Understanding Air France 447
Page 20
Flight Simulators
EASA modify the basis of the regulations in order to ensure better fidelity for simulators in reproducing realistic scenarios of abnormal situations.
EASA ensure the introduction into the training scenarios of the effects of surprise in order to train pilots to face these phenomena and to work in situations with a highly charged emotional factor.
Ergonomics
EASA require a review of the re-display and reconnection logic of the flight directors after their disappearance, in particular to review the conditions in which an action by the crew would be necessary to re-engage them.
Further, even if it is not sure that the crew followed the orders from the flight director while the stall warning was active, the orders from the crossbars were in contradiction with the inputs to make in this situation and thus may have troubled the crew.
Consequently, the BEA recommends that: EASA require a review of the functional or display logic of the flight director so that it disappears or presents appropriate orders when the stall warning is triggered.
In so much as certain on-board systems identified the problem, but the alerts presented to the crew only presented the symptoms:
EASA study the relevance of having a dedicated warning provided to the crew when specific monitoring is triggered, in order to facilitate comprehension of the situation.
EASA determine the conditions in which, on approach to stall, the presence of dedicated visual indications, combined with an aural warning should be made mandatory.
When airspeeds are below 60 kt, the stall warning is no longer available, even though it may be beneficial for it to be available at all times.
Consequently, the BEA recommends that: EASA require a review of the conditions for the functioning of the stall warning in flight when speed measurements are very low.
Operational and Technical Feedback
EASA improve the feedback process by making mandatory the operational and human factors analysis of in-service events in order to improve procedures and the content of training programs.
Specifically, that the DGAC take steps aimed at improving the relevance and the quality of incident reports written by flight crews and their distribution, in particular to manufacturers.
Oversight of the Operator
In-flight and ground inspections by the Authority within the airline never brought to light any major deviations, whether in relation to the operator’s conformity to the regulatory provisions, to the recurrent simulator training or in flight. Thus, the whole range of inspections did not bring to light the fragile nature of the CRM nor the weaknesses of the two copilots in manual airplane handling. Though respecting the regulatory requirements applicable to oversight, it appears that the organization, methods and means deployed by the authority were not adequate to detect the weaknesses of an operator and impose the necessary corrective measures.
Key Flight Recorder Parameters
The following is a collection of the key parameters from the flight recorder tracings provided by the final accident report.
Glossary
Ab Initio - A Latin term meaning "from the beginning" whereby an airline often hires a pilot with minimal qualifications and provides the training necessary to serve as a flight officer.
ACARS - Aircraft Communications Addressing and Reporting System. A messaging system used to deliver messages between the aircraft and ground stations, and in some cases ATC.
ADIRS - Air Data Inertial Reference Systems Three systems comprised of the Air Data and Inertial reference components.
ADS-C - Automatic Dependent Surveillance - Contract. An automatic position reporting system widely used in oceanic areas where radar is not available.
ADR - Air Data Reference. Three systems that provide altitude and airspeed data.
AOA -Angle of attack. The angle between the wing and the relative wind (the apparent wind resulting from the forward motion of the airplane)
ARCC - Aeronautical Rescue Coordination Centre
ATC - Air Traffic Control
BEA - Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (Office of Investigations and Analysis for the safety of civil aviation
CG - Center of Gravity
CPDLC - Controller Pilot Data Link Communications. A system for sending and receiving text messages between the aircraft and ATC that ensures the accuracy of the transmitted data. It is widely used in, though not limited to, oceanic areas where VHF radio coverage is not available.
CRM - Crew Resource Management (formerly Cockpit Resource Management). A human factors approach to more effectively managing of the flight, which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance the efficiency of operations.
CVR - Cockpit Voice Recorder. This recorder provides a multi-channel recording of radio, inter-phone, and other communications from each pilot station, and cockpit area microphone audio, for use in accident investigations. Maximum storage capacity is between 30 minutes and 2 hours.
DFDR - Digital Flight Data Recorder. This recorder constantly records several thousand aircraft parameters for use in accident investigations.
