Flight Operations

Night IFR Approach in IMC Claims IFR-Rated Private Pilot and Passenger

The following article is based on TSB Final Report A11O0239—Loss of Control—Collision with Terrain. This accident in Ottawa, Ont., took the lives of two local pilots and received a lot of media attention. The TSB report is a very compelling read for all of us, but particularly for IFR-rated private pilots or soon-to-be IFR-rated private pilots.

Summary

On December 14, 2011, a privately owned Cessna 177A Cardinal departed Wilkes-Barre Wyoming Valley Airport (KWBW), Pa., USA, with two persons on board, on an IFR flight plan to Ottawa/Carp Airport (CYRP), Ont. Approximately 44 NM from destination, because of low visibility and ceilings at destination, the aircraft diverted to its filed alternate of Ottawa/Macdonald-Cartier International Airport (CYOW), Ont. The aircraft was then cleared for an ILS approach to Runway 07. At about 19:12 (all times quoted are EST), while flying the approach in instrument meteorological conditions (IMC) at night, the aircraft collided with the ground approximately 1.9 NM west of the threshold of Runway 07. The aircraft was destroyed, and both occupants were fatally injured. There was no fire. The 406 MHz ELT activated on impact.


Wreckage of Cessna Cardinal 1.9 NM west of the threshold of Runway 07at CYOW

History of the flight

The aircraft was returning to CYRP from a 12-day trip to southern Florida and the Bahamas. Both persons on board were licensed pilots and generally shared the flying duties throughout the trip.

On December 13, 2011, the two pilots checked out of their hotel at 07:00 and departed Marsh Harbour International Airport (MYAM), Bahamas, at 09:57 for Newport News/Williamsburg International Airport (KPHF), Va. The flight consisted of three stops and 10.5 hr of flight time, arriving at KPHF at 00:16 on December 14, 2011. The pilots checked into a hotel at 00:55.

At 12:15 on December 14, 2011, the aircraft departed KPHF and arrived in Wilkes-Barre Wyoming Valley Airport (KWBW), Pa., at 14:51. At approximately 17:07, after civil twilight, the aircraft departed KWBW on an IFR flight plan destined for CYRP. At 18:40, approximately 44 NM south of CYRP, the pilot-in-command (PIC) requested a diversion to CYOW for a Runway 07 ILS approach. CYOW is located 15 NM east of CYRP. An ILS approach is unavailable at CYRP.

At 19:06, Ottawa Terminal ATC cleared the aircraft for the ILS approach to Runway 07 and issued radar vectors to intercept the final approach course. The aircraft intercepted the localizer approximately 8 NM from the threshold, and the terminal controller instructed the aircraft to contact the Ottawa tower controller. The tower controller informed the aircraft that it was number one in the landing sequence. At approximately 4.5 NM from CYOW, while on the ILS approach, the aircraft began to deviate north of the localizer. The tower controller informed the pilot of the deviation. The pilot acknowledged the information and informed the tower controller that they were trying to get back on track. A minute later, as the aircraft was approaching the centre of the localizer, the tower controller cleared the aircraft to land. Shortly after receiving the landing clearance, the aircraft began to deviate northbound again; the controller informed the pilot of the deviation. There was a brief, unrecognizable transmission on the tower frequency, but it could not be confirmed that it came from the Cessna 177. Eighteen seconds later, the controller instructed the aircraft to pull up and go around. There was no response.

At approximately 19:12, the aircraft entered a steep right turn with a rapid descent, and struck power lines before impacting the ground 1.9 NM west of the threshold of Runway 07. Radar data show that, while on the approach, the aircraft twice deviated significantly from the localizer to a point that would have caused the localizer indications on the aircraft instruments to go to full deflection. Airspeed on the approach was maintained above 100 kt until the loss of control (Figure 1).


Figure 1—Aircraft's flight path showing its deviations from the localizer during the final approach.

