Flight AF 447 on 1st June 2009
BEA - Interim report n°3 – Presentation
Jean-Paul Troadec –Well, ladies and gentlemen, hello and welcome to the BEA for this presentation of the third interim report of the safety investigation into the Airbus A 330 accident carrying out flight AF 447 Rio – Paris on 1st June 2009.
PRESENTATION OF THE INTERIM REPORT
Jean-Paul Troadec – The level of safety in civil aviation today is very high. And an accident is always the result of a chain of very improbable events that we cannot summarise with a sensational formula. I think you will understand this better after what we are going to present to you now, after which we will answer your questions. Alain, I'll hand over to you.
Alain Bouillard – Thank you, Director. Ladies and gentlemen, today I am going to present the works that are recorded in the interim report number 3. This interim report, as the director said, is the result of read-out work from the flight recorders, and divide this report …. The flight has been divided into 3 phases for this report:
Alain Bouillard – Phase 2 begins at the disconnection of the autopilot, which occurs at 2h10.05. The autopilot and auto-thrust disengage, the auto-thrust being the automatic management of the engines, the flight directors disappear and the flight laws change from normal – I would point out that in normal, the airplane is protected against stalling by angle of attack protections in particular, it changes from normal law to alternate law. Alternate law keeping simply a protection in load factor but not protecting; the protection from stalling being the stall warning.
Alain Bouillard – The invalidity of this speed will have lasted 54 seconds. It is then consistent with the other recorded speed, the one on the left side but the pilot flying – the pilot in the right seat – continues to make nose-up inputs. The altitude then reaches its maximum of around 38,000 feet, the flight attitude and angle of attack of the airplane are around 16 degrees. At 2h11.42, the Captain enters the cockpit, and in the seconds that follow all the speeds recorded become invalid and the stall warning stops. This invalidity is due to the airplane's very steep angle of attack which has the effect of making the recorded speed values considered invalid. This stall warning was continuous before its 54-second stop. The Captain's absence from the cockpit will have lasted around 10 minutes, since his departure about 1 minute 30 after the autopilot disconnected. The altitude is then 35,000 feet, the angle of attack exceeds 40 degrees and the airplane vertical speed– from the beginning of the descent to this moment– is around minus 11,000 feet /minute. The flight attitude of the airplane does not exceed 15 degrees and the engines are still at full thrust. The airplane undergoes several oscillations in roll reaching 40 degrees at times, the pilot flying makes an input on the side stick to the stop position on the left and nose-up which lasts 30 seconds. At 2h12minutes 02 seconds, the pilot in the right seat says "I don't have any displays" and the pilot in the left seat replies "we have no valid displays." At this instant, the thrust control levers are brought back to IDLE, the engines' N1's are at 55%. A few seconds later, the pilot flying makes nose-down inputs, which has the effect of reducing the aircraft flight attitude, of reducing the angles of attack, the speeds then become valid again and the stall warning is reactivated.
Alain Bouillard – No call was made for the unreliable airspeed procedure - unreliable IAS - which requires checking that the autopilot is OFF, that the auto-thrust is OFF, that the flight directors have been shut down, and that the pitch attitude for this procedure is 5 degrees and that engine thrust is on CLIMB. Nor was there any standard call out of the pitch attitude and vertical speed discrepancies. Neither of the co-pilots had undertaken any training in manual handling of the airplane on approach to stall or on stall recovery at high altitude. That is why I have proposed two safety recommendations: a safety recommendation that deals with the relief Captain and a safety recommendation that deals with pilot training for manual handling of airplanes. To try to understand the pilots' actions I have decided to set up a human factors group that will study the behaviour and the actions of the pilot, containing specialists in ergonomics, cognitive sciences -- psychologists, and doctors specialised in aviation. We are continuing to examine the pilots' seats to try to understand if the adjustment could have influenced their inputs on the sidesticks. We are also continuing to work on the flight computers to try to recover some parameters that are lacking today in the regulatory flight recorder – the FDR—in particular the speed values that were displayed on the right side.
We have also established that the angle of attack, which is a parameter that enables the stall warning to trigger, is not directly displayed to the pilot. I have also proposed a safety recommendation on this subject which will be presented to you a little later. I now hand over to the Director who is going to present the safety recommendations that have been issued with this interim report.
Jean-Paul Troadec - Thank you. First of all, a word or two about what it means to issue a recommendation. A recommendation is not a pious wish from the BEA. A recommendation is something that we make, of course, when we think that it is useful for safety but also that has a reasonable chance of being implemented. Because when we make a recommendation to an authority in general, it must answer us within three months and provide us with the follow up that it intends to give to this recommendation. So, this is something that commits us that also now commits the authority since the implementation of the new European regulation on accident investigations. We can make comments on the authority's response. So we see that a recommendation that is not followed up by an authority must be justified. At this stage we have thus been able to issue ten recommendations These recommendations of course complete those that have already been issued by the BEA in its previous reports. I remind you that there was a recommendation on the certification of Pitot probes which is currently the subject of a draft regulation from EASA. And there were also some recommendations on flight recorders. These recommendations originate from the investigative work. Of course, they will doubtless not be the last that we will make.
