BEA Report, Air France Flight 447 Crash - Pilots Lacked Proper Training


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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. 

At 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 ocean floor 

An 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). 

The BEA (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.  

On Friday 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. 

The 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. 

BEA 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 undertaken, successfully. 

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 cockpit. 


? The Captain?s departure occurred without clear operational instructions
? The crew composition was in accordance with the operator?s procedures
? There was no explicit task-sharing between the two copilots 

The airplane 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 [?]"

The airplane?s 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 were made 

? 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 flight. 

? 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 nose-up 

? Until the airplane was outside its flight envelope, the airplane?s longitudinal movements were consistent with the position of the flight control surfaces 

? 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 

The recordings 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. 

New Safety Recommendations 

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

Training for manual airplane handling 

The first 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 role of relief Captain in order to ensure better task-sharing in case of relief crews. 

One recommendation relating to airplane certification Angle of attack measurement 

This recommends that the regulatory authorities evaluate the relevance of requiring the presence of an angle of attack indicator directly accessible to pilots on board airplanes. 

Four recommendations on flight recorders 

Images recorders 

One recommends 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 recordings. 

Flight parameter recordings 

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.?


Dr Hunter also commented: ?We know that this accident occurred at the time of day when pilots ? like all of us ? are naturally less alert ? during their ?circadian low?. And we need to note that this was a European crew on a very long trans-Atlantic returning flight. Therefore to what extent might fatigue have contributed to this accident??

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