Understanding Air France 447 (28 page)

Analysis of the factors involved reveals numerous areas of pilot misinterpretation and misunderstanding. This fact alone should make us resolve to do a better job in educating our pilot population. These factors include:

• How to properly operate the weather radar to account for the low radar reflectivity of storms in the ITCZ.
  
• The proper pitch attitude and power setting to maintain or reestablish cruise flight.
  
• That Alternate Law provided no protections, could maintain a dangerously high pitch attitude with no back pressure at all, and provided nearly double the normal roll response to sidestick input.
  
• That the synthetic voice announcing "STALL, STALL, STALL" meant that the nose must be pitched down, as it would not happen on its own.
  
• That insufficient power exists at cruise altitude to constitute a stall recovery.
  
• A misidentification of the stall buffet for a high speed buffet. Believing they had "some crazy speed" the pilot flying even deployed the speed brakes momentarily, unaware that the wing on this airplane made Mach buffet extremely unlikely or perhaps not even possible.
  
• Both first officers lost the discipline of accomplishing the abnormal procedure, and failed to identify who was flying the airplane. The synthetic voice announced "DUAL INPUT" while both pilots were trying to fly the airplane, sometimes with conflicting commands.
  

But as egregious as all these error seem, and indeed were, we must realize that these pilots were the product of their training and experience, as are we all. Like the loyal family dog who lets in the burglar, one cannot truly be expected to effectively handle a crisis situation for which they have not been trained.

However, even the skills of pilots with extensive manual instrument flying experience will erode over time when those skills are not maintained with practice.

We must, therefore train our fellow airmen:

• To be able to handle the hand flying that the autopilot relieves them of,
  
• To be aware of the normal pitch attitudes and power settings that the flight directors and autothrust allow them to forget or never learn,
  
• To understand the weather they are surrounded by,
  
• To understand the aerodynamics that keep them aloft and,
  
• To understand the unique characteristics of their aircraft.
  

We must not allow mastery of the Flight Management System to be confused with airmanship.

It is our sacred duty to each other and to every passenger that ever climbs aboard.

We have been warned.

Appendix

Recommendations of the Investigation

The BEA released a number of safety recommendations in the various reports on the accident. These cover a range of subjects from airplane an simulator design to search and rescue. In the final report they are grouped primarily by which report the recommendations were issued in. I have arranged them below by subject.

Flight Recorders

Extend as rapidly as possible from 30 to 90 days the regulatory transmission time for Underwater Locator Beacons (ULBs) installed on flight recorders on airplanes performing public transport flights over maritime areas; make it mandatory, as rapidly as possible, for airplanes performing public transport flights over maritime areas to be equipped with an additional ULB capable of transmitting on a frequency (for example between 8.5 kHz and 9.5 kHz) and for a duration adapted to the pre-localization of wreckage;

Study the possibility of making it mandatory for airplanes performing public transport flights to regularly transmit basic flight parameters (for example position, altitude, speed, heading).

Ask the FLIRECP (ICAO Flight Recorder Panel) group to establish proposals on the conditions for implementing deployable recorders of the Eurocae ED-112 type for airplanes performing public transport flights.

That ICAO 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; and that at the same time, ICAO establish very strict rules for the readout of such recordings in order to guarantee the confidentiality of the recordings.

Today, the regulation requires recording of the flight parameters displayed on the left side. Some parameters essential to the analysis of the conduct of the flight are lacking, in particular those displayed to the pilot in the right seat: speed, altitude, attitudes, position of the flight director crossbars, etc. In addition, airplanes are equipped with complex systems whose functional analysis is limited and delayed by the absence of a recording of all of the data sources that they use.

Consequently, the BEA recommends: that EASA and the FAA make mandatory the recording:

• of the position of the flight director crossbars,
  
• of the parameters relating to the conduct of the flight displayed on the right side, in addition to those displayed on the left side;
  

And that EASA and the FAA evaluate the relevance of making mandatory the recording of the air data and inertial parameters of all of the sources used by the systems.

That EASA and ICAO make mandatory as quickly as possible, for airplanes making public transport flights with passengers over maritime or remote areas, triggering of data transmission to facilitate localization as soon as an emergency situation is detected on board;

And that EASA and ICAO study the possibility of making mandatory, for airplanes making public transport flights with passengers over maritime or remote areas, the activation of the emergency locator transmitter (ELT), as soon as an emergency situation is detected on board.

Certification

Undertake studies to determine with appropriate precision the composition of cloud masses at high altitude; and in coordination with the other regulatory authorities, based on the results obtained, to modify the certification criteria.

That EASA and the FAA evaluate the relevance of requiring the presence of an angle of attack indicator directly accessible to pilots on board airplanes.

Training for Manual Aircraft Handling

That EASA review the content of check and training programs and make mandatory, in particular, the setting up of specific and regular exercises dedicated to manual aircraft handling of approach to stall and stall recovery, including at high altitude.

