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Air France Memorandum Intended to Quell Pilot Union Unrest

Mon, Jun 21, 2010 — David Evans

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After the 2009 crash of Flight 447 due to unknown causes (and still under investigation by the French safety bureau), Air France pilots were quite upset about the fatal crash. (See Aviation Safety Journal, ‘Documentary Covers Last Minutes of Air France Flight 447,’ line 172 of transcript) Air France officials issued a memorandum intended to assuage the pilots; a careful reading of it suggests a potpourri of innocence and befuddlement.

The two heads of Air France flight operations and safety issued a lengthy analysis to the pilots. Pierre-Marie Gautron and Etienne Lichtenberger basically say the public debate in the media and elsewhere is misguided, pilots should rise above premature finger-pointing, the exact cause of the accident isn’t known, and Air France and Airbus are taking all reasonable steps in the circumstances.

Overall, the document is not out of character for an airline that’s suffered a major catastrophe that remains unsatisfactorily explained. However, the memorandum does indicate that pitot tubes are being replaced and inspected, and it contains references to erroneous speed readings. These assertions reinforce the theory that the pitots were giving speed readings that were too slow, causing the engines to apply more power, which led to a departure from controlled flight and a frightening descent 35,000 feet into the dark waters of the Atlantic.

Now that the accident airplane’s flight recorders will never be found, definitive analysis of the tragedy will be impossible. Causes of the disaster will probably be scattered further afield, into the realm of stormy weather, radar malfunction, flight control failure, and a host of other possible factors. The prior pitot failures are likely to become another straw in the wind of vague possibilities.

The tail of AF 447 was recovered but not the critical FDR/CVR.

The tail of AF 447 was recovered but not the critical FDR/CVR.

The across-the-board replacement of Thales pitot tubes by Goodrich designs demonstrates management’s willingness to apply tourniquets wherever and whenever. It’s also a tacit admission that they’d completely overlooked the potential for disaster in the long known history of the existing pitots. Because of the prior 32 incidents worldwide, there was ample scope to look further into the potential for calamitous developments resulting from pitot freeze-ups at high altitude in weather. That was apparently not done, the inevitable accident occurred, and now there’s a huge blotch of blameworthiness that is looking for ownership and inviting litigation.

To do this, Gautron and Lichtenberger construct a low-likelihood “search in vain” situation for the recorders, and introduce fixes that include new procedures for weather avoidance. They offer a scattergun approach to an accident, notwithstanding all camouflage, is obviously rooted in known pitot flaws. The Air France experience with the disappearance of Flight 447 is a sobering lesson in not allowing known flaws to ultimately prove their lethality.

The overhaul of Air France’s safety culture via a third party is reminiscent of what Korean Airlines (KAL) was forced into after a series of accidents. KAL hired a safety expert from Delta Air Lines to give them an in-depth safety “physical.” Indisputably, there was a turnaround in that case.

The memorandum contains some denial of the pitot tube circumstantial evidence (see highlighted section in the translation below).

The memorandum contains this phrase: “Truth requires that you know the probability of encountering such a scenario is extremely low [emphasis added], since it requires that the three probes frost up at the same time …”

In light of the Flight 447 aftermath, and all that the circumstantial evidence suggests, it’s a bit hard to swallow this bland statement.

Herewith, the Air France memorandum:

(Google Translation from the French)

Security Directorate

Directorate of Air Operations

Roissy, October 20, 2009

ENOUGH OF POLEMICS – AND FALSE DISCUSSION ON THE SAFETY OF FLIGHT!

(Assez de pole – et de faux debats sur la sécurité de vols !)

For the safety of flights in an airline is primarily:

– A continuous work on elements that guarantee security,

– A return to fundamental business driver.

As you will see, form, tone and content of such communication, addressed to all company pilots are unusual.

They are because the situation we are living since June 1 and is also the challenge for us is nothing other than ensuring the security of our air operations.

With the disappearance of flight AF447 in the Atlantic, Air France has experienced the worst disaster in its history, and more than four months later we still do not have elements that allow us to identify the factors that led to the loss of the aircraft. Therefore we are implementing measures on a wider scope.

