BEA Report, Air
France Flight 447 Crash - Pilots Lacked Proper Training
By Mike Mitchell
August 1, 2011 - Air France Flight 447, a Airbus
A330-203 registered F-GZCP was a scheduled airline
flight from Rio de Janeiro to Paris that took off about
10:29 PM on May 31, 2009, with 216 passengers and 12
flight crew (3 flight crew, 9 cabin crew) that crashed
into the Atlantic Ocean on June 1, 2009, killing all
onboard. This accident was the deadliest in the history
of Air France.
the time of the crash, Flight 447 had just dropped off
on radar, no prior warnings were given by the flight
crew to the controllers of any problems. Investigators
soon realized that Flight 447 had a crash, but
investigators did not know where. Investigators at the
time believed it was somewhere in the Atlantic.
The investigation into this accident was severely
hampered by the lack of any eyewitness evidence and
radar tracks, as well as by difficulty finding the
aircraft and its black boxes. In May 2011 the aircraft
and its black boxes were located and recovered from the
Air France spokesperson stated in early 3 June that ?the
aircraft sent a series of electronic messages over a
three-minute period, which represented about a minute of
information. Among the ACARS (Aircraft Communication
Addressing and Reporting System) transmissions in the
first minute is one message that indicates a fault in
the pitot-static system (code 34111506).
(Bureau of Enquiry and Analysis for Civil Aviation Safety) which
is an agency of the French government, responsible for
investigating aviation accidents and making safety
recommendations released a report in July which indicated the
pilots had not been trained to fly the aircraft by hand or to
recognize signs of malfunctioning speed sensors.
July 29, 2011, BEA released a report which included safety
recommendations. Over the past few weeks, analysis of the data
recovered from the Flight Data Recorder (FDR) and the Cockpit
Voice Recorder (CVR) has made a decisive contribution to the
investigation. This made it possible to determine the precise
circumstances of the accident, establish new facts and the
issuance of safety recommendations.
investigation is continuing in order to develop the analysis to
determine the causes of the accident, which will be included in
the BEA?s Final Report.
reported that at the beginning of the CVR, shortly after
midnight, the airplane was in cruise at flight level 350.
Autopilot 2 and autothrust were engaged. The flight was calm.
The crew was in VHF contact with the Recife ATC center.
The crew mentioned the high temperature (normal plus eleven) and noted that the meteorological conditions did not pose any problems. The Captain proposed that the copilot take a rest due to the length of his shift. The latter answered that he didn?t feel like sleeping.
At 1 h 35 min 15,
the crew informed the ATLANTICO controller that they had passed the
INTOL point then announced the following estimates: SALPU at 1 h 48 then
ORARO at 2 h 00. He also transmitted his SELCAL code and a test was
At 1 h 35 min 46,
the controller asked him to maintain FL350 and to give him his estimate
for TASIL point. Between 1 h 35 min 53 and 1 h 36 min 14, the controller
asked again for the estimated time at TASIL with no response from the
crew. There was no more contact between the crew and ATC.
A 1 h 55, the
Captain woke the second copilot and announced "[?] he?s going to take my
place". Between 1 h 59 min 32 and 2 h 01 min 46, the Captain attended
the briefing between the two copilots, during which the PF said, in
particular "the little bit of turbulence that you just saw [?] we should
find the same ahead [?] we?re in the cloud layer unfortunately we can?t
climb much for the moment because the temperature is falling more slowly
than forecast" and that "the logon with Dakar failed". The Captain left
? The Captain?s departure occurred without clear
? The Captain?s departure occurred without clear
approached the ORARO point. It was flying at flight level 350 and at
Mach 0.82 and the pitch attitude was about 2.5 degrees. The weight and
balance of the airplane were around 205 tons and 29% respectively.
Autopilot 2 and auto-thrust were engaged.
