PARIS (Bloomberg) — The pilots of Air France flight 447 that crashed into the Atlantic Ocean three years ago lacked the right training to respond to a surprise scenario, the French aviation investigator said Thursday in its final report of the incident.
The investigation uncovered “profound loss of understanding” in the cockpit in a moment of surprise, when the aircraft went into a stall and lost lift, the report found. The pilots lacked training for stall scenarios, and the authority recommended that flight simulation training be reviewed.
“The dual failure of the expected procedural responses shows the limits of the current safety model,” the French BEA authority said in its report. “The crew, whose work was becoming disrupted, likely never realized they were facing a ‘simple’ loss of all three airspeed sources.”
The crash of the Airbus A330 wide-body prompted a two- year search for the flight recorders to help determine why the plane disappeared, killing all 228 people aboard. The recordings revealed a state of confusion in the cockpit, with pilots not responding to stall warnings, highlighting a pressure point in modern aviation, where computers run most tasks and pilots are less trained in rapid crisis reaction.
Airbus, which helped fund the search for the recorders, has said that the aircraft was responsive throughout its descent into the Atlantic Ocean. The pilots were required to take over the controls after the auto-pilot disengaged because of faulty speed readings caused by iced-up sensors. That occurrence alone could not explain a crash, Airbus has said.
“Airbus has already started working at industry level to further reinforce the robustness of pitot probes requirements and actively supports related activities,” the manufacturer, based in Toulouse, France, said in a statement Thursday.
The BEA is the latest accident investigation agency to call for improved training for pilots in how to recognize a stall. So-called loss-of-control accidents, which include stalls, are the biggest cause of crashes and deaths around the world, according to statistics from Boeing.
The National Transportation Safety Board has issued several recommendations on the subject during the past decade, including a Pinnacle Airlines Colgan Air flight that crashed Feb. 12, 2009, near Buffalo, N.Y., killing all 49 people on the plane and a man on the ground.
Flight 447 crashed on June 1, 2009, en route to Paris from Rio de Janeiro. The disaster remained shrouded in mystery until the recorders were retrieved. It is unusual for modern aircraft to crash during their high-altitude cruise, as most accidents occur on takeoff or landing. Air France has defended its pilots, saying confusing cockpit readouts are partly to blame.
“The BEA report describes a crew who acted in line with the information provided by the cockpit instruments and systems, and the aircraft behavior as it was perceptible in the cockpit,” the airline said. “The reading of the various data did not enable them to apply the appropriate action.”
The BEA raised several recommendations that indicate shortcomings in how information is displayed to pilots on the A330, in particular the so-called flight director pilots rely on to fly the aircraft. When the autopilot disengaged, the flight director disappeared and other warnings sounded. That led the pilots to make wrong control inputs, although the BEA also found a dozen instances where pilots reacted properly.
The flight-recorder readings revealed that Chief Pilot Marc Dubois, 58, had been on a routine break when the autopilot disengaged, and that he at no point until the crash took back control of the jet. Instead, the two junior co-pilots, aged 37 and 32, shared the task of stabilizing the plane, with the senior pilot giving occasional commands from the background.
“The occurrence of the failure in the context of flight in cruise completely surprised the crew of flight AF447,” today’s report said. “The apparent difficulties in handling the aeroplane in turbulence in high altitude resulted in over- handling in roll and a sharp nose-up input” by the co-pilot, the report said.
Aviation safety specialists have said the trio were probably bewildered by erratic instrument readings and may have done the opposite of what was needed to keep the jet from crashing. The pilots had only three and a half minutes to avert disaster as the jet fell toward the ocean at a speed of 180 feet (55 meters) a second.
“The startle effect played a major role in the destabilization of the flight path and in the two pilots understanding the situation,” Thursday’s report found.
Pilots are trained to avert stalls, which occur when an aircraft slows enough that its wings lose lift, by dropping the nose to increase speed. Instead, the flight data showed that the pilot at the controls for most of the last minutes consistently angled the jet nose higher.
Air France said that it’s involved in “an ongoing process of improving flight safety procedures.”