So I’ve read the BEA report from one end to the other and overall it’s a solid and creditable effort. The report will probably disappoint those who are looking for a smoking gun, once again we see a system accident in which the outcome is derived from a complex interaction of system, environment, circumstance and human behavior.
However I do consider that the conclusions, and therefore recommendations, are hasty and incomplete.
This post is part of the Airbus aircraft family and system safety thread.
My immediate concerns revolve around the failure of the BEA to consider fully the effect of interaction between the aircrew and automation as a causal factor. There are five key technicalareas which I believe are worthy of further consideration, these are:
- the un-intended interaction of the stall warning logic with control inputs and the aircrafts flight state,
- the low attensity of the automatic trim adjustment in alternate law,
- the failure to differentiate between approach to stall and actually being in a stalled condition,
- the lack of a robust ‘inya face’ unusual attitude display of aircraft alpha and/or attitude to support recovery from an aircraft unusual attitude event, and
- the lack of ‘cross cockpit’ communication of control inputs by the FP to the NFP.
Yes the aircrew’s behaviour showed a lack of experience and failure to follow procedure, but we should remember that they were the product of a certified flight safety management system. So the real question is would we expect a crew of equivalent training and experience to have behaved differently?
To that end I agree with the BEA that there was a less than optimal allocation and management of crew resources, however there is sufficient information that a much more comprehensive and insightful analysis of crew behaviour could be undertaken. In an earlier report the BEA reviewed the response of other air crew to icing events, yet in this report there is no mention, and perhaps the final report will knit these threads together…
Fundamentally this accident poses the question, why are human beings in the cockpit? If the conclusion is that pilots are there to deal with situations outside the predictions of the designers, and all that goes with such an assumption, then it is one that the BEA has resolutely failed to make.