Weather and flight planning

At 16:21, while on the ground at KWBW, the PIC filed an IFR flight plan with Williamsport flight service station (FSS). The flight was planned to depart at 17:00 and cruise at 5 000 ft, and was estimated to take 2 hr and 10 min to CYRP. The alternate airport for the flight was CYOW; the forecast weather was within alternate limits at the time of filing.

When the pilot called the FSS to file the flight plan, a weather briefing was not requested. It could not be determined if the pilot accessed the latest weather reports on the Internet prior to the flight-plan phone call. The flight service specialist asked if the pilot wanted information relating to icing and proceeded to inform the pilot of an AIRMET that forecast moderate icing between 3 000 and 14 000 ft on the flight route. The pilot asked about the area around Watertown, which was on the flight route, and the flight service specialist indicated that there were no pilot reports, but that they might encounter some showers as indicated by the AIRMET.

The latest forecast weather available for CYOW at the time that the flight plan was filed was issued at 15:38. Forecast conditions at 18:00 were visibility greater than 6 SM, scattered cloud at 1 500 ft and broken ceiling at 4 000 ft. Between 18:00 and 20:00, the conditions were forecast to deteriorate temporarily to visibility of 2 SM in mist and ceiling at 900 ft overcast. At 20:00, conditions were forecast to improve to visibility greater than 6 SM in light snow and rain showers with overcast ceilings at 3 000 ft.

The latest actual weather at CYOW at the time that the flight plan was filed was issued at 16:00. It described conditions as wind 090º at 8 kt, visibility 3 SM in mist and ceiling overcast at 700 ft.

At 18:12, while cruising at 5 000 ft, 29 NM south of Watertown International Airport (KART), the pilot requested a weather update for KART and CYOW from Boston Flight Watch (BFW). The BFW specialist reported conditions at KART to be visibility 10 SM and overcast ceilings at 9 500 ft, and conditions at CYOW to be visibility 3 SM in mist and overcast ceiling at 200 ft. The specialist repeated the AIRMET previously described, and the PIC indicated that the crew would check for updates once the aircraft was across the border.

At 18:34, while crossing the Canada–USA border near Gananoque, Ont., the pilot requested a weather update for CYOW from Montréal ATC. The weather relayed was the same as previously reported by BFW. Six minutes later, the pilot asked to change the destination to CYOW.

At 19:06, before clearing the aircraft for the ILS approach, Ottawa Terminal ATC issued the latest weather to the pilot: ceiling at 200 ft AGL, visibility 3 SM in mist and wind 100° at 10 kt gusting to 15 kt.

The aircraft

The aircraft was certified, equipped and maintained in accordance with existing regulations. Examination of the aircraft wreckage determined that there were no signs of pre-impact damage or defects that would have precluded safe flight. The aircraft was not certified for flight into known icing conditions and did not have any anti-ice equipment other than a heated pitot tube.

The aircraft collided with the ground with the flaps selected up. In this configuration, the Cessna 177A stall speed is listed in the owner's manual as 57 kt.

The pilot and passenger

The PIC held a private pilot licence, a valid Category 3 medical certificate and a valid Group 3 instrument rating. The pilot's personal logbook, last completed prior to the return trip, contained the following totals (hr):

Total flying time                                 429.1

Night flying as PIC                             30.3

PIC on the accident aircraft                28.7

Actual instrument                               44.1

Simulated instrument (hood)              40.9

Simulator                                             41.8

While the logbook showed a total of 44.1 hr of actual instrument time, the TSB determined that this column was being used to record time spent flying on IFR flight plans rather than time spent in actual IMC. Analysis of the departure, arrival and en route weather of these recorded flights suggests the pilot had experienced very little, if any, actual flight in IMC.

Canadian Aviation Regulation (CAR) 401.05(2)(b)(i)(B) requires a pilot who is carrying passengers at night to have completed five night takeoffs and five night landings in the preceding six months. Records indicate that the PIC had completed only one takeoff and two landings at night in the prescribed time period.

