KOREAN AIR Flight KE 801 (August 6th 1997)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


01 hour 49 minutes (Agana Tower): Korean 801, Tower, how do you receive me?

 Not getting any reply, the controller thought the 747 was on the runway but that he couldn’t see it because of the rain.

 01 hour 50 minutes (Controller calling the vehicle): Is it with you now?

 01 hour 50 minutes (Driver of the “Follow me”): Nope!

 Another attempt to get in touch with the Jumbo Jet, in vain.

01 hour 50 minutes (Agana Tower): Korean 801, Tower, how do you read me?

 The controller called the vehicle back and the conversation continued between the two men:

“I don’t understand. It was with me. I cleared it to land. I don’t know where it’s got to now… I didn’t even see it.”

“You never saw it?”


“But has it landed?


“Oh, my God!”

The controller was now very concerned and called the radar control of Andersen military base. He wanted to know if the 747 had landed there. The runways are parallel and the crew could have mistaken the airport. After all this type of mistake happened fairly frequently.23

As the answer was negative, he called the vehicle once again:

“I can’t find it anywhere. The pilot called me, I allowed him to land… I’ve lost him.”

Fearing for the worst, the controller called Flight Ryan International 789. This was a Boeing 727 cargo on its approach. The words of the captain terrified him.

“Well, about fifteen minutes ago, we saw a bright red glow in the clouds. It was bit strange. We thought it was an optical effect.”

And at the same moment as the pilot was coming for his final approach, the same pilot added:

“Er, for your information, there’s big fire on the side of the hill.”

Astounded the controller called the “Follow me”.

“The Ryan flight has just told me there’s a fire on the other side of Nimitz Hill.”

“A fire on the other side of Nimitz Hill?”

“Affirmative. It could be a crash…”

The Ryan International flight continued circling for a long time over the sector giving information about the area’s geographical co-ordinates. It was no longer raining and the glow of the fires was visible from a long way off.

It eventually landed at 02 hours 03 and from then on the airport was completely closed to traffic.

 As sometimes happens in dramatic situations, there were scenes bordering on the burlesque. The aircraft had crashed onto territory belonging to the US Navy and the military authorities wouldn’t accept the idea of the civil administration trying to direct operations in a military area. Nobody knew who ought to direct rescue operations: the island’s Governor, the US Navy, the US Air Force, the US Coastguards, the airport authorities? It took time for the orders to come down from on high deciding who was to direct operations. The rescue teams had to reach the accident but it wasn’t the end of their problems for all that. Nimitz Hill is only served by a narrow, sinuous road. In the crash, the 747 tore up a pipeline on the side of the road. The debris of the mains prevented the rescue teams from advancing. The firemen’s vehicles tried going round it but the earth was all soaking and they got bogged down one after the other and the firemen had to continue on foot. It took two hours to get the vehicles free and to get them to the scene of the tragedy.

The result was dramatic because eight hours after the crash the burning wreck was still not mastered.

Several hours later, the American army sent hundreds of soldiers to search the debris. When they got out on Mount Nimitz, no one expected to find any survivors.

But quite unexpectedly, there were a few…

The tragedy caused 227 dead but there were 27 survivors some of whom were wandering around in the rain. Most of them explained that their first vision at the moment of impact was that of the luggage lockers opening above their heads. Dozens of bags fell out on the floor which seemed to be disappearing at each second. Then “fire burst out all over the place and spread at top speed throughout the cabin.”

A woman sitting in row 34 later recalled seeing her husband suddenly engulfed in flames. “Then in a fraction of a second he disappeared.”

Sitting in First Class, seat 3b, was Hyun Seong Hong, 36. He recalled that “everything happened in an instant”. He was sitting peacefully in his chair when there was a terrible noise. The passengers didn’t have the time to shout. “It was like in a disaster film with all the special effects; then the aircraft suddenly disappeared from the décor around them.” When he came round a few minutes later, he was lying in the wet grass. “It was just like daylight because there were flames everywhere.”

One of the hostesses was sitting on the jump seat R1, up front. She said she heard a terrible noise which she later called a “big boom”. She didn’t have time to be frightened because the aircraft was torn up all around her. In a few seconds, she was thrown out of the cabin and found herself in the rain still strapped to her jump seat. Without really understanding what had just happened to her, she unfastened her belt, went ten yards along a smoking partition and saw a passenger screaming. She rushed to help her.

 23   Read Erreurs de Pilotage Vol. 2 by the same author published by Altipresse.


VLADIVOSTOK AVIA Flight XF352 (July 4th 2001)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


02 hours 07 minutes 12 seconds (Radar controller): 845, turn to base leg. Descend 850 meters for final.

02 hours 07 minutes 17 seconds (Captain speaking to the radio): Roger 845… Down to 850 meters for final.

02 hours 07 minutes 21 seconds (Flight engineer): Gear down and locked!

And then suddenly the situation became dangerous because the speed was dropping dangerously low.

This brutal braking had three causes:

  • The engines were idling and the first officer hadn’t re-adjusted the power: nothing was pushing any more.
  • The aircraft had stopped going down. It had leveled out at 900 meters and this step helped it brake.
  • The landing gear was now down. The engineers had designed it so that it could land on beaten earth, so it was enormous and that meant enormous drag. To get an idea of its size all you have to do is compare it with the main Airbus A 321 landing gear which only has four wheels. The Tupolev had… 12 and they were big low pressure tires.28

Now, an aircraft needs airspeed to fly. Speed generates lift. No speed and you stall. The captain immediately warned:

02 hours 07 minutes 23 seconds (Captain): OK… But the speed is decreasing too much…

And as the aircraft was at 900 meters and they had been asked to go down to 850 meters, the captain carried on with a slightly authoritarian tone:

02 hours 07 minutes 25 seconds (Captain): Descend!

