Tuesday, October 8, 2013

Book Review: "Understanding Air France 447" by Capt. Bill Palmer

In a recent radio interview, a doctor described a procedure followed in many hospitals when a patient dies. The attending physician stands before his peers and presents the case – what symptoms were seen, what actions were taken, what results were observed, what errors were made, what needed actions were omitted, what lessons were learned, what changes ought to be made. Discussion ensues. The process is, literally, deathly serious as the cost of the knowledge gained is someone's life. This learning process is called "Morbidity & Mortality Rounds".

This process came very much to mind as I read Capt. Bill Palmer's excellent "Understanding Air France 447". In this case, aeronautical sins of commission and omission were committed. Fatal results ensued. 228 people died. Attention must be paid.

Perhaps in a more just world, the Chief Pilot at Air France would have come forward with a book that covers this ground. Of course, some combination of legal trepidation and organizational pride will preclude that from happening and so Capt. Palmer has stepped into the central role. By his deep expertise in the systems and behaviors of Airbus aircraft (and the A330 in particular), he is highly qualified to do so.

Although Capt. Palmer clearly cares deeply about safety, this is not a passionate book. It is, rather, a thorough, methodical and ordered presentation of the facts and circumstances with a minimum of inference. Conclusions are drawn when justified by evidence; possibilities are suggested only if supported by the record.

The author starts us off with an outline of the chronology of the event, the basic biographical data of the flight crew, and an overview of the operational environment that prevails on these long flights across the lonely South Atlantic. He reviews the adverse weather conditions that the flight encountered. We learn about the icing-related failure modes of the pitot-static system that in all likelihood caused a temporary loss of all airspeed data, precipitating the cascade of events leading to loss of the aircraft. A clear and helpful description of the Airbus' fly-by-wire system, its control laws and ancillary systems gives the reader a basis for understanding the events that follow with frightening speed.

At 02:10:05 UTC on 1 June 2009, due to absence of airspeed data, the autopilot on A330-200 aircraft F-GZCP disconnected, returning control to the Pilot Flying (PF). There was nothing else wrong with the aircraft. And yet, four minutes and 23 seconds later, the Airbus smashed into the unyielding surface of the ocean below. To aid in understanding how this could have happened, Capt. Palmer divides the period from autopilot disconnect to impact into four phases – three only seconds long, the fourth just a few minutes. He dissects each phase, examining crew actions and aircraft responses, slowly assembling a tragic picture of inadvertent error and ultimate futility.

As each phase of the event progressed, recovery of control became more challenging and less likely. During the first phase, the airplane was climbing while being subjected to inappropriate control inputs, yet recovery to controlled level flight would have been fairly simple. In contrast, sometime during the final phase the airplane probably became unrecoverable. At any event, approach to recovery would by then have required extremely aggressive measures beyond the experience, training, and probably the imagination of the pilots.

The first eight chapters of the book are concerned with the laying out of facts and the explanation of relevant background. They are the foundation on which the last three chapters stand. These are titled, "The Human Element", "Lessons Learned" and "Going Forward". Here, the author delves into the "Why?" of AF447. He discusses fatigue issues, control mode confusion, mis-understanding of aerodynamics in the cruise environment, and gaps in training. As is usually the case, there is no single "smoking gun" behind this tragedy – each of these factors probably played a role.

In his discussion of "Lessons Learned", Capt. Palmer points to a range of issues:

  • Better understanding of the mechanics of stalls at high-altitude is needed.
  • More refined understanding of the subtleties of degraded flight control laws is needed.
  • More time spent hand-flying in the cruise environment is needed.
  • Adoption of the 'Safe Harbor' concept (a fallback, fail-safe pitch-and-power configuration) is advisable.
  • The programmed behavior of the Flight Directors may have contributed to the accident and should be reviewed.
At the end of his book, the author calls for improvements in the training of line pilots to address these and other lessons and shortcomings. He sums up the situation pithily, saying:
"We must not allow mastery of the Flight Management System to be confused with airmanship."
...and his last sentence seems to be addressed to everyone in the industry who is charged with preparing pilots to take responsibility for the lives of passengers: "We have been warned."

11 comments:

Cedarglen said...

