In trying to determine the cause, it’s almost instinctive to focus on the pilot at the controls, since it was his inputs which led to the nose high pitch and stall. Indeed, in all of the other cruise incidents where mis-matched speeds caused some combination of auto-pilot/auto thrust shutdown along with an alternate law operating environment, the flight crews managed the situation, either proceeding in level flight or engaging in a shallow descent. The longest continuous period for the loss of valid air speed was 200 seconds in any of the recorded prior incidents.
But, regulators and airlines were aware of 32 prior cases where pitot tubes had been blocked and at least 13 previous incidents where flight crews were confronted with unreliable air speeds at cruise altitude under unfavorable weather circumstances. At what point does an organization become chiefly responsible for recognizing that an anomaly with severe life-safety implications is neither rare nor unexpected? When that realization occurs, what is the proper response to ensure readiness?
Since there seemed to be no easily available technologic solution to the problem other than changing to various types of pitot tubes, the requirement to fully prepare flight crews for continued occurrences was essential. This raises the issue of what constitutes preparation. BEA, the regulator, has pointed out that the AF-447 co-pilots were generally untrained in manual operation of the aircraft at cruise altitude and that they similarly had not been trained in dealing with unreliable air speeds at higher altitudes, either.
It’s both instructive and useful here to paraphrase the Air France action steps to address a problem:
- If an anomaly is noted, inform the rest of the crew immediately
- Officer-in-charge secures a stable environment (secure the aircraft flight path) and defines task-sharing
- Solve the problem using the following sequence:
a. confirm the problem
b. apply known procedures
c. assess the situation
d. make a decision on continuing
e. communicate decision
Significantly, it is deemed essential to verbalize the fact that a potential problem may exist and to then seek a stable environment while it is sorted out.
Among many changes made in the aftermath of AF-447 are two that stand out where communication and teamwork are concerned:
When a relief pilot is designated by the Captain they sit in the left hand seat and are the pilot not flying.
When a decision must be made, the copilot gives their opinion FIRST before the Captain, presumably to ensure honest and effective feedback.
AF-447 affords critical lessons in:
- how organizations manage readily apparent risk,
- employing decisive but measured action in a real-time emergency,
- the requirement for effective communication during problem-solving.