The French BEA is just holding the press conference to release the final report into the crash of the flight, this coverage is going to be updated as soon as important statements are being made. The summary of final report will be summarized as soon as the report has been released and processed as usual.
The aircraft had been flying normally crossing Natal with the captain being pilot monitoring and the first officer being pilot flying. The second first officer was taking his rest. The captain was not worried about the forecast weather conditions along the route, and while over the Atlantic left the cockpit for his rest period with the second first officer taking the left hand seat. There was no briefing, especially not with regards to the Intertropical Convergence Zone. After the captain left the cockpit the two first officers discussed the echos visible on the weather radar.
Ice crystals blocked the dynamic ports of the pitot probes, the autopilot disconnected and the altitude warning sounded, the aircraft climbed up to 38,000 feet with up to more than 6000 feet per minute climb rate.
The stall warning activated, several signals were sent to the captain by the pilot not flying (second first officer), the aircraft entered "pronounced stall" and the aircraft started to descend at more than 7000 feet per minute with an angle of attack of more than 40 degrees.
Just when the captain entered the cockpit the stall warning ceased and re-occurred, the AoA was between 35 and 40 degrees and the vertical rate of descent between 11000 and 15000 feet per minute until impact with the water.
The starting point was the formation of icy crystals which disrupted the air flow and pressure measured by the dynamic ports of the pitot tubes leading to airspeed inconsistencies and the disconnection of the autopilot and autothrust system. The pilot flying is supposed to take control manually monitoring the systems, detecting the airspeed inconsistencies and maintain a proper pitch attitude and thrust setting.
Instead of keeping the pitch at a maximum of 6 degrees, at which the aircraft would stall at high altitude, the pilot flying pitched up beyond that angle. The crew did not follow standard operating procedures.
The pilot not flying did not detect the deviation from the flight trajctory and speeds and did not call the deviations. The lack of such interventions led the pilot flying to take actions that did not reduce the pitch angle.
The flight directors provided indications to increase the nose up attitude.
The aircraft subsequently departed its flight envelope, the control stick remained in the nose up position.
The crew never referred to the stall alarm and the buffeting that occured. The crew never understood they were stalling.
The captain came back into the cockpit certainly having heard the stall warning and certainly having felt the strong vibrations caused by the buffets but also did NOT identify the aircraft was stalling.
The absence of training in manual handling of the aircraft at high altitude, especially also with regards to unreliable airspeeds can explain the reaction of the crew, also the trained procedure related to airspeed anomalies misled the crew to false required pitch angles.
25 safety recommendations were made with regards to pilot training, knowledge of systems especially in degraded modes, manual handling training, knowledge of flight dynamics.
Safety recommendations have also been made to search and rescue operations.
8 safety recommendation concern pilot training, 8 safety recommendations concern aircraft certification.
The accident is categorized as loss of control as result of loss of situational awareness.
The automated systems have improved safety substantially in the last years, however, as soon as the automated systems disconnect flight crew are increasingly unable to comprehend the resulting scenario. Information presented to the pilots as well as the cognitive capabilities of humans are in the focus of attention in this regard.
This concluded the factual presentation by the BEA, now the conference has entered the question and answer part.
In the last few seconds of the descent the aircraft had entered deep stall during which recovery was next to impossible except to specially trained to crew, no pilot could have recovered from this final stall. The aircraft should never have been allowed to leave the flight envelope and come into a situation of a developed stall, not to mention a deep stall.
The Airbus family of aircraft has never been put through stall recovery during certification opposite to the Boeing 787. The Boeing test crew flying the stall were surprised by the very different sounds associated with the stall of the aircraft in comparism to a Cessna.
In an intensive stress scenario the humans blank out aural signals first. Every military pilot, every test pilot knows that in intense stress situations aural alerts are not being heard.
Goodrich probes are not immune to icing as well, however, far fewer events have been registed with these probes.
At the start of the event the altitude indication dropped by 400 feet as result of the loss of Mach number due to the computed corrections, the loss of 400 feet of altitude has further provided incentive to increase the pitch angle.
Had the pilots done nothing after the autoflight systems disconnected it is difficult to know/estimate whether the accident would have happened or not. It is true however that in a number of other events the aircraft maintained its general flight envelope with the crew doing nothing following autoflight system disconnection.
There is no proof that the crew followed flight director indications. The green bars however are very attractive, pilots are used to continue what they do normally, and it is not implausible that the crew did follow the green bars of the flight director.
The flight director indications were not recorded by the flight data recorders, but were recomputed following the preliminary report #3, these computations and knowledge resulted thereof are a new element beyond report #3.
The false data off the air data computers following the obstruction of the pitot probes by ice crystals resulting in false instrument readings as well as the immediate actions by the crew created confusion making it impossible for the crew to determine what flight status they were in.
The obstruction of the pitot probes triggered the sequence of events, the subsequent actions by the crew de-stabilized the aircraft trjactory and led the aircraft to leave its flying envelope.
The pilot actions can be explained by the crew being afraid of getting into an overspeed scenario mainly also due to the noises that occurred at the flight deck. As a result the crew never realised they were stalling.
The 25 safety recommendations in the final report add to the 16 safety recommendations issued so far in the preliminary reports.
During the final 4 minutes of flight the flight directors disappeared and reappeared multiple times, the modes changed. The flight director indications did not provide for a recovery of the aircraft, however, at the initial stages of the aircraft leaving its assigned trajectory and approaching the boundaries of its flying envelope it was possible to recover the aircraft. As the crew never realized they were stalling they were never able to disregard the flight director and take the appropriate actions to lower the nose. Appropriate action to lower the nose and the flight director indications were inconsistent. The flight director indications would need to be taken in the context of the active mode indicated in the according announciators. The flight directors were NOT disengaged as they SHOULD have been. The modus of flight director operation is being further looked into.
There had been other similiar occurrences during which the altitude was maintained within +/- 500 feet. It is not possible to state, whether another crew could have kept the aircraft within its flying envelope or not, it is impossible to tell whether the accident would have happened with another crew at the controls or not. It is likely however that the accident would have happened to other crews as well.
A test flight verified that the stall buffeting was perceived at the pilot seats, bringing the nose down would have quickly returned (recovered) the aircraft into the flying envelope.
It is true that in FBW normal law it is not necessary to train pilots for a stall situation, and it is true that pilots are not really trained for stall scenarios.
The certification bodies have reviewed the unreliable airspeed procedures at high altitude and confirmed that maintaining a pitch angle of 5 degrees nose up would have provided time to sort out the unreliable airspeed and would have kept the aircraft flying.
This concluded the press conference. The final report is to be released in the next few hours.
fonte: Avherald.com