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Escalating
complexity:
DevOps learnings from
   Air France 447
Lindsay Holmwood
    @auxesis
Engineering Manager
          @
Bulletproof Networks
cucumber-nagios
     Visage
    Flapjack
•




 On 31 May 2009, Air France 447 departed from Rio de
Janeiro-Galeão International Airport at 22:29 UTC. It was
scheduled to arrive at Paris-Charles de Gaulle
International Airport 11 hours later.
•




 On 31 May 2009, Air France 447 departed from Rio de
Janeiro-Galeão International Airport at 22:29 UTC. It was
scheduled to arrive at Paris-Charles de Gaulle
International Airport 11 hours later.

•




 3 hours and 45 minutes later, it crashed into the Atlantic
Ocean, killing 216 passengers, and 12 aircrew.
•




 On 31 May 2009, Air France 447 departed from Rio de
Janeiro-Galeão International Airport at 22:29 UTC. It was
scheduled to arrive at Paris-Charles de Gaulle
International Airport 11 hours later.

•




 3 hours and 45 minutes later, it crashed into the Atlantic
Ocean, killing 216 passengers, and 12 aircrew.

•




 There were no survivors.
•




 This is AF447’s flight path:
•




 AF447 charted a course through a band of equatorial thunderstorms
•




 This is what happened in the last 15 minutes of the flight.
02:03:44 (Bonin) The inter-tropical convergence... look, we're in it, between 'Salpu'
                 and 'Tasil.' And then, look, we're right in it...

02:05:55 (Robert) Yes, let's call them in the back, to let them know...

02:05:59 (FA)      Yes? Marilyn.

02:06:04 (Bonin) Yes, Marilyn, it's Pierre up front... Listen, in 2 minutes, we're going
                 to be getting into an area where things are going to be moving around
                 a little bit more than now. You'll want to take care.

02:06:13 (FA)      Okay, we should sit down then?

02:06:15 (Bonin) Well, I think that's not a bad idea. Give your friends a heads-up.

02:06:18 (FA)      Yeah, okay, I'll tell the others in the back. Thanks a lot.

02:06:19 (Bonin) I'll call you back as soon as we're out of it.

02:06:20 (FA)      Okay.
02:03:44 (Bonin) The inter-tropical convergence... look, we're in it, between 'Salpu'
                 and 'Tasil.' And then, look, we're right in it...

02:05:55 (Robert) Yes, let's call them in the back, to let them know...

02:05:59 (FA)      Yes? Marilyn.

02:06:04 (Bonin) Yes, Marilyn, it's Pierre up front... Listen, in 2 minutes, we're going
                 to be getting into an area where things are going to be moving around
                 a little bit more than now. You'll want to take care.

02:06:13 (FA)      Okay, we should sit down then?

02:06:15 (Bonin) Well, I think that's not a bad idea. Give your friends a heads-up.

02:06:18 (FA)      Yeah, okay, I'll tell the others in the back. Thanks a lot.

02:06:19 (Bonin) I'll call you back as soon as we're out of it.

02:06:20 (FA)      Okay.
02:06:50 (Bonin) Let's go for the anti-icing system. It's better than nothing.

02:07:00 (Bonin) We seem to be at the end of the cloud layer, it might be okay.

02:08:03 (Robert) You can possibly pull it a little to the left.

02:08:05 (Bonin) You can possibly pull it a little to the left. We're agreed that we're in
                 manual, yeah?
Captain Marc Dubois hands control to Robert + Bonin,
•




and takes the second mandatory rest break.
02:10:06 (Bonin) I have the controls.

02:10:07 (Robert) Okay.

02:10:07 (Robert) What's this?

02:10:15 (Bonin) There's no good... there's no good speed indication.

02:10:16 (Robert) We've lost the, the, the speeds, then?

02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed.

02:10:28 (Bonin) Okay, okay, I'm descending.

02:10:30 (Robert) Stabilize.

02:10:31 (Bonin) Yeah.

02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend.

02:10:36 (Robert) Descend!
02:10:06 (Bonin) I have the controls.

02:10:07 (Robert) Okay.

02:10:07 (Robert) What's this?

02:10:15 (Bonin) There's no good... there's no good speed indication.

02:10:16 (Robert) We've lost the, the, the speeds, then?

02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed.

02:10:28 (Bonin) Okay, okay, I'm descending.

02:10:30 (Robert) Stabilize.

02:10:31 (Bonin) Yeah.

02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend.

02:10:36 (Robert) Descend!
02:10:06 (Bonin) I have the controls.

02:10:07 (Robert) Okay.

02:10:07 (Robert) What's this?

02:10:15 (Bonin) There's no good... there's no good speed indication.

02:10:16 (Robert) We've lost the, the, the speeds, then?

02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed.

02:10:28 (Bonin) Okay, okay, I'm descending.

02:10:30 (Robert) Stabilize.

02:10:31 (Bonin) Yeah.

02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend.

02:10:36 (Robert) Descend!
02:10:06 (Bonin) I have the controls.

02:10:07 (Robert) Okay.

02:10:07 (Robert) What's this?

02:10:15 (Bonin) There's no good... there's no good speed indication.

02:10:16 (Robert) We've lost the, the, the speeds, then?

02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed.

02:10:28 (Bonin) Okay, okay, I'm descending.

02:10:30 (Robert) Stabilize.

02:10:31 (Bonin) Yeah.

02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend.

02:10:36 (Robert) Descend!
02:10:37 (Bonin)   Here we go, we're descending.

02:10:38 (Robert) Gently!

02:10:41(Bonin)    We're... yeah, we're in a climb.

02:10:49 (Robert) Damn it, where is he?

02:10:55 (Robert) Damn it!

02:11:03 (Bonin)   I'm in TOGA, huh?

02:11:06 (Robert) Damn it, is he coming or not?

02:11:21 (Robert) We still have the engines! What the hell is happening? I don't
                  understand what's happening.

02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand
                  what’s happening or not?

02:11:32 (Bonin)   I don't have control of the plane any more now. I don't have control
                   of the plane at all!
02:10:37 (Bonin)   Here we go, we're descending.

02:10:38 (Robert) Gently!

02:10:41(Bonin)    We're... yeah, we're in a climb.

02:10:49 (Robert) Damn it, where is he?

02:10:55 (Robert) Damn it!

02:11:03 (Bonin)   I'm in TOGA, huh?

02:11:06 (Robert) Damn it, is he coming or not?

02:11:21 (Robert) We still have the engines! What the hell is happening? I don't
                  understand what's happening.

02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand
                  what’s happening or not?

02:11:32 (Bonin)   I don't have control of the plane any more now. I don't have control
                   of the plane at all!
02:10:37 (Bonin)   Here we go, we're descending.

02:10:38 (Robert) Gently!

02:10:41(Bonin)    We're... yeah, we're in a climb.

02:10:49 (Robert) Damn it, where is he?

02:10:55 (Robert) Damn it!

02:11:03 (Bonin)   I'm in TOGA, huh?

02:11:06 (Robert) Damn it, is he coming or not?

02:11:21 (Robert) We still have the engines! What the hell is happening? I don't
                  understand what's happening.

02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand
                  what’s happening or not?

02:11:32 (Bonin)   I don't have control of the plane any more now. I don't have control
                   of the plane at all!
02:10:37 (Bonin)   Here we go, we're descending.

02:10:38 (Robert) Gently!

02:10:41(Bonin)    We're... yeah, we're in a climb.

02:10:49 (Robert) Damn it, where is he?

02:10:55 (Robert) Damn it!

02:11:03 (Bonin)   I'm in TOGA, huh?

02:11:06 (Robert) Damn it, is he coming or not?

02:11:21 (Robert) We still have the engines! What the hell is happening? I don't
                  understand what's happening.

02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand
                  what’s happening or not?

02:11:32 (Bonin)   I don't have control of the plane any more now. I don't have control
                   of the plane at all!
02:11:37 (Robert) Controls to the left!