? The weight and
balance of the air plane were within operational limits. At 2 h 06 min
04, the PF called the cabin crew, telling them that "in two minutes we
should enter an area where it?ll move about a bit more than at the
moment, you should watch out" and he added "I?ll call you back as soon
as we?re out of it".
At 2 h 08 min 07,
the PNF said "you can maybe go a little to the left [?]". The airplane
began a slight turn to the left, the change in relation to the initial
route being about 12 degrees. The level of turbulence increased slightly
and the crew decided to reduce the speed to about Mach 0.8.
? The crew had
noticed returns on the weather radar
? The crew made a
heading change of 12? to the left of its route from the disconnection of
the autopilot to the triggering of the stall warning .
At 2 h 10 min 05,
the autopilot then auto-thrust disengaged and the PF said "I have the
controls". The airplane began to roll to the right and the PF made a
left nose-up input. The stall warning sounded twice in a row. The
recorded parameters show a sharp fall from about 275 kt to 60 kt in the
speed displayed on the left primary flight display (PFD), then a few
moments later in the speed displayed on the integrated standby
instrument system (ISIS).
? The AP
disconnected while the air plane was flying at upper limit of a slightly
turbulent cloud layer
? There was an inconsistency between the measured speeds, likely as a result of the obstruction of the Pitot probes in an ice crystal environment
? At the time of the autopilot disconnection, the Captain was resting. At 2 h 10 min 16, the PNF said "so, we?ve lost the speeds" then "alternate law protections [?]"
pitch attitude increased progressively beyond 10 degrees and the plane
started to climb.
? Even though they
identified and announced the loss of the speed indications, neither of
the two copilots called the procedure "Unreliable IAS"
? The copilots had
received no high altitude training for the "Unreliable IAS" procedure
and manual air craft handling
? No standard
callouts regarding the differences in pitch attitude and vertical speed
? There is no CRM
training for a crew made up of two copilots in a situation with a relief
Captain. The PF made nose-down inputs alternately to the right and to
the left. The climb speed, qui which had reached 7,000 ft/min, dropped
to 700 ft/min and the roll varied between 12 degrees to the right and 10
degrees to the left. The speed indicated on the left side increased
suddenly to 215 kt (Mach 0.68).
? The speed
displayed on the left PFD remained invalid for 29 seconds. The airplane
was then at an altitude of about 37,500 ft and the recorded angle of
attack was around 4 degrees.
From 2 h 10 min
50, the PNF tried several times to call the Captain back, from the
triggering of the stall warning to the end of the flight. At 2 h 10 min
51, the stall warning triggered again. The thrust levers were placed in
the TO/GA detent and the PF maintained his nose-up input. The recorded
angle of attack, of the order of 6 degrees at the triggering of the
stall warning, continued to increase. The trimmable horizontal
stabilizer (THS) began moving and passed from 3 to 13 degrees nose-up in
about 1 minute; it remained in this position until the end of the
? The approach to
stall was characterized by the triggering of the warning, then the
appearance of buffet
? A short time
after the triggering of the stall warning, the PF applied TO/GA thrust
and made a nose-up input
? In less than one
minute after the disconnection of the autopilot, the airplane was
outside its flight envelope following the manual inputs that were mainly
? Until the
airplane was outside its flight envelope, the airplane?s longitudinal
movements were consistent with the position of the flight control
? Neither of the
pilots made an y reference to the stall warning
? Neither of the
pilots formally identified the stall situation. About fifteen seconds
later, the speed displayed on the ISIS increased suddenly towards 185 kt.
? The invalidity of the speed displayed on the ISIS lasted 54 seconds. It was then consistent with the other speed displayed. The PF continued to make nose-up inputs. The airplane?s altitude reached its maximum of about 38,000 ft; its pitch attitude and its angle of attack were 16 degrees.
At 2 h 11 min 42,
the Captain came back into the cockpit. In the following seconds, all of
the recorded speeds became invalid and the stall warning stopped.
