By Captain Alan Price -Tripbase Air Safety Expert
- The A330 encountered high altitude turbulence, icing conditions, and a faulty pitot probe deice system allowed ice to form on the pitot probe. This led to faulty inputs to the flight data computers which led to loss of airspeed/unreliable airspeed indications in the cockpit.
- The autopilot/auto-throttle systems disengaged as designed and the most junior pilot, the pilot flying, stabilized the aircraft initially and then began to pitch nose up.
- The captain was on a rest break but was called back to the cockpit to assist the pilot crew, and rejoined the crew less than 2 minutes into this emergency.
- The crew began to experience stall warnings, which would normally call for adding power, lowering the nose to gain airspeed and leveling the aircraft once control was reestablished.
- For reasons not known, the pilot flying continued back pressure on the side stick controller, at one point reaching 40 degrees nose up with the aircraft fully stalled, instead of recovering from the stall.
- The A330 began a high rate of descent, nose high, falling toward the Atlantic at over 10,000 Feet/Minute (a huge rate of descent) in a fully stalled condition.
- The pilot not flying at one point made control inputs opposite to those of the pilot flying, yet the aircraft continued its descent into the Atlantic until impact, with forward airspeed of only 107 knots, fully stalled.
- Airline crews “NEVER” practice high-altitude stalls, focusing instead in simulator training on low-altitude stalls in the traffic pattern where altitude loss is a critical factor. With AF447, ground impact was initially no factor as the aircraft was cruising at 35,000′. Further, at this altitude, the engines are producing less than 40% of the thrust they generate at sea level. So, the crew had altitude to lose but much less power for recovery than in the normal low altitude training scenario. This crew had most likely never experienced a fully developed, high altitude stall and may have reverted to habitually trained behavior, the prime objective of which was to never, ever lose altitude, thereby avoiding ground contact.
- Airbus has a design philosophy that can best be summarized thusly (my words): ”Pilots make mistakes which can lead to an accident/undesired aircraft state. If we (the engineers) can design automated systems to reduce pilot mistakes, we can make our aircraft safer. So, let’s design the pilot out of the system to the maximum extent possible – we’ll produce safer aircraft and have fewer accidents.” Sounds good on the drawing board, but in truth, the past 20 years are littered with examples where Airbus engineers either did not anticipate an in-flight abnormality or they erred in software/interface design, both of which have led to major crew errors and accidents.
- As the aircraft descended toward the Atlantic, at one point both pilots made conflicting control inputs. The aircraft was confused, and while the flight software makes allowances for such a condition, the aircraft was trying to respond to an impossible circumstance wherein two pilots were giving conflicting directions to the flight controls. (In human terms, a case of “Cognitive Dissonance”) This one fact is a strong indicator of the confusion which was prevalent in the cockpit that night.
Thoughts on Air France 477
A Tragedy That Need Never Have Happened
By Captain Alan Price -Tripbase Air Safety Expert
The crash of Air France 447 on the night of May 31st, 2009 is a tragedy that need never have happened. Recent reports, based on data obtained from the A330’s FDR (Flight Data Recorder) and CVR (Cockpit Voice Recorder) have filled in the blanks about those final fatal 4 ½ minutes. Early “leaks” point to the usual suspects – the pilots – and tend to dismiss the role that both Airbus and Air France played in this tragic loss of life.
As a retired airline pilot versed in safety and human factor issues, I am saddened to see too little conversation about the “system failures” and too much about “individual failures”. In the lexicon of safety, there is a focus on blaming individuals (Blame Culture) and too little discussion of the system failures (Safety Culture). Early reports indicate the two First-Officers who were at the controls did not handle the abnormal appropriately but why did this happen?
Once the pitot sensing system iced over, a cascading series of events rapidly put the aircraft in grave peril. Failure of airspeed sensing on a modern glass cockpit aircraft is a serious emergency, and when compounded with turbulent conditions at night, all the more so. When airspeed fails, pilots are trained to set engine power based on weight and altitude, thereby allowing the engines to maintain an appropriate speed until speed sensing is recovered. For reasons unknown, this did not happen. Further, the nose of the A330 pitched up while engine power was near idle, leading to a loss of airspeed and a high-speed stall in which airflow over the wings is disrupted until the aircraft quits flying. In spite of these circumstances, recovery should have been a rather straight-forward matter as airspeed increased during the dive toward the Atlantic.