The passenger held a private pilot licence and a valid Category 3 medical certificate. Records indicate that the passenger had approximately 330 hr of experience, including 58 hr at night as PIC and 5.9 hr under simulated instrument conditions. The passenger did not possess an instrument rating.

Flight tests

Flight tests in Canada are evaluated using a 4-point marking scale. A detailed explanation of the marking scale is outlined in the Flight Test Guide—Instrument Rating published by Transport Canada (TC), but the following applies in general:

4 – Performance is well executed considering existing conditions.

3 – Performance is observed to include minor errors.

2 – Performance is observed to include major errors.

1 – Performance is observed to include critical errors, or the aim of the test sequence/item is not achieved.

The PIC had attempted 5 flight tests since beginning flight training in 2003.

On May 5, 2005, the PIC completed a private pilot flight test, which was assessed as a pass. On Exercise 24A: Instrument Flying—Full Panel, the PIC received a mark of 2. The pilot examiner noted that the candidate was “chasing the needle”, referring to a series of over-corrections in an effort to regain the desired track.

On October 26, 2007, the PIC completed an instrument-rating flight test, which was assessed as a pass. On Exercise 8: ILS Approach, the PIC received a mark of 2. The pilot examiner noted that the candidate let the glideslope deviate to ½-scale deflection inside the outer marker, because he was trying to read the pre-landing checklist. The PIC was granted an instrument rating valid to November 1, 2009.

On December 11, 2009, the PIC attempted an instrument rating renewal flight test, which was assessed as a fail. On Exercise 2: IFR Operational Knowledge, the PIC received a mark of 1. The pilot examiner noted that the candidate was unable to explain the approach ban and showed an unacceptable level of knowledge. The flight test was stopped on the ground after this exercise was failed.

On October 7, 2011, the PIC attempted an instrument rating renewal flight test, which was assessed as a fail. On Exercise 8: ILS Approach and Exercise 9: Missed Approach, the PIC received a mark of 1. The pilot examiner noted that the candidate let the glideslope deviate to full-scale deflection and let the course deviation indicator deflect fully en route to the missed-approach waypoint.

TC's Flight Test Guide—Instrument Rating describes the aim, description and performance criteria for each exercise to be completed on the flight test. For Exercise 8 (ILS or LPVFootnote 1 Instrument Approach [Precision Approach]), the Performance Criteria section, (i), states that assessment will be based on the candidate's ability to, “on final approach course, allow no more than ½-scale deflection of the localizer or glideslope indications”.

CAR Standard 421.49(4)(b) requires applicants renewing an instrument rating that expired more than 24 months before the date of application to rewrite the instrument-rating written examination (INRAT). The original instrument rating held by the PIC would have been expired for 24 months on November 1, 2011.

On October 31, 2011, the PIC completed an instrument-rating renewal flight test, which was assessed as a pass. The PIC received a mark of 2 on 4 exercises, including Arrival, Holding, RNAV Approach and ILS Approach. The pilot examiner noted on the flight test report that the candidate let the localizer deviate to ½-scale deflection upon interception. Notes written on a separate piece of paper during the flight test described the localizer deviation as ¾-scale. Had the most recent instrument-rating renewal flight test not been completed, the PIC would have had to rewrite the INRAT.

Factors affecting pilot decision making

The PIC had several work appointments that were scheduled for the day following the accident. In addition, the pilot also had personal commitments to attend to later that week.

In the Operators Guide to Human Factors in AviationFootnote 2 (OGHFA), the Flight Safety Foundation (FSF) describes the phenomenon of making a decision to continue to the planned destination or toward the planned goal even when significantly less risky alternatives exist. This phenomenon has been variously referred to as “press-on-itis”, “get-home-itis”, “hurry syndrome”, “plan continuation” and “goal fixation”Footnote 3.

