AF 447 report out
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AF 447 report out
original thread seems to have disapeared (its in TECHLOG now so go there for deatils I guess)
BBC News - Air France crash 'due to pilot and technical failure'
Technical failure and human error led to the loss of an Air France flight over the Atlantic in June 2009 and the deaths of 228 people, according to the final report into the crash.
The report by France's aviation authority, the BEA, says the crew did not react correctly after the Airbus A330 had technical failures.
.................................
Thursday's findings are in line with a preliminary report released last year by the BEA. That report said the pilots did not follow the proper procedures after the aircraft's speed sensors - called Pitot tubes - failed during a storm two hours after take-off. The plane stalled and lost altitude, the report said, and the captain did not retake control of the plane after taking a rest.
One of the mistakes of the crew, according to investigators, was to point the nose of the aircraft upwards, after it stalled, instead of down.
Investigators have found fault with both Airbus and Air France, sparking a row between the two firms over their accountability for the crash.
Both companies are under investigation by French magistrates for alleged manslaughter.
A separate judicial report will be released next week. This is also expected to echo Thursday's report by the BEA, the French news agency AFP says.
etc etc
BBC News - Air France crash 'due to pilot and technical failure'
Technical failure and human error led to the loss of an Air France flight over the Atlantic in June 2009 and the deaths of 228 people, according to the final report into the crash.
The report by France's aviation authority, the BEA, says the crew did not react correctly after the Airbus A330 had technical failures.
.................................
Thursday's findings are in line with a preliminary report released last year by the BEA. That report said the pilots did not follow the proper procedures after the aircraft's speed sensors - called Pitot tubes - failed during a storm two hours after take-off. The plane stalled and lost altitude, the report said, and the captain did not retake control of the plane after taking a rest.
One of the mistakes of the crew, according to investigators, was to point the nose of the aircraft upwards, after it stalled, instead of down.
Investigators have found fault with both Airbus and Air France, sparking a row between the two firms over their accountability for the crash.
Both companies are under investigation by French magistrates for alleged manslaughter.
A separate judicial report will be released next week. This is also expected to echo Thursday's report by the BEA, the French news agency AFP says.
etc etc
Last edited by Heathrow Harry; 5th Jul 2012 at 13:25.
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One of the mistakes of the crew, according to investigators, was to point the nose of the aircraft upwards, after it stalled, instead of down.
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Airbus sales pitch comes home to roost
deSitter,
If you were convinced by Airbus that the aircraft could not be stalled and you had no experience with the symptoms of stall in the A330, just maybe it wouldn't occur to you that you were stalled. The conflicting cues would probably lead to cognitive rejection of the stall and overspeed warnings and the total confusion of these guys exceeding their mental envelopes would probably keep it that way!
228 people lost their lives
- the best we can do is learn from it, in all of its nuances.
If you were convinced by Airbus that the aircraft could not be stalled and you had no experience with the symptoms of stall in the A330, just maybe it wouldn't occur to you that you were stalled. The conflicting cues would probably lead to cognitive rejection of the stall and overspeed warnings and the total confusion of these guys exceeding their mental envelopes would probably keep it that way!
228 people lost their lives
- the best we can do is learn from it, in all of its nuances.
If you were convinced by Airbus that the aircraft could not be stalled and you had no experience with the symptoms of stall in the A330, just maybe it wouldn't occur to you that you were stalled. The conflicting cues...
10 to 23 degrees nose-up attitude at levels above 300 is no, or is a conflicting, clue??
pitch+power=performance (i think its lesson 2 or 3 in basic flight training!)
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They tried TOGA at 37000 feet. That's a level of incompetence that is otherworldly. I'm not the litigious sort, but AF and Airbus should be sued for every sou they can be forced to disgorge.
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If you were convinced by Airbus that the aircraft could not be stalled and you had no experience with the symptoms of stall in the A330, just maybe it wouldn't occur to you that you were stalled. The conflicting cues would probably lead to cognitive rejection of the stall and overspeed warnings and the total confusion of these guys exceeding their mental envelopes would probably keep it that way!
Regardless of type the failure to fly pitch and power is inexcusable. Add the common sense reality that at 38,000 the plane is way to far into coffin corner for unreliable speed.
Regardless of type the failure to fly pitch and power is inexcusable. Add the common sense reality that at 38,000 the plane is way to far into coffin corner for unreliable speed.
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Final report (26 MB, Not finished downloading)
http://www.bea.aero/docspa/2009/f-cp...p090601.en.pdf
Web page for download mirrors and french
Rapport final
Enjoy ....
.
http://www.bea.aero/docspa/2009/f-cp...p090601.en.pdf
Web page for download mirrors and french
Rapport final
Enjoy ....
.
Last edited by alph2z; 5th Jul 2012 at 14:39.
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I found it easy for people on these forums to judge what happen that night! With error messages, alarms and confusion going on, and with short time to re-act, and possible adverse weather conditions that was not what they expected, they ended up having a bad day.
