Air france 447 crash- Reasons & Quality Aspects

Air France 447 Crash
UCLA-Extension
Quality Management Presentation
By Shivangi Jadhav

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

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

Brazilian
airspace.22:29
Senegal
airspace2:20
Cape
Verdean
airspace
3:45
The Incident
Air France 447 Flight Details
Last Contact
1:35

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.

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.

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.

Flight Search

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.

Analysis From Black Box Data

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.

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.

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.

What went wrong?
Pitot Tube functionality

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.

What went wrong?

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.

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.”

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.

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.

Fish Bone Diagram
Cause Effect
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.

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.

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.

References
http://en.wikipedia.org/wiki/Air_France_Flight_447
http://www.airfrance447.com/
http://en.wikipedia.org/wiki/Angle_of_attack
Thank You !

Air france 447 crash- Reasons & Quality Aspects

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