02:11:41 (Robert) ...what is that?

02:11:41 (Bonin)   I have the impression (we have) the speed

02:11:42 (Captain) Er, what are you doing?

02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening

02:11:45 (Bonin)   We’re losing control of the aeroplane there

02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything.
                  We’ve tried everything.

02:11:51 (Captain) So take that, take that

02:11:55 (Robert) Take that, take that

02:11:57 (Robert) Try to take that
02:11:37 (Robert) Controls to the left!

02:11:41 (Robert) ...what is that?

02:11:41 (Bonin)   I have the impression (we have) the speed

02:11:42 (Captain) Er, what are you doing?

02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening

02:11:45 (Bonin)   We’re losing control of the aeroplane there

02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything.
                  We’ve tried everything.

02:11:51 (Captain) So take that, take that

02:11:55 (Robert) Take that, take that

02:11:57 (Robert) Try to take that
02:11:37 (Robert) Controls to the left!

02:11:41 (Robert) ...what is that?

02:11:41 (Bonin)   I have the impression (we have) the speed

02:11:42 (Captain) Er, what are you doing?

02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening

02:11:45 (Bonin)   We’re losing control of the aeroplane there

02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything.
                  We’ve tried everything.

02:11:51 (Captain) So take that, take that

02:11:55 (Robert) Take that, take that

02:11:57 (Robert) Try to take that
02:11:58 (Bonin)   I have a problem - it’s that I don’t have vertical speed indication

02:12:01 (Captain) Alright

02:12:01 (Bonin)   I have no more displays

02:12:02 (Robert) We have no valid displays

02:12:04 (Bonin)   I have the impression that we have some crazy speed, no? What
                   do you think?

02:12:06 (Robert) No.

02:12:07 (Bonin)   No?

02:12:07 (Robert) No, above all don't extend the

02:12:07 (Bonin)   Okay

02:12:09 (Robert) Don't extend
02:11:58 (Bonin)   I have a problem - it’s that I don’t have vertical speed indication

02:12:01 (Captain) Alright

02:12:01 (Bonin)   I have no more displays

02:12:02 (Robert) We have no valid displays

02:12:04 (Bonin)   I have the impression that we have some crazy speed, no? What
                   do you think?

02:12:06 (Robert) No.

02:12:07 (Bonin)   No?

02:12:07 (Robert) No, above all don't extend the

02:12:07 (Bonin)   Okay

02:12:09 (Robert) Don't extend
02:12:11 (Bonin)   So we’re still going down

02:12:12 (Robert) We’re pulling

02:12:14 (Robert) What do you think about it? What do you think? What do we
                  need to do?

02:12:15 (Captain) There - I don’t know. There - it’s going down.

02:12:19 (Bonin)   There you are.

02:12:20 (Bonin)   That’s good we should be wings level, no it won’t

02:12:23 (Captain) The wings to flat horizon, the standby horizon

02:12:25 (Robert) The horizon!

02:12:26 (Bonin)   Okay

02:12:26 (Robert) Speed?
02:12:11 (Bonin)   So we’re still going down

02:12:12 (Robert) We’re pulling

02:12:14 (Robert) What do you think about it? What do you think? What do we
                  need to do?

02:12:15 (Captain) There - I don’t know. There - it’s going down.

02:12:19 (Bonin)   There you are.

02:12:20 (Bonin)   That’s good we should be wings level, no it won’t

02:12:23 (Captain) The wings to flat horizon, the standby horizon

02:12:25 (Robert) The horizon!

02:12:26 (Bonin)   Okay

02:12:26 (Robert) Speed?
02:12:27 (Robert) You're climbing

02:12:28 (Robert) You're going down down down

02:12:28 (Captain) Going down

02:12:30 (Bonin)   Am I going down now?

02:12:31 (Robert) Go down

02:12:32 (Captain) No you climb there

02:12:32 (Bonin)   I'm climbing okay so we're going down

02:12:34 (Captain) You're climbing

02:12:39 (Bonin)   Okay, we're in TOGA

02:12:41 (Bonin)   What are we here?

02:12:41 (Bonin)   On alti what do we have here?
02:12:27 (Robert) You're climbing

02:12:28 (Robert) You're going down down down

02:12:28 (Captain) Going down

02:12:30 (Bonin)   Am I going down now?

02:12:31 (Robert) Go down

02:12:32 (Captain) No you climb there

02:12:32 (Bonin)   I'm climbing okay so we're going down

02:12:34 (Captain) You're climbing

02:12:39 (Bonin)   Okay, we're in TOGA

02:12:41 (Bonin)   What are we here?

02:12:41 (Bonin)   On alti what do we have here?
02:12:27 (Robert) You're climbing

02:12:28 (Robert) You're going down down down

02:12:28 (Captain) Going down

02:12:30 (Bonin)   Am I going down now?

02:12:31 (Robert) Go down

02:12:32 (Captain) No you climb there

02:12:32 (Bonin)   I'm climbing okay so we're going down

02:12:34 (Captain) You're climbing

02:12:39 (Bonin)   Okay, we're in TOGA

02:12:41 (Bonin)   What are we here?

02:12:41 (Bonin)   On alti what do we have here?
02:12:43 (Captain) It's impossible

02:12:45 (Bonin)   In alti what do we have?

02:12:47 (Robert) What do you mean on altitude?

02:12:48 (Bonin)   Yeah yeah yeah, I'm going down, no?

02:12:50 (Robert) You're going down, yes

02:12:52 (Captain) Hey you

02:12:53 (Captain) You're in

02:12:54 (Captain) Get the wings horizontal

02:12:56 (Robert) Get the wings horizontal

02:12:56 (Bonin)   That's what I'm trying to do

02:12:57 (Captain) Get the wings horizontal!
02:12:43 (Captain) It's impossible

02:12:45 (Bonin)   In alti what do we have?

02:12:47 (Robert) What do you mean on altitude?

02:12:48 (Bonin)   Yeah yeah yeah, I'm going down, no?

02:12:50 (Robert) You're going down, yes

02:12:52 (Captain) Hey you

02:12:53 (Captain) You're in

02:12:54 (Captain) Get the wings horizontal

02:12:56 (Robert) Get the wings horizontal

02:12:56 (Bonin)   That's what I'm trying to do

02:12:57 (Captain) Get the wings horizontal!
02:12:43 (Captain) It's impossible

02:12:45 (Bonin)   In alti what do we have?

02:12:47 (Robert) What do you mean on altitude?

02:12:48 (Bonin)   Yeah yeah yeah, I'm going down, no?

02:12:50 (Robert) You're going down, yes

02:12:52 (Captain) Hey you

02:12:53 (Captain) You're in

02:12:54 (Captain) Get the wings horizontal

02:12:56 (Robert) Get the wings horizontal

02:12:56 (Bonin)   That's what I'm trying to do

02:12:57 (Captain) Get the wings horizontal!
02:12:58 (Bonin)    I'm at the limit... with the roll

02:13:00 (Captain) The rudder bar

02:13:05 (Captain) Wings horizontal.. go... gently, gently

02:13:11 (Captain) Hey er...

02:13:11 (Robert) We lost it all at the left

02:13:13 (Robert) I've got nothing there

02:13:15 (Captain) What do you have?

02:13:17 (Captain) No wait

02:13:18 (Bonin)    We're there, we're there, we're passing level one hundred

02:13:19 (Robert) Wait, me, I have, I have the controls, eh?

02:13:25 (Bonin)    What is... how come we're continuing to go down right now?
02:12:58 (Bonin)    I'm at the limit... with the roll

02:13:00 (Captain) The rudder bar

02:13:05 (Captain) Wings horizontal.. go... gently, gently

02:13:11 (Captain) Hey er...

02:13:11 (Robert) We lost it all at the left

02:13:13 (Robert) I've got nothing there

02:13:15 (Captain) What do you have?

