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How Panic Doomed Air France Flight 447

Posted: 12/08/11 08:00 AM ET

On the evening of May 31, 2009, 216 passengers and 12 crew members boarded an Air France Airbus 330 at Antonio Carlos Jobim International Airport in Rio de Janeiro, Brazil. The flight, Air France 447, departed at 7.29 p.m. local time for a scheduled 11-hour trip to Paris. It never arrived. At 7 o'clock the next morning, when the aircraft failed to appear on the radar screens of air traffic controllers in Europe, Air France began to worry and contacted civil aviation authorities. By 11 a.m., they concluded that AF447 had gone missing somewhere over the vast emptiness of the South Atlantic.

How, in the age of satellite navigation and instantaneous global communication, could a state-of-the art airliner simply vanish? It was a mystery that lasted for two years.

Not until earlier this year, when autonomous submersibles located the airliner's black boxes under more than two miles of water, were the last pieces of the puzzle put together. What doomed the 228 men, women and children aboard Air France 447 was neither weather nor technological failure, but simple human error. Under pressure, human beings can lose their ability to think clearly and to properly execute their training.

Over at Popular Mechanics I've got a long piece offering a detailed blow-by-blow account of how one of the co-pilots of the Air France jetliner managed, in the course of just five minutes, to take a perfectly operational airplane from an altitude of nearly seven miles down to impact with the ocean. Here, I'd like to offer a nutshell summary of what happened and what our understanding implies for the future of air safety.

Air France 447 was operating with three pilots: a captain, who was the most senior crewmember, and two co-pilots. At any given time, two of them were required to be in the cockpit, seated at the pair of seats equipped with controls. Four hours into the flight, the captain went to take a nap, leaving the flying of the plane to the more junior of the co-pilots, Pierre-Cédric Bonin. Sitting beside him was the other co-pilot, David Robert.

The crisis began mere minutes later, when the plane flew into clouds roiling up from a large tropical thunderstorm, and the moisture condensed and froze on the plane's external air-speed sensors. In response, the autopilot disengaged. For a few minutes, the pilots had no way of knowing how fast they were going, and had to fly the plane by hand -- something, crucially, that Bonin had no experience doing at that altitude.

The proper thing for Bonin to have done would have been to keep the plane flying level and to have Robert refer to a relevant checklist to sort out their airspeed problems. Instead, neither man consulted a checklist and Bonin pulled back on the controls, causing the airplane to climb and lose airspeed. Soon, he had put the plane into an aerodynamic stall, which means that the wings had lost their ability to generate lift. Even with engines at full power, the Airbus began to plummet toward the ocean.

As the severity of their predicament became more and more apparent, the pilots were unable to reason through the cause of their situation. Despite numerous boldfaced clues to the nature of their problem -- including a stall-warning alarm that blared 75 times -- they were simply baffled. As Robert put it, after the captain had hurried back to the cockpit, "We've totally lost control of the plane. We don't understand at all... We've tried everything."

Psychologists who study performance under pressure are well aware of the phenomenon of "brain freeze," the inability of the human mind to engage in complex reasoning in the grip of intense fear. It appears that arousal of the amygdala causes a partial shutdown of the frontal cortex, so that it becomes possible to engage only in instinctive or well-learned behaviour.

In the case of Air France 447, it appears that Bonin, in his panic, completely forgot one of the most basic tenets of flight training: when at risk of a stall, never pull back on the controls. Instead, he held back the controls in a kind of panicked death-grip all the way down to the ocean. Ironically, if he had simply taken his hands away, the plane would have regained speed and started flying again.

Compounding the problem was a peculiar feature of the Airbus's cockpit layout. Unlike a Boeing jet, in which one pilot's movement of the control yoke moves the other pilot's yoke as well, an Airbus features "asynchronous" controls, meaning that moving one control doesn't cause the other to move as well. Bonin's colleagues probably never knew that he had the controls all the way back -- perhaps because they never imagined that any certified airline pilot could engage in such a misguided response.

