Understanding Air France 447 (3 page)

02:14:07 Robert pulled back on his sidestick, and added, “I’m pitching up, I’m pitching up.” The thrust levers were retarded to idle for two seconds and the nose pitched up reaching 16°.

The captain warned, “You’re pitching up.”

Bonin said, “Well, we need to, we are at four thousand feet!”

02:14:16 At 2,500 feet from the surface, the Ground Proximity Warning System (GPWS), announced, “SINK RATE, PULL UP.”

The captain gave permission, “Go on, pull,” and Bonin enthusiastically remarked “Let’s go, pull up, pull up, pull up!”

The thrust levers were moved to TOGA and a nose-up command was applied by both pilots as the airplane pitched up toward 16° again.

02:14:22 Bonin pushed the takeover push-button on his sidestick cutting out Robert’s commands. The synthetic voice announced, “PRIORITY RIGHT,” and a red arrow illuminated on the glare-shield in front of Robert pointed to Bonin, who had taken control.

Bonin, still not having understood what happened said, “[expletive] we’re going to crash.”

The stall warning announced, “STALL, STALL.”

The GPWS warned, “PULL UP!”

“This can’t be true,” said Bonin.

“PULL UP!” shouted the GPWS.

Bonin: “But what’s happening?”

The captain commanded, “Ten degrees pitch attitude,” while the GPWS continued to alert “PULL UP.”

Robert pushed his sidestick forward, but Bonin was holding his takeover push-button down and his sidestick full back. Robert’s locked out inputs had no effect.

02:14:28, quarter past midnight local time. The A330 impacted the water at a 45° angle, 16° nose up in a 5° left bank with a forward ground speed and vertical speed both at 107 knots (123 mph, 10,900 feet per minute). The airplane was crushed from below and shattered into thousands of pieces. Survival was impossible. All 228 people, who came from 32 nations; 126 men, 82 women, 7 children, and one infant were killed.

02:47 - 05:30 Unaware that AF447 had crashed, the four control centers working the flight communicated with each other several times and questioned the estimated times of the flight’s progress, and noted that none had had radar or radio contact since 01:35. Attempts had been made to contact the flight by radio call, relay from other aircraft, ACARS messages (text messages) via the Air France Operations Control Center (which were rejected), and numerous direct SATCOM (Satellite telephone communications) call attempts to the aircraft.

04:59 Air France Operations Control Center contacted the Dakar controller; both noted their inability to contact the airplane.

05:23 The disappearance of the flight was registered and the search and rescue process was triggered.

08:22 - 09:09 The first emergency messages were sent by the Madrid and Senegalese control centers.

11:04 A Brazilian airplane took off to begin search and rescue operations.

Jun 6, 2009: Five days after the accident, the first floating wreckage was found. Over the next 12 days the remains of fifty victims (forty-five passengers, four flight attendants, and the captain), and about 1,000 parts and pieces of floating debris were recovered by French and Brazilian naval forces.

June 10 - July 10, 2009: Undersea searches were made to detect signals transmitted by the two flight recorders' emergency locater beacons, without success. The undersea terrain in the search area was extremely rugged with variations in depth from 2,300-14,000 feet over short distances. The search for the flight recorders was compared to searching for a shoebox in New York City.

July 2009: The first interim report on the accident was published

July - August 2009: Searches for the wreckage were conducted, including attempts to detect the underwater locator beacons (which were damaged in the breakup) with side-scan sonar and a Remotely Operated Vehicle (ROV), without success.

December 2009: The second Interim report on the accident was published.

April - May 2010: The third campaign of underwater searches for the wreckage continued without success, including deep water sonar and remote vehicles.

March 25, 2011: The fourth campaign of undersea searches began.

April 2, 2011: The wreckage was found 12,800 feet deep on a flat area surrounded by terrain. At that depth it is permanently dark with temperatures in the mid 30’s°F (2 °C to 3 °C). It was 6.5 miles from its last position transmitted by ACARS.