If either of this had happen individually, things would have been very different, but faith had it this night, that they just got handed to much on their plate at one time!
Differentiating between Low Speed Buffet or High Speed Buffet, was one issue.
Had a larger storm gone undetected due their WX radar settings!
Unreliable speed indication due to the pitot system.
Loads of system error messages etc.
It is easy to say what should have been done in hind-sight, when you know what is going to come!
The STUPID Stick vs Yoke debate / Airbus vs Boeing debate!
Completely irrelevant!
I am not expert, with a lot of if's, this could have been avoided, but who knows how other's would have re-acted in this first situation.
I would say the main error was that they did not divert around the storms, however I did read one report somewhere, that they might have been reluctant to do that, as that would have meant they would have had to done a re-fuelling stop, which would have delayed them. According to an article in Der Spiegel some time back.
A combination of Pilot error, company pressure and Airbus fault, seems that it has all added together to create a Swiss Cheese perfectly lined up for disaster.
If either of this had happen individually, things would have been very different, but faith had it this night, that they just got handed to much on their plate at one time!
Differentiating between Low Speed Buffet or High Speed Buffet, was one issue.
Had a larger storm gone undetected due their WX radar settings!
Unreliable speed indication due to the pitot system.
Loads of system error messages etc.
It is easy to say what should have been done in hind-sight, when you know what is going to come!
The STUPID Stick vs Yoke debate / Airbus vs Boeing debate!
Completely irrelevant!
I am not expert, with a lot of if's, this could have been avoided, but who knows how other's would have re-acted in this first situation.
I would say the main error was that they did not divert around the storms, however I did read one report somewhere, that they might have been reluctant to do that, as that would have meant they would have had to done a re-fuelling stop, which would have delayed them. According to an article in Der Spiegel some time back.
A combination of Pilot error, company pressure and Airbus fault, seems that it has all added together to create a Swiss Cheese perfectly lined up for disaster.
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BBC News - Air France crash 'due to pilot and technical failings'
85' degrees of thrust..That'll be why then.
85' degrees of thrust..That'll be why then.
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A lack of basic airmanship is just that. Unreliable airspeed indication is not a catastrophic failure. There is no "swiss cheese" here. This is a known event that occurred dozens of times on this specific type prior to AF 447. It should have been covered repeatedly. For a relatively "routine" emergency to cause a crash is a clear indication that the training and CRM culture at AF is an abject failure.
This is not an "AB" problem as much as an indication that things have tipped beyond the point of safety specific to basic airmanship. At the end of the day these pilots simply didn't know how to fly...a scary reality.
This is not an "AB" problem as much as an indication that things have tipped beyond the point of safety specific to basic airmanship. At the end of the day these pilots simply didn't know how to fly...a scary reality.
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I have heard so many scenarios and reports that they are all starting to blend. But one key (perhaps) element was that the stall warning horn shut off below 60kts and that when one of the pilots attempted to lower the nose or increase power, the plane accelerated to above 60 kts and then the stall warning activated, fooling the pilot into believing that he was about to stall.
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Some of the conclusions in the report are just outrageous.
WHAT! What nonsense is this???
What happened to PREVENTING a stall???? Already they should be applying the unreliable airspeed procedure/maintaining a safe pitch attitude with plenty of power, at least until they figure out what is going on.
The Airbus is a flying computer. Computers lie. Therefore you revert to RAW DATA and read past the FD bars, or whatever else.
OK... there is a STALL warning...... then the FD bars are still considered valid data? How about checking the airspeed indications first?
I left this until last. I agree spurious alerts are not good, but the question should be WHY IS IT GOING OFF? Stall relates to airspeed, so back round the merry-go-round we go....
As for the comments in the report regarding high pitch attitude (>16 degrees at FL370!) and FD bars agreeing............ WHERE IS COMMON SENSE?
Yes, yes... hindsight, arm-chair analysis, etc...
The crew not taking into account the stall warning, which could have been due to:
>> A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet,
>> A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet,
>> The absence of any visual information to confirm the approach-to-stall after the loss of the limit speeds,
>> Flight Director indications that may led the crew to believe that their actions were appropriate, even though they were not,
OK... there is a STALL warning...... then the FD bars are still considered valid data? How about checking the airspeed indications first?
>> The appearance at the beginning of the event of transient warnings that could be considered as spurious,
As for the comments in the report regarding high pitch attitude (>16 degrees at FL370!) and FD bars agreeing............
WHERE IS COMMON SENSE?Yes, yes... hindsight, arm-chair analysis, etc...
Last edited by ECAM_Actions; 5th Jul 2012 at 15:47.
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WRT AF447, no-one has explained the basic conundrum of accident investigation:
That people do things that they think are correct at the time - even those actions that sound/look like madness to us sitting at our desks post mortem.
