Including Air France flight 447, there have been twelve fatal loss-of-control airline accidents since the year 2000.
Altogether, they have killed 1,394 people.
The common factor in all of them was pilot inability to recognise what was happening and to do something effective about it in time to save the aircraft.
So what we're looking at here is an issue of human cognition.
Since the release of the cockpit voice transcript by the investigators of Air France 447, the fact that the pilots were totally at a loss to understand what was happening to their aircraft has become distressingly clear.
Before I start digging down into the immensely complex human aspects of this accident, I must make clear that, even when the BEA's final report comes out, we'll still be guessing at what was going on in the heads of the three pilots in charge of Air France 447.
But even if, after the final report, we are left guessing about what was actually going on in the pilots' heads, that does not absolve us from the responsibility of attempting to understand it.
Because unless we do understand, we can't work out intelligent ways to deal with these problems of pilot cognition and lack of situational awareness.
In Air France 447 the pilots were confronted with a situation they clearly didn't recognise,
or didn't believe,
or didn't understand.
They never appeared to come close to appreciating what they could do to save the aircraft, because they didn't understand what they were seeing.
The essential question is: how can that be? These pilots were fully qualified to operate this aircraft, and the same was true of the pilots in charge of the 11 other cases of loss of control since the year 2000.
I said before, understanding these events necessitates an understanding of human cognitive processes, and of how they are sustained.
Cognition has many components. Let's go back to those three words I mentioned, which describe what pilots have to be able to do when they look at an aircraft's instrument panel: recognise, believe, understand.
If the Air France 447 crew had recognised what the flight and engine instruments were telling them, had believed the information the displays were supplying, and had understood the whole picture conveyed by the numerous sources of data, they could have recovered that aircraft to safe flight at any point in the trajectory, except the final minute or so of flight.
What is in danger of happening following AF447, is that the industry reacts to this accident by trying to design the pilots totally out of the loop and to replace them with automation.
But the irony of that course of action would be that, in the case of Air France 447, the fatal sequence of events started with the automation disconnecting because it could not cope, leaving the pilots to fly the aircraft without it.
The problems for this crew started when the autopilot and autothrottle tripped out, and the aircraft's control system shifted out of normal law into alternate law.
In normal law, the crew have full, automatic flight-envelope protection.
In alternate law, the pilots themselves are entirely responsible for keeping the aircraft's flight within its safe performance envelope. Just like the old days.
Just, in fact, like most airliners still flying today.
The reason the automation tripped out is the GIGO principle that applies to all computing: Garbage In, Garbage Out.
An aircraft's automatics are designed to trip out when they recognise they're being fed unreliable data. Because if computers are fed incorrect data, their output will be incorrect, and this could lead to disaster.
So they hand over control to the pilots.
In Air France 447 this is where a minor technical problem became a major one, because of the pilots' misapprehension of what was going on and why.
That misapprehension was certainly not inevitable, but it was - and remains - a likely product of the way aeroplanes have changed, while airline pilot recurrent training has not evolved to take account of the differences in the modern flying task.
I maintain that what happened here is a symptom of the fact that the aviation system itself has already taken airline pilots out of the loop.
It didn't intend to, but that has been the effect.
When aeroplanes didn't have flight management systems, pilots had to work out their navigation and aircraft performance on paper. Planning a complex descent in difficult terrain while flying on instruments would require a combination of mental arithmetic and the use of pages of tables in the flight manual, or the use of a circular slide rule, or both.
The effect of doing these things with raw data meant that the pilots were more mentally engaged in the aircraft's trajectory planning than they are now.
With the old system, they could still make mistakes, and many lost their lives through their mistakes, but they didn't come to grief by losing control of their aeroplanes.
Air France 447 was a loss of control, or lack of control accident. The acronym LOC covers them both, and the result is the same.
LOC is becoming a modern phenomenon. Before Air France 447, it had already become the biggest killer accident category.
Why?
Pilots have no need to do their detailed calculations and trajectory planning any more because the FMS computers are more accurate than anything they could do.
One effect of this is that pilots become passive recipients of pre-packaged information, which is both accurate and intuitively presented, and thus seductively credible.
If it were ever to lie to you, it would lie so beautifully you would believe it.
The trouble is that, although pilots are given initial training in the mental skills needed to fly without automation, modern flying on the line does not give them any practice at using these skills.
And because recurrent training doesn't provide the practice either, the mental skills atrophy, and so does the knowledge and awareness that practice confers.
It wouldn't matter that such skills should atrophy if an aircraft's automatics could be guaranteed never to fail or, as in the case of Air France 447, never to withdraw their services for good reason.
Unfortunately, computers will occasionally fail.
The task the airline industry faces is rebuilding the pilot skills that automation takes away from them.
Contrary to a lot of comment you will hear, this is not a function of the atrophying of manual motor skills, it is brain skills and awareness that is being lost.
I would qualify that statement about loss of manual skills by saying that flying on instruments is a skill that needs frequent practice, because it requires sophisticated cognitive skills.
But even in instrument flying, it is not the loss of motor skills that's the killer, it's the loss of that ability to recognise, believe, and understand what the instruments are telling you.
But the loss of these skills is being covered up by the cleverness and reliability of flight management systems and the autopilot/autothrottle systems that they direct.
Even the pilots don't know whether they've lost these skills or not.
They don't find out unless the automatics fail. And with the stress of a systems failure reducing your brain's capacity to take good decisions, that's a bad time to find out you no longer have the skills to cope.
Just a simple analogy for you about the loss of skills: I recently discovered I had forgotten how to do long division. I don't need that skill any more because my calculator has rendered it redundant.
But my life and the lives of those around me do not depend on these atrophied skills of mine.
Whereas a pilot's cognition of what's going on, gleaned from raw data sources when that's all there is left, is essential for survival.
The training regime pilots are required to undergo is the underlying cause of Air France 447.
The training regime is not set by the airlines, it is set by the world's civil aviation authorities. They have failed to update pilot training requirements to take account of the massive changes in the nature of an airline pilot's job with the arrival of modern, highly automated aircraft.
So it's the world's civil aviation authorities who, above all others, shoulder the responsibility for Air France 447, and for the eleven other loss-of-control flights since 2000.
Let me list them. And remember these have been the cause of 1,384 unnecessary deaths:
2010 Afriqiyah Airways A330-200, Tripoli airport approach, Libya
2010 Ethiopian Airlines Boeing 737-800, in the Mediterranean Sea near Beirut
2009 Yemenia Airbus A310-200, in the Indian Ocean near the Comoros Islands
2009 Air France A330-300, South Atlantic
2009 Caspian Airlines Tu-154M, Iran
2009 Colgan Air Dash 8 Q400, Buffalo, NY, USA
2008 Aeroflot Nord 737-500, Perm, Russia
2007 Adam Air Boeing 737-400, Java Sea near Sulawesi
2006 Armavia Airbus A320-200, Black Sea near Sochi
2004 Flash Airlines 737-300, Red Sea near Sharm el-Sheikh
2000 Gulf Air A320-200, Arabian Gulf near Bahrain
2000 Crossair Saab 340B, Nr Zurich, Switzerland
This has to stop, and a modernised system of training for pilots that recognises how automation is causing essential skills to atrophy, is the only way of doing it.
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