Air france 447 crash- Reasons & Quality Aspects


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A case study presented as apart of Quality Class. This case study relates to the quality aspects observed in airfrance 2009 crash

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Air france 447 crash- Reasons & Quality Aspects

  1. 1. Air France 447 Crash UCLA-Extension Quality Management Presentation By Shivangi Jadhav
  2. 2. The Incident  An Aircraft departed Brazil on 31st May 2009 at 22:29 UTC to reach Paris after app.. 10:30 hrs.  Aircraft had 216 passengers+ aircrew of 12=Total 228.  It had 1 captain, 2 co-Pilates to manage the flight alternatively.  The aircraft left Brazilian Atlantic radar surveillance at 01:49 UTC. Last verbal contact was made at 1:35 UTC. 5/5/2014 2Air France 447 Crash
  3. 3. The Incident An Aircraft was due to pass from Brazilian airspace into Senegal airspace at approximately 02:20 (UTC), and then into Cape Verdean airspace at approximately 03:45.  Failed attempts to contact- Around 4:00 UTC controller in Senegal failed to contact aircraft. Another Airfrance flight also failed to contact. Further unsuccessful attempts made everyone to think something suspicious. Electric fault was reported at 2:14 AM. 5/5/2014 Air France 447 Crash 3
  4. 4. Brazilian airspace.22:29 Senegal airspace2:20 Cape Verdean airspace 3:45 The Incident Air France 447 Flight Details 5/5/2014 Air France 447 Crash 4 Last Contact 1:35
  5. 5. Flight Search Arial search began from Brazil and Senegal side of Atlantic. It was understood that might be due to the poor weather flight experienced electric fault and got crashed. By early afternoon on 1 June, officials with Air France and the French government told that there was "no hope for survivors" . On 2nd June 15:20 UTC Brazilian air force spotted the wreckage in the form of aircraft seat, a barrel, "white pieces and electrical conductors“ and 5km spread of oil. 5/5/2014 Air France 447 Crash 5
  6. 6. Flight Search 15 aircraft searched over 320,000 square kilometres of ocean. By 16 June 2009, a total of 50 bodies had been recovered from 80km of area. Following the end of the search for bodies, the search continued for the flight data recorder and the cockpit voice recorder, the so-called "black boxes“. The search was conducted in 3 phases till 2010 using robot submarines and pinger located hydrophones, but to fail. 5/5/2014 Air France 447 Crash 6
  7. 7. Flight Search  In July 2010, the US-based search consultancy Metron was engaged and based on prior probabilities from flight data and local condition reports, combined with the results from the previous searches phase 4 search begun with new search area focus. Finally on 26th April 2011 Flight data recorder followed by cockpit voice recorder was retrieved from 4000 meters deep flat ocean bed. Total 154 bodies were found during the whole search operation with 74 still unrecovered. 5/5/2014 Air France 447 Crash 7
  8. 8. Flight Search 5/5/2014 Air France 447 Crash 8
  9. 9. Analysis from Black Box Data What happened between 1:35 UTC to 2:20 UTC?? The onboard monitoring system via the Aircraft Communication Addressing and Reporting System(ACARS) transcripts indicate that between 02:10 UTC and 02:14 UTC, 6 failure reports (FLR) and 19 warnings (WRN) were transmitted. 5/5/2014 Air France 447 Crash 9
  10. 10. Analysis From Black Box Data 5/5/2014 Air France 447 Crash 10
  11. 11. Analysis from Black Box Data Around 2-0 clock captain left the cockpit and went to take rest giving warning that we are about to reach turbulence area. At 02:06 UTC, the pilot warned the cabin crew that they were about to enter an area of turbulence. Two minutes later, the pilots turned the aircraft slightly to the left. At 02:10:05 UTC the autopilot disengaged and airspeed display was malfunctioned. During the next thirty seconds, the aircraft rolled alternately left and right as the pilot adjusted to the altered handling characteristics of aircraft. At the same time pilot made an abrupt nose-up input on the side-stick. 5/5/2014 Air France 447 Crash 11
  12. 12. Analysis From Black Box Data At 02:11:10 UTC, the aircraft had climbed to its maximum altitude of around 38,000 feet with continuous nose up input and stall warnings which made pilots confused with lack of airspeed data. They had attempted to call Captain many times earlier. The wings lost lift and the aircraft stalled. At 2:11:40 Captain entered. The aircraft was oriented nose-up but descending steeply, stall warnings were also heard alternately. Pilots were confused what’s happening and they were unsure of the speed. It was descending at 10,912 feet per minute. Its pitch was 16.2 degrees (nose up), with a roll angle of 5.3 degrees left when it hit the ground at 2:14:28. 5/5/2014 Air France 447 Crash 12
  13. 13. What went wrong? 1. At 2:10 when aircraft reached turbulence area “Pitot tubes” which measures and control aircraft speed got obstructed with ice crystals giving unreliable speed data, causing autopilot disconnection. In case of loss of speed data, under-speed can lead to a stall and over-speed can lead to the aircraft breaking up because it is approaching the speed of sound and the structure of the plane is not made for enduring such speeds. 2. Autopilot Disconnection has two consequence. It increases the aircraft's sensitivity to roll. "stall protection" no longer operated. 5/5/2014 Air France 447 Crash 13
  14. 14. What went wrong? Pitot Tube functionality 5/5/2014 Air France 447 Crash 14
