15 ms·

The crash of Air France flight 447 (2021)

174 points by gus_leonel 3y ago

jmyeet 3y ago
It's kind of amazing how many of these accidents can come down to the pilots forgetting the most basic things. In this case, ultimately, the pilot and the co-pilot were exerting opposite controls. One to pull up, one to push the nose down. In a stall you push the nose down to gain aerodynamic lift. That's like Flying 101. But I guess when you panic, the natural instinct of wanting to pull up kicks in when you're rapidly losing altitude. Still, training? I saw another one the other day: Ethiopian Air Flight 961 [1] from 1996. This accidently ultimately came down to a single switch being on: manual cabin pressurization. This was on because a pilot reported an error in a previous flight and maintenance were trying to replicate it. The pilots (and passengers) passed out from hypoxia and didn't put on their oxygen masks. Again, not putting on your mask? Pretty basic. Also, Flying 101. If you lose (or don't have) pressurization, drop your altitutde. You get below 8000 feet and you're fine. There was an error but it wasn't ignored and it wasn't entirely obvious, causing revisions to be made. Also, hypoxia can impair judgement very quickly. But why keep climbing when something is wrong? [1]: https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_961 https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_961
- bombcar 3y ago
  > Unlike most other airliners, the control sticks on Airbus models are not mechanically linked and the pilots cannot directly feel what the other pilot is doing. This is a very bad design - at a bare minimum an incredibly loud and annoying alarm should go off if the pilots are fighting controls, because neither knows what the plane is receiving as an input.
  - deleted 3y ago
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  - t0mas88 3y ago
    It has been changed after this incident. There is now an alert for dual input. The resulting Airbus system is better than traditional connected yokes, because it doesn't have the unexpected opposite input anymore (with the alert) but it does also have an override switch for the captain's side. Which means you can overpower the first officer with just a button instead of physically having to wrestle for the controls. You can see it used here: https://youtube.com/shorts/nBmPXrBpp3Y https://youtube.com/shorts/nBmPXrBpp3Y You hear the normal 50.. 30.. etc. callouts and then when the captain goes full thrust you hear "priority left" which is the override button being pressed to pitch for go-around. That's much nicer than what we have teaching with traditional controls. Because at that point overpowering a startled pilot is a bit hard.
    - _cenw 3y ago
      The Dual Input alarm wasn't added, in fact it sounded several times during the Air France flight. FDR visualization: https://www.youtube.com/watch?v=0a06A78iXnQ https://www.youtube.com/watch?v=0a06A78iXnQ
      - t0mas88 3y ago
        Ah thanks. I thought I remembered from ground school that this was added afterwards. Interesting that the FO flying from the left seat did not recognise that callout as a big thing to react to.
    - bombcar 3y ago
      Of course that introduces the problem of "what if the captain is the startled pilot" - can the first office override the captain?
      - _cenw 3y ago
        Yes, but whoever hits the button last gets control, so you can take priority back. (Unless you manage to hit the priority button for 40 seconds - but I assume that's for locking out a broken stick that's doing inputs at rest)
      - 3y ago
  - formerly_proven 3y ago
    https://safetyfirst.airbus.com/app/themes/mh_newsdesk/documents/archives/dual-side-stick-inputs.pdf https://safetyfirst.airbus.com/app/themes/mh_newsdesk/docume... Section 6 > When a dual input situation is detected, the two green priority lights located on the cockpit front panel flash simultaneously. > After the visual indication has been triggered, a synthetic voice “DUAL INPUT” comes up every 5 sec, as long as the dual input condition persists. According to Wikipedia, this warning system worked as intended: > Confused, Bonin exclaimed, "I don't have control of the airplane any more now", and two seconds later, "I don't have control of the airplane at all!"[42] Robert responded to this by saying, "controls to the left", and took over control of the aircraft.[83][44] > He pushed his side-stick forward to lower the nose and recover from the stall; however, Bonin was still pulling his side-stick back. The inputs cancelled each other out and triggered an audible "dual input" warning. > ... > Bonin heard this and replied, "But I've been at maximum nose-up for a while!" When Captain Dubois heard this, he realized Bonin was causing the stall, and shouted, "No no no, don't climb! No No No!"[85][44] > When Robert heard this, he told Bonin to give him control of the airplane.[2] In response to this, Bonin temporarily gave the controls to Robert.[44][85][2] Robert pushed his side-stick forward to try to regain lift for the airplane to exit the stall. However, the aircraft was too low to recover from the stall. Shortly thereafter, the ground proximity warning system sounded an alarm, warning the crew about the aircraft's imminent crash with the ocean.
  - deleted 3y ago
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- dabluecaboose 3y ago
  Even as a flying novice, I was screaming to myself when they kept trying to pull up in a stall. I guess there had to have been some element of panic clouding their judgement, which is why pilots need to drill routine into their head so hard.
  - t0mas88 3y ago
    In normal law an Airbus doesn't stall with full back stick, that would just result in maximum AoA not a stall. In this case it had degraded to loose some of those protections due to icing of the sensors. That was confusing to the junior co-pilot, and they skipped basic procedures on who has control resulting in opposite inputs and a loss of control.
    - dabluecaboose 3y ago
      Yeah, I guess as someone who's had minimal instruction it seemed obvious. But reading the article it's clear that the junior FO was trained basically exclusively on the fly-by-wire Airbuses and probably didn't have that intuitive understanding when that protection was stripped away.
      - mrguyorama 3y ago
        The plane in this case doesn't matter. No training for stalls ever tells you to pull up. It's directly opposed to how stalls ARE trained. This pilot was a chaos monkey, and the other pilots were unable or unwilling to get the chaos monkey out of the situation. He had completely reverted to human instinct, which is terrible for flying, and also was letting himself override his copilot, who was handling the situation much better. People act like this situation wouldn't have happened had they had boeing style connected controls, but it's pretty likely that in this state, Bonin would have actively been wrestling with the controls to point the nose up in that state too. The only way to keep Bonin from killing everyone would have been to restrain him. There is no reliable way to "knock" someone out of that kind of panic state.
        3y ago
- rise-remold 3y ago
  The alarm in question was the same one used for invalid takeoff configuration, as hypoxia was already setting in.
- jackdawipper 3y ago
  Thats makes me think of the guy who disappeared flying a Cessna test flight to Tasmania, his last report he was talking of a large object descending on him. They rekon he had lost his sense of which way up he was and it is common to fly upside down. He was likely describing the ocean. I recall reading bigger planes can also fly upside down for long distances without piloting, maybe something like that was going on. If you think you are the wrong way up and try to get down, you are going to go up. here is the story - https://en.wikipedia.org/wiki/Disappearance_of_Frederick_Valentich https://en.wikipedia.org/wiki/Disappearance_of_Frederick_Val...
- itsmartapuntocm 3y ago
  Are you thinking of Helios Airways Flight 522? That Ethiopian Airlines flight was a hijacking. https://en.wikipedia.org/wiki/Helios_Airways_Flight_522 https://en.wikipedia.org/wiki/Helios_Airways_Flight_522
  - molenzwiebel 3y ago
    The same author as the OP also has a great article on Helios 522: https://admiralcloudberg.medium.com/lost-souls-of-grammatiko-the-crash-of-helios-airways-flight-522-ccf333b407a https://admiralcloudberg.medium.com/lost-souls-of-grammatiko...
  - jmyeet 3y ago
    Sorry, yes I am. Thank you. I guess I saw a few flight disaster things recently and got them mixed up.
- duxup 3y ago
  Often I don’t think it is as much “forgetting” but more getting behind the events to the extent they don’t properly assess / understand the situation and then make poor choices and it is too late.
- TillE 3y ago
  Yeah the "insane pilot error" crashes always get me. American 587 is another example where, in response to normal wake turbulence, the pilot mashed the rudder back and forth so hard it broke the stabilizer.
  - sokoloff 3y ago
    There was a widespread misinterpretation/incorrect belief of the certification rules at the time of that crash. There is an airspeed, called maneuvering speed (Va), at or below which it should not be possible to use the flight controls to remove parts of the aircraft. (The aircraft should run out of control authority or stall prior to exceeding any load limits [which is well before the removal of parts].) Every student pilot is taught this prior to passing their first knowledge test and checkride. The problem with that is the certification rules for Va are for a single input, not for a cyclically reversing sequence of inputs (which is what the first officer of AA 587 did). As the details became clear, this was a big topic of learning for many pilots, including myself. AA 587 was caused by the flight crew, but I don't put it into the "insane pilot error" category.
  - mrguyorama 3y ago
    The pilot in that case was essentially taught that doing so was an acceptable thing.
- braza 3y ago
  > how many of these accidents can come down to the pilots forgetting the most basic things. This is factually incorrect. If you read the Final Report you will see that the FP1 (the one that have placed the abnormal inputs in the side stick) did not had the appropriate training; actually the scenario that happen has not even in the trainings (Nightly mid-atlantic flight with screen disagreement with one of the FP missing that I’m normal law). At least for me, this accident was one of the top 3 most important in terms of safety measures and changes in aviation because the entire industry needed to think about the role of automation, training design, cockpit design, etc.
- afterburner 3y ago
  > But why keep climbing when something is wrong? Two possible reasons in this case. 1) Bonin might not have understood he was in full manual control, and that the computer was no longer restricting his pitch up command to the maximum advisable pitch. 2) The stall warning was intermittent on the way down, because it turns off below a certain air speed. Of course, low air speed contributes to stalling. They were stalling the whole time, but ironically as they started to gain air speed (a good thing) the stall warning would kick in because it was no longer below the lower limit for a stall warning. Also there's the ever present reason of panic, brain-lock, confusion, etc.
Coryodaniel 3y ago
99% Invisible had a great podcast on this … it’s a particularly interesting listen with all the frothing over AI. https://99percentinvisible.org/episode/children-of-the-magenta-automation-paradox-pt-1/ https://99percentinvisible.org/episode/children-of-the-magen...
rsync 3y ago
