safety investigation into the accident to the airbus a330, air france flight 447, june 1, 2009 human...
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Safety Investigation into the accident to the Airbus A330,
Air France flight 447, June 1, 2009
Human Factors Issues
Sébastien DAVID, Senior Safety InvestigatorHead of the Human Factors working group
June 2009
Investigationworking groups
- Sea searches- Systems - Operations - Maintenance
June 2011 June 2012
3rd
Inte
rim re
port
Flight RecordersRecovery Human Factors
Working group
AF447 Human Factors Group – Overview
June 2010
1st I
nter
im re
port
FINAL R
EPORT
2nd
Inte
rim re
port
AF447 Human Factors Group – Overview Organization
Initiation of HF investigation:- August 2011, after the release of the third interim report
Constitution:- Four experts (HF, pilots…)- Three BEA investigators
Coordination- Close coordination with IIC and other working group leaders
Group reportBEA internal document
- Used for the Final Report- Same format as BEA reports(based on the one recommended by ICAO Annex 13)
Human Factors Group - Objectives and Methodology
1. To explain safety measures supposed to ensure flight safety in similar operational situations
Human Factors Group - Objectives and Methodology
1. To explain safety measures supposed to ensure flight safety in similar operational situations
2. To analyse the performance of those safety measures for the investigated situation
Human Factors Group - Objectives and Methodology
Example of Fatigue Investigation
Part 1.16.7 in the Final Report« Aspects relating to fatigue »
Two steps: Fatigue estimation
Sleep aspects (length, quality…) Circadian factors Awakening
Evaluation of pilots performance, behaviors
P h ys ic a lc h a ra c te ris tics
H u m ans e n so ry
lim ita tio ns
O th er
PHYSICALSENSORY LIM ITS
I lln e s s/In c ap a cita tio n /
H e a lth /F itn e ss
L ife s tyle /
F a tigu e /A le rtn e ss
Illu s io ns
O th er
PHYSIOLOGY
A ction o rla c k o f ac tion
A c tion -p lan n ing
In fo rm ationp ro c es s in g /
D e c is io n m a k ing
A tten tio n /P e rce p tio n /M o n ito ring
S k ill/T e ch n iqu e/
A b ility
J u dg e m e nt
K n ow led gea c q u is it ion
S itu a tio n a la w a ren e s s/
D is o rien ta t ion
P e rso n a litya n d a tt itud es
M e n ta l/E m o tio n a l
PSYCHOLOGICALLIM ITATIONS
T a s ks c h ed u ling
P e rson a l t im ingo f a ctio ns
W o rk loa d ta sks h ed d ing
T a s ka llo ca tion
O th er
W ORKLOADM ANAGEM ENT
E xp erie n cea nd
q u a lif ica t io ns
R e c e n cy
A d eq u a cy o fk n o w le d ge
EXPERIENCEKNO W LEDGE
AND RECENC Y
L IV E W A R E (H U M A N)
Human Factors Group - Objectives and Methodology
Example of Fatigue Investigation
Fatigue estimation
Limitations on flight and duty times, as well as rest time in accordance with EC n°859/2008
Accident happened between midnight and 06h00 Circadian dip
Awakening and sleep: Lack of precise information
Impossible to evaluate accurately the level of fatigue of the crew
Human Factors Group - Objectives and Methodology
Example of Fatigue Investigation
Evaluation of pilots performance, behaviorsBased on CVR recording
Level of activity and implication of the augmented crew Vigilant attention
No signs of drowsiness or sleepiness
Fatigue management Captain’s questions
No evidence of performance or behaviors consistent witheffects of fatigue or sleepiness prior to the accident
Human Factors Group - Objectives and Methodology
1. To explain safety measures supposed to ensure flight safety in similar operational situations
2. To analyse the performance of those safety measures for the investigated situation
3. To make an evaluation of the rationality and the robustness of those safety measures
Human Factors Group - Objectives and Methodology
1. To explain safety measures supposed to ensure flight safety in similar operational situations
2. To analyse the performance of those safety measures for the investigated situation
3. To make an evaluation of the rationality and the robustness of those safety measures
4. To make recommandations
AF447 Human Factors Group – Analysis
1. From the cruise to the AP disconnection
A. Cruise and crossing the ITCZ: perception and management of operational riskB. Relief of Captain
2. From the AP disconnection to triggering of stall warning
A. Detection of problem B. Control of flight path C. Identification of the situation D. Attempt to control the flight pathE. Return to handling the failure
3. After triggering of stall warning
A. Piloting inputsB. Return of CaptainC. End of HF analysis
AF447 Human Factors Group – Analysis
1. From the cruise to the AP disconnection
A. Cruise and crossing the ITCZ: perception and management of operational riskB. Relief of Captain
2. From the AP disconnection to triggering of stall warning
A. DETECTION OF PROBLEM B. Control of flight path C. Identification of the situation D. Attempt to control the flight pathE. Return to handling the failure
3. After triggering of stall warning
A. Piloting inputsB. Return of CaptainC. End of HF analysis
Detection of a problem – The context
What was (is) known about the sequence of events:
Temporary inconsistency between the measured speeds, likely following obstruction of the pitot probes by ice crystals
Ice Crystals
MeasuredPressure
Þ Autopilot disconnection
Þ Reconfiguration to alternate law
Detection of a problem – The HF approach
What was used in the frame of the HF analysis:
Þ Available data put in the context of the crew
Þ Safety expectations in case of a sudden anomaly and implications on human performance
Þ For a good chance that these expectations of the crew may be met, necessity to have:
- the signs of the problem sufficiently salient- these signs credible and relevant- the available indications relating to the anomaly swiftly identifiable- actions sufficiently rehearsed to be associated with awareness of the anomaly- no signals or information available that suggest different actions
1. To control the flight path2. To detect the anomaly3. To « make sense » of this anomaly4. To take corresponding actions and decisions
Detection of a problem – The HF approach
What was used in the frame of the HF analysis:
Þ Case of speed anomalies
1. To control the flight path2. To identify the loss of consistency in indicated airspeed3. To « make sense » of this anomaly4. To manage the anomaly with:
Detection of a problem – The HF approach
Samples of how it was analysed by the HF group:
Salience of the speed anomaly very low compared to that of the autopilot disconnection
Reaction of the crew by taking over manual control⇒ No idea of why the AP disconnected⇒ Surprise of the pilots due to the new situation
No definition of the flight path to follow⇒ Large input on the PF sidestick
Identification of a speed indication anomaly⇒ No call out of the procedure⇒ No correlation between the loss of displayed speeds and the associated procedure
Absence of a constructed action plan⇒ Reactive management of the situation
Not specific to this crew
Findings
Training Basic Airmanship Human – Machine Interactions CRM Stress Procedures
Inputs for Safety Recommendations
AF447 Human Factors Group - Conclusions