So why did the 2 pilots do what they did - why did they think that a rapid climb was a correct action given their proximity to 'coffin corner'?
Guess we will never know but considered conjecture points to the fact that they didn't know (or didn't believe) they were stalled, certainly they were confused, disorientated, possibly suffering from information-overload and had reluctance to believe their instruments - all started by being IMC in a TS cell then losing speed indications, the AP disconnecting and the stall warnings being intermittment. Will have to read full report but no mention thus far about fatigue or circadian hi/lows - it was dark, so they would have been less than fully aroused.
Lessons?
Know how to work your radar properly;
Don't fly into TS cells;
In the ITCZ - don't go to sleep and carry extra fuel;
Replace faulty air data systems asap;
Design better stall-warning systems;
If speed indications lost, fly power-pitch combinations that will avoid the stall - get rid of FD bars;
If ever you lose control, remember "Controls centrally forward to unload and unstall, then roll wings level, then pitch to straight and level attitude (something sensible will have to be done with the power depending on ac type) - don't re-enter stall (get control of your heart rate) - check you are above safe altitude and check for damage/problems!".
(This may have to be done on the standby ISIS/HSI when you least expect it and are feeling tired - think about that when you are in the cruise next!)
Expect the unexpected;
Better training and encourage airmanship to reinforce all above.
That's just for starters.
That people do things that they think are correct at the time - even those actions that sound/look like madness to us sitting at our desks post mortem.
So why did the 2 pilots do what they did - why did they think that a rapid climb was a correct action given their proximity to 'coffin corner'?
Guess we will never know but considered conjecture points to the fact that they didn't know (or didn't believe) they were stalled, certainly they were confused, disorientated, possibly suffering from information-overload and had reluctance to believe their instruments - all started by being IMC in a TS cell then losing speed indications, the AP disconnecting and the stall warnings being intermittment. Will have to read full report but no mention thus far about fatigue or circadian hi/lows - it was dark, so they would have been less than fully aroused.
Lessons?
Know how to work your radar properly;
Don't fly into TS cells;
In the ITCZ - don't go to sleep and carry extra fuel;
Replace faulty air data systems asap;
Design better stall-warning systems;
If speed indications lost, fly power-pitch combinations that will avoid the stall - get rid of FD bars;
If ever you lose control, remember "Controls centrally forward to unload and unstall, then roll wings level, then pitch to straight and level attitude (something sensible will have to be done with the power depending on ac type) - don't re-enter stall (get control of your heart rate) - check you are above safe altitude and check for damage/problems!".
(This may have to be done on the standby ISIS/HSI when you least expect it and are feeling tired - think about that when you are in the cruise next!)
Expect the unexpected;
Better training and encourage airmanship to reinforce all above.
That's just for starters.
Last edited by flipster; 5th Jul 2012 at 15:46.
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I keep asking why these guys did not have a metal default in their heads for a normal pitch & power combination incase of a failure in the aircraft systems?
I have yet to find anyone who can come up with a satisfactory answer.
What is worrying me is that the airlines are heading down the road of multi crew licensing were young pilots will get very little time flying basic aircraft and practicing the very basics of flying.
I have yet to find anyone who can come up with a satisfactory answer.
What is worrying me is that the airlines are heading down the road of multi crew licensing were young pilots will get very little time flying basic aircraft and practicing the very basics of flying.
TOGA drills practised, TOGA drills carried out.
High level drills not practised, and not carried out.
Complete failure of drills and cross-checking even before the incident.
My reason. Training is far too short and far too easy. There is insufficient time to build up airmanship.
Bring back proper Unusual Attitude training.
I'd also question the wisdom of having pilots pay for their own training. Guess what? They ain't going to pay for more than the minimum, and they ain't going to train somewhere that fails people.
For what it's worth, I've had an ASI failure at night. Attitude and power. Total non event.
High level drills not practised, and not carried out.
Complete failure of drills and cross-checking even before the incident.
My reason. Training is far too short and far too easy. There is insufficient time to build up airmanship.
Bring back proper Unusual Attitude training.
I'd also question the wisdom of having pilots pay for their own training. Guess what? They ain't going to pay for more than the minimum, and they ain't going to train somewhere that fails people.
For what it's worth, I've had an ASI failure at night. Attitude and power. Total non event.
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[Not a pilot.] To a layman, it seems possible that the co-pilot seeing the altitude dropping rapidly and not sure which other instruments to trust, concluded that the plane was in a nose dive. The crew of 1979's TWA 841 (the nose dive over Michigan) knew immediately that they needed to pull back. I'm not saying that these examples are too similar, but such a mistake is something I could understand to be a result of two or so minutes of profound confusion.
As a layman I wonder what hints the center stick was giving Captain Gibson in 1979 compared to those offered by the side stick in 2009.
As a layman I wonder what hints the center stick was giving Captain Gibson in 1979 compared to those offered by the side stick in 2009.