Professionalism/Air France Flight 447

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Background[edit]

Flight Path[edit]

On May 31st, 2009, Air France Flight 447 (AFF447) departed from Rio de Janeiro-Galeao International Airport at 7:03pm local time and was scheduled to arrive at the Paris-Charles de Gaulle Airport 11 hours later. [1]. A few hours after takeoff, AFF447 crashed into the southern Atlantic Ocean killing all 228 people aboard. The AFF447 aircraft was an Airbus A330-200.

Air France Flight 447 intended flight path

Pilots[edit]

Three pilots were aboard the flight so that each could take a break during the 12 hour flight. The flight captain was Marc Dubois, who had logged over 11,000 flight hours. The other two co-pilots, David Roberts and Pierre Cedric-Bonin, had each logged 6,600 and 3,000 flight hours respectively.

Two Year Mystery[edit]

AFF447 disappeared beyond radar coverage and into darkness in the early morning hours. The loss of the flight was a mystery; no other plane had ever disappeared without a trace. There were no distress signals or any signs of the impending crash. With no evidence, it seemed as if the plane just fell out the sky without reason. [2]

Upon learning about the crash of the flight, the French Bureau d’Enquêtes et d’Analyses (BEA) instigated an international search effort. On the sixth day of the search, the first debris and bodies were found 38 nautical miles north of the last known position. [3]. However, when the debris was first recovered, the reasons behind the plane crash were unknown without the black box.

The Black Box[edit]

A black box recorder

A black box is an orange flight data and voice recording device equipped in the cockpit of commercial and corporate jets. It has become crucial for plane crash investigations by providing recordings final moments before an accident. To help locate the black box after a crash, each recorder has an underwater locator beacon, which is activated as soon as it comes in contact with water.[4] It can be exceedingly difficult to find the black box before the locator beacon battery life ends at 30 days. The search for the black box from AFF447 lasted nearly two years, until robot submarines finally located the coveted black box. [5].

Accident Sequence of Events[edit]

At approximately 1 hour and 36 minutes into the flight, the plane headed into a tropical storm unlike other planes in their proximity. About two hours into the flight, the Captain Dubois exchanged places with Roberts and retired to the back to sleep. Bonin was left in charge of the main controls. Unable to ascend to their desired altitude because of the higher external temperature, the co-pilots were forced to fly through the clouds. Approximately ten minutes after the pilot retired, the pitot tubes on the plane froze and caused the auto-pilot to disengage. At this point, Bonin manually took over control of plane and forced the plane into a steep climb. A stall warning went off immediately and persistently. Bonin failed to push the plane into a dive, despite training to do so. Roberts, unable to see that Bonin is pulling back on the side stick, notices that the plane is climbing and tells Bonin to descend. The vertical speed toward the ocean is accelerating and Bonin is still pulling back on the stick giving the plane barely enough forward speed to keep going. The stall warning continues to sound. After a few minutes, Captain Dubois returns to the cockpit. From his seat behind the two pilots, Captain Dubois is also unable to tell that Bonin is pulling back on the stick. The pilots do not understand the nature of the problem. Bonin finally proclaims that he has had the stick pulled back the whole time and Robert finally puts the nose of the plane down. At this point, there is not enough time left to build up speed during the dive to pull the plane back upward. 1 second later the plane crashes into the ocean. [6]

Responsible Parties[edit]

Airbus[edit]

Airbus, known for their fly-by-wire aircrafts, was the manufacturer of the AFF447 A330 aircraft. The fly-by-wire system has replaced the conventional manual flight controls in an aircraft cockpit with electronic controls. Rather than having heavy mechanical equipment to transmit signals from the cockpit found in conventional aircrafts, the fly-by-wire system transmits electronic signals based off of movement of flight controls in the cockpit. This includes side stick controls, which are on both sides of the cockpit and move independently of one another. Side sticks are used to raise and lower the nose of the plane only when the aircraft is not in auto-pilot. If the pilot on the right side of the cockpit is pulling back on the stick, the pilot on the left side of the cockpit does not see or feel it. Usually pilots enjoy the fly-by-wire side sticks because they require minimum effort. However, when auto-pilot disengages, the pilots may not be capable of manually controlling the plane. [7]

On AFF447, Roberts was unaware of Bonin's actions because they did not affect his side stick. Airbus has been criticized in the aftermath of this deadly crash for their aircraft model. A common criticism is that the Airbus A330 model is too reliant on auto-pilot systems. Traditional aircraft designs like Boeing planes, use control yokes, not side sticks, and the yokes are connected allowing for physical feedback communication between the pilots. Some claim that if AFF447 was a Boeing plane rather than Airbus, Roberts would have immediately noticed Bonin’s error and corrected it well before crashing. However, Airbus has a comparable safety record to traditional Boeing planes, so Airbus has not modified their implementation of fly-by-wire technology. [8]