Perhaps the most tragic moment of the entire transcript occurs in the final moments, when Bonin at last tells the others that he has had the controls back the entire time. "No, no, no," says the captain. But by then it is already too late.

What can we learn from AF447? Above all, the tragedy reinforces an unfortunate truth about air travel that many passengers do not appreciate: the most dangerous component of a modern commercial jetliner is the brain of its pilot. The majority of fatal airline accidents (vanishingly rare though they may be) are due to pilot error.

One way that airline manufacturers have tried to work around this problem is to increase the amount of automation, so that planes can largely fly themselves, but this tendency has had the paradoxical of compounding the problem: The more pilots rely on automation, the less practiced they are at flying a plane by hand when an emergency requires it.

As a pilot myself, I love taking the controls of an airplane and through it finding a perfect freedom of movement in the sky. I would never want a computer to take that away from me. The practical reality of moving passengers in perfect safety from point A to point B requires a different perspective. As technology improves, and flight control systems become more sophisticated, the relative inadequacy of we two-legged mammals will only become more apparent.

Ultimately, the idea of a relying on a human being in the cockpit may come to seem both sentimental and unaffordably risky.

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On the evening of May 31, 2009, 216 passengers and 12 crew members boarded an Air France Airbus 330 at Antonio Carlos Jobim International Airport in Rio de Janeiro, Brazil. The flight, Air France 447,...
On the evening of May 31, 2009, 216 passengers and 12 crew members boarded an Air France Airbus 330 at Antonio Carlos Jobim International Airport in Rio de Janeiro, Brazil. The flight, Air France 447,...
 
 
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09:37 AM on 12/15/2011
the french panicking during a crisis?

naaaaaaaaaaaaah
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Ergon
Man From Atlan
04:06 PM on 12/29/2011
Internet makes cheap shot artist braver.
11:26 AM on 12/13/2011
Mr. Wise, this article is an affront to any person interested in determining accident causation based on FACTS. Most statements you make are nothing more than your assumptions based on your reading of circumstantial evidences. For instance, you state that "if he had simply taken his hand away, the plane would have regained speed and started flying again". Really? You obviously know nothing about Airbus control laws and trim behaviors. Can you explain why the stall warning sounded twice AFTER Bonin did the correct thing by reducing pitch? When you figure it out, try re-writing your article.

Skybolt
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Ergon
Man From Atlan
04:09 PM on 12/29/2011
Air France pilots have a superb level of training. I don't like the writer's assumptions either.
11:17 AM on 12/12/2011
I don't understand how relying on automation would have helped in this situation. The whole problem as I understand it is that the aircraft met with supercooled water droplets that froze once they were ingested into the pitot probes. (This is the account offered by the Nova documentary). Now, the automated flight system on board the A330 needed accurate airspeed information in order for it to work properly, which it could not get from the pitot probes. How, then, is automation supposed to help when the very systems upon which it depends to work properly fail?

The view that the answer in this case is to remove human beings from the cockpit is too hasty. The problem may be too much automation in the cockpit, which various commentators in the Nova documentary said could lead to less experience actually *flying* the aircraft. Pilots in the simulator were able to save the jet when it encountered the same problem. This suggests, to me, that there is an element of human intelligence that can be very helpful when automated systems fail.

The real problem in this incident is a lack of experience in the cockpit, not a failure to rely properly on automation, or a fundamental flaw in human cognition that can only be surmounted by greater reliance on technology.
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12:59 PM on 12/12/2011
The automation didn't fail, it did what it is supposed to do in a situation like this which is switch to Alternate Law and drop several levels of automated protection. In essence, the computers are saying, "I can no longer fly this thing due to bad raw data, you fly it and you can do anything you want without me interfering."

