FLIGHT 447, AIRFRANCE 2009

On May 31, 2009 the flight 447, Airbus A330 of Air-France Took off from Rio de Janeiro
(Galeao Airport) bound for Paris Charles de Gaulle Airport, taking the air route through
the waypoints INTOL SALPU ORARO TASIL at FL350 [1]. The cockpit crew were
the captain Marc Dubois, with more than 6.250 flight hours of experience in which 1.700
were in board of an A330, first Officer David Robert (Copilot) in the left seat with 4.479
flight hours in boar an A330 and the first Officer Pierre-Cedric Bonin, with 807 Flight
hours inside an A330. [5] At around 2h 02, the captain left the cockpit and the First
Officer Bonin was piloting the airplane since then.

At around the 2h 08, the Weather Radar detected a storm system near SALPO, so the
crew made a course change following the procedure, no airplane can fly through a
storm. Once they made the detour, they realized that they were flying into a second and
even major storm system [2]. We can determinate that the first storm blocked the
weather radar to detect the second storm system, so the pilots have to fly through this
second storm system without another chance of course change, it was too late. So they
followed the procedure to disengage the Autothrottle of the engines, and started a
manually controlled throttle to fly through the storm, setting to 0.8 Mach speed and the
Engine de-icing turn on [1]. But the throttle stick dont return automatically to the true
throttle position, one must disengage the Autothrottle and also return manually the
throttle stick to the true position in an A330, this was not made it by the pilot in charge
[1].

This has a huge impact to the incoming troubles that were detected.

So the decision to fly through INTOL waypoint, were the plane entered into an extended
region with an enormous cumulonimbus and towering cumulus which can cause a lot of
flight influences like, thunderstorm activity that can create an electromagnetic
interference in radio activity in the airplane and a strong electric field around the
airplane, strong up and downward air motion creating turbulence and varying the
aerodynamics involved in the flight path. [2]

One of the most hazardous phenomena that can occur during the flight through
cumulonimbus systems are the high variation in temperature between the 4.000m and
10.000m where there is a high probability of mixed phase precipitation e.g. shower,
snow, hail, graupel which also may cause the improper behavior of air pressure
sensors.[2, page 222]. Adding this we have the supercooled water droplets, located
about FL150 to FL390 in June 01, 2009 in the path of flight 447. This droplets can
cause the frostbite of the most important sensor, the pitot tubes, which at the very
contact with this droplets, they are clogged and no wind measure can be obtain. [2]

As we can see in the ACARS [4] since approximately 2h 11, all the systems began to
fall down one by one, including the autopilot systems, auto throttle systems, and so on
the Electronic Flight Control Systems (EFCS), who controls all the fly by wire systems.
Doing a track of all the error messages we found out that at 2h 11min 49sec, the most
important

message

appears,

FLR/FR0906010210 34111506EFCS2

1,EFCS1,AFS,,,,,PROBE-PITOT 1X2 / 2X3 / 1X3 (9DA),HARD that means that there is

no measure available from all the three the pitot tubes inboard the A330. As we know
the most important measures are made by the pitot tubes and also the EFCS and the
Autopilot Systems take data from the Pitot tubes measures, and one of this data is the
air speed.

So we can conclude that this fail was one of the biggest causes of the accident, the fail
of the pitot tubes due mostly for the super cooled water that hit the pitot tubes, and this
generated the shutdown of all the electronic systems generating a whole kind of alarms
specially stall alarm which was the most intermittent alarm in that night. [4]

All the systems in shutdown process also causes a huge stress inside the cockpit cabin,
specially this stress is greater for the first Officer Pierre-Cedric Bonin, who was the less
experienced pilot, and this person was flying the airplane at that moment, as we can
see now in the Voice recorder: [3]

"Is he coming back?", rumored David Robert (37, second pilot), even shows frustration
when Mr Dubois take a minute to return to the cockpit.
"Hey, what are you..." hear you say to the Commander when he returns to the cabin of
pilots, to which Robert responds: "what is happening? I don't know, I don't know what is
happening."
Bonin: "I have a problem, I have no indication of vertical speed".

"I have no indication", to which his captain responds: "I don't know, but right now we're
going down."
"What do think? What do you think? What we should do?", said Robert, while the
aircraft moving from side to side.
"I don't have control of the plane, I have no control of the aircraft" said Bonin, when the
stall alarm sounded for the sixth time in two minutes.

