Seconds to Disaster: US Edition

SECONDS TO DISASTER

By Glenn Meade

And

Ray Ronan

It was no night for dying.

In Rio De Janeiro that late
May the temperature hung close to eighteen degrees. It was approaching
midwinter in Brazil but that night the air was balmy, not a breath of wind
whispered in the humid air. On Copacabana Beach, the sea glassy calm,
promenades thronged with families and lovers enjoying a stroll, groups of
tanned teenage boys and girls lazing in the sand, laughing and playing music.

On the Avenue Del Flores, the
Volkswagen bus carrying the twelve Air France crew led by Captain Marc Dubois
set out from the Hilton Hotel at seven-thirty p.m. The crew bus stop-started in
the heavy rush-hour traffic. As usual, pick-up was two and a half hours before
the flight’s scheduled take-off to allow ample room for road delays. The bus
driver on duty that evening always tried to be on time and waited duly outside
the hotel entrance for his crew.

“It was such a pleasant night,”
Oscar Hernandez, a member of the hotel staff remembered. “The crew was in good
spirits. They could certainly have had no intuition that a terrible disaster
was about to unfold. That they were being driven to their unspeakable deaths.”

Among the crew bus passengers,
thirty-two year old Air France co-pilot Pierre-Cedric Bonin had started flying
the Airbus A330 in April. His young wife Isabelle had come along with him on
the trip and she talked about how much she had loved her brief two-day stopover
in Rio.

The second co-pilot, David
Robert—on extended long-haul international flights, the practice is to have a
third cockpit crewmember—had 6,600 flight hours with Air France and had
qualified to fly the A330 in 2002.

Their captain, Marc Dubois, at
fifty, was a veteran pilot. Since June 1998 he had accumulated over 1700 hours
on the A330 alone and flew the four engine A340, a common practice in airlines,
which had both types on their fleet. This was his seventeenth rotation in the
South America sector.

But unknown to Captain Marc
Dubois and his fellow crew as they chatted on the short thirty-minute trip to
the airport, Air France Flight 447, bound for Paris over 5000 miles away on a
long journey over the dark, turbulent waters of the Atlantic, that night was to
be their last.

At Antonio Carlos Jobim International Airport, the crew
climbed down from the bus for what they assumed would be just another leg home.
The overcast sky held the temperature and humidity constant. Captain Dubois
talked with his crew as they waited for their bags, co-pilot Bonin hurried off
with his wife to help her check in.

The bus driver offloaded the
last of the luggage and Captain Dubois’ crew wheeled their suitcases inside.
Purser Anne Grimout, a forty-nine year-old from Ermenonville, in Normandy,
had worked for Air France for nearly twenty-five years. She chatted with Lucas
Gagliano, who was the only Brazilian national working on the flight.
Twenty-three year-old Lucas had returned to Brazil to attend his father’s
funeral two weeks before.

After queuing up for passport
control, Captain Dubois left the flight attendants to their own preparations,
while he led his two first officers to Air France operations.

In the office, Dubois was
handed the briefing pack for AF447 by the flight departure agent and sat down
with Robert and Bonin to plan their flight from Rio to Paris. Meanwhile, an
arriving Air France A330-200, registered as F-GZCP, touched down on the main
runway and taxied to its stand.

Ground staff at once commenced
preparation of the jet for its next flight. The two Air France crew’s paths
never crossed. The incoming crew had reported no major snags or malfunctions.
Once refueled, the aircraft was good to go, part of a continuous cycle of usage
that is the lot of modern aircraft. Down time is money lost. The more time an
aircraft is in use, the more profit the company makes.

In the briefing room, Dubois
and his first officers studied their route. Weather in the mid-Atlantic at that
time of year could be intense, massive storms a real threat. With no air
traffic control facilities mid-Atlantic, a pilot must rely on preflight
planning, reports from other aircraft enroute and their own aircraft’s radar to
negotiate a way around such storms. Severe weather systems were forecast.

But Dubois had often flown
this route before and all in all, it looked as if it was going to be another
routine flight.

While Dubois and his crew
finished going over the flight plan, their passengers were already proceeding
through check-in and immigration procedures. Two hundred and sixteen passengers
consisted of thirty-two nationalities. They included a baby and seven other
children. Sixty-one passengers were French citizens; fifty-eight were Brazilian
and twenty-eight German.

Thirty-four year-old Swede
Christine Schnabl and her five-year-old son Philippe were checked in and waiting
for the flight. Christine, living in Brazil for 10 years, worked for the
Swedish Chamber of Commerce in Rio and missed her relations in Sweden.