Lack of experience in the cockpit was not an issue. The crew flying the plane weren't "junior pilots" by any measure. The First Office had more A330 time than the Captain and the reserve pilot was a fully qualified A330 Captain, himself. If we jump to the wrong conclusions then we fix the wrong problems and risk a repeat. Any accident like this has a chain of causes, not a single cause, and may involve very technical and complex issues.
03:56 AM on 12/13/2011
Agree with you completely. Airlines have sought to dumb down the cockpit crew requirements so that any Joe(or Jane) off the street can be made into a pilot. It's the old adage "garbage in, garbage out"--start with inexperience and you end up with the same. Sure one can acquire a limited degree of operating knowledge over the years but there's no substitute for thousands of hands on flying before being hired on.
09:38 AM on 12/23/2011
Another point from this article - Pito probes are heated to prevent ice build-up. Something is not right with this fatal accident and the way we see it.
And yes, by letting yoke go plane would recover from stall - it has stall recovering system.
06:08 PM on 12/11/2011
850 comments and none blaming Bush or global warming. I guess the left fring doesn't read the science articles.
09:35 PM on 12/11/2011
Or maybe progressives don't try to politize everything as you just did.
10:58 AM on 12/11/2011
Yep... It's only a matter of time, maybe 20 years, until professional airline pilots are replaced by completely automated commercial airliners.

Full automation will happen in medical operating rooms as well. Human surgeons will be replaced by robots.
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Sheldon archer
Our facebook is Yuyun Archer
04:36 AM on 12/11/2011
Any experience pilot will tell you that flying consists of hours of boredom, interrupted by a few moments of sheer terror.
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01:55 PM on 12/11/2011
I've been a commercial, instrument and mulitiengine rated pilot for over 50 years and I've never experienced a moment of sheer terror.
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Sheldon archer
Our facebook is Yuyun Archer
05:56 PM on 12/11/2011
Well I am 77 and about the same and I sure have :-)
08:27 PM on 12/11/2011
Thanks for reassuring me!
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johndpieper
I dance the skies on laughter-silvered wings
02:31 AM on 12/11/2011
This is such a sad event and it never had to happen. This is exactly why we train almost hour for hour that we are actually in the air. One thing is clear. There is a deficiency in all training programs, but so far, there's no way to fix that. You can train, and train, and train in the simulators and with your training pilots but you can't create your body's physiological response of being in a real emergency. This might be an accident where this is glaringly true.

There's always that part of your brain that knows you are in a simulator, or with a much more qualified captain or training officer so no matter how hard you train, your body never goes into full stress response where you have to work very, very hard to not only trouble shoot the emergency you are in, but to suppress your anxiety response, your flight or fight response, pr the part of your brain that assigns the level of "agony" or "doom" you feel to pain, or situations where death could be the outcome.

Having said that, training problems are very good at creating muscle memories, or automatic responses from continued cause and effect training. To make the process easier check lists are created for most emergency events that you could face while flying commercial jets. Checklists remove the necessity to memorize sequences or trouble shooting processes which could be difficult to do in an emergency. It's right there for the pilot.

Crew coordination is also critical to training programs and while actually flying. There used to be a real hesitance for a co-pilot to question or second guess a captain when the co-pilot had concerns that the captain might be making a mistake. American air carriers have worked diligently to remove that hesitance or unwillingness to say, "Captain, I'm not sure that's appropriate", or "let's take a couple seconds to see if that right or if we're seeing everything as a whole". Both pilots are expected to speak up and work together. The cockpit during operation or during an emergency is no place for egos to be present. To help, while doing simulator training, or during flights with your check pilot, the captain will intentionally do something questionable hoping the first officer or other pilots present become comfortable with challenging a decision or action. Most captains encourage the sense of "we're both flying this airplane. You're input is important"

I do not know how Air France training programs are run, but I suspect they are similar. Most airlines require the most up to date, highly technical training to certify both captains and first officers. The flying public need  not worry when stepping onto an aircraft. I assure you.