Perhaps these pilots were "Children of the Magenta"[1] ? These AA instructional videos by Captain Vanderburgh are fascinating - even to a non-pilot like myself. They are especially relevant as we dip our toes into automobile auto-pilot and the "automation dependency" that comes along with it. Of particular note in this video: @ 12:30: "... tactily connected to the airplane ..." @ 14:15: "... we see automation dependent crews, lacking confidence in their own ability to fly an airplane are turning to ther autopilot ..." @ 17:35 - 18:15: (just listen) [1] https://www.youtube.com/watch?v=5ESJH1NLMLs https://www.youtube.com/watch?v=5ESJH1NLMLs
- deleted 3y ago
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- venusenvy47 3y ago
  Just FYI, Admiral Cloudberg has an article titled "Children of the Magenta", but it is related to a specific AA 965 crash in 1995. https://admiralcloudberg.medium.com/children-of-the-magenta-the-crash-of-american-airlines-flight-965-b16f57c34cfe https://admiralcloudberg.medium.com/children-of-the-magenta-...
- matheusmoreira 3y ago
  Autopilot, automation, algorithms, safeties, guarantees, envelopes... Illusions, gone at the first sign of trouble. I easily get used to such technological comforts and it is deeply traumatizing when they're talking away. The badassery men are capable of when they accept this and drive instead of allowing themselves to be driven is the stuff of legends. https://en.wikipedia.org/wiki/Mercury-Atlas_9 https://en.wikipedia.org/wiki/Mercury-Atlas_9 https://en.wikipedia.org/wiki/Gordon_Cooper https://en.wikipedia.org/wiki/Gordon_Cooper > Cooper lost all attitude readings. > [a short-circuit] left the automatic stabilization and control system without electric power. > Cooper noted that the carbon dioxide level was rising in the cabin and in his spacesuit. > "Things are beginning to stack up a little." > Turning to his understanding of star patterns, Cooper took manual control of the tiny capsule and successfully estimated the correct pitch for re-entry into the atmosphere. > Cooper drew lines on the capsule window to help him check his orientation before firing the re-entry rockets. > "So I used my wrist watch for time," he later recalled, "my eyeballs out the window for attitude." > "Then I fired my retrorockets at the right time and landed right by the carrier."
boredemployee 3y ago
I hate me for watching the news about it on that time. That's the flight that seeing all the details about on television gave me the fear of flying that I have these days, specially when above the ocean. I just can't overcome this.
- netsharc 3y ago
  I suppose you've heard it all, like the fact that there are more than 10000 planes currently in the air and we haven't heard about a plane crash for weeks now. If you go to https://globe.adsbexchange.com https://globe.adsbexchange.com and zoom out you can see all the planes around the world, flying safely. I suppose the only way through the fear is to fly and realize at the end that you're fine (although obviously IANAP)
  - ceejayoz 3y ago
    Also note that the last deadly airline crash in the US was all the way back in 2009. We've gone 14 years without a single one, which is a pretty remarkable safety record for the FAA and NTSB.
    - goles 3y ago
      I don’t know if it’s any comfort to scared fliers but even in the incredibly rare circumstances you are involved in a crash? It’s gonna be over quick. It’s gonna be bang, people are gonna scream, you’re gonna be the most scared you’re ever gonna be for like 15-90 seconds and then it’s all gonna be over. That’s if you even get to hear the bang in the first place.
      - sambapa 3y ago
        If you are involved in a plane crash then statistically you survive. So microscopically small chances of something bad happening times not so small chance of dying in a plane crash = nothing to worry about, you have to be incredible lucky to be so unlucky.
willsmith72 3y ago
Just makes me glad how small the consequences are if I have a day of shitty performance at work
- speedgoose 3y ago
  Yes. A few years after this event I broke production of some software payment service while working at AirFrance. Some avoidable error not caught during testing and validation. We had to rollback after some time and nobody died nor talk about it.
nocoiner 3y ago
As I recall, it’s linked in the (excellent) article, but William Langewiesche’s article about this crash is also very much worth reading: https://www.vanityfair.com/news/business/2014/10/air-france-flight-447-crash https://www.vanityfair.com/news/business/2014/10/air-france-... All of his articles about transportation disasters (Columbia, M/V Estonia, many other plane crashes) are very good and highly recommended.
andyjohnson0 3y ago
> A brief interruption to their airspeed indications, lasting less than a minute, had thrown two trained Air France pilots into a state of paralyzed agitation. I'm generally suspicious of technical solutions to human-factors problems. But I can't help wondering if some combination of voice stress analysis and measuring pilot coordination might be able to produce a warning that would have prompted the flight crew to see that they had stopped flying in an orderly way. Easy to say speculate, though, when you're not in that situation.
- roywiggins 3y ago
  > But I can't help wondering if some combination of voice stress analysis and measuring pilot coordination might be able to produce a warning that would have prompted the flight crew to see that they had stopped flying in an orderly way. I guess I don't know what you could do with that, flashing another alarm at an already overstressed flight crew seems like it's unlikely to help?
  - bombcar 3y ago
    The most likely thing to help in something like this, is for the plane to realize it's going to die, and just take over. And that has usually been the "airbus way", whereas Boeing has more had a notion of throw things to the pilots often enough so they know what they're doing.
    - vkou 3y ago
      The plane can't take over when it has no idea of what it's airspeed is. That's what caused this whole chain of problems in the first place.
      - skissane 3y ago
        We expect human pilots to be able to stop the plane from crashing when the airspeed is unknown. If that’s possible for humans, why not for computers?
molenzwiebel 3y ago
If you liked this article, definitely consider checking out other articles written by Kyra (Admiral_Cloudberg). She has done a ton of articles on almost all notable (near)crashes, including their root causes, investigations, and subsequent effects on the airplane industry. For some crashes that have interesting causes (at least from an engineering perspective) beyond "maintenance failed to identify a problem before takeoff" or "pilots fail to identify problem or take wrong actions", I strongly recommend the articles on TWA 800 (1996) [1] and the near-crash of SmartLynx Estonia 9001 (2018) [2]. The first goes into great detail exactly _how_ the FAA discovered the root cause, whereas the second one involves a logic oversight in the flight computers of a modern Airbus plane. [1]: https://admiralcloudberg.medium.com/memories-of-flame-the-crash-of-twa-flight-800-fecfd651a157 https://admiralcloudberg.medium.com/memories-of-flame-the-cr... [2]: https://admiralcloudberg.medium.com/the-dark-side-of-logic-the-near-crash-of-smartlynx-estonia-flight-9001-68b9f42b1fb2 https://admiralcloudberg.medium.com/the-dark-side-of-logic-t...
- networkchad 3y ago
  What a great article on TWA 800. My gramps was a retired manager from TWA and when that happened he was all over it calling his buddies still working there. Thanks for the article!
- DataJunkie 3y ago
  The article on TWA 800 was excellent, especially for those that don't know much about what happened. I've read the accident report, a few books, and even some of the conspiracy theories and this is the best "factual" summary.
moralestapia 3y ago
What an amazing article. I know comments here are meant to be more substantial, but this is truly one of the best written content I've ever come across. My most sincere admiration and thank you notes to the author for putting all of this together in such a great way!
- nocoiner 3y ago
  She writes one of these a week, and they’re all very high quality. I highly recommending subscribing. Seeing the new post is always one of the week’s highlights, just like how getting the “Money Stuff” edition is a highlight of every weekday morning (er, early afternoon).
  - moralestapia 3y ago
    Oh I agree, Money Stuff always puts a smile on my face even before reading it, ha.
  - mardifoufs 3y ago
    Yeah, and even the older articles hold up very well now that tons of them have been updated. It has been part of my weekly routine for 5 years now to read them, and I've got to say that the medium articles are a huge upgrade over the earlier Imgur galleries.
    - nocoiner 3y ago
      Yeah, I’ve been a follower for just about as long as you have, it sounds like. It’s been interesting seeing her growth and evolution as a writer. I think this is the only thing where I subscribe to someone’s Patreon, but it’s well worth it. I should probably consider bumping up my support amount.
markus_zhang 3y ago
Does anyone think lack of sleep is the major contributor of this event, or the invalidation of all three speed sensors? I think we do test pilots for alcohol and drug before a flight, but can we also test them for reaction and a couple of hazard scenarios? Do you think it is too much? About the sensors, is there any inexpensive way to increase the heat or anything to prevent it from happening again?
- Tronno 3y ago
  Re your last question, the article states Air France was in the middle of upgrading the pitot tubes across its fleet when the accident happened.
  - markus_zhang 3y ago
    Thanks, that's good to know.
- t0mas88 3y ago
  Every six months we go in the simulator and practice all kinds of failures and disasters. But lack of sleep is a real issue. Even more on the US side since rest rules are worse than European. Somehow it doesn't get the attention it deserves.
  - mcbutterbunz 3y ago
    > But lack of sleep is a real issue. Even more on the US side since rest rules are worse than European. Somehow it doesn't get the attention it deserves. IMO this is almost a cultural issue. We don't prioritize sleep as much as we should and even hold lack of sleep as something to be idolized (i.e. sleep = laziness). How many times do we hear about those CEOs or Founders that wake up super early after only 5 hours of sleep. They're driven, they're hungry, they have something you don't. You're just lazy. Everyone "knows" we need more sleep just like we know we should floss every day but we have better things to do.
    - 3y ago
jiehong 3y ago
I strongly recommend Mentour Pilot[0] and his many stories about airplanes issues on YouTube. [0]: https://m.youtube.com/watch?v=e5AGHEUxLME https://m.youtube.com/watch?v=e5AGHEUxLME
- mrguyorama 3y ago
  He feels like tiktok videos to me, and is therefore unwatchable unfortunately.
  - mb7733 3y ago
    I'm genuinely curious how an hour-long YouTube video, meticulously researched, scripted and animated feels like tiktok to you. The production value on those videos is really high. They are information dense and the creator goes out of his way not to sensationalize.
    - mrguyorama 3y ago
      Well, to answer your question, it's because I thought "Mentor Pilot" was an entirely different youtube channel! :/ I'll like this one
ra0x3 3y ago
Wow wow. What a read!
braza 3y ago
Since I started to study airline accidents, so far this one of the most fascinating in terms of human aspects and Crew Resource Management. The fact that the whole situation deteriorated less than 10 minutes after the Captain went to rest, it’s one of the biggest contrafactuals about this case.
