Air France transcripts paint picture of fatal human error

By Rebecca Davis 9 December 2011

When Air France Flight 447 crashed into the Atlantic on 1 June 2009, its causes became one of the greatest mysteries of aviation. Now Popular Mechanics has published the transcript of the pilots’ conversation in the final moments before the plane went down, and it makes for chilling reading. By REBECCA DAVIS.

All 228 passengers and crew members died aboard the Airbus A330-203 when it plunged into the ocean off the Brazilian coast, en route from Rio de Janeiro to Paris. Until now the cause of the disaster has been attributed to the fact that the aeroplane’s pitot tubes – responsible for measuring pressure and speed – malfunctioned when they iced up. When this happens, the autopilot switches off and the plane has to be manually controlled.

What the transcripts from the cockpit reveal, however, is that it was not singularly this that was to blame, but “a simple, but persistent mistake on the part of one of the pilots”, despite his extensive experience. Essentially what appears to have happened is that one of the pilots kept the nose of the plane up, over and over again, despite the fact that this was the worst action he could have taken. Meanwhile, an alarm in the cockpit explicitly telling the pilots that the plane was stalling was simply ignored.

This is attributed to a concept called “incomprehensibility”, which holds that people involved in accidents like this cannot figure out what is happening because things are changing so quickly and consequently fall back on ideas they have practised and understand. Their brains convince them that these are the most sensible courses of action – even when there is abundant evidence that the strategies are failing. Unfortunately, the question of how one trains pilots to overcome this is unanswered. DM

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