Procedural Changes Suggested Following Air France Flight 447
Accident
The French air accident investigating agency BEA
has issued a series of safety recommendations stemming from the
crash of Air France Flight 447 on June 1st, 2009. The interim
report issued Friday follows a full readout from the Flight Data
and Cockpit Voice recorders recovered in May of this year.
Among the findings in the report were that the captain’s
departure from the cockpit occurred without clear operational
instructions; the crew composition was in accordance with the
operator’s procedures; and there was no explicit task-sharing
between the two copilots. The data showed that the airplane was
within its normal weight and balance envelope.
The findings also show that the autopilot disconnected while the
air plane was flying at upper limit of a slightly turbulent cloud
layer, and there was an inconsistency between the measured speeds,
likely as a result of the obstruction of the Pitot probes in an ice
crystal environment. The captain was resting at the time of the
autopilot disconnect. Further, the agency says, even though they
identified and announced the loss of airspeed indications, neither
of the two copilots called the "Unreliable IAS" procedure, the
copilots had received no high altitude training for the "Unreliable
IAS" procedure and manual aircraft handling, no standard callouts
regarding the differences in pitch attitude and vertical speed were
made, and there is no CRM training for a crew made up of two
copilots in a situation with a relief captain. The speed displayed
on the left PFD reportedly remained invalid for 29 seconds.
The flight data also indicates that there was a problem with the
indication of angle of attack, and that each time the stall warning
was triggered, the angle of attack exceeded its theoretical trigger
value. The data recorder shows that stall warning was triggered
continuously for 54 seconds.
As a result, the BEA has issued a series of recommendations for
procedure changes based on the findings. The first recommends that
the regulatory authorities re-examine the content of training and
check programs, and in particular make mandatory the creation of
regular specific exercises aimed at manual airplane handling, as
well as approach to and recovery from stall, including at high
altitude. They further recommend that the regulatory authorities
define additional criteria for access to the role of relief captain
in order to ensure better task-sharing in case of relief crews.
The BEA additionally recommends that the regulatory authorities
evaluate the relevance of requiring the presence of an angle of
attack indicator directly accessible to pilots on board airplanes,
require that aircraft undertaking public transport flights with
passengers be equipped with an image recorder that makes it
possible to observe the whole of the instrument panel, along with
specific rules relating to the use of such recordings.
Finally, the BEA recommends that the regulatory authorities make
mandatory the triggering of data transmission to facilitate
localization when an emergency situation is detected on board, and
that they explore a mandate for the activation of the Emergency
Locator Transmitter (ELT) when an emergency situation is detected
on board.
ANN's Daily Aero-Linx (04.15.24)
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