It could happen to anyone. This time it happened to be a French airplane with French pilots flying for a French airline.
For two years the “black boxes” (the voice recorder and the DFDR) lay in peace on the floor of the Atlantic Ocean, 13,000 feet below the waves. For two years there was conjecture, speculation, and (some quite fine) attempts at reconstruction. Then the black boxes surfaced, along with other hard evidence, including the jackscrew from the Trimmable Horizontal Stabilizer.
For months as the Bureau d’Enquêtes et d’Analyses slowly released information, we (and the BEA) put together the tragic and terrifying story. But the story stopped abruptly, the last chapter removed or never written.
Now a French aviation writer, Jean-Pierre Otelli, has published that last chapter independently of Air France, Airbus Industrie, and The BEA. The story ends as we knew it would – badly and sadly – but now we have more grisly detail and less room for denial.
The Bureau d’Enquêtes et d’Analyses is incensed. In a press release on October 13, 2011, (look under News in the sidebar) they claim that the transcription released by Otelli “mentions personal conversations between the crew members that have no bearing on the event, which shows a lack of respect for the memory of the late crew members” (my emphasis). The same day the London Telegraph published an account of the final minutes. The account seems to have been shortened since October 13, and I have been unable to find the original. Those who are interested may add the following after “According to an official report released earlier this year, the last words were from Captain Dubois who said: ‘Ten degrees pitch.‘”:
But in his new book Mr Otelli asks who will be held responsible ‘for this mess’. ‘Is it a training problem, fatigue, lack of sleep, or is it due to the fact the pilots are confident that an Airbus can make up for all errors?,’ he writes. France’s air accident investigation unit, the BEA, reacted angrily to the publication of the book, with a spokesman saying printing the conversation showed a ‘lack of respect to the memory of the crew who died’. Air France has denied that its pilots were incompetent, but has since improved training, concentrating on how to fly a plane manually when there is a stall. Both Air France and Airbus are facing manslaughter charges, with a judicial investigation led by Paris judges already under way. A judge has already ordered Air France to pay some £120,000 in compensation to the families of each victim, but this is just a provisional figure which is likely to multiply many times over. THE FINAL MOMENTS Marc Dubois (captain): ‘Get your wings horizontal.’ David Robert (pilot): ‘Level your wings. ‘Pierre-Cedric Bonin (pilot): ‘That’s what I’m trying to do… What the… how is it we are going down like this?’Robert: ‘See what you can do with the commands up there, the primaries and so on…Climb climb, climb, climb. ‘Bonin: ‘But I have been pulling back on the stick all the way for a while. ‘Dubois: ‘No,no, no, don’t climb. ‘Robert: ‘Ok give me control, give me control.’Dubois: ‘Watch out you are pulling up. ‘Robert: ‘Am I?’Bonin: ‘Well you should, we are at 4,000.’As they approach the water, the on-board computer is heard to announce: ‘Sink rate. Pull up, pull up, pull up. ‘To which Captain Dubois reacts with the words: ‘Go on: pull.’Bonin: ‘We’re pulling, pulling, pulling, pulling.’The crew never discuss the possibility that they are about to crash, instead concentrating on trying to right the plane throughout the final four minutes. Dubois: ‘Ten degrees pitch. ‘Robert: ‘Go back up!…Go back up!…Go back up!… Go back up! ‘Bonin: ‘But I’ve been going down at maximum level for a while.’Dubois: ‘No, No, No!… Don’t go up !… No, No! ‘Bonin: ‘Go down, then!’Robert: ‘Damn it! We’re going to crash. It can’t be true!’Bonin: ‘But what’s happening?!’The recording stops.
What we know, briefly, is this: Air France 447 ventured into a line of thunderstorms along the InterTropical Convergence Zone. Four other flights diverted around the storms. In the zone the flight encountered unusually warm temperatures and supercooled water droplets – enough to briefly overwhelm the heaters in all three pitot tubes, denying airspeed information to the Flight Control Computers for long enough to cause them to kick off the autopilot and to degrade the flight controls from Normal Law to Roll Direct/Pitch Alternate Law. Despite the fact that by the book they were too heavy to climb, the pilot flying (First Officer David Robert) zoomed up from 35,000 feet to almost 38,000 feet, dissipating the aircraft’s energy and exposing it to coffin corner, where Mach buffet meets stalling speed. With brief lapses he held back pressure on the sidestick for the remainder of the flight.
First the airplane stalled (quit flying because the Angle of Attack was too great). Then, because of the steady back pressure on the sidestick, the autotrim wound the Trimmable Horizontal Stabilizer (more powerful than the elevators) to full nose up. (The THS jackscrew was found in this full nose up condition). By now the aircraft was in a deep stall, falling almost straight down in a near-level attitude.
There is plenty of room for argument about why it happened this way. Many (including David Learmount at Flight Global and myself) have started that discussion. It must continue, because we must know not only why F/O Robert stalled the aircraft, but much more importantly why he didn’t know he had stalled it, why he had a totally inaccurate picture of what was happening, and why there was a complete absence of situational awareness on that Flight Deck.
It may look as if I am placing blame solely on F/O Robert. Absolutely not. That would be much too easy. I and others have already written many pages (see AF447 on my blog) trying to piece together all the factors at work in this accident. We will write many more.
As in all accidents, there is a chain of events and decisions which gradually (at first!) reduce maneuvering room. The first of these was Captain Dubois’ decision to take crew rest approaching the ITCZ.
But before that came Air France’s decision to carry less fuel than the spirit of the regulations requires, by filing the Flight Plan as Rio to Bordeaux, alternate Paris. Even earlier, the brilliant (I am not being ironic or facetious, I admire the man) Bernard Ziegler designed the Airbus to be “pilot-proof” and impossible to stall. However he (or his designers) also left the autotrim functional in Pitch Alternate Law, an oversight I believe should be corrected ASAP. Finally, (and earliest of all) you and I and everyone else who has traveled since Airline Deregulation in 1978 believes or wants to believe in cheap seats.
It could happen to anyone.
Sadly, it has all been foreseen. Recently I read an article which bluntly calls out the forces that led to this accident. It is called The Training Paradox, and was written by pilot, engineer, and lawyer Mark. H. Goodrich. Some of the accidents and incidents he describes stood my hair on end. Unfortunately I cannot provide a link to it. I read it in Position Report, November 2011, Volume VIII Number 3. (This is the magazine of the Retired Airline Pilots of Canada).
The very experienced and knowledgeable Mr. Goodrich shows how the forces of deregulation have derailed traditional career paths and interrupted the passing along of knowledge. As a result, the craft, the trade, the profession if you will of flying is dying a slow death. Neither are regulatory bodies or airline management immune from this decay.
This time it was the French. It is not surprising they are in denial. But it could happen to anyone, and it will.