? The Captain came
back into the cockpit about 1 min 30 after the autopilot disconnection
? The angle of
attack is the parameter that enables the stall warning to be triggered;
if the angle of attack values become invalid, the stall warning stops
? By design, when
the speed measurements were lower than 60 kts, the 3 angle of attack
values became invalid
? Each time the
stall warning was triggered, the angle of attack exceeded its
theoretical trigger value
? The stall
warning was triggered continuously for 54seconds. The altitude was then
around 35,000 ft, the angle of attack exceeded 40 degrees and the
vertical speed was around -10 000 ft/min. The airplane?s pitch attitude
did not exceed 15 degrees and the engine N1 was close to 100%. The
airplane was subject to roll oscillations that sometimes reached 40
degrees. The PF made a nose-up left input on the sidestick to the stop
that lasted around 30 seconds.
? The airplane?s
angle of attack was not directly displayed to the pilots. At 2 h 12 min
02, the PF said "I don?t have any more indications", and the PNF said
"we have no valid indications". At that moment, the thrust levers were
in the IDLE detent and the engines? N1?s were at 55%. Around fifteen
seconds later, the PF made pitch-down inputs. In the following moments,
the angle of attack decreased, the speeds became valid again and the
stall warning was triggered again.
At 2 h 13 min 32,
the PF said "we?re going to arrive at level one hundred". About fifteen
seconds later, simultaneous inputs by both pilots on the sidesticks were
recorded and the PF said "go ahead you have the controls". The angle of
attack, when it was valid, always remained above 35 degrees.
? Throughout the
flight, the movements of the elevator and the THS were consistent with
the pilot?s inputs
? The engines were
working and always responded to the crew?s inputs,
? No announcement
was made to the passengers
stopped at 2 h 14 min 28. The last recorded values were a vertical speed
of -10,912 ft/min, a ground speed of 107 kt, pitch attitude of 16.2
degrees nose-up, roll angle of
5.3 degrees left and a magnetic heading of 270 degrees. No emergency
message was sent by the crew. The wreckage was found on the seabed at
3,900 m on 3 April 2011, 6.5 nautical miles north-north-east of the last
position transmitted by the airplane.
Analysis of the
history of the flight based on the readout of the flight recorders has
led to the issuing of ten new safety recommendations.
Three safety recommendations relating to operations
manual airplane handling
recommends that the regulatory authorities re-examine the content of
training and check programs and in particular make mandatory the
creation of regular specific exercises aimed at manual airplane
handling. Approach to and recovery from stall, including at high
altitude Relief Captain The following two recommend that the regulatory
authorities define additional criteria for access to the
relating to airplane certification Angle of attack measurement
that the regulatory authorities evaluate the relevance of requiring the
presence of an angle of attack indicator directly accessible to pilots
on board airplanes.
recommendations on flight recorders
that the regulatory authorities require that aircraft undertaking public
transport flights with passengers be equipped with an image recorder
that makes it possible to observe the whole of the instrument panel.
Another recommends defining strict rules relating to the use of such
There are two
recommendations on recording additional parameters.
There are two recommendations on the transmission of flight data
One recommends that the regulatory authorities make mandatory the triggering of data transmission to facilitate localization when an emergency situation is detected on board. The other recommends studying the possibility of making mandatory the activation of the Emergency Locator Transmitter (ELT) when an emergency situation is detected on board.
Questions Remain After Air France Crash Report
Dr Rob Hunter, British Airline Pilots Association?s (BALPA)
Head of Safety and Security, said, the ?report confirms the cold facts
about the aircraft?s last moments which led to this tragic crash. An
even bigger tragedy will be if this investigation descends into a
blame-game and the lessons are not fully learned.
?The pilots were flying an advanced and highly automated aircraft ? an Airbus A330. As far back as 1996 Dr Kathy Abbott of the USA?s Federal Aviation Administration raised concerns about the difficulties pilots can have in flying such aircraft. It is a matter of deep concern to us that the industry has not yet fully addressed her report?s recommendations.?
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