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AF 447 - Flight Crashed
 

AF 447 - Flight Crashed

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Air France Flight 447 (abbreviated AF447) was a scheduled commercial flight from Galeão International Airport in Rio de Janeiro, Brazil to Charles de Gaulle International Airport in Paris, France. On ...

Air France Flight 447 (abbreviated AF447) was a scheduled commercial flight from Galeão International Airport in Rio de Janeiro, Brazil to Charles de Gaulle International Airport in Paris, France. On 1 June 2009, the Airbus A330-200 airliner serving the flight crashed into the Atlantic Ocean, killing all 216 passengers and 12 aircrew.

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    AF 447 - Flight Crashed AF 447 - Flight Crashed Document Transcript

    • Flight AF 447 31. May 2009 Jürg SchmidThe Aircraft A330-200, entered service in 1998 1
    • Technology Fly-by-wire technology Glass cockpit Flight planning CommunicationCrew and Passengers 3 flight crew, 9 cabin crew, 216 passengers Part enlargement Pilot flying, pilot non flying 2
    • The flight Take off at 2229, weight 232.8t (MTOW 233t) At 01h 35min 15sec last communication, with ATLANTICO controllerThe weather 3
    • History of the accident 1 Cruise at FL 350, Mach 0.82, pitch 2.5° ANU, autopilot 2 and auto-thrust engaged At 2 h 08 min 04, left turn by 12°, speed reduced to Mach 0.80 At 2 h 10 min 05, autopilot and auto-thrust disengaged, PF “I have the controls” Hard nose up input, stall warning sounded twice, left PFD and ISIS speed 60 kts At 2 h 10 min 16, PNF “we’ve lost the speeds then”, “alternate law protections” Vertical speed reached 7000 ft/min”, dropped to 700 ft/minHistory of the accident 2 At 2 h 10 min 50, PNF tried several times to call Captain back At 2 h 10 min 51, stall warning triggered again and was on for 54 sec Thrust lever TO/GA, PF maintained nose-up inputs, AOA 6° increasing Trimmable horizontal stabilizer from 3° to 13° in 1 min, and stayed At 2 h 11 min 06, speed on ISIS 185 kts, PF continued with nose up inputs Altitude 38’000 ft, pitch and AOA 16° 4
    • History of the accident 3 At 2 h 11 min 45 Captain re-entered the cockpit In the following sec all speeds became invalid and the stall warning stopped Altitude then about 35’000 ft, AOA exceeded 40°, ROD about 10’000 ft/min At 2 h 12 min 02 , PF “I have no more displays”, PNF “we have no valid indications” Thrust IDLE detent, pitch down inputs, AOA decreased, speed again valid, stall warning At 2 h 14 min 28, PF said: “we are going to arrive at level one hundred”History of the accident 4 At 2 h 14 min 28 the recording stopped. Last values Vertical speed -10’912 ft/min Ground speed 107 kts Pitch attitude 16.2 ° ANU Roll 5.3° left Heading 270° 5
    • Final Report by BEA Chapter Conclusion, 51 Findings listed Several airplanes in same region altered routes to avoid clouds The copilots have not undertaken any in-flight training at high altitude Neither of the pilots made any reference to stall warning or buffet. In less than 1 min after AP disconnect its flight envelope, inappropriate pilot inputCause Map – Page 1 AND Why? Possible Solutions: OR Effect Cause Cause Start with the Goals (in red) that have been impacted. Evidence: Read the map to the right by asking Why questions.Step 2. Cause Map - Page 1 Flight control Loss of speed Pitot probes automation not indications clogged with operable (CAS) ice Safety Goal 228 poeple Impacted killed Evidence: Evidence: FDR records FDR records Airplane broke Plane unable Plane nose-up apart by impact to maintain and stall with water altitude AND Property Goal Airplane destroyed Impacted Crew failed to control flight manually Customer Goal Evidence: Impacted FDR records Eroded confidence in safety of AF Production Goal Impacted 6
    • Cause Map – Page 2 1 Pitot probes used vulnerable Step 2. Cause Map - Page 2 to icing Evidence: 17 cases of icing Loss of speed Pitot probes AND with Thales AA indications clogged with in 2003 - 2008 (CAS) ice Meteorological Crew decided to Evidence: keep the FDR records conditions/ thunderstorm planned route AND Evidence: Conflicting FDR records indications and alarms Evidence: Crew not aware FDR records that the plane at AND stall Crew consider stall warningsCrew failed to unreliable ? control flight OR manually Evidence: AND FDR records 2 Angle of attack Crew failed to not displayed restore aircraft from stall Evidence: AB designCause Map – Page 3 Step 2. Cause Map - Page 3 Absence of the Rest breaks Captain when routine in long problem starts flights Hard- / Soft-ware Co-pilots Evidence: problems that AND FDR records overloaded and disabled manual confused control ? 3 4 Evidence: No Task-sharing Crew failed to evidence thus AND not defined by restore aircraft far to indicate that the captain from stall Lack of Evidence: OR coordination in FDR records the cockpit AND Crew 4 performance Co-pilots did not problems brief the Captain AND on his return Evidence: 6 AND FDR records Co-pilots not trained for stall 5 at high altitude Left and right Evidence: controls not Training records linked Evidence: AB design 7
    • Cause Map – Page 4Step 2. Cause Map - Page 4 Crew failed to restore aircraftCustomer Goal from stall Impacted Eroded AND confidence in safety of AF Production Co-pilots not Goal trained for stall Impacted recovery 1 Evidence: Use of Pitots Training records vulnerable to icing AND 7 AF reluctant to Avoiding replace the unjustified Feedback from Pitot probes ? costs ? incidents not AND adequate AND / OR Evidence: 17 cases of icing with Thales AA in Replacement of Research by 2003 - 2008 the Pitot probes Airbus took too postponed long time Evidence: existing Evidence: existing Correspondence/ Correspondence/d documents ocuments “A crew can be faced with an unexpected situation leading to a momentary but profound loss of comprehension. If, in this case, the supposed capacity for initial mastery and then diagnosis is lost, the safety model is then in ‘common failure mode’.” 8
    • Safety Recommendations “Shall in no case create a presumption of blame or liability” (EU 996/2010) Flight recorders, image recorder, FD recorder. Certification of pitot tubes Training for manual airplane handling Additional criteria for access to the role of relief Captain Presence of an angle of attack indicatorReactions Operators Manufacturers Regulators Aviation industry actions 9
    • Underlying problems Basic experience versus highly automated aircraft Market competition Rising technical complexity versus individual know how Aviation – Nuclear – Offshore Thank you for your attention 10