02:13:17 (Captain) No wait

02:13:18 (Bonin)    We're there, we're there, we're passing level one hundred

02:13:19 (Robert) Wait, me, I have, I have the controls, eh?

02:13:25 (Bonin)    What is... how come we're continuing to go down right now?
02:12:58 (Bonin)    I'm at the limit... with the roll

02:13:00 (Captain) The rudder bar

02:13:05 (Captain) Wings horizontal.. go... gently, gently

02:13:11 (Captain) Hey er...

02:13:11 (Robert) We lost it all at the left

02:13:13 (Robert) I've got nothing there

02:13:15 (Captain) What do you have?

02:13:17 (Captain) No wait

02:13:18 (Bonin)    We're there, we're there, we're passing level one hundred

02:13:19 (Robert) Wait, me, I have, I have the controls, eh?

02:13:25 (Bonin)    What is... how come we're continuing to go down right now?
02:13:28 (Robert) Try to find what you can do with your controls up there

02:13:30 (Robert) The primaries and so on

02:13:30 (Captain) It won't do anything

02:13:31 (Captain) It won't do anything

02:13:31 (Bonin)   At level one hundred

02:13:36 (Bonin)   Nine thousand feet

02:13:38 (Captain) Careful with the rudder bar there

02:13:39 (Robert) Climb, climb, climb, climb

02:13:40 (Bonin)   But I've been at maxi nose-up for a while

02:13:42 (Captain) No, no, no... don't climb

02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
02:13:28 (Robert) Try to find what you can do with your controls up there

02:13:30 (Robert) The primaries and so on

02:13:30 (Captain) It won't do anything

02:13:31 (Captain) It won't do anything

02:13:31 (Bonin)   At level one hundred

02:13:36 (Bonin)   Nine thousand feet

02:13:38 (Captain) Careful with the rudder bar there

02:13:39 (Robert) Climb, climb, climb, climb

02:13:40 (Bonin)   But I've been at maxi nose-up for a while

02:13:42 (Captain) No, no, no... don't climb

02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
02:13:28 (Robert) Try to find what you can do with your controls up there

02:13:30 (Robert) The primaries and so on

02:13:30 (Captain) It won't do anything

02:13:31 (Captain) It won't do anything

02:13:31 (Bonin)   At level one hundred

02:13:36 (Bonin)   Nine thousand feet

02:13:38 (Captain) Careful with the rudder bar there

02:13:39 (Robert) Climb, climb, climb, climb

02:13:40 (Bonin)   But I've been at maxi nose-up for a while

02:13:42 (Captain) No, no, no... don't climb

02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
02:13:46 (Bonin)   Go ahead, you have the controls. We are still in TOGA, eh?

02:13:53 (Captain) AP OFF

02:13:59 (Bonin)   Gentlemen

02:14:05 (Captain) Watch out, you're pitching up there

02:14:05 (Robert) I'm pitching up

02:14:06 (Captain) You're pitching up

02:14:07 (Robert) I'm pitching up

02:14:07 (Bonin)   Well, we need to, we are at four thousand feet...
02:13:46 (Bonin)   Go ahead, you have the controls. We are still in TOGA, eh?

02:13:53 (Captain) AP OFF

02:13:59 (Bonin)   Gentlemen

02:14:05 (Captain) Watch out, you're pitching up there

02:14:05 (Robert) I'm pitching up

02:14:06 (Captain) You're pitching up

02:14:07 (Robert) I'm pitching up

02:14:07 (Bonin)   Well, we need to, we are at four thousand feet...
02:14:10 (Captain) You're pitching up

02:14:18 (Captain) Go on pull

02:14:19 (Bonin)   Let's go, pull up, pull up, pull up

02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!

02:14:25 (Bonin)   But what's happening?

02:14:26 (Captain) Ten degrees of pitch...

02:14:28           End of recording
02:14:10 (Captain) You're pitching up

02:14:18 (Captain) Go on pull

02:14:19 (Bonin)   Let's go, pull up, pull up, pull up

02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!

02:14:25 (Bonin)   But what's happening?

02:14:26 (Captain) Ten degrees of pitch...

02:14:28           End of recording
02:14:10 (Captain) You're pitching up

02:14:18 (Captain) Go on pull

02:14:19 (Bonin)   Let's go, pull up, pull up, pull up

02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!

02:14:25 (Bonin)   But what's happening?

02:14:26 (Captain) Ten degrees of pitch...

02:14:28           End of recording
02:14:10 (Captain) You're pitching up

02:14:18 (Captain) Go on pull

02:14:19 (Bonin)   Let's go, pull up, pull up, pull up

02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!

02:14:25 (Bonin)   But what's happening?

02:14:26 (Captain) Ten degrees of pitch...

02:14:28           End of recording
02:14:10 (Captain) You're pitching up

02:14:18 (Captain) Go on pull

02:14:19 (Bonin)   Let's go, pull up, pull up, pull up

02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!

02:14:25 (Bonin)   But what's happening?

02:14:26 (Captain) Ten degrees of pitch...

02:14:28           End of recording
02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!
02:14:23 (Bonin)   Damn it, we're going to crash... This can't be happening!
•




 Final Air France 447 Report: Pilots misunderstood their situation
•




 Poorly-trained pilots to blame for Air France crash that killed 228
•




 Final Air France crash report says pilots failed to react swiftly
•




 Air France 447 downed as crew ignored alarms
•




 Air France 447 crash a result of crew ignoring alarms
•




 The Atlantic
•




 Daily Mail
•




 CNN
•




 New Scientist
•




 Gizmodo
Convenient
 narrative
“root cause”
“human error”
Bad apples
“if we weed out the
bad apples, the system
    will equalise”
What you call "root cause" is
simply the place you stop
looking any further
                                     -- Sidney Dekker
          Professor of Human Factors & Flight Safety, Lund University
Dubois
                               10,988 flying hours, of which 6,258 as
total
                               Captain


hours on type                  1,747, all as Captain


in the previous six months     346 hours, 18 landings, 15 take-offs


in the previous three months   168 hours, 8 landings, 6 take-offs


in the previous 30 days        57 hours, 3 landings, 2 take-offs
Robert
total                          6,547 flying hours


hours on type                  4,479 flying hours


in the previous six months     204 hours, 9 landings, 11 take-offs


in the previous three months   99 hours, 6 landings, 5 take-offs


in the previous 30 days        39 hours, 2 landings, 2 take-offs
Bonin
total                          2,936 flying hours


hours on type                  807


in the previous six months     368 hours, 16 landings, 18 take-offs


in the previous three months   191 hours, 7 landings, 8 take-offs


in the previous 30 days        61 hours, 1 landings, 2 take-offs
Critical flaw:
How would other pilots
 react under the same
    circumstances?
What appears in the crew behavior is that most
probably, a different crew should have done
the same action. So, we cannot blame this
crew. What we can say is that most probably
this crew and most crews were not prepared to
face such an event.
                            -- Jean-Paul Troadec
                              Bureau d'Enquêtes et d'Analyses
                            pour la Sécurité de l'Aviation Civile
What appears in the crew behavior is that most
probably, a different crew should have done
the same action. So, we cannot blame this
crew. What we can say is that most probably
this crew and most crews were not prepared to
face such an event.
                            -- Jean-Paul Troadec
                              Bureau d'Enquêtes et d'Analyses
                            pour la Sécurité de l'Aviation Civile
Actors in a
complex system
Systems in a
complex system
Systems in a
series of nested
complex systems
“root cause”
Cartesian-Newtonian
    worldview
hindsight != foresight
[hindsight] converts a once
vague, unlikely future into an
   immediate, certain past
                                    -- Sidney Dekker
         Professor of Human Factors & Flight Safety, Lund University
We have all the facts
Investigation took

   3 years
Event unfolded in

10 minutes
Fog of War
Limited facts at hand
       in a rapidly
   developing situation
Local rationality
“people make what they
think are best decisions
based on data at hand”
Hindsight
affords us global
  rationality
What systems
were in play?
Modes of operation
Flight control modes
Normal law
  ground, flight, flare modes