This lack of findings leaves the field open to speculations of all self-proclaimed experts … that continue to spread in the media and in the lockers NTP to give their explanation of the accident, while the elements on which they rely are partial, inadequate or totally erroneous.

They throw and disorder in the public mind and give an unprofessional image of being a pilot, it would not matter if they do not cast also disturb the minds of some Air France pilots by making them doubt the correctness of our doctrine, our procedures and those of the manufacturer. Worse still, they doubt the pilots themselves of their own skills.

Purporting to act in the interests of flight safety, they do, in fact, contribute to the decline.

Far from controversial, this letter is to invite each driver to provide the right answers to the main question to an airline: how to improve flight safety.

We offer to share some answers in the following lines.

No false controversies and debates on issues of flight safety

Since 1 July, your boxes are flooded with leaflets and information of all kinds, whose tone and content do not invite serious reflection. We are sorry.

Some media will seize any statement … since it is an Air France pilot who speaks, and this even in the absence of any new information duly executed.

In contrast, management has deliberately chosen the opposite course, some of it makes the criticism in saying it wants to hide the truth. While we certainly have not sufficiently communicated, but we must remember:

a. it is the Board of Inquiry and Analysis is responsible for technical investigation and therefore it is his duty to communicate the facts, that’s what he did in the first progress report published last July

b. Findings that are thin, since they come from ACARS messages sent by the aircraft itself and initial analysis of some debris that was recovered. We have, at present, no registration and no path;

c. at this stage, the BEA has not issued recommendations intended for the company.

Despite this lack of physical evidence to guide our action, we are not left without anything and it is worth recalling what was done for 4 months: continued work on the elements that ensure flight safety.

In the absence of clearly defined cases, the guiding principle is this: we have chosen to strengthen our defenses on all matters on which we interviewed following the occurrence of AF 447.

Work in time on the fundamentals of security is the only option that can bring us more in terms of flight safety.

In this perspective and beyond the immediate actions following the accident, we have already:

– Replaced the pitot tubes … on the whole fleet Airbus 330/340 and then in early August on the manufacturer’s recommendation and EASA, we installed tubes in positions Goodrich CdB and Stand By;

– Launched a campaign of systematic inspection of pitot tubes A320

– Created a mock specific IAS questionable Airbus more than half of NTPs have followed so far and believe it is appropriate and useful,

– A procedure is in place to remove any doubt, to strengthen monitoring of the positions of our aircraft by SC CCO, without waiting for the amendment of agreements,

– Created training materials “Ice Crystals” and “Reminders for the use of radar,” – Modified the content of sessions divisions 4S Boeing to introduce a presentation of the elements of the AF 447 and strengthen our defenses against the dangers caused by the storms.

We do not stop there and we will continue this process by:

– Calling for outside experts, composed of individuals recognized internationally, to make a systemic study of flight safety,

– Carrying on A320, replacement probes Thales BA in positions CDB and Stand By, by Goodrich probes, identical to the 330/340,

– Launching the re-engineering of the preparation and monitoring of flights;

– The launch meeting was held October 19 and was attended by specialists of air operations, service lines (NI), the flight preparation of the dispatch, and Security Directorate;

– Creating groups of instructors referents, whose function will be to harmonize the educational messages,

– Pursuing the establishment of system safety management, particularly on aspects “safety culture” and “just culture” in the deployment of system security management.

This list is not exhaustive and we will complete whenever we deem useful.

Know that we are determined to continue along this path, that of continually improving our processes, although we are currently experiencing difficulties in the deployment of some ambitious projects like OMPNT …Other companies have faced the same challenges before us and were able to overcome them. Therefore, these difficulties should not lead us to reject it in all our projects.

We are ready to open discussions with trade unions and 100% dedicated to finding ways that will ensure that these discussions will be conducted with serenity, with the expertise and all the seriousness it deserves for flight safety.

A return to fundamentals of being a pilot.

Recently, some union publications have pointed to the difficulties of control A320 simulators when icing simultaneous three pitot tubes takeoff. They criticized the fact that this exercise was originally chosen as subsequently amended (by inventing a pressure Airbus to make, of course, history even more attractive and therefore credible).

