Hi,
An chronology ...........
AF 447. Significant events.
chronology
Note:
The equipment must operate an aircraft throughout its flight envelope and we accept that there may be failures whose probability of occurrence should not exceed a threshold defined by the level of risk (minor, major, hazardous, catastrophic). In the case of blocked pitot probes, it can not be used in probability because it is not a failure but a fault or defect. The manufacturer and the regulator have the obligation to eliminate all the defects of an airplane.
Before the crash
October 1993:
certification of the A330 with the Rosemount Pitot probe P / N 0851GR. DGAC and Airbus made a number of impasses:
Impasse 1: the JAR 25 requires that the equipment of an aircraft operate in all foreseeable conditions [1309 (a)] and recommends the vulnerability assessment of the Pitot probes to ice crystals and test their operation in these conditions [ACJ 25.1419.4]. DGAC and Airbus has failed to establish the proper functioning of the Pitot probes in the presence of ice crystals in the certification of the A 330.
Impasse 2: the JAR 25 requires that an alarm "LOCK PITOT" is available to drivers * 1309 (c) +. This alarm does not exist.
Impasse 3: JAR 25 requires that the alarm works as a dropout the incidence is higher than the value at which the alarm occurred * 207 +. For the A 330, the manufacturer has provided that when the velocity measurements of the three ADR is less than 60 kt, the values of incidence of the three ADR are invalid and the stall alarm is then ineffective.
December 1995:
TFU 34.13.00.005. Airbus made the finding of a lack of certification for Pitot probes in the presence of ice crystals and start the development of the probe Goodrich P / N 0851HL. This document certifies that the case of inconsistency rates were measured in the A340 fleet of Air France at that time.
August 1996:
The NTSB made the following recommendation: Revise the icing certification testing regulation to Ensure That airplanes are Properly Tested for All Conditions in Which They Are Authorized to operate, or are able Otherwise Shown to Be Such of safe flight into conditions. If safe operations Can not Be Demonstrated by the manufacturer, Operational limitations Should Be Imposed in flight to Prohibit Such terms and Flight Crew Should Be Provided With The Means to POSITIVELY determined When They are in icing conditions That Exceed the limits for aircraft certification. (Class II, Priority Action) (A-96-56)
November 1996:
Certification of the probe Goodrich P / N 0851HL
April 1998:
certification of the probe Sextant (Thales) P / N C16195AA. How Sextant Pitot probe
(then Thales) C16195-AA has it been certified by the DGCA in the light of experience Rosemount?
June 1998:
Airbus said that pilot training is not necessary to drop
January 1999:
The BFU recommended changing the certification standards of the Pitot probes.
February 2001:
Implementation of the new procedure "Unreliable AIRSPEED" AD 2001-069 (B) by DGAC
June 2001:
The FAA also requires that new AD 2001-13-13 procedure specifying the risk is out of the flight and that the response to an "unsafe condition"
August 2001:
The DGAC mandates the replacement of the sensor by Rosemount probes
Goodrich and Thales AA by AD 2001-354 (B).
July 2002:
In the ILO 999.0068/02/VHR, Airbus made the observation of defects of the probe Thales (ex
Sextant) P / N C16195AA.
December 2002:
The FAA mandates the replacement of the sensor by Rosemount probes Goodrich and Thales AA stating that the risk is out of the flight and that is the answer to an "unsafe condition"
January 2005:
Thales launches the project "ADELINE" Actual air data equipment IS Composed of a large number of probes and pressure sensors Individual. This equipment Delivers vital parameters for the safety of the aircraft's flight Such as air speed, altitude and angle of attack. The loss of These Data Can cause aircraft crashes Especially in case of probe icing.
August 2006:
Airbus fixed frequency of cleaning probes all visits "C", that is to say, every 21 months. The manufacturer Bombardier has had the same problem on some sensors equipping its DHC-8. Transport Canada responded aggressively by AD CF-
2005-15R1 of 23 June 2008 to impose a cleaning every 600 hours of flight, that is to say every 4 months.
September 2007:
The EASA is the finding of a lack of certification of Pitot probes in a
conference in Seville.
September 2007:
In a Service Bulletin, Airbus recommends but does not require the replacement of the probe by the probe C16195AA Thales Thales C16195BA
August 2008:
Air France decided to replace the AA probe by the probes BA "on failure" by the
NT 34-029
September 2008:
2 ACA Events Company. Airbus recognizes "the difficulty encountered by the crew for a rapid implementation and effective procedure unreliable AIRSPEED and reflects a change checklists"
September 2008:
Air France Airbus expresses its great concern over the numerous cases
inconsistency of measured speeds "as flight safety IS involved"
September / October 2008:
the shortcomings of the probe C16195BA Thales, "which was not designed to
respond to icing problems, "are recognized by Airbus and Air France (TFN Info N ° 5).
September 2008:
The DGAC EASA requests on whether to mandate the replacement of AA by the probes probes BA (issuance of AD)
September 2008:
The VCA offers the publication of an operational refuses to DGCA
November 2008:
Air France simply asks its drivers to be vigilant with a note that does not refer to the procedure to apply and does not reflect the dangerous nature of events. Some drivers do not see it go
March 2009:
Thales confirms the limitations of tests of the Pitot probes in "wind tunnel"
March 2009:
The response to the DGAC EASA that "unsafe condition" is not demonstrated and it is
no need to mandate the replacement of the AA probe.
