May 25, 2011 | Mark Paradies

Pilot Error, Fatigue, or Bad Design?

I was reading an article in The Wall Street Journal titled:

Black Boxes Point to Pilot Error

The story said:

The pilots of an Air France jet that crashed into the Atlantic Ocean two years ago apparently became distracted with faulty airspeed indicators and failed to properly deal with other vital systems, including adjusting engine thrust, according to people familiar with preliminary findings from the plane’s recorders.

There’s more details in the article but I started thinking … WHY did the pilots respond inappropriately?

I naturally started thinking through the 15 Questions for troubleshooting human error on the front side of the Root Cause Tree®.

Were the pilots fatigued? Did that cause them to react slowly (this was an overnight flight).

What about the automation and displays in the cockpit? I’ve heard that people can easily get confused in Airbus cockpits and easily loose situational awareness.

What about the pilots training? Usually international pilots are some of the most senior but it is worth a look.

The article said:

Slated to be disclosed by investigators on Friday, the sequence of events captured on the recorders is expected to highlight that the jet slowed dangerously shortly after the autopilot disconnected. The pilots almost immediately faced the beginning of what became a series of automation failures or disconnects related to problems with the plane’s airspeed sensors, these people said.


The crew methodically tried to respond to the warnings, according to people familiar with the probe, but apparently had difficulty sorting out the warning messages, chimes and other cues while also keeping close track of essential displays showing engine power and aircraft trajectory.

Makes me think that human-machine design is much more the cause than simple “human error.”

The article also says:

The Air France pilots were never trained to handle precisely such an emergency, …

Ahhh … training may be an issue.

And what about crew teamwork?

What about previous incidents?

The WSJ also reports:

The previous interim report indicated that in late March 2009, less than three months before the crash, European aviation regulators decided that the string of pitot-icing problems on widebody Airbus models wasn’t serious enough to require mandatory replacement of pitot tubes.

The Root Cause Tree® helps analyze these types of problems.

To get your training to use the Root Cause Tree®, attend one of the public TapRooT® Courses:

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