AirSafe - Additional Resources And Offers

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f-cp090601ae2Interim Report n 2Bureau d’Enquêtes et d’Analysespour la sécurité de l’aviation civileZone Sud - Bâtiment 153200 rue de ParisAéroport du Bourget93352 Le Bourget Cedex - FranceT : 33 1 49 92 72 00 - F : 33 1 49 92 72 03www.bea.aeroon the accident on 1st June 2009to the Airbus A330-203registered F-GZCPoperated by Air Franceflight AF 447 Rio de Janeiro – ParisN ISBN : 978-2-11-098715-0Bureau d’Enquêtes et d’Analysespour la sécurité de l’aviation civileMinistère de l’écologie, de l’énergie, du développement durable et de la mer, en charge des technologies vertes et des négociations sur le climat

ForewordThis document presents an update on the progress of the technicalinvestigation as of 30 November 2009. It adds to the first Interim reportpublished by BEA on 2 July 2009.In accordance with Annex 13 to the Convention on International CivilAviation, with EC directive 94/56 and with the French Civil AviationCode (Book VII), the investigation has not been not conducted so as toapportion blame, nor to assess individual or collective responsibility. Thesole objective is to draw lessons from this occurrence which may help toprevent future accidents.Consequently, the use of this report for any purpose other than for theprevention of future accidents could lead to erroneous interpretations.SPECIAL FOREWORD TO ENGLISH EDITIONThis report has been translated and published by the BEA to make itsreading easier for English-speaking people. As accurate as the translationmay be, the original text in French should be considered as the work ofreference.1F-GZCP - 1st June 2009

Table of ContentsFOREWORD1GLOSSARY5SYNOPSIS7UPDATE ON THE INVESTIGATION9COMPLETED PARAGRAPHS1.11 Flight Recorders11111.12 Wreckage and Impact Information111.12.1 Debris identification111.12.2 Repositioning of the debris according to the aircraft layout 121.12.3 Visual Inspections151.12.4 Summary311.13 Medical and Pathological Information321.16 Tests and Research1.16.1 Summary of the Sea Searches3333NEW PARAGRAPHS431.6 Aircraft information1.6.11 Functioning of the automated systems43431.7 Meteorological Conditions1.7.3 Meteorological Analyses49491.16 Tests and Research1.16.3 Study of losses of or temporary anomalies in indicatedspeeds occurring in cruise on Airbus A330 / A340501.17 Information on Organisations and Management1.17.6 Type certification and Continuing Airworthiness53551.18 Additional Information1.18.5 System certification1.18.6 Earlier events associated with incorrect air speed indications1.18.7 History of the Pitot probes on Airbus A330 andmanagement at Air France6060645065FINDINGS694 - RECOMMENDATIONS714.1 Flight Recorders714.2 Certification723F-GZCP - 1st June 2009

FCPCFCSCFCUFCTMFDFDRFLFMAFMGECFPAFPDAuto-thrustAir Accident Investigation Branch (UK)Aircraft Communications Addressing and Reporting SystemAir Data and Inertial Reference UnitAir Data ReferenceAutomatic PilotEuropean Aviation Safety AgencyFailure Modes, Effects and Criticality AnalysisAirworthiness Review MeetingAir Traffic Service UnitAustralian Transport Safety BureauBundesstelle für Flugunfalluntersuchung(German aviation accident investigation bureau)Service BulletinCalibrated Air SpeedToulouse aeronautical test centre(Centre d’Essais Aéronautiques de Toulouse)Centro de Investigação e Prevenção de Acidentes aeronãuticos(Brazilian aviation accident investigation bureau)Current Flight ReportCockpit Voice RecorderFrench Armament Procurement AgencyDirectorate General of Civil Aviation FranceDesign Organisation ApprovalElectronic Centralized Aircraft MonitoringElectronic Flight Control SystemEmergency Locator TransmitterFederal Aviation AdministrationFlight Controls Primary ComputerFlight Controls Secondary ComputerFlight Control UnitFlight Crew Training ManualFlight DirectorFlight Data RecorderFlight LevelFlight Mode AnnunciatorFlight Management Guidance and Envelope ComputerFlight Path AngleFlight Path Director5F-GZCP - 1st June 2009

