Lessons from Air France Flight 447 Rio-to-Paris crash (+video)

Pilot error, defective sensors, inadequate training and insufficient oversight combined to send an Air France passenger plane plunging into the south Atlantic in 2009 in the airline's worst disaster, French investigators said on Thursday.

The final report on the Rio-Paris Airbus A330 crash that killed 228 people went further than expected in castigating the air safety establishment, saying France's flag carrier was subject to less inspection than smaller rivals.

The BEA investigation authority called for improved training of pilots, instructors and inspectors, and better cockpit design among 25 recommendations to prevent a repeat of the catastrophe.

Pilots' trade unions and Air France have been at loggerheads with planemaker Airbus over who or what was to blame for the airline's worst loss.

The report upheld initial findings that the crew of flight AF447 had mishandled their response to the loss of speed readings from faulty sensors that became iced up in turbulent conditions over the south Atlantic on June 1, 2009.

The doomed aircraft plunged for four minutes in darkness in an aerodynamic stall as its wings gasped for air while pilots failed to react to repeated stall alarms, according to flight recorders recovered two years after the crash.

"This accident results from an airplane being taken out of its normal operating environment by a crew that had not understood the situation," said BEA director Jean-Paul Troadec.

He added, however, that the same situation could have occurred with a different crew on board.

The report also found that the A330's speed sensors, known as pitot tubes and designed by France's Thales, were only upgraded after the disaster, even though there had been previous incidents with the equipment.

It urged a review of aircraft stall warning systems following criticism of the alarm's erratic behavior when the plane was deep into its 38,000-foot plunge.

Families of crash victims immediately criticized the report as too soft on the aerospace industry, ensuring that a row over responsibility for the accident will linger as Air France and Airbus both face a French manslaughter investigation.

"To deny, as the BEA has done, the extremely significant influence of technical defects is to go into denial about the reality of this accident," said Olivier Morice, a lawyer for families of some of the victims.
"The victims' families cannot accept this."

Training for Surprises 

Air France defended the pilots, saying they had responded to confused and conflicting information, including multiple warnings and alarms, aerodynamic noises and vibrations.

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