April 2009:
Air France decided to replace AA Pitot probes by the probes BA and received his first batch in May. 15 precursor events to Air France between May 10, 2008 and June 1, 2009.
9 have been an ASR. Neither BEA nor the DGAC have analyzed the ASR (same for ASR ACA) Generally, an event related to the failure of the Pitot probes were analyzed by the BEA or received followed by DGAC
Note:
BEA and Airbus have identified 32 events related to the failure of the Pitot probes between 2003 and
2009. Must be added those that occurred between 1993 and the replacement of the Rosemount probe (to
AFR in particular) and those that occurred in the A320 fleet. This should go a long way ...
On June 1, 2009 2h10.05, the crew of Flight 447 suddenly recovers its A330 in manual control. Thales Pitot probes are blocked, the indications are inconsistent speed, the autopilot and auto-thrust is disconnected, the flight controls are passed into law ALTERNATE degraded. The computers were in dilapidated meaning "we do not know how, make do." They left the pilot's lack of understanding what was happening.
While control of the aircraft is reduced, the crew must keep it in a very limited flight envelope and deal in a very short period of time, to an incredible number of alarms, some of which are as false as the speeds they have under the eyes. It's an overload, an "unsafe condition".
The A 330 stall and can not be recovered.
228 victims.
After the crash
June 4, 2009:
Airbus reminds pilots to apply the procedure in case of inconsistency of measured velocities. Airbus acknowledged that it be difficult to apply in October 2008 ...
June 9, 2009:
EASA says, "That We confirm the type Airbus A330 Airbus aircraft and All Other kinds are airworthy and safe to operate"
August 10, 2009:
EASA and Airbus conduct emergency (PAD 09-099) to the elimination of the Pitot probe Thales AA. To do this, EASA issues a "airworthiness directive" (AD) by claiming that it is a simple precaution. However, an "airworthiness directive" for a precautionary measure, it does not exist. An "airworthiness directive" provides an answer to an "unsafe condition". When the manufacturer and EASA detect a problem that is not an "unsafe condition" but that requires a response, EASA must issue a SAFETY INFORMATION BULLETIN
(SIB). To remove the pitot probe Thales AA, EASA issued AD and not a one ILS. there
was therefore an "unsafe condition" that required a response before the accident.
August 31, 2009:
EASA began changing the certification standards of the Pitot probes by the diffusion of NPA 2009-08. It is a "safety priority" (page 3 paragraph AI5). The Agency confirms that it has erred in not modifying these standards before the accident. She had made the finding of the necessity of this change in 2007 after the BFU in 1999 and Airbus
1995
September 4, 2009:
Airbus is trying to influence the FAA so that it specifies in the future as AD
removal of the probe AA is a precautionary measure. The FAA does not comply
September 8, 2009:
The FAA conducts emergency disposal of the AA by the Pitot probe AD 2009-18 -
08 indicating that the response to an "unsafe condition"
October 20, 2009:
Air France officials are belatedly measures they deem necessary to remedy the defect of the Pitot probes
November 30, 2009:
EASA NPA proposes 2009.12 with a change in the CS-25. Among these changes, the loss of all information transmission becomes a catastrophic risk
December 17, 2009:
In its report No. 2, the BEA specifies that the inconsistency of the measured velocities is a major risk classified by EASA. But at the time of the accident, the current document CS25 which deals with the certification states that the loss of primary information speed is a risk that the probability of occurrence must be "Extremely Remote". It is a probability that the risk class
"Hazardous".
December 17, 2009:
In its report No. 2, the BEA dare say that the analysis of events related to the blocking of the Pitot probes conducted after the accident showed that the tests for validation of these facilities did not appear not suitable for high-altitude flights. The BEA wants us to believe that the certification standards of the Pitot probes are "appeared" out of date after the accident of June 1, 2009. It is a lie because the BEA can not ignore that this observation was made by Airbus in 1995 by the BFU in 1999 and by EASA in 2007
May 12, 2010:
Airbus amend the procedure for dropping out and recommends the training of pilots
in this area
January 2011:
In No. 11 of "The Airbus Safety Magazine," says Jacques Rosay display in TOGA initial action and the procedure would stall before its amendment, the A330 can make unrecoverable
July 28, 2011:
In a "Safety Information Bulletin," EASA inform operators that the standards used for certification of aircraft in icing conditions do not take into account phenomena such as ice crystals or freezing rain. In practice, this means that the protective equipment against icing (including Pitot probes) may not be suitable for all conditions as they arise. EASA recommends that airlines reviewing existing procedures and if necessary amend them or develop. See the NTSB's recommendation in August 1996.
July 29, 2011:
BEA removes a recommendation on dropping out in its report No. 3. it
appears that the system STALL WARNING the A330 does not comply with JAR 25 207 (c).
My conclusions
EASA and Airbus have ignored an "unsafe condition" generated by the recurrent failure of the Pitot probes, leaving the pilots with the task of ensuring accountability of the "unsafe condition" by applying a checklist while according to its definition, an "unsafe condition" can lead the crew in a physical distress or excessive workload that does not allow it to perform its tasks accurately or to carry out.
DGAC and BEA have left to do, Air France has not taken the necessary steps.
(updated 14/10/2011) HMC
Original document (French , PDF)
http://henrimarnetcornus.20minutes-b...1271654027.pdf