Thus three recommendations relating to operations, one on certification, all come directly from the investigation over the past few weeks, along with the recommendations on flight recorders.
It is the investigative work which has highlighted the fact that some parameters are missing to better understand this event and finally in the context of a work group which had been set up by the BEA following the accident on the localisation problems of aircraft which crash at sea, this work has continued and culminated in two recommendations on the transmission of flight date that the BEA is including in this report.
25 minutes 31 seconds – SAFETY RECOMMENDATIONS
So the recommendations concerning operations:
Jean-Paul Troadec - So about flight parameters, there are already a lot of flight parameters which are recorded. On the A330, there are 1000 flight parameters, but not all have the same importance of course. Unfortunately, some parameters which would be useful to us in this investigation are not recorded. For example, the precise knowledge today, via the flight recorders, of the parameters displayed on the right are not available so we believe that the recording of additional parameters should be made mandatory of course this would have to be discussed in detail. It is not just in this accident that this question is asked and therefore it is a subject which should be examined at EASA and the FAA level since of course this involves all aircraft whether of American construction, or French or European construction.
Jean-Paul Troadec - We have some skills in this field but we will call, as Alain said, on ergonomics specialists etc. to try to understand, to understand what were and to analyse what the crew's actions were.
– start of questions
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Accident to the Airbus A320 registered C-FTJP, flight AC624, on 29 March 2015, Halifax Airport (Canada). Information on 30 March 2015
Accident in Argentina, between two Airbus Helicopters AS 350's on Monday 9 March 2015. Information on 10 March 2015
ATR 72-600 registered B-22816, accident on 4 February 2015 in Taipei (Taiwan). Information on 4 February 2015
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Boeing 777-200 - Flight MH 370 - Malaysia Airlines. Information on 24 March 2014.
Accident on 4 March 2013 to the Hawker Beechcraft Premier 1A model 390, registered VP-CAZ, near Annemasse aerodrome (74). Information on 6 March 2014.
Accident to a Socata TBM 700, registered N115KC, at Mouffy (89) on 19 November 2013. Information on 20 November 2013.
Fokker 27, registered I-MLVT and operated by Miniliner, 25 October 2013, Paris Charles de Gaulle Airport, France. Information on 8 November 2013.
Accident to the accident to the ATR 72-600 in the vicinity of Pakse airport (Champasak province), Flight QV 301. Information on 21 October 2013.
Aeroplane State Awareness during Go-Around. Publication on 16 August 2013.
Accident to the A300-600, registered N155UP, Flight UP1354, Birmingham USA Alabama, 14 August 2013. Information on 14 August 2013.
Accident to the TBM 850, registered N850GC, Vertaizon (63), 8 August 2013. Information on 11 August 2013.
Accident to the Gulfstream G IV registered N823GA on 13 July 2012 in Le Castellet Airport (83). Information on 18 July 2013.
Accident on July 28 2013 to the Boeing 777-300 registered F-GSQA at Paris Charles-de-Gaulle Airport (France).
Accident on August 15 2011 to the Bombardier CRJ700 Canadair Regional Jet Series 700 registered F-GRZH at Lyon Saint Exupéry Airport (France).
Accident on June 11 2014 to the Piper J3C registered N61903 at Rolleville (France).
