FROM LIBRARY: THE FINAL WORD, AIR FRANCE FLIGHT 447, 2 OF 5

Allow me, first of all, to thank the organizers of this conference for having given the Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile [BEA] a complete half day to speak about the history of the Air France Flight 447 accident investigation, whose final report was published on July 5, 2012. We have chosen to present to you three main components of the investigation: readout of the flight recorders, analysis of human factors, and relations with the families and the news media.

Presentations will be made by two BEA investigators, Sebastien David, head of the Human Factors Working Group, and Léopold Sartorius, head of the Systems Working Group. You will then hear from Martine Del Bono, responsible for communications, news media, and family relations at the BEA. The investigator-in-charge, Alain Bouillard, regrets that he is unable to attend the conference.

We have now finally reached the end of three years of an exceptional investigation. It was exceptional firstly because of the international dimension: the 228 victims came from 32 nationalities, which led to numerous issues in communication such as language barriers and cultural differences, without speaking of time differences.

Exceptional, too, due to the almost simultaneous accident involving a Yemenia aircraft off the coast of Moroni, the investigation of which also heavily involved the BEA. This meant that in July 2009, the BEA was leading two undersea search campaigns, one in the Indian Ocean and the other in the middle of the south Atlantic. At this time, the BEA was also investigating a third major accident that occurred six months before in the Mediterranean Sea involving an A320.

An exceptional mystery also surrounded the exact circumstances of the Air France 447 accident as the aircraft had disappeared without any message from the crew and beyond radar coverage. These circumstances were only clarified thanks to the readout of the flight recorders in May 2011, Exceptional news media attention accompanied the various stages of this investigation, marked by several phases of undersea searches and the publication of three interim reports. It was the first major aircraft accident in a new era of accelerated news media coverage.

Sadly, it was also exceptional in the number of violations by third parties of the ethics of safety investigation, which requires respect for the confidentiality of working documents that are not published by the authority in charge of the investigation. I have requested two police investigations, unfortunately without conclusions. Finally, there was an exceptional level of controversy and unjust accusations against the BEA investigators, whose professional integrity and impartiality were called into question.

We then needed to understand the reasons for the pilots’ actions and how the loss of airspeed indications alone could have led to such a disaster. Air France Flight 447 engine recovery. Further progress in the investigation allowed us to understand the causes of the accident and to publish the final report on July 5, 2012. In contrast to the previous report, this publication did not generate negative reactions, even on the part of those who had previously been so critical of the BEA one year before. In fact, this report illustrates the complexity of the event.

Of course, this accident had its origins in the obstruction of the pitot probes by ice crystals and, as a consequence, the temporary loss of airspeed indications. Above all, however, it resulted from the airplane exiting its flight envelope due to the crew’s losing situational awareness. This category of accident, classified as loss of control, has emerged over the last decade or so as the most deadly in public transport. It involves airplanes of both classic design as well as recent planes with a high level of automation.

The BEA, which is associated with a large number of investigations worldwide, has investigated several accidents in this category. We have also investigated a similar category of accidents classified as CFIT where, while still within the airplane’s flight envelope, the loss of flight path control resulting from a loss of situational awareness by the crew has led to disaster. We are currently carrying out a study of this category of accident.

A lot of work and research is being undertaken within the international aviation community on subjects related to loss of situational awareness by the flight crew. The BEA’s conclusions and recommendations on pilot training are consistent with these themes.

Automated systems are used on modern airliners during most of the flight, and they have considerably improved safety. The problem is that automated systems are not always used, either involuntarily when they disconnect or, in some situations, deliberately. Then, whether it’s a classic or a modern airplane type, flight path control requires that pilots have perfect situational awareness.

This comes from the quality of the information provided to pilots, the way in which it is presented, the consistency of the signals that they perceive via the various sensory channels, and their ability to make sense of these signals from their training and experience.

But the acceptance of a recommendation is often just the beginning of a long process that could take years. To assess the real impact of our investigations on safety, we should check the effective implementation of our investigations. This task, I will propose to our European counterparts to share with us, taking advantage of the newly created European safety recommendations database.