The FSF states that the following are some of the reasons that aircrews may be susceptible to “press-on-itis”:

  • They have a personal commitment/appointment at the completion of the flight, or they may simply want to get to the destination.
  • They want to “just get the job done” (excessive commitment to task accomplishment) and are influenced by organizational goals such as on-time arrival, fuel savings and passenger convenience.
  • They focus solely on aircraft flight path control, due to turbulence and other distractions.
  • “We are almost there, let's just do it and get it over with.”
  • They become task-saturated.
  • They are fatigued.
  • They lose situational awareness and are not fully aware of the potentially perilous situation.
  • They have not set performance limits and trigger gates that require a go-around.
  • They are not fully aware of their own limitations and/or the aircraft's limitations.

Analysis

The PIC was appropriately licensed and instrument rated. However, the most recent, and other, flight test reports showed signs that the PIC had continued difficulty conducting ILS approaches. In addition, the PIC was not current in night-flying operations, and had very little, if any, experience in actual IMC. Most of the PIC's instrument-flying experience was acquired during training in simulated IMC and in the simulator. This experience may not have presented the PIC with an accurate representation of the conditions and pressures faced in actual conditions.

The PIC chose to depart KWBW into forecast icing conditions despite the fact the aircraft was not certified for such operations. While en route, the pilot was informed of deteriorating conditions in the Ottawa area but chose to continue. This decision and the previous day's long flying schedule, combined with work and personal commitments, suggest the PIC may have been susceptible to the phenomenon known as “press-on-itis”.

While on the ILS approach into Ottawa in unfamiliar night IMC, the pilot had significant difficulty maintaining the localizer. During the approach, the tower controller twice advised the pilot that the aircraft was deviating from the approach course. During the second attempt to regain the localizer, the pilot most likely made a steep right turn, which quickly developed into a rapid descent and loss of control.

Airframe icing could not be completely ruled out as a possible contributor to the loss of control, but the high airspeed (> 40 kt above the stall speed) that was maintained until the loss of control suggests that it was unlikely. Icing likely did not contribute to the aircraft's repeated deviation from the localizer and over-correction.

Finding as to causes and contributing factors

  1. During an attempt to fly the precision approach at night in weather conditions unfamiliar to the pilot, control of the aircraft was lost and the aircraft collided with the ground.

Findings as to risk

  1. If pilots possess limited currency and experience at night or in instrument flight conditions, the risk of a loss of control is increased when operating an aircraft in marginal weather conditions.
  2. Non-recognition of the effects of the phenomenon known as “press-on-itis” can lead to increased risk that a decision will be made to depart or continue a flight when significantly less risky alternatives exist.

Other finding

  1. The pilot did not meet the recency requirements for night flying with passengers.

This particular accident has created a lot of discussions in pilot lounges as well as on various online aviation blogs. Thought-provoking issues are addressed, challenged and debated. Such issues include the realities and challenges of IFR training, IFR qualification for commercial pilots as opposed to private pilots, giving and taking check rides, passing and failing those check rides, the need for actual IMC time, mentorship, IFR theoretical knowledge, pressure and the insidious effects of fatigue. While briefly mentioned in the report under “Factors affecting pilot decision making”, one has to wonder whether fatigue could have been a contributing factor in this accident. Read again the pilots’ schedules described in the report for December 13 (over 17 hours) and December 14 (close to 8 hours). Combined with very poor weather and the pressing desire to get home, the cumulative effects of fatigue may have played a role in this accident. Want to learn more from this accident and others? Hit the blogs, but check your feelings at the door. —Ed.       

Sustained Stall

By Mark Lacagnina. The following article was originally published in the August 2012 Issue of the Flight Safety Foundation’s Aero Safety World magazine, and is reprinted with permission.

Blocked pitot tubes, excessive control inputs and cockpit confusion doomed Air France 447

Within four and a half minutes in the early hours of June 1, 2009, an Airbus A330-200 operating as Air France Flight 447 from Rio de Janeiro, Brazil, to Paris, departed from cruise flight at 35 000 ft and descended into the Atlantic Ocean, killing all 216 passengers and 12 crew members. Glimpses of what might have gone wrong emerged from several interim reports issued by the French Bureau d’Enquêtes et d’Analyses (BEA) during its long investigation of the accident. In July 2012, the bureau published a nearly 300-page final report providing a full picture of what likely happened during those critical moments.