Computers are much better at monitoring than pilots, and on this night, the cockpit was filled with disparate warnings, lights, and sounds – all computer generated and the combination of which could have led to a failure to diagnose the core problem – unreliable airspeed. No one knows for sure why abnormal procedures were not followed, why a stall resulted, but it appears that pilot proficiency is most probably a contributing factor. On international aircraft such as the A330, landing are few and far between and the majority of a pilot’s time is spent adjusting the automation and monitoring flight conditions. My good friend Dr. Earl Wiener is famous for noting that computers are “dumb and dutiful”…they do what we tell them to do, but good old piloting skills are invaluable when faced with compound emergencies. In this automated world, a pilot has to proactively work to insure his skills do not atrophy and that he stays mentally engaged with the aircraft, always asking “what if” questions.
Now to the system break-downs:
- First, both Airbus and Air France knew of the faulty pitot system on the A330 but failed to act with suitable urgency. The directives sent out by Airbus were voluntary, not mandatory. Tragically, Air France had received the new pitot systems but had not yet modified this ill-fated A330.
- Second, the loss of proficiency among the international pilot community is a well-known challenge. Many airlines, aware of the challenges facing their pilots, have added extra simulator sessions for pilots to practice abnormal procedures, take-off and landings, and other issues which are relevant to international flying. High-speed upset and recovery have been a special focus for some years now, yet these pilots seemed ill-prepared to deal with the very issue which confronted AF 447. While Air France cannot be blamed for all failings, this is one they should and could have foreseen and addressed. Since faulty airspeed sensing was a known problem, why did Air France not address this issue in training and position an abnormal checklist procedure more conveniently for its cockpit crews?
- Finally, we are creatures of our culture. The pilot group at Air France needs to be very involved in analyzing the root causes of this crash and insuring its members are professionally prepared for future events which may challenge their skills. This process begins with by taking a hard look at their culture by asking a few simple questions – did our culture contribute to a sense of complacency? Could we have been more prepared? What could we as pilots have done differently?
The manner in which these questions are addressed can insure that the next in-flight abnormal becomes a non-event.
Memorial Day Travelers Want More For The Money
Anxious Bargain Hunters Driving Travel Website Search Numbers Up
By Katie Walmsley – Tripbase Travel Journalist
The economy may be in better shape than last year, but for the legions of Americans planning memorial weekend travel, keeping costs down will still be uppermost in their minds. A yearly AAA survey predicts this year’s Memorial day will see more vacationers than any since 2007 – but the same survey also shows travelers planning to spend 14% less even than last year. Why? Higher gas prices, which also affect the price of air travel, mean less money for everything else. Added to a still shaky economy –people are clinging tightly to hard earned cash.
The figures for Memorial Day seem to ring true for vacationers at other times of the year as well. Travel figures are certainly improved from their lowest points during the recession; when concepts such as the ‘staycation’ became part of our lexicon. Indeed the US Department of Commerce reports the domestic tourism industry experienced extensive growth in 2010, overtaking most other industry sectors – and it forecasts a similar upward trajectory for tourism in the US and worldwide over the next few years. RevPAR reported US hotel occupancy increased 8.4% in January 2011 from the previous year. Most countries reported slightly higher international arrivals rates in 2010 than 2009 – in fact a recent Priceline survey showed 68% of respondents claiming that , this year, a ‘staycation’ wasn’t going to cut it.
This is good news for the travel industry – but it comes with one big caveat. People simply don’t have cash to spare. They still want to vacation; but affordability is paramount. The solution for most is to devote hours to trawling the Internet, in an effort to get the biggest bang for their buck. Noting the trend; the travel industry is responding in kind. Attracting web traffic by saving travelers money and cutting down on their research time has become the holy grail of many travel websites. Indeed according to Marketingcharts.com, multi-category travel sites (sites that search various aspects of travel) account for half the top 10 travel sites viewed in February/ March 2011. Compete.com claims Kayak, which searches numerous travel websites to find the lowest prices on airfares, hotels and car rental, has seen a roughly 22 % increase in web traffic over the past year.
