The Human Factors That Caused Air France Flt 447 to Crash

The Human Factors That Caused Air France Flight 447 to Crash 1

The Human Factors That Caused Air France Flight 447 to Crash

Safety and Emergency Management Systems

Derrick Todd

2015-08-04

David Hojberg, Janelle Walters, Natalie Wintemute


Summary of the Crash

Air France Flight 447 (AF 447) was a tragic air accident that resulted in 228 casualties

(Air France Flight 447, n.d.). On the evening of May 31st, 2009 Air France took off from Brazil en

route to Paris with 216 passengers and 12 crew members (Air France Flight 447, n.d.). The

aircraft entered into a thunderstorm area and experienced St. Elmo’s Fire. This weather

phenomenon served as an instigator, as the pitot tubes had frozen from the cold temperatures

outside. The pilots lost three navigation systems. This accident has become Air France’s most

deadly crash. For years, investigators searched for the black boxes of the Airbus A330-200 that

would reveal what caused the tragic fate of this flight. It was not until two years later that the

voice data recorder and cockpit voice recorder were recovered from the Atlantic Ocean sea bed

(99 Percent Invisible, 2015). Prior to receiving the data from the voice recorders, there was

confusion from aviation experts and the public as to why the AF 447 crashed into the ocean.

After much investigation it was determined that human factors played a large role in the

demise of this flight; from beginning to end, the flight was tainted with fatigue, complacency,

lack of communication and resources. Lack of training and knowledge, stress and pressure, and

ultimately, lack of teamwork, would work together to put the nose of the A330-200 into an

aerodynamic stall spiraling towards the Atlantic Ocean (Sinyi, 2013). These nine various human

factors issues all created the perfect storm that hindered the abilities of three experienced

pilots from safely flying their aircraft to their destination.

Fatigue


Fatigue became one of the most prominent human factors that aided in the demise of

AF 447. The flight from Rio de Janeiro to Paris, France is an 11 hour flight, thus requiring three

pilots to successfully fly the route without breaking any crew duty rest period rules (Air France

Flight 447, n.d.). The three pilots included experienced Captain Marc Dubois, and co-pilots

David Robert and Pierre-Cedric Bonin (Allen, 2014). It is well documented that Marc Dubois was

awake all night and the day prior with his companion, only sleeping for one hour the night prior

to his flight. This distraction notably impaired his ability to sleep during the next day leading up

to his overnight flight to Paris (Langewiesche, 2014).

Dubois’ lack of rest carried over during his flight, as he was eager to take his break

around 0215 GMT, approximately 3 hours into their flight (Air France Flight 447, n.d.). Marc

Dubois was called back to the cockpit 1 minute and 38 seconds after the pitot tubes froze. Still

drowsy from his sleep, he had only a few minutes to understand how the situation had

escalated so quickly, and try to find a solution. Still fatigued from his short rest period, Marc

Dubois lacked the knowledge of the situation and the resources necessary. Dubois was unable

to assess the situation and accurately advice his co-pilots of what to do prior to the crash.


Complacency

The most prominent factor regarding complacency in the case of the AF 447 is the

sophistication of the Airbus A330-200. First the lack of manual flying time allows pilots to

become reliant on the systems of the aircraft and reduces the amount of manual time so

greatly that pilots can become flustered should manual controls need to be taken. The A330-

200 requires about 2 minutes of manual piloting during take-off, and another 2 minutes during

lading, only regained during the final 500 feet of decent (Mayday, 2013).

Again relating to the sophistication of the aircraft, safer systems can cause individuals to

become complacent. When pilots believe that a system is safer and more fool-proof per se, he

or she will be more willing to engage in riskier behaviour, as compared to a less sophisticated

aircraft. In the case of AF 447, this can be seen throughout the period of bad weather which

occurred during flight. Captain Dubois made a decision to fly directly through a massive system

of bad weather. Co-pilot Bonin later stated he was happy they were in an A330. While it will

never be known exactly what the crew were thinking, the reliability of the aircraft definitely

played apart. The two Co-pilots constantly flew that route and felt confident flying through the

storm; whereas other aircraft in the area that night chose to fly around the weather systems,

and were not affected. Captain Dubois was a new edition to KLM’s management staff and was

piloting the flight as recurrent training.


Lack of Communication

Communication is an integral part of every crew’s operation. In the case of AF 447,

communication was definitely on the back burner. There was evident lack of communication

between all of the pilots. First communication should have been given from Captain Dubois to

have Co-pilot Robert take controls, as he has significantly more flight hours than Co-pilot Bonin.