- whycome 3y ago
  > contrafactuals As in “if the captain didn’t go to sleep, they’d have been fine”?
  - braza 3y ago
    Fine it’s a strong word in that context; the likelihood of the Captain and the Flying Pilot 2 make the same inputs as the FP1 it’s way reduced. The Captain also lost the screen disagreement that happened.
    - whycome 3y ago
      I wasn’t questioning your use of the term. It was my first time encountering it and was just trying to gather the context of your use (and understand a new word). I think the usage there was fine
  - afterburner 3y ago
    Not OP, but more specifically, if the most experienced flight officer didn't leave the cockpit just as they were flying into the worst part of a storm and left the matter to the reluctant and nervous junior officers.
oatmeal1 3y ago
HN seriously just needs to watch Air Disasters. Goes into the details of the investigation, financial consequences, and changes in regulations after disasters.
psunavy03 3y ago
I fly a desk herding cats, I mean devs, for a living now. But as a Navy-trained aviator, this and the Colgan Air mishap in Buffalo always make me cringe. I can't entirely judge the crew, because the human mind is a strange thing that has ways of rationalizing truly abnormal situations and behavior. That said, an obvious Crew Resource Management failure compounded the issues here. That said, I believe aerobatics and out-of-control flight training need to be a lot more common in the civilian sector for professional pilots than they are. Awareness of your angle of attack, and knowledge of how an aircraft behaves at high AOA close to (and if possible beyond) stall don't seem to be taught well in the civilian sector, or at least outside the tactical jet community. The idea that a professional pilot can't understand that a deeply stalled aircraft can be nose-up and still have a heinous sink rate is profoundly bothering to me, just like the Colgan Air pilots who couldn't recognize severe wing rock as a sign of a deeply-departed state. Both of these required (if even possible at that point) aggressive nose-down pitch inputs to break the AOA. And even then, the aircraft is going to lose a ridiculous amount of altitude before it gains enough airspeed back to give you enough pitch authority to scoop out of the ensuing dive. Horrible. It also boggles my mind that Airbus didn't think at first to design an aircraft which avoided the split control problem they had. One person and one person only needs to be in control of the aircraft at all times.
- molenzwiebel 3y ago
  Time and time again we learn that people do stupid things under stress. Consider Transair flight 810 [1], in which a simple engine failure during takeoff results in a complete loss of the aircraft when both pilots mistakenly identify the _wrong_ engine as malfunctioning, despite identifying the failure correctly only minutes earlier. OP has an article on that crash too, actually [2]. [1]: https://en.wikipedia.org/wiki/Transair_Flight_810 https://en.wikipedia.org/wiki/Transair_Flight_810 [2]: https://admiralcloudberg.medium.com/dark-waters-of-self-delusion-the-crash-of-transair-flight-810-a4eeb033bc00 https://admiralcloudberg.medium.com/dark-waters-of-self-delu...
  - psunavy03 3y ago
    Another very common failure mode, and really all you can do is mandate an SOP that the crew member vocalizes which engine they're turning off, and the other crew member verifies that it's the correct engine. The other answer to "people do stupid things under stress" is the common maxim that every emergency procedure in every aircraft starts the same way. Somewhere in the cockpit is probably a standard-issue mechanical 8-day clock, and the first thing you do in any emergency is stop and wind the clock. Not because it does anything to the aircraft, precisely the opposite. It makes you stop for a second or two for the "oh shit" moment to pass. Then you analyze what's actually going on. The other saying that's always briefed is "no fast hands in the cockpit." You may need to be expeditious, but you still vocalize what you're doing with your crew or wingman and methodically go through the emergency procedure. You get in a lot more trouble flipping switches willy-nilly based on what you think you have than if you just stop, breathe, and look at what the aircraft is telling you. I still can recite the steps from memory: - Maintain aircraft control - Analyze the situation - Apply the appropriate emergency procedure(s) - Land when conditions permit
JackFr 3y ago
I got this: while (true) { try { airspeed = getAirspeed(); } catch (Exception e) { log.warn(“”,e); } }
oatmeal1 3y ago
After this crash the French word for idiot was changed to Bonin.
kloch 3y ago
It's tempting to blame the inexperienced first officers, their training, or the CRM failures on this flight, but the blame for this crash has to land squarely on the atrociously bad UX of the Airbus cockpit. Sensory overload and no clear readout of what is actually broken (pitot tube icing in this case) is bad but the fly-by-wire joystick configuration is what really doomed this flight. In Boeing airliners and many other types of aircraft the control sticks are mechanically linked together: you can physically feel if the other pilot is fighting your inputs: > “Controls to the left,” Robert said, still worried about their bank angle. Pressing the priority button on his side stick, he took control and locked out Bonin, but Bonin immediately pressed his own priority button and assumed control again. If the controls were mechanically linked Robert would have recognized his inputs were being overridden and would have been able to save the plane.
- _cenw 3y ago
  * The overhead panel would've shown FAULT on the ADIRs. * The ECAM did show IF SPD DISAGREE: ADR CHECK PROC. * The plane did shout DUAL INPUT several times, and a button to lock out the other pilot is right on the stick. You can hear it being used by Bonin. I'd say this is a failure of lack of crew resource management (not even technical ability) more than anything else.
  - deleted 3y ago
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  - cyberax 3y ago
    The thing is, people in high-stress situations tend to miss audio cues. That's why Boeing uses stick shakers for the stall warnings. And there were _several_ incidents with Airbuses that were caused by dual inputs.
- oatmeal1 3y ago
  > It's tempting to blame the inexperienced first officers or their training but the blame for this crash has to land squarely on the atrociously bad UX of the Airbus cockpit. The real problem is that someone who doesn't look at his most critical instrument* in instrument flying conditions, causes a stall, doesn't respond to stall warnings, doesn't communicate, refuses to hand over controls even though he doesn't understand what is happening, is in the cockpit at all. Either the training was inadequate, or deficiencies in Bonin's flying were overlooked.
free_energy_min 3y ago
Anyone understand if the readings fully came back? If so why wouldn’t the plane go back to normal law?
- deleted 3y ago
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Simplicitas 3y ago
This brings up an interesting question: If the control was fully automated, the computer entirely in charged, would this have happened?
- fakedang 3y ago
  As shown in the article, when the pitot readings were incorrect and the initial 3 second stall warning was displayed, a veteran pilot would simply have had to let the plane continue on in normal law mode, without any action. But Bonin was too overreliant on the incorrect action from the autopilot (moving to alternate law), which itself was an incorrect result from the incorrect readings of the Pitot tubes. Pitot tube icing is one of those issues where automation becomes useless entirely.
legitster 3y ago
> Behind the scenes, the loss of valid airspeed data had triggered a shift in the Airbus’s complex flight control laws. In “normal law,” computers interpret pilots’ side stick inputs and move the control surfaces in accordance with what is reasonable at that altitude, speed, and configuration. This improves the handling of the airplane to such an extent that no particular skill is required to fly it gracefully. Normal law also comes with full flight envelope protections in roll, pitch, speed, and load factor. > If sensor failures occur, the controls drop down a level to “alternate law.” This law contains several sub-laws with slightly different configurations, but in general, alternate law means that some or all computer moderation of control inputs remains, but flight envelope protections are removed. The autopilot and auto thrust cease to function. > In the event of further failures, the controls can enter direct law, in which there are no flight envelope protections and side stick inputs correspond directly to the position of the control surfaces, with no adjustment by the computer. This makes the airplane fly rather like a classic airliner, similar to most older Boeing models. When you think of all of the Tesla accidents, this still seems to be the failure mode for autonomous systems. It's safer 95% of the time. But when it fails, it's because the users are so dependent on the systems that they don't even have the simplest of skills to prevent catastrophe.
- akira2501 3y ago
  > it's because the users are so dependent on the systems that they don't even have the simplest of skills to prevent catastrophe. One pilot was pushing full nose down. The other full nose up. The system _did_ tell them that they were doing this, but in the sea of other alarms, it didn't register with them. The lack of alarm prioritization and the lack of crew resource management training in the face of an emergency seem like the major human factors here. Half of that is in the design of the plane, the other half in how the company trains their pilots to handle severe emergencies.
- _cenw 3y ago
  I'd be hesitant to compare these. The aircraft still operated as designed. It detected that the input data was bad and turned the automation off. The pilot flying just didn't seem to grasp what that means. Most Tesla Autopilot failures aren't drivers that don't know how to drive, it's the automation making bad inputs.
mercurialsolo 3y ago
This is a fabulously well written article in the means of a technical thriller. "All of this happened near instantaneously, leaving the pilots completely in control of the airplane with little advance warning." Complex systems have such a low-window for handling or preventing failure that it is impossible to deal with it at manual scale unless we have a super-good control panels and copilots. Why we need a lot more work on observability and interpretability while operating complex systems.
jcalvinowens 3y ago
The article misses the key takeaway from this incident IMHO. When the controls were pegged at full aft deflection, the stall warning would cease, because instrument readings in the deep stall were considered invalid by the computer. Whenever the pilot would start to push forward to recover, the computer stopped rejecting the readings, and started sounding the stall warning again! So every time the pilot started to do the right thing, the airplane would start screaming "STALL STALL" at him, and he would pull the stick back again to make it stop. I firmly believe that they would still be alive if the stall warning had either not been installed at all, or had functioned properly.
- zerocrates 3y ago
  This is mentioned in the article.
  - jcalvinowens 3y ago
    Only in passing. The dramatized retelling through the first part of the article completely glosses over it.