FPVftGPSHDGHFIAC / SULBUTCV/SFlight Path VectorFeetGlobal Positioning SystemHeadingHigh FrequencyInterstate Aviation Committee (CIS)International Civil Aviation OrganisationInstrument Meteorological ConditionsInstrument Rating / Inertial ReferenceIntegrated Standby Instrument SystemJoint Aviation AuthoritiesJoint Aviation RegulationsKilohertzKnotLower Deck Mobile Crew RestNormal OperationNational Transportation Safety BoardPrimary Flight DisplayPost Flight ReportProbe Heat ComputerPressure, static – air data measurementTotal PressureQuick Reference HandbookRudder Travel Limiter UnitStatic Air TemperatureSatellite Data UnitSecrétariat Général de la Mer(General Secretariat for the Sea)Solid State Cockpit Voice RecorderSolid State Flight Data RecorderSign Status MatrixStandard (altimeter setting)True Air SpeedTotal Air TemperatureTraffic alert and Collision Avoidance SystemTrackUnreliable Air SpeedUnderwater Locator BeaconUniversal Time CoordinatedVertical speed6F-GZCP - 1st June 2009

f-cp090601ae2SynopsisDate of accident1st June 2009 at around 2 h 15(1)AircraftAirbus A330-203registered F-GZCPSite of accidentNear the TASIL point, ininternational wa-ters, AtlanticOcean(1)All times inthis report areUTC, exceptwhere otherwisespecified. Twohours should beadded to obtainthe legal timeapplicable inmetropolitanFrance on theday of theincident. Theestimated timeof the accidentis based on theinterruption in theACARS messages.OwnerAir FranceOperatorAir FranceType of flightInternational public transport ofpassengersScheduled flight AF447Persons on boardFlight crew: 3Cabin crew: 9Passengers: 216SummaryOn 31 May 2009, flight AF447 took off from Rio de Janeiro Galeão airportbound for Paris Charles de Gaulle. The airplane was in contact with theBrazilian ATLANTICO ATC centre on the INTOL – SALPU – ORARO route atFL350. There were no further communications with the crew after passing theINTOL point. At 2 h 10, a position message and some maintenance messageswere transmitted by the ACARS automatic system. Bodies and airplane partswere found from 6 June 2009 onwards by the French and Brazilian urtCrew12--Passengers216--Third parties---Destroyed7F-GZCP - 1st June 2009publicationDecember 2009

UPDATE ON THE INVESTIGATIONSince the publication of the first Interim Report on 2 July 2009, the investigationhas continued, still in close association with foreign investigation organisationsand the companies involved and in coordination with those responsible forthe judicial investigation. The working groups have continued their work ofgathering and analyzing information useful to the investigation. Their activityhas focused on the elements of wreckage recovered,the meteorological situation,the maintenance messages transmitted by ACARS,the certification and the continuing airworthiness of the Pitot probes,events where speed inconsistencies were encountered in cruise.The results of this work have been integrated into this report. It has made itpossible to complete the paragraphs of the first report published on 2 July2009 and to introduce new paragraphs.This second interim report presents the first safety recommendations.At this stage, in the absence of any data from the flight recorders, the mainparts of the airplane and any witness testimony on the flight, the precisecircumstances of the accident, and therefore its causes, have still not beendetermined. The investigative work is continuing with this objective.The working group responsible for the sea searches is preparing the thirdphase aimed at localising the wreckage and recovering the flight recorders.This group is made up of the American, Russian, German, Brazilian and Britishinvestigation organisations and the Secrétariat Général de la Mer, and benefitsfrom the participation of experts from Airbus, Air France and the US Navy. Twoplenary meetings were held, the first on 12 and 13 October and the second on10 November 2009. A third meeting is planned for the 15 December 2009, withthe objective of putting in place the means required to begin the campaignin February 2010.9F-GZCP - 1st June 2009

