Air France’s failure to tell its own pilots about a frightening inflight crisis aboard an Airbus 340 flight bound for Madagascar on August 16, 2008, may have prevented a Rio-Paris flight crew from understanding how to save a similar French aircraft that crashed nine months later.
Until now, critical details of the 2008 flight, Air France 373 from Paris to Tananarive, have never been disclosed by the airline, Airbus, French or European regulators. Notably, it was not covered in the final report by the French Government’s Bureau d’Enquêtes et d’Analyses (BEA) or during a lengthy press conference on 5 July 2012, which reviewed the Rio-Paris Air France 447 crash that took the lives of 228 passengers and crew on June 1, 2009.
The 2008 Madagascar flight has become central to a manslaughter investigation conducted on behalf of French Investigating Judge Sylvia Zimmerman. Details of the experts’ technical report are not scheduled to be released by Zimmerman until September 2012. Victims’ families, their attorneys and other interested parties, who read it confidentially in early July, agree prosecutors may see the undisclosed 2008 emergency as the smoking gun in a potential felony case against Air France and Airbus.
Previously hidden facts about Madagascar-bound flight 373 have astounded aviation safety experts.
“It’s almost a dress rehearsal for what happened on doomed flight 447,” said one veteran French flight safety analyst with intimate knowledge of the Airbus flight control system. “There is no logical explanation for hiding it behind vaguely worded safety bulletins to the pilots that ignored critical details.
“If Air France and Airbus had done the right thing and notified Airbus pilots about the specifics of this near-disaster on the Madagascar-bound flight, new emergency procedures and better training certainly could have saved the lives of 228 passengers and crew on Flight 447.
“Nearly everything the crew of the Rio-Paris flight needed to know about averting disaster on the night of June 1, 2009 was in the Air France captain’s Madagascar flight incident report withheld from company pilots and other Airbus A330/340 operating airlines. This kind of negligence could certainly become a problem for potential defendants.”
Clearly, this was the most important of nine Air France A330/340 unreliable airspeed emergencies in 2008-2009, culminating in a tenth event, Flight 447 from Rio to Paris.
Flight 373 “could have quickly become a crash course on how to safely handle the unreliable airspeed incident triggered by frozen airspeed monitors known as pitot tubes,” says this expert, who has spent many years studying the Airbus automated flight control system, which is designed to prevent the stall that took down the state-of-the-art A330.
The undisclosed incident report filed by the Air France 373 pilot in 2008 is likely to become central to Judge Zimmerman’s decision next year on a potential manslaughter case against the airline, the manufacturer and other as-yet-unnamed defendants. If that case goes forward it could be merged with a civil trial in a Paris court.
In the final French BEA report on the crash, experts explained that failure of the plane’s flight director following loss of reliable airspeed and shutdown of the automatic pilot, compounded their problems. The broken flight director, which normally displays the trajectory to be followed by the crew, misled the pilots. Acting on erroneous altitude information, the co-pilot flying the plane made the dangerous mistake of manually climbing.
Because the pilots were never trained for this emergency situation and had no comparable experience flying the plane manually at high altitude, they climbed excessively. The plane went into a stall as the defective flight director continued issuing inaccurate and contradictory directions.
When the pilots tried to recover they were confronted with incorrect airspeed and altitude readings, multiple computer failures and very loud alarms in the vicinity of thunderstorms. Even worse, emergency procedure messages displayed on the plane’s flight display during the crisis never told them to take the critical step of turning off the broken flight director.
Except for the fact that they were flying during daylight, the pilots of the August 2008 Paris-Madagascar Airbus 340 faced identical problems to those that later confronted flight 447 to Paris. When the captain lost reliable airspeed due to pitot tube icing, he did not set power and pitch according to flight procedures or maintain level flight as prescribed by the Air France emergency procedure checklist. In the midst of heavy turbulence, he immediately descended 4,000 feet, ignoring both the flight director and a brief stall warning.
