Report: Boeing 737-800 struck runway construction markers on takeoff at Paris-CDG

August 30, 2011

Take-off trajectory of AMV6104 (source: BEA)

The French Bureau d’Enquêtes et d’Analyses (BEA) released the final report of their investigation into a serious incident in which a Boeing 737-800 struck runway construction markers on takeoff from Paris-CDG, France.

On August 17, 2008 at 00:57 local time, AMC Airlines Flight AMV6104 struck some provisional lights at the end  runway 27L at Paris-Charles de Gaulle Airport. Then, during the rotation, it destroyed some markers on the safety-barrier positioned in front of the construction zone. It took off before a provisional blast fence and continued its flight to its destination.
Repair works on runway 09R/27L were in progress between 4 and 20 August 2008. During this period, the last 1,240 metres of runway  27L were closed for flight operations. The AMC Airlines Boeing 737 commenced takeoff from after lining up from taxiway Y11, leaving 2360 metres for takeoff. This was reported to the crew by ground controller.

The crew had calculated takeoff parameters using a computer program, but the takeoff distance calculated by the program was not known to the crew.

BEA Concluded that:
The event was caused by the crew’s failure to take into account the length of the runway available for takeoff.
The following factors may have contributed to the event:

  • ˆ the inadequacy of the OPT utilisation procedures set up by the operator AMC to prevent such an error;
  • ˆ the impaired level of crew performance, specifically related to the pilots’ fatigue.
More information:

French pilot union suspends participation in AF447 investigation

August 4, 2011

The French airline pilot union SNPL  (Syndicat National des Pilotes de Ligne) suspended their participation in the Air France Flight 447 accident investigation after expressing concerns about the recent progress report published by BEA.

In a statement on their website, SNPL said that the confidence in BEA is “seriously damaged” because the BEA progress report published on July 29 did not contain a safety recommendation relating to the functioning of the stall warning. This recommendation was withdrawn from the draft report. SNPL is also concerned about other “significant” alterations in the progress report, but does not elaborate.

BEA explained in a statement that the safety recommention “was withdrawn because it appeared to BEA investigators that the recommendation was premature at this stage of the investigation.”  A new working group, which will be made up of specialists in cognitive sciences, ergonomics and psychology will have to examine all aspects linked to man-machine interactions and to the pilots’ actions in the last few minutes of the flight.

“Only after all of this work has been completed and included in the Final Report will it be possible for a recommendation on the functioning of the stall warning to be made, based on reasoned scientific analysis, work in which EASA will participate,” BEA says. Also, “it should be noted that the warning sounded uninterruptedly for 54 seconds after the beginning of the stall, without provoking any appropriate reaction from the crew. This fact must be analysed as a priority by the working group.”

More information:

 


BEA releases third interim report on AF447 accident

July 29, 2011

The French BEA releases the third interim report in the course of their investigation into the cause of the fatal accident involving an Air France Airbus A330 in the Atlantic Ocean.

The third BEA Interim Report will be published on Friday 29 July 2011. This report will present the exact circumstances of the accident with an initial analysis and some new findings based on the data recovered from the flight recorders. At the same time, a press briefing will be organised at the BEA at 14 h 30.

The report will be available here: http://www.bea.aero/en/enquetes/flight.af.447/flight.af.447.php

 

 


BEA publishes AF447 investigation update

May 27, 2011

The French Bureau d’Enquêtes et d’Analyses (BEA) released an update with factual findings of their investigation into the AF447 accident.

Faced with the regular disclosure of partial and often approximate information since 16 May, the BEA wished to publish the update  so as to inform the families of the victims and the public about the first facts established, based on analysis of the data from the flight recorders, which started on 14 May for the FDR and 15 May for the CVR.

The updatr describes in a factual manner the chain of events that led to the accident and presents newly established facts. The initial analyses will be developed in a further interim report that is scheduled to be published towards the end of July 2011.

Only after long and detailed investigative work will the causes of the accident be determined and safety recommendations issued, this being the main mission of the BEA. The latter will be included in the final report.

View this document on Scribd

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Parts of FDR found in AF447 underwater search

April 28, 2011

The FDR chassis on the Ocean floor (photo: BEA)

During the underwater search for the wreckage of Air France Flight 447 which crashed in the Atlantic Ocean in June 2o09, an ROV found the chassis of the airplane’s Flight Data Recorder (FDR).  