Truth requires that you know that the probability of encountering such a scenario is extremely low, since it requires that the three probes frosting at the same time, while the aircraft is climbing and later, icing results in a durable sealing total and absolute for these probes. For it to grow, it is necessary that all conditions are maintained and appear simultaneously. Furthermore, Airbus has indicated that this failure to the simulator does not accurately simulate the chain of consequences in the real world.

Furthermore, no such event has been identified on Airbus, and no similar event has been identified in the analysis of RAS on incidents of pitot tubes Air France has known since 2001.

We have removed this year because he was teaching-cons and some advocated to solve this problem, a deviation from this doctrine.

Because you must be convinced of an essential element that you do not remember often enough: our key risks – in terms of likelihood and severity – are elsewhere.

We did not find them in extreme cases, in the most unlikely situations, but in the daily operation in our most mundane activities.

And most surprisingly, when conducting the analysis of factors contributing to these incidents is that:

– The application of simple procedures could have prevented the event;

– There is no procedure to correct or create new procedure.

In other words, simply to apply our doctrine, our procedures, in calm and serenity.

We offer a few examples:

– An overshoot does not accelerate the pace by taking the risk of forgetting an ad or disrupt the normal work, although the altitude of RDG is low on the contrary, it requires actions consistent, sequenced and verified by the PNF, keeping in mind that before stabilizing at altitude, we must begin by taking over a little, showing the trim and push off the PNF should check everything before. The passenger comfort, in this case, secondary.

– An alarm “config” is a “no go,” even if we think being able to identify the cause, and verify that the flaps are extended. Nothing we can say that they will not return during the takeoff roll or there is not another hidden fault. This alarm is a “forbidden”. We should not have to deal with this type of incident feedback, because it should not exist. Time pressure can not be an excuse, or the execution of the mission a sufficient reason to override.

– Inserts speeds V1, VR, V2 in the MCDU must be the subject of two double-checks: firstly by the one that inserts the data under the “control action”, the second under a “cross-check.” Even if the other crew member was shown a straight face during the pre-flight or during the previous flight.

– A takeoff path must be scrupulously respected when it is the path of failure (EGPWS?) and that the restriction is a restriction barrier. By choosing a different course, a pilot only increases the risk even if the impression of moving away from the most significant obstacles, because in case of failure, besides the fact that the crew did not know necessarily the constraint on the inclination (climb gradient?) it would have to maintain during its trajectory will consume the slope, which has a basic need.

We could show you other examples of equivalents (for this you really need to read or reread the latest publications of “Overview”). We have chosen these because they illustrate the factors that have led some of us to make those deviations that have generated risk and can be summarized in a few sentences:

– Commitment to “too” well done – conduct an RDG flexible compliance schedule, improve margins over obstacles, etc.

– The Overconfidence,

– Feel good about his aircraft and its environment, to the point of granting deviations due to coarse thinking hazard control,

– The feeling of extreme security, thinking that despite redundancy in systems, procedures and alarms, we are immune to the consequences.

Each of us can draw on personal experience and identify precursors of such situations or equivalent events.

We thought we could control these “basic” risks thanks to our professionalism, our procedures, our training and that we would not see more such incidents. We thought the situation would encourage everyone to be extra vigilant.

It is clear that this is not the case and recent events have proved otherwise.

Conclusion:

Like you, we feel great difficulty to the fact of not knowing what happened and did not understand the causes of this accident.

The reality is so and it is not unlikely that we remain in ignorance. The temptation is great for some to call into question the entire foundation and in particular the doctrine, procedures and practices essential to our business that we have taken so long to formalize cooperation with all industry airline.

We ask you not to yield to the temptation to express yourselves with extreme excesses.

Flight safety requires a methodical long-term approach. We are committed to continuing and identifying any particular lines of simplification.

In everyday life, we must ensure the safety of our operations and for this we ask:

1. That you focus on the fundamentals of being a pilot during the duration of the mission. It’s your daily contribution to simplification;

2. To apply rigorous procedures that are robust and shared by all. That way you get involved in daily safety;

3. To assume fully the role assigned to you within the crew. That’s how you give meaning to your action.

Pierre- Marie Gautron             Etienne Lichtenberger

Director of Flight Operations            Director of Safety


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