[PDF] On the Accident on 1st June 2009 to the Airbus A330-203

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Ministère de l'Écologie, du Développement durable, des Transports et du Logement

Bureau d'Enquêtes et d'Analyses

pour la sécurité de l'aviation civile

Bureau d'Enquêtes et d'Analyses

pour la sécurité de l'aviation civile

Zone Sud - Bâtiment 153

200 rue de Paris

Aéroport du Bourget

93352 Le Bourget Cedex - France

T : +33 1 49 92 72 00 - F : +33 1 49 92 72 03

www.bea.aero

Final Report

On the accident on 1

st

June 2009

to the Airbus A330-203 registered F-GZCP operated by Air France ?ight AF 447 Rio de Janeiro - Paris

Published July 2012

F-GZCP - 1

st

June 2009

1 The BEA is the French Civil Aviation Safety Investigation Authority. Its investigations are conducted with the sole objective of improving aviation safety and are n ot intended to apportion blame or liability. BEA investigations are independent, separate and conducted without prejudice to any judicial or administrative action that may be taken to determine blame o r liability.

SPECIAL FOREWORD TO ENGLISH EDITION

This report has been translated and published by the BEA to make its rea ding easier for English-speaking people. As accurate as the translation may be, the original text in

French is the work or reference.

Safety Investigations

Update: 27 July 2012

F-GZCP - 1

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June 2009

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Table of Contents

SAFETY INVESTIGATIONS 1

TABLE OF ILLUSTRATIONS 7

GLOSSARY 11

SYNOPSIS 17

ORGANISATION OF THE INVESTIGATION 19

1 ? FACTUAL INFORMATION 21

1.1 History of Flight

21

1.2 Killed and Injured

24

1.3 Damage to Aircraft

24

1.4 Other Damage

24

1.5 Personnel Information

24

1.5.1 Flight crew

24

1.5.2 Cabin crew

29

1.6 Aircraft Information

30

1.6.1 Airframe

30

1.6.2 Engines

30

1.6.3 Weight and balance

30

1.6.4 Condition of the aircraft before departure

31

1.6.5 Maintenance operations follow-up

31

1.6.6 Information on the airspeed measuring system

31

1.6.7 Checks and maintenance of the Pitot probes

33

1.6.8 Radio communications system

34

1.6.9 Systems function

35

1.6.10 Specific points on overspeed

42

1.6.11 Angle of attack protection and stall warning

43

1.6.12 REC MAX and OPTI flight levels

45

1.6.13 Onboard weather radar

45

1.7 Meteorological Conditions

46

1.7.1 Meteorological situation

46

1.7.2 Forecast charts

46

1.7.3 Meteorological analyses

47

1.8 Aids to Navigation

48

1.9 Telecommunications

48

1.9.1 Communications between the aeroplane and the ATC centres

48

1.9.2 Means of monitoring used by air traffic control services

49

1.9.3 Coordination between the control centres

52

1.10 Aerodrome Information

53

1.11 Flight Recorders

53

1.11.1 Flight recorder opening operations and read-out

54

1.11.2 Analysis of the flight recorder data

57

1.11.3 Analysis of computers

62

F-GZCP - 1

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4

1.12 Wreckage and Impact Information

64

1.12.1 Localisation of the floating debris and the wreckage site

64

1.12.2 Work performed on floating debris

66

1.12.3 Examination of the wreckage

77

1.12.4 Summary

81

1.13 Medical and Pathological Information

81

1.14 Fire

81

1.15 Survival Aspects and SAR

81

1.16 Tests and Research

83

1.16.1 Underwater search and recovery operations

83

1.16.2 Study of unreliable indicated airspeed events

(temporary loss or anomalies) occurring in cruise on Airbus A330/A340 85

1.16.3 Analysis of functioning of systems

88

1.16.4 Analysis of aircraft performance

90

1.16.5 Reconstruction of the information available to the crew

93

1.16.6 Simulation of flight AF 447 in the Eurocat system

99

1.16.7 Aspects relating to fatigue

100

1.16.8 Work on Human Factors

101

1.16.9 Examination of the cockpit seats

106

1.17 Information on Organisations and Management

110

1.17.1 Organisation of Air France

110

1.17.2 Organisation of oversight of the operator by the DGAC

126

1.17.3 Air traffic services for a trans-oceanic flight

129

1.17.4 Search and Rescue (SAR)

130

1.18 Additional Information

136

1.18.1 Type Certification and continuing airworthiness

136

1.18.2 Information supplied to ight crews on the unreliable IAS situ

ation 147

1.18.3 Information on the Stall

150

1.18.4 Simulator fidelity

154

1.18.5 Testimony

157

1.18.6 Previous Accidents and Recommendations

159

1.19 Useful or Effective Investigation Techniques

162

1.19.1 Resources used for phase 4

162

1.19.2 Resources used for phase 5

166

2 ? ANALYSIS 167

2.1 Accident Scenario

167

2.1.1 From the beginning of the CVR recording until

the autopilot disconnection 167

2.1.2 From the autopilot disconnection to triggering of the STALL 2 warn

ing 171

2.1.3 From the triggering of the STALL 2 warning until the end of the ight

178

2.2 Pilot Training and Recurrent Training

182

2.2.1 Manual aeroplane handling and functional representation of igh

t 183

2.2.2 CRM training and exercises

184

2.2.3 Augmented crews

184

2.2.4 Flight simulators

185

2.2.5 Aeroplane behaviour in reconfiguration laws

186

2.3 Ergonomics

187

2.3.1 ECAM

187

2.3.2 Operation of the flight directors

188

2.3.3 Stall warning (operation and identification)

189

F-GZCP - 1

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2.4 Operational and technical feedback