  15. 15. What went wrong? 3. Pilot kept the nose up increasing angle of attack.  With autopilot disengaged ,pilots have to just balance the aircraft against turbulence by moving nose left and right. Pitot tubes get restored some time when ice melts and pilots would have retrieved autopilot mode.  The pilot kept nose up by reaching maximum height of 38000 ft and comparatively speed decreased increasing angle of attack which made wings to loose the lift and it started stalling. 4. The pilots did not read out the available data (vertical velocity, altitude, etc.) which was displayed correctly though airspeed data was incorrect. Pilot did not notice that they have reached maximum possible altitude and even stall prevention did not worked as autopilot was disengaged. 5/5/2014 Air France 447 Crash 15
  16. 16. What went wrong? 5/5/2014 Air France 447 Crash 16
  17. 17. Who is at fault? Human Factors 1.The pilot-in-control pulled back on the stick, thus increasing the angle of attack and causing the aircraft to climb rapidly, and then to loose the lift finally. Instead they had to pull nose down to gain the speed and stop the stall warnings. 2. The crew failed to recognize that the aircraft had stalled. The two co-pilots had poor management of the "startle effect", leaving them in an emotionally charged situation. 3. No communication took place among pilots on what was being done. 4.It is noticed that none of the 3 pilots had slept enough a night before with captain having only 1 hr sleep. 5. Unsuccessful 6 attempts to reach captain when contacted by co-Pilates. 5/5/2014 Air France 447 Crash 17
  18. 18. Who is at fault? System Design and faults 1. In a July 2012 CBS report, Sullenberger suggested that the design of the Airbus cockpit might have been a factor in the accident. The flight controls are not linked between the two pilot seats, and the left seat pilot was not aware that the right seat pilot was holding the stick back the entire time. 2. Pitot tubes from Goodrich pitot probes P/N 0851HL model are found to be far better than the Thales model that has resulted in "reports of airspeed indication discrepancies while flying at high altitudes in inclement weather conditions", that "could result in reduced control of the airplane.” 5/5/2014 Air France 447 Crash 18
  19. 19. Who is at fault? 3. Misleading stall warnings. The stall warning deactivates by design when the angle of attack measurements are considered invalid, and also when the airspeed drops below a certain limit. In consequence, the stall warning stopped and came back on several times during the stall; in particular, it came on whenever the pilot pushed forward on the stick and then stopped when he pulled back; this may have confused the pilots. 5/5/2014 Air France 447 Crash 19
  20. 20. Who is at fault? Airline or Pitot tube vendor or authorities? 1. There had been previous problems affecting the speed readings on other A330, awaiting a recommendation from Airbus, Air France delayed installing new pitot tubes on A330/A340, but increased inspection frequencies in these planes. 2. The crew lacked practical training in manually handling the aircraft both at high altitude and in the event of anomalies of speed indication. 3. It seems that pilots were unaware of the consequences of failure of pitot tubes, absence of autopilot mode, importance of angle of attack etc and when it coupled with faulty display they were unable to recalculate their action to recover the flight. 5/5/2014 Air France 447 Crash 20
  21. 21. Fish Bone Diagram Cause Effect 5/5/2014 Air France 447 Crash 21 Air France 447 crash ENVIRONMENT Lightening PERSONNEL METHODMACHINE MEASUREMENTENERGY TIME Insufficient Sleep a day before MATERIAL Negligence to altitude velocity readings Unawarance of consequences Least experienced on controls No reporting of what was done among pilots Iong ack time from captain Night, after dinner Ice crystals in pitot tubes Malfunctioning of Pitot tubes Autopilot switched off Increased TurbulenceMisleading stall warnings Nose up position Thales Pitot tubes unreliable Unreliable speed reading from Pitot tubes. Angle of attack invalid at low speed Increased Turbulence Stall protection disabled Manual controls have to be used. Lack of practical training Control position not visible to other pilot Failure to recognize stall Flying at high altitude with low speed.
  22. 22. Actions taken By AirFrance By 17 June 2009, Air France had replaced all pitot probes on its A330 type aircraft. On 12 August 2009 , It was declared that Thales model C16195AA pitot tubes were no longer to be used. On 20 December 2010, Airbus issued a warning regarding pitot tubes, advising pilots not to re-engage the autopilot following failure of the airspeed indicators. On 20 June 2009, Air France announced that each victim's family would be paid roughly €17,500 in initial compensation. 5/5/2014 Air France 447 Crash 22
  23. 23. Report From BEA BEA is the French authority responsible for safety investigations into accidents or incidents in civil aviation. The report produced by BEA is attached here for reference. Few points from which highlighted below. 1. Display for angle of attack in cockpit. 2. Use of drift measuring Buoys to locate the debris more quickly. 3. Addition of section “Effects of Surprises” in training manual for pilots. 4. Improving flight simulators and exercises. 5. Improving quality and robustness of incident reports created by crew to record the minute details. 5/5/2014 Air France 447 Crash 23
  24. 24. References Thank You ! 5/5/2014 Air France 447 Crash 24