Vacation recommendation engine Tripbase.com takes it another step and has users enter travel preferences, including a choice between fly or drive, along with a budget, and then uses artificial intelligence to recommend various destinations including airfare/ car rental, accommodation and more, that conform to how much users wish to spend.
This new type of Internet site has the potential to further what is already a fundamental change in the landscape of the travel industry. Less conventional destinations, like India, Colombia and Taiwan, that may not immediately spring to mind when booking a trip, have all reported a growth in tourism and anticipate a continuation of this trend. Why? Because people still want to travel, they just don’t want to hemorrhage money doing so. Those countries are less expensive once you get there, and people’s desire to see their vacation fund go further is opening their minds to more unorthodox locations. Companies like Tripbase that start with your budget, and then offer travel suggestions are achieving success because they recognize that for 2011 vacationers, cost comes before all other considerations. Indeed Tripbase has tapped into the notion that vacationers often haven’t historically traveled to certain destinations, simply because they did not know those places had the potential to fulfill their travel goals at their desired budget. The desire to close their wallet is actually opening many travelers minds.
The idea behind the Tripbase model is one other websites are actively seeking to emulate. Google has finally received Department of Justice approval to acquire flight information tracker ITA software, which provides the multi airfare search ability behind such sites as Kayak, and Orbitz. Google’s own post on the settlement implies they’re confident users everywhere will be attracted to a tool that gives them power to search multiple airlines and destinations as the touch of a button ; ‘How cool would it be if you could type ‘flights to somewhere sunny for under $500 in May’ into Google and get not just a set of links but also flight times, fares and a link to sites where you can actually buy tickets quickly and easily?’ Google asks. It can only be hoped from the $700 million ITA price tag that Google will find travelers think it’s pretty cool as well.
Current Rash of In-Flight Incidents
By Captain Alan Price -Tripbase Air Safety Expert
The individual who banged on the door of the American flight descending into San Francisco sounds like a lone wolf and/or a mentally disturbed person. His cousin was quoted as saying he was not political or particularly religious. A perfect MO for someone who bids their time and then takes action to further some supposed agenda. One passenger said he was shouting “ala akbar” (God is great) when being subdued. With this man, God is not so great as he is seeking to harm his fellow man.Some thoughts on security when flying. On this flight, banging on the locked cockpit door is not going to accomplish anything. Since 911, cockpit doors have been armor plated and secured with sophisticated locks, so only the uninformed would try such a stunt. While alarming to the passengers, his chances of gaining entry to the cockpit were nil. I recently wrote that situational awareness is critically important. Be aware of people and circumstances around you, and when something seems inconsistent with the norm, either tell a crew member or take some action until help arrives. Thus, the reaction of the passengers was most appropriate, assisting the flight attendant in subduing the individual and insuring the cockpit is not breached. Whatever you need to do to prevent an unauthorized person from gaining entry to the cockpit, do it!
The traveling public is more concerned and involved. This group of passengers did just the right thing. The plastic hand ties are now kept on the aircraft to subdue anyone who represents a threat to the flight and were used to good effect in this case. We cannot know what intent this person had, but suffice it to say, this was a fool’s mission and one quickly aborted by a quick thinking flight attendant and an alert group of passengers.
The threatening note onboard the Delta flight is troubling, but not uncommon. It is a fairly recent but common phenomena to see this sort of behavior. Generally, a disturbed person is responsible, but the crew cannot take chances and as in this case, will typically divert to a near-by airfield to have the aircraft, passengers, and baggage screened to insure there are no real threats. Be aware in cases such as this, everyone is considered a suspect until screening clears each of us from involvement. Do not be offended, but thankful that appropriate security measures are in place to keep you and your fellow passengers safe.
Safety Tips: Traveling During State Department Alert
By Captain Alan Price -Tripbase Air Safety Expert
As a military and commercial pilot with over 20,000 hours flying time, I can well appreciate a traveler’s need to feel safe. My first tip in this traveler’s survival guide is to maintain “Situational Awareness” (SA). SA if the life-blood of the professional pilot,from staying ahead of the aircraft and the environment in which we operate, to knowing and understanding as much as possible about which passengers are traveling on a given day. SA is, quite simply, one’s best means to anticipate and avoid threatening situations. SA is a nice concept, but what does it mean specifically?
