AF471 - Nov 16th 2011 - Final Report
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AF471 - Nov 16th 2011 - Final Report
French BEA have released there final report into the serious incident that occurred on AF471 a Boeing 777-200 flying from Caracas to Paris-Charles de Gaulle on Nov 16th 2011. The Commander was PF, Co-pilot was PNF a relief pilot was seated on the observers seat.
Basically a Summary;
The BEA has found the probable cause was - ''inadequate monitoring of flight parameters by the flight crew.''
Whilst there were 3 contributing factors;
Report here - http://www.bea.aero/docspa/2011/f-pp...p111116.en.pdf
My questions are what the hell is going on in Air France training programs and safety classes?? I've read numerous reports now AF6 (2010), AF447 (2009), AF1620 (2012), AF2184 (2012), AF3093 (2012).
I've never seen such serious breaches of basic safety and so many in the space of 5 years (And there are MANY incidents!) with such a big carrier.
If this was some African carrier they wouldn't be flying in Europe. What's so different about AF?
Basically a Summary;
- Aircraft was operating in CAT III conditions on ILS approach to runway 08R at LFPG in LVP.
- AF471 at 136kts angled at 1 degree nose up, descended through 320ft when the Master Caution indicated that the flight mode had changed from LAND 3 to LAND 2.
- Relief pilot calls out ''Alarm'' the PNF calls out ''go-around'', the PF responds by applying full power to initiate the go-around, which disconnected the Auto-Throttle.
- Nose-up pitch command on the control yoke is recorded however insufficient enough to disconnect the Autopilot.
- The aircraft began to accelerate the attitude changes from +1.15 degrees to -0.5 degrees.
- PF orders flaps to 20, pitch decreases further to 2 degrees nose down.
- Relief pilot calls out ''Pitch!'' - 10 seconds after the G/A, both crew pull on the yoke and Autopilot disconnects, aircraft pitches sharply resulting in +1.84G's vertical acceleration. Altitude changes from 2 degrees nose down to 7 degrees nose up - Subsequently reducing to 4 degrees nose up.
- The speed is now 169kts, the Relief pilot again calls out ''Pitch!''.
- The crew apply nose up input on the control yoke, the aircraft reaches its lowest point of 63 feet at 180kts, the nose then rises to 11 degrees nose up in 2 seconds, subsequently 19 degrees nose up and the aircraft climbs to safety.
- Climbing through 870 feet the gear is retracted and the crew position the aircraft for a second approach, followed by a safe landing.
The BEA has found the probable cause was - ''inadequate monitoring of flight parameters by the flight crew.''
Whilst there were 3 contributing factors;
- 1. Partial execution of the go-around procedure.
- 2. Inadequate management of the automatic systems during execution.
- 3. The conflict of plans of action between respecting the operators instruction and continuing the landing, which seemed to be safely possible according to the manufacturer.
Report here - http://www.bea.aero/docspa/2011/f-pp...p111116.en.pdf
My questions are what the hell is going on in Air France training programs and safety classes?? I've read numerous reports now AF6 (2010), AF447 (2009), AF1620 (2012), AF2184 (2012), AF3093 (2012).
I've never seen such serious breaches of basic safety and so many in the space of 5 years (And there are MANY incidents!) with such a big carrier.
If this was some African carrier they wouldn't be flying in Europe. What's so different about AF?
Last edited by Jack1985; 2nd Feb 2014 at 18:59. Reason: Typo's
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If this was some African carrier they wouldn't be flying in Europe
My questions are what the hell is going on in Air France
It seems that being a large, western, legacy carrier these days doesn't guarantee a higher level of training & safety. Is excessive cost cutting starting to bite?
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Air France is unsafe
Air france should be blacklisted and prevented from flying in Europe.
In my opinion it's not a question are they going to have another crash or not, just when!!!!!
I don't know what's going on there, maybe somebody that works in AF can enlighten us.
My opinion: part of the problem is being French, and the arrogance they display, why did they not learn any lessons from the AF 447 crash, was the chief pilot, head of training, accountable manager been fired?
In my opinion it's not a question are they going to have another crash or not, just when!!!!!
I don't know what's going on there, maybe somebody that works in AF can enlighten us.
My opinion: part of the problem is being French, and the arrogance they display, why did they not learn any lessons from the AF 447 crash, was the chief pilot, head of training, accountable manager been fired?
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Lordy.
Down the back, 10 seconds would seem like a long time to be accelerating nose-down close to the ground.
The French version of the report doesn't seem to have any more details, but 63 feet doesn't seem to be many seconds remaining for this world, and even if instantaneous, 1.84g seems to be rather a lot at such speeds, presumably needing a fairly dramatic angle of attack.
Another highlight seems to be 3 seconds of disagreement on the direction to fly from 29:57 to 30:00.
I guess the impact on pitch of full power was handled automatically, or there might have been even more fun and games.
Down the back, 10 seconds would seem like a long time to be accelerating nose-down close to the ground.
The French version of the report doesn't seem to have any more details, but 63 feet doesn't seem to be many seconds remaining for this world, and even if instantaneous, 1.84g seems to be rather a lot at such speeds, presumably needing a fairly dramatic angle of attack.
