Airlines Lobbying usurp Citizens Rights of Pilots in Latest FAA Ruling

Cargo Carriers Lawyers and the Power of Dollars Overcomes Cargo Pilots Safety Rights of One Man One Vote.

Fatigue, the greatest Human Factors problem in commercial aviation, was introduced back into the recipe of severe hazards by the work of lobbying lawyers working for the US cargo carrier industry. US Transportation officials chose to succumb to the political pressure and apparently to the financial power of lobbyists who argued that commercial cargo carriers would be subject to undue financial pressures if the cargo airlines were required to operate safely.

Instead, it appears to me that these company lawyers argued to the FAA lawyers that there is not case law that cites fatigue as causing cargo crashes that impact the public. In my opinion, no one at the FAA acts as a safety manager or safety regulator or safety administrator but rather act as lawyers and consider events related to flight operations only from the point of view of what has happened in the past. But the FEDEX B727 Tallahassee, FL fatigue related crash did not take out a neighborhood and therefore didn’t affect the public, so it appears that to an FAA lawyer only administrator, this and other similar fatigue related cargo carrier mishaps do not affect their judgment of their ability to think legally.

Did the FAA lawyers or the cargo industry lawyers look at the huge casualty costs of operating under the federal regulations as they have existed and now exist?

If, as I believe, the lawyers were trained as safety regulators, they would see the risk that fatigued cargo pilots could crash into a city such as San Diego, Philadelphia, Newark, Louisville or any number of cities overflown by cargo pilots at 5-6am at the end of a fatiguing 16 hour day of 8 or more hours of flight time.

In my opinion, the FAA is not protecting the rights of citizen pilots flying for cargo carriers. It appears to me that the FAA, the US Federal Government, is not protecting the rights of citizens living under the flight path of cargo flights arriving at 5-6am in major city hub airports. Instead, it appears to me that elected and appointed US officials are choosing to give corporation lobbying lawyers better rights than individual US citizens, so that the corporations can make more money, while the safety of the public is not protected.

The FAA Safety Policy is “One Level of Safety.” However, it appears that the FAA has dragged out some old past century bureaucrats to recreate government of the dollar, by the dollar and for the dollar, instead of “of the people, by the people and for the people,” as noted by US President Abraham Lincoln in his famous Gettysburg Address.

It is my opinion the old style bureaucrats, who have so totally screwed up the management of safety in domestic commercial aviation for so many years, should instead leave aviation safety management to people who are experienced and by this degree qualified to make decisions of regulation.

The best example is to look at the terrible mess that the FAA’s regulations have had on the US commercial airline industry. I believe that it took more than 20 years of failed regulations to institute effective wind-shear, fatigue, baggage management and TCAS standards. Now it appears that they are involved in another 20-year struggle to handle effective crew training and human factors fatigue standards.

But then we should look at all of the lives lost in the air and on the ground, the airplanes destroyed, the property destroyed year after year for the past 40 years in US domestic airline disasters? The data shows thousands of lives lost, billions of dollars destroyed, all under commercial airline operations certified and regulated by the FAA.

In my opinion it is now time that the FAA should be led by someone from the airline industry, someone who actually has some experience and therefore credentials as a successful aviation safety manager? Can the US really afford to re-create two levels of safety in commercial aviation? Was not that FAA policy already discredited years ago?

So, can anyone tell me if lawyers really study any aviation safety policy, theory or philosophy in law school? If so, I sure would like to see the law school syllabus reference, because I sure have not been able to find one.

I believe it is time for new leadership in aviation safety in America.

Practice, Procedure, Policy, Technique, Philosophy: What really is "BEST?"

This is one of the basics. Knowing these relationships helps us understand how to do alot of other things correctly. Back to basics is always valuable.
I will challenge my readers to put them in a logical order:

Practice, Procedure, Policy, Technique, Philosophy: What is the right order?

Then read my letter below.

Dear All my Friends:

With respect to the term "best practices," I would like to make a comment. What we are really fostering here is better labeled "Best Procedures." To clarify, procedures are documents, they are published, they are written down and promulgated by an authoritative source such as a company or a regulatory agency, they are dated, they are signed, they can be and almost always are formally modified, updated and changed through a formal process.

As safety advocates for Flight Safety Foundation (FSF), it is my opinion that we should be fostering Best Procedures.

The term practice most often denotes the work of an instructor in teaching students how to carry out a procedure, which the practitioner then uses as a tool for conducting the Standard Operating Procedures correctly, consistently and safely.

The follow-on term is technique. Technique is the individual styles that operators and practitioners employ to make the practice smooth, tailored to the operation and refined.

Best Procedures is what we, I believe, should be advocating. Leave the techniques and practices to the individuals who are the technicians and practitioners.

As FSF, should we not be about influencing commercial companies and regulatory agencies to set up new authoritative written and published formal methods of operating? Is not our real customer, if you will, is not our real customer each company and regulatory agency? Are not these the parties that we are really trying to address and influence?

Can we expect to address all commercial pilots (70,000 just in the US) with a suggestion on how to adjust their practices? Remember that PRACTICES ARE NOT WRITTEN DOWN. But Procedures are. So this is the difference.

And the use of the word protocol is even more problematic, because we really do not know the authority of the protocol writer?

I would encourage us and the rest of the commercial airline industry to consider using the term BEST PROCEDURES from now on and leave the practices to the practitioners.