- _cenw 3y ago
  It's important to note the stall indication itself wasn't disregarded, but the indicated airspeed (that is a prerequisite). This plane was in the exceptional situation of falling out of the sky faster than it was moving forward.
- SoftTalker 3y ago
  Not a pilot but I believe that pulling the stick back is exactly the wrong thing to do in a stall. The pilot should have instinctively known that pulling back on the stick would not recover a stall. On the other hand, pilots are taught to "trust the instruments" but IIRC the aircraft had no angle of attack indicator, and the airspeed tubes were frozen over. So lots of bad or missing information, contributing to stress and panic, which does strange things to otherwise normal people.
  - 3y ago
Tronno 3y ago
In post-mortems involving pilot error, what strikes me is that airliner cockpit design sounds so convoluted, unintuitive, and just plain bad. The burden of disentangling this bad design is always placed on the pilots - through extensive training and rote memorization - which inevitably fails under stress. In this particular example, consider: - the opposing pilot inputs being signaled only by a pair of little green lights - the cacophony of warning lights and alarms which, together, say little more than "something is wrong" - instruments that direct a pilot to pull up during a full stall - sensor failures with no clear indicator - computer safeguards suddenly removed without a stated reason Etc. And the expectation towards the crew is to quickly and corrently reason about this stream of conflicting signals, while embroiled in a sudden emergency. It smacks of pure engineer-driven design, assembled with serious attention to the technical issues, but with near-zero empathy for the humans who will be operating the contraption. Reminds me of internal web tools at so many companies. They present giant messy forms, with checkboxes and dropdowns for every conceivable edge case, which have to be manipulated just so or the system explodes. And when something breaks, of course it's the user's fault every time.
- cedws 3y ago
  I also wonder why airspeed is derived by some formula applied to the measurement of flow along a tube that can be blocked by ice and become useless. Why not use GPS primarily and fall back to that if needed? Or the other way around even. If you expect an instrument to routinely fail, it just seems logical to at least have a backup.
  - thatswrong0 3y ago
    Ground speed and airspeed are not the same thing. You need to measure airspeed directly. And I think there are generally 3 pitot tubes on planes.
  - flerchin 3y ago
    Jetstreams are hundreds of kph. Meaning groundspeed can be hundreds of kph off of airspeed. Meaning GPS is a very poor backup airspeed indicator.
CoconutPilot 3y ago
One thing that stands out to me is the incorrect use of the word "law" when referring to flight modes. Is this just a bad translation? Are any native French speakers familiar with the Airbus documentation able to comment if the concepts make more sense in French?
- Glawen 3y ago
  The word loi (law) is indeed used in french controls engineering, not only for planes. See https://fr.m.wikipedia.org/wiki/Loi_de_commande_de_vol https://fr.m.wikipedia.org/wiki/Loi_de_commande_de_vol Cannot say if it is good or bad to be honest, I believe Airbus themselves decided on the English term law to translate the french term.
  - GiorgioG 3y ago
    No it isn't. https://en.wikipedia.org/wiki/Flight_control_modes https://en.wikipedia.org/wiki/Flight_control_modes
    - Glawen 3y ago
      I updated in the meantime, what isn't?
- baby_souffle 3y ago
  > One thing that stands out to me is the incorrect use of the word "law" when referring to flight modes. Is this just a bad translation? Are any native French speakers familiar with the Airbus documentation able to comment if the concepts make more sense in French? The word "law" can mean several things depending on the context and it's not uncommon to hear of a system following some subset of rules as operating under a certain "law". If it's more palatable, you can `s/law/mode/g` even though you may technically have a few different possible modes under some higher "law/regime" [0] [0] https://en.wikipedia.org/wiki/Flight_control_modes https://en.wikipedia.org/wiki/Flight_control_modes
dreamcompiler 3y ago
I'm amazed that the autopilot kicked off just because the pitot tubes froze. The A330 has an inertial reference unit as well as (almost certainly) GPS, both of which could have provided ground speed. Air speed could be extrapolated from previous air speed and inferred from ground speed, engine thrust, and known weather. IRU and GPS could also have provided altitude and thus climb rate. And we know the plane had a barometer, although it had to be corrected for airspeed according to TFA. I'm guessing the plane also had a radar altimeter, but maybe not. With all these sources of information, the autopilot could have said "Hey the pitot tubes are giving me weird data, but no worries. Still flying the plane. Carry on." Why didn't that happen?
- thatswrong0 3y ago
  > Air speed could be extrapolated from previous air speed and inferred from ground speed, engine thrust, and known weather. I think this is probably the main sticking point. I don't think you can do this accurately without some direct measurement. If the plane thinks its air speed is fine but it's actually approaching its stall speed because it guessed its airspeed incorrectly, that'd be really bad.
  - dreamcompiler 3y ago
    Stall is determined solely by angle-of-attack, which TFA points out. Airspeed doesn't factor in to whether the computer thinks it's about to stall. Here's the relevant sentence: "Crews involved in similar incidents reported that they assumed the brief stall warnings were generated by the erroneous airspeed readings, a not unreasonable interpretation which breaks down only when one learns that the stall warning calculations are based on angle of attack and do not incorporate any airspeed data."
    - thatswrong0 3y ago
      Except that AoA vanes are not perfect and are speed sensitive. > From the A330/A340 FCTM (Flight Crew Training Manual) section 8.110.4: > The ADRs provide a number of outputs to many systems and a blockage of the pitot and/or static systems may also lead to the following: > … > Alpha floor activation (because AOA outputs from the sensors are corrected by speed inputs) From what I can tell, these systems are all pretty complicated and have undergone significant real world testing to ensure that the expected protections actually work, assuming the flight computer is receiving accurate data. Which is precisely why they have Alternate Laws - if they can’t guarantee that these protections can work, then they won’t.
Hinrik 3y ago
This crash was also covered on an episode[1] of the Black Box Down podcast. [1]: https://roosterteeth.com/watch/black-box-down-2020-7-30 https://roosterteeth.com/watch/black-box-down-2020-7-30
rich_sasha 3y ago
As someone who follows aviation and flew the Flight Simulator quite a bit when young, I don't quite understand how it all happened. The mechanics are clear, but aren't pilots trained _ad nauseam_ precisely against this kind of events? It read like this was two panicking guys shouting at each other. By contrast, listening to the recording of the Hudson River landing, it was stunning just how eerily calm the pilots was there. You hear them opening the manual and reading from it IIRC! I don't mean it like, they're dumb cos I watched a YouTube video, I just don't understand. Especially since, as the article claims, pitot tubes all freezing at the same time is somewhat common.
- V99 3y ago
  I think it's just an "everybody has a plan until they get punched in the mouth" situation. In an actual emergency some people react well and go back to their training, others panic & freeze up. And it's hard to predict, you do tons of emergency situations during all the flight training they would have gone through in sims and actual planes, but in the back of your mind you still know it's coming and not a real emergency when the instructor pulls the power out to simulate an engine failure or tapes up a piece of paper to block the airspeed indicator.
- davidktr 3y ago
  If you have an hour to spare, I found this video by an experienced pilot extremely helpful: https://www.youtube.com/watch?v=e5AGHEUxLME https://www.youtube.com/watch?v=e5AGHEUxLME
  - rich_sasha 3y ago
    You're right, a great video, thanks for the top tip. If nothing else, it provides complexity to the situation, which I felt was somewhat missing from the article.
- mplanchard 3y ago
  My understanding is that this incident is one of the reasons why pilots are now trained ad-nauseum for such events, but that training for things like high-altitude stalls was not the norm previously
this_steve_j 3y ago
This was quite a big mess! Let’s see if there is a way to break it down in a Safety II fashion. 1. Airline human resources deviated from the traditional practice of hiring experienced rudder and stick pilots. 1. Overly permissive company attitudes toward crew rest and a lack of awareness about how it can affect vigilance and fitness for duty. 1. Breakdown of the ceremonies that transfer command and control in the cockpit. 1. Lack of training for high altitude stall recovery. 1. Activities performed in low altitude stall recovery training scenarios are orthogonal to a successful recovery in high altitude stall scenarios. 1. Automation surprise followed by alert saturation combined with incongruous perceptual signals and loss of situational awareness. 1. Aircraft control systems that failed to resolve the ambiguous delegation of authority (double PF) dilemma. 1. Highly compressed timeline of events in a physically disorienting environment. 1. What else?
eep_social 3y ago
I love what the author is doing but I honestly don’t understand the gushing over their writing style. To me, it feels full of speculation and melodrama, exactly the language investigators don’t use when they write the accident reports: > pilots into a state of paralyzed agitation.. > all the while trying desperately to understand.. > But there is a reason, written between the lines of the cockpit voice recorder transcript, hidden away within the mysterious code that governs human behavior, a key to the secrets of the profoundly irrational. Its lessons could not be more important, even for those who believe themselves above the doomed crew of flight 447, as the boundary between the responsibilities of man and machine grows ever dimmer. > Overwhelmed by the noise of the warnings, the terrifying vibrations, and the wildly fluctuating instrument readings, his brain seemed to shut down, paralyzed by confusion and fear. Citations needed.
rnoises 3y ago
On a slightly different note, this sort of thing is what makes me question whether we can have an orderly progression from the current Level 2 self-driving in cars to Level 5. When a plane does most of its flying by itself, if it can cause this much chaos by handing control back to a trained pilot without much warning, how much worse would it be when a car hands control back to a inexperienced, distracted driver in tricky driving conditions... especially considering that reaction times need to be much faster on the road?
brohee 3y ago
IMHO something is still missing. Bonin's father was a pilot (in Air France AFAIK) and I can't help but think the likelihood he was the best candidate was low, but that legacy played a part. I also wonder if he had much passion for flying or was just following his father footsteps. I wish they would value passion more, easily demonstrated with military/glider (I must miss some..) experience.

