On May 27, the French Bureau d’Enquêtes et d’Analyses (BEA) decided to publish what they called “… a note with information on the first facts established, based on analysis of the data from the flight recorders” about the crash of Rio-Paris Air France flight AF447 on June 9, 2009. The note followed the end of underwater debris recovery operations and the successful retrieval of the flight’s black boxes from the ocean bed.
After initial analysis, it had been announced that the flight data seemed intact and its study would certainly help shed a light on the events leading to the catastrophe. But as was officially declared on a May 16 briefing after the recovery, “This work will take several weeks, after which a further interim report will be written and then published during the summer.” The end of July was mentioned somewhere else.
So it seems unclear why the BEA opted to publish such an early note. While adding much new information to the puzzle, said document appears incomplete and inconclusive. It carefully avoids making any judgement calls and pretends to simply relay facts about the flight’s last minutes as deciphered from the flight recorders. It is not an analysis but a simple reading of data. But there are huge holes in that data, and whether these elements were withheld or remain missing, my opinion is that the note serves no purpose whatsoever other than to feed the sensationalistic crave of the media. And maybe worse, but more on this later.
Basically, voice exchanges, flight control inputs, engine settings, instrument indications and the plane’s attitude and speed are reported for the duration of the crisis, which lasted less than four minutes. We learn that the crew of three was composed of a captain – who was taking a rest when trouble struck – and two co-pilots, one of which was in command for most of the emergency. We learn that, as suspected, pitot icing probably led to speed indication inconsistency and a flurry of subsequent instrumentation failure. We learn that the crew’s input on the controls was absolutely inconsistent with logic and procedures, unless they were seeing a different picture than the one we are presented with.
I won’t elaborate on the details. The note is available for those who want to read more on that. There are also yet another few thousand new posts on the third related thread of the PPRuNe forum and probably many more elsewhere. Many very qualified people – and some much less qualified – are asking as many interesting questions about the new data, what it means, what seems to be missing, and ultimately why what happened, happened.
But what strikes me as incredibly odd is that despite an initial survey of the black boxes’ recordings, this note describes the end but does not offer even a hint of why such end was met. So why publish it? The BEA owes it to itself to remain professional and unbiased in its approach, and yet it goes public and issues a statement that not only offers no hypothesis, but seems to yield more questions than answers.
Why not wait? Why not push the investigation deeper until the data reveals its secrets? Having to wait for an answer is what the world expects any way. But if one reads between the lines, I think two facts are implied in the note:
1 – The hardware (the plane and the airline) had issues but these were not terminal; nothing that proper procedure shouldn’t have handled.
2 – The software (in our case the human element) seemed to have acted in defiance of logic.
Again: if we don’t yet know what happened, why give such subtly crafted silent hints? They are empty of any meaning at this stage. They will definitely send the media and public into a frenzy of emotional tug-of-war, refuel a hundred different theories and feed the daytime nightmares of many a frequent flyer. But what else?
I personally see no difference between Steven Spielberg’s “Jaws” and the BEA note. Feed the public some blood, give them a taste of what it must have been like, what it could be like, what it will be like, if ever again. All in very neutral words that appear to stick to numbers and facts. But readers have an imagination. Let it do the rest.
Oh, but wait a minute… What’s happening in France from June 20 to June 26? Yes, the famous Salon du Bourget. Biggest plane sale in the world. And who probably stands to win – or lose – a fortune in sales there? Yes, Airbus.
So, would it be so far-fetched to speculate that they needed an early statement crafted from actual data but putting implicit blame on icing and on the human factor rather than their gear?
All right, I’m probably doing my own little dose of over-analysis and my anti-sensationalism likely stinks of just the opposite. Still. I believe that that note, incomplete and blurry as it is, might once again do more harm than good. Bloody politics.
And in the end, this endless quest of ours, this never-ending search for who or what to blame when things go wrong, is flawed and hypocritical. There is no choice. We are always to blame. The human factor is the only factor. We can’t blame gravity for prevailing, it was us who defied it in the first place. We can’t blame the weather for icing the pitots, it was us who flew the pitots up there. We can’t even blame a mechanical part or a bit of software for failing. It was us who built it.
Every step of the way, from concept to design, manufacture, operation and maintenance, we introduce a risk factor by being the volatile element. And rarely but unavoidably, somewhere between the drawing board and the playing field, good old Murphy shows up and claims an old debt, pinching and twisting just where it hurts most: the hidden imperfection, the unnoticed defect, the new bug, the poor design.
We should accept that fact and stop pretending the fault isn’t ours. It always is. There is nobody else around. And maybe this is a normal thing, as hurtful and painful as it might seem. The universe has a tendency towards entropy. Maybe our mishaps, as tragic as they are, remain nothing than perfectly ordinary grains of salt in a cosmic self-regulating pattern.
As always, my sympathies to all affected. The note sure will not have helped. Maybe further investigation will.