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    Si vis pacem, para bellum
  • Birthday 04/18/1949

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  1. According to the final report the accident resulted from the following succession of major events: temporary inconsistency between the measured speeds, likely as a result of the obstruction of the pitot tubes by ice crystals, causing autopilot disconnection and reconfiguration to alternate law; the crew made inappropriate control inputs that destabilized the flight path; the crew failed to follow appropriate procedure for loss of displayed airspeed information; the crew were late in identifying and correcting the deviation from the flight path; the crew lacked understanding of the approach to stall; the crew failed to recognize the aircraft had stalled and consequently did not make inputs that would have made it possible to recover from the stall. These events resulted from the following major factors in combination: feedback mechanisms on the part of those involved made it impossible to identify and remedy the repeated non-application of the procedure for inconsistent airspeed, and to ensure that crews were trained in icing of the pitot probes and its consequences; the crew lacked practical training in manually handling the aircraft both at high altitude and in the event of anomalies of speed indication; the two co-pilots' task sharing was weakened both by incomprehension of the situation at the time of autopilot disconnection, and by poor management of the "startle effect", leaving them in an emotionally charged situation; the cockpit lacked a clear display of the inconsistencies in airspeed readings identified by the flight computers; the crew did not respond to the stall warning, whether due to a failure to identify the aural warning, to the transience of the stall warnings that could have been considered spurious, to the absence of any visual information that could confirm that the aircraft was approaching stall after losing the characteristic speeds, to confusing stall-related buffet for overspeed-related buffet, to the indications by the Flight Director that might have confirmed the crew's mistaken view of their actions, or to difficulty in identifying and understanding the implications of the switch to alternate law, which does not protect the angle of attack. https://www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf
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