The final report of the French safety investigation of the Air France AF447 disaster is a shocker, and directly relevant to how pilots are trained to fly the latest Airbuses and Boeings.
Never mind that all 228 people on board the A332 jet flying between Rio and Paris on June 1, 2009 died when it slapped down onto the mid-Atlantic in a nose-high belly flop at nearly 11,000 feet per minute.
This tragedy is all about the modern airline managements that have come from business schools, not flying schools, and have variously a contempt for the old-fashioned excessive costs of flying excellence, or no understanding that dumbed-down, tick-the-boxes cheap training leaves pilots inadequately equipped to save an airliner when it surprises pilots with an unusual malfunction or control crisis.
As happened to the Air France Airbus, the pilots of which had been inadequately yet legally trained to the harmonised international dumbed-down criteria endorsed by airline management clubs such as ICAO and carbon-copied by regulators such as CASA in this country.
AF447’s two junior pilots had been, according to the report, inadequately briefed by a more experienced captain, who left them at the controls without a clear handover of command as acting-captain when he retreated for a rest break while they flew into the towering cloud tops of the inter-tropical convergence zone that stretches from South America to Africa on the way to Paris.
The external speed-measuring pitots froze up, and caused the computer-controlled flight management system to disconnect the autopilot, at which point the two less-experienced co-pilots mishandled the Airbus so badly that, after only a minute with 3½ minutes left before impact, the flight was doomed even though the iced-up pitots had cleared and the jet was mechanically 100% functional when it crashed into the sea with such force that some of the recovered bodies were sliced in two by retaining seat belts.
The actual report is much more brutal than the widely reported press conference that released it. In emphasising the failure of knowledge and appropriate responses by the crew, it uses language similar to that employed by psychologists in discussing clinical hysteria, rather than histrionics. It says:
“The crew progressively becoming destructured, and likely never understood they were faced with a simple loss of three sources of air-speed information.
“The loss of co-ordination and the willing but chaotic co-operation in managing the surprise generated by the autopilot disconnection led quickly to loss of cognitive control of the situation and subsequently to loss of physical control of the aircraft.”
It speculates as to why the junior pilot flying kept the jet in an extreme nose-high attitude for almost the entire sequence of events following the autopilot disconnection, causing a high-speed stall as it headed for the clear air above the turbulent storm tops where it might have been thought there would be safety.
A continuous 54-second stall alarm was ignored. The report surmises that it wasn’t believed, and says there is no recognition at any time by the two junior pilots or the captain, that the jet was stalled. When the flight computers didn’t receive valid angle of attack data, the stall warning ceased, only to come back as the data returned, a fact that Air France says is a design fault in the Airbus control system, and that confused and misled its pilots.
The French safety agency, however, notes that one of the co-pilots diluted the time he could have spent on trouble shooting in trying to summon the captain, who arrived eventually and stood at the rear of the cockpit saying very little despite his junior colleagues saying they didn’t understand what was happening, had tried everything and had lost control of the aircraft.
While the report draws attention to possible deficiencies in the Airbus computer-driven flight management system, it also examines 13 similar incidents in which pilots had correctly responded to temporarily frozen air-speed measuring pitots, and retained control of their A330s or A340s without any injury to passengers or threat to the aircraft.
It recommends changes to pilot training in order to deal with “surprises” or “startle” effects, and the safety agency recently reported on a subsequent Air France A340 incident similar in many respects to the AF447 disaster in that the pilots broke all the rules for dealing with a crisis, had no recollection of hearing any aural alarms, and flirted with causing another potentially deadly high-altitude stall.
As foreshadowed in an earlier article on Crikey blog Plane Talking, AF447 is likely to become something of a lightning rod for concerns that undue reliance on automation in any modern Airbus or Boeing poses increased safety risks. This is something the major airline manufacturers have already raised, out of the public gaze, at safety and technical forums.
AF447 shouldn’t be a debate about how airliners are designed so much as one about how they are operated by appropriately trained professionals in an effective regulatory environment.
Very interesting analysis. Back in the good old days
of flight training in Cessna’s (where professional
pilots often started) if you heard the stall warning
it was stick forward, nose down immediately, or
experience the wrath of the instructor.
Your comments on undue reliance on automation
(read flight computers) ring true. If the aircraft was
in cloud with no visual reference to attitude
it would appear that they thought the computer
would do the right thing.
I think this comes down to the heart the new business model where it’s mainly about protecting shareholder equity at all costs – and of course this is reflected in the various pay disputes and cost cutting in engineering we see in many of the major airlines including the flying red rat.
The guy up the front is the star player and he or she needs to be able to dance when the music starts.
I’ve held a pilot’s license for 35 years and a commercial license for 30 of them. A great deal of emphasis early on in training was to fly by power and the attitude of the aircraft, especially where the nose is in relation to the real horizon on the artificial horizon.
That seems to be an emphasis that has not made the transition to the glass cockpit, but it has proved its worth to me numerous times, not just as a technique to recover a risky situation but as a means of focusing attention on the task at hand and allaying panic.
But I still feel deeply for the pilots of AF447, convinced, perhaps, that the whole FRED running the aircraft was telling them a monstrous lie. Time to set cruise power and trust the humble AH and turn and balance indicator.
The new “cut costs at all costs” business model has reduced pilots to glorified bus drivers. I doubt ICAO nor CASA will wake up until many more disasters occur.