Air France[edit]

A pitot tube attached to a plane
Individual pitot tube

Air France is another potential responsible party, especially since they are responsible for pilot training. After the deadly crash, some questioned whether or not the pilots had been trained to deal with a stall under stressful conditions when auto-pilot was disengaged. Today pilots are accustomed to full automation flying, so when a technical malfunction occurs resulting in solely manual controls, stress arises and pilots may act irrationally. When AFF447 lost the airspeed readings from the pitot tubes, Bonin irrationally pulled back on the side sticks.[6]Ideally, pilots should calmly manage such situations, but these pilots did not receive training in manually flying the aircraft under those conditions.

The European Aviation Safety Agency (EASA) knew there were serious problems with the model of Thales pitot tubes installed in many of the Airbus A330s before the AFF447 disaster. Not all of the A330 fleet was equipped with the malfunctioning pitot tubes, so Air France questioned whether or not to change out all of their A330 aircraft’s pitot tubes. Two months after the deadly crash, EASA mandated that all existing Thales pitot tubes be immediately replaced with the revised version. Some fingers were pointed at Air France saying it is not the pilot’s responsibility to know how to cope with technical failures with auto-pilot. [9] Moving forward a new question exists: Should machine manufacturers be fully responsible for fact checking humans?

Pilot Error[edit]

Despite Airbus and Air France's role in the crash, the primary source of error is largely attributed to pilot errors in communication and Bonin's actions. From transcript analysis, it is clear that Bonin was under a great amount of stress. Bonin, only 32 years old, had 8,000 flight hours less than the flight captain.[6] The combination of stress and inexperience resulted in Bonin's flawed decision-making.

Decision-making under pressure

The SRK classification model states that there are three tiers of decision-making: skill, rule, and knowledge-based. In skill based mode, smooth completion of a task is performed without conscious thought. It is indicative of familiarity with the environment and the task. Rule-based behavior applies a pre-packaged set of acceptable behaviors if a given situation occurs. Knowledge based actions are performed with a high-level of conscious thought and usually occur in novel situations where a person lacks experience.[10]

Bonin's inexperience sent him into knowledge-based, rather than skill-based, mode. A common error in knowledge-based mode is a person's inability to correctly diagnose the causes of a problem under significant time-pressure because of lack of expertise.[10] Bonin, who was under significant stress, incorrectly diagnosed the situation.[6] Similar errors have been seen in studies of rookie police officers. In one study, rookie and elite officers decision-making were compared under a staged high-pressure situation where an assailant brandished either a cell phone or a gun. The rookie officers were 43.36% more likely to incorrectly assess the situation due to inexperience and fire when the assailant carried a cell phone. [11]

The second error in decision-making resulted from Bonin's incorrect assessment. He transitioned into rule-based mode and incorrectly applied a rule to the wrong situation. Take off/go around switch (TO/GA ) is a common pilot maneuver used during take off to gain altitude and speed. Because the plane was losing altitude and speed, Bonin thought he should apply TO/GA. In the transcript he explicitly states,"I'm in TOGA, huh?" Experts agree that his assessment was illogical because TO/GA is ineffective at high altitudes. [6] Bonin's assessment of TOGA led him to pull back on the control column, the exact action that would cause the plane to stall and crash.

Over-reliance on Technology[edit]

Bonin's decision-making was the result of a high pressure situation and inexperience. Experts say that Bonin and Roberts should have been able to compensate for simple mechanical errors [6] The overall unpreparedness of Bonin and Robert's to fly in high altitude situations when the autopilot disengaged suggests an over-reliance on technology.

As automated flight systems have advanced, pilots have taken a passive role in flying. One pilot stated in regards to a recent flight,"I didn't fly. The computer flew. I sat in the front office monitoring systems."[12] The lack of involvement of pilots has resulted in degradation of their flying skills. The FAA recently reported that pilot over-reliance may result errors such as: insufficient cross verification, not recognizing autopilot or autothrottle disengagement, or not maintaining target speed, heading, or altitude. Each of these errors were seen in the case of flight 447.[13]This phenomena has been termed "Automation Addiction" in aviation.[14] Although the automated systems are regarded as safer than humans when functioning, the inability of humans to take over and make critical decisions when necessary is highly dangerous. The results can be seen in the outcome of AFF447,Asiana Airlines Flight 214, and potentially Malaysia Flight 370. One solution that has been recommended is allowing pilots to fly manually more often.

