Safety in Commercial Aviation: 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 • Interface Design Issue: Side Stick Controls • Airline: Air France • Side stick controls responsible for front-to-back and side- to-side movements (BEA, 2012) • Aircraft: -200 • Side stick controls on either side of the are not • Flight: 447 correlated with one another (Air Safety Week, New York, • Flight Route: Rio de Janero, Brazil to , France 2012) • Crew: • Design led to miscommunication between pulling/pushing the side stick • Captain: Marc Dubois • First Officer: David Robert Figure 6. The wreckage of Flight 447 found over a two-year span post-crash (BBC News, • First Officer: Pierre-Cedric Bonin 2011). • Side Stick Control Coordination • Fatalities: 228 people • Correlation of side stick controls would alert all pilots via sensory feedback to when controls are in use • The final 2012 BEA, The Bureau of Enquiry and Analysis for Civil , report did not acknowledge the lack of coordination between the side stick controls as a contributing factor to the crash (BEA, 2012) Figure 1. The actual Airbus A330 of Flight 447 Figure 3. Side Stick Controls in an Airbus A330-200 (Quora, 2016). • Replacement photographed on a landing strip 2 years prior to the • Manufacturing and Maintenance Error: Pitot Tubes • Immediate replacement of pitot tubes, and other devices, incident (Wikinews, 2019). • Pitot tubes responsible for detecting air speed of the when known to be faulty aircraft • 10 days post-crash, all pitot tubes on Airbus A330/A340 • Freezing of pitot tubes led to the disengaging aircrafts had been replaced (BEA, 2012) Sequence of Events (Cathal et al., 2010; BEA, 2012) • Air France knew pitot tubes were faulty (Ezzeddine, 2017) • Training for Stalls and High Altitude Manual Flying • Pitot tubes freeze causing autopilot to disengage • Pitot tubes not required to be replaced immediately (BEA, 2012) • Further advanced training in onset and recovery, • Turbulence causes aircraft to roll; pilot induced oscillations particularly at high altitude, is necessary • Bonin pulls side stick; nose rises and speed decreases • As of 2011, there is still no report of Air France changing • Abrupt decrease in speed unknown to pilots their training procedures regarding manual flying at high • Dramatic speed decrease causes aircraft to stall altitude or high altitude stalls (Martins et al., 2012). • Bonin still pulling side stick, Robert begins pushing side stick • “Dual input” warning signal sounds 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 adjusting the factors that led to this disaster will save future lives • Ground proximity warning sounds Figure 4. The three locations of pitot tubes on an Airbus A330- by informing the issues examined here; regarding interface design • Crash into less than 5 minutes after pitot tubes 200 (Airliners, 2018). issues, manufacturing and maintenance errors, and pilot training freezing • Pilot Training in Emergency Procedures for emergency procedures. • Flight 447 pilots were not appropriately trained (Bhangu et al., 2013; Martins et al., 2012) Acknowledgements • Manual flying at a high altitude The author acknowledges Dr. Gabriella Hancock for her guidance, • Aircraft stall onset and recovery support, and encouragement with this poster and throughout our • Anomalous reports of air speed professional endeavours. The author also recognizes Patrick O’Connell for his constant optimism and confidence in her achievements. References References available upon request. Figure 2. The for Air France Flight 447 from Rio For more information de Janero to Paris Figure 5. Pilots of Flight 447. (from left to right): Marc Dubois, (BBC News, 2009). David Robert, Pierre-Cedric Bonin (Air Disasters, 2016). Please contact [email protected] for more information on this topic.