That EASA define additional criteria for access to the role of relief captain so as to ensure better task-sharing in case of augmented crews; and that, provisionally, the DGAC define additional criteria for access to the role of relief captain so as to ensure better task-sharing in case of augmented crews.

Search and Rescue

ICAO ensure the implementation of SAR coordination plans or regional protocols covering all of the maritime or remote areas for which international coordination would be required in the application of SAR procedures, including in the South Atlantic area.

The DGAC, in concert with the other services responsible, develop a homogeneous framework for training and for approval of operators responsible for search and rescue activities in France.

ICAO define the framework for the training of SAR operators in its standards and recommended practices.

Within France: the DGAC designate a point of contact at ICAO for the ARCC that has adequate means to accomplish his/her missions.

ICAO ensure each Member State has a national point of contact and makes his/her contact information available.

ICAO amend Annex 12 on search and rescue operations so as to encourage contracting states to equip their search aircraft with buoys to measure drift and to drop them, when these units are involved in the search for persons lost at sea.

Air Traffic Control

The Brazilian and Senegalese authorities make mandatory the utilization, by airplanes so equipped, of ADS-C and CPDLC functions in the zones in question.

ICAO request the involved States to accelerate the operational implementation of air traffic control and communication systems that allow a permanent and reliable link to be made between ground and airplane in all of the areas where HF remains the only means of communication between the ground and airplanes.

Pilot Training

EASA ensure the integration, in type rating and recurrent training programs, of exercises that take into account all of the reconfiguration laws. The objective sought is to make its recognition and understanding easier for crews especially when dealing with the level of protection available and the possible differences in handling characteristics, including at the limits of the flight envelope.

More generally, EASA ensure that type rating and recurrent training programs take into account the specificities of the aircraft for which they are designed.

EASA define recurrent training program requirements to make sure, through practical exercises, that the theoretical knowledge, particularly on flight mechanics, is well understood.

EASA review the requirements for initial, recurrent and type rating training for pilots in order to develop and maintain a capacity to manage crew resources when faced with the surprise generated by unexpected situations.

EASA ensure that operators reinforce CRM training to enable acquisition and maintenance of adequate behavioral automatic responses in unexpected and unusual situations with a highly charged emotional factor.

EASA define criteria for selection and recurrent training among instructors that would allow a high and standardized level of instruction to be reached.

Flight Simulators

EASA modify the basis of the regulations in order to ensure better fidelity for simulators in reproducing realistic scenarios of abnormal situations.

EASA ensure the introduction into the training scenarios of the effects of surprise in order to train pilots to face these phenomena and to work in situations with a highly charged emotional factor.

Ergonomics

EASA require a review of the re-display and reconnection logic of the flight directors after their disappearance, in particular to review the conditions in which an action by the crew would be necessary to re-engage them.

Further, even if it is not sure that the crew followed the orders from the flight director while the stall warning was active, the orders from the crossbars were in contradiction with the inputs to make in this situation and thus may have troubled the crew.

Consequently, the BEA recommends that: EASA require a review of the functional or display logic of the flight director so that it disappears or presents appropriate orders when the stall warning is triggered.

In so much as certain on-board systems identified the problem, but the alerts presented to the crew only presented the symptoms:

EASA study the relevance of having a dedicated warning provided to the crew when specific monitoring is triggered, in order to facilitate comprehension of the situation.

EASA determine the conditions in which, on approach to stall, the presence of dedicated visual indications, combined with an aural warning should be made mandatory.

When airspeeds are below 60 kt, the stall warning is no longer available, even though it may be beneficial for it to be available at all times.

Consequently, the BEA recommends that: EASA require a review of the conditions for the functioning of the stall warning in flight when speed measurements are very low.

Operational and Technical Feedback

EASA improve the feedback process by making mandatory the operational and human factors analysis of in-service events in order to improve procedures and the content of training programs.

Specifically, that the DGAC take steps aimed at improving the relevance and the quality of incident reports written by flight crews and their distribution, in particular to manufacturers.

Oversight of the Operator

In-flight and ground inspections by the Authority within the airline never brought to light any major deviations, whether in relation to the operator’s conformity to the regulatory provisions, to the recurrent simulator training or in flight. Thus, the whole range of inspections did not bring to light the fragile nature of the CRM nor the weaknesses of the two copilots in manual airplane handling. Though respecting the regulatory requirements applicable to oversight, it appears that the organization, methods and means deployed by the authority were not adequate to detect the weaknesses of an operator and impose the necessary corrective measures.

Key Flight Recorder Parameters

The following is a collection of the key parameters from the flight recorder tracings provided by the final accident report. 

Glossary

Ab Initio - A Latin term meaning "from the beginning" whereby an airline often hires a pilot with minimal qualifications and provides the training necessary to serve as a flight officer.

ACARS - Aircraft Communications Addressing and Reporting System. A messaging system used to deliver messages between the aircraft and ground stations, and in some cases ATC.