In fact the first officer just turned the Autopilot control but he did nothing to adjust the power. So the airspeed dropped further to 237 mph. As a result, lift dropped too. The consequences were felt immediately: the aircraft sank by itself.

The captain naturally understood that he had to increase the thrust but his reaction was far from dynamic.

02 hours 07 minutes 27 seconds (Captain): Keep 850 meters and you set 70% of NI for the thrust.

In front of his desk, the flight engineer pushed the levers forward and confirmed the captain’s order.

02 hours 07 minutes 29 seconds (Engineer): Agreed… 70…

Unfortunately it wasn’t enough. The speed continued to drop. It was now only 225 mph and in that configuration the minimum airspeed recommended by the manufacturer was 230 mph. As a result, the aircraft became slightly unstable. It was almost imperceptible but it just didn’t have the extra 6 mph which would’ve made it that bit healthier. It was all the more important because the first officer had just gone off into a left turn as the controller had asked him to. The banking reached 23 degrees (position 4).

The captain was getting worried… The aircraft was becoming a little more unstable, nothing serious. It was just a little bit of trembling which could be passed off as slight turbulence. But this was the sign that the beast slumbering inside the machine could well and truly wake up.

The captain ordered the power to be increased a bit more.

02 hours 07 minutes 30 seconds (Captain): 350 kph (218 mph)… speed in range… set 75% N1.

02 hours 07 minutes 33 seconds (Engineer): Roger 7 – 5.

02 hours 07 minutes 37 seconds (Navigator): Approaching 850 meters.

Things were getting surreptitiously worse. At that moment however, the situation was not dramatic at all. All that was needed was to push the throttle fully forward for a few seconds and, especially, not pull back on the stick.

The captain came in again:

02 hours 07 minutes 39 seconds (Captain): Power 80.

02 hours 07 minutes 40 seconds (Engineer): 80.

Still not enough… In fact, the process was rather classic. Little by little, the aircraft’s nose goes up and drag increases. Airspeed does not go back up. The angle of attack increases also. Everything happens as though the crew wants to stall the aircraft. Here, the speed went down to 216 mph imperceptibly, then back up to 218 mph.

The captain intervened again but once more his reaction was very lame:

02 hours 07 minutes 42 seconds (Captain): 82%.

02 hours 07 minutes 43 seconds (Engineer): OK 82.

02 hours 07 minutes 44 seconds (Navigator): We’re at 850 meters.

02 hours 07 minutes 45 seconds (Captain): Roger 850 meters.

Speed was maintained at 218 mph with difficulty. The aircraft was still turning. The angle of attack was still high and the crew weren’t taking any really effective measures. They had to set full throttle on without hesitating but the captain instead just reacted in little bursts. It wasn’t enough because the Autopilot didn’t like what was going on either. It was acting in its own corner to maintain the height at 850 meters. And it was pulling up too. It was a sort of vicious circle. The more the Tupolev slowed down, the more the nose rose on the horizon. The angle of attack reached 16.5 degrees.

The first officer didn’t notice anything.

02 hours 07 minutes 47 seconds: this was the beginning of the tragedy.

The increase in the angle of attack set off a very loud alarm. At that moment, there was nothing else to do but push softly on the stick and open up the three engine throttles.

But the first officer reacted very badly. Surprised by the sudden alarm, he pushed the stick forwards violently. The movement was so brutal that it deactivated the Autopilot. A second alarm sounded to warn them that the AP had been disconnected and that now the aircraft would have to be flown manually.

Naturally the captain realized that things were getting worse.

He got angry:

02 hours 07 minutes 49 seconds (Captain): Fuck, what the hell are you doing?

02 hours 07 minutes 51 seconds (Captain): Speed!!

Unfortunately he didn’t take over the controls again…

Panicked by being told off, the first officer pushed the stick again but his action was even clumsier. In pushing, he banked the aircraft even further to the left. First, 30 degrees, then 44 degrees and then 48 degrees… The speed rose back up to 250 mph but because the aircraft was still in the clouds, the first officer didn’t realize this and he kept banking.

The captain exploded:

02 hours 07 minutes 53 seconds (Captain): Fuck, push up the throttle!!!

At this moment you might be wondering why the captain was just giving orders. It would have been much simpler to take over the controls. Was it strain which prevented him from reacting? Were the events happening too suddenly? Nobody knows… Except that his capacity for reaction was very low. Besides, the Russian arrangement whereby there are a lot of crew members on the flight deck here caused a major problem. It reduced their individual sense of responsibility. In fact everybody had more or less access to the controls but in an emergency, everybody relied on the others to make the right move. It is evident that the “Crew Resource Management” techniques taught all over the world were quite unknown in Vladivostok Avia. 29

And in these circumstances, obviously nothing happens. All you can hear is incomprehensible orders blurted out wildly in the cockpit. The one with the least experience among the four was the first officer. He had no idea what to do and he was the one at the controls!

02 hours 07 minutes 53 seconds (First officer): Stop… Stop… Where? Where?

These rambling remarks showed how lost he really was. Everything was rushing all over the place and, perturbed by what was going on around him, the first officer had lost spatial awareness. The aircraft was still in the cloud. There were no outside markers, no horizon in the night. Not the slightest light which could enable them to see position of the aircraft. Only the artificial horizon on the instrument panel indicated that the Tupolev was very much banking but the first officer wasn’t even looking at it. The human brain isn’t made for flying blind. The best pilot in the world couldn’t keep the wings horizontal without any instruments. He needs an instrument panel and he has to know how to use them because even then, instruments aren’t enough. An American study showed that a beginner can fly without instruments for exactly… 178 seconds. A little less than three minutes. After that time, he loses all notion of space awareness around him. He has vertigo and doesn’t know where vertical is. He can perfectly well fly an aircraft inverted whilst still feeling that he’s flying it normally.

