What Crucial Evidence Was Missing from the 2022 Air France/Airbus Manslaughter Trial and Why
Flight Safety Information Commentary
By Roger Rapoport
Senior Editor
In May 30, 2009 a state-of-the-art Air France Airbus 330, designed with ‘fail-safe’ AI stall protections took off from Rio’s Anton Carlos Jobim Airport. Three hours and forty-five minutes later the aircraft carrying 228 passengers and crew disappeared in the South Atlantic. In many important ways this tragedy, which has become the Titanic of aviation accidents, defines the central paradox of commercial aviation: Hidden dangers continue to threaten air safety, even on the best planes in the sky.
Attempts to resolve this problem continue to challenge the industry. Exhibit A is the French Public Prosecutor’s involuntary manslaughter case brought against Air France and Airbus. This nine-week Paris trial heard by a three judge tribunal featured dueling testimony from many of the nation’s leading aviation experts representing the defendants, flight 447 pilots and bereaved families of all those lost.
Missing was testimony documenting the 25-year history of regulatory and airline failures to correct high altitude stall recovery training in the face of substantial evidence. While the tribunal’s April 17 verdict will be worldwide news, it will not detail the astonishing fact that high altitude stall procedures, which led directly to the Air France 447 crash, were incorrectly taught for decades.
Long before the Rio/Paris crash many of the world’s top air safety experts, including test pilots at Boeing, Airbus, and McDonnell Douglas, leaders of the prestigious Flight Safety Foundation, veteran accident investigators and Air France captains had been warning that high altitude stall recovery procedures and guidelines were dead wrong.
A quick summary of what leaders of all three aircraft companies had to say was memorialized in a video filmed at the Smithsonian. This warning was central to a 1998 industry-led Upset Recovery Training Aid created by airlines, manufacturers, government regulatory agencies and pilot associations. It was submitted to airlines and regulators worldwide.
Turning a blind eye to this evidence, top regulatory officials at the Federal Aviation Administration, the Joint Aviation Authority (now the European Aviation Agency), and airlines, including Air France, failed to correct erroneous high altitude stall recovery training and regulations. To qualify and periodically re-qualify for their licenses, pilots around the world were required to demonstrate their ability to handle a stall by performing a completely incorrect procedure that could ultimately become the difference between life and death. Again and again the “error” was requiring pilots to “power out” rather than descend in the face of a potential stall, something which is particularly problematic at high altitude.
Worse, those who challenged the conventional wisdom, including the outspoken chief pilots at both Airbus and Boeing, Larry Rockliff and David Carbaugh, were persona non grata on this critical safety issue. These experts insisted that the correct stall recovery procedure was to proactively reduce the angle of attack, losing altitude as necessary.
Their aerodynamic evidence, based on well-documented test flights was ignored and silenced by an industry which was leadenly intransigent about changing long-held procedures, ultimately putting lives at risk. It was not as if they didn’t have the evidence either. A series of crashes, including a West Caribbean Airways MD-82 jet that went down in Venezuela in August 2005 with 160 aboard, backed up the experts. This event fully documented their devastating critique of the wrong procedure mandated by the regulators and the airlines.
While government accident investigators incorrectly attributed disasters like this one to “pilot error” the fact was that the pilots and their passengers were victims of regulatory and corporate malpractice. Incredibly just one regulatory agency, Transport Canada, saw the light and corrected this training error in 2005.
“The engine thrust available at high altitude is much less than at low altitude because the air density is thinner, “ explains Carbaugh.
Any pilot brave enough to challenge the conventional wisdom, such as Air France Captain Jerome Agnel, one of four key whistleblowers in this story, did so at risk to their livelihood.
After saving an Airbus 330 from a near stall on an August 2008 Madagascar-bound flight by correctly descending, he confronted a top company safety official in Paris. Obviously following the mandated requirement for stall recovery could have led to a crash. Instead of listening to Agnel and warning all his Air France flight crews of this hidden danger, that Air France executive reprimanded Captain Agnel for not following company procedures.
“I’m alive,” responded the right-thinking Air France captain who probably saved hundreds from a crash in the Sudan.
Three months later, in November 2008, Agnel’s view was confirmed by a 222-page update of the 1998 Airplane Upset Recovery Training Aide. Created by a team of 70 world-class aviation industry experts, the group was co-chaired by Boeing Chief Pilot Carbaugh and Airbus Chief Pilot for the Americas Rockliff (the next two whistleblowers), and Bob Vandel, executive vice-president of the Flight Safety Foundation. This update was submitted to the group’s FAA organizer, Operation Safety Inspector Gloria LaRoche, formerly a veteran United Airlines captain.
Like Agnel, this crystal clear document warned that it was only a matter of time before another crash proved that the industry’s continuation bias on high altitude stall recovery procedure was fatally wrong. Among the recipients of this critical document was Air France’s safety chief together with his counterparts at regulatory agencies and airlines worldwide.
Despite all this, the vital warning and detailed explanation of the correct recovery procedure were not shared with Air France pilots. Even after the FAA put the document online in December 2008, officials at that agency and European Air Safety Agency failed to take long overdue regulatory action.
