MADAGASCAR FLIGHT NINE MONTHS BEFORE HAD SAME PROBLEM
July 18, 2012 update

NEW REPORT FROM BEA
July 5, 2011 update

Book Tells Hidden Story of Rio-Paris Air France Crash
December 1, 2011 book published

PRESS RELEASE

From the Independent

"According to Roger Rapoport, an American aviation expert and author of The Rio/Paris Crash: Air France 447, the altitude could have been so loud that the pilots may not have even been aware of the stall alarm. The French investigations agency responsible for the report, BEA, makes 25 recommendations to ensure that a disaster of this type never happens again.

At the heart of the measures is a profound rethink about the extent to which modern airline pilots depend on their computers, leaving them literally helpless in a crisis like this.

"Modern pilots are not trained for crises like this," Mr Rapoport said.

"They are not trained to fly at high altitude. An experienced military pilot might have known what to do in a situation like this, but not these pilots."

What people are saying

"Painful, surprising and full of lessons the aviation community was not ready to hear, Roger Rapoport, an honored American author, tells the story of the disaster of Air France flight 447 from Rio to Paris on June 1, 2009. Here is the fascinating story of the long and difficult search for the wreck, an operation of unprecedented scale since the disappearance of the famous pilot Amelia Earhart ... in 1937. Rapoport has taken risks ... as he recounts the drama that took place in the cockpit of Air France 447.... He has seen many people and built a solid case. He is also careful not to draw conclusions based on weak or inaccurate information. This is probably his greatest achievement.

The Chronicle Aeromorning.com Sparaco.

vol air france 447

$9.99 available on Amazon Kindle,
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Investigators annouce surprising report findings (new update 7/5/12)

Aviation accident investigators at the French BEA released their surprising final report at Le Bourget today on Air France 447, the Airbus 330 with 228 aboard that disappeared into the Atlantic off the coast of Brazil on June 1, 2009 writes Roger Rapoport.

Lost for 22 months, the plane was recovered by a team led by the Woods Hole Oceanographic Institute in April 2011. The report has important new information and I'll continue to update this story, which is the subject of my book The Rio-Paris Crash: Air France 447 (published in English by Lexographic Press and in French by Altipresse).

Air France pilots who took command of the aircraft after the automated flight control system failed at 35,000 feet had never been never trained to fly this jet manually at high altitude. The BEA makes it clear that there was no dress rehearsal for this early morning crisis in an Air France simulator. Their lack of hands on experience was built on the assumption that the Airbus 330 couldn't stall thanks to built in fly by wire protections. When these protections were lost a series of errors brought the plane down in just four minutes.

The new report shows that the pilots probably had perhaps a minute to recover from the crisis that began after icing of the aircraft’s speed indicators quickly moved the aircraft from autopilot to manual control.

“After that,” says Patrick Magisson, an Air France Airbus A320 pilot and member of the SNPL pilot union’s safety committee, “it was probably too late.”

Lack of reliable airspeed and misleading altitude information combined with failure of the flight director confused copilots Pierre Bonin and David Robert (the pilot Marc Dubois was taking a nap). Carefully following instructions from their faulty instruments, the pilots may not have realized they were going into a stall until it was too late to recover.

The crisis in the cockpit appears to have been compounded by failure of the flight director, which displays the proper pitch and bank angles required for aircraft to follow a designated trajectory. Lack of reliable airspeed and incorrect altitude readings trigged by instrument failure and the absence of Air France training all contributed to a stall the pilots didn’t understand.

Airbus and Air France emergency procedures for a plane disabled by failed airspeed indicators failed to instruct the pilots to take one critical step: turn off the broken flight director to avoid accidentally putting the plane into a stall. This information is buried deep in the airplane’s manual but it was not part of pilot training for recovery from a crisis like that facing Air France 447 on the night flight from Brazil.

The problem began when the pilots lost their airspeed reading because external probes monitoring this data were frozen by unexpected ice. Now flying manually, pilots Pierre Bonin and David Robert were told by the flight director on their display that the plane had dropped 300 feet. This information was false and triggered a critical problem.