The right order is: The ordered ideas of our own innovations become our philosophy. Our leadership transforms our philosophy into our policy. Our need for standardized action transforms policy into procedures. Operational reality creates practicality for our actions and our human factors translates practice into individual techniques.

So for my readers the correct order is: philosophy, policy, procedures, practice and technique. Any or all of them may be fostered as "best." That is the right of global free speech.

But in fostering Safety, it is my recommendation that we use the taxonomy BEST PROCEDURES. This denotes standardization, authority and actions based on research, science and accountability. The excellent safety records of organizations that adhere to this order may give you motive to agree.

Best regards, Paul Miller

"BEST PROCEDURES" vs Best Practices: which is the More Correct Taxonomy??

With respect to the term "best practices," I would like to make a comment. What we are really fostering here is better labeled "Best Procedures." To clarify, procedures are documents, they are published, they are written down and promulgated by an authoritative source such as a company or a regulatory agency, they are dated, they are signed, they can be and almost always are formally modified, updated and changed through a formal process.

As safety advocate, it is my opinion that we should be fostering Best Procedures.

The term practice most often denotes the work of an instructor in teaching students how to carry out a procedure, which the practitioner then uses as a tool for conducting the Standard Operating Procedures correctly, consistently and safely.

The follow-on term is technique. Technique is the individual styles that operators and practitioners employ to make the practice smooth, tailored to the operation and refined.

Best Procedures is what we, I believe, should be advocating. Leave the techniques and practices to the individuals who are the technicians and practitioners.

As safety advocates should we not be about influencing commercial companies and regulatory agencies to set up new authoritative written and published formal methods of operating? Is not our real customer, if you will, is not our real customer each company and regulatory agency? Are not these the parties that we are really trying to address and influence?

Can we expect to address all commercial pilots (70,000 just in the US) with a suggestion on how to adjust their practices? Remember that PRACTICES ARE NOT WRITTEN DOWN. But Procedures are. So this is the difference.

I would encourage us and the rest of the commercial airline industry to consider using the term BEST PROCEDURES from now on and leave the practices to the practitioners and the techniques to the technicians.

Taxonomy is important if we are ever going to be able to communicate.

Bad Math by ICAO?

ICAO may be fostering bad mishap math. ICAO is stating that an increase in mishaps is attributable to an increase in flight operations. If that were so mathematically, than as any airline operated more flights and or flew more hours, their mishap rate would directly increase.

But that is not the case anecdotaly, statistically, case historically or in the experience of this pilot. The author of the ICAO report is looking for the reasons for more mishaps in the wrong place. This is critically important error on the part of ICAO, especially if everyone is trying to achieve the goal of reducing aviation mishaps. ICAO math would have us reducing flight operations in order to reduce the commercial mishap rate.

But is not our goal to solve the mathematical problem of mishaps and rates by finding methods of prevention? To do so, wouldn't you have to know what are the causes of mishaps in the first place?

It is my opinion that aviation mishaps are a direct result of unresolved hazards. The rate of mishap occurrence is therefore reducible by resolving hazards to aviation as quickly as possible. As the factors affecting the rate are reduced through Safety Procedures, the numbers of mishaps will be reduced. That in my opinion is the correct Safety Math.

Accident are therefore a mathematical function of unresolved hazards and are not a mathematical function of hours flown, nor of take-offs or other related operational factors. In my opinion ICAO is using bad math to address the issue of safety hazards and accident rates.

The correct safety math is therefore a function of how quickly we can eliminate hazards. As the rate of hazard occurrence and the actual numbers of hazards are reduced, then the rate of aviation mishaps disasters will be reduced. In fact, it is actually how rapidly we eliminate hazards that also counts, since a hazard over time results in heightened mishaps. Accident Rate is a direct function of unresolved hazards and nothing else.

Even though ICAO is not providing the mathematical or safety leadership needed globally to move commercial aviation safety in the correct and desired direction, it is my hope that many other safety minded managers are, and are doing so by regularly working to quickly resolve hazards to safe flight operations.

Best regards, Paul Miller



Wednesday, December 7, 2011
ICAO Issues Global Safety Report
Aviation accidents around the world ticked higher last year, attributable to the resurgence in air traffic, according to ICAO's inaugural State of Global Aviation Safety Report issued this week.

The number of accidents attributed to scheduled commercial flights increased in 2010 to 121, compared to 113 in 2009, resulting in an accident rate of 4.0 per million departures. The accident rate in 2009 was 3.9 per million departures. While the overall number of fatalities in 2010 was below those in 2005 and 2006, there has been an increase in fatalities over the past three years, ICAO said, increasing from 670 in 2009 to 707 in 2010.

At the same time, the number of scheduled commercial flights increased by 4.5 percent globally since 2009, which represents the first significant annual growth in the sector since 2007 and coincides with an increase of 4.2 percent in the global GDP. North America, which represents a third of global air transport traffic in terms of departures, was the only region to see a small decrease (0.6 percent) in its aggregate traffic figures.

"In the context of this period of renewed growth, and in light of anticipated increases in air travel, it is imperative to maintain a very strong focus on initiatives that will further improve safety outcomes in the future. ICAO is therefore continuously developing and refining more proactive and risk-based methods to further reduce the global accident rate, enabling the safe expansion of air travel in all regions," according to the report.

"ICAO is working in partnership with the international aviation community to achieve continuous reductions in the global accident rate, with an emphasis to improve safety performance in those regions experiencing significantly higher accident rates or having specific safety challenges."