In reality, in the case of the Tupolev, it took much less time for the whole crew to become spatially disorientated. After a dozen or so seconds, the first officer didn’t know how he was flying. His reactions then became tragically typical. He pushed the stick to the right and the left and panic overwhelmed the cockpit.


28   An Airbus 321 and a Tupolev 154 carry more or less the same number of passengers.

29   A management technique which enables one to use the resources of a crew with a maximum efficiency and safety.


SPANAIR Flight JKK022 (August 20th 2008)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


The crew attempted to analyze the situation. Meanwhile, the temperature continued rising. The gauge now showed 103° C… It was now certain; they had a malfunction, probably the “RAT” probe. 9

This probe was in the shape of a metal tube fitted to the front right part of the fuselage… Was it really malfunctioning? The fact that it was overheating didn’t mean that it wasn’t working. It was the heater designed to prevent it from icing which was heating! The captain hesitated… After all, it would cool down as soon as they took off, except that the probe heater should normally never function by itself when the aircraft is on the ground.

And things didn’t get better… A final glance at the instrument showed that the probe’s temperature had now reached 104°C. In fact the examination of the black boxes showed that it hadn’t stopped going up, ever since the aircraft had left the apron. At that moment, the crew didn’t know that the dysfunction was in an electric relay. It was still functioning when it should have been deactivated when the aircraft was on the ground.

Note that this dysfunction wasn’t anything new. It was the sixth time in three days that it had occurred and nothing had been done.10 In fact, Spanair was in the typical situation of an airline going through a crisis; you could sense it was the end of an era. Professional conscientiousness had become a theoretical concept.

Blocked on the holding point, the Iberia Airbus was still waiting to take the DC-9’s place but the crew was still hesitating.

Finally the captain decided he needed more time to think.

13 hours 26 minutes 27 seconds (Captain): 5022, we have a technical problem… We cancel our take off for the moment.

There was silence on the frequency. It was rather rare for a lined up aircraft to make such a message.

13 hours 26 minutes 45 seconds (Controller): What are you going to do, 5022?

13 hours 26 minutes 52 seconds (Captain hesitating): Well, we’d like to get off the runway.

13 hours 26 minutes 56 seconds (Controller): Roger, 5022, next exit on your left.

The aircraft moved forward a few yards and turned into “Zulu 6”. As soon as the runway was free, the Iberia Airbus behind it lined up in its place.

At first, the DC-9 turned left again on ZW1 and halted facing south on heading 185. Then, it remained where it was for seven minutes. This pause revealed a lot about the situation. In fact the captain and the first officer were talking but couldn’t decide whether or not to go back to the gate.11 The temperature of the probe had now stabilized at 104 degrees C. Returning would mean a considerable loss of time and they were already late… On the other hand, no pilot ever wants to take off with an inoperative system. In the present case, it was obvious that there was an electrical problem somewhere. A short circuit could start a fire in flight. 12

Finally, after hesitating a lot, the captain took a decision. This was reasonable:

13 hours 33 minutes 12 seconds (Captain to Tower): 5022, well… we haven’t solved our problem… we want to return to the parking.

There were a few seconds of silence… The controller informed his shift supervisor that Flight Spanair 5022 had just been canceled. Another position on the apron had to be found for it. But this wasn’t so simple because the aircraft couldn’t go back to Gate T21. Meanwhile, another aircraft had taken its place and the passengers were already disembarking. A quick consultation took place in the tower to solve the problem, and then the controller answered:

13 hours 33 minutes 47 seconds (Controller): Copied, Spanair 5022, taxi towards Romeo 11. We’ll ask your technical team to join you there.

The DC-9 continued taxiing slowly towards its new place on the apron, just in front of Terminal 4. It was much closer than Gate T21. This was therefore an advantage because the clock was ticking by. From now on, the crew was going to be split between its desire to solve the problem and to get going again as quickly as possible.

While the aircraft was taxiing, its flaps were deflected in the 11° take-off configuration, and, at first they remained like that. The two men were actually concentrating on the probe overheating problem and nothing else seemed to concern them. The captain asked the first officer to make a brief announcement on the Public Address System to inform the passengers about what was going on. He explained on the intercom that they had “a technical problem, nothing serious, just a red light somewhere.” Conversations in the cabin ceased at once. The atmosphere became tense. Even if the words “not serious” had been said, everybody was puzzled.

It was 13 hours 39 minutes when the DC-9 reached Romeo 11. A gangway was already in place to meet it. It was only then that the captain raised the flaps at last… The APU 13 was switched off. There was therefore no longer any air conditioning.

Everything went quickly. Everybody was aware that the time factor was vital because the passengers couldn’t be left for long in such conditions. As soon as the gangway was set up a ground staff and two Spanair technicians were at the door. The steward got up from his jump seat and the captain had them come into the cockpit. There was no need to be a specialist to understand the problem. All you had to do was glance at the RAT temperature indicator diodes on the top of the instrument panel to see that the probe was overheating. It was still at 104 degrees C.

The technicians however were reassuring. One of them explained that “of course it was overheating, but that as soon as the aircraft got airborne, the air flow would cool the probe down and everything would be back to normal. It should be possible for you to leave like that”.

At first Captain Garcia Luna seemed to disagree.

