Wednesday, October 2, 2013

Air France 447 Trial in the News

An article published today (October 2, '13)  in the Times of London reported on the testimony of Michael Oakley, the coroner in the case of the crash of Air France 447 on June 1, 2009.

The  inquest was told that the crew had no training on flying the plane manually at high altitude. The coroner stated that "The pilots were not adequately trained to handle the aircraft safely in the particular high altitude emergency situation that night" and "highlighted serious public concern of whether pilots are overly dependent on technology”.

This is a  major point in my book Understanding Air France 447.  Pilots who routinely fly the airplane only with the autopilot and flight director engaged (i.e., never without it), are ill prepared to take control when those systems are suddenly and unexpectedly unavailable. Any skill, from playing the piano, to manually flying heavy transport aircraft requires practice. Those skills degrade in measurable amounts when that practice is not performed. Those whose skills were never well established to begin with, are at even greater risk of failure to perform when that performance is required suddenly and unexpectedly.

Mr Oakley added: “This disaster highlights public concern of whether pilots are too dependent on technology and are not retaining the skills required to properly fly complex commercial aircraft.”

When a pilot's training and experience all center around always operating with the flight director, autothrottle, and autopilot engaged, he may never have had those skills in any meaningful way in the first place.  I estimate that hand flying while still following a flight director relieves the pilot of 75% of the mental work of flying the airplane, and is not adequate preparation for a time when none of them are available. While we could perhaps at one time assume that any pilot qualifying on a heavy jet transport had thousands of hours of manual instrument flying experience, that is no longer true. 

I am confident that this same theme will arise out of the investigation of Asiana 214, the Korean B-777 that crashed in SFO while executing a visual approach, slamming into the seawall prior to the runway threshold. 

The coroner in the Air France case further stated that “The blockage of the tubes and the manner in which the stall alarm system ceased providing alerts at low speeds probably caused the pilots’ confusion and contributed to the accident.”

I find that contribution to be minimal, for the stall warning was unable to provide alerts for only 7 seconds of the 40 seconds of which the pitot tubes were clogged. The airplane climbed nearly 3000 feet, and lost about 100 knots of airspeed in the first minute. During this time, the proper time to stablize the airplane's attitude and simply maintain level flight, the stall warning functioned perfectly. As the airplane's angle of attack approached and exceeded the point of stalling, it sounded constantly for 53 seconds. Yet, during this time there was little stall recovery action from the crew other than to apply full power - which at that altitude is about as effective as simply hoping the airplane recovers. By the time the stall warning was intermittent, the situation was so extreme, that it would have required particular insight of the crew to recover. This is because the stall warning only became intermittent when the angle of attack exceeded about 45°( pitch attitude rarely exceeded 15° nose up). The airplane stalled as the angle of attack exceeded only 8°. They would have had to known to manually reduce the  stabilizer trim, which had run to full nose up by that time. That stabilizer trim, however, is never used in normal flight on Airbus aircraft, nor is its position displayed. 

Another important factor is the probably fatigue state of the crew. As outlined in the book, there is evidence to show that all three crew members were fatigued. As a result, their minimal manual flying skills were further diminished by a reduced mental capacity equivalent to an over-the-limit blood alcohol level. Combined with the startle effect of the sudden and unexpected change in the situation they became confused and unable to fly the airplane.

The article appears here: but requires a subscription to access the full text. 


Karlene Petitt said...

Bill, this is interesting and I suspected it was coming. You know that I agree with you on the need to know how to fly.

Fascinating conversation... I just flew with a Captain who was a 747-400 instructor when automation was just coming into play.

He was faced with the challenge of encouraging pilots to use the automation. They all felt more comfortable flying the plane and did not understand how to program the box.

I tried to explain that world has flip flopped. Now people program and are not flying. Thus losing their skills. We need to encourage flying.

He did not agree. So what can you do when you're an FO? He told me I should go bid Captain on a narrow body. lol. Perhaps. It doesn't matter what plane I fly... reality is reality.

Absolutely fatigue was an issue. We'll be seeing more signs of that in the future too. Our brains don't function fatigued.

Thanks for sharing the news of today.

Bill Palmer: flybywire said...

Thanks Karlene.
Back then we assumed everybody who got to that point knew how to fly. The checkout was to train you to use all the machine had to offer.
That assumption, might not be as valid as it once was!

Anonymous said...