 Alternate law
alternate law 1, alternate law 2
Law
reconfiguration

feedback
There are three major categories of message that can be transmitted:

• non-vocal (ATC) communication messages with an air
  traffic control centre
• operational communication messages (AOC) with the
  operator’s operations centre
• maintenance messages, exclusively from the aircraft to the
  maintenance centre
Time of Reception   Message
02:10               WRN/WN0906010210 221002006AUTO FLT AP OFF
02:10               WRN/WN0906010210 226201006AUTO FLT REAC W/S DET FAULT
02:10               WRN/WN0906010210 279100506F/CTL ALTN LAW
02:10               WRN/WN0906010210 228300206FLAG ON CAPT PFD SPD LIMIT
02:10               #0210/+2.98-30.59
02:10               WRN/WN0906010210 228301206FLAG ON F/O PFD SPD LIMIT
02:10               WRN/WN0906010210 223002506AUTO FLT A/THR OFF
02:10               WRN/WN0906010210 344300506NAV TCAS FAULT
02:11               WRN/WN0906010210 228300106FLAG ON CAPT PFD FD
02:11               WRN/WN0906010210 228301106FLAG ON F/O PFD FD
02:11               WRN/WN0906010210 272302006F/CTL RUD TRV LIM FAULT
02:11               WRN/WN0906010210 279045506MAINTENANCE STATUS EFCS 2
02:11               WRN/WN0906010210 279045006MAINTENANCE STATUS EFCS 1
02:11               FLR/FR0906010210 34111506EFCS2 1,EFCS1,AFS,,,,,PROBE-PITOT 1X2 / 2X3 / 1X3 (9DA),HARD
02:11               FLR/FR0906010210 27933406EFCS1 X2,EFCS2X,,,,,,FCPC2 (2CE2) /WRG:ADIRU1 BUS ADR1-2 TO FCPC2,HARD
02:12               WRN/WN0906010211 341200106FLAG ON CAPT PFD FPV
02:12               WRN/WN0906010211 341201106FLAG ON F/O PFD FPV
02:12               WRN/WN0906010212 341040006NAV ADR DISAGREE
02:13               FLR/FR0906010211 34220006ISIS 1,,,,,,,ISIS(22FN-10FC) SPEED OR MACH FUNCTION,HARD
02:13               FLR/FR0906010211 34123406IR2 1,EFCS1X,IR1,IR3,,,,ADIRU2 (1FP2),HARD
2:13:16 ~ 2:13:41   Possible "Loss of Signal" with satellite
02:13               WRN/WN0906010213 279002506F/CTL PRIM 1 FAULT
02:13               WRN/WN0906010213 279004006F/CTL SEC 1 FAULT
02:14               WRN/WN0906010214 341036006MAINTENANCE STATUS ADR 2
02:14               FLR/FR0906010213 22833406AFS 1,,,,,,,FMGEC1(1CA1),INTERMITTENT
02:14               WRN/WN0906010214 213100206ADVISORY CABIN VERTICAL SPEED
02:10   WRN/WN0906010210 279100506F/CTL ALTN LAW
02:10   WRN/WN0906010210 279100506F/CTL ALTN LAW
small textual warning here
Realisation
02:13:40 (Bonin)   But I've been at maxi nose-up for a while

02:13:42 (Captain) No, no, no... don't climb

02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!

                   ...

02:14:28           End of recording
How does your HA
provide feedback?
Reconfiguration
  feedback?
How do these modes
behave differently?
What about modes
you haven’t seen?
Sensory feedback
Obvious change in

color,   size, font
Know how
colour is processed

by the brain
Familiarise yourself
    with type
Familiarise yourself
     with type
Familiarise yourself
     with type
Optimise for 3am you
Input control
Co-pilot feedback
Averaged input
dual input feedback
CRM
Startling
 effect
Are your inputs
  averaged?
How do your
engineers troubleshoot
  during incidents?
Every man
for himself?
How do you co-
ordinate change?
Does someone
have overview?
How is that
responsibility
  assigned?
How is information
  disseminated?
How does
the business know
what is happening?
Do you have a
  process?
Do you practice this?
What data do
you rely on?
Pair
Vocalise
Minimise
       &

Compartmentalise
Record
Timeline
maintained by
co-ordinator
HUD
isolated sensors
different values
discrepancies
02:12:27 (Robert) You're climbing

02:12:28 (Robert) You're going down down down

02:12:28 (Captain) Going down

02:12:30 (Bonin)   Am I going down now?

02:12:31 (Robert) Go down

02:12:32 (Captain) No you climb there

02:12:32 (Bonin)   I'm climbing okay so we're going down

02:12:34 (Captain) You're climbing

02:12:39 (Bonin)   Okay, we're in TOGA

02:12:41 (Bonin)   What are we here?

02:12:41 (Bonin)   On alti what do we have here?
CRM
Contextual
navigation
different
 navigation
requirements
dashboards
deep dive on details
test a theory
scientific method:
   improvised
linkable
correlation
human pattern
 recognition
human pattern
          recognition
(provided there is enough adaptive capacity)
Stream
 of alerts
70 stall warnings
•




 Final Air France 447 Report: Pilots misunderstood their situation
•




 Poorly-trained pilots to blame for Air France crash that killed 228
•




 Final Air France crash report says pilots failed to react swiftly
•




 Air France 447 downed as crew ignored alarms
•




 Air France 447 crash a result of crew ignoring alarms
“They should
have reacted!”
autopilot disconnect
alternate law
reconfiguration
alert priority level?
overwhelmed
by feedback
Alert Fatigue
startling effect
reduced
adaptive
capacity
dampening
Brute force:

manual silence
limit # of engineers who
   watch alerts
     & graphs
smarter alert
aggregation?
PagerDuty
Flapjack
Systems thinking
System capable
  of failure
System capable
  of success
•




 System that enables communication
•




 System that enables communication
•




 System that exposes secrets
•




 System that enables communication
•




 System that exposes secrets

•




 System that rob us
•




 System that enables communication
•




 System that exposes secrets

•




 System that rob us
•




 System that funds innovation
•




 System that enables communication
•




 System that exposes secrets

•




 System that rob us
•




 System that funds innovation

•




 System that kills us
•




 System that enables communication
•




 System that exposes secrets

•




 System that rob us
•




 System that funds innovation

•




 System that kills us
•




 System that allow us to fly across the world
Failure is pervasive
Failure is complex
Failure is just another
 mode of operation
Your system
    may not

   control
     fate of

people’s lives
But people may
 depend on it
Anthropocentrism
Technocentrism
The squishy
middle ground
Operable Systems
man + machine
No amoral actors
We need to look at it from a systems
approach, a human/technology system that
has to work together. This involves aircraft
design and certification, training and human
factors. If you look at the human factors
alone, then you're missing half or two-thirds
of the total system failure
                         -- Chesley Sullenberger
                  Pilot, US 1549, Hudson River Ditching
We need to look at it from a systems
approach, a human/technology system that
has to work together. This involves aircraft
design and certification, training and human
factors. If you look at the human factors
alone, then you're missing half or two-thirds
of the total system failure
                         -- Chesley Sullenberger
                  Pilot, US 1549, Hudson River Ditching
•




    Damn it, we're going to crash... This can't be happening!
•




 Final Air France 447 Report: Pilots misunderstood their situation
•




 Poorly-trained pilots to blame for Air France crash that killed 228
•




 Final Air France crash report says pilots failed to react swiftly
•




 Air France 447 downed as crew ignored alarms
•




 Air France 447 crash a result of crew ignoring alarms
Thank you
Liked the talk? Let @auxesis know!