During all this talking, several people came and went inside the cockpit. To make things easier, the steward Gabriel Guerrero went out into the front galley. José Fernandez Vazquez, the other Spanair captain now appeared to enquire what was going on. A technician explained what was happening. Lourdes Flores then appeared; she wanted to know what to tell the passengers because they wouldn’t stop asking her questions… In the middle of all this disorder the technicians gave their opinion. Their suggestions were sometimes a bit odd. One of them even proposed cooling the probe with dry ice. It would be easy because there was a large stock at the airport.14 Quite obviously you’d need a ladder to reach the probe on the side of the fuselage but it ought to work… The mind boggles at such an unexpected idea because how on earth would cooling down the probe solve the electrical problem?

Naturally Captain Garcia Luna didn’t agree with this new suggestion and he reminded them that they had been informed about the problem several days ago now. And of course, nothing had been done about it. He demanded that the problem be repaired now and as nobody seemed to be taking his request seriously he finished by getting angry.

13 hours 51 minutes 48 seconds (Captain testily): I’m telling you, we’re wasting a lot of time here, and I’m going to make a report on what’s going on here.

At the same moment, the first signs of protest from the passengers could be heard coming from the cabin. Some of them were complaining because it was too hot. Everybody understood the aircraft had a breakdown and fear was wriggling its way into people’s minds. The first officer’s talk about a red light hadn’t reassured anybody. The technicians going to and from into the cockpit didn’t help matters, either.

A rather corpulent Spanish passenger suddenly got up. He was aggressive. He drew attention to the fact that there were a lot of children on board and that they couldn’t be left in this situation forever.

Very calmly, the hostess explained that it was nothing but a slight incident of no consequence. Another passenger wanted to know if there was a problem with the engines. The stewardess replied that she didn’t know but that she’d find out. So she headed for the cockpit but didn’t come back.

The protests started mounting quickly. Some passengers could be heard saying they wanted to leave the aircraft. So it was the Cabin Senior Lourdes Romero who returned to explain that that was quite impossible. Now that they were aboard the aircraft, they couldn’t disembark. It’d be too impractical, the luggage would have to be recovered from the cargo compartment, the manifest modified, the police formalities gone through again… Some passengers didn’t believe this reason because they were on a domestic flight and there weren’t any administrative formalities.


9   The Ram Air Temperature probe has the advantage of not taking into account kinetic heating which takes place in contact with air above 250 mph.

10   In fact, the breakdown was caused by a failure of relay R2-5, which remained permanently connected when it should be disconnected automatically when the aircraft is on the ground.

11   Although the transcription of the conversations were not recovered from the CVR, the information had been transmitted later by the first officer to the two maintenance mechanics.

12   See the crash of Flight Swissair 111 in “Le Secret des Boites Noires” by the same author.

AIR FRANCE Flight AF 447 (June 1st 2009)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


It was probably at this moment that the Pitot tubes iced over. Nothing has enabled anyone to find out what the real reason for this icing over was. Was the anti-icing switched on too late? Was the phenomenon particularly strong that night? Was it a defect in the Pitot tube heating system? Whatever it was, the probes got blocked by ice and no longer provided information about the airspeed. The indication disappeared off the PFD. The computer instantly switched over to “Alternate” law. Certain computerized protective systems were no longer activated and the auto-throttles were blocked in the position they were in. This meant that the computer no longer stabilized the power in relation to the aircraft’s needs: it was now up to the first officers themselves to adjust the thrust of the engines.

With the autopilot disconnected, there was no longer anybody to correct the turbulence and the Airbus banked slightly 8.4° to the right. Note that at this moment there was nothing dramatic about the situation. After the accident, lots of pilots tested the situation in an Airbus 330 simulator and the aircraft never took on a position presenting the slightest danger. It remained perfectly stable. 51

At that moment, all that was needed was for the first officer to correct his mini-stick very slightly to the left and bring the wings back to the horizontal and the incident would have had no aftermath. This was basic flying: no difficulty for a correctly trained crewman.

Unfortunately that wasn’t what happened… At the moment when Pierre-Cédric B took hold of the stick, his reaction was quite out of proportion. With something like a panic reflex, he positioned the stick on “pull up” or ¾ of its maximum position and he maintained this position. The pitch attitude of the Airbus climbed to 11 degrees and the aircraft started climbing with a vertical speed of 5 200 feet per minute.

At that altitude, such a climb rate was enormous.

Obviously a second alarm sounded at once. This was the “C-Chord”. This warns the pilots that the aircraft has quit the altitude for which it was programmed. It was no longer at level 350!

They had to descend…

Finally it was the stall alarm which resounded. Nothing could be more normal, speed was decreasing rapidly and above all the angle of attack had increased brutally: it was now 5 degrees. 52

It is impossible not to hear this stall alarm. It is in the form of a synthetic warning. A very bass man’s voice announced:

02 hours 10 minutes 10.4 seconds (Synthetic voice): STALL! 53

The word “Stall” is followed by a strange sound called a “Cricket”. It’s a sort of ringing which is deliberately unpleasant so it doesn’t go unnoticed. There’s even less the risk of not hearing it because the “stall” alarm has priority over all others. If the word “stall” echoes round the cockpit, all the other alarms are silenced because nothing else is as serious. Stalling at high altitude is the worst thing that can happen to an aircraft.

02 hours 10 minutes 11 seconds (Synthetic voice): STALL!

02 hours 10 minutes 11.3 seconds (First officer David R): What’s that?

When the stall alarm sounds in an aircraft, the immediate reaction of any well trained pilot is to push. At flying schools, the trainees are taught that if they hear this alarm, it means that the aircraft’s nose is too far up and the angle of attack is too high. The only way to recover is to push the stick to “dive”, i.e. forward. It’s urgent!