Given the circumstances of the thunderstorms approaching before Captain Dubois’ rest, he

should have mandated who was in control.

Another imperative communication shortfall was when Captain Dubois re-emerged from

the crew rest area. He sat in the jump seat and had the chance to take a fresh look at the

situation, and should have regained control of the aircraft. Not only did he continue to sit jump,

but no communication was given to what had previously occurred. The only questions that

were asked were “what was happening?”; nothing was stated about what the co-pilots had

done and how they could have effectively corrected the situation. In the end communication

and working together could have saved Flight 447 and the 228 souls on-board.

Pressure

The pressure had mounted on Co-pilot Bonin to navigate their aircraft through the

thunderstorms approaching the aircraft, especially once Captain Dubois left for his rest period.

Bonin had expressed concern over the turbulence they would face while approaching the

oncoming thunderstorms to both Dubois and Robert. After many dismissals to climb to their

recommended maximum height of 37,000 feet, Bonin was uncomfortable to speak his opinion.


It was noted that Bonin was self-aware of his rank as a co-pilot, and would not go against

Dubois’ instructions (Langewiesche, 2014).

Once the pitot tubes had frozen and the pilot’s lost control of their vertical height and

speed, it was obvious there was pressure to quickly solve the problem and return to straight

and level flying. Another problem the pilots were experiencing was making sure not to disturb

the passengers, and fellow crew members while searching for an answer. Finally, after Captain

Dubois was alerted of the situation and awoken from his rest, he was forced to solve the

problem in a limited amount of time. It seemed as though all the human factors were working

together to cause such a large disturbance to the pilots brains, thus hindering their ability to

recognize they were in a stall, before it was too late.

Stress

The stress incurred by both the Co-pilots and the Captain was so severe, that it

debilitated their knowledge of basic aircraft warning systems. The Air France crash has become

an example of what happens when pilots become complacent with their computer aided flying.

As technology increased and became more sophisticated, it was well documented that Airbus

had designed the most refined cockpit in the world. The A330 was supposed to set a new

standard for computer-aided flying. Unfortunately, the Air France crash uncovered the

dangerous side effects to allowing pilots to actually be in control of the aircraft for so few hours

of their duty time.


The stress increased as the pressure to regain control of the aircraft also increased. The

pilots were faced with the difficult decision of understanding the situation. It seemed all the

pilots did not communicate with each other, and each tried to solve the problem on their own.

The stress became increasingly obvious when investigators reviewed the voice data recorder.

The pilots were not capable of processing and approaching the situation in a calm and

reasonable manner. If the pilots were better able to communicate and logically assess the

situation, this accident could have been avoided.

Lack of Training

A leading cause for the aircraft to have entered a stall was the consistent nose up

attitude that was being held by the second officer. After the pitot static system went offline due

to ice build-up, the autopilot automatically shut off and handed flying over to the pilots at

which time the second officer who had less than 3000 flight hours took over. With the pitot

system down, the aircraft read a 400 foot drop in altitude; this is when the second officer

started to pull back on the stick. For a few minutes the aircraft did ascend, but a drop in

airspeed stalled the aircraft and it started to fall. The aircraft did recognize the stall and gave

out the verbal alarm “stall stall stall” Co-pilot Bonin did hear the alarm but for some reason

held the aircraft in the nose up attitude. This action was done until the Captain re-entered the

flight deck, and realized the stall and told Co-pilot Bonin to lower the nose. This action was too

late and the aircraft crashed in the ocean in a nose up attitude.


From very early on in a pilot's training, they are shown what a stall is, how an aircraft

enters a stall and, most importantly how to recover once in a stall. This is a very fundamental

part of training for any pilot. They are taught that when an aircraft enters a stall, they must

lower the nose to gain more air speed and the stall will eventually be broken. Inadequate initial

training or recurrence training could be why the pilot’s neglected to understand why the

aircraft had stalled and not recovered properly.

Lack of knowledge

Lack of knowledge goes hand in hand with lack of training. After investigators looked

into the accident many deficiencies were noted and many mistakes had been made by the flight

crew. As stated above, the primary factor of the crash was the aircraft stalling. Between the

amount of flight hours of the crew, and the stall alarm going off, the crew should have been

able to easily correct the issue, with ample time to do so. The stall warning was ignored and the

aircraft was kept in a nose up attitude, ultimately leading to loss of sustainable lift.

