BEA - Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile - Zone Sud - Bâtiment 153 - 200, rue de Paris - Aéroport du Bourget - 93352 Le Bourget Cedex - FRANCE - Téléphone 33 1 49 92 72 00 - Télécopie 33 1 49 92 72 03BEA - Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile - Zone Sud - Bâtiment 153 - 200, rue de Paris - Aéroport du Bourget - 93352 Le Bourget Cedex - FRANCE - Téléphone 33 1 49 92 72 00 - Télécopie 33 1 49 92 72 03

 

Flight AF 447 on 1st June 2009

A330-203, registered F-GZCP

 

BEA - Interim report n°3 – Presentation

INTRODUCTION

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.
A few words to start with to show you what we have arranged as far as communication is concerned. This presentation is being broadcast live on the Internet for the families who will be able to follow it all the way through. The interim report will be put on line in its French version at the end of the afternoon and in its English version next Tuesday. On this point, I would ask Internet users to be patient. There may be a lot of you logging on and our server will doubtless be put to use beyond its capacity. I would ask you in advance to excuse us if that is the case. This interim report was drafted thanks to the read-out of the recorders, which justifies the efforts made to find them. May I remind you that they were recovered at the beginning of may and read out only on 15 May at the BEA. In barely two and a half months the investigation team directed by Alain Bouillard, who has been working relentlessly, has been able to reconstruct the precise chain of circumstances leading to the accident, carry out a specific number of analyses and formulate new safety recommendations. Of course, there are still a lot of points to be cleared up in this accident. The investigation is far from being completed but we have made a lot of progress in understanding the events that led to the accident to the point of being able to issue several safety recommendations. On this subject, and speaking particularly to the families, I would like to say how much I deplore the use of terse and simplistic formulas by some media to define this accident.

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:
A first phase which goes from the beginning of the recording in the cockpit recorder until the the autopilot disconnects.
A second phase which begins at the disconnection of the autopilot and which stops at the triggering of the stall warning
And the third phase, which starts at the triggering of the stall warning and which stops at the end of the flight.
To put this work into context a little, I would point out that this flight was a flight from Rio to Paris, 228 persons had taken a seat on board and the flight crew was made up of three pilots: a Captain and two co-pilots given the length of the leg. The recording begins – phase 1 – the recording begins then while the flight is en route to NATAL. The flight proceeds without problems, the Captain is in the left seat as usual, he is the PNF. In the right seat, one of the two co-pilots is pilot flying. The third co-pilot has gone to rest in order to undertake the following duty session. The flight is performed at flight level 350, at a speed of Mach 0.82 which is the normal cruise speed for this aircraft. At about 1h55, on the approach to the ORARO point, the Captain wakes the second co-pilot for him to replace him. He attends the briefing between the two co-pilots, a briefing that makes a reference in particular to the slight turbulence and to slight weather problems that he could encounter on the flight. At that moment, the pilot leaves the cockpit and is replaced in his duty as PNF in the left seat by the second co-pilot, the first co-pilot remaining as pilot flying and ensuring the Captain's relief. On the approach to ORARO, the flight is still at level 350, at Mach 0.82 and the flight attitude is 2 degrees 5, a little later when calling the cabin crew the pilots mention turbulence that they might encounter some minutes later, and request the cabin crew to make the necessary arrangements for this part of the flight. A few moments later, slight turbulence is recorded and the aircraft enters the cloud layer. Some minutes later, at around 2h08, the PNF – the pilot in the left seat– suggests to the pilot flying to divert his route slightly to the left in response probably to some echoes that have been detected on the weather radar. He also reduces the airplane speed from Mach 0.82 to Mach 0.8, the speed adopted in turbulence. At this moment, in the background noise heard on the cockpit voice recorder, we notice a significant change in background noise, attributed in all likelihood to the presence of ice crystals. In the seconds that follow, the three Pitot probes are blocked by ice crystals and there is a loss of and inconsistency in the speeds displayed to the crew. This is what I call the end of phase 1.