To my readers from across the globe

Welcome:
If you are a safety manager for a commercial airline, I want to extend a welcome to you. I want to offer my ideas to you to help you make your own airline safer. I know that being a Safety Manager is a very hard job. You either have the choice of doing very little and waiting until a mishap (accident) happens and then you have 2-3 years of mishap investigating to do.

OR

You can work very hard long hours to prevent mishaps from occurring in the first place.

In either case, you will work very hard. The big difference?

In the case of prevention, you will enjoy the holidays with your family, your company will be profitable and all of the employees will enjoy happy careers.

In the case of mishap investigation, you will work so very hard and in the end, realize that all of this pain, suffering, damage and all this waste could have been and should have been prevented and you will have a stack of photographs, a larger stack of papers, a huge smoking hole and a lifetime of regret.

Please follow my blog so that I can give you some ideas on how to be a successful Safety Manager.

All my best regards, Paul Miller

If you would like to send me an email to ask a question or clarify the English language part of all of this, please do.

http://paulmiller@safetyforecast.com and I will answer you individually.

Safety Tools vs Safety Managers (RevA): Which Works Best?

All safety programs are only tools. So, to do the work of Safety your company needs someone who knows how to use the tools.

The Safety Manager has to be a "skilled works-man in the trade of Safety." Programs from "on-high" in and of themselves do not Safety make.

The mistake many airlines make is to approach Safety with a not-too-smart manager, who is both excels at "bureaucratic compliance" and intimidating flightcrew, but most often someone who does not have original thoughts nor innovative thinking.

To use all of the Safety tools provided by various Safety advocate organizations a company needs a skilled Safety person, someone who knows how to use the tools to create safety. It is not enough just to dress up in the clothes and look the part, you actually have to do the work or no safety is achieved.

Six Rules for Failure?

Here are unspoken managerial safety problems. I call them:

"Miller's Six Rules to Fail-While-Complying"

1. Many companies are run by managers who do not know their own industry well. In commercial aviation many managers are not line pilots. Many managers do not come from the ranks of the company's own line holders.

2. They will act as if they are trying to comply with any program placed on them by their superiors. Their work is to comply with a regulator or industry inspector, and not necessarily make their own company operation safer.

3. But they will not embrace the spirit of these regulatory programs.

4. They will not adapt these programs to be effective for their own local operation

5. They will not innovate new programs that will work for them.

6. They will suppress any person in their organization that attempts, suggests or recommends safety innovation that falls outside of the letter of the regulation or law governing their operations.

So ICAO, FAA and other government regulators can recommend or require all types of safety programs, but were not many of these programs recommended by safety organizations and safety pioneers more than 20 years ago and longer in the case of many safety programs? So, how effective are regulators themselves at being the global advocate for commercial aviation safety?
So in my opinion, if the local organization does not do everything to help themselves, are they not more or less likely to fail?

As I read the papers, watch the news, I regularly observe regulators, major airlines and aircraft manufacturers adhering to some or all of the six rules for failure?

Examples? Crew fatigue.

Safety Manager Tool for Accident Prevention

To understand how to prevent a mishap, it is critical to understand the terms Risk and Hazard.

A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.

This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.

Why is it important to eliminate hazards?????

Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.

But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.

A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.

When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.

So I have written a mathematical formula to describe this and it is called, MILLER'S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodocity by looking at the trigonometric sine function and MILLER'S FORMULA FOR RISK becomes Z= sine |X| N(Y).

There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled "Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!" copyrighted 2003.

If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.

See other safety discussions on my web site: http://safetyforecast.com

Be safe. Remember that $afetyPay$

new blog

See my blog and web site now at http://safetyforecast.com

Air France 447: Critique of Otelli's French book

Heard about the book today. Jean-Pierre Otelli who specializes in aviation safety, publishes his book "Piloting Error, Volume 5" today.

But in my opinion, he only re-analyses the facts collected in BEA's report. I believe that the BEA's report is seriously flawed and the book adds little to mishap prevention.

Read my many articles in my other safety blogs to learn more.

http://safetyforecasts.com/
http://bettersafeaviation.blogspot.com/

Would you like proof that BEA's investigation is flawed?

Simple: there is little if any recommended corrective action contained in the report, that, if followed, would have prevented this mishap. Rather, the book and report appears to center on finding fault, assigning blame and extracting tribute for damages. So, the investigation is really a legal investigation and not a Safety Investigation. I have explained in the blog that the only value to a Safety investigation is to find ways to prevent a recurrence.
It appears to me training is weak at AF as well. So, that is a managerial responsibility and regulatory duty. Remember that this crew was certified by the airline's training dept and national aeronautical regulators before they were assigned to operate this flight. If their performance as a crew and as individuals was substandard, as alleged in the BEA's report, then that would be a direct indictment of the training and certification authority credibility, would it not?

From my background training experience, when we first learned basic and radio instrument procedures in basic jet training, an important segment of that training were procedures to employ when some of the instruments failed. Some of this training focuses on the failure of attitude and/or directional gyro equipment and is called partial panel procedures. Some other procedures focused on loss of pitot-static instruments, some or all and teach you to remain in stable flight using attitude instruments and standard engine power settings. Other procedures cover magnetic and/or directional gyro or heading instrument failures, still others cover what to do if part of your navigation instrumentation fails.