Now, the first officer did exactly the opposite. He pulled up… It’s an instinctive reaction found in a lot of trainee pilots during their early stall training.

We won’t repeat here all the figures relating to the angle of attack, the pitch attitude and the aircraft’s speed which were shown by the flight recorders. The accumulation of figures would be tiresome for the reader. Suffice it to say that all during these events, Pierre-Cédric B’s use of the joystick was always exaggerated and he was nearly always “pulling up”.

The result was that the Stall alarm didn’t stop sounding:

02 hours 10 minutes 13 seconds (Synthetic voice): STALL!

02 hours 10 minutes 13.4 seconds (Synthetic voice): STALL!

02 hours 10 minutes 15.1 seconds (First officer Pierre-Cédric B): We don’t have a good… we don’t have a good indication… of speed.

02 hours 10 minutes 15.9 seconds (First officer David R): We’ve lost the speed, have we?

The Airbus continued climbing. Three seconds later, its vertical speed was increasing by 6 700 feet per minute. At that altitude it is difficult, to imagine an airliner with such a climb rate; and as the laws of physics must be respected, what is given on one side is obviously taken away on the other… You don’t get an aircraft weighing more than 200 tons moving towards the stratosphere without there being substantial consequences somewhere: the airspeed dropped to 93 knots and the Mach to 0.29… Note that the aircraft was very compliant because the pilot also rolled it very brutally. The Airbus banked from one wing to the other. In identical conditions a lot of aircraft just wouldn’t stand such bad treatment. Most of them would certainly stall. We have seen earlier how a Tupolev 154 went into a flat spin for much less than this…

Now the Airbus just banked peacefully ten or so degrees to the right and left without abruptly dropping off into the void. The problem was that each time it banked, the first officer reacted far too strongly by pulling the stick as far as it would go. In fact, since the problems had begun, the way he reacted on the controls was quite out of proportion to what was happening. His movements were quite exaggerated.

It was the second first officer who realized first that the parameters were deteriorating very seriously: the rate of climb was now 7 000 feet per minute!

02 hours 10 minutes 27 seconds (First officer David R): Watch your speed!

02 hours 10 minutes 28.3 seconds (First officer David R): Watch your speed!

02 hours 10 minutes 28.3 seconds (First officer Pierre-Cédric B): Okay. Okay. I’m going down.

02 hours 10 minutes 30 seconds (First officer David R): You’re stabilizing…

02 hours 10 minutes 30.7 seconds (First officer Pierre-Cédric B): Yeah…

02 hours 10 minutes 31.2 seconds (First officer David R): Go down… We’re going up according to that. According to that you’re going up. So, go down!

02 hours 10 minutes 35.2 seconds (First officer Pierre-Cédric B): Okay.

It is important to note that the Pitot tubes had been iced over for 29 seconds now. With the action of the de-icing system however, probe No 1 had just started functioning again. The airspeed showed up at once on the left PFD. The information was coherent again but the crew didn’t seem to notice that the problem had partly disappeared. On the right, Pierre-Cédric continued to shake the machine excessively. The Airbus was now at 37 124 feet.

Clearly very worried, David R insisted:

02 hours 10 minutes 36.4 seconds (First officer David R): Go down!

02 hours 10 minutes 36.7 seconds (First officer Pierre-Cédric B): We’re off, we’re going down.

Then because obviously, once again, his action was excessive, David R warned:

02 hours 10 minutes 38.5 seconds (First officer David R): Gently!

David R was right. They had to reduce their attitude and return to the initial cruising level. Pierre-Cédric let off pulling on his mini-stick and the airspeed rose quickly from 105 to 223 knots. As for the vertical speed, it dropped to 1 100 feet per minute; this was still too much for this altitude but the figure was a bit more reasonable. All the Airbus wanted to do was just carry on. All they had to do was not pull on the stick. The roll seemed to be under control too. The angle of attack went below 5 degrees. The stall alarm fell silent… The situation might get better if Pierre-Cédric would just let off a bit with his stick. He had to dive gently… He had to resist the instinctive temptation of all beginners who want to hold the aircraft back when it’s going to stall. The BEA investigators explained later that at that moment the flight path of the Airbus could’ve been mastered…

02 hours 10 minutes 41.6 seconds (First officer Pierre-Cédric B): We’re on… yeah… we’re on “climb”…

In the left-hand seat, David R seemed to understand that his colleague wasn’t going to recover the situation. The captain had to come back. Whilst pressing the call button which chimed in the couchettes next door, he cried out:

02 hours 10 minutes 49.8 seconds (First officer David R): Shit, where is he? … Er?

At that moment, the Airbus was at 37 512 feet. This was more than 2 500 feet above its initial cruising level. However, at no moment did the right-hand stick go into the “dive” position. What was worse… after being in the neutral position, it gradually slipped backwards. The result was immediate: in spite of the engine thrust: the angle of attack increased immediately. It reached 13 degrees and the stall alarm’s powerful voice resounded again:

02 hours 10 minutes 51.2 seconds (Synthetic voice): STALL! 54

02 hours 10 minutes 51.4 seconds (Synthetic voice): STALL!

02 hours 10 minutes 53 seconds (Synthetic voice): STALL!

02 hours 10 minutes 54.2 seconds (Synthetic voice): STALL!

On the right, there was no reaction… Not a word. Strangely, only David R seemed to realize that something abnormal was going on. He exploded:

02 hours 10 minutes 54.9 seconds (First officer David R): Fucking hell!

At the same moment someone called on the interphone, but it wasn’t the captain.

02 hours 10 minutes 55.9 seconds (woman’s voice): Hallo?

02 hours 10 minutes 56.8 seconds (Synthetic voice): STALL!

02 hours 10 minutes 57.6 seconds (Synthetic voice): STALL!

