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Dublin: 12 °C Wednesday 19 June, 2013

Flight AF447: ‘Crew in a state of near-total loss of control’

The final stage of the official report into the crash has been published today. Three Irish doctors died when the plane crashed into the sea en route from Rio to Paris.

Workers unloading debris, belonging to crashed Air France flight AF447, from the Brazilian Navy's Constitution Frigate
Workers unloading debris, belonging to crashed Air France flight AF447, from the Brazilian Navy's Constitution Frigate
Image: AP Photo/Eraldo Peres, File

FRENCH INVESTIGATORS SAY a combination of mistakes by inadequately trained pilots and faulty equipment caused an Air France jet to plunge into the Atlantic in 2009, killing all 228 people aboard.

Three Irish women lost their lives in the crash: Jane Deasy, Eithne Walls and Aisling Butler. All three doctors were returning home from a holiday together.

The body of Jane Deasy, who was from Dublin, was identified in June 2009 and was repatriated from Brazil to Ireland. The bodies of Aisling Butler, from Roscrea, and Eithne Walls, from Co. Down, have never been found.

The BEA air accident investigation agency is recommending better training for pilots and stricter plane certification rules as a result of its three-year probe into the crash of Flight 447.

The report lists a combination of “human and technical factors” behind the crash. The plane flying from Rio de Janeiro to Paris crashed into the sea during a nighttime thunderstorm in Air France’s deadliest ever accident.

In one fatal decision, the report says, one of the co-pilots in the cockpit at the time nosed the Airbus A330 upward during a stall — instead of downward, as he should have — because of false data from sensors about the plane’s position.

Chief investigator Alain Bouillard said the two pilots at the controls never understood that the plane was in a stall. He said only a well-experienced crew with a clear understanding of the situation could have stabilized the plane in those conditions.

In this case, the crew was in a state of near-total loss of control.

Robert Soulas, who lost his daughter and son-in-law in the crash, says investigators said the flight director system indicated the “erroneous information” that the plane was diving downward, “and therefore to compensate, the pilot had a tendency to pull on the throttle to make it rise up.”

However, the plane was in a stall instead. A basic maneuver for stall recovery, which pilots are taught at the outset of their flight training, is to push the yoke forward and apply full throttle to lower the nose of the plane and build up speed.

But because the pilot thought the plane was diving, he nosed up.

Problems with speed sensors

The family members showed sympathy toward the pilots, saying they were dealing with bad equipment in an exceptionally challenging situation, with dozens of warning signals going off.

Soulas noted that manufacturers had known for years about problems with the plane’s speed sensors — called pitot tubes — freezing over, but didn’t order the faulty models systematically replaced until after the crash.

He said the “inappropriate behavior of the pilots” was prompted by “indication errors.” He also said pilots should have had better training.

Pilot Gerard Arnoux defended the pilots’ actions, saying they were doing what they had been taught to do.

“A normal pilot on a normal airliner follows” the signals on the flight director system, which tells them to go left, right, up or down, he said.

The BEA’s findings in a preliminary report last year raised worrisome questions about the reactions of the two co-pilots as the A330 went into an aerodynamic stall, and their ability to fly manually as the autopilot disengaged. Broader concerns were raised about training for pilots worldwide flying high-tech planes when confronted with a high-altitude crisis.

The final report included a study of the plane’s black box flight recorders, uncovered in a costly and extraordinarily complex search in the ocean depths.

In a separate French judicial investigation still under way, Air France and Airbus have been handed preliminary manslaughter charges.

Earlier: Final report into doomed Air France flight expected today>

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Comments (13 Comments)

  • there is no bright side to this case but the success in retrieving the black boxes provided investigators the data and they formulated a picture of what happened and as a result they can move forward in rectifying what went wrong so that air travel can continue to be a safe way to travel.

    Reply
  • There is an opinion I read somewhere that the passengers may not have realised the plane was doomed. There was turbulence of course, but the plane didn’t flip over or freefall to the ocean…it hit the water with the nose slightly pitched up like it was ascending.

    I hope that opinion is how it was.

    Reply
  • Hopefully this will give the families some small closure. still haunts me when ever I read a report about it. RIP Eithne and of course all the other victims.

