[PDF] Accident on 25 July 2000 at La Patte dOie in Gonesse (95) to the

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Accident

on 25 July 2000 at La Patte d'Oie in Gonesse (95) to the Concorde registered F-BTSC operated by Air France

MINISTERE DE L'EQUIPEMENT DES TRANSPORTS ET DU LOGEMENT -- BUREAU D'ENQUETES ET D'ANALYSES POUR LA SECURITE DE L'AVIATION CIVILE -- FRANCE

REPORT translation

f-sc000725a

F-BTSC - 25 july 2000 - 2 -

FOREWORD

This report presents the technical conclusions reached by the BEA on the circumstances and causes of this accident. In accordance with Annex 13 of the Convention on International Civil Aviation, with EC directive 94/56 and with Law No 99-243 of 29 March 1999, the analysis of the accident and the conclusions and safety recommendations contained in this report are intended neither to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. In accordance with Law No 78-753 of 17 July 1978, this document is released subject to literary and artistic copyright. Copying, distribution or the use of this document for commercial purposes is forbidden.

SPECIAL FOREWORD TO ENGLISH EDITION

This report has been translated and published by the Bureau Enquêtes-Accidents to make its reading easier for English-speaking people. As accurate as the translation may be, the original text in French is the work of reference.

F-BTSC - 25 july 2000 - 3 -

Table of contents

FOREWORD__________________________________________________________________ 2 LIST OF ILLUSTRATIONS_______________________________________________________ 9 GLOSSARY _________________________________________________________________ 11 SYNOPSIS __________________________________________________________________ 14 ORGANISATION OF THE INVESTIGATION________________________________________ 15