174 points by gus_leonel 3y ago

It's kind of amazing how many of these accidents can come down to the pilots forgetting the most basic things. In this case, ultimately, the pilot and the co-pilot were exerting opposite controls. One to pull up, one to push the nose down. In a stall you push the nose down to gain aerodynamic lift. That's like Flying 101. But I guess when you panic, the natural instinct of wanting to pull up kicks in when you're rapidly losing altitude. Still, training? I saw another one the other day: Ethiopian Air Flight 961 [1] from 1996. This accidently ultimately came down to a single switch being on: manual cabin pressurization. This was on because a pilot reported an error in a previous flight and maintenance were trying to replicate it. The pilots (and passengers) passed out from hypoxia and didn't put on their oxygen masks. Again, not putting on your mask? Pretty basic. Also, Flying 101. If you lose (or don't have) pressurization, drop your altitutde. You get below 8000 feet and you're fine. There was an error but it wasn't ignored and it wasn't entirely obvious, causing revisions to be made. Also, hypoxia can impair judgement very quickly. But why keep climbing when something is wrong? [1]: https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_961 https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_961

bombcar 3y ago
> Unlike most other airliners, the control sticks on Airbus models are not mechanically linked and the pilots cannot directly feel what the other pilot is doing. This is a very bad design - at a bare minimum an incredibly loud and annoying alarm should go off if the pilots are fighting controls, because neither knows what the plane is receiving as an input.
- deleted 3y ago
  [deleted]
- t0mas88 3y ago
  It has been changed after this incident. There is now an alert for dual input. The resulting Airbus system is better than traditional connected yokes, because it doesn't have the unexpected opposite input anymore (with the alert) but it does also have an override switch for the captain's side. Which means you can overpower the first officer with just a button instead of physically having to wrestle for the controls. You can see it used here: https://youtube.com/shorts/nBmPXrBpp3Y https://youtube.com/shorts/nBmPXrBpp3Y You hear the normal 50.. 30.. etc. callouts and then when the captain goes full thrust you hear "priority left" which is the override button being pressed to pitch for go-around. That's much nicer than what we have teaching with traditional controls. Because at that point overpowering a startled pilot is a bit hard.
  - _cenw 3y ago
    The Dual Input alarm wasn't added, in fact it sounded several times during the Air France flight. FDR visualization: https://www.youtube.com/watch?v=0a06A78iXnQ https://www.youtube.com/watch?v=0a06A78iXnQ
    - t0mas88 3y ago
      Ah thanks. I thought I remembered from ground school that this was added afterwards. Interesting that the FO flying from the left seat did not recognise that callout as a big thing to react to.
  - bombcar 3y ago
    Of course that introduces the problem of "what if the captain is the startled pilot" - can the first office override the captain?
    - _cenw 3y ago
      Yes, but whoever hits the button last gets control, so you can take priority back. (Unless you manage to hit the priority button for 40 seconds - but I assume that's for locking out a broken stick that's doing inputs at rest)
    - 3y ago
- formerly_proven 3y ago
  https://safetyfirst.airbus.com/app/themes/mh_newsdesk/documents/archives/dual-side-stick-inputs.pdf https://safetyfirst.airbus.com/app/themes/mh_newsdesk/docume... Section 6 > When a dual input situation is detected, the two green priority lights located on the cockpit front panel flash simultaneously. > After the visual indication has been triggered, a synthetic voice “DUAL INPUT” comes up every 5 sec, as long as the dual input condition persists. According to Wikipedia, this warning system worked as intended: > Confused, Bonin exclaimed, "I don't have control of the airplane any more now", and two seconds later, "I don't have control of the airplane at all!"[42] Robert responded to this by saying, "controls to the left", and took over control of the aircraft.[83][44] > He pushed his side-stick forward to lower the nose and recover from the stall; however, Bonin was still pulling his side-stick back. The inputs cancelled each other out and triggered an audible "dual input" warning. > ... > Bonin heard this and replied, "But I've been at maximum nose-up for a while!" When Captain Dubois heard this, he realized Bonin was causing the stall, and shouted, "No no no, don't climb! No No No!"[85][44] > When Robert heard this, he told Bonin to give him control of the airplane.[2] In response to this, Bonin temporarily gave the controls to Robert.[44][85][2] Robert pushed his side-stick forward to try to regain lift for the airplane to exit the stall. However, the aircraft was too low to recover from the stall. Shortly thereafter, the ground proximity warning system sounded an alarm, warning the crew about the aircraft's imminent crash with the ocean.
- deleted 3y ago
  [deleted]
dabluecaboose 3y ago
Even as a flying novice, I was screaming to myself when they kept trying to pull up in a stall. I guess there had to have been some element of panic clouding their judgement, which is why pilots need to drill routine into their head so hard.
- t0mas88 3y ago
  In normal law an Airbus doesn't stall with full back stick, that would just result in maximum AoA not a stall. In this case it had degraded to loose some of those protections due to icing of the sensors. That was confusing to the junior co-pilot, and they skipped basic procedures on who has control resulting in opposite inputs and a loss of control.
  - dabluecaboose 3y ago
    Yeah, I guess as someone who's had minimal instruction it seemed obvious. But reading the article it's clear that the junior FO was trained basically exclusively on the fly-by-wire Airbuses and probably didn't have that intuitive understanding when that protection was stripped away.
    - mrguyorama 3y ago
      The plane in this case doesn't matter. No training for stalls ever tells you to pull up. It's directly opposed to how stalls ARE trained. This pilot was a chaos monkey, and the other pilots were unable or unwilling to get the chaos monkey out of the situation. He had completely reverted to human instinct, which is terrible for flying, and also was letting himself override his copilot, who was handling the situation much better. People act like this situation wouldn't have happened had they had boeing style connected controls, but it's pretty likely that in this state, Bonin would have actively been wrestling with the controls to point the nose up in that state too. The only way to keep Bonin from killing everyone would have been to restrain him. There is no reliable way to "knock" someone out of that kind of panic state.
      - 3y ago
rise-remold 3y ago
The alarm in question was the same one used for invalid takeoff configuration, as hypoxia was already setting in.
jackdawipper 3y ago
Thats makes me think of the guy who disappeared flying a Cessna test flight to Tasmania, his last report he was talking of a large object descending on him. They rekon he had lost his sense of which way up he was and it is common to fly upside down. He was likely describing the ocean. I recall reading bigger planes can also fly upside down for long distances without piloting, maybe something like that was going on. If you think you are the wrong way up and try to get down, you are going to go up. here is the story - https://en.wikipedia.org/wiki/Disappearance_of_Frederick_Valentich https://en.wikipedia.org/wiki/Disappearance_of_Frederick_Val...
itsmartapuntocm 3y ago
Are you thinking of Helios Airways Flight 522? That Ethiopian Airlines flight was a hijacking. https://en.wikipedia.org/wiki/Helios_Airways_Flight_522 https://en.wikipedia.org/wiki/Helios_Airways_Flight_522
- molenzwiebel 3y ago
  The same author as the OP also has a great article on Helios 522: https://admiralcloudberg.medium.com/lost-souls-of-grammatiko-the-crash-of-helios-airways-flight-522-ccf333b407a https://admiralcloudberg.medium.com/lost-souls-of-grammatiko...
- jmyeet 3y ago
  Sorry, yes I am. Thank you. I guess I saw a few flight disaster things recently and got them mixed up.
duxup 3y ago
Often I don’t think it is as much “forgetting” but more getting behind the events to the extent they don’t properly assess / understand the situation and then make poor choices and it is too late.
TillE 3y ago
Yeah the "insane pilot error" crashes always get me. American 587 is another example where, in response to normal wake turbulence, the pilot mashed the rudder back and forth so hard it broke the stabilizer.
- sokoloff 3y ago
  There was a widespread misinterpretation/incorrect belief of the certification rules at the time of that crash. There is an airspeed, called maneuvering speed (Va), at or below which it should not be possible to use the flight controls to remove parts of the aircraft. (The aircraft should run out of control authority or stall prior to exceeding any load limits [which is well before the removal of parts].) Every student pilot is taught this prior to passing their first knowledge test and checkride. The problem with that is the certification rules for Va are for a single input, not for a cyclically reversing sequence of inputs (which is what the first officer of AA 587 did). As the details became clear, this was a big topic of learning for many pilots, including myself. AA 587 was caused by the flight crew, but I don't put it into the "insane pilot error" category.
- mrguyorama 3y ago
  The pilot in that case was essentially taught that doing so was an acceptable thing.
braza 3y ago
> how many of these accidents can come down to the pilots forgetting the most basic things. This is factually incorrect. If you read the Final Report you will see that the FP1 (the one that have placed the abnormal inputs in the side stick) did not had the appropriate training; actually the scenario that happen has not even in the trainings (Nightly mid-atlantic flight with screen disagreement with one of the FP missing that I’m normal law). At least for me, this accident was one of the top 3 most important in terms of safety measures and changes in aviation because the entire industry needed to think about the role of automation, training design, cockpit design, etc.
afterburner 3y ago
> But why keep climbing when something is wrong? Two possible reasons in this case. 1) Bonin might not have understood he was in full manual control, and that the computer was no longer restricting his pitch up command to the maximum advisable pitch. 2) The stall warning was intermittent on the way down, because it turns off below a certain air speed. Of course, low air speed contributes to stalling. They were stalling the whole time, but ironically as they started to gain air speed (a good thing) the stall warning would kick in because it was no longer below the lower limit for a stall warning. Also there's the ever present reason of panic, brain-lock, confusion, etc.