 

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.
At that moment, the pilot flying who is on the right, states "I have the controls". The airplane makes a slight roll to the right, countered by the pilot who makes a nose-up input at the same time. The stall warning is triggered briefly twice and the recorded parameters at this moment, the left side speed parameters, show a sudden drop in speed which goes from 275 knots to 60 knots. Then a few moments later, it is the turn of the speed on the safety instrument, the ISIS, which falls from 275 to 60 knots. At 2h10.16 seconds, the pilot in the left seat, the pilot not flying, says "we have lost the speeds" then "alternate law". Under the nose-up inputs the flight attitude increases progressively beyond ten degrees and the airplane starts an ascending trajectory. The PF at this moment makes some nose-down inputs and alternately from left to right to counter the roll. The airplane climb speed which had reached more than 7,000 feet/minute goes down progressively to 700 feet/minute and the roll is still equivalent from left to right to around 10 degrees. At this moment, the speed displayed on the left side increases suddenly to 215 knots and becomes valid again. The Mach is 0.68; the invalidity of the left side speed on the left PFD lasted 29 seconds. The airplane is then at an altitude of 37,500 feet and the recorded angle of attack is around 4 degrees. At 2h10 minutes 50 seconds, the pilot in the left seat – the pilot not flying – tries several times to call back the Captain. This is the end of phase 2 which lasted less than one minute and this is the moment that the stall warning starts, is reactivated which is the beginning of phase 3.
At 2h 10 minutes 51 seconds, the stall warning is triggered again. At this time, probably by the pilot flying, the thrust control levers are placed on TO/GA, which is full thrust, and the PF – pilot flying – maintains his nose-up input. The recorded angle of attack at this moment, is of the order of six degrees at the triggering of the stall warning but continues to increase. In less than one minute after the warning trigger, the disconnection of the autopilot, the airplane exits its flight envelope. Neither of the two pilots refer to the stall warning, neither of the pilots has formally identified the stall situation. About fifteen seconds later, the speed displayed on the backup safety instrument, on the ISIS, increases suddenly, and becomes valid again.

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.
At 2h 13 minutes 32 seconds, the pilot flying says "we are going to arrive at level 100", some moments later, he will say at 2h13.36, the altitude of 9,000 feet, 9300 feet recorded, the flight attitude is then 12 degrees, the angle of attack still above 35 degrees and the vertical speed -12,000 feet/minute, which corresponds to about 4000 metres per minute, 240 km/h. The angle of attack, when it is valid, is always above 35 degrees. The recordings stop at 2h14 minutes 28 seconds, the last recorded values are a flight attitude of the order of 15 degrees and a vertical speed of nearly -11,000 feet/minute. There was no emergency message issued by the crew and as you know, the wreckage would be found at the beginning of April at a depth of 3,900 metres.
This is the flight path that was reconstructed from a little before arrival at the ORARO point and the figures that you see are on the slides which were shown throughout this presentation to help you follow this flight path throughout.
The main findings at this stage show that the crew complied with the operator's procedures: two co-pilots, commercial pilots, above level 200, which is according to regulations, in accordance with the operator's procedures. There was no explicit or implicit division of tasks, not clearly, this was not expressed clearly from the start by the Captain. There is no training in crew resource management for a crew made up of two co-pilots.

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:
Well, first of all as Alain has just said, it is a matter of strengthening crews' skills in manual handling of aircraft and particularly in manual handling at high altitude, including approach to stall and stall recovery. I would like to make clear that these recommendations are aimed at EASA and that they have a general impact. It is not only the Pitot probe failures that led to the autopilot disconnecting. Other failures may lead to this disconnection and the pilot is then in a situation requiring manual handling at high altitude for which he may not have been sufficiently trained.
The following recommendation relates to the relief Captain. When the Captain is absent from the cockpit, part of his duties are taken over by one of the co-pilots and we estimate that additional criteria should be defined allowing access to this duty in order to ensure a better distribution of tasks in the case of strengthened crews on long haul flights.
One recommendation concerns the aircraft certification and this is the problem of the angle of attack display. The angle of attack is not a piloting parameter but is important information to know what margins the airplane has in relation to stall. This angle of attack display is not directly presented to the pilot. He can find it somewhere in his computer but it's quite complicated and so we do not wish to recommend directly requiring it but we think that a study should be carried out to assess whether it is justified to integrate the presence of an angle of attack display which is directly accessible. We believe that in this particular case, in the case of this accident, if the pilots had had directly available an angle of attack display, they would probably have been in a better position to understand the situation.
Concerning flight recorders, the recommendations that are addressed are useful for investigators. Today we record parameters, the airplane's technical parameters, flight parameters and sound parameters. So there are two recorders, there is no recording of images; whereas, it is felt that in this accident, as Alain has just said, and as our pursuit of the investigation will show further, if we had a precise vision of what the pilots saw at any moment on the instrument panel, well then this accident would be a lot easier to understand and this is not the only case. We have encountered many examples where this information is lacking. This is a recommendation which has been made several times by the BEA and by other authorities. Unfortunately it has never come to anything, perhaps because it was a little too– I was going to say – a little too ambitious. We wish simply to limit this image recording to a view of the instrument panel, which comes back to parameter recording. Earlier, we brought up the question of the route diversion probably as a result of echoes on the radar seen by the pilots well there is no recording of what the pilots saw on their radar and that, that would be very useful to us, that would be very useful to us today.
But of course, it is felt that we are approaching a somewhat delicate subject, for pilots in particular and so we believe that this recommendation should be accompanied by another recommendation which would define strict rules on the presentation of these recordings, well, in order to guarantee that they are only used for safety purposes, in particular in the case of an investigation. So this recommendation sorry this last recommendation is for ICAO which is the organisation where this can be discussed.