April 26 – May 13, 2011: Beginning of the fifth campaign of undersea searches. The BEA team, made up of twelve investigators and experts, devoted itself to the localization and recovery of the flight recorders, mapping the accident site, then recovering airplane parts that were useful to the safety investigation.

May 1-3, 2011: 23 months after the accident, discovery and recovery of the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR).

May 13, 2011: Readout and analysis of the flight recorders at the BEA headquarters began.

May 21 – June 3, 2011: Continuation of undersea operations. The ship and equipment were made available by the BEA to representatives of the judicial authorities, which made it possible for them to recover the remains of one hundred and three victims.

July 2011: The third interim report on the accident was published.

July 2012: The final accident report was issued by the BEA.

How could one of the world’s most modern airliners, with an excellent safety record and qualified crew, fall out of the sky and disappear?

Like any aircraft accident, Air France 447’s crash was a result of a chain of events and circumstances. Remove any one of these, and the accident would likely not have happened.

The crew was unable to maintain control, stalled the airplane, and crashed within four and a half minutes of autopilot disconnection. Communication issues delayed the discovery that the airplane was lost by several hours, and added two years to the search for the wreckage.

Amazingly, no component on the airplane actually failed. But, the pitot tubes were overcome by conditions that were not anticipated, causing a loss of reliable airspeed data. A cascade of system disconnections, downgrades, and human errors followed, and the loss of the flight in this manner shocked the airline industry.

Weather, design factors, pilot competence, training, and human factors all played a part.

To understand what really happened requires an understanding of the human element, the weather, and the machine. This is what I will provide.

Chapter 2: The Flight Crew

There were three pilots: Captain Mark Dubois, First Officer David Robert, and First Officer Pierre-Cedric Bonin.

58-year-old Captain Marc Dubois had joined Air France in 1988 and at the time of the accident had approximately 11,000 flight hours, including 1,700 hours on the Airbus A330, all as captain.

He earned his Private license in 1974. While working as a flight attendant for Air France between 1976 and 1982, he earned his commercial certificate (1977), instrument rating (1978), instructor rating (1979), mountain airport rating (1980), and took the written tests for first class professional and airline transport ratings.

He flew a range of Cessna, Piper, and Beech aircraft and several models of light twin turboprops.

In 1982 he earned his 1st class professional pilot’s license
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, and worked as a demonstration pilot for Intra Avia Service Company in the first months of 1983. He worked for various companies until August of 1984, and was an independent pilot until February of 1988 when he was hired by Air Inter at age 37.

While at Air Inter he received a Caravelle XII and A300 type ratings, his airline transport pilot certificate, and 1st class pilot instructor rating.

In March/April 1997 he received his A320 type rating as Air Inter and Air France merged. In June 1998, he received a 737-200 type rating and at the age of 47 was first appointed as captain. A new A320 type rating (within Air France) was issued in May 2001.

In October 2006, at age 55, he received his A330 type rating and had an unsatisfactory line test flight in January 2007. His training was extended, and a month later he passed.

An A340 rating was added in August 2007 with a captain checkout complete in September.

Captain Mark Dubois had flown 16 trips to South America since he arrived in the A330/A340 division nearly two years earlier.

37-year-old David Robert had over 6,500 total hours, almost 4,500 hours of which was in the A330.

He earned his basic license and passed his airline pilot theory test in 1992 at 20 years old. In 1993 he received his professional pilot’s license and multi-engine instrument rating. At this time Air France stopped pilot hiring and drew up a waiting list due to economic issues.

In 1997 he trained as an air traffic control engineer at the French civil aviation university, ENAC. In August 1997, Air France called and he delayed joining in order to finish his training at ENAC. In July 1998, age 26, he started training at Air France and earned an A320 type rating in November of that year. His airline transport license was issued in April 2001.

He received his A340 type rating in February 2002, followed by an A330 type rating in October.

