Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

How Did A Flyable Plane Crash in Just Over Four Minutes?

142 views

Published on

How does a flyable plane go from 30,000 feet to crash into the ocean in just over 4 minutes? Do not read this if you're getting ready to take a flight. A cascade of events, of which human error played a big role. The key is to learn from such an event so the lives lost were not in vain.

Published in: Education
  • Be the first to comment

  • Be the first to like this

How Did A Flyable Plane Crash in Just Over Four Minutes?

  1. 1. Why Did Air France 447, a Flyable Plane, Crash?
  2. 2. Last warning from the flight computer: “Pull up.” Co-pilot yells: “We’re going to crash. I don’t believe it. But what’s happening?” Seconds later one of the co-pilots exclaims: “F@ck! We’re dead.” Air France 447 Human-Machine Interface Failure
  3. 3. The Rule of Seven: Every catastrophe has 7 events. Six Cascade Events leading to the final event, the catastrophe. At least one of the Cascade Events involves human error. Thus most catastrophes can be avoided. Anatomy of Catastrophe
  4. 4. On 1 June 2009, an Airbus A330 owned by Air France entered a high altitude stall and four minutes and twenty-three seconds later crashed into the ocean. All 228 passengers and crew on board were killed. As with any plane crash, the Rule of Seven applies, with a mechanical failure initiating a catastrophic series of events. THE FACTS
  5. 5. 31 May 2009; 10:29 GMT: Air France Flight 447 takes off from Rio de Janeiro en route to Paris. 1 June 2009: The plane is approaching a line of storms along the equator. 02:01:46 am: After briefing the co-pilots, the Captain leaves the cockpit. THE TIMELINE
  6. 6. 02:10:05 am: Pitot tubes freeze, causing the air speed indicator to provide faulty readings; causing autopilot to disengage, transitioning control of the aircraft from ‘normal law’ (computer control) to ‘alternate law’ (pilot control). Auto-thrust disengages three seconds later. Co-pilot over-corrects, putting aircraft dangerously nose-up. THE TIMELINE
  7. 7. 02:10:11 am: First stall warning. Nose still up. 02:10:22 am: Plane reaches apex, stalls, starts to drop, eventually reaching a downward speed of 10,000 feet per minute. THE TIMELINE
  8. 8. 02:11:43 am: Captain re-enters the cabin: “What the fuck are you doing?” No one seems to understand the plane is in a stall. 02:12:30 am: One Co-pilot asks: “Am I going down now?” 02:13:23 am: Both Co-pilots are trying to control the aircraft from their seats, giving dual inputs that are contradictory. THE TIMELINE
  9. 9. 02:14:14 am: Last warning from the computer: “Pull up.” Co-pilot yells: “We’re going to crash. I don’t believe it. But what’s happening?” Seconds later one of the co-pilots exclaims “F@ck. We’re dead.” 02:14:28 am: Air France 447 hits the water with a downward speed of 11,000 feet per minute (125 miles per hour). THE TIMELINE
  10. 10. ELAPSED TIME FROM FIRST INDICATION OF TROUBLE: 4 MINUTES 23 SECONDS THE TIMELINE
  11. 11. A tired pilot and inexperienced co-pilots. The Captain and co-pilots, arrived in Rio de Janeiro 3 days before the flight. The Captain reportedly spent his time with an off-duty flight attendant and had only 1 hour of sleep the night before the flight. One co-pilot had his wife with him for the trip. The other co-pilot was doing the flight to maintain his flight proficiency since he had matriculated to an executive position at Air France. Fatigue most likely did play a factor, especially since the Captain was supposedly asleep when the initial problem occurred and was slow to respond to calls from the cockpit for help. The off-duty attendant was also on board the fatal flight. Cascade 1
  12. 12. Lesson: Physical condition is often a factor in catastrophes; and personal issues can also impinge.
  13. 13. Flight planning designed to save fuel, not anticipate problems, might have kept them from diverting around the storms. The Intertropical Convergence Zone lay directly in their path. The storm topped out too high for the plane to climb over, but there were gaps that could be negotiated if one deviated from the straight-line course. Flight 447 flew directly into the system. Why? Cascade 2