A great review Frank. Thank you. Other have recommended Capt. Palmer's book as well and it is on my list.
-C.

Cedarglen said...

Addendum/FYI: Amazon has a Kindle edition for $10. Trade paperback is about $18. -C.

Frank Van Haste said...

Craig, if it's the sort of thing that floats your boat, Bill will send you a signed copy via his web site for $19. (I always make the cover image in my reviews clickable to a source for the book...same here.)

Frank

Karlene Petitt said...

Frank this is an outstanding review! And... you called it exactly perfect. An interesting read and informational for anyone on the plane....or any plane as far as that goes.

Cedarglen said...

Thanks again Frank,
I'm winding up Capt. Palmer's book with electrons and pixels, but enjoy retaining hard copies when there is some small link to the author. Proud to have as signed one from Karlene (and awaiting her next) and just received Eric Auxier's novel, **The Last Bush Pilots**. (I don't think Eric's book has anything to do with airplane drivers that served B41 and B43!!) Your reviews are great Frank and perhaps you should consider a book. The perspectives of an IFR/PP that flies as a serious professional are worth reading, as fiction or non-fiction. I guess it is always about time... -C. (HTML tag did not work; some other time.)

Frank Van Haste said...

You're too kind, Craig. I'm moving toward some changes in my life that I anticipate will make some time available for new things; and I do have a couple of ideas for serious written work. We'll have to see what develops, but thanks for your thoughts. I'm glad you find the reviews useful -- I enjoy writing them.

Frank

Cedar Glen said...

Hi Frank! It may be too early to post this, but I too am enjoying Captain Bill Palmer's book. Some of the detail is 'thick' for a non-Airbus driver or a mostly grounded guy like me, but he misses nothing. At least so far, I think I'd still favor a full-control human over the box, but I'm still reading.
I just finished Eric Auxier's *The Last Bush Pilots. Eric's writing is near perfect. His introductions and early action is great and with letter-perfect dialogue. The resolution is a bit anti-climatic for a medium-length novel, but the writing is so good that I'll give his book a 4.8/5 when I do the formal review. If you've not already read it, I hope you do. Through 300 pages of letter-perfect writing, my first reading caught but two tiny errors - well within the the range. I hope you read Captain Auxier's book.
Yes, I've heard about the Plamer/AF447 book from several folks and it is worth reading. He is selling nothing beyond professional conclusions that carry substantial weight. Your review is great and I'll second your motion. Regards - C.

Cedar Glen said...

I don't know why it is now calling me "Cedar Glen" as opposed to "Cedarglen," but I hope your end can figure it out. Teaching a new computer has a lot in common with teaching a one ton shark to kiss you without drawing blood. Smile a lot, I guess! -C.

Frank Van Haste said...

Craig:

re: Capt. Auxier's book, thanks for the point-out. I shall put it in my queue.

re: 'Cedar Glen' vs. 'Cedarglen'...is it possible that you possess a Google+ identity as the former? The Googleplex is, for its own benefit (and not ours) trying to integrate G+ identities into Blogger. I get from them "Wouldn't you like to use your G+ profile here?" queries routinely. If you ever acceded to one of those it would explain the phenomenon of which you complain.

I am spring-loaded to decline any proposition from the mother ship on the assumption that it is good for them but will only be good for me by accident. GI-not-YF!

Of course, they're still better than Facebook (about which the less said the better). FB is the work of Satan and Zuckerberg is his familiar.

Regards,

Frank

Anonymous said...

I think we've "been warned" MANY MANY TIMES about the transformation of a Captain from a Master of Basic Aviation Flight manevers/ his/her performance envelope/Type rating to a Systems Manager ever since that horrible never-should-have-been Hapsburg flyby. And the multiple Airbus Flight/Test Crew Only-aboard similar accidents. The more Boeing moves in that direction, the more we are going to see these PREVENTABLES! Sure, everyting's fine on a CAVU leg, but HUGE Oceanic Storms over Africa CAN'T be dismissed as fly-over-its. Ask the Rutan Voyager crew. ISS confirms some T-heads at FL 500! Add insufficient radar coverage, poor ATC in remote areas, and...

Frank Van Haste said...

Anonymous, thanks for your comment. I concur!

Frank