Over-reliance on technology in other areas of life can also be dangerous, such with GPS. The resultant outcomes have been termed "Death by GPS".[15] People are blindly trusting the GPS, even when prompted to travel down remote backgrounds in dangerous terrain. This often results in being stranded, and some cases, death.[15]

Autonomous Cars[edit]

Google's Lexus RX 450h self-driving car

In 2012, there were 33,561 motor vehicle crash fatalities in the United States.[16] Given the danger of driving, self-driving cars represent a way to improve safety and efficiency when driving. As self-driving technology develops, it will be imperative to question how to utilize the safety potential of technology to the fullest, while also allowing drivers to maintain essential skills in the event of an emergency. One solution to this has been Stop-and-Go Pilot which was developed by Mercedes. Stop-and-Go allows the car drives itself, but only operates when the driver's hands are on the wheel.[17]

Conclusion[edit]

In the wake of the crash of AFF447, blame was directed in several directions. The brunt of the blame was on the pilots for communication and decision-making errors due to an over-reliance on auto-pilot. The situation of the AFF447 pilots poses a new obligation of professionals in all fields. The current role of a professional to be able to question the status quo when necessary and maintain their professional opinion despite external pressure. With the increasing prevalence of automated technology, professionals will now be required to not only question managers, but to question the tools and machines they use.

References[edit]

  1. About AF 447. Retrieved from http://www.airfrance447.com/about/
  2. Air France Flight 447: 'Damn it, we're going to crash' Retrieved from http://www.telegraph.co.uk/technology/9231855/Air-France-Flight-447-Damn-it-were-going-to-crash.html.
  3. In Search of Air France Flight 447. Retrieved from https://www.informs.org/ORMS-Today/Public-Articles/August-Volume-38-Number-4/In-Search-of-Air-France-Flight-447.
  4. Air Crash Investigation. Received from http://natgeotv.com/uk/air-crash-investigation/black-box,
  5. Air France Flight 447: 'Damn it, we're going to crash' Retrieved from http://www.telegraph.co.uk/technology/9231855/Air-France-Flight-447-Damn-it-were-going-to-crash.html.
  6. a b c d e f Wise, J. (2011, December 6). What Really Happened Aboard Air France Flight 447. May 5, 2014, from Popular Mechanics http://www.popularmechanics.com/technology/aviation/crashes/what-really-happened-aboard-air-france-447-6611877
  7. Air France Flight 447: 'Damn it, we're going to crash' Retrieved from http://www.telegraph.co.uk/technology/9231855/Air-France-Flight-447-Damn-it-were-going-to-crash.html.
  8. Air France Flight 447: 'Damn it, we're going to crash' Retrieved from http://www.telegraph.co.uk/technology/9231855/Air-France-Flight-447-Damn-it-were-going-to-crash.html.
  9. Air France Flight 447 Report: How the Plane Went Down Retrieved from http://www.thedailybeast.com/articles/2012/07/05/air-france-447-report-how-the-plane-went-down.html
  10. a b Embrey, D. (n.d.). Understanding Human Behaviour and Error . Wigan, Lancashire, UK.
  11. Vickers, J. N., & Lewinski, W. (2012). Performing under pressure: Gaze control, decision making and shooting performance of elite and rookie police officers. Human Movement Science , 31 (1), 101-117
  12. Jonas, G. (2012, July 18). George Jonas: Once a pilot, now a computer’s sidekick. Retrieved May 05, 2014, from National Pos
  13. PARC/CAST Flight Deck Automation WG. (2013). Operational Use of Flight Path Management Systems. Federal Aviation Administration.
  14. Bosker, B. (2013, July 11). 'Automation Addiction' And The Asiana Crash: What Happens When We Trust Computers Too Much? Retrieved May 06, 2014, from Huffington Post Tech: http://www.huffingtonpost.com/2013/07/11/automation-addiction_asiana-crash_n_3576059.html
  15. a b Foxnews.com. (2011, February 04). Experts Warn of 'Death by GPS' as More People Visit Remote Wildernesses. Retrieved May 05, 2014, from Fox News: http://www.foxnews.com/tech/2011/02/04/death-gps-rise/
  16. NHSTA's National Center for Statistical Analysis. (2013). Traffic Safety Facts Research Not. U.S. Department of Transportation, National Highway Traffic Safety Administration.
  17. KPMG. Self-Driving Cars: Are We Ready? KPMG LLP.