  14. 14. By standards, with a destination of Paris, the flight’s fuel supply did not have a sufficient safety margin. But the pilot didn’t enter Paris as the destination for the fuel requirement; he entered Bordeaux. Rio to Paris: 9,163 kilometers; 5,963 miles. Rio to Bordeaux: 8,679 kilometers; 5,392 miles. The safety margin was satisfied if the plane was going to land at Bordeaux. Any diversion around the storm would have burned fuel the plane needed to make it to its actual destination, Paris. Cascade 2
  15. 15. LESSON: Circumventing rules by finding loopholes can cause disaster.
  16. 16. The air speed indicator pitot tubes froze up. Mechanical failure often has a history. Actually, multiple histories: rarely do they occur unannounced and rarely is the fatal failure the first time the mechanical failure occurred. The specifications and licensing for pitot tubes for airspeed indicators dates back to 1947. Before jet planes were used. Cascade 3
  17. 17. The air speed indicator pitot tubes froze up. A failure of airspeed indicators was fraught with danger, especially with the increasing reliance on the autopilot. In 1998, a Lufthansa plane lost its airspeed indicator while over Frankfurt Airport. Fortunately, the pitot tube de-iced when the plane descended and it was able to land safely. Even the manufacturer of the tubes realized that a failure of their product could cause a crash. They formed a task force, a red flag of danger, to look into the problem four years before Air France Flight 447. Airbus also knew the pitot tubes were a problem, with a history of 9 incidents in 6 months in 2008. A year before Air France Flight 447. Cascade 3
  18. 18. LESSON: Delays in dealing with potential mechanical problems that have been noted can easily be a key cascade event leading to a catastrophe. Often, the cause of the delay is cost cutting or the reluctance to spend additional funds. The backwards looking funding for safety is ultimately more expensive than prevention and spending.
  19. 19. One co-pilot reacted inappropriately. At 2:10:05 am, on 1 June 2009, the pitot tubes on Air France 447 froze up. This caused the air speed indicator to fail. This caused the autopilot to disengage. The auto thrust disengaged at 2:10:08. At this point, the plane was still flying level, at a steady speed and altitude. If the pilots did nothing, nothing would have changed. The co-pilots did something. Cascade 4
  20. 20. One co-pilot reacted inappropriately. The flight controls on an Airbus are unlike those in the movies with the traditional yoke. Instead, a computer keyboard could be pulled out in front. To the right side for each pilot, was a control stick, much like that for a video game. Cascade 4
  21. 21. The co-pilot nominally in charge, reacted. The flight recorder showed he was putting too much input into the stick, most likely from gripping it too hard. He also did something that was dangerous: he pulled back. It was the wrong response. Six seconds later, with the stick pulled back 3/4th of the way, the plane entered an unsustainable climb. The co-pilot kept pulling back. Cascade 4
  22. 22. “STALL.” A mechanical male voice intoned that word once in the cockpit six seconds after the co-pilot took control. The machine was trying to tell the human he was making a mistake. The problem was easily solvable, but they had a new problem. The nose of the aircraft was 12 degrees up. An unsustainable climb. 02:10:22 am: Plane reaches apex, plane stalls, starts to drop, eventually reaching a downward speed of 10,000 feet per minute. Cascade 4
  23. 23. LESSON: As we become more reliant on machines, we lose some of our skills to react and control situations when the machines fail. For planes, the line between normal operation and disaster is a thin one given the machines involved. As the systems get increasingly complex, the possibility of errors increases exponentially. The machine can try, but not completely compensate for human error.
  24. 24. Leadership confusion in the cockpit, compounded by control design. When the captain left the cockpit, he did not specifically designate which of the two co-pilots was in charge. There are two sticks in the cockpit and each can over-rule the other in the Airbus model. Cascade 5
  25. 25. One minute and seventeen seconds after the pitots froze, the captain had still not appeared. The plane reached apogee at 38,000 feet. With nose up at 23 degrees and essentially stalled out, the plane begins to drop, quickly reaching a descent of 4,000 feet per minute. A co-pilot told the Captain when he arrived in the cockpit: “We completely lost control of the airplane, and we don’t understand anything.” Cascade 5
