Catastrophic System Failure: An Analytical Case Study of Flight 447 Rebecca M. E. Chompff & Gabriella M. Hancock, Ph. D Department of Psychology College of Liberal Arts California State University, Long Beach

Introduction Analyses Discussion

• Date: June 9, 2009 • Communication Dynamics (David et al., 2018) • Airline: Air France • Transaction level approach used to investigate changes in communication dynamics under unexpected situations • Aircraft: -200 • Features of communication pattern: • Flight: 447 • Fixed effects, Preferential attachment, triadic effects, • Flight Route: Rio de Janero, Brazil to , France persistence, recency, participation shifts • Crew: • BIC values help predict communication dynamics at a specific time • Captain: Marc Dubois • Results: • First Officer: David Robert • Normal flight phase, standard communication pattern Figure 6. The wreckage of Flight 447 found over a two-year span post-crash (BBC News, 2011). • First Officer: Pierre-Cedric Bonin • Emergency flight, non-standardized communication • Fatalities: 228 people pattern • Communication Dynamics • Patterned changes in the underlying dynamics contributed • Communication training for pilots in stressful and to transaction failures and created a dysfunctional network emergency situations between pilots • Lack of such training contributes to dysfunctional communication network regarding potentially critical information (David et al, 2018) Figure 1. The actual Airbus A330 of Flight 447 Figure 3. Lower scores are more • Human Computer Interface (HCI) Design of Airbus A330 photographed on a landing predictive of the communication strip 2 years prior to the dynamics at a particular phase • Immediate replacement of pitot tubes, and other devices, incident (Wikinews, 2019). (David et al., 2018) when known to be faulty • 10 days post-crash, all pitot tubes on Airbus A330/A340 • Human Computer Interface (HCI) Design of the Airbus aircrafts had been replaced (BEA, 2012) • Airbus A330 Side Stick Controls function independently, Sequence of Events (Cathal et al., 2010; BEA, 2012) • Inconsistency not in unison • Pitot tubes freeze causing to disengage • Frozen pitot tubes caused autopilot to turn off (Ezzeddine, • More advanced training necessary when autopilot fails and recovery of aircraft control • Turbulence causes aircraft to roll; pilot induced oscillations 2017) • Bonin pulls side stick; nose rises and speed decreases • Auditory warning signal indicating autopilot turned off, • As of 2011, there is still no report of Air France changing but did not indicate reason their training procedures regarding manual flying at high • Abrupt decrease in speed unknown to pilots • Auditory warning, but did not indicate reason altitude or when autopilot fails (Martins et al., 2012) • Dramatic speed decrease causes aircraft to stall (Wikipedia, n.d.) • Bonin still pulling side stick, Robert begins pushing side stick • Pilots forced to fly manually when autopilot turned off, • “Dual input” warning signal sounds without clear reason which caused confusion Conclusion • Dubois reenters cabin By analyzing incidents like Air France Flight 447, we can • Dubois realizes the simultaneous commands to the control minimize the likelihood of future tragedies. Fatal system failures sticks is the issue that stem from interactive effects of human error and far-reaching • Aircraft too low to recover human-machine system considerations. Acknowledging and Figure 4. The three locations of Pitot Tubes on adjusting the factors that led to this disaster will save future lives • Ground proximity warning sounds an Airbus A330 (Airliners, 2018) by informing the issues examined here; regarding communication • Crash into less than 5 minutes after pitot tubes dynamics, HCI Airbus design, and airspeed inconsistencies freezing • Airspeed Inconsistency (McClellan, 2007) • Flight Director (FD) Display responsible for guiding aircraft along flight path Acknowledgements • FD also responsible for indicating air speed • FD and autopilot attached as a single system, but FD can The author acknowledges Dr. Gabriella Hancock for her guidance, be used manually support, and encouragement with this poster and throughout our • Change in FD but not in professional endeavours. The author also recognizes Patrick O’Connell autopilot means an issue for his constant optimism and confidence in her achievements. has occurred with the system • FD did not give consistent References airspeed, causing confusion References available upon request. Figure 2. The flight manual flying plan for Air France For more information Flight 447 from Rio Figure 5. Airbus A330 Flight de Janero to Paris Director Display (Infinite Flight Please contact [email protected] for more (BBC News, 2009). Community, 2016) information on this topic.