This was an accident that easily could have been avoided.
02:20 AM on 12/11/2011
Flight 447 did not crash because of human error. That was likely the reason given so that the airline manufacturers would not get sued for aircraft design flaw. Flight attendants have learned to dread flying the airbus planes because according to them during severe turbulence the fuselage shakes and twists very hard in a wringing motion, much like a wet dog shaking the water off its back. Flight attendants have been catapulted to the ceilings and inside kitchen galleys during such moments, sustaining severe injuries to the extremities, back and neck. As a therapist, I have had the privilege of treating a number of them. One American Airline flght attendant adamantly stated, "if it ain't Boeing, I ain't flying! " Remember that numerous Airbus crashes and accidents like engines dropping off the wings during takeoff have been recently occurring, but the media just has not taken interest.
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Sheldon archer
Our facebook is Yuyun Archer
04:35 AM on 12/11/2011
I am an experienced pilot. How about me taking one of your patients for psychological therapy? Just because one of your patients dislikes the Airbus, that makes you an expert in crash investigation?
06:37 PM on 12/11/2011
Your experence as a pilot allows you to decide that the flight attendants' fractured bones, bruised nerves and herniated discs are caused by psychological issues and not impact against aircraft walls, food carts and various fixtures? Go back to napping at the wheels!
08:26 AM on 12/11/2011
Dude, they have the black box.
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joyfree
Jaded by life, but ever hopeful...
09:32 PM on 12/11/2011
Short and sweet! Fanned and faved.
01:04 AM on 12/11/2011
So Bonin killed himself and everyone on board. Whoops.
11:52 PM on 12/10/2011
Does anyone see a show on NATIONAL GEOGRAPHIC called Mayday, or maybe its called Air Disaster and every episode they tend to focus on one disaster. I remember one incident where the pilot gave the control of the plane to his 7 year old kid! I also distinctly remember the AIR JAPAN disaster where the passengers knew all the way that they were dying....about 45 minutes prior to the crash. Some wrote letters to their loved ones with their blood.
Ghastly if you think about it.
You know they say that Air travel is the safest means of travel and it probably is, but I would not want to be in an airplane, completely helpless, plummeting down in the middle of the cold ocean in the dark of the night. It may only be minutes but for those unfortunates those minutes might have seemed like hours.
10:18 PM on 12/10/2011
I crossed paths with a commercial airline instructor who communicated to me that he would never fly an airbus again, for all of the reasons the experts were shouting years ago when it was on the drawing board. Compromising passenger and flight staff safety for costs is outright immoral.
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gmjonn
08:26 PM on 12/10/2011
Sounds like a poor choice on Airbus part to use a "asynchronous" controls type set up.
08:17 PM on 12/10/2011
It seems that many comments deride the Airbus. I too thought at a fly by wire plane an bad idea. The film clip of the Airbus prototype over flying its landing at the Moscow International Air Show, and crashing into the forest spoke volumes about the dangers of fly by wire. Then there was Captain Sully Sullenberger landing an Airbus in the Hudson River. The finesse that Capt. Sullenberger displayed makes me wonder.
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02:43 AM on 12/11/2011
All Boeing aircraft are now fly by wire and have been since a few generations of 737s ago. Top line jet fighters have been fly by wire for 40 years. Your complaint isn't against fly by wire, it is against the computer systems that are imposed between the pilot's controls and the control surfaces, themselves. All fly by wire does is actuate controls that were, previously, actuated by hydraulic links and cable-pushrod systems. Believe me, those were maintenance nightmares.

The only direct actuated and unboosted systems are on light aircraft where the control forces are manageable by human muscle. You don;t have a complaint against fly by wire, you have a complaint against software programmers.
07:49 PM on 12/10/2011
How many airbus planes have crashed or had serious accidents like engines falling off since they first rolled off the European assembly line? Flight attendants are leery of flying on an airbus because during turbulence its fuselage shakes like a wet dog shaking the water off its back. An American flight attendant is so paranoid about airbuses that she refuses to fly on an airbus. "If it ain't Boeing I ain't going."
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live by the golden rule
06:40 PM on 12/10/2011
Same problem with cars, where "pilot error" (or, increasingly, texting) is responsible for tens of thousands of deaths a year in the US alone.