This was the ninth time that the stall alarm sounded since the beginning of the problem and strangely enough the crew still didn’t seem to hear it. It was now 54 seconds that the anemometric probes had iced over. We have seen that probe No 1 had started working again after a 29 second interruption. Now probe No 3 was working again. The information it sent was coherent. The CAS ISIS speed showed up again on the right hand screen. There shouldn’t have been any problems any more…55 All that was left to do was for the effects of the right-hand first officer’s exaggerated movements to be mastered:

02 hours 10 minutes 59.4 seconds (woman’s voice on the interphone): Yes?

Before continuing with the description of the facts, it is important to explain what happens during a stall. On most aircraft, when the angle of attack reaches a limit, there is no longer enough lift and the aircraft stalls. In general, the nose drops brutally. We say it’s “saluting”.56 As we have already said, it’s often at this moment that trainees react badly by pulling the stick backward to try and neutralize the fall. Now you have to do exactly the opposite: when the aircraft stalls or when it is on the point of doing so, the pilot has to follow up the “salute” by pushing on the stick forward. Thus at the same time as the attitude diminishes, the angle of attack returns to its normal level and lift is recovered.


 51   The author has personally tested the situation in an A 330 simulator and has come to the same conclusions. The aircraft doesn’t budge.

52   The alarm is triggered when the angle of incidence goes over 4 degrees.

53   Stall: all Airbus controls are in English.

54   Despite the repetitive nature of these stall alarm calls, they are all transcribed here with the exact time they were set off. Indeed they were vitally important in the succession of events and cannot be ignored.

AIR INDIA Flight IX 812 (May 22nd 2010)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


Then at around 3 o’clock, the captain fell asleep… and the least that can be said is that his sleep didn’t go unnoticed. Later when the NSTB investigators heard17 the recording, they explained that “it was the first time that they’d ever heard a pilot snoring on the flight deck.” Nothing to do with the calm breathing of a peaceful sleeper: it was vigorous snoring, overwhelming the cockpit and lasting exactly one hour and 33 minutes.

In the meantime, the first officer looked after the aircraft. And he did a good job. Twice, when control asked for his position, he even took the trouble to speak softly so as not to disturb the sleep of the blessed.

At 6 o’clock18 in the morning the aircraft was 180 nautical miles from Mangalore with the captain still in the arms of Morpheus. The landing was due in half an hour and the aircraft was still at its 37 000 feet cruising altitude. For the first officer, it was now time to switch over to Mangalore approach frequency: 127.55 Mhz.

Here is the transcription of the conversation with the air controllers:

At 6 hours 02 minutes 48 seconds (First officer): Mangalore control… Express India 812, good morning.

The air controller’s response was immediate. Mangalore is a small airport and it wasn’t exactly the rush hour.

6 hours 02 minutes 50 seconds (Mangalore approach): Express India 812, control, good morning. Go ahead.

6 hours 02 minutes 59 seconds (First officer): Flight level 370, squawking 0544, and approaching IGAMA point… 812. 19

6 hours 03 minutes 02 seconds (Mangalore approach): Express India 812, roger, report IGAMA.

6 hours 03 minutes 05 seconds (First officer): Call you IGAMA, Express India 812.

It was early in the morning… perhaps the controller was tired, too. One can’t help but notice that he wasn’t very reactive. He only had two aircraft to keep an eye on but he nonetheless insisted that Flight 812 call him back when it passed over IGAMA, even though the first officer had just told him that they were almost over it. Actually the Mangalore approach radar had broken down a few days earlier and the man seemed to be at a loss without it.

Nothing happened for… 12 seconds before the first officer called back.

6 hours 03 minutes 17 seconds (First officer): Mangalore, Express 812, position now over IGAMA point, Flight Level 370…

6 hours 03 minutes 20 seconds (Mangalore approach): Express India 812, control… er… Roger

Four minutes went by before there was any further communication with the controller. Only the captain’s snoring left a trace on the flight recorder. No matter, the first officer was working as he wanted and he was probably quite happy with this relative isolation.

Now that the aircraft was approaching its destination, he had to get a weather report of the field. It was the end of May and the weather could turn out to be a problem. Even though the monsoon was due to start in a month’s time, it was already hot and it could rain suddenly.

6 hours 07 minutes 02 seconds (First officer): Mangalore control, Express 812, requesting latest Mangalore weather?

6 hours 07 minutes 06 seconds (Mangalore approach): Express India, Control… Here’s Mangalore 0000 report: wind calm, visibility 6 kilometers… clouds few at 2 000 feet… temperature 27 degrees… dew point 26… and QNH 1006 hectoPascals.

It was dawn. As was often the case at this time of the year, the sun was rising over a grey, hot and humid atmosphere. Despite the early hour, it was already 27 degrees C and that was just the beginning… the local forecast had predicted that it would reach 38 degrees C during the day. And what was all the more surprising was that despite the high temperature, the dew point was 26. This meant that the weather was nearly foggy.21

6 hours 07 minutes 18 seconds (First officer): Understood, 1006 hectopascals and runway 24… and confirm we are identified on radar 812.

6 hours 07 minutes 22 seconds (Mangalore approach): Negative sir, the radar not available.

So now, we have a first officer who is working all by himself in the cockpit, with a captain snoring happily next to him and with the aircraft about to land at one of the most difficult airports in India whose approach radar wasn’t working. Given the circumstances, the crew had to take certain important decisions which should have been dealt with during a briefing made by the captain. Obviously, no such thing had taken place. At first, the first officer was happy to just take in the information.

