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

They had three pilots onboard who did not understand that you push the nose down in a stall. Still can't come to grips with that.

That's what killed them in the Colgan crash in Buffalo too.....

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 :sad: - the best we can do is learn from it, in all of its nuances.

AB skates. Had the airplane had conventional control columns the captain would have seen what his unskilled comrades were up to (no pun intended).

More to the point, they had three pilots, none of whom realised that the aircraft was in a stalled condition.

etc etc

10 to 23 degrees nose-up attitude at levels above 300 is no, or is a conflicting, clue??:ugh:

pitch+power=performance (i think its lesson 2 or 3 in basic flight training!)

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.

Didn't stop the A310 over Paris. And that had a yoke.

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.

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 ....
.

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.

BBC News - Air France crash 'due to pilot and technical failings'

85' degrees of thrust..That'll be why then.
:ugh:

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.

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.

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............ :ugh: WHERE IS COMMON SENSE?

Yes, yes... hindsight, arm-chair analysis, etc...

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.

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.

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.

[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.

30 years later!!:ugh:

Things have changed, to the good (technology) and the bad (basic flighing skills/schools etc etc)

So the Mighty Captain would have realized the problem and known how to deal with it? Just mislead by that side stick and those damn First Officers hu?

Get real and stop playing this Captain vs First Officer game. They were a crew and unfortunately they seem to have not realized what the problem was and that the aircraft was in fact stalled.

Pitch and thrust. It's all in the QRH.

AF447 pitch didn't drop below the horizon the entire time. In fact, for most of the fall, the nose was pegged somewhere above +14 degrees of pitch.

In 1979, you'd have control forces you could feel. In 2009, the side-stick removes all tactile feedback.

Another point worth mentioning is that during the hard pitch-up by the pilots of AF447, the stab trim wound all the way back to +13 degrees.

Interesting that many are not discussing this point.

Any A380 pilots want to comment on the display of pitch trim there? Interesting to know if they did it differently.

Folks, we have ninth thread on AF447 up and running in the Tech Log. Please continue discussion there.

Mods, please merge.

I don't agree. Many pilots had complained about the unnatural aspect of the sidesticks and their feeling of disconnection from the airplane. This accident showed how the pilots are also disconnected from each other. That's a fundamental design flaw.

Would they have been able to recover had it been in daylight hours?
ie have the confidence to ignore the stall warning that occured when they lowered the nose?

Question from an occasional spamcan (and armchair)flyer: is it possible that with the trim all back (without the crew immediately aware of it), one would need to pitch down and/or roll the trim wheel forward for a very long time to get the plane unstalled. For such a long time that after half the time actually needed a confused pilot could get the impression that he must already be in the first quarter of an outside loop and therefore ceases his efforts?

Exactly fotoguzzi; the crew's reactions were those of laymen.

Rule 1 for a trained pilot is Fly the F#cking Aircraft, which they completely failed to do.

To quote from page 185 of the final report

"Current training practices do not fill the gap left by the non-existence of manual flying
at high altitude, or the lack of experience on conventional aeroplanes. Furthermore,
they limit the pilots’ abilities to acquire or maintain basic airmanship skills."

For the sake of accuracy

Pilots are taught that you cannot stall a 330 in NORMAL LAW

Pilots are taught that you CAN STALL a 330 in ALTERNATE LAW

They were in alternate law once their pito tubes froze up.

Training and experience count...........
 

Other A330 pilots encountered similar senarios without major incident because they flew attitude and power setting. How many times does a "STALL STALL" warning have to go off before someone reduces Angle of Attack? It seems the SO took the low level wind-shear response (TOGA plus full aft stick) and assumed the aircraft was in normal mode. Very poor CRM and the lack of captaincy are other factors. Yes the Airbus has "hiddens" such as non moving Thrust levers, non moving stab trim wheel, independent side sticks but at the end of the day when was the last time those in the flying seats had recovered from a real Stall in a real aircraft? 5000 h of automated Airbus flight and maybe 250h of real flying at the beginining of the SO' and FO's JAR Integrated course training......



Ten years before this accident, Airbus Chief Test Pilot Capt W Wainwright wrote an article on Stall recovery - it is doubtful many Airbus pilots have read it. Had the AF447 crew been taught and applied these techniques history would be different:

http://www.google.co.uk/url?sa=t&rct...NBc9_0_SR-U9Sg


We know there were many factors aggravating the situation but responsibility lies with the pilots, the airline, the manufacturer, the training system and the regulators. How much will be judged to have the greater share will depend on honesty, openness and sadly politics. I hope we can learn from the mistakes made and ensure a safer flying future by improving pilot selection, training, and mentoring, developing CRM/SMS so it is of real value and not a box ticking , white-wash exercise. I hope AF447 will lead to a clarifying of systems, improvment to the automation/pilot interface, designing controls that keep all the flight crew in the loop.