Pilot Bonin followed the flight director’s erroneous instructions to regain the “lost” altitude. With no training handling this jet at high altitude he nosed up to 37,000 feet, far more than the intended 300 foot correction.

Patrick Magisson notes that one remarkable and completely unexpected problem certainly contributed to the confusion.

“Erroneous altitude information from the flight control system triggered a very loud alarm which misled them. When they then heard the first short stall warning both pilots were probably startled. It appears they didn’t realize it was linked to a real stall situation.

“In recurrent training we were not familiar with hearing that uncommon stall warning. In fact all our training exercises deal with false stall warnings in other situations. This particular warning was unfamiliar to all Air France pilots. I had only heard this type of warning once during my type rating training and it turned out to be wrong.

“When the stall warning resumed 43 seconds after the first loss of airspeed indication, they were overwhelmed by noise including the much louder altitude warning. By now there was a huge increase in warnings and they didn’t have any way of knowing which ones were true and which ones were false. To make matters more complicated the emergency procedures they were supposed to follow failed to instruct them to ignore the flight director.

“Faced with altitude and stall warnings and pitching up with no valid airspeed indications they were now in a situation that was impossible to understand. It’s hard to imagine but just four seconds before the second stall warning, which lasted for 54 seconds, the flight director was telling the pilots to pitch up. That was deadly advice.”

Bonin didn’t realize that misinformation from the plane’s computer system was pushing the plane toward a stall at 38,000 feet. Even after the flight director finally told Bonin to nose down, it quickly reversed itself and recommded another climb. This reduced airspeed and contributed to the stall.

“This analysis explains why the pilot kept trying to climb in a situation when he should have recovered from the stall by putting the nose down,” says Magisson.

“There is no real explanation for Bonin’s continued nose up inputs. Perhaps he was so stressed flying the plane at high altitude in turbulence that he made pitch up inputs to control the roll.” “What the pilots did was wrong but it is completely understandable,” says John Clemes, a Canadian investment banker in Paris who heads Entraide Solidarité Air France 447, one of three family associations representing relatives of the 228 crash victims.

Clemes, who lost his brother Brad in the crash, believes the pilots “had too much confidence in a couple of indicators. They didn’t understand the false indications or that they were in a stall. They only had a short time to bring the nose down, gain airspeed and then climb back to the right altitude. The pilots flying Air France 447 had not been trained for this procedure.”

“Essentially,” says Magisson, “they were pitching up in the dark with no clue as to their real situation. They were not trained to fly manually at this high altitude. Lack of training meant they never understood the situation they were in.”

“A lot of people have said this accident was all the responsibility of the pilots,” adds Clemes. “That’s absolutely not the case. A super experienced pilot who properly turned off the flight director would have still had a very hard time avoiding this crash after the erroneous climb.

“And that assumes he had extensive experience flying an Airbus manually at high altitude, something the industry had not been doing. It was a real deadly trap and if you are properly trained on what happens when you lose airspeed at this altitude it is still very hard to get out of it.”

Magisson agrees and suggests that Air France and Airbus did not properly apply lessons learned from similar incidents prior to Air France 447. For reasons that are hard to understand, the failure of the airspeed monitoring devices known as pitot tubes was treated as a mechanical problem. While Air France had planned to swap out the pitots on AF 447 after it returned to Paris on June 1, 2009, this fleet retrofit was not accompanied by special pilot training implemented only after the crash.

“For all the other crews who entered this unreliable airspeed situation it was a real close shave.”
The BEA report cites the experience of another Air France pilot flying an A340 to Madagascar in the identical unreliable airspeed situation as Air France 447.

“This Airbus 340 captain dropped the plane 4,000 feet to avoid a stall and saved the plane,” says Magisson. “In this instance a few months before the doomed Rio-Paris flight, the airspeed indicators froze during daylight. That helped them navigate but they still had a very hard time.”

The BEA has made 25 safety recommendations in the wake of the Air France tragedy.

Look for a further update here shortly on the BEA report.

for more information and interviews call 231 720-0930 or email rogerdrapoport@me.com

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