There is an alternative way of looking at the 2009 Air France disaster in which an A330-200 performing AF447 between Rio and Paris was so atrociously mishandled that it was belly flopped at high speed into the mid Atlantic with all systems functioning as designed and the pilots in a state of utter confusion and disarray.
That explanation, which is supported by carefully rereading the final report by France’s air safety investigator, involves bad blood and misbehavior in the cockpit by persons whose conduct and competency is the legal responsibility of Air France, and which slaughtered all 228 people on board.
The report into the accident was released mid year, and has been nagging at the minds of various people who doubt that this was a consequence of a flaw in the Airbus control systems when in fact the mishandling of the jet by the least competent of the three pilots on board was not meaningfully countered by the two more experienced pilots.
The turning point in reconsidering AF447 was an analysis of the accident by David Learmount of Flightglobal, which drew attention to the fact that the captain’s seat on the left side of the cockpit was left in the maximum aft or ‘lounge’ position from after he pushed it back to exit for a rest break until the jet crashed.
That seat was occupied after the Captain departed by the more senior of the two co-pilots, but who had not been designated as the pilot flying by the captain. As the pilot not flying, and required to take directions in a junior role from his less experienced colleague, he then sits there in a state of detachment while his inferior stuffs it all up, until at high speed and low altitude, over a dark ocean in the middle of the night, he realizes that he and everyone else on board is going to die.
At this stage, according to the report, the captain, who had been recalled to the flight deck, is standing at the back of the cockpit, in a position to have clearly observed the conduct of the flight and the setting of the pilot flying’s sidestick controller, doing nothing effectual to deal with the situation.
On this alternative analysis this is not about any confusion that may have been caused by the audio alerts generated by the control system, but pride, envy, bloody mindedness and a gross failure of those in the cockpit to cooperatively work as a team to resolve the issues.
These are matters which reflect severely on the failure of Air France to manage the competencies of those entrusted to fly one of its jets, which resulted in a manifestly avoidable tragedy.
Did the investigator, the BEA, frame its report to downplay the human factors versus the systems factors, and thus deflect criticism of Air France?
Not at all. Everything a reader needs in order to form a very negative view of how Air France was managing its safety of flight obligations is meticulously noted in the report, but the authors have left it to the reader to do the hard work in that respect, or to chose to wrestle with the technical issues more than human issues. The BEA notes the events in the cockpit quite clearly, but it does so in a report in which the reader needs to use a marker pen, or a highlight on the screen, to define what is a narrative as to what the investigators thought happened, and the technical matters that they describe.
In that sense the AF447 report is reminiscent of the official NZ investigation of the Mt Erebus disaster, in which that author did include the terrible truths about the incorrectly entered navigational data that had been preloaded into the DC-10 before it set off for Antarctica, but chose not to highlight them.
There is another problem. We do not appear to have a complete transcript of everything that was said on the cockpit voice recorder. It could be because of the traumatic nature of the recording, yet it might also add very important detail that those who study the report would have reasonably expected to have been included after its detailed scene setting account as to how the cockpit was set up from the moment the captain, about to go on his rostered rest break, tells the least experienced co-pilot he will be in charge in the absence from the cockpit of his more experienced colleague.
After that the more experienced first officer returns to the cockpit, discovers his inferior is in charge, and sits, seemingly detached from the action, while a transient problem with ice blocking one of the speed measuring pitots leads to an autopilot disconnection at which point the less experienced first officer totally loses the plot.
The professional relationships between the pilots in the cockpit is broken. Soon the jet and everyone inside while be broken as well. How Air France could have ever let such a dismal state of affairs undermine the safety of this flight isn’t addressed in this report, yet it leaps from the pages.
The BEA report, although it can be criticised as tricky to read, does actually provide all of the information needed to reach a conclusion that a very bad interaction was present in the cockpit in the minutes before the flight slammed onto the surface of the ocean in a nose high attitude, with engines running but the wing stalled.
While technical issues have so far dominated public discourse about AF447 the human and work place and flight standards issues may well have their day in 2013.