190

2.5 Oversight of the Operator by the national aviation safety

authority (DGAC/DSAC) 192

2.6 SAR operations

193

2.7 Radio-communications with control services

194

2.7.1 Controllers' and crew's planned actions

194

2.7.2 Limits on the use of the Eurocat system in Senegal

194

2.7.3 Alert service provision

195

2.8 Lessons learnt from the search for the wreckage of flight AF 447

195

3 ? CONCLUSION 197

3.1 Findings

197

3.2 Causes of the Accident

199

4 ? SAFETY RECOMMENDATIONS 203

4.1 Recommendations from Interim Report n°2

203

4.1.1 Flight Recorders

203

4.1.2 Certification

204

4.2 Recommendations from Interim Report n°3

204

4.2.1 Recommendations on Operations

204

4.2.2 Recommendation relating to Certification

205

4.2.3 Recommendations relating to Flight Recorders

205

4.2.4 Recommendations relating to Transmission of Flight Data

206

4.3 New Recommendations

207

4.3.1 SAR coordination plans over maritime and remote areas

207

4.3.2 Training of SAR operators

207

4.3.3 Organisation of SAR in France

208

4.3.4 Air Traffic Control

208

4.3.5 Initial and recurrent training of pilots

208

4.3.6 Improving flight simulators and exercises

210

4.3.7 Ergonomics

210

4.3.8 Operational and Technical Feedback

212

4.3.9 Oversight of the Operator

212

4.3.10 Release of Drift Measuring Buoys

213

5 ? CHANGES MADE FOLLOWING THE ACCIDENT 215

5.1 Air France

215

5.1.1 Aeroplane maintenance and equipment

215

5.1.2 Modifications to reference systems

215

5.1.3 Crew training

215

5.2 Airbus

216

5.3 EASA

216

5.3.1 Certification measures to improve aviation safety

216

5.3.2 Rulemaking actions from EASA to improve aviation safety

216

5.4 Aviation industry actions

217

LIST OF APPENDICES 219

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Table of Illustrations

Figure 1: Flight profile

23
Figure 2: Position of the Pitot probes on the Airbus A330 32

Figure 3: Pitot probe (with protection caps)

32
Figure 4: Diagram of the speed measurement system architecture 33

Figure 5: FCU display

37

Figure 6: PFD in normal law 39

Figure 7: PFD in alternate 2 law

39

Figure 8: Pitot probe diagram

40

Figure 9: Overview

41
Figure 10: Effect of a drop in total measured pressure on standard altit ude and vertical speed 42
Figure 11: Evolution of stall warning threshold in relation to Mach 44

Figure 12: Example of a “PROG" page from FMS

45
Figure 13: TEMSI chart overlaid with infrarouge image at 0 h 00 47
Figure 14: Strip filled out by ATLANTICO controller 49
Figure 15: Representation of air traffic by the Eurocat system 51

Figure 16: FDR

54

Figure 17: CVR

54

Figure 18: FDR CSMU after removal of cover

54

Figure 19: FDR memory board

55

Figure 20: Removal of internal protective layers

55

Figure 21: Opening of CVR CSMU

56
Figure 22: CVR memory board after removal of thermal protections 56

Figure 23: CVR memory boards before cleaning

56
Figure 24: Level of turbulence observed during flight 58
Figure 25: Position and detail of “AIR DATA" selector 59
Figure 26: Parameters from 2 h 10 min 04 to 2 h 10 min 26 60
Figure 27: Parameters from 2 h 10 min 26 to 2 h 10 min 50 61
Figure 28: Parameters from 2 h 10 min 50 to 2 h 11 min 46 62
Figure 29: Optical disk showing the location of the readable zones 63

Figure 30: Memory component from one of the FCDC

64
Figure 31: All of floating debris (found between 6 and 26 June), last known position and wreckage site 65

Figure 32: Wreckage localisation

66
Figure 33: Position of the recovered parts (exterior and cargo) 66
Figure 34: Position of the cabin part debris recovered in relation to th e aircraft layout 67
Figure 35: Part of Galley G3: downwards deformation at the level of the galley's heavy parts 68
Figure 36: Luggage rack fitting deformed towards the front Toilet door ( L54) 68
Figure 37: Metallic stiffeners deformed by buckling 68
Figure 38: Floor of the LDMCR: with bottom-upwards deformation 69
Figure 39: Ceiling of the LDMCR: with top-downwards deformation 69
Figure 40: Passenger oxygen container recovered closed: the deformations on the cover matched those on the box 69
Figure 41: Passenger oxygen container recovered open: the three pins are in place 70

F-GZCP - 1

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June 2009

8 Figure 42: Flap extension mechanism (or flap track) No. 3 in retracted position 70
Figure 43: Part of the No. 3 flap track fairing on the left wing 71
Figure 44: Fin - In the foreground the base of the fin with the centr al and forward attachment lugs 71
Figure 45: Rib 2 bent upwards as a result of bottom-upwards compression loads 72

Figure 46: HF antenna support

72
Figure 47: Arm 36G, right view: failure of the rudder attachments 73
Figure 48: Frame 87: shearing of the frame and fuselage skin along the f rame 74
Figure 49: Right-hand aft lug: shearing of the fuselage along main frame s 86-87 74
Figure 50: Frames 84 to 87: S-shaped deformation of frame 87, with frame s 84 and 85 pushed in backwards; failure of the horizontal stabiliser actuator suppo rts between frames 86 and 87 (red circle) 75

Figure 51: Fin centre and aft attachments

75
Figure 52: Rear view of the left-hand aft lug: there were marks showing a backwards pivoting of frames 86 and 87 76
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