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Air France Flight 4590 (Management (Organisational / System factors…

- - - - Questions as to weather flight crew checked tyre condition prior to departure
      - Suggested premature engine shutdown during incident
      - Poor workmanship by Continental airlines mechanic resulting in loss of metal strip which allegedly caused the tyre damage
      - Pilot's decision to continue flying for a turnaround rather than to abort the flight
    - - Safety Record of concordes prior incident - 40,000 flight & 900,000 hours with no reported failures
        
        Bad history
      - An expectation that the airspeed indications were correct was present leading to inappropriate actions taken by the pilot flying
    - - Captain
        
        54
        
        had been with Air France since 1967
        
        13,477 Flight hours
        
        317 hours with Concorde
        
        16 rotations of South America sector flying since 2007
        
        Oceanic route qualification valid until 31 May 2010
      - First Officer
        
        50
        
        had been with Air France since 1971
        
        10,035 Flight hours
        
        2,698 hours on Concorde
      - Flight Engineer
        
        58
        
        had been with Air France since 1968
        
        12,532 flight hours
        
        937 hours with Concorde
      - Crew
        
        Design error
        
        System Design
        
        TriPod Beta
        
        Risk assessment
        
        Physical domain
        
        manual handing injuries may occur
        
        Ground crew
        
        Organisational domain
        
        Procedural event analysis took
      - Management
        
        System design
        
        Bow Tie Method
        
        risk assessment
    - - First officer and Second officer were present on the flight deck and monitoring the performance of the aircraft
    - - Expectation of flight crew to provide safe flight care
      - Complying with time frames and requests of Air Traffic control at Charles De Gaulle Airport
      - Misconception by the flight crew of which 'laws' the flight computer was working in
      - Confusing amongst the flight crew as to why the autopilot disconnected
    - - Captain: Male, ages 58, French nationality
        
        specific instructions for crossing the inter tropical convergence zone (ITCZ) were not passed on
      - First Officer: Male aged 37, French nationality
      - Second officer: Male, aged 32, French nationality
    - - No information available on flight Crew rest level achieved during slip in Rio De Janeiro
      - Analysis of Flight Crew roster for month preceding crash showed all flight, duty and rest times were in accordance with regulations
- - - - Perception
      - Compatibility
      - display design
      - Attention & workload
    - - Anthropometrics
      - Physical workload
      - Work space layout
    - - Work organisation
      - Environmental stress
      - Function allocation
      - task analysis
      - psycho-social issue
  - - - Continental airlines use of improper materials for maintenance activities
      - Runway 26R not checked sufficiently for debries in between departures
    - - Known of tyre defect issues for the past 20 years prior to accident
      - Inadequate CRM training provided to Flight Crew
  - - - Workload shared between 2 pilots. Teamwork essential
    - - Ineffective crew resource management displayed by flight crew
  - - - Written
      - Oral
- - - - Standard airbus cockpit layout
    - - Control all reachable from seated position
    - - Length and insufficient area for an aborted landing
    - - Standard Airbus cockpit layout
    - - Command seat = left hand seat Co-pilot seat = right hand seat observer seat in rear of cockpit
  - - - Flight controls are manipulated by electronic signals via computer
    - - Incorrect indication on the flight display mislead Flight crew
      - Design limitation of human-machine interface requires more cognitive input at times when stress levels are high
      - Cockpit instruments did not provide clear indications as to what the problem was
      - No tactile feedback through flight controls as 'fly by wire' design
    - - Flight computer system is complex however if understood should provide flight crew with ease of use
    - - Tripod Beta
        
        Risk Assessment
      - Previous concerns regarding tyres
        
        Bow Tie method
      - Fuel in wings
        
        Tripod Beta
  - - - Flight conducted at night, no visual external references of up/down only instruments
    - - Overload of sensors
      - Overload of alarms
- - - - upto 31 may 2009 = 18870 flying hours
  - - - running time = 18870 flying hours