       Thank you
Sidney Dekker
Field Guide to Understand Human Error
Drift Into Failure
Just Culture

Jon Rauser
Look at Your Data @ Velocity

Ryan Tomayko
Distributed Management @ Monktoberfest 2012

BEA Report on AF447 incident

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Escalating complexity: DevOps learnings from Air France 447

  • 2. Lindsay Holmwood @auxesis
  • 3. Engineering Manager @ Bulletproof Networks
  • 4.
  • 5. cucumber-nagios Visage Flapjack
  • 6.
  • 7. • On 31 May 2009, Air France 447 departed from Rio de Janeiro-Galeão International Airport at 22:29 UTC. It was scheduled to arrive at Paris-Charles de Gaulle International Airport 11 hours later.
  • 8. • On 31 May 2009, Air France 447 departed from Rio de Janeiro-Galeão International Airport at 22:29 UTC. It was scheduled to arrive at Paris-Charles de Gaulle International Airport 11 hours later. • 3 hours and 45 minutes later, it crashed into the Atlantic Ocean, killing 216 passengers, and 12 aircrew.
  • 9. • On 31 May 2009, Air France 447 departed from Rio de Janeiro-Galeão International Airport at 22:29 UTC. It was scheduled to arrive at Paris-Charles de Gaulle International Airport 11 hours later. • 3 hours and 45 minutes later, it crashed into the Atlantic Ocean, killing 216 passengers, and 12 aircrew. • There were no survivors.
  • 10.
  • 11. • This is AF447’s flight path:
  • 12.
  • 13. • AF447 charted a course through a band of equatorial thunderstorms
  • 14.
  • 15. • This is what happened in the last 15 minutes of the flight.
  • 16.
  • 17. 02:03:44 (Bonin) The inter-tropical convergence... look, we're in it, between 'Salpu' and 'Tasil.' And then, look, we're right in it... 02:05:55 (Robert) Yes, let's call them in the back, to let them know... 02:05:59 (FA) Yes? Marilyn. 02:06:04 (Bonin) Yes, Marilyn, it's Pierre up front... Listen, in 2 minutes, we're going to be getting into an area where things are going to be moving around a little bit more than now. You'll want to take care. 02:06:13 (FA) Okay, we should sit down then? 02:06:15 (Bonin) Well, I think that's not a bad idea. Give your friends a heads-up. 02:06:18 (FA) Yeah, okay, I'll tell the others in the back. Thanks a lot. 02:06:19 (Bonin) I'll call you back as soon as we're out of it. 02:06:20 (FA) Okay.
  • 18. 02:03:44 (Bonin) The inter-tropical convergence... look, we're in it, between 'Salpu' and 'Tasil.' And then, look, we're right in it... 02:05:55 (Robert) Yes, let's call them in the back, to let them know... 02:05:59 (FA) Yes? Marilyn. 02:06:04 (Bonin) Yes, Marilyn, it's Pierre up front... Listen, in 2 minutes, we're going to be getting into an area where things are going to be moving around a little bit more than now. You'll want to take care. 02:06:13 (FA) Okay, we should sit down then? 02:06:15 (Bonin) Well, I think that's not a bad idea. Give your friends a heads-up. 02:06:18 (FA) Yeah, okay, I'll tell the others in the back. Thanks a lot. 02:06:19 (Bonin) I'll call you back as soon as we're out of it. 02:06:20 (FA) Okay.
  • 19.
  • 20. 02:06:50 (Bonin) Let's go for the anti-icing system. It's better than nothing. 02:07:00 (Bonin) We seem to be at the end of the cloud layer, it might be okay. 02:08:03 (Robert) You can possibly pull it a little to the left. 02:08:05 (Bonin) You can possibly pull it a little to the left. We're agreed that we're in manual, yeah?
  • 21.
  • 22. Captain Marc Dubois hands control to Robert + Bonin, • and takes the second mandatory rest break.
  • 23.
  • 24. 02:10:06 (Bonin) I have the controls. 02:10:07 (Robert) Okay. 02:10:07 (Robert) What's this? 02:10:15 (Bonin) There's no good... there's no good speed indication. 02:10:16 (Robert) We've lost the, the, the speeds, then? 02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed. 02:10:28 (Bonin) Okay, okay, I'm descending. 02:10:30 (Robert) Stabilize. 02:10:31 (Bonin) Yeah. 02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend. 02:10:36 (Robert) Descend!
  • 25. 02:10:06 (Bonin) I have the controls. 02:10:07 (Robert) Okay. 02:10:07 (Robert) What's this? 02:10:15 (Bonin) There's no good... there's no good speed indication. 02:10:16 (Robert) We've lost the, the, the speeds, then? 02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed. 02:10:28 (Bonin) Okay, okay, I'm descending. 02:10:30 (Robert) Stabilize. 02:10:31 (Bonin) Yeah. 02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend. 02:10:36 (Robert) Descend!
  • 26. 02:10:06 (Bonin) I have the controls. 02:10:07 (Robert) Okay. 02:10:07 (Robert) What's this? 02:10:15 (Bonin) There's no good... there's no good speed indication. 02:10:16 (Robert) We've lost the, the, the speeds, then? 02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed. 02:10:28 (Bonin) Okay, okay, I'm descending. 02:10:30 (Robert) Stabilize. 02:10:31 (Bonin) Yeah. 02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend. 02:10:36 (Robert) Descend!
  • 27. 02:10:06 (Bonin) I have the controls. 02:10:07 (Robert) Okay. 02:10:07 (Robert) What's this? 02:10:15 (Bonin) There's no good... there's no good speed indication. 02:10:16 (Robert) We've lost the, the, the speeds, then? 02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed. 02:10:28 (Bonin) Okay, okay, I'm descending. 02:10:30 (Robert) Stabilize. 02:10:31 (Bonin) Yeah. 02:10:31 (Robert) Descend... It says we're going up... It says we're going up, so descend. 02:10:36 (Robert) Descend!
  • 28.
  • 29. 02:10:37 (Bonin) Here we go, we're descending. 02:10:38 (Robert) Gently! 02:10:41(Bonin) We're... yeah, we're in a climb. 02:10:49 (Robert) Damn it, where is he? 02:10:55 (Robert) Damn it! 02:11:03 (Bonin) I'm in TOGA, huh? 02:11:06 (Robert) Damn it, is he coming or not? 02:11:21 (Robert) We still have the engines! What the hell is happening? I don't understand what's happening. 02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand what’s happening or not? 02:11:32 (Bonin) I don't have control of the plane any more now. I don't have control of the plane at all!
  • 30. 02:10:37 (Bonin) Here we go, we're descending. 02:10:38 (Robert) Gently! 02:10:41(Bonin) We're... yeah, we're in a climb. 02:10:49 (Robert) Damn it, where is he? 02:10:55 (Robert) Damn it! 02:11:03 (Bonin) I'm in TOGA, huh? 02:11:06 (Robert) Damn it, is he coming or not? 02:11:21 (Robert) We still have the engines! What the hell is happening? I don't understand what's happening. 02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand what’s happening or not? 02:11:32 (Bonin) I don't have control of the plane any more now. I don't have control of the plane at all!
  • 31. 02:10:37 (Bonin) Here we go, we're descending. 02:10:38 (Robert) Gently! 02:10:41(Bonin) We're... yeah, we're in a climb. 02:10:49 (Robert) Damn it, where is he? 02:10:55 (Robert) Damn it! 02:11:03 (Bonin) I'm in TOGA, huh? 02:11:06 (Robert) Damn it, is he coming or not? 02:11:21 (Robert) We still have the engines! What the hell is happening? I don't understand what's happening. 02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand what’s happening or not? 02:11:32 (Bonin) I don't have control of the plane any more now. I don't have control of the plane at all!
