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Final Air France crash report says pilots failed to react swiftly
(CNN) -- A series of errors by pilots and a failure to react effectively to technical problems led to the crash of Air France Flight 447, France's Bureau of Investigation and Analysis said Thursday in its final report on the disaster. The Brazil-to-France flight plunged into the Atlantic Ocean on June 1, 2009, killing all 228 people on board. (edition.cnn.com) Más...Sort type: [Top] [Newest]
I hesitate to ask this question, since I am just a private pilot with a few hundred hours, but what the heck. Time and time again we learn of accidents due to pitot tube problems. With today's electronic GPS systems, why is that not a good backup system for airspeed, and altitude issues, when a pitot probe blockage is suspect ?
The unfortunate lesson of this accident is that had the pilots reverted to basic private pilot skills they could have averted the result. Secondary flight displays/cross referencing, pitch for airspeed power for altitude and stick and rudder rule the day. The lesson? We are entering the zone where classic airmanship takes a back seat to automation and the brain lock is switched permanently on for a generation that will know nothing other then automated cockpits.
I don't know that the A 330 has those basic instruments. Needle/ball may be non existent and the airspeed is a computer display that was over ridden by maintenance reporting, the way I read previous reports. Popular Mechanics, you'll have to Google it, published the entire voice recording of the incident. I didn't find a clue of why the FO made the decisions he did keeping in mind he had over 11,000 hours logged. These weren't rookies, but rather an elite, experienced flight crew.
Mark,
The cockpit voice recorder transcript is also available here:
http://www.bea.aero/docspa/2009/f-cp090601.en/pdf/annexe.01.en.pdf
"Needle and ball" information was available to the crew throughout the incident. The only thing they lost was reliable airspeed indication. Similar to any other loss of instrumentation, there is a well-defined procedure for unreliable airspeed indications, which the crew simply failed to implement.
All,
There can be little doubt that the crew's failure to implement basic and required procedures after loss of airspeed information was the root cause of the outcome. There has been much speculation that various features of the Airbus FBW controls contributed to the outcome, but there is little evidence of this in the record.
When reliable airspeed information was lost, the autopilot disconnected and control logic went to one of the alternate laws. The crew was aware of and acknowledged this. They were also aware that the autothrottle function had disconnected, and made manual thrust adjustments throughout the incident. Although there has been speculation about conflicting control inputs, the record from the flight data recorder does not support this.
The primary focus needs to be on the human factors that led the crew to respond so inappropriately to the situation. The report focuses on the "startle" factor, from which the crew apparently never recovered. Although I have been flying (off and on) since the 60s, with a commercial license with instrument rating I of course have only a small fraction of the training and experience of this crew. But even so I can look back to at least three times in my career when I stared uncomprehending at the instruments while a situation developed, without a clue what instruments I knew as well as the back of my hand were telling me. I can only speculate that this is what the flight crew was going through.
For those who are interested in learning more about the A330 systems--for example, description of the various control laws or side stick control priority system--there is a marvellous resource at:
http://www.smartcockpit.com/
This has comprehensive technical manuals on most models of commercial and business jets (and some turboprops) including all models of Airbus.
Ben
The cockpit voice recorder transcript is also available here:
http://www.bea.aero/docspa/2009/f-cp090601.en/pdf/annexe.01.en.pdf
"Needle and ball" information was available to the crew throughout the incident. The only thing they lost was reliable airspeed indication. Similar to any other loss of instrumentation, there is a well-defined procedure for unreliable airspeed indications, which the crew simply failed to implement.
All,
There can be little doubt that the crew's failure to implement basic and required procedures after loss of airspeed information was the root cause of the outcome. There has been much speculation that various features of the Airbus FBW controls contributed to the outcome, but there is little evidence of this in the record.
When reliable airspeed information was lost, the autopilot disconnected and control logic went to one of the alternate laws. The crew was aware of and acknowledged this. They were also aware that the autothrottle function had disconnected, and made manual thrust adjustments throughout the incident. Although there has been speculation about conflicting control inputs, the record from the flight data recorder does not support this.
The primary focus needs to be on the human factors that led the crew to respond so inappropriately to the situation. The report focuses on the "startle" factor, from which the crew apparently never recovered. Although I have been flying (off and on) since the 60s, with a commercial license with instrument rating I of course have only a small fraction of the training and experience of this crew. But even so I can look back to at least three times in my career when I stared uncomprehending at the instruments while a situation developed, without a clue what instruments I knew as well as the back of my hand were telling me. I can only speculate that this is what the flight crew was going through.
For those who are interested in learning more about the A330 systems--for example, description of the various control laws or side stick control priority system--there is a marvellous resource at:
http://www.smartcockpit.com/
This has comprehensive technical manuals on most models of commercial and business jets (and some turboprops) including all models of Airbus.
Ben
Excellent work their...nice to read something with substance.
Thanks Ben. Much more thorough than the MI article. It tells me a lot about state of mind when the FO was concerned about who was going to handle the landing hours into the future. When the computer handed off the controls he was unprepared to follow through. His mind was not engaged in flying the airplane nor had he been engaged for some time. He, in effect, forgot how to fly.
And don't ever put youself down again with that "I'M JUST A PRIVATE PILOT" business. There was not a one of us in here that got an ATP on a solo flight. And hours do build!!!!!!!!!!!!!