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Final Report on 2009 Air France Crash - released July 2012

Final Report on 2009 Air France Crash - released July 2012

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Published by Patrick
On the accident on 1st June 2009
to the Airbus A330-203
registered F-GZCP
operated by Air France
flight AF 447 Rio de Janeiro - Paris
On the accident on 1st June 2009
to the Airbus A330-203
registered F-GZCP
operated by Air France
flight AF 447 Rio de Janeiro - Paris

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Published by: Patrick on Jul 05, 2012
Copyright:Public Domain


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The crew possessed the licenses and ratings required to undertake the flight.

The aeroplane possessed a valid Certificate of Airworthiness, and had been
maintained in accordance with the regulations.

The aeroplane’s weight and balance were within operational limits.

The aeroplane had taken off from Rio de Janeiro without any known technical
problems, except on one of the three radio management panels.

The composition of the crew was in accordance with the operator’s procedures.

The meteorological situation was not exceptional for the month of June in the
inter-tropical convergence zone.

There were powerful cumulonimbus clusters on the route of AF 447. Some of
them could have been the centre of some notable turbulence.

An additional meteorological analysis showed the presence of strong
condensation towards AF 447’s flight level, probably associated with convection

The precise composition of the cloud masses above 30,000 feet is little known,
in particular with regard to the super-cooled water/ice crystal divide, especially
with regard to the size of the latter.

Several aeroplanes that were flying before and after AF 447, at about the same
altitude, altered their routes in order to avoid cloud masses.

The crew had identified some returns on the weather radar and made a heading
change of 12° to the left of their route.

At the time of the autopilot disconnection, the Captain was taking a rest.

The departure of the Captain was done without leaving any specific instructions
for crossing the ITCZ.

There was an implicit designation of a pilot as relief Captain.

There was an inconsistency between the speeds measured, likely following the
blockage of the Pitot probes by ice crystals.

The AP then the A/THR disconnected while the aeroplane was flying at the upper
limit of a slightly turbulent cloud layer.

The aeroplane systems detected an inconsistency in the measured airspeeds. The
flight control law was reconfigured to alternate 2B.

No failure message on the ECAM clearly indicates the detection by the system of
an inconsistency in measured airspeeds.

The pilots detected an anomaly through the autopilot disconnection warning
that surprised them.

F-GZCP - 1st

June 2009


Although having identified and called out the loss of the airspeed indications,
neither of the two copilots called the “Unreliable IAS” procedure.

The Flight Directors did not disconnect.

The crossbars disappeared and then re-appeared on several occasions, changing
mode several times.

The copilots had not undertaken any in-flight training, at high altitude, for the
“vol avec IAS douteuse” procedure or on manual aeroplane handling.

The speed displayed on the left PFD was incorrect for 29 seconds, that of the
speed on the ISIS for 54 seconds and the speed displayed on the right PFD for
61 seconds at most.

In less than one minute after autopilot disconnection, the aeroplane exited its
flight envelope following inappropriate pilot inputs.

The Captain came back into the cockpit about 1 min 30 after the autopilot

Throughout the flight, the movements of the flight control surfaces were
consistent with the pilot’s inputs.

Up to the exit from the flight envelope, the aeroplane’s movements were
consistent with the position of the flight control surfaces.

There is no regulatory CRM training for a crew made up of two copilots in a
situation with a relief Captain.

The approach to stall was characterised by the triggering of the warning then the
appearance of buffet.

In the absence of a display of the limit speeds on the speed tape on the PFD, the
aural stall warning is not confirmed by any specific visual display.

The stall warning sounded continuously for 54 seconds.

Neither of the pilots made any reference to the stall warning or to buffet.

A short time after the triggering of the stall warning, the PF selected TO/GA thrust
and made a nose-up input.

Neither of the pilots formally identified the stall situation.

The theoretical training undertaken by the copilots, as well as some documents,
including the OSV note, associated the buffet phenomenon with the approach to
stall as well as to overspeed. On the Airbus A330, the buffet phenomenon is only
encountered on the approach to stall.

The angle of attack is the parameter that allows the stall warning to be triggered;
if the angle of attack values become invalid, the warning stops.

By design, when the measured speed values are lower than 60 kt, the measured
angle of attack values are invalidated.

Each time that the stall warning triggered, the angle of attack exceeded the value
of its theoretical trigger threshold.

The aeroplane’s angle of attack is not directly displayed to the pilots.

F-GZCP - 1st

June 2009


The engines functioned normally and always responded to the crew’s inputs.

The PNF called out imprecise flight path corrections. They were however essential
and sufficient for short-term management of the situation.

The last recorded values were a pitch attitude of 16.2 degrees nose-up, roll of
5.3 degrees to the left and a vertical speed of -10,912 ft/min.

The Pitot probes installed on F-GZCP met requirements that were stricter than
the certification standards.

Analysis of the events related to the loss of airspeed indications had led Airbus
and Air France to replace C16195AA Pitot probes by the C16195BA model. The
first aeroplane had been modified on 30 May 2009.

EASA had analyzed Pitot probe icing events; it had confirmed the severity of the
failure and had decided not to make the probe change mandatory.

The flight was not transferred between the Brazilian and Senegalese control


Between 8 h 22 and 9 h 09, the first emergency alert messages were sent by the
Madrid and Brest control centres.

The crew was not able to use the ADS-C and CPDLC functions with DAKAR Oceanic.
If the connection had been established, the loss of altitude would have generated
an alert on the controller’s screen.

The first floating aeroplane parts were found 5 days after the accident.

The flight recorders were recovered 23 months after the accident.

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