6 hours 07 minutes 27 seconds (First officer): Er… Roger… Express 812…

You could feel him hesitating. There was nothing impossible about making a no radar approach. There are thousands of airports around the world which don’t have one and which receive aircraft every day. Except that, as we’ve seen, Mangalore isn’t just any airport and that the first officer had to decide all by himself.

One long minute went by… his voice was ill-at-ease when he ended up asking:

6 hours 08 minutes 41 seconds (First officer): Er… Mangalore Control… Express India 812… Er… what kind of approach can we expect for Runway 24 in Mangalore?

This wasn’t an idle question. With no radar assistance, he had to choose the procedure which would enable him to reach the final approach. This sadly wasn’t the kind of problem that the crews raised at Mangalore since they were usually guided by radar.

The answer came back rather dryly.

6 hours 08 minutes 48 seconds (Mangalore approach): ILS – DME arc approach.

6 hours 08 minutes 50 seconds (First officer): Roger, we’re going to make an ILS DME Arc… Express 812… Er… We are ready for the descent.

6 hours 08 minutes 55 seconds (Mangalore approach): Standby… 812.

The first officer maintained therefore his level at 37 000 feet. Another silence in the cockpit punctuated only by the captain’s snoring. A minute later, it was the controller’s turn to ask a question which just showed that he wasn’t really awake either.

6 hours 09 minutes 48 seconds (Mangalore approach): Express India 812, it’s the control… Er… how far are you from IGAMA point? Express India 812…

The first officer was naturally surprised. He’d flown over the IGAMA point just five minutes earlier. He’d announced the fact clearly to the controller who had acknowledged the message.

6 hours 09 minutes 55 seconds (First officer): Express India 812, we’ve already checked IGAMA at 00 h 04.

The controller tried to wriggle out of it so as not to appear to be asking stupid questions.

6 hours 10 minutes 04 seconds (Mangalore control): Er… Yes, well, so report distance flown from IGAMA?

6 hours 10 minutes 14 seconds (First officer): Well… we’re 48 nautical from inbound IGAMA. 22

6 hours 10 minutes 20 seconds (Mangalore control): Control Roger.

A silence, then :

6 hours 11 minutes 05 seconds (Mangalore control): Express India 812, call me for descent when you’re on radial 287 and at 80 nautical miles from MML beacon.

For some unknown reason, the controller was delaying the Boeing’s descent. Was he being over-cautious to make sure it was kept away from other traffic? There were only two aircraft however in his airspace. Not exactly anything to get stressed about, even with a broken down radar system. Moreover the other flight was Air India Express’ Flight 372 which was arriving from Bahrain heading for Calicut (after a stopover in Qatar). 24 It had to descend too, but its flight path didn’t interfere with the first officer’s.

Why didn’t the controller let the Boeing descend? Besides the situation was so unclear that it caused confusion and the message didn’t reach the right person: it was Flight 372’s captain who answered.

6 hours 11 minutes 11 seconds (Flight 372 Captain): Understood Express India 372. We’ll call you on radial 287 for the descent when we’re 80 nautical miles from VOR MML.

Then the controller obviously noticed that he was no longer dealing with the right person and couldn’t stop himself from being irritable.

6 hours 11 minutes 24 seconds (Mangalore control): Negative!! Express India 812, from Mangalore Radar, call me when you’re on radial 287 and 80 nautical miles from MML.

6 hours 11 minutes 25 seconds (First officer): Roger… for your information, we’re already on radial 287 and we’ll call you at 80 nautical miles from MML for descent.

6 hours 11 minutes 39 seconds (Mangalore control): Affirm.

As the Boeing was practically over the required position, it would seem now normal for the controller to clear it to descend. In fact, he didn’t even answer. The outcome of this inexplicable delay turned out to be disastrous. It must be said that, up until now the first officer hadn’t made a single mistake. Even though he was working all by himself, there weren’t any problems with his handling of the radio and the aircraft was right on course. These tasks were not at all beyond Ahluwalia’s capability. All he needed was to be able to start his descent so that he wouldn’t be too high when arriving at Mangalore.

Another five minutes went by; the Boeing maintained 37 000 feet. The grayish mass of the Indian Ocean slipped by rapidly under the wings.


17 National Transportation Safety Board, the American enquiry board in charge of investigations accidents.

18 To understand the text better, the times are now expressed in Mangalore local time.

19 The point, IGAMA, is 203 miles west of Mangalore, in the Indian Ocean.

20   As is the rule in aeronautics, the controller uses GMT. The weather report which he gave was therefore the one that had just been published, 7 minutes earlier.

21   When the atmospheric temperature is the same as the dew point, tiny drops of water in suspension which change into fog. In this story with the parameters 27/26, all that was needed was for the outside temperature to drop by one degree for the visibility to drop radically.

22   55 miles

23   MML Beacon: a VOR/DME beacon near Mangalore. In the original English text, the specialists noticed that the control made another mistake by asking for them to put off until 80 nautical miles, saying “from” instead of “until”.

24   Calicut airport is 112 miles away on the coast south of Mangalore.

AIR INDIA Flight IX 212 (May 26th 2010)

Extract from Pilot Errors Volume 5

by Jean-Pierre Otelli

Copyright Altipresse


At 21 hours 53 minutes 22 seconds, an alarm sounded in the cockpit because the Autopilot couldn’t hold the aircraft’s altitude. Unfortunately this “two-tone” alarm acted like an electric shock on the unlucky first officer. The young man panicked and tried everything and anything he could to push his seat back. He leaned forward but couldn’t find the lever… His movements were all chaotic in fact and he couldn’t get free except by pushing against anything within reach. Now, what was the most sensitive thing within reach? It was obviously the control column.

