A comprehensive report but dominated by the fear of opening Pandora's box!
It is no surprise that the BEA's final report concludes that there were two essential elements for the crash of the Airbus A330; the first, the icing and subsequent blockage of the Pitot tubes and secondly poor pilot management of the situation which took the aircraft out of its flight envelope.Thus, human error is reconfirmed as the prime cause of the accident because the pilots failed to identify and properly manage a problem already known to exist in such conditions. Experts in cognitive sciences attempted to analyze and to understand the inappropriate reactions of the pilots which is a step in the right direction.
However, as in the interim report, the final report demonstrates the same linear character
giving us an analysis which ignores a fundamental aspect of the incident: systemic risk management, or in this case, the problem of the icing up of the Pitot tubes which was already known, casting doubt on the effectiveness of provisions meant to guarantee flight safety. Had the risk been adequately appreciated?
Similarly, the philosophy behind pilot training tends, insidiously, to produce "aircraft operators" rather than airmen/airwomen. Preferring to follow general market tendencies, largely dominated by profit, which generates a new generation of airline pilot which is easier and cheaper to produce. What is at stake is a possible link between the errors assigned the the crew of AF447 and cost saving/cutting in airline pilot training programs.
These are the two fundamental questions that the BEA seems to have carefully avoided, either by choice of method, or maybe by a discrete political will from behind the curtains.
How to manage in-flight risk?
The report mentions, laconically, the thirteen reported cases of loss of airspeed indication, without addressing, at any time, risk management required by such a recurrence, or, at least, to wonder about it. Any «unreliable airspeed» situation is extremely critical and requires immediate pilot action in order to keep the aircraft within flight envelope limitations. Something the pilots of the A330 were not able to do.
Identifying and understanding the real causes of such a failure is fundamental if we are to avoid a catastrophic repetition of AF447's fatal accident. The threat and error management model (R.L.Helmreich) is a powerful analytical tool that highlights the examination of the Human Factor based on harmful links between threats and errors.
Threats - thunderstorms, technical failures, human and/or organizational factors - don't necessarily cause accidents. However, they significantly increase the complexity of pilot tasks and consequently induce a higher error generation rate. There is no doubt that the build up of ice on the Pitot tubes and the subsequent impact on the aircraft flight instruments and control modes created an extremely complex situation that the pilots didn't manage to control.
Trying to understand why and how errors emerge without taking into account latent threats is necessarily doomed to failure. That’s why the low interest shown by the BEA to the repeated Pitot tubes problems is somewhat surprising. This sequence of events and management that was made could very well indicate the presence of a systemic threat, which does not appear to have aroused the curiosity of investigators.
How to explain the pilot error?
Error is basically inherent to human nature, no one can argue with that. Pilot training, whether on the ground, in the air, using flight simulators or implementing standard operating procedures, are processes and techniques which strive to reduce the number of errors made, without being able to eliminate error all together.
It's not so much a question of why pilots make mistakes, but what are the contributing factors that made them make the mistake. This is why the BEA called upon recognized specialists to understand why the pilots reacted the way they did.
Human factors, them again!
Thus, the report found a series of failures on the part of the crew, starting with them failing to identify an unreliable airspeed situation that should have triggered an immediate and well defined series of actions by the manufacturer. The pilots were obviously destabilized by the sudden disconnection of the Auto-Pilot and the immediate flooding of their senses by so many warnings and messages that forced them into a state of Loss of Situational Awareness.
In such conditions it was unlikely, or even impossible, to identify and recover from the aircraft stall. For the BEA, the pilots lacked basic airmanship, meaning a too high dependence on automation and aircraft systems reliability. But is it not strange that the report attributes one of the major causes of the accident to "natural phenomenon" when they could be symptoms of a greater evil?
Indeed, the report also discusses the initial destabilization of the crew and their low resistance when faced with an unexpected (unpredictable?) situation. That is to say, the ability to deal with a problem that they may not have been trained to deal with. The whole question is then: does a lack of basic airmanship increase the risk of sensorial overload in such complicated situations, or would the complexity of the situation have overcome even the best trained and resilient crews?
What is airmanship exactly? Often a subject of discussion, but in basic terms, the optimal combination of natural flying skills, knowledge, experience and good common sense, or judgment. What is often forgotten is resilience, or how a pilot reacts under extreme pressure. Resilience is precisely the faculty that enables a person to cope with a traumatic event. It is the steel that underpins the strength of reinforced concrete.
As without this hidden force the pilot can lose very quickly his, or her, ability to deal with a situation that is rapidly evolving before his or her eyes, resulting in a complete loss of control of the situation. This is something that you cannot teach, but that needs to be recognized and evaluated during initial pilot training. We absolutely need all three fundamental pillars, flying skills, knowledge and resilience to have airmanship. As a matter of fact, this basic understanding seems to have become an alien concept when looking at modern airline pilot training more focused on training «aircraft operators» at the lowest possible cost.
Recommending more exercises in flight simulators cannot be bad. Except that the tendency of the aeronautical industry is completely in the other direction, like most other industries, they are trying to reduce costs. In other words, the additional exercises recommended by the BEA will be detrimental to other exercises that will be removed. Until another recommendation requires them to be reinstated or reinforced?
However, no matter how praiseworthy this recommendation is, doesn't it miss the problem completely? The crew lost their situational awareness and thereby their ability to face and deal with the problem, thereby their ability to save the situation. So won't more hours in the simulator be like an extra coat of paint to hide the cracks on the wall? What we need to understand is whether the cracks are generic to the current system, or unique to the crew of AF447. Yet another systemic threat!
It must be said that the authors of the report did a fine job, however one must regret that the recommendations don't go far enough and seem to reveal the guiding hand of Political correctness. Hiding behind the cover of an ongoing judicial enquiry, the report very prudently avoids any potentially damaging comments to the establishment, in this case the Aeronautical Industry. Travel by air remains one of the safest means of transport in the world, but to maintain that position, there is a price to pay, rigorous training methods, without which we risk the onset of complacency in safety and training. That is in fact the basic question: do we prefer the illusion that this image of safety is never ending, no matter how we deal with it, or should we strive for continual improvement whatever the cost?