Another highlight seems to be 3 seconds of disagreement on the direction to fly from 29:57 to 30:00.
I guess the impact on pitch of full power was handled automatically, or there might have been even more fun and games.
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Another automation dependency situation when going to manual flight is considered an emergency for some pilots?
Another highlight seems to be 3 seconds of disagreement on the direction to fly from 29:57 to 30:00
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Between 9 h 29 min 57 and 9 h 30 the PFs nose-down input and the PNFs nose-up input on the wheel cancelled each other out: the wheel returned to the neutral position.
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How hard is it to just go manual and go 15 degrees up and add go around power? Everybody I know can do it easily. Learn how to fly so you don't need automation. You will never be in a 4400 fpm descent pushing buttons. Learn how to fly, not push buttons.
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bubbers
Automation cannot be blamed for this. If you press multiply key instead of divide you don't bame the calculator and throw it away but learn to use it properly.The problem is pilots have stopped monitoring the progress of the flight. They have lost the scan. Flying manually cannot be the only solution in highly automated aircraft. Flying manually 747-400 is no big deal for a classic captain but he should not be cleared till he is at ease with the automation.
Automation cannot be blamed for this. If you press multiply key instead of divide you don't bame the calculator and throw it away but learn to use it properly.The problem is pilots have stopped monitoring the progress of the flight. They have lost the scan. Flying manually cannot be the only solution in highly automated aircraft. Flying manually 747-400 is no big deal for a classic captain but he should not be cleared till he is at ease with the automation.
Yes, this was Automation mishandling rather than reliance- they WERE doing an Auto-land after all.
All he had to do was push the TOGA switches- that or simply make a one-push down-grade to CATIIIA (Though that seems to be against the operators SOPs).
Why do AF operate with a 20'DH for CatIIIB?
All he had to do was push the TOGA switches- that or simply make a one-push down-grade to CATIIIA (Though that seems to be against the operators SOPs).
Why do AF operate with a 20'DH for CatIIIB?
Originally Posted by Wizofoz
All he had to do was push the TOGA switches- that or simply make a one-push down-grade to CATIIIA (Though that seems to be against the operators SOPs).
I recall BA coming very close in a 747 as well when a pilot came from another Boeing type where the TOGA buttons were located in a different spot.
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bubbers 44
Your enthusiasm for manual skill this time makes you forget the reality. This was a CAT III approach and people who only love to fly manually or are uncomfortable with automatics should not be in the cockpit. He made a mistake of pressing A/THROTTLE disconnect button instead of TOGA levers that can happen but incidents rarely happen due to one mistake. He desired a G/A but he did not ensure that was happenning. Had he disconnected AP and not monitored the GA the result would have been more serious. In automated aircraft any pilot who keeps disconnecting AP to manage the situation because of poor knowledge needs to be retrained. You don't get cleared for CATIII for manual skills do you? You cannot get airborne without automation the whole world is RVSM.
Your enthusiasm for manual skill this time makes you forget the reality. This was a CAT III approach and people who only love to fly manually or are uncomfortable with automatics should not be in the cockpit. He made a mistake of pressing A/THROTTLE disconnect button instead of TOGA levers that can happen but incidents rarely happen due to one mistake. He desired a G/A but he did not ensure that was happenning. Had he disconnected AP and not monitored the GA the result would have been more serious. In automated aircraft any pilot who keeps disconnecting AP to manage the situation because of poor knowledge needs to be retrained. You don't get cleared for CATIII for manual skills do you? You cannot get airborne without automation the whole world is RVSM.
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Yes he needed to have pressed the TOGA button/lever.
Once P/F disconnected A/T instead (inadvertently) will pressing TOGA create the desired go around?
Will A/T then re-engage or must power be set and A/T re-selected?
Do you ever practice how to recover from an incorrect procedure in a time critical situation?
He could have disconnected the A/P and continued with the miss manually,
but it seems his brain was slow to shift into Go Around mode. Definitely behind the aircraft at that point.
Once P/F disconnected A/T instead (inadvertently) will pressing TOGA create the desired go around?
Will A/T then re-engage or must power be set and A/T re-selected?
Do you ever practice how to recover from an incorrect procedure in a time critical situation?
He could have disconnected the A/P and continued with the miss manually,
but it seems his brain was slow to shift into Go Around mode. Definitely behind the aircraft at that point.
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Am sure the said Pilot was trained appropriately and previously demonstrated proficiency in consistently maintaining the requisite standard..on this occasion there might have been Human Factors issues at hand...Fatigue?Subtle incapacitation due to...??? Just wondering!
Also..was this Captain ex FBW Airbus pilot? Regressing to old habits under pressure syndrome!
Also..was this Captain ex FBW Airbus pilot? Regressing to old habits under pressure syndrome!
Once P/F disconnected A/T instead (inadvertently) will pressing TOGA create the desired go around?
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Yes, cat lll approaches require automation but somewhere in the cockpit at least one pilot has to know what to do if pushing a button doesn't work. If not then we will hear more repeats of this incident. It is your choice.
As the yokes are mechanically linked, I am not too sure how such information is registered on QAR FDR or is it mainly according to the pilots accounts ... ?
Why do AF operate with a 20'DH for CatIIIB?