COMPLETED PARAGRAPHS(the paragraph numbers correspond to those in the Interim Reportissued on 2 July 2009 and the titles of some sections have been changed)1.11 Flight RecordersAccording to the information supplied by Air France, the airplane was equippedwith two flight recorders, in accordance with the regulations in force:Flight Data Recorder (FDR) Manufacturer: HoneywellModel: 4700Type number: 980-4700-042Serial number: 11469This Solid State Flight Data Recorder (SSFDR) has a recording capacity of atleast twenty-five hours. The decoding document, supplied with this airplane,has around 1,300 parameters.Cockpit Voice Recorder (CVR) Manufacturer: HoneywellModel: 6022Type number: 980-6022-001Serial number: 12768This Solid State Cockpit Voice Recorder (SSCVR) has a recording capacity of atleast two hours in standard quality and thirty minutes in high quality.Both recorders were equipped with the regulation Underwater LocatorBeacons (ULB) whose transmission duration is at least 30 days, on the 37.5 kHzfrequency.Note: the manufacturer of the beacons stated that the duration of transmission was ofthe order of forty days.1.12 Wreckage and Impact Information1.12.1 Debris identificationAll the pieces of debris were found by the French and Brazilian Navies. Theywere detailed in a database that includes about 1,000 references concerningthe aircraft parts.Almost all of the aircraft debris was identified and classified by type: cabin,cargo compartment, wing, belly fairing, LDMCR (Lower Deck Mobile CrewRest). This information completed the position, date and recovery time datathat had been referenced previously.Most of the parts found were low-density honeycomb or compositematerial parts.11F-GZCP - 1st June 2009

They were identified: either directly with the Part Number when this was identifiable; or indirectly by analysing the shapes, materials, coating colours andmanufacturer’s documentation when the Part Number was not available.1.12.2 Repositioning of the debris according to the aircraft layoutAll of the debris was gathered in a hangar at the CEAT in Toulouse. Most of thedebris could be positioned precisely in relation to the aircraft layout.Forward part ofthe aircraftGeneral view of the hangarRight aisleLeft aisleView of the hangar: central part of the aircraft12F-GZCP - 1st June 2009

View of the hangar: aft part of the aircraftThis repositioning provides a distribution of the debris: from the forward (radome) to the aft end (vertical stabiliser) of the aircraft; from the left- to the right-hand side of the aircraft for the cabin or wing parts.Vertical stabiliser, radome, flight control surfaces, engine cowling, enginepylon, belly fairingRudderVertical stabiliserCargo compartment CabinEngine pylonUnderbellyLH wingEngineRadomePosition of the recovered parts (exterior and cargo)13F-GZCP - 1st June 2009

Position of the cabin part debris recovered in relation to the aircraft layout14F-GZCP - 1st June 2009

1.12.3 Visual Inspections1.12.3.1. Cabin parts A high degree of vertical compression can be seen on the cabin partssuch as the galleys, stowage, partitions and toilet doors. This verticalcompression is observable from the front (stowage and toilet at the levelof door 1) to the rear of the aircraft (Galley G5), and from the right- to theleft-hand sides.Certain overhead luggage racks were found with their fuselage attachmentfittings. Besides the damage due to the vertical compression, these fittingshave deformations that are due to a forward movement of the overheadluggage racks.Part of Galley G3: downwards deformation at the level of the galley ’s heavy partsFrontLuggage rack tting deformedtowards the frontToilet door (L54) metallic stiffenersdeformed by buckling15F-GZCP - 1st June 2009

x The lifejackets that were found were all in their packaging.Lifejacket found in its packagingx Three Cabin Crew seats were recovered. The two seats located onthe partition at the level of left-hand door 1 (photos below) were notdeformed; which was also the case for the corresponding seat beltfasteners and attachments. The seat located at the level of right-handdoor 2 was damaged due to the deformation of the partition on whichit was attached.Cabin crew seats located on the toilet L11 partition at the level of left-hand door 116F-GZCP - 1st June 2009 Cargo compartment partsThe outer parts making up the LDMCR were all found.The wall fragments were crumpled. The reconstitution of the ceiling showedit was