Accident on 24 March 2015 at Prads-Haute-Bléone (Alpes-de-Haute-Provence, France) to the Airbus A320-211 registered D-AIPX operated by Germanwings
Incident to the Airbus A320 registered TS-IMC and operated by tunisair, on 12 March 2013 at Paris Orly Airport (France). Report published in English on 24 September 2014
Accident to the McDonnell Douglas MD-83, registered EC-LTV, on 24 July 2014 in the region of Gossi (Mali). Interim Report published in English on 20 September 2014
Accident on 31 July 2013 to the Cirrus SR-20 registered F-HCPT in Poncins (France), final report published in English on 24 July 2014
Serious incident on 27 February 2012 to the Airbus A330-200 registered F-GZCG and operated by Air France in cruise at FL360 over Tanzania, final report published in English on 24 July 2014
Accident on 25 April 2010 to the Beechcraft 200 registered F-OIAN and operated by Air Alizé at Nadi (Fiji), final report published in English on 24 July 2014
serious incident on 10 May 2012 on Paris le Bourget airport (France) to the Beechcraft 200 King Air registered EC-KNP and operated by Air Taxi and Charter International, final report published in English on 1st July 2014
Accident on 19 August 2012 in Feings (France) to the Cameron Balloons Z-750 registered F-HDJH operated by Air Magic, SARL Flying Circus, published in English on 27 June 2014
Accident on 16 July 2013 in Authon-la-Plaine (France) to Lindstrand 180 A balloon registered F-GSAE operated by Aerfun Montgolfières, published in English on 27 June 2014
Serious incident on 29 June 2010 near Basel-Mulhouse airport (France) between the Airbus A319 registered HB-JZQ operated by easyJet Switzerland and the Airbus A319 registered F-GRHA operated by Air France, published in English on 12 May 2014
Accident on 4 March 2013 just after takeoff from Annemasse (France) to the Beechcraft Premier 1A registered VP-CAZ, published in English on 2 May 2014
Study, events Associated with an engine malfunction, Thielert TAE 125 engines, published in English on 17 April 2014
Accident on 16 October 2012 to the Bombardier CRJ-700 registered F-GRZE and operated by Brit Air at Lorient Lann Bihoué Aerodrome (France), published in English on 18 March 2014
Serious Incident on 16 November 2011 to the Boeing 777-200 registered F-GSPP at Paris Charles de Gaulle Airport (95)
Accident on 24 March 2012 on approach to Tunis Carthage Airport (Tunisia) to the Airbus A319 registered F-GRHU and operated by Air France, published in English on 20 december 2013.
Serious incident on 3 April 2012 on approach to Tel Aviv Ben Gurion Airport (Israel) to the Airbus A320-214 registered F-HEPE and operated by Air France, published in English on 20 december 2013.
Serious incident on 14 september 2010 in Wuxi (China) to the Airbus A319 registered B-6054 and operated by Sichuan Airlines. Civil Aviation Administration of China final report, published on 29 november 2013.
Serious incident on 13 March 2012 to the Airbus A340-300 registered F-GLZU and operated by Air France, on approach to Paris Charles de Gaulle Airport (France) Report published in English on 12 September 2013.
Incident on 25 June 2011 to the ATR 72 registered F-OIQU and operated by Air Tahiti, on initial climb, after take-off from Papeete airport (French Polynesia). Report published in English on 23 July 2013.
Accident on 10 June 2008 to the Airbus 310 registered ST-ATN, Flight Sudan Airways 109 at Khartoum Airport, Sudan. Sudanese Air Accident Investigation Central Directorate report.
Serious incident on 16 January 2010 to aircraft EP-IBB at Stockholm/Arlanda Airport, Stockholm county, Sweden. Statens haverikommission, Swedish Accident Investigation Authority report.
Incident on 17 June 2012 to the BAe146 registered EI-RJW at Basel-Mulhouse-Freiburg Airport (France). Final Report published in English on 25 October 2012.
Incident on 18 November 2011 to the ATR 72-212A registered F-OIQO at Moorea aerodrome (French Polynesia). Final Report published in English on 18 October 2012.
Accident on 17 june 2011 to the Piper PA-39 "Twin Comanche" registered G-AYZE at Peille (France). Final Report published in English on 15 October 2012.
Accident on 28 October 2010 off Adélie Land (Antarctica) to the AS 350 B3 Squirrel registered F-GJFJ operated by SAF HELICOPTERES. Final Report published in English on 24 September 2012.
Serious incident on 15 April 2010 south-east of Brive-la-Roche (19) to the Hawker Beechcraft Corporation Beech B200GT registered F-HSFA operated by SEFA. Final Report published in English on 20 August 2012.
Accident on July 12, 2010 to the Bombardier CRJ700 registered F-GRZN at Bilbao Airport (Spain). Final Report published in English on 25 July 2012.
Accident on 4 April 2011 to the Robin DR400-120 registered F-GABB at Le Touquet Paris-Plage aerodrome (62). Final Report published in English on 24 July 2012.
Accident on 25 July 2010 to the Schweizer 269 C helicopter registered F-GJGQ at Coullons (45). Final Report published in English on 24 July 2012.
Accident on 24 May 2012 to the aircraf Embraer ERJ 145 MP registered F-GUBF at Ljubljana aerodrome (Slovenia), runway 31. Final Report published in English on 24 July 2012.
Serious incident on 17 January 2011 to the Boeing 777 registered F-GSPM in cruise, over the Atlantic ocean. Final Report published in English on 16 July 2012.
Serious incident on 16 August 2008 on take-off from Paris Charles de Gaulle Airport (95) to the Boeing 737-800 registered SU-BPZ operated by AMC Airlines. Final Report published in English on 29 August 2011.
Accident on 1st June 2009 between Rio and Paris to the Airbus A330-203 registered F-GZCP, flight AF 447. Final Report, published on 5 July 2012.