BEA Conclussions

I cannot resist to 'paste' here the conclusion BEA extracts from its investigation on the probable causes of the accident. They are a lot, but worth to read them, in my opinion:

 "Thus, the accident resulted from the following succession of events:

□ Temporary inconsistency between the airspeed measurements, likely following the obstruction of the Pitot probes by ice crystals that, in particular, caused the autopilot disconnection and the reconfiguration to alternate law;

     □   Inappropriate control inputs that destabilized the flight path;

□   The lack of any link by the crew between the loss of indicated speeds called out and the appropriate procedure;

□   The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;

□ The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;

□  The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it.

These events can be explained by a combination of the following factors:

□  The feedback mechanisms on the part of all those involved that made it

     impossible:

--  To identify the repeated non-application of the loss of airspeed         

     information  procedure  and to remedy this,

    --  To ensure that the risk model for crews in cruise included icing of the        

          Pitot probes and its consequences;

□  The absence of any training, at high altitude, in manual aeroplane handling and in the procedure for ”Vol avec IAS douteuse”;

□  Task-sharing that was weakened by:

   --   incomprehension of the situation when the autopilot disconnection   

         occurred,

--  Poor management of the startle effect that generated a highly charged emotional factor for the two copilots;

--  The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers;

--  The crew not taking into account the stall warning, which could have been due to:

--   A failure to identify the aural warning, due to low exposure time in training to stall      

     phenomena, stall warnings and buffet,

--  The appearance at the beginning of the event of transient warnings that could be    

     considered as spurious,

--  The absence of any visual information to confirm the approach-to-stall after the loss

     of the limit speeds,

--  The possible confusion with an overspeed situation in which buffet is also

     considered as  a symptom, 

--  Flight Director indications that may led the crew to believe that their actions were

    appropriate, even though they were not,

□  The difficulty in recognizing and understanding the implications of a     

     reconfiguration in alternate law with no angle of attack protection."

Have a nice night all. I love you.

TWRman