Large section of the tail being recovered from the Atlantic Ocean
Large section of the tail being recovered from the Atlantic Ocean

According to the report, the trouble began when the A330’s pitot tubes were obstructed by ice crystals, causing the various air data sources to produce unreliable airspeed information. Reacting as designed, the electronic flight control system (EFCS) rejected the air data, disengaged the autopilot and autothrottle, and reverted to a lower control law that provides fewer protections against flight-envelope deviations. Startled by the unexpected and unfamiliar situation, and with turbulence making sidestick control inputs difficult, the pilot flying (PF) inadvertently commanded a steep nose-up pitch change while leveling the airplane’s wings.

The flight crew—a copilot and a relief pilot filling in for the resting captain—recognized the loss of reliable airspeed data but did not conduct the associated checklist procedure. Confusion reigned on the flight deck, and crew coordination vanished. Without automatic angle-of-attack protection, the airplane entered a stall. The crew either believed that the stall warnings were spurious or mistook the airframe buffeting as a sign of an overspeed. No recovery action was taken, and the A330 remained in a stall as it descended to the sea.

Based on the findings of the investigation, the BEA made 41 recommendations to various organizations worldwide on topics including pilot training, equipment certification, air traffic control (ATC) and search and rescue.

Agumented Crew

Air France 447 had an augmented flight crew comprising a captain and two copilots. When the airplane departed from Rio de Janeiro at 2229 coordinated universal time (1929 local), the captain was in the left seat and serving as pilot not flying (PNF), and one of the copilots was flying from the right seat.

The captain, 58, had 10 988 flight hours, including 1 747 hours as pilot-in-command in type. The PF, 32, had 2 936 flight hours, including 807 hours in type. The other copilot was 37 and had 6 547 flight hours, with 4 479 hours in type.

About two hours after departing from Rio, the flight crew received information from the airline’s operations center about an area of convective activity developing along the route between the SALPU and TASIL navigation waypoints. Shortly thereafter, the PF remarked that the airplane was “entering the cloud layer,” and the light turbulence to which the flight had been exposed increased slightly.

The report said that statements captured by the cockpit voice recorder indicated that the PF became preoccupied with the conditions they might encounter as the flight progressed through the intertropical convergence zone (ITCZ). Several times, he expressed concern about the turbulence and the relatively warm outside air that limited the airplane’s performance and precluded a climb to FL370 (approximately 37 000 ft), to get above the clouds. He suggested that they request clearance from ATC to climb to FL360, which is not a standard level for their direction of flight.

“Some anxiety was noticeable” in the PF’s statements, the report said. “The captain appeared very unresponsive to the concerns expressed by the PF about the ITCZ. He favored waiting and responding to any turbulence noted.” The report said that the captain had crossed the ITCZ many times and likely considered the present conditions as normal.

Preparing for a rest break at 0152, the captain woke the other copilot, who was in the crew rest facility, and summoned him to the cockpit. The copilot took the left seat vacated by the captain and was briefed by the PF about the flight conditions. The turbulence had subsided, but the PF said that they could expect more turbulence ahead and that they presently could not attempt to climb above the clouds. The PF also noted that they had not been able to establish a position-reporting data link with the Dakar Oceanic flight information region (FIR).

The captain did not contribute any information to the briefing before he left the cockpit at 0200 and went to the crew rest facility. He also did not specifically designate which copilot would serve as the “relief pilot”—that is, the captain’s replacement—although he implied that the copilot in the right seat (the PF) would fill that role. The report said that the decision was questionable considering the significantly higher experience level of the other copilot.

At this point, the A330 was nearing the ORARO waypoint, which is between SALPU and TASIL, and entering the ITCZ. Airspeed was Mach 0.82, and the pitch attitude was 2.5º nose-up. The turbulence increased again, and the PF advised the cabin crew that the turbulence soon would intensify. “You’ll have to watch out there,” he said. “I’ll call you when we’re out of it.”

