This process came very much to mind as I read Capt. Bill Palmer's excellent "Understanding Air France 447". In this case, aeronautical sins of commission and omission were committed. Fatal results ensued. 228 people died. Attention must be paid.
Perhaps in a more just world, the Chief Pilot at Air France would have come forward with a book that covers this ground. Of course, some combination of legal trepidation and organizational pride will preclude that from happening and so Capt. Palmer has stepped into the central role. By his deep expertise in the systems and behaviors of Airbus aircraft (and the A330 in particular), he is highly qualified to do so.
The author starts us off with an outline of the chronology of the event, the basic biographical data of the flight crew, and an overview of the operational environment that prevails on these long flights across the lonely South Atlantic. He reviews the adverse weather conditions that the flight encountered. We learn about the icing-related failure modes of the pitot-static system that in all likelihood caused a temporary loss of all airspeed data, precipitating the cascade of events leading to loss of the aircraft. A clear and helpful description of the Airbus' fly-by-wire system, its control laws and ancillary systems gives the reader a basis for understanding the events that follow with frightening speed.
At 02:10:05 UTC on 1 June 2009, due to absence of airspeed data, the autopilot on A330-200 aircraft F-GZCP disconnected, returning control to the Pilot Flying (PF). There was nothing else wrong with the aircraft. And yet, four minutes and 23 seconds later, the Airbus smashed into the unyielding surface of the ocean below. To aid in understanding how this could have happened, Capt. Palmer divides the period from autopilot disconnect to impact into four phases three only seconds long, the fourth just a few minutes. He dissects each phase, examining crew actions and aircraft responses, slowly assembling a tragic picture of inadvertent error and ultimate futility.
As each phase of the event progressed, recovery of control became more challenging and less likely. During the first phase, the airplane was climbing while being subjected to inappropriate control inputs, yet recovery to controlled level flight would have been fairly simple. In contrast, sometime during the final phase the airplane probably became unrecoverable. At any event, approach to recovery would by then have required extremely aggressive measures beyond the experience, training, and probably the imagination of the pilots.
The first eight chapters of the book are concerned with the laying out of facts and the explanation of relevant background. They are the foundation on which the last three chapters stand. These are titled, "The Human Element", "Lessons Learned" and "Going Forward". Here, the author delves into the "Why?" of AF447. He discusses fatigue issues, control mode confusion, mis-understanding of aerodynamics in the cruise environment, and gaps in training. As is usually the case, there is no single "smoking gun" behind this tragedy each of these factors probably played a role.
In his discussion of "Lessons Learned", Capt. Palmer points to a range of issues:
- Better understanding of the mechanics of stalls at high-altitude is needed.
- More refined understanding of the subtleties of degraded flight control laws is needed.
- More time spent hand-flying in the cruise environment is needed.
- Adoption of the 'Safe Harbor' concept (a fallback, fail-safe pitch-and-power configuration) is advisable.
- The programmed behavior of the Flight Directors may have contributed to the accident and should be reviewed.
"We must not allow mastery of the Flight Management System to be confused with airmanship."...and his last sentence seems to be addressed to everyone in the industry who is charged with preparing pilots to take responsibility for the lives of passengers: "We have been warned."