“Because he could see the horizon he had a major advantage over the Air France pilots who were blindsided in a storm at night,” says a technical expert who has read the investigator’s summary of the previously undisclosed Madagascar flight report.
“Once the pitots froze and reliable airspeed was lost, misinformation was being fed to the pilots,” says the safety analyst. “When one part of an integrated flight control system fails the whole thing can fall apart. It’s almost as if the plane is trying to commit suicide.
“The Madagascar incident proved that every Airbus pilot needed immediate retraining on unreliable airspeed incidents and new emergency procedures spelling out the importance of ignoring the flight director which became a critical problem on the Rio-Paris flight. The Madagascar pilot’s experience opened the door to immediate remedial action in a life threatening situation.
“None of the Air France pilots knew about this until last week. If they had been properly informed back in 2008, it’s entirely possible that the worst disaster in the airline’s history could have been avoided.”
The BEA, Air France, Airbus, the European Air Safety Agency and France’s Directorate General for Civil Aviation have not yet responded to requests for more information on Air France flight 373.
Roger Rapoport is the author of The Rio-Paris Crash: Air France 447 which has also been published in French as Crash Rio-Paris. He has interviewed several hundred pilots, regulators, investigators, scientists officials at Air France and Airbus over the past three years.
Publisher’s Note: Author Roger Rapoport is available for media interviews and can be reached at firstname.lastname@example.org or by phone at 231 720-0930 in Michigan (EDT). Here is a link to the London Independent story on Rapoport’s update to his book.
FAQs for journalists:
Is it true that every Airbus 330/340 pilot in the world, on June 1, 2009, was trained and knew that in the event of an unreliable airspeed event that it was mandatory to immediately disregard and turn off the flight director?
Yes, it is true for pilots outside Air France, and this would apply twice: first "if the safe conduct of the flight is affected" (quoted from the very first item of the Airbus "unreliable airspeed indication" check list). This refers to a close ground proximity threat. In this case, pilots have to switch of Autopilot (AP) and Flight Director (FD), and adjust pitch and power as required to ensure climb, depending on the altitude. Airbus procedure then instructs pilots to level off for troubleshooting when at, or above minimum safe altitude. And the AP/FD OFF item is once again the very first to be performed.
Air France procedures, however, were different, as the "unreliable airspeed procedure" was split.
One part contained the "memory items" beginning with AP/FD OFF, and apply required pitch and power settings. After leveling off the pilots were expected to follow additional abnormal procedures for a "flight with unreliable airspeed" Air France did NOT request switching off the AP/FD. This deviation from Airbus standard operating procedure is mentionned by the French BEA in its final report on Air France 447.
So in summary, Air France pilots were trained to switch off AP/FD only at low altitudes, when applying the emergency procedure, but never trained to face an unreliable airspeed indication at high altitude.
Was this stated anywhere in training and the manual. More to the point did all the pilots in the nine other 2008-09 Air France unreliable airspeed events prior to AF 447 turn off their flight directors immediately?
Experts who have studied these events believe some pilots did turn off their flight directors and some didn't. More details may emerge in the judicial investigation.
Do you think this was reported to Air France or Airbus in any of the pilot incident reports following these unreliable airspeed events?
Probably not, and even if it was reported, the associated severity was low,that the incidents were considered as minor and unconsequential.This was typically the case for the Madagascar incident, which was considered benign and unconsequential, despite a very thorough captain's Air Safety Report that should have been shared with all Air France pilots in the event they encountered a similar situation. This is particularly important given Air France's demonstrated failure to train their pilots for these high altitude abnormal airspeed events.
When the captain of Madagascar bound Flight 373 rapidly descended in turbulence after he lost airspeed indication, did he "ignore" the flight director and NOT necessarily turn it off?
Exactly. And this reflects a general culture in the company, where pilots very often fly the plane manually (i.e during the approaches), and sometimes fly "through" the FD, the Pilot Flying acting on the controls before the copilot not flying has time to adjust FD orders