We practiced all of these procedures this right from the beginning. Along the way with every new aircraft, with every new organization, these procedures remained a significant part of regular training. At my last sim/training session a year before retirement, we practiced these procedures and focused especially on the loss of pitot-static instruments. We trained heavily on this.
So, were these AF447 crew members trained by AF in this area? There certainly appears to be a question here. However, does the report by BEA or the book by Otelli investigate this?

AF 447: Pitot Tube Loss Procedures?

The loss of pitot static instrumentation is an emergency for which commercial pilots are or should be trained. In the case of the loss of pitot static instrumentation, a general procedure is to use the instruments available that are not dependent on the pitot static systems or to use back up pitot static systems and instruments. In either case, the safety of the flight is possible and the crew should be able to maintain safe flight until either the aircraft can be moved out of the icing conditions which are often the cause of the loss of pitot static instruments or the aircraft can be moved to VMC so that the crew can land the aircraft with use of available instrumentation and procedures.

In the case of AF 447, there appears to be a procedural issue as well as an equipment failure. That said, the crew I am sure was more than capable of operating in the condition where the pitot static system failed. Why did they not?
Were the clues to determine this condition not available or masked or conflicted by other clues?

I wonder what each commercial pilot reading this and other reports thinks? We have read what BEA thinks and their reports are not credible.

Safety Risk

Consider the mathematics formula, Z=XY. When plotted on a 3D graph, the function gets very large very quickly.

Consider that Z is risk and that X is severity and that Y is probability. Then this formula is saying that severity and probability are multiplied, they are not added or otherwise combined mathematically.

If this Z=XY then risk is a very rapidly increasing number. That means that unresolved safety risks are very dangerous.

Plot this graph on your own graphing program. But remember to use only the positive part of the graph, that is, the positive values of X and Y. This will yield just the positive values of Z, that is, just the positive values of Risk, since mathematically, these are the values which make sense in reality.

Working Jointly as a Safety Manager: How does that work?

So now you are probably asking, "Okay, how do I get 14 pilot association committees to work with me, the airline safety manager?"

I am so glad that you asked!!!

The key to success here is by working Jointly with the pilot association. What is that? Your airline does not have a pilot association? Hmmm, I wonder if the airline management has done everything possible to discourage a pilot union from forming? If so, they have really done the airline a great disservice. What is that? You say that this same airline management team has only provided the minimum of one person for the entire airline safety program? Wow! That same team has really done the airline a disservice!

In the case about which I previously spoke, our pilot union had 14 committees and well in excess of 100 people doing volunteer safety work on behalf of the union membership. But who also benefited?

Well of course the answer is that the company benefited greatly.

So, how many airlines have the model of a Joint Safety Program?

Not too many.

How many could have an exceptionally effective safety program at very little extra cost by working Jointly with the pilot group?

I would say, just about everyone could.

Should Safety Managers be good listeners?

Safety managers must be good listeners. It has been my experience that few if any reports from people participating in safety suggestions are actually "trivial."

My experience is actually just the opposite. My experience is that everyone who came to my office to make a report had an important idea to share or an important here-to-fore unreported risk to which to bring our attention.

By listening to the person reporting and taking time to clarify their concern, our safety programs achieved two important goals. First, we found risks that only one person recognized. Funny how in an organization of 300 people, that only one person will see and be willing to report a very valid hazardous risk. Not sure why that is so, but it is. Second, by listening to all who came in to report, and publishing all reports and recognizing the best each week, we developed the excellent reputation of being the "good listener." You would be amazed at the things that really need to be fixed that no one else noticed or bothered to tell anyone about.

So, my suggestion is do not worry about "triviality." In fact the report may be of quite some significance when you later understand its true potential for prevention.

Again that is my experience and I would add, that by doing so, our safety program achieved the goal of reducing losses due to injuries and deaths, property damaged or destroyed to zero. So, I would say that this program worked very well in four very different organizations.

Can Safety Be Done by One Manager? I would add, that Safety is not a job that can be done by one. In fact at my pilot association we had 14 committees that dealt with some portion of the safety pie, yes 14! And we were not the company, we were just the pilot group. Safety is not something that can be done from an asset poor point of view! Safety requires a great deal of attention.
What many airlines have found is that by failing to do the safety job of prevention well, that instead they wind up doing the mishap investigation job. And what a huge waste of time and money that is!!

There has never been a mishap investigation in which I participated, where in the end the conclusion that this mishap was preventable was not reached!

It has been said, "You seem to be convinced that a flawed world can be actually made flawless."

My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller's Rule for Safety Management: ALL SAFETY IS LOCAL.

Any one safety manager cannot make a "flawed world ..... flawless." He or she can only affect the operation over which they have control.

I can personally recommend steps to each LOCAL Flight Operations Safety Manager that have worked extremely well to achieve mishap free flight operations.

One person commented, "In a process oriented investigation "human error" cannot be the ultimate root cause. You need to ask yourself, "Why did the humans make the errors?"

My response to this is, "True, but you also need to go further and ask what procedures can be put into the SOP and become part of the training program that will help flight crew members overcome their human errors.

For example, lets say that a very important system characteristic is buried on page 49 of a chapter in the Aircraft Operating Manual. Well, maybe if it is considered to be so important, should it be bold faced, underlined and not buried on page 49? In other words, humans make errors that can easily be corrected. Safety managers need to find ways to help the flight operation correct errors as they are occurring and are reported.