  • 32. 02:10:37 (Bonin) Here we go, we're descending. 02:10:38 (Robert) Gently! 02:10:41(Bonin) We're... yeah, we're in a climb. 02:10:49 (Robert) Damn it, where is he? 02:10:55 (Robert) Damn it! 02:11:03 (Bonin) I'm in TOGA, huh? 02:11:06 (Robert) Damn it, is he coming or not? 02:11:21 (Robert) We still have the engines! What the hell is happening? I don't understand what's happening. 02:11:21 (Robert) But we’ve got the engines. What's happening? Do you understand what’s happening or not? 02:11:32 (Bonin) I don't have control of the plane any more now. I don't have control of the plane at all!
  • 33.
  • 34. 02:11:37 (Robert) Controls to the left! 02:11:41 (Robert) ...what is that? 02:11:41 (Bonin) I have the impression (we have) the speed 02:11:42 (Captain) Er, what are you doing? 02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening 02:11:45 (Bonin) We’re losing control of the aeroplane there 02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything. We’ve tried everything. 02:11:51 (Captain) So take that, take that 02:11:55 (Robert) Take that, take that 02:11:57 (Robert) Try to take that
  • 35. 02:11:37 (Robert) Controls to the left! 02:11:41 (Robert) ...what is that? 02:11:41 (Bonin) I have the impression (we have) the speed 02:11:42 (Captain) Er, what are you doing? 02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening 02:11:45 (Bonin) We’re losing control of the aeroplane there 02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything. We’ve tried everything. 02:11:51 (Captain) So take that, take that 02:11:55 (Robert) Take that, take that 02:11:57 (Robert) Try to take that
  • 36. 02:11:37 (Robert) Controls to the left! 02:11:41 (Robert) ...what is that? 02:11:41 (Bonin) I have the impression (we have) the speed 02:11:42 (Captain) Er, what are you doing? 02:11:43 (Robert) What’s happening? I don’t know, I don’t know what’s happening 02:11:45 (Bonin) We’re losing control of the aeroplane there 02:11:46 (Robert) We lost all control of the aeroplane. We don’t understand anything. We’ve tried everything. 02:11:51 (Captain) So take that, take that 02:11:55 (Robert) Take that, take that 02:11:57 (Robert) Try to take that
  • 37.
  • 38. 02:11:58 (Bonin) I have a problem - it’s that I don’t have vertical speed indication 02:12:01 (Captain) Alright 02:12:01 (Bonin) I have no more displays 02:12:02 (Robert) We have no valid displays 02:12:04 (Bonin) I have the impression that we have some crazy speed, no? What do you think? 02:12:06 (Robert) No. 02:12:07 (Bonin) No? 02:12:07 (Robert) No, above all don't extend the 02:12:07 (Bonin) Okay 02:12:09 (Robert) Don't extend
  • 39. 02:11:58 (Bonin) I have a problem - it’s that I don’t have vertical speed indication 02:12:01 (Captain) Alright 02:12:01 (Bonin) I have no more displays 02:12:02 (Robert) We have no valid displays 02:12:04 (Bonin) I have the impression that we have some crazy speed, no? What do you think? 02:12:06 (Robert) No. 02:12:07 (Bonin) No? 02:12:07 (Robert) No, above all don't extend the 02:12:07 (Bonin) Okay 02:12:09 (Robert) Don't extend
  • 40.
  • 41. 02:12:11 (Bonin) So we’re still going down 02:12:12 (Robert) We’re pulling 02:12:14 (Robert) What do you think about it? What do you think? What do we need to do? 02:12:15 (Captain) There - I don’t know. There - it’s going down. 02:12:19 (Bonin) There you are. 02:12:20 (Bonin) That’s good we should be wings level, no it won’t 02:12:23 (Captain) The wings to flat horizon, the standby horizon 02:12:25 (Robert) The horizon! 02:12:26 (Bonin) Okay 02:12:26 (Robert) Speed?
  • 42. 02:12:11 (Bonin) So we’re still going down 02:12:12 (Robert) We’re pulling 02:12:14 (Robert) What do you think about it? What do you think? What do we need to do? 02:12:15 (Captain) There - I don’t know. There - it’s going down. 02:12:19 (Bonin) There you are. 02:12:20 (Bonin) That’s good we should be wings level, no it won’t 02:12:23 (Captain) The wings to flat horizon, the standby horizon 02:12:25 (Robert) The horizon! 02:12:26 (Bonin) Okay 02:12:26 (Robert) Speed?
  • 43.
  • 44. 02:12:27 (Robert) You're climbing 02:12:28 (Robert) You're going down down down 02:12:28 (Captain) Going down 02:12:30 (Bonin) Am I going down now? 02:12:31 (Robert) Go down 02:12:32 (Captain) No you climb there 02:12:32 (Bonin) I'm climbing okay so we're going down 02:12:34 (Captain) You're climbing 02:12:39 (Bonin) Okay, we're in TOGA 02:12:41 (Bonin) What are we here? 02:12:41 (Bonin) On alti what do we have here?
  • 45. 02:12:27 (Robert) You're climbing 02:12:28 (Robert) You're going down down down 02:12:28 (Captain) Going down 02:12:30 (Bonin) Am I going down now? 02:12:31 (Robert) Go down 02:12:32 (Captain) No you climb there 02:12:32 (Bonin) I'm climbing okay so we're going down 02:12:34 (Captain) You're climbing 02:12:39 (Bonin) Okay, we're in TOGA 02:12:41 (Bonin) What are we here? 02:12:41 (Bonin) On alti what do we have here?
  • 46. 02:12:27 (Robert) You're climbing 02:12:28 (Robert) You're going down down down 02:12:28 (Captain) Going down 02:12:30 (Bonin) Am I going down now? 02:12:31 (Robert) Go down 02:12:32 (Captain) No you climb there 02:12:32 (Bonin) I'm climbing okay so we're going down 02:12:34 (Captain) You're climbing 02:12:39 (Bonin) Okay, we're in TOGA 02:12:41 (Bonin) What are we here? 02:12:41 (Bonin) On alti what do we have here?
  • 47.
  • 48. 02:12:43 (Captain) It's impossible 02:12:45 (Bonin) In alti what do we have? 02:12:47 (Robert) What do you mean on altitude? 02:12:48 (Bonin) Yeah yeah yeah, I'm going down, no? 02:12:50 (Robert) You're going down, yes 02:12:52 (Captain) Hey you 02:12:53 (Captain) You're in 02:12:54 (Captain) Get the wings horizontal 02:12:56 (Robert) Get the wings horizontal 02:12:56 (Bonin) That's what I'm trying to do 02:12:57 (Captain) Get the wings horizontal!
  • 49. 02:12:43 (Captain) It's impossible 02:12:45 (Bonin) In alti what do we have? 02:12:47 (Robert) What do you mean on altitude? 02:12:48 (Bonin) Yeah yeah yeah, I'm going down, no? 02:12:50 (Robert) You're going down, yes 02:12:52 (Captain) Hey you 02:12:53 (Captain) You're in 02:12:54 (Captain) Get the wings horizontal 02:12:56 (Robert) Get the wings horizontal 02:12:56 (Bonin) That's what I'm trying to do 02:12:57 (Captain) Get the wings horizontal!
  • 50. 02:12:43 (Captain) It's impossible 02:12:45 (Bonin) In alti what do we have? 02:12:47 (Robert) What do you mean on altitude? 02:12:48 (Bonin) Yeah yeah yeah, I'm going down, no? 02:12:50 (Robert) You're going down, yes 02:12:52 (Captain) Hey you 02:12:53 (Captain) You're in 02:12:54 (Captain) Get the wings horizontal 02:12:56 (Robert) Get the wings horizontal 02:12:56 (Bonin) That's what I'm trying to do 02:12:57 (Captain) Get the wings horizontal!
  • 51.
  • 52. 02:12:58 (Bonin) I'm at the limit... with the roll 02:13:00 (Captain) The rudder bar 02:13:05 (Captain) Wings horizontal.. go... gently, gently 02:13:11 (Captain) Hey er... 02:13:11 (Robert) We lost it all at the left 02:13:13 (Robert) I've got nothing there 02:13:15 (Captain) What do you have? 02:13:17 (Captain) No wait 02:13:18 (Bonin) We're there, we're there, we're passing level one hundred 02:13:19 (Robert) Wait, me, I have, I have the controls, eh? 02:13:25 (Bonin) What is... how come we're continuing to go down right now?