DGAC - Direction Generale de l’Aviation civile (French Director General of Civil Aviation)
EASA - European Aviation Safety Agency. The Agency promotes the highest common standards of safety and environmental protection in civil aviation in Europe and worldwide. It is the centerpiece of a new regulatory system which provides for a single European market in the aviation industry.
ECAM - Electronic Centralized Aircraft Monitor. This system provides display and monitoring of aircraft systems. It uses the two center display screens on the instrument panel, and includes alerts, non-normal checklists, and other information.
ECP - Recurrent training in simulators
ELT - Emergency Locator Transmitter. A transmitter that sends an emergency location signal (trackable by satellite and search and rescue personnel). ELTs are typically triggered automatically by impact forces.
FCPC - Flight Control Primary Computer (PRIM)
Flight Director - A display, on the A330 consisting of a horizontal and a vertical command bars on the primary flight display (PFD). The command bars are generated by the flight management computer and provide pitch and roll guidance to the pilot to follow identical to the commands the autopilot follows when it is on. The FD and autopilot are usually both on in flight.
FO - First Officer
FPV - Flight Path Vector. A display on the PFD that shows the lateral and horizontal trajectory of the airplane independent of attitude.
GPWS - Ground Proximity Warning System
HF Radio - High Frequency radio. A radio spectrum (shortwave) that allows for long distance radio communications. It is widely used in oceanic areas where VHF radio coverage is not available. It is highly subject to interference and poor transmission quality.
ICAO - International Civil Aviation Organization. Promotes understanding and security through cooperative aviation regulation.
IR - Inertial Reference. Three systems that provide attitude, heading, position, and other inertial based data
Mach - In reference to a scale where Mach 1.0 equals the speed of sound.
N1 - The speed of the fan stage of the engine, expressed in percent, though 100% is not the upper limit. It is the primary thrust setting parameter.
ND - Navigation Display. On the A330 this display includes a moving map display, weather radar, TCAS, terrain, and additional navigation data.
PIC - Pilot in Command
PF - Pilot Flying
PFD - Primary Flight Display. On the A330 this one display includes attitude, airspeed, heading, altitude, vertical speed, auto-flight mode annunciations, and some additional information.
PNF - Pilot not Flying.
SAR - Search and Resecue.
SELCAL - Selective Calling. A system that allows the radio operator to transmit an aircraft’s unique
SELCAL code. When the radio receiver recognizes its code, it sounds a call signal in the cockpit alerting the crew to contact the radio operator for a message.
THS - Trimmable Horizontal Stabilizer. aka: stab
TOGA - Takeoff/Go Around: A thrust setting and the full forward thrust lever position. If selected in flight with the flaps are out, it also commands the autopilot/flight director system to provide go-around guidance.
ULB - Underwater Locator Beacon
VHF Radio - Very High Frequency radio. The common radio band used aeronautical radio transmission. The transmissions are usually of good quality, but are limited to line-of-sight transmissions, and are therefore unusable for long distance communications.
About the Author
Bill Palmer is a currently an A330 captain for a major international airline.
As a member of his airline’s A330 development team for the introduction of the airplane to its fleet, he has been intimately involved in A330 fleet since 2002. He was the lead author and editor for the airline’s A330 systems manual, and has written numerous A330 training publications. He has served as an airplane and simulator instructor, check airman, designated examiner, and also on training related projects from video production to simulator certification.
Bill started flying at the age of 15, soloed on his 16th birthday and completed his private certificate at 17. He attended Embry-Riddle Aeronautical University and holds a BS in Aeronautical Science. He earned his flight instructor certificate in 1978 and has been instructing almost non-stop since then, while holding airplane, instrument, multi-engine, and ground instructor certificates. Besides light aircraft he has also taught on the 727, 757, A320, DC-10, and A330, and written manuals for the DC-10, A330, and B-787 fleets. He has also produced numerous training publications and videos for the various fleets as well.
Bill holds an ATP with type ratings in A320, A330, B757/767, B777, DC10, and commercial glider and flight engineer-turbojet ratings.