In 2005 he was assigned to Air Calédonie Internationale airline to carry out flights on the A330 between Tokyo and Nouméa, New Caledonia (a French owned island 850 miles east of Australia). While in Nouméa, he also flew the small single engine TB10.

In May 2008, he was appointed as a member of a core group at the Technical Flight Crew Division as representative of the Flight Crew hub.

Before the outbound Paris to Rio flight, his last A330 landing was March 9, 2009, nearly three months earlier. He flew the outbound flight to meet the recency of experience requirements to keep his dual A330/A340 rating up to date.

David Robert had flown 39 trips to South America since arriving in the A330/A340 division seven years earlier.

32-year-old Pierre-Cédric Bonin, was the least experienced pilot of the three. He had slightly less than 3,000 hours total time and 800 hours on the A330.

He received his private pilot license and passed his airline transport theory test in 2000, and his professional pilot’s license, multi-engine instrument type rating, and glider pilot’s license in 2001 at age 22.

He was selected by Air France in October 2003 and started training at the Amaury de la Grange flying school in Merville, France.

He received his A320 type rating in 2004, and his airline transport license in August 2007.

He finished his A340 type rating June 2008, and his A330 type rating followed in December 2008.

Pierre-Cédric Bonin had performed five trips to South America since arriving in the A330/A340 division one year earlier.

Nine flight attendants and 216 passengers were also on board, including First Officer Bonin’s wife and an off-duty flight attendant allegedly accompanying Captain Dubois.
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The Layover

After the flight from Paris, the crew had a three day layover in Rio De Janerio. While that may seem like it would be plenty of time to get adequate rest for the return flight, fighting fatigue on international flights that span multiple time zones is a challenge.

Could fatigue have been a factor in the crews inability to figure out what the problem was and solve it? Possibly. A 1997 study concluded that 17 hours awake is equivalent to a .05% blood-alcohol level.
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The flight pushed back for a twelve hour flight at 8pm local time, 11pm in Paris. No matter how you look at it, it was a long flight on the back side of the clock. It is not easy to flip your body clock over by 12 hours to simply sleep all day, in order to work all night. The presence of three pilots on the two-pilot airplane and an on-board rest facility are a testament to that, though not a complete solution.

The French investigative TV program
Pièces à Conviction
(French for “incriminating evidence"), in an analysis of Air France 447, claimed that Captain Dubois and a female friend and First Officer Bonin and his wife spent their three day layover in Rio together.
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The captain's fatigue state was described by a guide, who accompanied them in a helicopter they chartered a few hours before the fatal flight, as being so tired that he was probably not fit to fly. The program also said that remarks were made that they would be able to rest on the plane.

The French news magazine
Le Point
released a story on March 15, 2013 based on a previously undisclosed judicial report that included a voice recorder conversation not included in the official accident report. The magazine revealed a comment made by Captain Dubois at 01:04, "
I didn’t sleep enough last night. One hour – it’s not enough.”
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It also claimed t
hat the two first officers were also dangerously tired.
In his book
Air Crashes and Miracle Landings
, Christopher Bartlett states “it has been said that Air France pilots regarded the long flight back to France as a good chance to have a good rest and recuperate after having fun in Rio de Janeiro.”

The above allegations fall short of what I would consider as factual evidence. One must question a tour guide’s qualifications to determine the captain’s fitness to fly. The BEA reports did not comment on the activities of the layover, or the duration of it, concluding that the private lives of the pilots were out of the scope of the investigation. But these publications do raise the legitimate question if fatigue could have been a contributing factor to the crew’s inability to properly diagnose and maintain control of the situation.

About an hour before the autopilot disconnected, the captain offered First Officer Bonin an opportunity to take a nap. One must assume that he had some reason to offer this, such as looking or behaving tired. The captain said, “Try maybe to sleep twenty minutes when he comes back or before if you want.” Bonin turned down the offer. “Oh … that’s kind” he said. “For the moment I don’t feel like it, but if I do feel like it, yeah.”