Final Report – AF 447

Flight AF 447 on 1st June 2009 (A330-203, registered F-GZCP)

During the night of Sunday 31 May to Monday 1st June 2009, the Airbus A330-203 registered F-GZCP operated by Air France crashed into the Atlantic Ocean. The aeroplane had taken off at 22 h 29 to undertake scheduled flight AF 447 between Rio de Janeiro Galeão and Paris Charles de Gaulle. 12 crew members (3 flight crew, 9 cabin crew) and 216 passengers, from thirty-two nationalities, were on board. The last radio communication between the crew and the Brazilian ATC took place at 1 h 35. Between 2 h 10 and 2 h 15, a position message and 24 maintenance messages were transmitted by the ACARS system. On Monday 1st June 2009 at around 7 h 45, the BEA was alerted by the Air France Operations Coordination Centre.

After having established without doubt that the airplane had disappeared in international waters, and in accordance with Annex 13 to the Convention on International Civil Aviation and to the French Civil Aviation Code (Book VII), the BEA, as Investigation Authority of the State of Registry of the aeroplane, instituted a safety investigation and a team was formed to conduct it.

In accordance with the provisions of Annex 13, Brazilian, American, British, German and Senegalese accredited representatives were associated with the investigation as the State of the engine manufacturer (NTSB) and because they were able to supply essential information to the investigation (CENIPA, ANAC) or because they provided assistance in the sea search phases (AAIB, BFU).

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… Thus, the accident resulted from the following series of events:

Temporary inconsistency between the measured speeds, likely as a result of the obstruction of the Pitot probes by ice crystals that caused the autopilot disconnection and the reconfiguration to alternate law;

ˆInappropriate control inputs that destabilised the flight path;

ˆThe lack of any link, by the crew, between the loss of displayed airspeed information and the appropriate procedure;

The late identification of the deviation from the flight path by the PNF and insufficient correction applied by the PF;

The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;

The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it.

These events can be explained by a combination of the following factors:

The lack of effective feedback mechanisms on the part of those involved that made it impossible to:

Identify the repeated non-application of the IAS procedure and to remedy this,

Ensure that the risk model for crews in cruise included icing of the Pitot probes and its consequences;

The lack of practical training in high altitude manual aeroplane handling and in the procedure for speed anomalies;

Task-sharing weakened by:

Incomprehension of the situation at the time of autopilot disconnection,

Poor management of the startle effect, resulting in a highly charged emotional factor for the two co-pilots;ˆ

The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers;

The crew not taking into account the stall warning, which could have been due to:

A failure to identify the aural warning,

The appearance at the beginning of the event of brief warnings that could have been considered as spurious,„

The absence of any visual information to confirm the approach-to-stall after the loss of the characteristic speeds,

Possible confusion with an overspeed situation in which buffet is also considered a symptom,

Flight Director indications that may have confirmed the crew’s view of its actions, even though they were inappropriate,

The difficulty in identifying and understanding the implications of the reconfiguration to alternate law with no angle of attack protection.

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Press conference on 5 July 2012  |  Final Report  |  Investigation Chronology  |  Reports (2009-11)  |  Sea search operations  |

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Final Report Presentation:

http://www.bea.aero/fr/enquetes/vol.af.447/presentation.rapport.final.05juillet2012.en.pdf (pdf 759KB)

Summary (pdf -691KB) |  Safety Recommendations (pdf -288KB) |

Final Report:

http://www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf   – (26.6 MB)

http://media.webcastor.fr/vod/bea/pdf/f-cp090601.en.pdf (mirror site)

Final Report Appendices:

Appendix 01 –  CVR Transcript
Appendix 02 –   FDR Chronology
Appendix 03 –   Graphs of parameters
Appendix 04 –   SAR communications
Appendix 05 –   Air France “Vol avec IAS douteuse” procedure
Appendix 06 –   Airbus “Unreliable speed indication” procedure
Appendix 07 –   Extracts from Air France briefing brochure (« IAS douteuse » exercise)
Appendix 08 –   “Info OSV” document
Appendix 09 –   Certification envelope of Pitot probes
Appendix 10 –   Additional Air France unusual “STALL warning”  procedure
Appendix 11 –   Airbus “STALL WARNING” technical supplement
Appendix 12 –   TEMSI chart

The BEA (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile) is the French authority responsible for carrying out safety investigations relating to accidents or serious incidents in civil aviation.

link to BEA: [http://www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php]

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