Cost cutting shares some of the blame: Since the 1990s Long haul operators have moved from having Two experienced Crews (2 capts, 2 FOs) to a Cruise Pilots (SO's with no flying below 10 to 15 thousand feet).

This combined with what Airbus claims is just 3h hands on flying a year for most Long Haul Captains plus an EU system of zero to hero in 250h (with multiple guess aeronautical knowledge) before 1000s of hours watching automation on FBW jets must also account in part for the AF447 FO and SO interaction and actions.

Of course other maufacturers aircraft have stalled with sad loss of life. If it were not for the Airbus protection systems, the accident rates could well be higher. But, for some observers, AF447 is Airbus' Titanic moment. Even if not expressed directly by the Company, the "unsinkable" / "unstallable" claims made by some pilots have echoed around Simulator halls and online forums for years. It might be true 99% of the time until an iceberg/pitot ice event is poorly handled.

Traditionally, Pilots are entrusted with baby sitting the automation. By bombarding a pilot with claims throughout his training and career, that the automation is better/ more reliable/ more efficient than the pilot can lead to a mind set where the computer baby sits the pilot and a transfer of responsibility occurs.

"This machine will get me out of trouble if I just trust the alpha protection and do what I did in the SIM"


"OK, the automatics have given up and handed me manual control, don't panic!, what's the attitude and thrust setting, strange speed indications! , rate of roll/yaw pitch?, cross check with alternative EFIS and standby instruments, is that weather related turbulence or stall/mach buffet?, The stall warning is going off, fly pitch and power......."

The trim would take some winding to move the stab, yes. It would definitely be necessary to unwind it to un-stall the aircraft, as +13 degrees of pitch trim is a very large amount, to the point that elevator effectiveness would be very questionable to even start pitching the nose over.

Again, a lot of what we are discussing comes back to basic airmanship. It would be clear from the ADI that the aircraft is stable in pitch and not looping. It would seem that they didn't doubt the validity of the ADIs at any time.

A question we will never get an answer to is why they ignored altitude data? It was the pitot probes that were blocked, not the static ports?

I can't understand why the senior pilot was in bed after 2 hours of flight. Was he at work or not?

You`re not a pilot, are you?

Angelorange
False .. they are moving (and it's an index by side) but in silence ... (no clac clac :) )
Check here:
http://www.pprune.org/tech-log/39510...resume-26.html
http://i277.photobucket.com/albums/k...0_IMG_3037.jpg

Now I absolutely grant you that the crew had already f**ked up beyond all recognition by this point, but refer to RobertS975 - post #15.

Once they were deep into the incident the warning worked bass ackwards; they reduced AoA, speed increased beyond 60KIAS, the stall warning sounded, they pulled back again, speed reduced, and the stall warning stopped.

That is an aspect of this accident that *still* hasn't received enough attention for my satisfaction. It's a long way from being the most important factor, but it's there and it seems to me the last thing you need when in a high-stress situation trying to work out what the is going on. I still haven't had a cogent explanation of why that design decision was taken; the aircraft shouldn't be anywhere near 60KIAS in anything resembling normal operation, if it IS then it's in deep stall, so why not just hang the stall warning inhibit off the WoW logic, for instance?

Take a look at this hilarous assessment by a nonpilot "aviation expert":

Air France 447 Report: How the Plane Went Down - The Daily Beast

"Global warming" - yeah, sure...........

This is possibly far more significant than the reports suggest.
The stall warning was clearly misbehaving so they would have ignored it and concentrated on the unwinding altimeter and the overspeed warnings.
Looks like we are in a steep dive - pull up before the wings come off.

Yes, they made the wrong decisions but they were faced with multiple conflicting bogus sources of information.

It would be interesting to put a few dozen pilots into the simulator and present them with the same symptoms of bogosity overload. Would you have got it right ?.

There but for the grace ......

Sometimes us simple little spam can drivers have an advantage over you sophisticated heavy guys. I surely recognise your skills and knowledge but sometimes all that complication and the multi, multi event possibilities seem just to get in the way.

What frightens me is not losing my life in some sudden aviation event, for that I value the odds and how well you all do your jobs day to day, a remarkable achievement in itself, but sitting in the back next to my loved ones with the nose up and the wings sawing side to side for three minutes and wondering why the pilot doesn't push the nose down.

I have flown a lot since this crash but I don't have the comfort in doing it that I used to. Strangely it is worse on longer, 'heavy' flights too.

+1

I didn't know they were getting over-speed alerts as well?? Are you sure?