Footnotes
1. The indicated airspeed is the airspeed that shows on the airspeed indicator. As altitude increases, this value decreases in comparison to the actual speed through the air.
2. The first class professional pilot’s license is no longer issued by French authorities, but it was a grade between the commercial and airline transport ratings that allowed the pilot to act as first officer on any aircraft and captain on aircraft weighing up to about 46,000 lbs.
3. http://abcnews.go.com/blogs/headlines/2012/06/was-air-france-captain-with-a-woman-when-flight-447-was-in-trouble/
4. Fatigue, alcohol and performance impairment NATURE, Volume 388, 17 JULY 1997, page 235
5. http://www.youtube.com/watch?v=j9kFag4j2pQ
6. http://www.lepoint.fr/societe/crash-du-rio-paris-la-fatigue-des-pilotes-a-ete-cachee-15-03-2013-1640312_23.php
7. http://www.bea.aero/en/enquetes/flight.af.447/questions29juillet2011.en.php
8. http://earthobservatory.nasa.gov/IOTD/view.php?id=703
9. The animation can be viewed in a web browser at this address: http://www.bea.aero/en/enquetes/flight.af.447/trajectoires/trajectoires010609.html
10. AF447 Final Accident Report page 40
11. Photo licensed to the public domain
12. http://www.flyafrica.info/forums/showthread.php?20124-Similar-event-experienced-as-AF447
13. http://www.gcaa.gov.ae/en/epublication/pages/investigationreport.aspx
14. ”Storm Finder. New weather radars should help airline pilots avoid turbulence and passenger injuries” Aviation Week & Space Technology dated September 13 2004
15. Appendix 9 from the AF447 final report
16. AF447 Final Accident Report page 65
17. AF447 Final Accident Report page 40
18. Air France A330-200 photo copyright Wim Callaert
19. http://www.boeing.com/commercial/aeromagazine/aero_12/attack_military.html
20. http://www.boeing.com/commercial/aeromagazine/aero_12/attack_story.html
21. AF447 Final Accident Report page 43
22. AF447 Final Accident Report page 106
23. Airbus ”Safety First” Development of A380 Flight Controls part 1
24. This is similar to the normal operation of many conventionally controlled transport airplanes, which will lockout or limit some surfaces with flaps or slats extended.
25. AF447 Final Accident Report page 174
26. Engine speed is measured in percent RPM of the fan stage of the engine, commonly referred to as N1.
27. As per phone conversation with Airbus experts on the accident.
28. http://en.wikipedia.org/wiki/Northwest_Airlines_Flight_6231
29. http://en.wikipedia.org/wiki/Birgenair_Flight_301
30. http://en.wikipedia.org/wiki/Aeroper%C3%BA_Flight_603
31. http://www.ntsb.gov/doclib/reports/2010/aar1003.PDF
32. AF447 Final Accident Report page 195
33. American Airlines Flight 587 Accident report, page 160
34. http://www.ausbt.com.au/pilot-panic-brought-down-air-france-af447-investigators
http://www.huffingtonpost.com/jeff-wise/how-panic-doomed-an-airli_b_1135004.html
35. http://www.killology.com/art_psych_combat.htm
36. AF447 Final Accident Report page 204
37. Statistical Summary of Commercial Jet Airplane Accidents-Worldwide Operations, 2002-20011, Boeing Commercial Airplane Group,http://www.boeing.com/news/techissues/PDF/statsum.pdf
38. Aviation Week and Space Technology, Amping the Envelope December 2, 2012
39. Loss of Control in Flight, Training Foundations and Solutions, Randall Brooks, European Airline Training Symposium, November 2010
40. Statistical Summary of Commercial Jet Airplane Accidents-Worldwide Operations, 2002-2011, p.22, Boeing Commercial Airplane Group http://www.boeing.com/news/techissues/PDF/statsum.pdf
41. Aviation Week and Space Technology, Amping the Envelope December 2, 2012
42. http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/all_safos/media/2013/SAFO13002.PDF
43. Degradation of Pilot Skills, Graduate Thesis, University of North Dakota, Michael W. Gillen, December 2008
44. AF447 Final Accident Report page 192