1 - FACTUAL INFORMATION ___________________________________________________ 17

1.1 History of the Flight _______________________________________________________ 17

1.2 Injuries to Persons ________________________________________________________ 18

1.3 Damage to Aircraft ________________________________________________________ 18

1.4 Other Damage ____________________________________________________________ 18

1.5 Personnel Information _____________________________________________________ 18

1.5.1 Flight Crew____________________________________________________________ 18

1.5.1.1 Captain ___________________________________________________________ 18

1.5.1.2 First Officer ________________________________________________________ 19

1.5.1.3 Flight Engineer _____________________________________________________ 20

1.5.2 Cabin Crew ___________________________________________________________ 20

1.5.2.1 Cabin Services Director_______________________________________________ 20

1.5.2.2 Flight Attendants ____________________________________________________ 20

1.6 Aircraft Information________________________________________________________ 21

1.6.1 Airframe ______________________________________________________________ 21

1.6.1.1 Information ________________________________________________________ 21

1.6.1.2 Maintenance _______________________________________________________ 21

1.6.2 Landing Gear __________________________________________________________ 22

1.6.2.1 General ___________________________________________________________ 22

1.6.2.2 Landing Gear Retraction______________________________________________ 22

1.6.2.3 Braking ___________________________________________________________ 25

1.6.2.4 Deflectors _________________________________________________________ 25

1.6.2.5 Wheels and Tyres ___________________________________________________ 26

1.6.3 Fuel _________________________________________________________________ 27

1.6.4 Engines ______________________________________________________________ 28

1.6.4.1 General ___________________________________________________________ 28

1.6.4.2 CONTINGENCY Mode _______________________________________________ 29

1.6.4.3 Reheat Cutout______________________________________________________ 29

1.6.4.4 Fire Protection______________________________________________________ 29

1.6.4.5 Engine Maintenance _________________________________________________ 30

1.6.5 Weight and balance _____________________________________________________ 31

1.6.5.1 Weight____________________________________________________________ 31

F-BTSC - 25 july 2000 - 4 -

1.6.5.2 CG_______________________________________________________________ 32

1.6.5.2.1 CG Determined during Flight Preparation _____________________________ 32

1.6.5.2.2 CG Determined from Investigation Data ______________________________ 32

1.6.6 Takeoff Performance ____________________________________________________ 33

1.6.7 Aircraft systems ________________________________________________________ 34

1.6.7.1 Flight Controls______________________________________________________ 34

1.6.7.2 Air Conditioning_____________________________________________________ 35

1.6.7.3 Le GPWS _________________________________________________________ 35

1.7 Meteorological Conditions__________________________________________________ 36

1.7.1 General Situation at 12 h 00 ______________________________________________ 36

1.7.1.1 At Altitude _________________________________________________________ 36

1.7.1.2 On the Ground _____________________________________________________ 36

1.7.2 Situation at the Aerodrome _______________________________________________ 36

1.7.3 Documents Supplied to the Crew___________________________________________ 37

1.8 Aids to Navigation_________________________________________________________ 37

1.9 Telecommunications ______________________________________________________ 37

1.9.1 Radar Track ___________________________________________________________ 37

1.9.2 Telecommunications ____________________________________________________ 38

1.9.2.1 ATIS _____________________________________________________________ 38

1.9.2.2 Flight Data Frequency________________________________________________ 38

1.9.2.3 Ground Frequency __________________________________________________ 39

1.9.2.4 Loc South Frequency ________________________________________________ 39

1.10 Aerodrome Information ___________________________________________________ 39

1.10.1 General _____________________________________________________________ 39

1.10.2 Runway Inspections____________________________________________________ 40

1.10.2.1 Regulations _______________________________________________________ 40

1.10.2.2 The inspections on 25 July 2000_______________________________________ 42

1.11 Flight Recorders _________________________________________________________ 42

1.11.1 Recorder Types and Readout ____________________________________________ 42

1.11.1.1 Cockpit Voice Recorder (CVR) ________________________________________ 42

1.11.1.2 Flight Data Recorder (FDR) __________________________________________ 43

1.11.1.3 QAR ____________________________________________________________ 43

1.11.2 Cockpit Voice Recorder _________________________________________________ 44

1.11.2.1 CVR Readout _____________________________________________________ 44

1.11.2.1.1 Time-base ____________________________________________________ 44

1.11.2.1.2 Software Used _________________________________________________ 45

1.11.2.2 Transcript of the Recording___________________________________________ 47

1.11.2.3 Identification of the Alarms and Noises__________________________________ 50

1.11.2.3 1 Procedure_____________________________________________________ 50

1.11.2.3.2 Supplementary Research_________________________________________ 52