Her husband Fernando and their
three-year-old daughter Celine had flown to Paris earlier with a different
airline, intending to travel together for the homeward journey to Sweden for a
holiday.  According to one newspaper report, the Rio-based family always
flew separately. Mr. and Mrs. Schnabl always feared they would all die together
if their airplane crashed, and so they booked different flights.
[1]

It was a decision that was
going to tear this loving family apart forever.

By the time everyone was
onboard it was already past scheduled departure of p.m. local, 10 p.m. UTC. The
flight attendant’s headcount confirmed the numbers.

Captain Dubois signed the load
sheet and the ground crew said ‘bon voyage’ before closing the door.

Ground crew confirmed pre-departure
checks were complete and just before 10:10 p.m., the flight crew called the
tower for pushback and engine start and they received the clearance to do so.

Satisfied that everything was
as it should be, Captain Dubois called for brake release. At 10:10 p.m., Flight
447 pushed back from the gate. A short taxi later, the A330 powered down the
runway, increasing speed until it climbed gracefully into the air at 10:29 p.m.

Once airborne the crew
contacted Rio De Janeiro approach control and soon after were passed over to
the Curitiba air traffic control center which cleared them to climb to
thirty-five thousand feet—FL 350—at 10:45 p.m.

Like many modern airlines Air
France equip their aircraft with aviation’s equivalent to a fax or SMS facility
called ACARS
[2]
.

At 10:51 p.m., via ACARS, the
crew asked for and received the weather pertaining to the Brazilian airfields
of Belo Horizonte, Salvador de Bahia and Recife.

These were airfields Captain
Dubois was keeping in mind should he have need of a bolt hole in the highly unlikely
event of an emergency.

But that night, the unlikely
was about to happen.

Almost six thousand miles away in Paris, France, and
nearly three hours later—2:10 a.m. UTC—a chatter of mysterious automated
computer error messages were transmitted from the fight deck of Dubois’ Airbus
to the Air France operations office at Charles De Gaulle Airport.

Personnel on duty that night
were horrified by a long list of ACARS signals that suddenly exploded on their
screens.

One remembered staring
open-mouthed at the arriving messages. “It was so unreal. All of us who saw the
ACARS communications coming from Fight 447 knew that something truly awful,
something catastrophic was happening before our eyes.”

The cascade of messages
signaled a calamitous series of events was unfolding on board the Airbus A330
above the turbulent Atlantic.

Operations staff watched their
screens in utter disbelief. “The failure messages kept coming,” another staff
member on duty recalled. “But there were no Mayday signals, no radio voice
signals transmitted from the cockpit. There was no evidence of any emergency
transmissions directly from the crew.”

In the space of only four
minutes, twenty-four encoded messages were transmitted, signaling unreliable
sensor data, autopilot disconnect and a series of colossal sub-systems failures
on board the Airbus.

At 2:14 p.m. the last message
was transmitted from Dubois’ flight deck, indicating either a massive
decompression failure or that the aircraft was moving with extremely high
vertical velocity, or both, for the cabin was dropping at faster than thirty
feet a second—an incredible rate.

In Paris, personnel on duty in
the operations’ office that morning anxiously watched their computers but no
further signals were received from the stricken airliner that only moments
before was powering its way through the stormy darkness above the Atlantic.

Air France Flight 447, with two hundred and
twenty-eight passengers and crew on board, had disappeared from their screens
without a trace.

There is a saying of
Einstein’s that is much quoted in the field of air crash investigation, or
indeed any field that demands critical analytical skills—look long enough at a
problem and an answer will present itself.

The fall of Air France Flight
447 was an unusual event. Unusual because it was marked by no emergency calls
from the cockpit crew, no mayday signals, no last minute communications that
could have hinted at why the aircraft simply vanished.

And unusual because
catastrophic air accidents rarely happen in mid-flight. Most accidents occur
within a critical eleven minute window of the flight phase, during take-off and
landing.

Aircraft don’t typically fall
out of the sky.

And long before such a
catastrophe might happen, a series of significant events has usually been set
in motion, which may later offer causal clues to accident investigators.

In the case of Air France 447,
though few solid answers were at first evident, the vast and deep Atlantic was
soon about to offer up the first indications of what may have occurred.

Three days after Flight 447 disappeared the first physical
evidence began to materialize. Eventually, fifty-three bodies of crew and
passengers, an almost complete tail section, and numerous aircraft parts had
been found floating near the accident zone, within the first week. They
indicated, as investigators had suspected, that Flight 447 had suffered a
catastrophic disaster.

An oceanographic research
vessel, The Pourquoi Pas?, which was busily mapping the Mid-Atlantic Ridge
where three tectonic plates confront each other at depths of up to five miles,
had been called in to aid the underwater search. Part-owned by the French navy,
the vessel carried onboard two mini-submarines. One of the subs, the Nautilus,
had brought much of the great Titanic’s treasures to the surface. The Nautilus
was one of the few submarines in the world capable of descending to and
trawling the deep oceans where Captain Dubois’ Airbus had disappeared.