Some have also said, that crew selection and training criteria are often driven by both financial and safety level aspects. FAA and other civilian authorities have criteria set at minimal requirements. But one company may decide to exceed those.
For example, one company may decide to select pilots (1) which have a Commercial Pilots License from a school with a weak syllabus and accept those after a minimal medical and psychological selection process, accepting captains with only 3,000 flight hours. Another company may have require at least a masters degree in technical sciences and demand a very strict medical and psychological selection criteria and accept captains only after 30,000 hrs. The same could and often does apply to training. One set of training requirements are used for a Government operation and another set of training criteria are used for a major airline."

But my response is this. You still have to train flight crew in the company SOP. You still have to check to the SOP and make your operation "procedure oriented" and not technique oriented. This way flight crew are performing procedures and not using their own techniques to operate.

Further, as the operation improves its control, it will develop a need to have more standardization in procedures just so that mixed crews can operate efficiently.

Should the FAA tolerate such a wide variance between airlines? It is the Topic for another day.

Forecasting involves learning from previous mishaps

We can forecast by learning from the mishaps of other organizations.

We learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap.

Did you know for example that Safety Theory tells us that flight crew will make 1000 errors which could lead to 100 reportable events, which could lead to 10 incidents and which could lead to 1 major mishap.

Many people do not believe that or do not understand this very valuable nugget of safety information. This is the key to succeeding in the safety profession and I will tell you this from my own 43 years of experience. You can achieve zero mishaps, you can prevent mishaps at your airline.

Here is how to do it. You must have a reporting system that allows flight crew members to speak about and report their errors and those that they observe. Next the safety person has to investigate these errors, figure out how they impact the operation and take steps to correct the organic reason for the errors. Most often in my experience this involved some adjustment, modification or addition to SOP. But the safety person has to be well versed in flight ops and SOP so that the changes to SOP make sense.

Unfortunately all too many people believe that until an event, incident or mishap occurs, that their operation doesn't "have a problem." However the problems are there because we are human. They will always be there. The key is to incorporate the error reporting process into day to day operations, to talk about them and fix them right then and there.

Allowing human errors to "fester," to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.
But I believe that as humans we are constantly making errors. A good program that enables us to report and act on these errors as they first occur will enable us to always be one step ahead of the hazards and therefore operate free from mishaps.

Safety Forecasting for Air France?

Many more mishaps of the same type. They haven't fixed the root causes of the mishaps which they suffered and instead chose to blame everyone else.
Proof? Was it not AF procedure to have a man in a truck do a Foreign Object Damage (FOD) check of the runway prior to the Concorde conducting a take off? If the loss of parts by another airline was a known hazard and the airline had a preventative procedure to counter this threat, why did the mishap acft depart before such a FOD check was made?
Why would AF not advise and train its own pilots about the differences in runway friction between a grooved runway and a non grooved runway such as in Toronto? Why did AF training not equip pilots to go around when landing in a storm?
Why didn't AF take better care of flight crew out over the ocean by sending them the latest weather?
Would I suspect AF to be ready to have another mishap real soon?

Probabilities seem good for that event, in my opinion.

How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy

Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world?

Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:

Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the "Safety Investigation" by claiming that the "Common Good of the Traveling Public is at Risk!" Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of "What Happened" and "How do we keep this event from ever happening again?" are lost in the rush to "Who was at fault?" and "Who pays?"

Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap's recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.

Rule Three: Generate "Legal Uncertainty" using the term "Probable Cause" [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that "reasonable doubt" is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.

Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.

Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the "Traveling Public."

Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the "Parties To The Investigation" and those "Parties To the Investigation" without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the "inevitability of tragic human loss" in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.

Well, that about sums it up, no?

One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?

Could this be why in commercial aviation we observe the essentially "same disaster" or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn't this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?

Shouldn't the purpose of a Safety Investigation be to "find out what went wrong and take action to ensure that this event never happens again?" Isn't that what all of us do in life to keep from making the same mistake twice? Why wouldn't that same reasoning apply when we are talking about "Flying the Traveling Public Around the World in Our Commercial Aviation system?"

Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?

Or are we just stuck on Rules One through Six?

Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to "someone else?"

Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.

When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?

If so, their voices have yet to be heard.

This of course is my opinion.

Grim Safety Forecast for Air France

The recommendation is contained in the latest BEA accident report investigating the loss of the Air France Flight 447, a document that outlines 10 new safety recommendations, including improved pilot stall-awareness training, the inclusion of cockpit cameras, and adding angle-of-attack readouts in the cockpit.
But it's the inclusion of a call for mandatory data streaming technology that is sure to raise the biggest objections with airlines, who will have to pay for it.

This is a grim future for Air France if these are the BEA's main plan to prevent this event from reoccurring.
I can agree with the angle of attack recommendation. I can agree with the stall awareness training.
But did not having the cameras cause the mishap? Of course not; this is just someone trying to get the camera in the cockpit nnd using thes dead people to do it.
Did not having data streaming from the acft cause the mishap? No, in fact it was not having weather data streaming TO THE AIRCRAFT that was in great part responsible for the mishap.

So, it is my opinion that AF will have a string of these mishaps, more of the same!

AF447 again and again?

AF447 will undoubtedly reoccur again and again because the aircraft mishap investigation board failed to discover the cause of the mishap and instead blamed the mishap on the crew. Not only is this an inaccurate and unsubstantiated conclusion, it is also a conclusion that is misinformative. No airline reading this report will be able to use the report to take steps to prevent a similar mishap from occurring again. That is a very large error on the part of the company and the country.