1.11.2.3.2.1 Recordings in flight __________________________________________ 52

1.11.2.3.2.2 400 Hz demodulation ________________________________________ 53

1.11.2.3.3 Research Results_______________________________________________ 54

1.11.3 FDR Readout_________________________________________________________ 54

1.11.3.1 The Flight ________________________________________________________ 54

1.11.3.1.1 Analysis of Parameters __________________________________________ 54

1.11.3.1.2 Values of Parameters____________________________________________ 56

1.11.3.2 Track (end of report) ________________________________________________ 60

1.12 Wreckage and Impact Information __________________________________________ 60

1.12.1 The Runway__________________________________________________________ 60

1.12.1.1 Water Deflector ____________________________________________________ 60

1.12.1.2 Pieces of Tyre _____________________________________________________ 61

1.12.1.3 Piece of Metal _____________________________________________________ 62

1.12.1.4 Structural Element__________________________________________________ 62

F-BTSC - 25 july 2000 - 5 -

1.12.1.5 Brake Servo Valve Cover ____________________________________________ 63

1.12.1.6 Piece of Concrete and Signs of Explosion _______________________________ 63

1.12.1.7 Lighting __________________________________________________________ 63

1.12.1.8 Tyre tracks _______________________________________________________ 63

1.12.1.9 Soot Deposits on Runway____________________________________________ 65

1.12.2 Between Runway 26 Right and the Accident Site _____________________________ 67

1.12.3 The Accident Site______________________________________________________ 68

1.12.3.1 Description of Site and Plan __________________________________________ 68

1.12.3.2 Instrument Indications_______________________________________________ 72

1.12.3.3 Examination of Engines______________________________________________ 78

1.12.3.3.1 Secondary exhaust nozzles _______________________________________ 78

1.12.3.3.2 Primary exhaust nozzles _________________________________________ 78

1.12.3.3.3 General findings________________________________________________ 78

1.12.3.4 Examination of Wheels and Tyres______________________________________ 80

1.12.3.4.1 Wheel No 1____________________________________________________ 80

1.12.3.4.2 Wheel No 2____________________________________________________ 80

1.12.3.4.3 Wheel No 5____________________________________________________ 80

1.12.3.4.4 Wheel No 6____________________________________________________ 80

1.12.4 Work on the Wreckage__________________________________________________ 81

1.12.4.1 Reconstruction of the Wing and Examination of the Debris __________________ 81

1.12.4.1.1 Upper Wing ___________________________________________________ 82

1.12.4.1.2 Lower Wing ___________________________________________________ 83

1.12.4.2 Aft part of Fuselage_________________________________________________ 84

1.12.4.3 Examination of the Seats ____________________________________________ 84

1.12.4.4 Examination of the Landing Gear ______________________________________ 84

1.12.4.5 Examination of the Dry Bays__________________________________________ 86

1.12.4.5.1 Description ____________________________________________________ 86

1.12.4.5.2 Examination ___________________________________________________ 87

1.12.4.5.2.1 Forward Part _______________________________________________ 87

1.12.4.5.2.2 Aft Part ___________________________________________________ 87

1.12.4.6 Structural Resistance to Fire__________________________________________ 88

1.13 Medical and Pathological Information________________________________________ 88

1.14 Fire ____________________________________________________________________ 88

1.15 Survival Aspects_________________________________________________________ 89

1.16 Tests and Research ______________________________________________________ 89

1.16.1 Flight Preparation for AFR 4590___________________________________________ 89

1.16.1.1 Flight Preparation at Air France _______________________________________ 89

1.16.1.1.1 Flight Planning _________________________________________________ 89

1.16.1.1.2 Flight Departure ________________________________________________ 89

1.16.1.1.3 Ramp ________________________________________________________ 90

1.16.1.1.4 Traffic ________________________________________________________ 90

1.16.1.2 Preparation of Flight AFR 4590________________________________________ 90

1.16.1.2.1 Flight Planning _________________________________________________ 90

1.16.1.2.2 Flight Departure ________________________________________________ 91

1.16.1.2.3 Ramp ________________________________________________________ 91

1.16.1.2.4 Traffic ________________________________________________________ 92

1.16.2 Aircraft Loading _______________________________________________________ 92

1.16.3 Observation and Pictures of the Event______________________________________ 93

1.16.4 Previous Events_______________________________________________________ 94

1.16.4.1 Nature of Events ___________________________________________________ 94

1.16.4.2 Events which caused Structural Damage to Tanks_________________________ 95

1.16.4.2.1 Event on 14 June 1979 at Washington ______________________________ 96

1.16.4.2.2 Other Events __________________________________________________ 98

1.16.5 Tyre destruction Mechanism _____________________________________________ 98

1.16.5.1 Experimental Tests _________________________________________________ 98

1.16.5.2. Theoretical Study of Metallic Strip Cutting Tyre __________________________ 101

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1.16.5.3 Tests Carried out at the CEAT _______________________________________ 101