Coryodaniel 3y ago

99% Invisible had a great podcast on this … it’s a particularly interesting listen with all the frothing over AI. https://99percentinvisible.org/episode/children-of-the-magenta-automation-paradox-pt-1/ https://99percentinvisible.org/episode/children-of-the-magen...

rsync 3y ago

Perhaps these pilots were "Children of the Magenta"[1] ? These AA instructional videos by Captain Vanderburgh are fascinating - even to a non-pilot like myself. They are especially relevant as we dip our toes into automobile auto-pilot and the "automation dependency" that comes along with it. Of particular note in this video: @ 12:30: "... tactily connected to the airplane ..." @ 14:15: "... we see automation dependent crews, lacking confidence in their own ability to fly an airplane are turning to ther autopilot ..." @ 17:35 - 18:15: (just listen) [1] https://www.youtube.com/watch?v=5ESJH1NLMLs https://www.youtube.com/watch?v=5ESJH1NLMLs

deleted 3y ago
[deleted]
venusenvy47 3y ago
Just FYI, Admiral Cloudberg has an article titled "Children of the Magenta", but it is related to a specific AA 965 crash in 1995. https://admiralcloudberg.medium.com/children-of-the-magenta-the-crash-of-american-airlines-flight-965-b16f57c34cfe https://admiralcloudberg.medium.com/children-of-the-magenta-...
matheusmoreira 3y ago
Autopilot, automation, algorithms, safeties, guarantees, envelopes... Illusions, gone at the first sign of trouble. I easily get used to such technological comforts and it is deeply traumatizing when they're talking away. The badassery men are capable of when they accept this and drive instead of allowing themselves to be driven is the stuff of legends. https://en.wikipedia.org/wiki/Mercury-Atlas_9 https://en.wikipedia.org/wiki/Mercury-Atlas_9 https://en.wikipedia.org/wiki/Gordon_Cooper https://en.wikipedia.org/wiki/Gordon_Cooper > Cooper lost all attitude readings. > [a short-circuit] left the automatic stabilization and control system without electric power. > Cooper noted that the carbon dioxide level was rising in the cabin and in his spacesuit. > "Things are beginning to stack up a little." > Turning to his understanding of star patterns, Cooper took manual control of the tiny capsule and successfully estimated the correct pitch for re-entry into the atmosphere. > Cooper drew lines on the capsule window to help him check his orientation before firing the re-entry rockets. > "So I used my wrist watch for time," he later recalled, "my eyeballs out the window for attitude." > "Then I fired my retrorockets at the right time and landed right by the carrier."

boredemployee 3y ago

I hate me for watching the news about it on that time. That's the flight that seeing all the details about on television gave me the fear of flying that I have these days, specially when above the ocean. I just can't overcome this.

netsharc 3y ago
I suppose you've heard it all, like the fact that there are more than 10000 planes currently in the air and we haven't heard about a plane crash for weeks now. If you go to https://globe.adsbexchange.com https://globe.adsbexchange.com and zoom out you can see all the planes around the world, flying safely. I suppose the only way through the fear is to fly and realize at the end that you're fine (although obviously IANAP)
- ceejayoz 3y ago
  Also note that the last deadly airline crash in the US was all the way back in 2009. We've gone 14 years without a single one, which is a pretty remarkable safety record for the FAA and NTSB.
  - goles 3y ago
    I don’t know if it’s any comfort to scared fliers but even in the incredibly rare circumstances you are involved in a crash? It’s gonna be over quick. It’s gonna be bang, people are gonna scream, you’re gonna be the most scared you’re ever gonna be for like 15-90 seconds and then it’s all gonna be over. That’s if you even get to hear the bang in the first place.
    - sambapa 3y ago
      If you are involved in a plane crash then statistically you survive. So microscopically small chances of something bad happening times not so small chance of dying in a plane crash = nothing to worry about, you have to be incredible lucky to be so unlucky.

willsmith72 3y ago

Just makes me glad how small the consequences are if I have a day of shitty performance at work

speedgoose 3y ago
Yes. A few years after this event I broke production of some software payment service while working at AirFrance. Some avoidable error not caught during testing and validation. We had to rollback after some time and nobody died nor talk about it.

nocoiner 3y ago

As I recall, it’s linked in the (excellent) article, but William Langewiesche’s article about this crash is also very much worth reading: https://www.vanityfair.com/news/business/2014/10/air-france-flight-447-crash https://www.vanityfair.com/news/business/2014/10/air-france-... All of his articles about transportation disasters (Columbia, M/V Estonia, many other plane crashes) are very good and highly recommended.

andyjohnson0 3y ago

> A brief interruption to their airspeed indications, lasting less than a minute, had thrown two trained Air France pilots into a state of paralyzed agitation. I'm generally suspicious of technical solutions to human-factors problems. But I can't help wondering if some combination of voice stress analysis and measuring pilot coordination might be able to produce a warning that would have prompted the flight crew to see that they had stopped flying in an orderly way. Easy to say speculate, though, when you're not in that situation.

roywiggins 3y ago
> But I can't help wondering if some combination of voice stress analysis and measuring pilot coordination might be able to produce a warning that would have prompted the flight crew to see that they had stopped flying in an orderly way. I guess I don't know what you could do with that, flashing another alarm at an already overstressed flight crew seems like it's unlikely to help?
- bombcar 3y ago
  The most likely thing to help in something like this, is for the plane to realize it's going to die, and just take over. And that has usually been the "airbus way", whereas Boeing has more had a notion of throw things to the pilots often enough so they know what they're doing.
  - vkou 3y ago
    The plane can't take over when it has no idea of what it's airspeed is. That's what caused this whole chain of problems in the first place.
    - skissane 3y ago
      We expect human pilots to be able to stop the plane from crashing when the airspeed is unknown. If that’s possible for humans, why not for computers?

molenzwiebel 3y ago

If you liked this article, definitely consider checking out other articles written by Kyra (Admiral_Cloudberg). She has done a ton of articles on almost all notable (near)crashes, including their root causes, investigations, and subsequent effects on the airplane industry. For some crashes that have interesting causes (at least from an engineering perspective) beyond "maintenance failed to identify a problem before takeoff" or "pilots fail to identify problem or take wrong actions", I strongly recommend the articles on TWA 800 (1996) [1] and the near-crash of SmartLynx Estonia 9001 (2018) [2]. The first goes into great detail exactly _how_ the FAA discovered the root cause, whereas the second one involves a logic oversight in the flight computers of a modern Airbus plane. [1]: https://admiralcloudberg.medium.com/memories-of-flame-the-crash-of-twa-flight-800-fecfd651a157 https://admiralcloudberg.medium.com/memories-of-flame-the-cr... [2]: https://admiralcloudberg.medium.com/the-dark-side-of-logic-the-near-crash-of-smartlynx-estonia-flight-9001-68b9f42b1fb2 https://admiralcloudberg.medium.com/the-dark-side-of-logic-t...

networkchad 3y ago
What a great article on TWA 800. My gramps was a retired manager from TWA and when that happened he was all over it calling his buddies still working there. Thanks for the article!
DataJunkie 3y ago
The article on TWA 800 was excellent, especially for those that don't know much about what happened. I've read the accident report, a few books, and even some of the conspiracy theories and this is the best "factual" summary.

moralestapia 3y ago

What an amazing article. I know comments here are meant to be more substantial, but this is truly one of the best written content I've ever come across. My most sincere admiration and thank you notes to the author for putting all of this together in such a great way!

nocoiner 3y ago
She writes one of these a week, and they’re all very high quality. I highly recommending subscribing. Seeing the new post is always one of the week’s highlights, just like how getting the “Money Stuff” edition is a highlight of every weekday morning (er, early afternoon).
- moralestapia 3y ago
  Oh I agree, Money Stuff always puts a smile on my face even before reading it, ha.
- mardifoufs 3y ago
  Yeah, and even the older articles hold up very well now that tons of them have been updated. It has been part of my weekly routine for 5 years now to read them, and I've got to say that the medium articles are a huge upgrade over the earlier Imgur galleries.
  - nocoiner 3y ago
    Yeah, I’ve been a follower for just about as long as you have, it sounds like. It’s been interesting seeing her growth and evolution as a writer. I think this is the only thing where I subscribe to someone’s Patreon, but it’s well worth it. I should probably consider bumping up my support amount.

markus_zhang 3y ago

Does anyone think lack of sleep is the major contributor of this event, or the invalidation of all three speed sensors? I think we do test pilots for alcohol and drug before a flight, but can we also test them for reaction and a couple of hazard scenarios? Do you think it is too much? About the sensors, is there any inexpensive way to increase the heat or anything to prevent it from happening again?