“This incomprehensible bureaucratic roadblock potentially threatened even the most experienced flight crew,”says 777 Captain and veteran accident investigator Shem Captain Malmquist, a professor at Florida Institute of Technology.
Making matters worse was a critical design error compounding the challenges faced by the Air France 447 crew over the Atlantic early on the morning of June 1, 2009.
To prevent the stall warning alarm from triggering during the first part of a takeoff roll, the Airbus design team set this critical alarm feature to sound only when airspeed was above 80 knots. Below that speed the stall alarm warning would not go off. This ignored the distinct possibility that in the predictable event of unreliable airspeed indication, the stall warning system could send pilots completely wrong information. That is exactly what happened to Air France 447.
All three airspeed indicators (pitots) froze. False alarms from this failed system incorrectly told the pilots their jet was going to stall every time they correctly lowered the nose to prevent a stall. At the same time it told them they were not in a stall when they followed a broken flight director instrument’s instruction to climb into a potential stall.
As Boeing’s Carbaugh points out: “Every time the flight crew correctly put the nose down to descend and prevent a stall, the airspeed indication increased above 80 knots and triggered a stall warning. When they stopped the descent and put the nose back up, the incorrect airspeed indication system turned off the stall warning alarm. I wish we had added a three-minute YouTube video to our upset recovery report update and sent it to all pilots. It could have made a critical difference.”
Overwhelming evidence from the Air France 447 crash and another low-altitude stall crash on a Buffalo bound Colgan Air (Continental) flight in February 2009 finally forced the American government to take action.
After intense lobbying by relatives and friends of the Colgan Air victims, and continuing press coverage, Congress passed a law in August 2010 requiring the FAA to change its ongoing insistent focus on approach to stall recovery regulation and training requirement. In 2013 the FAA issued a final ruling requiring retraining of all airline pilots on the correct identification and recovery from a stall condition within five years.
Air France and the European Air Safety Agency followed suit. In the end it cost the industry over $100 million to complete this pilot retraining in 2018, two decades after the first Airplane Upset Recovery Training Aid was issued by the industry group.
Despite these changes Carbaugh and Rockliff agree the industry has marginally corrected how pilots are trained to handle stall recovery in many unexpected situations. As Malmquist explains: “Current pilot training is not realistic. The stall training scenarios are predictable and do not reflect the circumstances that represent real-world scenarios.”
Rockliff agrees: “These scenarios are almost exclusively limited to low and medium altitude environments that still focus on approach to stall, which is completely different from an actual stall. Missing from the training and testing process is the completely unexpected element presented to the pilot. The training script and testing outcome have no element of realism. Once again the regulatory system has not handled this opportunity to improve, with an operational methodology.”
Gloria LaRoche, the FAA official who filed a whistleblower lawsuit over incorrect stall recovery procedures in 2010 (and dropped it in 2011 after the FAA began to take corrective action on this issue with an advisory circular) agrees: “The industry still has a long way to go on this important training.”
Clearly the April 17 Paris verdict from the tribunal in the French manslaughter case against Air France and Airbus will lead the prevailing party to claim vindication along with a vigorous dissent from the losing party.
Missing from this dialogue will be the most important lesson learned from Air France 447. When automation system design doesn't work, a quick-thinking pilot is all that stands between a safe landing and disaster.
The complete failure of the regulators in America and France to listen to the collective wisdom of test pilots who flew the correct high altitude stall recovery procedure years before Air France 447 and similar crashes is a tragedy, one which now appears to have been avoidable.
As Larry Rockliff, now a worldwide independent aviation consultant, explains: “It’s easier to change the Ten Commandments than correct a dangerously obsolete government regulation in aviation.”
How ironic that the responsible regulatory aviation agencies, especially EASA (which successfully claimed immunity in this manslaughter case), were not co-defendants in this historic legal action.”
“You can’t blame the pilots for not doing a high altitude stall recovery procedure that did not exist,” says LaRoche.“At the time of the Air France 447 and the Colgan Air crashes neither EASA or the FAA had a correct procedure for stall recovery.”
Sadly, Captain Agnel’s correct court testimony was disputed by his former boss at the fall 2022 Paris trial. That Air France safety manager insisted that his company’s failure to share Agnel’s prescient warning after the near crash of the 2008 Madagascar flight, was the correct decision.
It’s hard to believe that manufacturers and airlines that can send computer updates to flight crews in seconds are overseen by bureaucrats who take decades to acknowledge and correct their mistakes. We now know, for sure, that when government regulators fail to watch over us in this new automation age, we all lose.
“The problem,”says Carbaugh,“is that large bureaucracies move slowly. In aviation that cost lives.”
Roger Rapoport, has been writing about Air France 447 for nearly 14 years. He is the coauthor of Angle of Attack: Air France 447 and the Future of Aviation Safety, and Grounded (both lexographicpress.com) and the producer of the feature film Pilot Error. Visit rogerrapoport.com for more information.
Copyright © 2023 Roger Rapoport