So far we can see the huge stress for the confusing signals that were activated at that
moment.

Marc Dubois (57, Captain): "Put the wings horizonatales."

David Robert (37, second pilot): "Leveling the wings."
Pierre-Cedric Bonin (32, pilot flying): "that's what I'm trying to do... "What the hell... How
is it that we are going down this way?"
Robert: "look what you can do with the commands, the primary and so on... climb.
Climb, climb, climb."
Bonin: "But I have been pulling the lever until the end for a while."
Dubois: "No, no, no, not go up."

In this part we can see that due the early error of not adjust the throttle leveler once it
was shut down the auto throttle, has an impact in the speed of the airplane, the pilots
ignore the airspeed in that moment due the shutdown of the EFCS and the Pitot tubes

failure, so instinctively, Bonin tried to pull up the airplane so at high alpha (angle of
attack) the lift coefficient is greater and there is more lift, but the speed was not the
enough to do this maneuver, so they slow down and also affects to the lift, setting the
airplane in a Stall situation.

Dubois at the end realized that, and tries to go nose down to gain speed, but we have
this part of the conversation to analyze:
[3]
Dubois: "care that you are pulling up."
Robert: 'Am I doing it?'
Bonin: "well, you should be doing it, we are at 4000 feet (1,200 m)."
Note: the second pilot, Bonin, thinks that it is better to keep the nose of the plane up to
not continue lowering
Bonin: "We are pulling, pulling, pulling and pulling."
Note: The crew not speaks of the possibility of that are about to crash, instead try to
level the plane during the last minutes.
Dubois: "ten degrees of tilt above!."
Robert: "back to the top... Back to top... "Back up!"
Bonin: "But I've been down at the highest level for a while."
Dubois: "No, no, no...!" Do not go up... No, no

Here we can see that there is a misunderstanding between Bonin and Dubois, they
didnt know each other actions. The difference between an Airbus and a Boeing is that
the joystick in Airbus is independent from captain to copilot, it means that the actions
that are made it by the captain arent known by the copilot. In a Boeing the wheel moves
simultaneously. This difference is a big factor that also affected to the accident.

At 2h 14min 46s the plane crushed in the ocean and all the 228 passengers including
the crew died.

In summary we can give now the causes of the accident:

The second storm system was not read by the Weather Radar, and so by the
crew. (Secondary cause)

The procedure to flight through a storm, disengaging the autothrottle was not
correct. (Primary Cause)

The supercooled water ruin the all the three pitot tubes (Primary Cause)

The EFCS fails due the fail on pitot tubes. (Secondary Cause)

The misunderstanding of the situation and the lack of comprehension between

the pilots of what to do in that situation affected the flight in their last minutes.
(Primary cause).

As a conclusion, what can we learn about this accident? First, there must be a better
way of communication and interaction between the airplane and a weather station who
can give them more information about the conditions of the flight route and options that
the flight can have to avoid the storm. Second, the flight procedures must be very strict
and specific about how it works and how this interacts with the pilots through the
instruments that they have, and what the pilots have to do correctly, without forgetting
any step. Third, more investigation about the phenomena of supercooled water and how
we can flight in this conditions or new procedures when the pitot tubes measures are
not available.

Finally a better communication and training required in this situations of stress in the
cockpit, and in Airbus, only one pilot must use the joystick at a time.

BIBLIOGRAPHY
[1]
[2]

AF 447 FINAL REPORT (July, 2012) retrieved from:

http://www.bea.aero/en/enquetes/flight.af.447/rapport.final.en.php (April 16,
2015)
The accident of AF-447 flight analysis and reconstruction of weather situation
along the flight path (2010) retrieved from:
http://www.zmne.hu/aarms/docs/Volume9/Issue2/pdf/02.pdf (April 17, 2015)

[3]

Pilots Conversation (April 6, 2012) retrieved from:

http://vuelasinmiedo.es/aviacion/la-conversacion-de-los-pilotos-del-airfrance-447accidentado-en-el-atlantico (April 17, 2015)

[4]

Flight 447 ACARS (June 26, 2009) retrieved from:

https://luckybogey.wordpress.com/2009/06/29/af-flight-447-acars-messagesdecoded/ (April 18, 2015)

[5]

Flight 447 additional information (May 27, 2011) retrieved from

http://www.airfrance447.com/about/ (April 18, 2015)