Tronno 3y ago
Re your last question, the article states Air France was in the middle of upgrading the pitot tubes across its fleet when the accident happened.
- markus_zhang 3y ago
  Thanks, that's good to know.
t0mas88 3y ago
Every six months we go in the simulator and practice all kinds of failures and disasters. But lack of sleep is a real issue. Even more on the US side since rest rules are worse than European. Somehow it doesn't get the attention it deserves.
- mcbutterbunz 3y ago
  > But lack of sleep is a real issue. Even more on the US side since rest rules are worse than European. Somehow it doesn't get the attention it deserves. IMO this is almost a cultural issue. We don't prioritize sleep as much as we should and even hold lack of sleep as something to be idolized (i.e. sleep = laziness). How many times do we hear about those CEOs or Founders that wake up super early after only 5 hours of sleep. They're driven, they're hungry, they have something you don't. You're just lazy. Everyone "knows" we need more sleep just like we know we should floss every day but we have better things to do.
  - 3y ago

jiehong 3y ago

I strongly recommend Mentour Pilot[0] and his many stories about airplanes issues on YouTube. [0]: https://m.youtube.com/watch?v=e5AGHEUxLME https://m.youtube.com/watch?v=e5AGHEUxLME

mrguyorama 3y ago
He feels like tiktok videos to me, and is therefore unwatchable unfortunately.
- mb7733 3y ago
  I'm genuinely curious how an hour-long YouTube video, meticulously researched, scripted and animated feels like tiktok to you. The production value on those videos is really high. They are information dense and the creator goes out of his way not to sensationalize.
  - mrguyorama 3y ago
    Well, to answer your question, it's because I thought "Mentor Pilot" was an entirely different youtube channel! :/ I'll like this one

ra0x3 3y ago

Wow wow. What a read!

braza 3y ago

Since I started to study airline accidents, so far this one of the most fascinating in terms of human aspects and Crew Resource Management. The fact that the whole situation deteriorated less than 10 minutes after the Captain went to rest, it’s one of the biggest contrafactuals about this case.

whycome 3y ago
> contrafactuals As in “if the captain didn’t go to sleep, they’d have been fine”?
- braza 3y ago
  Fine it’s a strong word in that context; the likelihood of the Captain and the Flying Pilot 2 make the same inputs as the FP1 it’s way reduced. The Captain also lost the screen disagreement that happened.
  - whycome 3y ago
    I wasn’t questioning your use of the term. It was my first time encountering it and was just trying to gather the context of your use (and understand a new word). I think the usage there was fine
- afterburner 3y ago
  Not OP, but more specifically, if the most experienced flight officer didn't leave the cockpit just as they were flying into the worst part of a storm and left the matter to the reluctant and nervous junior officers.

oatmeal1 3y ago

HN seriously just needs to watch Air Disasters. Goes into the details of the investigation, financial consequences, and changes in regulations after disasters.

psunavy03 3y ago

I fly a desk herding cats, I mean devs, for a living now. But as a Navy-trained aviator, this and the Colgan Air mishap in Buffalo always make me cringe. I can't entirely judge the crew, because the human mind is a strange thing that has ways of rationalizing truly abnormal situations and behavior. That said, an obvious Crew Resource Management failure compounded the issues here. That said, I believe aerobatics and out-of-control flight training need to be a lot more common in the civilian sector for professional pilots than they are. Awareness of your angle of attack, and knowledge of how an aircraft behaves at high AOA close to (and if possible beyond) stall don't seem to be taught well in the civilian sector, or at least outside the tactical jet community. The idea that a professional pilot can't understand that a deeply stalled aircraft can be nose-up and still have a heinous sink rate is profoundly bothering to me, just like the Colgan Air pilots who couldn't recognize severe wing rock as a sign of a deeply-departed state. Both of these required (if even possible at that point) aggressive nose-down pitch inputs to break the AOA. And even then, the aircraft is going to lose a ridiculous amount of altitude before it gains enough airspeed back to give you enough pitch authority to scoop out of the ensuing dive. Horrible. It also boggles my mind that Airbus didn't think at first to design an aircraft which avoided the split control problem they had. One person and one person only needs to be in control of the aircraft at all times.

molenzwiebel 3y ago
Time and time again we learn that people do stupid things under stress. Consider Transair flight 810 [1], in which a simple engine failure during takeoff results in a complete loss of the aircraft when both pilots mistakenly identify the _wrong_ engine as malfunctioning, despite identifying the failure correctly only minutes earlier. OP has an article on that crash too, actually [2]. [1]: https://en.wikipedia.org/wiki/Transair_Flight_810 https://en.wikipedia.org/wiki/Transair_Flight_810 [2]: https://admiralcloudberg.medium.com/dark-waters-of-self-delusion-the-crash-of-transair-flight-810-a4eeb033bc00 https://admiralcloudberg.medium.com/dark-waters-of-self-delu...
- psunavy03 3y ago
  Another very common failure mode, and really all you can do is mandate an SOP that the crew member vocalizes which engine they're turning off, and the other crew member verifies that it's the correct engine. The other answer to "people do stupid things under stress" is the common maxim that every emergency procedure in every aircraft starts the same way. Somewhere in the cockpit is probably a standard-issue mechanical 8-day clock, and the first thing you do in any emergency is stop and wind the clock. Not because it does anything to the aircraft, precisely the opposite. It makes you stop for a second or two for the "oh shit" moment to pass. Then you analyze what's actually going on. The other saying that's always briefed is "no fast hands in the cockpit." You may need to be expeditious, but you still vocalize what you're doing with your crew or wingman and methodically go through the emergency procedure. You get in a lot more trouble flipping switches willy-nilly based on what you think you have than if you just stop, breathe, and look at what the aircraft is telling you. I still can recite the steps from memory: - Maintain aircraft control - Analyze the situation - Apply the appropriate emergency procedure(s) - Land when conditions permit

JackFr 3y ago

I got this: while (true) { try { airspeed = getAirspeed(); } catch (Exception e) { log.warn(“”,e); } }

oatmeal1 3y ago

After this crash the French word for idiot was changed to Bonin.

kloch 3y ago

It's tempting to blame the inexperienced first officers, their training, or the CRM failures on this flight, but the blame for this crash has to land squarely on the atrociously bad UX of the Airbus cockpit. Sensory overload and no clear readout of what is actually broken (pitot tube icing in this case) is bad but the fly-by-wire joystick configuration is what really doomed this flight. In Boeing airliners and many other types of aircraft the control sticks are mechanically linked together: you can physically feel if the other pilot is fighting your inputs: > “Controls to the left,” Robert said, still worried about their bank angle. Pressing the priority button on his side stick, he took control and locked out Bonin, but Bonin immediately pressed his own priority button and assumed control again. If the controls were mechanically linked Robert would have recognized his inputs were being overridden and would have been able to save the plane.

_cenw 3y ago
* The overhead panel would've shown FAULT on the ADIRs. * The ECAM did show IF SPD DISAGREE: ADR CHECK PROC. * The plane did shout DUAL INPUT several times, and a button to lock out the other pilot is right on the stick. You can hear it being used by Bonin. I'd say this is a failure of lack of crew resource management (not even technical ability) more than anything else.
- deleted 3y ago
  [deleted]
- cyberax 3y ago
  The thing is, people in high-stress situations tend to miss audio cues. That's why Boeing uses stick shakers for the stall warnings. And there were _several_ incidents with Airbuses that were caused by dual inputs.
oatmeal1 3y ago
> It's tempting to blame the inexperienced first officers or their training but the blame for this crash has to land squarely on the atrociously bad UX of the Airbus cockpit. The real problem is that someone who doesn't look at his most critical instrument* in instrument flying conditions, causes a stall, doesn't respond to stall warnings, doesn't communicate, refuses to hand over controls even though he doesn't understand what is happening, is in the cockpit at all. Either the training was inadequate, or deficiencies in Bonin's flying were overlooked.

free_energy_min 3y ago

Anyone understand if the readings fully came back? If so why wouldn’t the plane go back to normal law?

deleted 3y ago
[deleted]

Simplicitas 3y ago

This brings up an interesting question: If the control was fully automated, the computer entirely in charged, would this have happened?

fakedang 3y ago
As shown in the article, when the pitot readings were incorrect and the initial 3 second stall warning was displayed, a veteran pilot would simply have had to let the plane continue on in normal law mode, without any action. But Bonin was too overreliant on the incorrect action from the autopilot (moving to alternate law), which itself was an incorrect result from the incorrect readings of the Pitot tubes. Pitot tube icing is one of those issues where automation becomes useless entirely.

legitster 3y ago

> Behind the scenes, the loss of valid airspeed data had triggered a shift in the Airbus’s complex flight control laws. In “normal law,” computers interpret pilots’ side stick inputs and move the control surfaces in accordance with what is reasonable at that altitude, speed, and configuration. This improves the handling of the airplane to such an extent that no particular skill is required to fly it gracefully. Normal law also comes with full flight envelope protections in roll, pitch, speed, and load factor. > If sensor failures occur, the controls drop down a level to “alternate law.” This law contains several sub-laws with slightly different configurations, but in general, alternate law means that some or all computer moderation of control inputs remains, but flight envelope protections are removed. The autopilot and auto thrust cease to function. > In the event of further failures, the controls can enter direct law, in which there are no flight envelope protections and side stick inputs correspond directly to the position of the control surfaces, with no adjustment by the computer. This makes the airplane fly rather like a classic airliner, similar to most older Boeing models. When you think of all of the Tesla accidents, this still seems to be the failure mode for autonomous systems. It's safer 95% of the time. But when it fails, it's because the users are so dependent on the systems that they don't even have the simplest of skills to prevent catastrophe.

akira2501 3y ago
> it's because the users are so dependent on the systems that they don't even have the simplest of skills to prevent catastrophe. One pilot was pushing full nose down. The other full nose up. The system _did_ tell them that they were doing this, but in the sea of other alarms, it didn't register with them. The lack of alarm prioritization and the lack of crew resource management training in the face of an emergency seem like the major human factors here. Half of that is in the design of the plane, the other half in how the company trains their pilots to handle severe emergencies.
_cenw 3y ago
I'd be hesitant to compare these. The aircraft still operated as designed. It detected that the input data was bad and turned the automation off. The pilot flying just didn't seem to grasp what that means. Most Tesla Autopilot failures aren't drivers that don't know how to drive, it's the automation making bad inputs.

mercurialsolo 3y ago

This is a fabulously well written article in the means of a technical thriller. "All of this happened near instantaneously, leaving the pilots completely in control of the airplane with little advance warning." Complex systems have such a low-window for handling or preventing failure that it is impossible to deal with it at manual scale unless we have a super-good control panels and copilots. Why we need a lot more work on observability and interpretability while operating complex systems.

jcalvinowens 3y ago

The article misses the key takeaway from this incident IMHO. When the controls were pegged at full aft deflection, the stall warning would cease, because instrument readings in the deep stall were considered invalid by the computer. Whenever the pilot would start to push forward to recover, the computer stopped rejecting the readings, and started sounding the stall warning again! So every time the pilot started to do the right thing, the airplane would start screaming "STALL STALL" at him, and he would pull the stick back again to make it stop. I firmly believe that they would still be alive if the stall warning had either not been installed at all, or had functioned properly.