At 0208, the PNF, who was examining the weather radar display, suggested that they “go to the left a bit.” The selected heading then was adjusted 12º left. In addition, “the crew decided to reduce the speed to about Mach 0.80, and engine deicing was turned on,” the report said.

Exiting the Envelope

At 0210:05, the autopilot and autothrottle disengaged, and the PF announced, “I have the controls.” The PNF responded, “All right.”

The airplane, which already had been near its performance limits in high-altitude cruise, “exited its flight envelope” within a minute of autopilot disengagement, the report said. “Neither of the two crewmembers had the clarity of thought necessary to take the corrective actions. However, every passing second required a more purposeful corrective piloting input.”

The airspeed shown on the left primary flight display (PFD) decreased rapidly from about 275 kt to 60 kt. A few moments later, the airspeeds shown on the integrated standby instrument system and the right PFD also decreased.

The ice crystal icing that had blocked the A330’s pitot probes is a phenomenon that is not well understood, according to the report. “In the presence of ice crystals, there is no visible accretion of ice or frost on the outside, nor on the nose of the probe, since the crystals bounce off of these surfaces. However, the ice crystals can be ingested by the probe air intake. According to the flight conditions (altitude, temperature, Mach), if the concentration of crystals is greater than the capacity for deicing of the heating element and evacuation by the purge holes, the crystals accumulate in large numbers in the probe tube.” The resulting disruption of total pressure measurement produces unreliable airspeed information, causing reversion from normal to alternate flight control law.

The airplane had pitched about 2º nose-down and had begun rolling right when the autopilot disengaged. “The PF made rapid and high-amplitude roll control inputs, more or less from stop to stop,” the report said. “He also made a nose-up input that increased the aeroplane’s pitch attitude up to 11 degrees in 10 seconds.” As a result, the airplane began to climb rapidly. The aural and visual stall warnings activated twice, briefly.

“The excessive nature of the PF’s inputs can be explained by the startle effect and the emotional shock at the autopilot disconnection,” the report said. “Although the PF’s initial excessive nose-up reaction may thus be fairly easily understood, the same is not true for the persistence of this input.”

The PNF was not immediately aware of the PF’s control inputs or that, because of the unreliable airspeed data, the EFCS control law had changed from normal, which would prevent the airplane from reaching stall angle-of-attack, to alternate, which would not prevent a stall. He reacted to the stall warnings by saying, “What was that?”

The PNF then noticed the airspeed anomalies, as well as the reversion to alternate control law. At 0210:16, he announced, “We’ve lost the speeds,” and added, “alternate law protections.” The PF also noticed the airspeed anomalies. “We haven’t got a good display of speed,” he said.

However, neither pilot called for the abnormal/emergency checklist that addresses unreliable airspeed indications. Among the checklist actions is disengagement of the flight directors, which can—and did in this case—present erroneous cues in the absence of consistent airspeed information.

The report said that the pilots did not focus on the problem involving the abnormal airspeed indications because they might have perceived “a much more complex overall problem than simply the loss of airspeed information.”

“However, neither pilot called for the abnormal/emergency checklist that addresses unreliable airspeed indications.”

Several messages appeared on the electronic centralized aircraft monitor (ECAM), and the PNF read them out “in a disorganized manner,” the report said, also noting that none of the ECAM messages provided an “explicit indication that could allow a rapid and accurate diagnosis” of the situation.

At 0210:27, the PNF observed indications that the airplane was climbing and said, twice, “Go back down.” The PF acknowledged and made several nose-down sidestick inputs that reduced the pitch attitude and the vertical speed. However, the report said that, possibly due to an erroneous flight director prompt to increase the pitch attitude, the PF did not make control inputs sufficient to halt the climb.

At 0210:36, the airspeed information shown on the left PFD returned to normal; the indication was 223 kt. “The aeroplane had lost about 50 kt since the autopilot disconnection and the beginning of the climb,” the report said.