As with all accidents, it takes more than one thing to go wrong, it is usually a sting of

events. The BEA stated "The combination of the [Airbus] warning system ergonomics, and the

conditions under which [Air France] pilots are trained and exposed to stalls during their

professional and recurrent training, did not result in reasonably reliable expected behaviour

patterns” (newscientist, 2012). If the crew had taken a moment to evaluate the situation

thoroughly and think through their training, perhaps this disaster could have been avoided.


The BEA has since made recommendations, including making sure the pilots have a solid

understanding of the physics of flight. They also recommend that in simulators, more abnormal

situations take place, this includes surprise events and emotionally highly charged situations.

The BEA also stated that the pilots “should at least assign a minimum degree of legitimacy to

such alarms” (newscientist, 2012).

Lack of teamwork

During the flight, it was stated that the Captain decided to go have his rest period during

a critical time in the flight, during thunderstorms. He therefore left Co-pilot Robert to handle

the radios and the less experienced Co-pilot Bonin to fly the aircraft.

When the aircraft started to stall, the pilots did not work as a team or properly

communicate what they were doing. For a long period of time, Bonin was holding the aircraft in

a nose up attitude, increasing the stall; at some point Robert took over the flight controls. Due

to a lack of teamwork and communication, Bonin did not know Robert had taken over control.

Both pilots were trying to fly the aircraft without letting the other know. It was only when

Captain Dubois came back to the flight deck that the situation was sorted out, but by this time it

was too late and the aircraft was too close to the ocean to recover. If the pilots had worked as a

team and the Captain made a better decision to not leave the flight deck, the crash could have

been avoided.


Lack of Resources

With larger more complex aircraft, pilots have become increasingly more reliant on the

computer systems and instruments to safely and efficiently fly the aircraft. However this could

also work against them as they could lose some of their core piloting abilities.

During the storm, the temperature dropped to around -40◦ Celsius causing ice to form

on the pitot static system, thus causing the pilots to lose core instrumentation. Pilots are

trained to deal with the loss of instruments, by using alternative instruments to gain the

adequate information necessary. However, with the loss of instruments the pilots were left

confused and they did not know how to recover from the false readings. The inability to gauge

the instruments properly was one of many factors which aided in the aircraft accident. If the

pitot system had not gone offline, the pilots may not have lost control of the plane and the

situation.

Conclusion

The accident of Air France Flight 447 was set out to be a normal flight with an

experienced crew. All of the issues that plagued the flight were, alone, very small and fixable.

However it was a combination of these nine human factors that ultimately caused the crash.

Inadequate training and teamwork amongst the pilots was a result from company training. The

lack of resources, even though important, cannot be solely blamed either. As with all aviation

incidents or accidents, an amalgamation of human factors and errors must take place in order a

tragedy to take place. With the appropriate skills, training, knowledge


Bibliography

Air France Flight 447. (n.d.). About AF447. Retrieved July 29, 2015, from Air France Flight 447

Information of The Crash of Air France Flight 447: http://www.airfrance447.com/about/

Allen, P. (2014, October 13). 'F***, we're dead!': Pilot's cry as Air France jet plunged into

Atlantic as final moments of doomed Flight 447 and its two sleeping pilots are revealed.

Retrieved from Daily Mail Online: http://www.dailymail.co.uk/news/article-2790768/f-

dead-pilot-shouted-air-france-jet-plunged-atlantic-final-moments-doomed-flight-447-

two-sleeping-pilots-revealed.html

Langewiesche, W. (2014). The Human Factor. Vanity fair, 2-3.

Marks, P. (201, July 5). Air France 447 downes as crew ignored alarms. Retrieve August 3, 2015.

From https://www.newscientist.com/blogs/onepercents/2012/af447-final-report.html

Mars, Roman. "Children of the Magenta (Automation Paradox, Pt. 1)." Audio blog post. 99 Percent

Invisible. 99 Percent Invisible, 23 June 2015. Web. 30 July 2015.

<http://99percentinvisible.org/episode/children-of-the-magenta-automation-paradox-pt-1/>.

Sinyi, M. (Director). (2013). Air Crash Investigation Air France Flight 447: Vanished [Motion Picture].

The Human Factors That Caused Air France Flt 447 to Crash

Documents

Transcript of The Human Factors That Caused Air France Flt 447 to Crash