1.16.5.3.1 Low-speed Tests ______________________________________________ 101

1.16.5.3.2 Metallic Strip Dynamic Peneration Test _____________________________ 102

1.16.5.4 Examinations Carried out at the LRCCP________________________________ 102

1.16.6 Metallic Strip found on the Runway _______________________________________ 103

1.16.6.1 Observations on N 13067 ___________________________________________ 104

1.16.6.2 Manufacturer's Documentation _______________________________________ 106

1.16.6.2.1 Disassembly and Repair of Wear Strips_____________________________ 106

1.16.6.2.2 Space between the Core Door and the Fan Reverser Cowl _____________ 107

1.16.6.3 Maintenance on N 13067 ___________________________________________ 107

1.16.6.4 Examination of the Wear Strip________________________________________ 108

1.16.6.5 Examination of Samples taken from N 13067____________________________ 108

1.16.6.6 Analysis of the Photos of the Cowl on N 13067 __________________________ 109

1.16.7 Rupture of Tank 5 ____________________________________________________ 109

1.16.7.1 Examination of the Pieces of the Tank _________________________________ 110

1.16.7.1.1 Piece Found on Runway ________________________________________ 110

1.16.7.1.2 Piece of the Underside Found at the Accident Site ____________________ 111

1.16.7.1.3 Other Piece found in the Aircraft Wreckage__________________________ 112

1.16.7.2 Tank Rupture Mechanism___________________________________________ 112

1.16.7.2.1 Rupture by Tyre Impact _________________________________________ 114

1.16.7.2.1.1 The Principle ______________________________________________ 114

1.16.7.2.1.2 Tests ____________________________________________________ 114

1.16.7.2.1.3 Calculations_______________________________________________ 115

1.16.7.2.1.4 Possible Energy Sources ____________________________________ 116

1.16.7.2.2 Rupture by Pressure Surge ______________________________________ 116

1.16.7.2.2.1 Method Employed __________________________________________ 116

1.16.7.2.2.2 The Results_______________________________________________ 117

1.16.7.3 The Fuel in Tank 5 ________________________________________________ 118

1.16.7.4 Conclusion ______________________________________________________ 119

1.16.8 Possible Origin of Combustion___________________________________________ 119

1.16.8.1 Flame stabilisation and retention______________________________________ 119

1.16.8.2 Estimation of fuel flow ______________________________________________ 120

1.16.8.3 Ignition and Propagation of the Flame _________________________________ 121

1.16.8.3.1 Engine Surge _________________________________________________ 121

1.16.8.3.2 Electric Arc___________________________________________________ 121

1.16.8.3.3 Contact with the Hot Sections of the Engine _________________________ 122

1.16.8.3.4 Conclusion ___________________________________________________ 124

1.16.9 Engines ____________________________________________________________ 124

1.16.9.1 Observations on the Engines ________________________________________ 124

1.16.9.1.1 Disassembly of Engines 1 and 2 __________________________________ 125

1.16.9.1.1.1 Engine 1 _________________________________________________ 125

1.16.9.1.1.2 Engine 2 _________________________________________________ 126

1.16.9.1.2 Examination of Engines 3 and 4___________________________________ 127

1.16.9.1.2.1 Engine 3 _________________________________________________ 127

1.16.9.1.2.2 Engine 4 _________________________________________________ 127

1.16.9.1.3 Laboratory Research ___________________________________________ 128

1.16.9.1.3.1 Engine 1 _________________________________________________ 128

1.16.9.1.3.2 Engine 2 _________________________________________________ 130

1.16.9.1.3.3 Examination of the HP fuel valve selectors_______________________ 130

1.16.9.2 Tyre Debris Ingestion during Operation ________________________________ 131

1.16.9.3 Data Readout ____________________________________________________ 131

1.16.9.4 Engine Operation _________________________________________________ 134

1.16.9.4.1 Engine 1_____________________________________________________ 134

1.16.9.4.2 Engine 2_____________________________________________________ 135

1.16.9.4.3 Engines 3 and 4 _______________________________________________ 135

1.16.9.4.4 Conclusion ___________________________________________________ 136

1.16.10 Origin of the Non-retraction of the Landing Gear____________________________ 136

1.16.11 Rudder Switch to Mechanical Mode______________________________________ 137

1.16.12 Alarms ____________________________________________________________ 138

1.16.12.1 Toilet Smoke Alarm_______________________________________________ 138

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1.16.12.2 Engine Fire Alarm ________________________________________________ 138

