Air France Flight 447 (abbreviated AF447) was a scheduled commercial flight from Galeão International Airport in Rio de Janeiro, Brazil to Charles de Gaulle International Airport in Paris, France. On 1 June 2009, the Airbus A330-200 airliner serving the flight crashed into the Atlantic Ocean, killing all 216 passengers and 12 aircrew.

1. Flight AF 447
31. May 2009
Jürg Schmid
The Aircraft
 A330-200, entered service in 1998
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2. Technology
 Fly-by-wire technology
 Glass cockpit
 Flight planning
 Communication
Crew and Passengers
 3 flight crew, 9 cabin crew, 216 passengers
 Part enlargement
 Pilot flying, pilot non flying
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3. The flight
 Take off at 2229, weight 232.8t (MTOW 233t)
 At 01h 35min 15sec last communication, with
ATLANTICO controller
The weather
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4. History of the accident 1
 Cruise at FL 350, Mach 0.82, pitch 2.5° ANU, autopilot 2 and
auto-thrust engaged
 At 2 h 08 min 04, left turn by 12°, speed reduced to Mach
0.80
 At 2 h 10 min 05, autopilot and auto-thrust disengaged, PF “I
have the controls”
 Hard nose up input, stall warning sounded twice, left PFD
and ISIS speed 60 kts
 At 2 h 10 min 16, PNF “we’ve lost the speeds then”,
“alternate law protections”
 Vertical speed reached 7000 ft/min”, dropped to 700 ft/min
History of the accident 2
 At 2 h 10 min 50, PNF tried several times to call
Captain back
 At 2 h 10 min 51, stall warning triggered again and was on
for 54 sec
 Thrust lever TO/GA, PF maintained nose-up inputs, AOA 6°
increasing
 Trimmable horizontal stabilizer from 3° to 13° in 1 min, and
stayed
 At 2 h 11 min 06, speed on ISIS 185 kts, PF continued with
nose up inputs
 Altitude 38’000 ft, pitch and AOA 16°
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5. History of the accident 3
 At 2 h 11 min 45 Captain re-entered the cockpit
 In the following sec all speeds became invalid and the stall
warning stopped
 Altitude then about 35’000 ft, AOA exceeded 40°, ROD about
10’000 ft/min
 At 2 h 12 min 02 , PF “I have no more displays”, PNF “we
have no valid indications”
 Thrust IDLE detent, pitch down inputs, AOA decreased,
speed again valid, stall warning
 At 2 h 14 min 28, PF said: “we are going to arrive at level
one hundred”
History of the accident 4
 At 2 h 14 min 28 the recording stopped. Last values
 Vertical speed -10’912 ft/min
 Ground speed 107 kts
 Pitch attitude 16.2 ° ANU
 Roll 5.3° left
 Heading 270°
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6. Final Report by BEA
 Chapter Conclusion, 51 Findings listed
 Several airplanes in same region altered routes to avoid
clouds
 The copilots have not undertaken any in-flight training
at high altitude
 Neither of the pilots made any reference to stall
warning or buffet.
 In less than 1 min after AP disconnect its flight
envelope, inappropriate pilot input
Cause Map – Page 1
AND
Why? Possible Solutions:
OR
Effect Cause
Cause
Start with the Goals (in red) that have been impacted. Evidence:
Read the map to the right by asking Why questions.
Step 2. Cause Map - Page 1
Flight control Loss of speed Pitot probes
automation not indications clogged with
operable (CAS) ice
Safety Goal 228 poeple
Impacted killed Evidence: Evidence:
FDR records FDR records
Airplane broke Plane unable
Plane nose-up
apart by impact to maintain and stall
with water altitude
AND
Property
Goal Airplane
destroyed
Impacted
Crew failed to
control flight
manually
Customer Goal Evidence:
Impacted FDR records
Eroded
confidence in
safety of AF
Production
Goal
Impacted
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7. Cause Map – Page 2
1
Pitot probes
used vulnerable
Step 2. Cause Map - Page 2 to icing
Evidence:
17 cases of icing
Loss of speed Pitot probes AND with Thales AA
indications clogged with in 2003 - 2008
(CAS) ice
Meteorological Crew decided to
Evidence: keep the
FDR records
conditions/
thunderstorm planned route
AND
Evidence:
Conflicting FDR records
indications and
alarms
Evidence:
Crew not aware FDR records
that the plane at AND
stall
Crew consider
stall warnings
Crew failed to
unreliable ?
control flight
OR
manually
Evidence: AND
FDR records 2
Angle of attack
Crew failed to
not displayed
restore aircraft
from stall
Evidence:
AB design
Cause Map – Page 3
Step 2. Cause Map - Page 3
Absence of the Rest breaks
Captain when routine in long
problem starts flights
Hard- / Soft-ware Co-pilots Evidence:
problems that AND FDR records
overloaded and
disabled manual confused
control ? 3
4
Evidence: No Task-sharing
Crew failed to evidence thus AND not defined by
restore aircraft far to indicate that the captain
from stall
Lack of Evidence:
OR coordination in FDR records
the cockpit AND
Crew 4
performance Co-pilots did not
problems brief the Captain
AND on his return
Evidence:
6 AND FDR records
Co-pilots not
trained for stall 5
at high altitude
Left and right
Evidence: controls not
Training records linked
Evidence:
AB design
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8. Cause Map – Page 4
Step 2. Cause Map - Page 4
Crew failed to
restore aircraft
Customer Goal from stall
Impacted
Eroded AND
confidence in
safety of AF
Production Co-pilots not
Goal trained for stall
Impacted recovery
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Evidence: Use of Pitots
Training records vulnerable to
icing
AND
7 AF reluctant to Avoiding
replace the unjustified
Feedback from
Pitot probes ? costs ?
incidents not AND
adequate
AND / OR
Evidence:
17 cases of icing
with Thales AA in Replacement of Research by
2003 - 2008 the Pitot probes Airbus took too
postponed long time
Evidence: existing Evidence: existing
Correspondence/ Correspondence/d
documents ocuments
“A crew can be faced with an unexpected situation
leading to a momentary but profound loss of
comprehension. If, in this case, the supposed capacity
for initial mastery and then diagnosis is lost, the safety
model is then in ‘common failure mode’.”
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9. Safety Recommendations
 “Shall in no case create a presumption of blame or
liability” (EU 996/2010)
 Flight recorders, image recorder, FD recorder.
 Certification of pitot tubes
 Training for manual airplane handling
 Additional criteria for access to the role of relief
Captain
 Presence of an angle of attack indicator
Reactions
 Operators
 Manufacturers
 Regulators
 Aviation industry actions
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10. Underlying problems
 Basic experience versus highly automated aircraft
 Market competition
 Rising technical complexity versus individual know how
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Thank you for your attention
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