Lessons from Air France Flight 447 Rio-to-Paris crash (+video)
The final report on the crash of Air France Flight 447 says France's flagship carrier was subject to fewer inspections than smaller airlines. The investigators issued 25 recommendations, including ways to improve pilot training, cockpit design, and inspections.
(Page 2 of 2)
"In this degraded environment, the crew, combining the competence of the captain and two co-pilots, remained fully engaged in flying the plane until the last moments."Skip to next paragraph
Subscribe Today to the Monitor
Cockpit recordings showed that the captain was taking a scheduled break when the aircraft hit a shower of ice particles at night during an equatorial storm over the ocean, with the least experienced of two co-pilots at the controls.
The investigation has centered on the actions of this pilot and why the crew ignored dozens of audible stall alarms, as well as protocols which may have discouraged the senior co-pilot from overriding his colleague to take full control.
Flight data suggested the crew mainly pulled back on the control stick instead of pushing it forward to create more lift, which is the procedure for coping with a stall.
According to representatives of victims' families, that may have been due to faulty information displayed on a panel called the flight director, an element they said had been revealed to them by the BEA but was omitted from the press release.
By the time the captain returned, the plane was in such a dire state that the aircraft's computers gave up trying to calculate its position and turned the stall warning off.
At that point, the pilots nudged the nose forward only for the alarm to come back to life, a contradiction severely criticized by pilot unions who say it confused the crew.
Aircraft manufacturers say that by this stage the A330 was beyond recovery, but the BEA nevertheless recommended a review of stall warning behavior.
Airbus said it had already started working on improvements to the speed sensors and would implement other findings.
The 219-page report provides food for psychologists as well as aircraft designers, with calls for improvements not only in the way pilots are taught to fly manually at high altitude but also in the way they respond to unexpected shocks.
Instructors should spring surprises on trainee pilots during practices and should themselves be better trained, it said.
"There is a lot to learn from this report on coping with surprise and handling aircraft in unusual situations," said Paul Hayes, safety director at aviation consultancy Ascend.
"It's dark en route, nothing much is happening and then all of a sudden all the bells and whistles go off and humans don't always react well."
In a potentially far-reaching recommendation, the BEA tore up the traditional unity of France's civil service and pointed to systemic failings in regulation and supervision of Air France by the DGAC aviation authority.
It also said Air France was subject to a proportionately smaller number of spot-checks by a team of just 12 roving official flight-deck inspectors than smaller airlines.
While a small airline faces one inspection for every 1,000 flights on average, Air France receives only one visit in 4,000.
"In this context, the probability of discovering deviations, even those that are purely regulatory, is greatly reduced for an airline like Air France," the report said.