  • 53. 02:12:58 (Bonin) I'm at the limit... with the roll 02:13:00 (Captain) The rudder bar 02:13:05 (Captain) Wings horizontal.. go... gently, gently 02:13:11 (Captain) Hey er... 02:13:11 (Robert) We lost it all at the left 02:13:13 (Robert) I've got nothing there 02:13:15 (Captain) What do you have? 02:13:17 (Captain) No wait 02:13:18 (Bonin) We're there, we're there, we're passing level one hundred 02:13:19 (Robert) Wait, me, I have, I have the controls, eh? 02:13:25 (Bonin) What is... how come we're continuing to go down right now?
  • 54. 02:12:58 (Bonin) I'm at the limit... with the roll 02:13:00 (Captain) The rudder bar 02:13:05 (Captain) Wings horizontal.. go... gently, gently 02:13:11 (Captain) Hey er... 02:13:11 (Robert) We lost it all at the left 02:13:13 (Robert) I've got nothing there 02:13:15 (Captain) What do you have? 02:13:17 (Captain) No wait 02:13:18 (Bonin) We're there, we're there, we're passing level one hundred 02:13:19 (Robert) Wait, me, I have, I have the controls, eh? 02:13:25 (Bonin) What is... how come we're continuing to go down right now?
  • 55.
  • 56. 02:13:28 (Robert) Try to find what you can do with your controls up there 02:13:30 (Robert) The primaries and so on 02:13:30 (Captain) It won't do anything 02:13:31 (Captain) It won't do anything 02:13:31 (Bonin) At level one hundred 02:13:36 (Bonin) Nine thousand feet 02:13:38 (Captain) Careful with the rudder bar there 02:13:39 (Robert) Climb, climb, climb, climb 02:13:40 (Bonin) But I've been at maxi nose-up for a while 02:13:42 (Captain) No, no, no... don't climb 02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
  • 57. 02:13:28 (Robert) Try to find what you can do with your controls up there 02:13:30 (Robert) The primaries and so on 02:13:30 (Captain) It won't do anything 02:13:31 (Captain) It won't do anything 02:13:31 (Bonin) At level one hundred 02:13:36 (Bonin) Nine thousand feet 02:13:38 (Captain) Careful with the rudder bar there 02:13:39 (Robert) Climb, climb, climb, climb 02:13:40 (Bonin) But I've been at maxi nose-up for a while 02:13:42 (Captain) No, no, no... don't climb 02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
  • 58. 02:13:28 (Robert) Try to find what you can do with your controls up there 02:13:30 (Robert) The primaries and so on 02:13:30 (Captain) It won't do anything 02:13:31 (Captain) It won't do anything 02:13:31 (Bonin) At level one hundred 02:13:36 (Bonin) Nine thousand feet 02:13:38 (Captain) Careful with the rudder bar there 02:13:39 (Robert) Climb, climb, climb, climb 02:13:40 (Bonin) But I've been at maxi nose-up for a while 02:13:42 (Captain) No, no, no... don't climb 02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls!
  • 59.
  • 60. 02:13:46 (Bonin) Go ahead, you have the controls. We are still in TOGA, eh? 02:13:53 (Captain) AP OFF 02:13:59 (Bonin) Gentlemen 02:14:05 (Captain) Watch out, you're pitching up there 02:14:05 (Robert) I'm pitching up 02:14:06 (Captain) You're pitching up 02:14:07 (Robert) I'm pitching up 02:14:07 (Bonin) Well, we need to, we are at four thousand feet...
  • 61. 02:13:46 (Bonin) Go ahead, you have the controls. We are still in TOGA, eh? 02:13:53 (Captain) AP OFF 02:13:59 (Bonin) Gentlemen 02:14:05 (Captain) Watch out, you're pitching up there 02:14:05 (Robert) I'm pitching up 02:14:06 (Captain) You're pitching up 02:14:07 (Robert) I'm pitching up 02:14:07 (Bonin) Well, we need to, we are at four thousand feet...
  • 62.
  • 63. 02:14:10 (Captain) You're pitching up 02:14:18 (Captain) Go on pull 02:14:19 (Bonin) Let's go, pull up, pull up, pull up 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening! 02:14:25 (Bonin) But what's happening? 02:14:26 (Captain) Ten degrees of pitch... 02:14:28 End of recording
  • 64. 02:14:10 (Captain) You're pitching up 02:14:18 (Captain) Go on pull 02:14:19 (Bonin) Let's go, pull up, pull up, pull up 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening! 02:14:25 (Bonin) But what's happening? 02:14:26 (Captain) Ten degrees of pitch... 02:14:28 End of recording
  • 65. 02:14:10 (Captain) You're pitching up 02:14:18 (Captain) Go on pull 02:14:19 (Bonin) Let's go, pull up, pull up, pull up 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening! 02:14:25 (Bonin) But what's happening? 02:14:26 (Captain) Ten degrees of pitch... 02:14:28 End of recording
  • 66. 02:14:10 (Captain) You're pitching up 02:14:18 (Captain) Go on pull 02:14:19 (Bonin) Let's go, pull up, pull up, pull up 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening! 02:14:25 (Bonin) But what's happening? 02:14:26 (Captain) Ten degrees of pitch... 02:14:28 End of recording
  • 67. 02:14:10 (Captain) You're pitching up 02:14:18 (Captain) Go on pull 02:14:19 (Bonin) Let's go, pull up, pull up, pull up 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening! 02:14:25 (Bonin) But what's happening? 02:14:26 (Captain) Ten degrees of pitch... 02:14:28 End of recording
  • 68. 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening!
  • 69. 02:14:23 (Bonin) Damn it, we're going to crash... This can't be happening!
  • 70.
  • 71.
  • 72. • Final Air France 447 Report: Pilots misunderstood their situation • Poorly-trained pilots to blame for Air France crash that killed 228 • Final Air France crash report says pilots failed to react swiftly • Air France 447 downed as crew ignored alarms • Air France 447 crash a result of crew ignoring alarms
  • 73. • The Atlantic • Daily Mail • CNN • New Scientist • Gizmodo
  • 78. “if we weed out the bad apples, the system will equalise”
  • 79. What you call "root cause" is simply the place you stop looking any further -- Sidney Dekker Professor of Human Factors & Flight Safety, Lund University
  • 80. Dubois 10,988 flying hours, of which 6,258 as total Captain hours on type 1,747, all as Captain in the previous six months 346 hours, 18 landings, 15 take-offs in the previous three months 168 hours, 8 landings, 6 take-offs in the previous 30 days 57 hours, 3 landings, 2 take-offs
  • 81. Robert total 6,547 flying hours hours on type 4,479 flying hours in the previous six months 204 hours, 9 landings, 11 take-offs in the previous three months 99 hours, 6 landings, 5 take-offs in the previous 30 days 39 hours, 2 landings, 2 take-offs
  • 82. Bonin total 2,936 flying hours hours on type 807 in the previous six months 368 hours, 16 landings, 18 take-offs in the previous three months 191 hours, 7 landings, 8 take-offs in the previous 30 days 61 hours, 1 landings, 2 take-offs
  • 83.
  • 84. Critical flaw: How would other pilots react under the same circumstances?
  • 85. What appears in the crew behavior is that most probably, a different crew should have done the same action. So, we cannot blame this crew. What we can say is that most probably this crew and most crews were not prepared to face such an event. -- Jean-Paul Troadec Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
  • 86. What appears in the crew behavior is that most probably, a different crew should have done the same action. So, we cannot blame this crew. What we can say is that most probably this crew and most crews were not prepared to face such an event. -- Jean-Paul Troadec Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