1.16.13 Study of Aircraft Track ________________________________________________ 139

1.16.13.1 Flight Simulator Tests _____________________________________________ 139

1.16.13.2 Deviation from the Track___________________________________________ 139

1.16.13.3 Effect of the Early Rotation _________________________________________ 141

1.16.13.4 Consequences of Aborting the Takeoff________________________________ 141

1.17 Information on Organisations and Management ______________________________ 142

1.17.1 Concorde Operations at Air France _______________________________________ 142

1.17.1.1 Flight Crew ______________________________________________________ 142

1.17.1.2 Cabin Crew ______________________________________________________ 143

1.17.1.3 Maintenance _____________________________________________________ 143

1.17.1.4 Operations Manual ________________________________________________ 143

1.17.1.4.1 Procedures from the GEN.OPS ___________________________________ 143

1.17.1.4.2 Extracts of Procedures from Concorde TU Manual ____________________ 144

1.17.1.4.3 Concorde Flight Manual Procedures _______________________________ 145

1.17.1.4.4 Fuel Transfer Procedures________________________________________ 146

1.17.2 Airworthiness Oversight ________________________________________________ 146

1.17.2.1 General _________________________________________________________ 146

1.17.2.2 Points Related to Tyres and Structural Damage__________________________ 147

1.17.2.3 Other Significant Areas in Airworthiness Oversight________________________ 149

1.18 Additional Information ___________________________________________________ 149

1.18.1 Certification of Landing Gear and Tyres____________________________________ 149

1.18.1.1 General _________________________________________________________ 149

1.18.1.1.1 Requirements for Tyres ___________________________________________ 150

1.18.1.1.2 Landing Gear Requirements _______________________________________ 150

1.18.1.2 Substantiation Provided for Certification________________________________ 150

1.18.2 Absence of the Spacer on the left main Landing Gear_________________________ 150

1.18.2.1 Maintenance Operations____________________________________________ 151

1.18.2.1.1 Documentation________________________________________________ 152

1.18.2.1.2 Work performed _______________________________________________ 152

1.18.2.2 Examination of the Bogie ___________________________________________ 153

1.18.2.3 Possible consequences on the Landing Gear of the Absence of the Spacer ____ 154

1.18.2.3.1 Mechanical Aspect_____________________________________________ 154

1.18.2.3.2 Effects on the Electrical Wiring and Pipes ___________________________ 154

18.2.3.3 Displacement of the Bogie __________________________________________ 155

1.18.2.4 Examination of the Other Wheels on the left Bogie________________________ 156

1.18.2.5 Study of the Beginning of the Flight ___________________________________ 156

1.18.3 Prevention of Debris-related Risks on the Movement Area _____________________ 157

1.18.3.1 Current Regulations in France _______________________________________ 157

1.18.3.2 Prevention of debris-related Risks at Paris Charles de Gaulle _______________ 158

1.18.3.2.1 Manoeuvring Area _____________________________________________ 158

1.18.3.2.2 The Apron____________________________________________________ 158

2 - ANALYSIS_______________________________________________________________ 160

2.1 Accident Scenario________________________________________________________ 160

2.1.1 Flight Preparation______________________________________________________ 160

2.1.2 The Flight until Engine Power-up__________________________________________ 160

2.1.3 The Flight up until the Loss of Thrust on Engine 1_____________________________ 162

2.1.4 Loss of Control of the Aircraft_____________________________________________ 167

2.2 Crew Actions____________________________________________________________ 167

2.3 Sequence Leading to Ignition of the Kerosene Leak____________________________ 169

2.3.1 Destruction of Tyre No 2 ________________________________________________ 169

2.3.2 The Destruction of the Lower Panel of Tank 5________________________________ 169

2.3.3 The Fire _____________________________________________________________ 170

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2.4 Runway Surveillance _____________________________________________________ 171