The sole and critically important purpose of an aircraft mishap safety investigation is to determine the cause of the mishap. Period. By accurately determining the cause of the mishap, the safety investigation informs all of us on how to prevent this mishap from occurring again.

Instead, the board doing the investigation has chosen to take their license to do a safety investigation and use the investigation as a legal tool to attempt to lay legal blame for the mishap on flight crew. This is a total aberration of the legitimacy of the entire process of safety investigations.

While companies and countries have the right to do a legal investigation to protect their legal interests, it is not their place to take the safety investigation and abscond with it for their own legal purposes. The public deserves and the industry deserves an unbiased safety mishap investigation.
What has been publish so far is not that at all.

This is a terrible miscarriage of safety and a great example of why the fox should not be guarding the hen house.

Go Arounds, Missed Approaches and variations?

I would like to suggest that each reader spend a few minutes thinking about how many different procedures that their airline or aviation organization has for conducting a missed approach and/or a go around.

Your first reaction might be "Just one." But take another minute and consider the variations. Each aircraft type has a slightly different set of procedures. How about the case when an engine is inop? What if the weather is IMC and tower is using IFR procedures in the ATA?
What if the weather is VMC and tower is using VFR procedures in the ATA? How about the case of the flight executing a cleared IFR approach procedure, but when handed off to tower, the clearance reads, "Cleared for a visual approach to land?"
What if the terrain for the runway in use dictates immediate maneuvers, the weather is IMC and tower assumed that you would have broken out and is taken by surprise that you are going around and a large thunder storm is in the missed approach path?
Does your training program give line pilots training and sufficient sim practice to be superbly proficient in all types of MA/GA's?

What if the weather is so bad that the airframe is icing up with mixed clear and rime during the last 1000 feet and the previous aircraft has not cleared the runway and now tower orders a GA? Has the crew practiced and become proficient in this scenario?

I hope that each reader considers all of the variations on MA and GA for a while and feels free to post a comment on this subject.
Thanks and more to follow on this subject.

Safety Forecasts More AF Mishaps

Safety Forecasts and Plans has determined that since AF has devoted so many resources towards trying to prove that they were not legally at fault for the deaths of their AF 447 passengers, that AF has not devoted sufficient resources to preventing future mishaps of all kinds, and therefor should plan on more mishaps for the future.

The statistical review of the past 10 years shows that AF mishaps were preventable, yet AF took steps insufficient to prevent them. Since AF has seemingly now devoted enormous resources to the trying to defend themselves, such as spending as much as $35 million to recover a DFDR by submarine, when all that they had to do was to walk into their own dispatch office and witness supervisory personnel not taking preventative steps to advise line captains about weather hazards in their path.

Example? AF 358 flew into a thunderstorm upon landing. Was the thunderstorm present prior to approach? Did dispatch, flight ops or anyone at AF have a thunderstorm avoidance policy? Did the policy undergo scrutiny, study or in anyway become part of flight operations procedures subsequent to AF 447 departing?

It appears that the thunderstorm avoidance procedures at AF was not change after AF 358 crashed in Toronto. Remember that this crash happened in August of 2005.

AF 447 occurred June 2009. So four years occurred and AF 447 flew into a thunderstorm. So once again the same mishap occurred all over again. And Why?

Very simply because no one in AF, or Canada or any other body determined that the cause of the mishap was flying into a thunderstorm. Blame was placed legally at the hands of the flight crew. Legal blame, legal blame was the product of the Canada Aircraft Safety Mishap Board. In fact it appears that the board didn't complete the safety task at all.

Should not have the board instead of assigning blame, determined the cause to be an encounter with a thunderstorm? Who claims that the aircraft can fly in thunderstorms? Does the manufacturer? Who does?
And yet less than 4 years later, AF flies another aircraft into a thunderstorm and the various mishap boards are all focusing on the actions of the crew once inside the storm!!!!!!! How absolutely ridiculous and illogical can any attempt be?

The manufacturer of no commercial aircraft and the regulator of no civil aviation authority anywhere in the world builds or certifies any commercial aircraft to operate inside of a thunderstorm.

So why does AF continue to do so? Why does any board expect to find any differing result in the event of an encounter?

AF 447, Safety Forecasting and Planning

Did the AF dispatch office fail to fulfill their duty to look at satellite data?
Did AF flight ops management have a procedure to get the information about recent bad weather enroute passed to transoceanic flight crews, especially those transiting the tropical convergence zone?

When you who are safety managers look at these questions, do you wonder why this lack of procedure was allowed to occur when so many lives are at stake?

If you who are safety managers are able to see that this could be a problem for your airline, then you have created e forecast of things to come.

Did AF 447 use correct Turbulent Penetration Procedures?

The second issue seems to be flight crew training when in heavy turbulence and when the pitot-static system is not operating.
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.

Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.

The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.

I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?

Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.

Other procedures include all of the various heaters and engine ignition circuits should be placed on.

Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.

Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?

Does FAA even do safety correctly?

