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Air France Flight 447, References - Coggle Diagram

- - - - This lack of visibility of the other control stick contributed in the stall due to both pilots cancelling out each others controls.
      - There was no direct or visible alarm or notification of the control cancelling each other out. The Captain only discovered what was causing the stall when it was too late.
  - - - The second pilot took over the main controls at this point attempting to re correct the roll and pulled the stick to the left. Creating an unstable roll between the left and right side.
        
        The second pilot then overcorrected then for an undetermined reason positioned the stick in the nose up direction ascending the aircraft into colder temperatures.
    - - Noise may have prevented the Captain from hearing the alarms and not awaken from his rest sooner.
- - - - Physical Ergonomic factors
        
        Age 58
        
        Wears corrective lenses
      - Hold the type rating for A300, A320, A330 and A340.
      - Considered a very experienced Pilot in the industry, although the experience was majority on less automated aircraft's. (Bureau, 2012)
    - - Fatigue after flying for close to the 10 hours, he decided to take his scheduled rest break while ascending towards an electrical storm and passing over a communication dead zone.
        
        Fatigue may have contributed to his reaction time once entering back into the cockpit after being woken by the First Officer. By the time he realised the reason for the stall it was too late to correct.
        
        Found in the CVR his voice came across calm when communicating to the cabin crew and other pilots. (Bureau, 2012)
      - Poor decision making and lack of ability to transfer information to the Second Officer taking his seat in control.
        
        Therefor when the Second Officer took over controls he was unsure how to approach the storm. (Bureau, 2012)
        
        This could be considered setting the Second Officer up for failure from the point he took over the Captains seat.
  - - - Physical Ergonomic factors
        
        Age 37
        
        Wears corrective lenses.
    - - Graduated from a high end flight school in France, also is a qualified air traffic control engineer. (Bureau, 2012)
    - - Stress and panic as found on the CVR he attempted to wake the Captain once the sequence of events begun and he realised they needed assistance.
        
        Found during the investigation of the CVR he was very quiet and seemed frustrated at the initial warning alarms but remained respectful when communicating with the Second Officer. (Bureau, 2012)
  - - - He has a young family two boys the ages of 4 and 8, may have contributed to his stress levels wanting to return home to them. (Bureau, 2012)
      - He got married at a young age and was known to be extremely in love with his wife. Also contributing to his stress levels.(Bureau, 2012)
      - Once the sequence of events and warning alarms begun, his situational awareness may have been compromised due to his family life. (Bureau, 2012)
      - While having control over the aircraft during the accident sequence he made poor decisions and acted in a way of panic steering the controls in the wrong direction which contributed to the aircraft stalling. (Bureau, 2012)
        
        This also effected his effectiveness to communicate with the First Officer of his actions.
    - - The least experienced of the three.
      - Age 32
      - Hold type rating for A320, A330 and A340.
      - Being younger he was known in the fleet to have quick reaction time.
- - - - This was not included in the flight insinuator assessment for flying the A330.
  - - - Maximum hours of flying per pilot is 10 hours which required the work tasks to be carried out by three pilots instead of just the two which the design pf the aircraft was for two pilots. (Bureau, 2012)
      - Why was the Captain assigned to take his scheduled break when the aircraft was known to be within the dead zone at that time of the trip. (Bureau, 2012)
        
        This left the less experienced pilots in command during a higher risk environment.
  - - - Flight path could have been re-evaluated and diverted to a safer route.
  - - - Before the A447 incident, the investigation of the pitot probes on the Airbus found that the system was considered unsafe to operate. (Bureau, 2012)
        
        Although was not compulsory for the company to substitute.
        
        It was after the incident that the system was considered hazardous and required to be acted upon immediately.
      - At the time of the event it was not an requirement to replace the model of pitot probes, therefore Air France was free to decide when they could replace the failing system.(Bureau, 2012)
        
        Air France after the investigation shared some responsibility for the sequence of events and causal factors which resulted in the tragedy.
- - - - Airspeed indicators displayed false readings minutes after they entered the storm cloud and the anti-icing system was engaged.
        
        Autopilot then deactivated due to the airspeed indicators giving false readings.
        
        Which then the failure within the operating systems lead to the follow on effect of the engines auto-thrust deactivating.
    - - This increased the likelihood of failure within the operating systems of the pitot probes. Effecting the flight control system.
        
        The pitpot probes are equipped with a heating system to prevent the system freezing or becoming blocked. In the case the low performance of the model F-GZCP on the aircraft contributed to the system failing.(Bureau, 2012)
        
        This model had been previously known to fail but had not yet been the result of an incident on a larger scale of investigation.
        
        Air France was in the process of substituting this model.