Once again another well written update. However, I do have to wonder how a coroner knows so much about how poorly the crew of AF447 was prepared for high altitude stall avoidance / recovery. He is a coroner, how is he a credible source on pitot-static systems and high altitude stall recovery / training. (Note my slight sarcasm)

Nevertheless, you and Karlene highlight the growing dependence on automation. I was fortunate enough to attend a company safety meeting a few weeks ago with ALPA, Company, and FAA representatives present. In this meeting there was discussion regarding high altitude upset recovery and the startle factor and how best to simulate such an event in the simulator. Supposedly Alaska Airlines has developed quite a successful training scenario to recreate high altitude upsets with a high startle factor. Unfortunately, a majority of pilots did not react quick enough to recover during the scenario. But, this does begin to bring the "fly the airplane" mentality - back - into the 121 training environment.

Many years ago I came across a great video that I believe was used in American Airlines recurrent classes - automation dependence. The instructor emphasizes hand flying the airplane and putting the airplane where YOU, the pilot, want it to go if the automation is taking it somewhere you do not like. Click Click, Click Click, jokingly used by the instructor to emphasize disconnecting the autopilot and auto-throttles and to just fly the plane.

I make an attempt to hand fly my aircraft with as little automation assistance as possible during both VMC/IMC conditions because I recognize the value in maintaining those skills - even if my company does not (differing operating environments require a different approach however). Nevertheless, I do have great concern regarding the training foundation that the rest of the world is establishing in regards to the MPL / aircrew license philosophy with minimal actual flying experience and basket loads of simulator / jet system management training.

How do we highlight the negatives of the MPL, in the face of LOC accidents? How do we as industry stakeholders help and protect the integrity of professional pilot training when there is growing financial influence to minimize training time. Our safety and training folks have remarked that we just do not have enough time in the simulator to accomplish everything in our training program, AND add additional scenarios. Which, to me is frightening. Perhaps we do not need to shoot 8 ILS approaches in the sim. Perhaps four will suffice, freeing up time to reintroduce or take a first-look at pilots' basic airmenship skills.

Okay - I'm done. I apologize for the extended comment. Thanks again for the new information on AF447.

Bill Palmer: flybywire said...

I thought the same thing about the coroner, though I can't say that he got anything wrong. He must have experts that he can call on with the report issued in his name, even though he didn't necessarily come up with it all. (guessing)

In regards to the "click click click",I've told my students many times: "If you're working for it, instead of it working for you, click it off! You can put it back on even a few seconds later if you want, but make the airplane go where you want it to go!"

On the subject of upset recovery and preventing Loss of Control Inflight (LOC-I), I referenced in my book the work of Randall Brooks and Aviation Performance Solutions.
A very interesting interview with Randy can be found on the October 10 Airplane Geeks podcast. He talks about how while a simulator can be a good tool, nothing replaces the part of actually doing some of this work in an airplane.

With a simulator, we know it's always bolted to the floor and we're going to walk out just fine. In an airplane, you feel forces that can't be duplicated in a sim ( g-force ranges from the slightly negative to 2.5 g's, for one). Having recently taken a some aerobatic lessons in a glider, I can certainly attest to the difference!

I was glad to hear in this podcast how APS is providing this training to Ab Initio pilots for at least one operator, providing critical skills early in their pilot career.

Loss of Control In-flight is now the largest cause of air carrier accidents - not because there's an increase in its occurrence, but because the other big causes have been so well addressed (like controlled flight into terrain (CFIT).

This led to the formation of the International Committee for Aviation Training in Extended Envelopes (ICATEE) (, which coincidentally first met on the day of the Air France 447 Accident. There are a number of interesting resources on their website.

As for the MPL, the intent should be to train a pilot to be an effective crew member in a multi-pilot operation, which has skills beyond a single pilot operation. However, it should not be used as a means to place a pilot in the cockpit who is not competent to take over at any time, for any reason.

Hand flying (FD off too) should be encouraged during good conditions to maintain skills that easily erode with non-use.

I know my airline's A330 sim training has placed additional emphasis on some hand flying, not that there was ever a great deal of it,but sim time is expensive and the pressure is always to reduce cost. Like you said, there always seems to be something else to cram into the program - and additional sim periods don't seem to be one of them.

While there's a lot a training department can do, there's also a lot that the line pilots can do to help encourage the maintenance of plain old pilot skills.