Why does the FAA not take immediate and rapid action on safety issues when a flight crew member, the NTSB or anyone else for that matter brings the issue and a solution to their attention? Quite a simple answer really: the FAA is run by lawyers and not safety professionals. Lawyers deny that there is a problem of their own origin, because to "admit a problem" ( lawyerspeak, not safetyspeak) would be to admit fault and therefore legal liability in a tort court.
Instead of safety resolutions, the FAA maintains deniablity until pressure from the press and the public is so great that they cannot deny "something has to be changed!", usually the result of a press grabbing major air disaster, such as Continental/Colgan 3407.
A safety professional, on the otherhand, would have been looking at the problem, in this case, flight crew training, as soon as the first evidence of a problem was revealed.
The sad part about the lawyer approach of the FAA is that hundreds of innocent people have to die and grab headlines in order for a change to be made.
If the FAA were instead run by safety professionals, changes would occur without a lot of needless loss of life.
As far as comments such as, "Regulation created in a knee jerk reaction can do more damage to the commercial air industry than the industry (or passengers) can afford. Is it worthwhile to ground perfectly safe aircraft and aircraft operations on the basis that if there are no aircraft flying or no-one can afford to travel by air no crashes can happen..." frankly, I do not even know where to categorize this illogical line of reasoning.

As far as I know, there has never been a recommendation by a safety professional that said no aircraft should be flying or make flying so expensive that no one can travel. These kind of statements are known as "make up an outlandish course of action, pretend that a safety professional said it, and see how many people you can fool," type of statement, also know as "red herrings."
Safety on the other hand is good for business.


Paul

AF447 Pitot Tubes Issue

1. For many commercial aircraft, there is an emergency procedure for when pitot static based flight instruments become inoperable.
Pitot static based flight instruments include airspeed indications, altimeters and rate of climb instruments.

2. The scenarios encountered that might render these systems inoperative include a blocked pitot tube or a blocked static port.

A. In the past safety investigations found the following factors involved in pitot tube blockage:
1. loss of pitot tube heater allowing ice to build up or precipitation to clog the tube and/ or the associated plumbing.
2. a protective maintenance cover left on the pitot tube
3. insect, bird or other debris or object entering the pitot tube.

B. In the past, safety investigators have found the following factor most commonly involved in static port blockage:
1. Masking tape place over the static port by crews washing, waxing or painting the plane, where the tape was not removed prior to flight.

3. Since from what has been reported in the media that the flight was proceeding normally, it can be deduced that the problem with the pitot and static system was most likely due to the pitot tube icing over due to lack of heat.

A. Since most pitot heat systems are electrically powered, it is possible that there was some interruption in that electrical system.
B. When the loss of pitot static powered instrumentation occurs, the flight crew is directed by emergency procedures to use instruments which indicate flight attitude, that is pitch, roll and yaw.
C. The attitude instrument most often found in jet powered tranport aircraft is the attitude indicator. It will simultaneously indicate pitch, roll and yaw.
D. Attitude instruments are most often powered on commercial jet transport aircraft electrically and therefore will provide valid data in the event the pitot static system is inoperative. Their source is either laser ringed gyros, mechanical gyros or other similar systems.
E. Laws of aerodynamic performance state that pitch-attitude controls airspeed and engine power controls altitude. So as long as the flight crew maintains the cruise pitch attitude and the cruise power settings on the engine, the aircraft should stay relatively level in flight and the airspeed should remain at the speed required for cruise flight. The crew is often directed to seek an area of clear sky outside of icing conditions or precipitation in an attempt to regain use of the pitot-static system in the event icing caused the problem.

4. This is an emergency procedure which is successful and will allow the flight crew to maintain control of the aircraft through all flight regimes. I can speak from experience that this procedure works just fine. I can also state that this procedure is practiced in training simulators at many US airlines and I would suspect at many European airlines as well.


5. If the investigators state that the aircraft stalled, there are many scenarios by which this could have taken place. One common scenario is that the pitot tube ices up decreasing the dynamic pressure input to the airspeed indicator and rate of climb indicator. The static pressure port may not be blocked so it continues to show static pressure. If the crew does not cross check the pitch-attitude indicator, and only looks at pitot-static instruments, they may see an increasing airspeed and react by increasing pitch and reducing power. This could lead to as stall within a short time at altitude with an aircraft heavily laden with fuel, passengers and cargo.

6. To prevent this type of mishap, many airlines employ training in emergency procedures for the loss of pitot static instruments. The procedure includes disconnecting the auto pilot from control of the aircraft and hand flying the aircraft, again using pitch attitude and engine power settings from a chart. The charts carried on the aircraft include variables such as flight altitude and aircraft weight.

7. If the loss of pitot static system occurred while in a severe thunderstorm, the crew would have had to deal with both the severe turbulence, icing, possible lightning as well as the disconnecting of the autopilot. That would have been a handful for any crew to handle, but that is why most major airlines have strong training programs.

AF447

1. Air France Flight Control Dispatcher in Paris should have been monitoring AF 447. Flight Control should have been monitoring all hazards impacting the flight such as severe convective weather and rerouted AF 447 around the hazard.

A. Scheduled passenger airlines that operate under both US and European regulations control all flight operations from a central office known as "Flight Control" or "Dispatch." Despite the name "dispatch," (meaning to send out or send off) the office uses the radio and data call sign of "Flight Control." By US and European aviation regulations Flight Control must be in continuous communications and control of all dispatched flights. By US and European aviation regulations Flight Control is legally in control of the flight from before engine start and taxi out until the flight parks in its final parking spot at the completion of the flight. This is known as "block to block."

