Directorate of Air Operations
Roissy, October 20, 2009
ENOUGH OF POLE - FALSE AND DISCUSSION ON THE SAFETY OF FLIGHT!
For the safety of flights in an airline is primarily:
- A continuous work on elements that guarantee security,
- A return to fundamental business driver.
As you will see, form, tone and content of such communication, addressed to all company
pilots are unusual.
They are because the situation we are living since June 1 and is also the challenge for us is
nothing other than ensuring the security of our air operations.
With the disappearance of flight AF447 in the Atlantic, Air France has experienced the worst
disaster in its history, and more than four months later we still do not have elements that allow
us to identify the factors that led to the loss of the aircraft. Therefore we are implementing
measures on a wider scope.
This lack of findings leaves the field open to speculations of all self-proclaimed experts "Sc
flight safety" that continue to spread in the media and in the lockers NTP to give their
explanation of the accident, while the elements on which they rely are partial, inadequate or
They throw and disorder in the public mind and give an unprofessional image of being a pilot,
it would not matter if they do not cast also disturb the minds of some Air France pilots by
making them doubt the correctness of our doctrine, our procedures and those of the
manufacturer. Worse still, they doubt the pilots themselves of their own skills.
Purporting to act in the interests of flight safety, they do, in fact, contribute to the decline.
Far from controversial, this letter is to invite each driver to provide the right answers to the
main question to an airline: how to improve flight safety.
We offer to share some answers in the following lines.
No false controversies and debates on issues of flight safety
Since 1 July, your boxes are flooded with leaflets and information of all kinds, whose tone and
content do not invite serious reflection. We are sorry.
Some media will seize any statement or any pseudorapport into their field day, since it is an
Air France pilot who speaks, and this even in the absence of any new information duly
In contrast, management has deliberately chosen the opposite course, some of it makes the
criticism in saying it wants to hide the truth. While we certainly have not sufficiently
communicated, but we must remember:
1. it is the Board of Inquiry and Analysis is responsible for technical investigation and
therefore it is his duty to communicate the facts, that's what he did in the first progress report
published last July 2;
2. Findings that are thin, since they come from ACARS messages sent by the aircraft itself
and initial analysis of some debris was recovered. We have, at present, no registration and no
3. at this stage, the BEA has not issued recommendations intended for the company.
Despite this lack of physical evidence to guide our action, we are not left without anything and
it is worth recalling what was done for 4 months: continued work on the elements that ensure
In the absence of clearly defined cases, the guiding principle is this: we have chosen to
strengthen our defenses on all matters on which we interviewed following the occurrence of
Work in time on the fundamentals of security is the only option that can bring us more in
terms of flight safety.
In this perspective and beyond the immediate actions following the accident, we have already:
- Replaced the pitot tubes AA Thales Thales tubes by BA, on the whole fleet Airbus 330/340
and then in early August on the manufacturer's recommendation and EASA, we installed
tubes in positions Goodrich CoB and Stand By;
- Launched a campaign of systematic inspection of pitot tubes A320
- Created a mock specific IAS questionable Airbus more than half of NTPs have followed so
far and believe it is appropriate and useful,
- A procedure in place to remove any doubt, to strengthen monitoring of the positions of our
aircraft by SC CCO, without waiting for the amendment of agreements,
- Created training materials "Ice Crystals" and "Reminders for the use of radar,"
- Modified the content of sessions divisions 4S Boeing to introduce a presentation of the
elements of the AF 447 and strengthen our defenses against the dangers caused by the
We do not stop there and we will continue this process by:
- Calling for a mission outside experts, composed of individuals recognized internationally, to
make a systemic study of flight safety,
- Carrying on A320, replacement probes Thales BA in positions CBD and Stand By, by
Goodrich probes, identical to the 330/340,
- Launching the re-engineering of the preparation and monitoring of flights;
- The launch meeting was held October 19 and was attended by specialists of air operations,
service lines (NI), the flight preparation of the dispatch, and Security Directorate;
- Creating groups of instructors referents, whose function will be to harmonize the educational
- Pursuing the establishment of system safety management, particularly on aspects "safety
culture" and "just culture" in the deployment of system security management.
This list is not exhaustive and we will complete whenever we deem useful.
Know that we are determined to continue along this path, that of continually improving our
processes, although we are currently experiencing difficulties in the deployment of some
ambitious projects like OMPNT. Other companies have faced the same challenges before us
and were able to overcome them. Therefore, these difficulties should not lead us to reject it all
We are ready to open discussions with trade unions and 100%, provided to find ways that will
ensure that these discussions will be conducted with serenity, with the expertise and all the
seriousness it deserves flight safety.
