regulations control all flight operations from a central office known as “Flight Control” or “Dispatch.” Despite the name “dispatch,” (meaning to send out or send off) the office uses the radio and data call sign of “Flight Control.” By US and European aviation regulations Flight Control must be in continuous communications and control of all dispatched flights. By US and European aviation regulations Flight Control is legally in control of the flight from before engine start and taxi out until the flight parks in its final parking spot at the completion of the flight. This is known as “block to block.”

B. Flight Control plans the flight route prior to flight and files this flight plan with international aeronautical agencies that control the airspace through which the flight is planned to proceed. The agency determines the actual flight route and provides this authorization to Flight Control and the flight crew just prior to the flight departing its origin. During the flight, when entering oceanic airspace, this agency is coordinated through agreements between international civil aviation organization member states (ICAO) and is handled through radio calls in a non-radar environment.

C. Flight crew members, especially the captain, must be authorized to move the flight by Flight Control and must remain in constant communications with Flight Control during the flight, by regulation. This regulation is in place so that Flight Control is able to pass along information materially and directly affecting the flight, such as weather enroute and at destination and remain in control of the flight for all sorts of reasons affecting international authorizations for airspace entrance and transit.

2. No modern jet passenger transport aircraft in service then or today are certified to penetrate and fly into severe thunderstorms with tops above 50,000 feet, such as those in the tropical convergence zone near the equator.

A. Modern jet passenger transport aircraft are capable of flying high enough to be above much if not all of severe convective weather in the US, in Europe and over much of the non-tropical oceanic routes between Europe, the US and Asia. As a result, most of the time pilots can handle enroute weather with the information available on on-board weather radar and by looking out visually during day light and at night if in the clear. But at night, especially if the flight is operating in the clouds or at lower altitudes and in the vicinity of heavy, severe convective weather, weather radar might not be powerful enough to display the full extent of severe convective weather ahead on the flight path.

B. In the areas near the equator, severe convective weather very often occurs with heights much greater than modern jet passenger transport aircraft are capable of flying. This is a known meteorological phenomenon and these storms occurs routinely day and night. (Repeat these two statements in your mind.) They are observable by satellite with both optical, infrared and other technologies. In many cases they are exceed the ability of onboard radar to determine their size, severity, and height. On board radar in these cases is only useful for defining the edges of the storms for circumnavigation if the aircraft is outside of precipitation.

C. Oceanic navigation areas where modern jet passenger transport aircraft operate and are authorized to operate routes, such as from Brazil to Europe and to North America lie outside ground based weather radar coverage and therefore are not observable by ground based radar.

D. Weather information in these areas are obtained by weather imaging from a wide range of both photographic, infra red and other technology satellites. This information is made available from government agencies to airline Flight Control offices and other subscribers through commercial services by way of the internet. This internet facilitated information is not now accessible in the cockpit (although current technology would allow it and it is accessible in some cases onboard passenger aircraft in the cabin where on board internet is provided). Therefore the only way that flight crew can be advised of this critically important weather data is by Flight Control advising them by radio and data communications from the Dispatch or Flight Control Office.

E. It does not appear that the lack of action on the part of the Air France Flight Control Office in Paris is being investigated as a relevant factor in the loss of AF 447. Rather the attention of investigators and journalists is being redirected towards equipment manufacturers such as Air Bus and the flight crew.

3. Sophisticated weather data is accessible at Flight Control. Managing this information is the direct legal responsibility of Flight Control. US and European aviation regulations thereby give Flight Control the direct responsibility and authority to keep dispatched flights informed of weather hazards along the route of flight and at destination. (Repeat that to your self.)

A. Flight Control is fully equipped with all internet facilitated current satellite based meteorological information. Flight Control has the current and up to the minute information about severe weather phenomenon and the ability and the responsibility to communicate that information to the flight crew.

B. Flight crew graphic information, such as satellite images of photographic or infrared data are provided only at the time of preflight briefing, which can be as much as 1 ½ hours prior to departure. Very often the briefing itself is prepared an hour before the flight crew arrives to receive their briefing, because Flight Control may be dispatching multiple flights at or about the same time. A flight crew that is three hours into a flight for example, could possibly have therefore weather data that is five and a half hours old, in other words, not current.

4. Since severe weather, such as tropical convergence zone thunderstorms can routinely develop at a build-up rate of 4000-6000 feet per minute, new severe convective weather with heights of 60,000 feet, and higher, can develop in a very short period of time. Areas and lines of these thunderstorms can and do develop in the space of less than two hours and can build to heights well above the flight capability of modern jet passenger transport aircraft and pose severe hazards to flight such as hail, severe turbulence, lightning, icing and heavy precipitation.

5. No modern jet passenger transport aircraft are or have been certified to operate in severe thunderstorms, although many have been strengthened, equipped with electrical bond wiring and some level of engine, wing and windscreen deicing in the event that they encounter these severe convective weather conditions of a thunderstorm inadvertently.

6. Actual US and European aviation regulations require flights to be dispatched and while airborne to remain miles away from severe convective weather activity.

A. Yet in this case, the Air France Flight Control did not reroute AF447 around a known area of severe convective weather, that had heights above the possible service ceiling of the Airbus 330.

Why not? Why has the investigation not asked this question?

AF 447 pitot tubes iced up?

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.