Posted by: reformedmusings | July 8, 2012

Final Report on Air France Flight 447 Crash

I wrote a post based on the preliminary report released last year. The final report has been released and may be found here. It basically fleshes out what the preliminary report said. Bottom line is that a fully trained, current and qualified flight crew caused a perfectly good airplane to plunge about 35,000 feet into the ocean in about four-and-a-half minutes, killing 228 people. My analysis and lessons learned posted here were right on target. If you fly, please read my earlier post. Please!

It is clear from the Flight 447 cockpit voice recorder that the crew never figured out the basic issue, which was icing in the pitot tubes. The A330 flight manual makes clear that such circumstances are temporary, usually only lasting a few minutes. The flight manual also contains procedures for flying with unreliable airspeed indications. The crew never thought through the situation, never discovered the underlying problem, and therefore never applied the proper procedures. Rather, they did just the opposite.

As I said in my earlier post, this was a classic failure to apply basic airmanship. Essentially, the pilots could have (and should have) done absolutely nothing and their instruments would have returned in a few minutes. The aircraft was already trimmed for level flight and would have stayed that way if the pilot hadn’t started trying to correct for problems that didn’t exist. The final report covers their tragic actions in detail. Even so, they could have recovered the aircraft at any time before they reached about 10,000 feet and maybe a bit later by applying known pitch and power settings as recorded in the flight manual. They could have gotten close to those values simply by guessing based on their cruise settings. After descending passing 10,000 feet or so in an uncontrolled condition at night in a heavy aircraft, it was basically all over but the splash.

Bottom line for pilots is to think and analyze before acting. In case of a real or perceived emergency, wind the clock first while you assess the situation. Very few situations require immediate action, and those are usually readily apparent and well-practiced in training. Don’t be so dependent on the host of computer and automatic systems that you forget how to aviate at the most basic level.

I will be haunted by the cockpit voice recorder transcript for some time. In the final seconds, the last words of the pilot that had taken the initial wrong actions at 35,000 feet were most haunting of all: “We’re going to crash…This can’t be true…But what’s happening?” Those words sum up the underlying tragedy. They had all the documented training necessary to handle the initial, very minor situation, but never figured it out. As a pilot, if you don’t know what to do, sometimes the best course is to do nothing. Oh, that they had simply let the aircraft fly itself when they initially lost their airspeed indications, 228 more people would be alive today. I pray for all the families involved.



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