B. Flight Control plans the flight route prior to flight and files this flight plan with international aeronautical agencies that control the airspace through which the flight is planned to proceed. The agency determines the actual flight route and provides this authorization to Flight Control and the flight crew just prior to the flight departing its origin. During the flight, when entering oceanic airspace, this agency is coordinated through agreements between international civil aviation organization member states (ICAO) and is handled through radio calls in a non-radar environment.

C. Flight crew members, especially the captain, must be authorized to move the flight by Flight Control and must remain in constant communications with Flight Control during the flight, by regulation. This regulation is in place so that Flight Control is able to pass along information materially and directly affecting the flight, such as weather enroute and at destination and remain in control of the flight for all sorts of reasons affecting international authorizations for airspace entrance and transit.

2. No modern jet passenger transport aircraft in service then or today are certified to penetrate and fly into severe thunderstorms with tops above 50,000 feet, such as those in the tropical convergence zone near the equator.

A. Modern jet passenger transport aircraft are capable of flying high enough to be above much if not all of severe convective weather in the US, in Europe and over much of the non-tropical oceanic routes between Europe, the US and Asia. As a result, most of the time pilots can handle enroute weather with the information available on on-board weather radar and by looking out visually during day light and at night if in the clear. But at night, especially if the flight is operating in the clouds or at lower altitudes and in the vicinity of heavy, severe convective weather, weather radar might not be powerful enough to display the full extent of severe convective weather ahead on the flight path.

B. In the areas near the equator, severe convective weather very often occurs with heights much greater than modern jet passenger transport aircraft are capable of flying. This is a known meteorological phenomenon and these storms occurs routinely day and night. (Repeat these two statements in your mind.) They are observable by satellite with both optical, infrared and other technologies. In many cases they are exceed the ability of onboard radar to determine their size, severity, and height. On board radar in these cases is only useful for defining the edges of the storms for circumnavigation if the aircraft is outside of precipitation.

C. Oceanic navigation areas where modern jet passenger transport aircraft operate and are authorized to operate routes, such as from Brazil to Europe and to North America lie outside ground based weather radar coverage and therefore are not observable by ground based radar.

D. Weather information in these areas are obtained by weather imaging from a wide range of both photographic, infra red and other technology satellites. This information is made available from government agencies to airline Flight Control offices and other subscribers through commercial services by way of the internet. This internet facilitated information is not now accessible in the cockpit (although current technology would allow it and it is accessible in some cases onboard passenger aircraft in the cabin where on board internet is provided). Therefore the only way that flight crew can be advised of this critically important weather data is by Flight Control advising them by radio and data communications from the Dispatch or Flight Control Office.

E. It does not appear that the lack of action on the part of the Air France Flight Control Office in Paris is being investigated as a relevant factor in the loss of AF 447. Rather the attention of investigators and journalists is being redirected towards equipment manufacturers such as Air Bus and the flight crew.

3. Sophisticated weather data is accessible at Flight Control. Managing this information is the direct legal responsibility of Flight Control. US and European aviation regulations thereby give Flight Control the direct responsibility and authority to keep dispatched flights informed of weather hazards along the route of flight and at destination. (Repeat that to your self.)

A. Flight Control is fully equipped with all internet facilitated current satellite based meteorological information. Flight Control has the current and up to the minute information about severe weather phenomenon and the ability and the responsibility to communicate that information to the flight crew.

B. Flight crew graphic information, such as satellite images of photographic or infrared data are provided only at the time of preflight briefing, which can be as much as 1 ½ hours prior to departure. Very often the briefing itself is prepared an hour before the flight crew arrives to receive their briefing, because Flight Control may be dispatching multiple flights at or about the same time. A flight crew that is three hours into a flight for example, could possibly have therefore weather data that is five and a half hours old, in other words, not current.

4. Since severe weather, such as tropical convergence zone thunderstorms can routinely develop at a build-up rate of 4000-6000 feet per minute, new severe convective weather with heights of 60,000 feet, and higher, can develop in a very short period of time. Areas and lines of these thunderstorms can and do develop in the space of less than two hours and can build to heights well above the flight capability of modern jet passenger transport aircraft and pose severe hazards to flight such as hail, severe turbulence, lightning, icing and heavy precipitation.

5. No modern jet passenger transport aircraft are or have been certified to operate in severe thunderstorms, although many have been strengthened, equipped with electrical bond wiring and some level of engine, wing and windscreen deicing in the event that they encounter these severe convective weather conditions of a thunderstorm inadvertently.

6. Actual US and European aviation regulations require flights to be dispatched and while airborne to remain miles away from severe convective weather activity.

A. Yet in this case, the Air France Flight Control did not reroute AF447 around a known area of severe convective weather, that had heights above the possible service ceiling of the Airbus 330.

Why not? Why has the investigation not asked this question?

Can we look forward in safety?

Can we look forward in safety to forecast hazards and plan a strategy of action to prevent damage?
Some people think that you can. Do you?

AF447: What will they find in Black Boxes?

Could new attempts to raise black boxes by investigators of the AF447 disaster be nothing more than attempts to exonerate all responsible parties?

Has Airbus, Air France, the FAA or any other manufacturer or regulator conducted testing inside 70,000 ft thunderstorms?

Have French officials, Air France, Airbus or the FAA been able to explain why the Air France dispatch office, a recipient of regularly updated satellite photography, was unable to inform AF447 of extremely severe weather in the flight path assigned to AF447 by that same dispatch office?