A return to fundamentals of being a pilot
Recently, some union publications have pointed to the difficulties of control A320 simulators
when icing simultaneous three pitot tubes takeoff. They criticized the fact that this exercise
was originally chosen as subsequently amended (by inventing a pressure Airbus to make, of
course, history even more attractive and therefore credible).
Truth requires that you know that the probability of encountering such a scenario is extremely
low, since it requires that the three probes frosting at the same time, while the aircraft is
climbing and more, icing results in a durable sealing total and absolute these probes. For it
grows, it is necessary that all conditions are maintained and appear simultaneously.
Furthermore, Airbus has indicated that this failure to the simulator does not accurately
simulate the chain of consequences in the real world.
Furthermore, no such event has been identified on Airbus, and no similar event has been
identified in the analysis of RAS on incidents of pitot tubes Air France has known since 2001.
We have removed this year because he was teaching-cons and some advocated to solve this
problem, a deviation from this doctrine.
Because you must be convinced of an essential element that you do not remember often
enough: our key risks - in terms of likelihood and severity - are elsewhere.
We did not find them in extreme cases, in the most unlikely situations, but in the daily
operation in our most mundane activities.
And most surprisingly, when conducting the analysis of factors contributing to these incidents
- The application of simple procedures could have prevented the event;
- There is no procedure to correct or create new procedure.
In other words, simply to apply our doctrine, our procedures, in the calm and serenity.
We offer a few examples:
- An overshoot does not accelerate the pace by taking the risk of forgetting an ad or disrupt
the normal work, although the altitude of RDG is low on the contrary, it requires actions
consistent, sequenced and verified by the PNF, keeping in mind that before stabilizing at
altitude, we must begin by taking over a little, showing the trim and push off the PNF should
check everything before . The passenger comfort, in this case, secondary.
- An alarm "config" is a "no go, even if we think being able to identify the cause, and verify
that the flaps are extended. Nothing we can say that they will not return during the takeoff roll
or there is not another hidden fault. This alarm is a "forbidden". We should not have to deal
with this type of incident feedback, because it should not exist. Time pressure can not be an
excuse, the execution of the mission a sufficient reason to override.
- Inserts speeds V1, VR, V2 in the MCDU must be the subject of two investigations: one by
one that inserts the data under the "control action", the second under the "cross-check "Even
if the other crew member was shown a straight face during the pre-flight or during the
- A takeoff path must be scrupulously respected when it is the path of failure and that the
restriction is a restriction barrier. By choosing a different course, a driver only increases the
risk even if the impression of moving away from the most significant obstacles, because in
case of failure, besides the fact that the crew did not know necessarily the constraint on the
inclination it would have to maintain during its trajectory will consume the slope, which has a
We could show you other examples of equivalents (for this you need to read or reread the
latest publications Overview).
We have chosen because they illustrate the factors that have led some of us to make those
deviations that have generated risk and can be summarized in a few sentences:
- Commitment to "too" well done - conduct an RDG flexible compliance schedule, improve
margins over obstacles, etc..
- The surconfiance,
- Feel good about his aircraft and its environment, to the point of granting deviations coarse
thinking hazard control,
- The feeling of extreme security, thinking that redundancy in systems, procedures, alarms,
we are immune to the consequences.
Each of us can draw on personal experience and identify precursors of such situations or
We thought we control these risks "basic" thanks to our professionalism, our procedures, our
training and that we would see more such incidents. We thought the situation would
encourage everyone to be extra vigilant.
It is clear that this is not the case and recent events have proved otherwise.
Like you, we feel great difficulty to the fact of not knowing what happened and did not
understand the causes of this accident.
The reality is so and it is not unlikely that we remain in ignorance.
The temptation is great for some to call into question the entire building and in particular the
doctrine, procedures and practices essential to our business that we have taken so long to
formalize cooperation with all industry airline.
We ask you not to yield to the temptation to voice the most speak with extreme excesses.
Flight safety requires a methodical long-term. We are committed to continue and to identify
any particular lines of simplification.
In everyday life, we must ensure the safety of our operations and for this we ask:
1. you focus on the fundamentals of being a pilot during the duration of the mission. It's your
daily contribution to simplification;
2. to apply rigorous procedures that are robust and shared by all. That way you get involved
in daily safety;
3. to assume fully the role assigned to you within the crew. That's how you give meaning to
Pierre-Etienne Marie Gautron Lichtenberger
Director of Flight Operations Director of Security
Security Directorate management of air operations