Final Report
On the accident on 1st June 2009
to the Airbus A330-203
registered F-GZCP
operated by Air France
flight AF 447 Rio de Janeiro - Paris
-GZCP - 1
st June 2009 3
Table of Contents
SAFETY INVESTIGATIONS 1 TABLE OF FIGURES 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
4
F-GZCP - 1
st June 2009
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 flight crews on the unreliable IAS situation 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
2.1 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 warning 171
2.1.3 From the triggering of the STALL 2 warning until the end of the flight 178
2.2 Pilot Training and Recurrent Training 182
2.2.1 Manual aeroplane handling and functional representation of flight 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 - 1st June 2009 5
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
3.1 Findings 197
3.2 Causes of the Accident 199
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
5.1 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
Table of figures
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 altitude
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 the 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 70F-GZCP - 1
st 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 central 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 frame 74
Figure 49: Right-hand aft lug: shearing of the fuselage along main frames 86-87 74
Figure 50: Frames 84 to 87: S-shaped deformation of frame 87, with frames 84 and 85
pushed in backwards; failure of the horizontal stabiliser actuator supports
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
Figure 53: Tensile failure of the centre spar at the level of the attachment
of the lateral load pick-up rods 76
Figure 54: Compression failure of the aft spar at the level of the attachments
of the lateral load pick-up rods and failure of the left-hand rod by buckling 77
Figure 55: Sonar Images of the debris field 77
Figure 56: Parts of the fuselage 78
Figure 57: Left engine air intake 78
Figure 58: Engine pylon 79
Figure 59: Cartography of the parts subsequently brought to the surface 79
Figure 60: Front view of engine 80
Figure 61: Trimmable horizontal stabiliser screwjack after being raised on board 80
Figure 62: Evolutions of recorded angles of attack and of the stall warning trigger threshold 89
Figure 63: Comparison between the recorded positions of the elevator and THS
and the simulation 90
Figure 64: Comparison between altitudes of the aeroplane and the simulation (longitudinal axis) 91
Figure 65: Flight envelope 92
Figure 66: Evolution of normal acceleration recorded at the time of activation
of the stall warning 92
Figure 67: Speed displays on the PFD 93
Figure 68: Evolution of the 3 CAS 94
Figure 69: Evolution of FD crossbars 96
Figure 70: Position of the area where ECAM messages are displayed 97
Figure 71: ECAM displays at different moments (if no message has been erased) 97
Figure 72: Evolution of the REC MAX (simulation) Source Airbus 99
Figure 73: Source: Airbus FCOM supplied to Air France 103
Figure 74: Source FCOM Airbus 104
Figure 75: Source TU Air France 104
Figure 76: View of the cockpit seats 106
Figure 77: General view of the left seat 106
Figure 78: The seat’s horizontal position adjustment systems 107
Figure 79: Right seat armrest on the side-stick side 108
Figure 80: Roller marks on the guidance rail 108
Figure 81: Right side seat cushion 109F-GZCP - 1
st June 2009 9
Figure 82: Marks on the adjustment mechanism 109
Figure 83: Dial indicating armrest position 110
Figure 84: Malformation of the crotch belt fastening 110
Figure 85: A typical display on a flight logging interface 111
Figure 86: Strip created after coordination between ATLANTICO and DAKAR Océanic 129
Figure 87: Arrangement of the SRR in metropolitan France 133
Figure 88: Lift graph with high and low Mach 150
Figure 89: Flight envelope at high altitude 151
Figure 90: Alucia 163
Figure 91: AUV REMUS 6000 163
Figure 92: General view using sonar imaging: 120 kHz, range of 700 m 163
Figure 93: Engine 164
Figure 94: Wing 164
Figure 95: Section of fuselage 164
Figure 96: Landing gear 165
Figure 97: Overlay of sonar images taken with various settings: 120 kHz,
700 m range scale - 410 kHz, 100 m range scale - 410 kHz, 50 m range scale 165
Figure 98: Visualisation of the photo mosaic obtained with REMUS AUV images
and the aeroplane debris identified by using the REMORA ROV 166F-GZCP - 1
st June 2009 11
Glossary
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A/THR
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Auto Thrust
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AAIB
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Air Accident Investigation Branch (UK)
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AC
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Advisory Circular
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ACARS
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Aircraft Communication Addressing and Reporting System
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ACC
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Area Control Centre
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ACJ
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Advisory Circular Joint
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ACP
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Audio Control Panel
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AD
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Airworthiness Directive
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AD
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Airworthiness Directive
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ADIRU
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Air Data Inertial Reference Unit
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ADM
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Air Data Module
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ADR
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Air Data Reference
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ADS-B
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Automatic Dependant Surveillance-Broadcast
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ADS-C
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Automatic Dependant Surveillance-Contract
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AIP
|
Aeronautical Information Publication
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AIRAC
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Aeronautical Information Regulation And Control
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AMC
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Acceptable Means of Compliance
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AMU
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Audio Management Unit
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AOA
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Angle Of Attack
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AOC
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Air Operator’s Certificate
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AP
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Autopilot
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APU
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Auxiliary Power Unit
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ARCC
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Aeronautical Rescue Coordination Centre
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ARM
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Airworthiness Review Meeting
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ASR
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Air Safety Report
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ATC
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Air Traffic Control
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ATIMS
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Air Traffic and Information Management System
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ATL
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Aircraft Technical Log
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ATPL
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Airline Transport Pilot Licence
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ATSB
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Australian Transport Safety Bureau
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ATSU
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Air Traffic Service Unit
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AUV
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Autonomous Underwater Vehicle
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BFU
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Bundesstelle für Flugunfalluntersuchung
(German investigation authority)
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CAA
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Civil Aviation Authority
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CAS
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Calibrated Air Speed
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CAT
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Clear Air Turbulence
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CCQ
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Cross Crew Qualification
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CENIPA
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Centro de Investigação e Prevenção de Acidentes aeronãuticos
(Brazilian investigation authority)
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