A “Traveler’s Guide” to Maintaining SA:
1. Don’t make assumptions. As Americans, we are used to assuming things will go as they have always gone. Break this habit by becoming a curious person, ask questions, and research your situation before your travel. This is a life-skill that will serve you in good stead, whether traveling domestically or to foreign destinations. If abroad, consult the US Embassy Website and the CDC website for critical information. If traveling by air, the particular airline’s website may also offer timely and relevant information about your route and destination.
2. Be skeptical. We are used to taking people at their word, and believing that what seems to be is. I’m not saying abandon all trust in humanity, but a healthy dose of skepticism goes a long way. From a pilot’s perspective, it is an essential part of the job to always ask “what if” questions. Put yourself through this simple exercise by asking what if questions concerning your environment, the people you depend upon, and your expectations for what should happen in the future. Such a mental board game will uncover inconsistencies that need further investigation and give you mental preparation for contingencies which “may” occur, but which are out of the normal order of things.
There are some specifics about travel by air that will also prove useful:
3. Look around at your fellow travelers, understand who is sitting where on the aircraft, and decide in advance who you could depend upon in a crisis. Every professional pilot and flight attendant does this simple exercise on every flight. You want to know who would be on your team if the chips are down. It is amazing what you can see and surmise just by watching how people act and react, how they dress, and interact with others. File this information away and ensure you know where your dependable persons are seated.
4. Know your aircraft and equipment.
- Read the seat-back information about your aircraft, and pay special attention to door and window exits, flight attendant briefings (yes, they can be boring, but boring may save your life), and where you would best try to exit an aircraft in a ground evacuation. Does the aircraft have life rafts, life preservers, or seat flotation cushions? Great to know for over-water flights. Look at the emergency track lighting on the floor and decide in advance which exit you would use and what the track lighting looks like at this exit – you may be crawling on the floor in a smoke-filled cabin and need this information.
- Think through how you would put the emergency oxygen mask should you need to use it and decide which fellow passengers may need your assistance in putting on their masks. Traveler’s Note: These oxygen systems are designed ONLY for rapid decompressions at altitudes where oxygen use is necessary and will not protect you in a smoke or fume filled cabin because they use a mix of pure oxygen and ambient cabin air.
5. Understand the security situation in the passenger cabin. Since “9/11”, airlines have had to reinvent what we in the industry call the “Common Strategy” – how to deal with security threats to a flight. In many cases our adversary is not interested in negotiation but in destruction. It is not likely you can reason with such a person. They must be disarmed and disabled and you may be the only person who can do this.
- If you see a security threat developing, immediately notify a flight attendant and your fellow passengers. While we do not want to overreact or misread a situation, when it becomes clear a threat exists take action to diffuse it by working with those around you.
- Realize that there may be more than one person involved in a threat to a flight. Check “six” to ensure there are not others involved in the threat.
- The cockpit/flight deck is the most critical location in an aircraft. Flight deck doors are locked and hardened to prevent unauthorized entry. The highest threat times are when pilot crewmembers are entering or exiting the cockpit. Be especially vigilant during these times to provide an extra set of eyes to protect the cockpit from unauthorized intrusion.
6. Stay alert.
- Earlier, we mentioned the importance of maintaining SA. I rarely drink alcoholic beverages on a flight. This is a personal choice, as I never wish to compromise my mental ability to respond to an emergency. Your life may depend upon your ability to think clearly and act concisely.
- Look for inconsistencies in your environment – things that do not look right. If you have a gut feeling something is amiss, investigate further, ask a crewmember, and persist until you resolve the inconsistency. Many onboard situations have been prevented from becoming consequential by alert passengers.
7. Enjoy your flight. I know, it seems that might not be possible with all these security tips floating around in your mind, but realize that flying is approximately 50 times safer than driving. It is the loss of control, which troubles some fearful flyers so realize in this you are not alone. Through better preparation, you will feel more at ease and more in control of your circumstances. You will enjoy your flight more because of your mental preparation and rest satisfied you have done all you can do to make your flight safe and enjoyable for you and your fellow passengers. Truly, you are part of the flight crew team and the safety system on each and every flight you make.