At 21 hours 53 minutes 35 seconds, 50 pounds’ pressure was applied to the controls. The result was immediate : the dive increased. Worse still, the more the aircraft dived, the more the first officer lost his balance and leaned against the instrument panel, and so the more he tried to hold onto that ”something” which was in front of him. So he pushed even harder on the column. This vicious circle brought the pitch-down attitude to -22°. As a comparison, during a normal landing, the angle of descent to the runway is only 3 degrees.16 In these conditions, the airspeed rose quickly, the Mach Number reaching 0.82.17 The “overspeed” alarm was set off immediately.

One second later, the first officer pushed even harder on the column and the aircraft started to go over into negative Gs. This meant that the passengers no longer felt any sensation of weight. In the cabin, anything that wasn’t fastened down flew into the air: mugs, meal cartons with nice oily dishes, magazines, clothes.

Everything was floating slowly up to the ceiling.

Then suddenly the dive decreased by a couple of degrees. The situation seemed to be recovering.

Everything floating around fell back down slowly onto the passengers. For five little seconds, the first officer had managed to bring the column backwards a bit. The black box recorded that the attitude went back up to -20 degrees… But it didn’t last. Another loss of balance, more confusion, and the young man was once again jammed between his seat and the column… The weight of his body was pushing forwards and the deadly plunge started all over again…

In the cabin, the passengers were howling louder and louder.

Now, there was something more serious. As this clumsy first officer made all these disorderly movements, he pushed down on the left and set the aircraft off into a turn. The Boeing wasn’t just diving, it was also banking. It was the beginning of a maneuver which the specialists call “spiral dive”. And this maneuver always finishes badly when there’s a beginner at the controls.

This comical situation would be enough to make you smile. It would be a good film gag because you can just see the clumsy pilot stupidly waving his arms about between his seat and the instrument panel. Except that it wasn’t a funny film and the aircraft was now in distress with its altimeter dropping at full speed.

On the other side of the door, the captain had naturally understood that something very serious was going on. But he was still off-balance. His feet were leaving the cabin floor imperceptibly and the only thing he could do was hang onto the “L1” Jump Seat harness. It was then that he saw that the flight attendant could help him because she was just next to the keypad.

He screamed : “Open the door, quick !”

At first, the attendant couldn’t do anything because she had difficulty standing up. But the Captain insisted:

“Tell him to open the door, quick… at once!

Before carrying on with this story, you need some more details about cockpits and their security systems. Ever since 9/11, the doors are now armored and there’s no way that trying to break the door down with your shoulder is going to work like it did in the past. The cockpit door is now opened by means of a key pad similar to the ones found on any building entrance. The flight attendant therefore had three ways of getting into the cockpit:

  • She could use the “Cockpit Entry Call”. This is a very simple code, consisting of a single figure, after which you press the “Enter” key. But this code doesn’t open the door. That would be too simple… It triggers off a chime inside the cockpit. On more recent aircraft, a camera films the person in front of the door and his picture appears on a screen located to the right of the captain. He then presses a switch to unlock the door. For safety’s sake, most aircraft are now also equipped with a peephole.
  • She could also use the interphone to call the flight deck and ask him to open the door.
  • And then, there’s the last solution. In an emergency, she can use the “Emergency Access Code” which enables you to open the door from outside. This special code is generally known to only three people aboard the aircraft : the captain, the first officer and the Cabin Senior. Even the other flight attendants don’t know it. For obvious security reasons, the code is changed very often.

The Cabin Senior obeyed the captain’s instructions. She punched in the code, “1 + enter”, which asked the first officer to open the door by pressing the button.

But he didn’t.

Panicking, she repeated the operation several times but to no avail. Seizing the telephone receiver, she called the cockpit. But the first officer still didn’t react.

Meanwhile the aircraft continued to dive.

At this moment the captain managed to reach the keypad. He had to hurry because things were now beginning to get out of control very dramatically.

There was an incredible din in the cockpit. First of all, there was the aerodynamic noise, louder now because of the increased speed. Then, there were the door chimes made by the flight attendant, wanting him to open the door and ringing several times. Then a second chime for when she tried to reach him on the interphone. But more than anything, it was all the aircraft alarms which were howling on all sides. The overspeed horns… the autopilot warning the rapid decrease in altitude… the MMO alarm… All this created a dramatic sound environment which was completely destabilizing the first officer. Entangled in the controls as he was, he couldn’t do a thing.

His only reaction was to howl for help.

“I can’t!”

“Come and help me!”

“I can’t!”

The door was still shut unfortunately. And as the first officer made no attempt to open it, nobody could help him. He couldn’t stabilize the aircraft, or open the door, or answer the flight attendant’s calls. When listening to the black box later, some investigators explained that the panic overcoming the young man was close to hysteria.

Finally the captain managed to punch in the Emergency Access Code. And the door opened.

He rushed in.

It took him only a fraction of a second to realize that things were worse than he imagined. The aircraft was now engaged in a -26° dive. The moving marker on the speed indicator was now in the red. The aircraft was banking 5 degrees to the left. The Mach overspeed clacker sounded with its ugly ratchet noise18. Impossible not to hear its irritating tac-tac-tac-tac-tac-tac…


13 The first door on the left of the cabin.

14 All the words spoken outside the cockpit obviously weren’t recorded by the black box but were reported to the investigators by the people concerned afterwards.

15 The Boeing controls are fitted with sensors which detect the force applied to the controls by each pilot.

16 This is in fact an approach trajectory and not an attitude, but the comparison is still applicable.

17 82% of the speed of sound.

18 The Emergency Access Code is fixed by the airline which generally uses the same code for each type of aircraft. Unlike the Cockpit Entry Code, it has a lot of figures (there aren’t any letters) and not all the crew know it.