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  • M i n i s t è r e d e l ’ É c o l o g i e , d u D é v e l o p p e m e n t d u r a b l e , d e s Tr a n s p o r t s e t d u L o g e m e n t

    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 1st June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro - Paris

    Published July 2012

  • F-GZCP - 1st June 2009 1

    BEA investigations are conducted in accordance with the provisions of Regulation No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation.

    The BEA is the French Civil Aviation Safety Investigation Authority. Its investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liability. BEA investigations are independent, separate and are conducted without prejudice to any judicial or administrative action that may be taken to determine blame or liability.

    SPECIAL FOREWORD TO ENGLISH EDITION

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

    Safety Investigations

  • F-GZCP - 1st 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

  • F-GZCP - 1st June 2009 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 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 - 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 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 - 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

  • F-GZCP - 1st June 2009 7

    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 70

  • F-GZCP - 1st June 2009 8

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