‘I Don’t Have Control’

The PNF was calling the captain to return to the cockpit at 0210:51, when the stall warnings activated again. Pre-stall buffeting began seconds later. “The crew never referred either to the stall warning or the buffet that they had likely felt,” the report said.

The PF applied takeoff/go-around thrust but continued to apply nose-up control inputs. This is how pilots typically are trained to react to stall indications at low altitude, the report said, noting, however, that “at this point, only descent … through a nose-down input on the sidestick would have made it possible to bring the aeroplane back within the flight envelope.”

The buffeting, aerodynamic noise and misleading flight director indications might have caused the PF to believe that an overspeed situation existed, the report said. He reduced thrust to idle and attempted to extend the speed brakes.

The EFCS autotrim system reacted to the PF’s continued back pressure on the sidestick by moving the horizontal stabilizer to its full airplane-nose-up position, where it remained until the end of the flight. “The PF continued to make nose-up inputs,” the report said. “The aeroplane’s altitude reached its maximum of about 38,000 ft; its pitch attitude and angle-of-attack were 16 degrees.”

At 0211:38, the PF told the PNF, “I don’t have control of the plane at all.” The PNF responded by announcing, “Controls to the left,” and pressing the pushbutton on his sidestick to transfer flight control priority from the PF’s sidestick to his sidestick.

“The PF almost immediately took back priority without any callout and continued piloting,” the report said. “The priority takeover by the PF could not be explained but bears witness to the de-structuring of the task sharing” between the pilots.

The captain likely noticed the airframe buffeting and the airplane’s high pitch attitude while returning to the cockpit at 0211:42. The continuous aural master warning and intermittent stall warning, the confusing instrument indications and the stress conveyed by the two copilots when they told him that they had lost control of the airplane likely made it difficult for the captain to grasp the situation, the report said. “Subsequently, his interventions showed that he had also not identified the stall.”

The airplane was descending through 35 000 ft at 10 000 fpm with a 40º angle-of-attack and with roll oscillations reaching 40º. “Only an extremely purposeful crew with a good comprehension of the situation could have carried out a maneuver that would have made it possible to perhaps recover control of the aeroplane,” the report said.

At 0212:02, the PF said, “I have no more displays,” and the PNF said, “We have no valid indications.”

“At that moment, the thrust levers were in the ‘IDLE’ detent and the engines’ N1s [fan speeds] were at 55 percent,” the report said. “Around 15 seconds later, the PF made pitch-down inputs. In the following moments, the angle-of-attack decreased, the speeds became valid again and the stall warning triggered again.”

At 0214:17, the ground-proximity warning system began to generate “SINK RATE” and “PULL UP” warnings.

The flight data recorder ceased to function at 0214:28. “The last recorded values were a vertical speed of 10,913 fpm, a groundspeed of 107 kt, pitch attitude of 16.2 degrees nose-up, roll angle of 5.3 degrees left, and a magnetic heading of 270 degrees,” the report said. “No emergency message was transmitted by the crew. The wreckage was found at a depth of 3,900 m [12,796 ft] on 2 April 2011.” 

This article is based on the English translation of the BEA’s “Final Report on the Accident on 1st June 2009 to the Airbus A330-203, Registered F-CZCP, Operated by Air France, Flight AF 447, Rio de Janeiro–Paris.” The report is available in English and the original French at www.bea.aero.

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Footnotes

Footnotes:

Footnote 1

localizer performance with vertical guidance

Return to footnote 1 referrer

Footnote 2

European Advisory Committee, Operators Guide to Human Factors in Aviation. Flight Safety Foundation (2009), available at http://www.skybrary.aero/index.php/Portal:OGHFA (last accessed 25 October 2013)

Return to footnote 2 referrer

Footnote 3

European Advisory Committee, “Press-on-itis” (OGHFA Briefing note), Operators Guide to Human Factors in Aviation, Flight Safety Foundation (2009), available at http://www.skybrary.aero/index.php/Press-on-itis_(OGHFA_BN) (last accessed on 25 October 2013)

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