    Reply
  • Why does every article refer to the three Irish girls’ job (ie the 3 doctors)? Would they do it if they were barmaids or unemployed or any other? Why can it not be three Irish women, fullstop? Surely it’s WHO they were, not WHAT they were that was important

    Reply
  • There is a bad smell of this report or at least in the way it has been reported. (not by the journal.ie but in general by the media.) It is easy to blame the pilots especially when they are dead. This is usually done for reasons other than a truthful evaluation of the facts.

    The report clearly states that the pilots were fed false information by their instruments. They reacted exactly as their training had trained them to do.

    The fault must therefore lie with the engineering of the aircraft. There is no stick pusher fitted to the A330 to warn of an impending stall. Even if one were fitted, it probably would not have worked as most rely on pitot tubes for speed information. Weather reports indicated turbulence would be encountered during the flight and any buffeting in the stall could easily have been mistaken for turbulence. The pilots had no access to external visual information as it was a dark moonless night therefore they were “flying on instruments” and 100% reliant on these instruments.

    There is no possible way that the pilots can be to blame for this accident unless other speed information was available to them through GPS. Even then the question has to be asked, why are there no systems on board that can notice the discrepancies between the two readings and bring it to the attention of the pilots?

    Simply put the engineering is at fault not the pilots. If they persist in laying blame where it does not lie, nothing ever improves.

    Ar dheis Dé go raibh a n-anamacha.

    Reply
    • The BEA report is not blaming the pilots like the headline here suggests. It runs through the psychology of the mistakes that were made and sets them in context against the information available to the pilots due to technical failure. It goes on to make recommendations on how such cognitive errors can mitigated by training in the future.

      The term in quotes on the headline ‘Crew in a state of near-total loss of control’ is not in the report. It does mention total loss of cognitive control which is something completely different from what the headline suggests and one can see the context below.

      Below are quotes from the actual report.

      Between the autopilot disconnection and the triggering of the STALL 2 warning, numerous messages were displayed on the ECAM. None of these messages helped the crew to identify the problem associated with the anomalous airspeed. Furthermore, the management of the priorities of the various messages resulted in a rapid changeover of the information displayed, which further complicated the crew’s analysis and understanding of the situation.

      The occurrence of the failure in the context of flight in cruise completely surprised the pilots of flight AF 447. The apparent difficulties with aeroplane handling at high altitude in turbulence led to excessive handling inputs in roll and a sharp nose-up input by the PF. (pilot flying)

      In the minute that followed the autopilot disconnection, the failure of the attempts to understand the situation and the de-structuring of crew cooperation fed on each other until the total loss of cognitive control of the situation. The underlying behavioural hypotheses in classifying the loss of airspeed information as “major” were not validated in the context of this accident. Confirmation of this classification thus supposes additional work on operational feedback that would enable improvements, where required, in crew training, the ergonomics of information supplied to them and the design of procedures.

      Reply
  • The crew, albeit perhaps indirectly, still bear some responsibility. Failure of the pitot-static system is something aircrew are suppossed trained for. The aircraft should have been flown with reference to the gyroscopic instruments in the first instance. Very easy for me to say sitting here safely on the ground, and it may well be more correctly defined as a systems failure if training in this regard is deficient.

    Whether training gives enough emphasis to such basic airmanship as opposed to “systems management” would be an interesting question to pose. There have been concerns about automated systems degrading crew situational awareness for years, along with crew training which has de-emphasised basic airmanship to a significant degree.

    It’s not like this hasn’t happened before:

    (Northwest airlines, 1974)
    http://en.m.wikipedia.org/wiki/Northwest_Airlines_Flight_6231#section_3

    (AeroPeru, 1996)
    http://en.m.wikipedia.org/wiki/Aeroperú_Flight_603

    Reply
    • Yes Karl what you is true and if you read the BEA report it goes through in detail the psychology that lead the pilots to make these errors. And the pilots did make an error but it was deficiencies within the pilot alert systems that were the true cause of the accident. Furthermore the report demonstrates that it was a series of circumstances that combined to create an unusual situation for which the crew were not adequately trained. Had the pilot alert system been designed properly the cognitive overload would not have occurred.

      It is mainly the headline on this article I take issue with. It is untrue and misleading and I notice that the same inference was not used by the print media that I saw today.

      Reply

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