2.5 Concorde Operations at Air France _________________________________________ 172

2.5.1 Functioning of the Concorde flight Division __________________________________ 172

2.5.2 Functioning of Maintenance______________________________________________ 172

2.6 Maintenance at Continental Airlines _________________________________________ 173

2.7 Airworthiness Oversight __________________________________________________ 173

2.8 Flight Recorders _________________________________________________________ 174

2.9 Risks associated with the Presence of Asbestos ______________________________ 174

3 - CONCLUSION____________________________________________________________ 176

3.1 Findings________________________________________________________________ 176

3.2 Probable Causes_________________________________________________________ 178

4 - RECOMMENDATIONS _____________________________________________________ 179

4.1 Preliminary Recommendation ______________________________________________ 179

4.2 Recommendations Specific to Concorde_____________________________________ 180

4.2.1 ____________________________________________________________________ 180

4.2.2 ____________________________________________________________________ 180

4.2.3 ____________________________________________________________________ 181

4.2.4 ____________________________________________________________________ 181

4.3 General Recommendations ________________________________________________ 181

4.3.1 ____________________________________________________________________ 181

4.3.2 ____________________________________________________________________ 181

4.3.3 ____________________________________________________________________ 182

4.3.4 ____________________________________________________________________ 182

4.3.5 ____________________________________________________________________ 182

4.3.6 ____________________________________________________________________ 183

4.3.7 ____________________________________________________________________ 183

4.3.8 ____________________________________________________________________ 183

4.3.9 ____________________________________________________________________ 183

COMMENTS FROM THE UK ACCREDITED REPRESENTATIVE ______________________ 184 LIST OF APPENDICES _______________________________________________________ 189

F-BTSC - 25 july 2000 - 9 -

List of illustrations

Figure 1: Hydraulic systems for landing gear manoeuvres______________________________ 23 Figure 2: Landing gear retraction sequence _________________________________________ 24 Figure 3: Synoptic diagram of main landing gear braking_______________________________ 25 Figure 4: Water deflector________________________________________________________ 25 Figure 5: Main gear: view from above______________________________________________ 26 Figure 6: Concorde fuel tanks____________________________________________________ 28 Figure 7: Fire Detection System __________________________________________________ 30 Figure 8: Air Conditioning System_________________________________________________ 35 Figure 9: Track of F-BTSC based on AVISO data ____________________________________ 37 Figure 10: Paris Charles de Gaulle south double runway_______________________________ 40 Figure 11: Synchronisation ______________________________________________________ 45 Figure 12: Temporal representation of signal ________________________________________ 46 Figure 13: Time-frequency representation of signal ___________________________________ 46 Figure 14: Frequency representation of signal _______________________________________ 47 Figure 15: Identification of a selector noise__________________________________________ 50 Figure 16: Identical sound with different background noises ____________________________ 51 Figure 17: Engine operation: shut down on the left, in flight on the right ___________________ 52 Figure 18: 400 Hz demodulation__________________________________________________ 53 Figure 19: Part located at line 157 - right part of deflector ______________________________ 61 Figure 20: Piece of tyre at line 180 - piece of tyre at line 152____________________________ 61 Figure 21: Piece found at line 152 ________________________________________________ 62 Figure 22: Part found at line 160__________________________________________________ 62 Figure 23: Part found at line 175__________________________________________________ 63 Figure 24: Marks of Wheel No 2 and soot on the runway_______________________________ 64 Figure 25: Marks of left bogie tyres and edge light ____________________________________ 65 Figure 26: Soot marks on the runway______________________________________________ 66 Figure 27: Left main gear wheel marks_____________________________________________ 66 Figure 28: Burnt grass on the edge on the runway____________________________________ 67 Figure 29: BEA/IGN/FLEXIMAGE image - Aerial photo of the accident site_________________ 68 Figure 30: Wreckage distribution plan______________________________________________ 69 Figure 31: Aerial view with indications of zones ______________________________________ 70 Figure 32: Impact marks ________________________________________________________ 70 Figure 33: Aerial view with position of main parts_____________________________________ 71 Figure 34: Overall view of instrument panel _________________________________________ 73 Figure 35: General view of engine 4 upper nozzle ____________________________________ 78 Figure 36: Engine 2 exhaust nozzle _______________________________________________ 78quotesdbs_dbs17.pdfusesText_23

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