  26. 26. Lesson: Teamwork is more important than individual skills, especially in a complex scenario such as an airplane cockpit. And in any situation, a leader must always be clearly designated.
  27. 27. The humans and the machine were at odds. Every time they lowered the nose, stall alarms went back on—but the plane was already stalled. The Captain entered the cockpit one minute and thirty-eight seconds after the problem began, an incredibly long time in a dangerous situation. Cascade 6
  28. 28. The humans and the machine were at odds. Finally the stall alarm went off. But not because the situation had been fixed. It was because the situation was so bad it went beyond the parameters of the computer, which rejected the flight data is was receiving as invalid. In other words, Air France Flight 447 was in such bad shape, the computer had not been programmed for this situation. Cascade 6
  29. 29. At this point they were dropping through thirteen thousand feet. This altitude was their last chance to save the plane and themselves. It would have required a pilot to go against instincts, ignore the stall warning, and put the nose down thirty degrees. Then dive to regain an angle of attack that gave the wings lift. It would have taken almost all their altitude, brought them down to just above the wave tops, but it was possible. It did not happen. Cascade 6
  30. 30. LESSON: The same human and machine problems that get one into a deadly situation often prevent one from getting out of it.
  31. 31. Plane impacts with water. Four minutes and twenty seconds is all it took from first problem to death. The forward airspeed at impact was only 107 knots even though the engines were at full thrust. The downward speed was 11,000 feet per minute. Everyone was instantly killed on impact. Final Event
  32. 32. LESSON: Most of us think we’re better than we really are and unless we are truly in a life- threatening situation, we don’t know how we will really react. The problem with the machine-human interface is that almost all the time the machine is right, but when it fails, humans have to do things they might not be prepared for. Final Event
  33. 33. LESSON: Given that drones are conducting so many military missions now, and autopilots do the vast majority of piloting on civilian airplanes, it is almost inevitable that the day will come when there will be no pilots in the cockpit and machines will do all the flying. In the same way, we are seeing the dawn of where cars will drive themselves and we will simply be passengers. But we have to ask ourselves: Do we trust machines more than we trust ourselves? Final Event
  34. 34. Seven Ways to Prevent Catastrophes 1. Have a Special Ops preparation mindset 2. Focus by utilizing both big picture & detail thinkers 3. Conduct Special Forces Area Studies 4. Use the Special Forces CARVER formula 5. Have a “10th man” 6. Conduct After Action Reviews 7. Write and USE Standing Operating Procedures (SOPs)
  35. 35. Are you interested in a presentation about various catastrophes and how the cascade events could have been prevented? Events covered range from human-machine interface, to leadership, to communication, cost-cutting, engineering, group think, perseverance, systematic failure, and more? Catastrophes are cascade events culminating in disastrous chaos. War is chaos. Special Forces is the most elite unit trained for a variety of combat situations. What makes Special Forces elite is our mindset and preparation. Are you interested in a presentation on how to use Special Forces tactics, techniques and mental attitude to help your organization anticipate and prevent potential catastrophes? Please email bob@bobmayer.com Summary
  36. 36. Print Book Free downloadable Powerpoint slideshows on survival, history writing, and interesting information is available HERE
  37. 37. The guide on the left is a complete preparation and survival guide. The one on the right is a pocket-size manual focusing on survival essentials.
  38. 38. New York Times bestselling author, graduate of West Point and former Green Beret. He’s had over 75 books published, including the #1 bestselling series Green Berets, Shadow Warriors, Time Patrol, Area 51, and Atlantis. Born in the Bronx and having traveled the world he now lives peacefully with his wife and dogs. Sort of. www.bobmayer.com

×