The chassis didn not contain the Crash Survivable Memory Unit (CSMU) that contains the data. It was surrounded by debris from other parts of the airplane.

The searches are continuing.

More information


Report: Premature thrust during rolling takeoff caused runway B737 excursion

December 23, 2010

According to a French investigation report, the runway excursion incident involving a Boeing 737 in August 2009 was caused by the premature application of thrust during a rolling takeoff.

On August 29, 2009 an Air Algérie Boeing 737-8D6 departed the right side of runway 36L at Lyon-Saint-Exupéry Airport (LYS/LFLL), France during takeoff. It rolled for about 250 meters on the grass verge alongside the runway. The aircraft joined the track after hitting a runway edge light and continued the takeoff.

On arrival in Sétif-Ain Arat Airport (QSF/DAAS), Algeria, minor damage was found on the right engine, the airframe and nose gear. There were 39 passengers and seven crew members on board.

The BEA report states: “The overrun is due to a non-compliance with the procedure of “rolling takeoff” by premature application of  takeoff thrust as the aircraft, light and with a rear centre of gravity, had not yet entered the runway. A possible tendency of the Pilot Flying to add thrust before the complete alignment of the aircraft on the centreline of the runway contributed to the occurrence of this serious incident.
The decision to continue the takeoff after having  returned to the track with a speed of less than V1, led the crew to continue the flight with a plane of which they did not know the extent of damage.”

Takeoff path on runway 36L


Report: blocked AOA sensors caused loss of control during A320 check flight

September 17, 2010

The French Bureau d’Enquêtes et d’Analyses (BEA) issued their final report of the investigation into the cause of a fatal accident involving an Airbus A320 in November 2008, citing amongst others blocked AOA sensors.

Airbus A320 D-AXLA had been leased by XL Airways Germany since May 2006. The airplane was due to be returned to its owner, Air New Zealand, on December 1, 2008. The Airbus was ferried to Perpignan (PGF), France where it underwent maintenance at EAS Industries. It was also repainted in full Air New Zealand livery. The leasing agreement specified a programme of in-flight checks to ensure the airplane was fit for purpose.

The programme of planned checks could not be performed in general air traffic, so the flight was shortened. In level flight at FL320, angle of attack sensors 1 and 2 stopped moving and their positions did not change until the end of the flight. After about an hour of flight, the aeroplane returned to the departure aerodrome airspace and the crew was cleared to carry out an ILS procedure to runway 33, followed by a go around and a departure towards Frankfurt/Main (Germany). Shortly before overflying the initial approach fix, the crew carried out the check on the angle of attack protections in normal law. They lost control of the aeroplane, which crashed into the sea killing all seven on board.

BEA concluded that the accident was caused by the loss of control of the aeroplane by the crew following the improvised demonstration of the functioning of the angle of attack protections, while the blockage of the angle of attack sensors made it impossible for these protections to trigger.
The crew was not aware of the blockage of the angle of attack sensors. They did not take into account the speeds mentioned in the programme of checks available to them and consequently did not stop the demonstration before the stall.

ˆˆThe following factors contributed to the accident:

  • The decision to carry out the demonstration at a low height;
  • The crew’s management, during the thrust increase, of the strong increase in the longitudinal pitch, the crew not having identified the pitch-up stop position of the horizontal stabiliser nor acted on the trim wheel to correct it, nor reduced engine thrust;
  • The crew having to manage the conduct of the flight, follow the programme of in-flight checks, adapted during the flight, and the preparation of the following stage, which greatly increased the work load and led the crew to improvise according to the constraints encountered;
  • The decision to use a flight programme developed for crews trained for test flights, which led the crew to undertake checks without knowing their aim;
  • The absence of a regulatory framework in relation to non-revenue flights in the areas of air traffic management, of operations and of operational aspects;
  • The absence of consistency in the rinsing task in the aeroplane cleaning procedure, and in particular the absence of protection of the AOA sensors, during rinsing with water of the aeroplane three days before the flight. This led to the blockage of the AOA sensors through freezing of the water that was able to penetrate inside the sensor bodies.

The following factors also probably contributed to the accident

  • Inadequate coordination between an atypical team composed of three airline pilots in the cockpit;
  • The fatigue that may have reduced the crew’s awareness of the various items of information relating to the state of the systems.

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