However, after four weeks of
scouring the ocean depths for evidence of the crash, the sub failed to
locate the aircraft remains, or the black box.

“The black boxes may never be
found,” said Paul-Louis Arslanian, the head of the French enquiry. “And it may
not matter. We’ve had cases where we never found the black boxes and we were
able to reconstruct what happened, and there have been cases where we found
them and they didn’t tell us anything useful.”

Yet unless you have all the
evidence in front of you, nothing can be discounted. For without answers,
without connecting the dots to give a true picture of all the factors that
contributed to the disappearance of Flight 447, another airliner could suffer
the same fate. Although the aircraft—registered as F-GZCP—had completed 2644
take offs and landings the catastrophic problem or problems which surfaced that
disastrous evening, on that particular flight, could go back a long way. Of
course, eventually the black boxes were found and the evidence soon pointed to
a catastrophic accident that, sadly, was avoidable.

Certainly some of the evidence
will be a shock to readers, unfamiliar with cockpit crew procedure and airline
industry policies.

Much of the time air crashes,
as we will see, are a confluence of events—a cascade of bad luck, bad
decisions, inappropriate airline company policy, insufficient training and
failure of regulatory authority or various combinations of all five as well as
other factors.

Some of that bad luck is often
aided by the airline industry itself. We believe that some of its guiding
principles—an endless and aggressive pursuit of bottom-line profit—no doubt
contribute to the creeping erosion of safety standards, which puts both
passenger and crew lives at serious risk.

There are more incidents, a
term used for near accidents or events which could have led to an accident,
than you may imagine and it’s the increase in these incidents which is causing
concern.

Many major accidents are often
preceded by similar incidents in which it was only by coincidence that a loss
did not occur. Air crash investigators tell us that for every accident there
were hundreds of similar incidences; if so, are fatal accidents the only gauge
of airline safety?

NASA’s Aviation Safety
Reporting System, ASRS, collects confidential reports sent to it by airline
industry workers. Their system indicates a marked increase in the number of
incidences reported in recent years—and NASA says the true number of reports could
be far greater.

It is possible that many who
work in the US airline industry either do not know about the system or are in
fear of reprimand or retribution. But according to NASA
,
“More
than 975,000 reports have been submitted to date and no reporter's identity has
ever been breached. We de-identify reports before entering them into the
incident database.”
[3]

The team at NASA believes such
a system is vital:
“When organizations want to learn more about
the occurrence of events, the best approach is simply to ask those involved.”
[4]

With the growth of aircraft
size and passenger capacity, when accidents occur they could well be monumental
disasters. It is true that 2010 was the safest year with regards to loss of
aircraft. But in 2011 the safety improvement was
modest
at best.
[5]
The number of people killed did not trend down but upwards. The number of incidents
reported did not trend down but upwards
.

It is common knowledge among
flight safety experts that the last decade can be regarded as “the lost decade”
because no improvements in flight safety matters have been made in that period.

This book will not only pose
and answer questions as to
why
accidents happen, but also offer
solutions as to how they can be further prevented. It will also make passengers
aware of how
they
can consciously limit their risk.

Simple but smart choices by
passengers can make a huge difference in reducing their risk of exposure to
danger while they and their families are flying.

In a world where air travel is
set to grow at an exponential rate in the coming decades, this book will teach
you how to fly smart and safe as a passenger.

It will teach you how to avoid
the potential pitfalls that exist in commercial aviation—pitfalls that can
sometimes expose unknowing air travelers to increased risk of being involved in
a fatal air accident. In conversations and meetings with other pilots and
industry experts, we learned about what
they
do to make their flight safer
for crew and passengers.

This information should be
shared with the public.

There is an even more
contentious issue we intend to explore: what parts do both the airline industry
and the worldwide aviation authorities responsible for governing that industry
contribute in playing dice with passenger lives? And play dice they certainly
do, through negligence and collusion, as the following pages will reveal.

The reality is many insiders
in the airline business will concede that Air France Flight 447 was an accident
that never should have happened, but was waiting to happen.

And the real tragedy, like so
many of the disastrous accidents and terrifying incidents you are about to read
about, is that scores of such calamities could well have been avoided by the
airline industry and its watchdog authorities.

It’s a theme that we will be
returning to in the chapters ahead—how each and all of our lives are put at
increasing risk daily when we fly and for one reason only. The aggressive
pursuit of profit—and the erosion of safety standards caused by that same
relentless pursuit.

A pursuit, as we will see
especially affects the lives and careers of airline cockpit crew, for it is in
their professional hands that we place ourselves each time we fly.

And when crews go wrong,
everything
goes wrong.