  • 89. Systems in a series of nested complex systems
  • 91. Cartesian-Newtonian worldview
  • 92.
  • 94. [hindsight] converts a once vague, unlikely future into an immediate, certain past -- Sidney Dekker Professor of Human Factors & Flight Safety, Lund University
  • 95. We have all the facts
  • 96.
  • 97.
  • 98.
  • 99.
  • 100.
  • 101.
  • 102.
  • 103.
  • 104.
  • 105.
  • 106.
  • 107. Investigation took 3 years
  • 110. Limited facts at hand in a rapidly developing situation
  • 112. “people make what they think are best decisions based on data at hand”
  • 114.
  • 118. Normal law ground, flight, flare modes Alternate law alternate law 1, alternate law 2
  • 119.
  • 120.
  • 121.
  • 122.
  • 124.
  • 125. There are three major categories of message that can be transmitted: • non-vocal (ATC) communication messages with an air traffic control centre • operational communication messages (AOC) with the operator’s operations centre • maintenance messages, exclusively from the aircraft to the maintenance centre
  • 126. Time of Reception Message 02:10 WRN/WN0906010210 221002006AUTO FLT AP OFF 02:10 WRN/WN0906010210 226201006AUTO FLT REAC W/S DET FAULT 02:10 WRN/WN0906010210 279100506F/CTL ALTN LAW 02:10 WRN/WN0906010210 228300206FLAG ON CAPT PFD SPD LIMIT 02:10 #0210/+2.98-30.59 02:10 WRN/WN0906010210 228301206FLAG ON F/O PFD SPD LIMIT 02:10 WRN/WN0906010210 223002506AUTO FLT A/THR OFF 02:10 WRN/WN0906010210 344300506NAV TCAS FAULT 02:11 WRN/WN0906010210 228300106FLAG ON CAPT PFD FD 02:11 WRN/WN0906010210 228301106FLAG ON F/O PFD FD 02:11 WRN/WN0906010210 272302006F/CTL RUD TRV LIM FAULT 02:11 WRN/WN0906010210 279045506MAINTENANCE STATUS EFCS 2 02:11 WRN/WN0906010210 279045006MAINTENANCE STATUS EFCS 1 02:11 FLR/FR0906010210 34111506EFCS2 1,EFCS1,AFS,,,,,PROBE-PITOT 1X2 / 2X3 / 1X3 (9DA),HARD 02:11 FLR/FR0906010210 27933406EFCS1 X2,EFCS2X,,,,,,FCPC2 (2CE2) /WRG:ADIRU1 BUS ADR1-2 TO FCPC2,HARD 02:12 WRN/WN0906010211 341200106FLAG ON CAPT PFD FPV 02:12 WRN/WN0906010211 341201106FLAG ON F/O PFD FPV 02:12 WRN/WN0906010212 341040006NAV ADR DISAGREE 02:13 FLR/FR0906010211 34220006ISIS 1,,,,,,,ISIS(22FN-10FC) SPEED OR MACH FUNCTION,HARD 02:13 FLR/FR0906010211 34123406IR2 1,EFCS1X,IR1,IR3,,,,ADIRU2 (1FP2),HARD 2:13:16 ~ 2:13:41 Possible "Loss of Signal" with satellite 02:13 WRN/WN0906010213 279002506F/CTL PRIM 1 FAULT 02:13 WRN/WN0906010213 279004006F/CTL SEC 1 FAULT 02:14 WRN/WN0906010214 341036006MAINTENANCE STATUS ADR 2 02:14 FLR/FR0906010213 22833406AFS 1,,,,,,,FMGEC1(1CA1),INTERMITTENT 02:14 WRN/WN0906010214 213100206ADVISORY CABIN VERTICAL SPEED
  • 127. 02:10 WRN/WN0906010210 279100506F/CTL ALTN LAW
  • 128. 02:10 WRN/WN0906010210 279100506F/CTL ALTN LAW
  • 131. 02:13:40 (Bonin) But I've been at maxi nose-up for a while 02:13:42 (Captain) No, no, no... don't climb 02:13:43 (Robert) Descend, then... Give me the controls... Give me the controls! ... 02:14:28 End of recording
  • 132.
  • 133. How does your HA provide feedback?
  • 135. How do these modes behave differently?
  • 136. What about modes you haven’t seen?
  • 137.
  • 140. Know how colour is processed by the brain
  • 141. Familiarise yourself with type
  • 142. Familiarise yourself with type
  • 143. Familiarise yourself with type
  • 145.
  • 150. CRM
  • 152.
  • 153. Are your inputs averaged?
  • 154. How do your engineers troubleshoot during incidents?
  • 156. How do you co- ordinate change?
  • 159. How is information disseminated?
  • 160. How does the business know what is happening?
  • 161. Do you have a process?
  • 162. Do you practice this?
  • 163. What data do you rely on?
  • 164.
  • 165. Pair
  • 167. Minimise & Compartmentalise
  • 168. Record
  • 171.
  • 172. HUD
  • 174.
  • 177. 02:12:27 (Robert) You're climbing 02:12:28 (Robert) You're going down down down 02:12:28 (Captain) Going down 02:12:30 (Bonin) Am I going down now? 02:12:31 (Robert) Go down 02:12:32 (Captain) No you climb there 02:12:32 (Bonin) I'm climbing okay so we're going down 02:12:34 (Captain) You're climbing 02:12:39 (Bonin) Okay, we're in TOGA 02:12:41 (Bonin) What are we here? 02:12:41 (Bonin) On alti what do we have here?
  • 178. CRM
  • 179.
  • 183. deep dive on details
  • 185. scientific method: improvised
  • 189. human pattern recognition (provided there is enough adaptive capacity)
  • 190.
  • 193. • Final Air France 447 Report: Pilots misunderstood their situation • Poorly-trained pilots to blame for Air France crash that killed 228 • Final Air France crash report says pilots failed to react swiftly • Air France 447 downed as crew ignored alarms • Air France 447 crash a result of crew ignoring alarms
  • 202.
  • 204.
  • 206. limit # of engineers who watch alerts & graphs
  • 210.
  • 212. System capable of failure
  • 213. System capable of success
  • 214.
  • 215. • System that enables communication
  • 216. • System that enables communication • System that exposes secrets
  • 217. • System that enables communication • System that exposes secrets • System that rob us
  • 218. • System that enables communication • System that exposes secrets • System that rob us • System that funds innovation
  • 219. • System that enables communication • System that exposes secrets • System that rob us • System that funds innovation • System that kills us
  • 220. • System that enables communication • System that exposes secrets • System that rob us • System that funds innovation • System that kills us • System that allow us to fly across the world
  • 223. Failure is just another mode of operation
  • 224. Your system may not control fate of people’s lives
  • 225. But people may depend on it
  • 226.
  • 232. We need to look at it from a systems approach, a human/technology system that has to work together. This involves aircraft design and certification, training and human factors. If you look at the human factors alone, then you're missing half or two-thirds of the total system failure -- Chesley Sullenberger Pilot, US 1549, Hudson River Ditching
  • 233. We need to look at it from a systems approach, a human/technology system that has to work together. This involves aircraft design and certification, training and human factors. If you look at the human factors alone, then you're missing half or two-thirds of the total system failure -- Chesley Sullenberger Pilot, US 1549, Hudson River Ditching
  • 234. Damn it, we're going to crash... This can't be happening!
  • 235. • Final Air France 447 Report: Pilots misunderstood their situation • Poorly-trained pilots to blame for Air France crash that killed 228 • Final Air France crash report says pilots failed to react swiftly • Air France 447 downed as crew ignored alarms • Air France 447 crash a result of crew ignoring alarms
  • 237. Liked the talk? Let @auxesis know! Thank you
  • 238. Sidney Dekker Field Guide to Understand Human Error Drift Into Failure Just Culture Jon Rauser Look at Your Data @ Velocity Ryan Tomayko Distributed Management @ Monktoberfest 2012 BEA Report on AF447 incident