 

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.
Lastly, one other recommendation aims to study whether it is justified to require the recording of other specific parameters such as inertial parameters for example, speed parameters, here we think a further study should be conducted.
Well the last recommendations have been drawn up within a working group that has been directed by BEA since the accident and which groups together different authorities and manufacturers. The problems of course are linked to the difficulties we have had locating the airplane wreckage. At the time, the Air France A330 broadcast its position every ten minutes by satellite, and the last position of the airplane was known 5 minutes before the accident, which obviously gave us a great circle of uncertainty. It is a matter therefore of reducing as much as possible this localisation difficulty by reducing the size of the circle, increasing possibly the frequency of transmissions or by triggering transmission at specific moments. So this working group determined that it was possible to choose a certain number of parameters which were indicators of an emergency situation. An emergency situation that means that an accident is very probable and so at that moment, information would be automatically triggered, via the ACARS system for example, which would give the position of the airplane. In this way we could envisage finding the wreckage in a relatively limited circle. Today we know that the technical resources available enable us—with a good chance, to recover the wreckage, to recover the recorders. We have demonstrated this since at a depth of 4000 metres we were able to find the recorders after only a few days' search. It is certainly a little ambitious to imagine that we are going to be able to transmit flight parameters continuously especially if there are several thousand but by using the current technique of the recorders, being able to locate the wreckage much more easily would be a considerable advantage.
A similar recommendation concerns the emergency locator beacon, the emergency locator beacon is an instrument for localising which is not very reliable that is it is often destroyed on impact and so it would be logical to activate it some moments before a possible accident.
Well, all these recommendations are quite far advanced. The working group has worked well and we think that this is the time to recommend them.
So I would like to finish here, with the continuation of the investigation.
So the pursuit of the investigation under Alain Bouillard is continuing. I think the presentation which was made showed that many things are still to be understood in this accident. Perhaps the most difficult will be to understand what the pilots' actions were, so, there that requires the implementation of a human factors working group which will call on skills also outside the BEA.

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.
Examination of the aircraft parts is ongoing. You know that parts were unloaded at Bayonne a while ago, that they are currently in the General Armament Directorate's hangars in Toulouse. They are available to us and, in particular the computers could provide further information on the flight parameters. Well, it turns out that we have brought up more parts than necessary in reality. Since we began raising the parts, we were not sure of being able to read out the recorders. The read-out of the recorders has given us enough information to choose the parts that are going to be examined. There are two themes which are, which we could describe as doubtless the most systemic. That is to say that, we think it is necessary to examine the way in which flight safety is organised at Air France and the way in which the monitoring actions of the oversight authority are conducted.
Still on the technical side, it is also necessary to continue the analysis of the working of the aircraft systems. In particular earlier on the problem of the stall warning was brought up which disappears in certain circumstances while the airplane is actually stalled. That could have corresponded, could have troubled the crew in their understanding of the event. This is one of the subjects which is going to be examined as well as others which are linked to the airplane handling.
The last two themes are themes which have already been relatively well developed, which are not, which have not called the accident into question, which did not cause the accident but as far as the search and rescue operations are concerned, we know that it took more than six hours to determine the loss of the airplane and so the rescue operations started very late and that  doubtless contributed to the difficulties in locating the wreckage so this coordination brings into play the control services, it may also bring into play the airline's services and, I think that there is reason to look into how this coordination is ensured, what are each person's functions.
And then, finally there is the problem of air traffic control in ocean zones not covered by radars that is to say that there are problems with transmission, radio transmission, there are also positioning problems, problems of airplane localisation by air traffic control centres and it appeared that in the circumstances of this accident, this did not work very well.
There you are, ladies and gentlemen, thank you for your attention. Now we can move on to questions.

– start of questions

 

 

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