zerocrates 3y ago
This is mentioned in the article.
- jcalvinowens 3y ago
  Only in passing. The dramatized retelling through the first part of the article completely glosses over it.
_cenw 3y ago
It's important to note the stall indication itself wasn't disregarded, but the indicated airspeed (that is a prerequisite). This plane was in the exceptional situation of falling out of the sky faster than it was moving forward.
SoftTalker 3y ago
Not a pilot but I believe that pulling the stick back is exactly the wrong thing to do in a stall. The pilot should have instinctively known that pulling back on the stick would not recover a stall. On the other hand, pilots are taught to "trust the instruments" but IIRC the aircraft had no angle of attack indicator, and the airspeed tubes were frozen over. So lots of bad or missing information, contributing to stress and panic, which does strange things to otherwise normal people.
- 3y ago

Tronno 3y ago

In post-mortems involving pilot error, what strikes me is that airliner cockpit design sounds so convoluted, unintuitive, and just plain bad. The burden of disentangling this bad design is always placed on the pilots - through extensive training and rote memorization - which inevitably fails under stress. In this particular example, consider: - the opposing pilot inputs being signaled only by a pair of little green lights - the cacophony of warning lights and alarms which, together, say little more than "something is wrong" - instruments that direct a pilot to pull up during a full stall - sensor failures with no clear indicator - computer safeguards suddenly removed without a stated reason Etc. And the expectation towards the crew is to quickly and corrently reason about this stream of conflicting signals, while embroiled in a sudden emergency. It smacks of pure engineer-driven design, assembled with serious attention to the technical issues, but with near-zero empathy for the humans who will be operating the contraption. Reminds me of internal web tools at so many companies. They present giant messy forms, with checkboxes and dropdowns for every conceivable edge case, which have to be manipulated just so or the system explodes. And when something breaks, of course it's the user's fault every time.

cedws 3y ago
I also wonder why airspeed is derived by some formula applied to the measurement of flow along a tube that can be blocked by ice and become useless. Why not use GPS primarily and fall back to that if needed? Or the other way around even. If you expect an instrument to routinely fail, it just seems logical to at least have a backup.
- thatswrong0 3y ago
  Ground speed and airspeed are not the same thing. You need to measure airspeed directly. And I think there are generally 3 pitot tubes on planes.
- flerchin 3y ago
  Jetstreams are hundreds of kph. Meaning groundspeed can be hundreds of kph off of airspeed. Meaning GPS is a very poor backup airspeed indicator.

CoconutPilot 3y ago

One thing that stands out to me is the incorrect use of the word "law" when referring to flight modes. Is this just a bad translation? Are any native French speakers familiar with the Airbus documentation able to comment if the concepts make more sense in French?

Glawen 3y ago
The word loi (law) is indeed used in french controls engineering, not only for planes. See https://fr.m.wikipedia.org/wiki/Loi_de_commande_de_vol https://fr.m.wikipedia.org/wiki/Loi_de_commande_de_vol Cannot say if it is good or bad to be honest, I believe Airbus themselves decided on the English term law to translate the french term.
- GiorgioG 3y ago
  No it isn't. https://en.wikipedia.org/wiki/Flight_control_modes https://en.wikipedia.org/wiki/Flight_control_modes
  - Glawen 3y ago
    I updated in the meantime, what isn't?
baby_souffle 3y ago
> One thing that stands out to me is the incorrect use of the word "law" when referring to flight modes. Is this just a bad translation? Are any native French speakers familiar with the Airbus documentation able to comment if the concepts make more sense in French? The word "law" can mean several things depending on the context and it's not uncommon to hear of a system following some subset of rules as operating under a certain "law". If it's more palatable, you can `s/law/mode/g` even though you may technically have a few different possible modes under some higher "law/regime" [0] [0] https://en.wikipedia.org/wiki/Flight_control_modes https://en.wikipedia.org/wiki/Flight_control_modes

dreamcompiler 3y ago

I'm amazed that the autopilot kicked off just because the pitot tubes froze. The A330 has an inertial reference unit as well as (almost certainly) GPS, both of which could have provided ground speed. Air speed could be extrapolated from previous air speed and inferred from ground speed, engine thrust, and known weather. IRU and GPS could also have provided altitude and thus climb rate. And we know the plane had a barometer, although it had to be corrected for airspeed according to TFA. I'm guessing the plane also had a radar altimeter, but maybe not. With all these sources of information, the autopilot could have said "Hey the pitot tubes are giving me weird data, but no worries. Still flying the plane. Carry on." Why didn't that happen?

thatswrong0 3y ago
> Air speed could be extrapolated from previous air speed and inferred from ground speed, engine thrust, and known weather. I think this is probably the main sticking point. I don't think you can do this accurately without some direct measurement. If the plane thinks its air speed is fine but it's actually approaching its stall speed because it guessed its airspeed incorrectly, that'd be really bad.
- dreamcompiler 3y ago
  Stall is determined solely by angle-of-attack, which TFA points out. Airspeed doesn't factor in to whether the computer thinks it's about to stall. Here's the relevant sentence: "Crews involved in similar incidents reported that they assumed the brief stall warnings were generated by the erroneous airspeed readings, a not unreasonable interpretation which breaks down only when one learns that the stall warning calculations are based on angle of attack and do not incorporate any airspeed data."
  - thatswrong0 3y ago
    Except that AoA vanes are not perfect and are speed sensitive. > From the A330/A340 FCTM (Flight Crew Training Manual) section 8.110.4: > The ADRs provide a number of outputs to many systems and a blockage of the pitot and/or static systems may also lead to the following: > … > Alpha floor activation (because AOA outputs from the sensors are corrected by speed inputs) From what I can tell, these systems are all pretty complicated and have undergone significant real world testing to ensure that the expected protections actually work, assuming the flight computer is receiving accurate data. Which is precisely why they have Alternate Laws - if they can’t guarantee that these protections can work, then they won’t.

Hinrik 3y ago

This crash was also covered on an episode[1] of the Black Box Down podcast. [1]: https://roosterteeth.com/watch/black-box-down-2020-7-30 https://roosterteeth.com/watch/black-box-down-2020-7-30

rich_sasha 3y ago

As someone who follows aviation and flew the Flight Simulator quite a bit when young, I don't quite understand how it all happened. The mechanics are clear, but aren't pilots trained _ad nauseam_ precisely against this kind of events? It read like this was two panicking guys shouting at each other. By contrast, listening to the recording of the Hudson River landing, it was stunning just how eerily calm the pilots was there. You hear them opening the manual and reading from it IIRC! I don't mean it like, they're dumb cos I watched a YouTube video, I just don't understand. Especially since, as the article claims, pitot tubes all freezing at the same time is somewhat common.

V99 3y ago
I think it's just an "everybody has a plan until they get punched in the mouth" situation. In an actual emergency some people react well and go back to their training, others panic & freeze up. And it's hard to predict, you do tons of emergency situations during all the flight training they would have gone through in sims and actual planes, but in the back of your mind you still know it's coming and not a real emergency when the instructor pulls the power out to simulate an engine failure or tapes up a piece of paper to block the airspeed indicator.
davidktr 3y ago
If you have an hour to spare, I found this video by an experienced pilot extremely helpful: https://www.youtube.com/watch?v=e5AGHEUxLME https://www.youtube.com/watch?v=e5AGHEUxLME
- rich_sasha 3y ago
  You're right, a great video, thanks for the top tip. If nothing else, it provides complexity to the situation, which I felt was somewhat missing from the article.
mplanchard 3y ago
My understanding is that this incident is one of the reasons why pilots are now trained ad-nauseum for such events, but that training for things like high-altitude stalls was not the norm previously

this_steve_j 3y ago

This was quite a big mess! Let’s see if there is a way to break it down in a Safety II fashion. 1. Airline human resources deviated from the traditional practice of hiring experienced rudder and stick pilots. 1. Overly permissive company attitudes toward crew rest and a lack of awareness about how it can affect vigilance and fitness for duty. 1. Breakdown of the ceremonies that transfer command and control in the cockpit. 1. Lack of training for high altitude stall recovery. 1. Activities performed in low altitude stall recovery training scenarios are orthogonal to a successful recovery in high altitude stall scenarios. 1. Automation surprise followed by alert saturation combined with incongruous perceptual signals and loss of situational awareness. 1. Aircraft control systems that failed to resolve the ambiguous delegation of authority (double PF) dilemma. 1. Highly compressed timeline of events in a physically disorienting environment. 1. What else?

eep_social 3y ago

I love what the author is doing but I honestly don’t understand the gushing over their writing style. To me, it feels full of speculation and melodrama, exactly the language investigators don’t use when they write the accident reports: > pilots into a state of paralyzed agitation.. > all the while trying desperately to understand.. > But there is a reason, written between the lines of the cockpit voice recorder transcript, hidden away within the mysterious code that governs human behavior, a key to the secrets of the profoundly irrational. Its lessons could not be more important, even for those who believe themselves above the doomed crew of flight 447, as the boundary between the responsibilities of man and machine grows ever dimmer. > Overwhelmed by the noise of the warnings, the terrifying vibrations, and the wildly fluctuating instrument readings, his brain seemed to shut down, paralyzed by confusion and fear. Citations needed.

rnoises 3y ago

On a slightly different note, this sort of thing is what makes me question whether we can have an orderly progression from the current Level 2 self-driving in cars to Level 5. When a plane does most of its flying by itself, if it can cause this much chaos by handing control back to a trained pilot without much warning, how much worse would it be when a car hands control back to a inexperienced, distracted driver in tricky driving conditions... especially considering that reaction times need to be much faster on the road?

brohee 3y ago

IMHO something is still missing. Bonin's father was a pilot (in Air France AFAIK) and I can't help but think the likelihood he was the best candidate was low, but that legacy played a part. I also wonder if he had much passion for flying or was just following his father footsteps. I wish they would value passion more, easily demonstrated with military/glider (I must miss some..) experience.