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Rapport D'enquête Parution : Décembre 2018 RAPPORT D’ENQUÊTE Incident grave survenu le 22 mai 2015 à Paris – Charles-de-Gaulle (95) au Boeing 777-F immatriculé F-GUOC exploité par Air France www.bea.aero @BEA_Aero Les enquêtes de sécurité Le BEA est l’autorité française d’enquêtes de sécurité de l’aviation civile. Ses enquêtes ont pour unique objectif l’amélioration de la sécurité aérienne et ne visent nullement la détermination des fautes ou responsabilités. Les enquêtes du BEA sont indépendantes, distinctes et sans préjudice de toute action judiciaire ou administrative visant à déterminer des fautes ou des responsabilités. 2 F-GUOC - 22 mai 2015 Table des matières LES ENQUÊTES DE SÉCURITÉ 2 SYNOPSIS 10 ORGANISATION DE L’ENQUETE 12 1 - RENSEIGNEMENTS DE BASE 13 1.1 Déroulement du vol 13 1.2 Tués et blessés 14 1.3 Dommages à l’aéronef 15 1.4 Autres dommages 15 1.5 Renseignements sur le personnel 15 1.5.1 Équipage de conduite 15 1.6 Renseignements sur l’aéronef 16 1.6.1 Cellule 16 1.6.2 Procédure d’insertion de données sur Boeing 777 (Air France) 16 1.6.3 Outil de calcul des performances (OPT) et procédures associées 20 1.6.4 Vitesses de référence calculées par le FMS 21 1.6.5 Message V SPEEDS UNAVAILABLE affiché au CDU du FMS 22 1.6.6 Optimisation de la configuration des volets au décollage 24 1.6.7 Procédure TAIL STRIKE 26 1.7 Renseignements météorologiques 26 1.8 Aides à la navigation 26 1.9 Télécommunications 26 1.10 Renseignements sur l’aérodrome 27 1.11 Enregistreurs de bord 27 1.12 Renseignements sur l’épave et sur l’impact 30 1.13 Renseignements médicaux et pathologiques 30 1.14 Incendie 30 1.15 Questions relatives à la survie des occupants 30 1.16 Essais et recherches 30 1.16.1 Simulations effectuées par Boeing 30 1.16.2 Séance de simulateur effectuée par le BEA 31 1.17 Renseignements sur les organismes et la gestion 33 1.17.1 Prise en compte du risque par Air France 33 1.17.2 Surveillance des opérations aériennes 34 1.17.3 Prise en compte du sujet des erreurs d’insertion par les autorités de l’aviation civile 37 3 F-GUOC - 22 mai 2015 1.18 Renseignements supplémentaires 48 1.18.1 Témoignages 48 1.18.2 OFP, « carton décollage » et ECD utilisés pour la préparation du vol de l’événement 55 1.18.3 Paramètres au décollage calculés par l’OPT à partir de la masse correcte et de la masse erronée 57 1.18.4 Incidents similaires sur Boeing 777-300 57 1.18.5 Étude publiée par le BEA en 2008 et intitulée “Utilisation de paramètres erronés au décollage” 58 1.18.6 Autres études internationales 60 1.18.7 Système LINTOP de calcul de performance 61 1.18.8 Fonctionnalité EFB de comparaison de la masse sur Boeing 777 61 1.18.9 Systèmes TOS et TOM d’Airbus 62 1.19 Techniques d’enquête utiles ou efficaces 62 2 - ANALYSE 63 2.1 Scénario 63 2.2 Analyse de l’événement 67 2.2.1 Performance des barrières opérationnelles dans l’événement 67 2.2.2 Mobilisation des ordres de grandeur 68 2.2.3 Compatibilité des procédures et interfaces avec l’environnement opérationnel 69 2.2.4 Vitesses de référence calculées par le FMS, message V SPEEDS UNAVAILABLE 71 2.2.5 Protection contre l’insertion de vitesses de décollage trop basses 73 2.2.6 Chronologie du décollage 73 2.2.7 Décision de poursuivre le vol 73 2.2.8 Conclusion sur l’événement 74 2.3 Gestion du risque par Air France 75 2.4 Prise en compte du risque par la DSAC 76 2.5 Gestion du risque par les autorités de l’aviation civile 77 3 - CONCLUSION 80 3.1 Faits établis par l’enquête 80 3.2 Causes et facteurs contributifs 81 4 F-GUOC - 22 mai 2015 4 - ACTIONS DE SÉCURITÉ ENTREPRISES ET RECOMMANDATIONS DE SECURITE 83 4.1 Actions de sécurité entreprises depuis l’incident grave 83 4.1.1 Actions prises par Air France 83 4.1.2 Actions prises par la DGAC 84 4.1.3 Actions prises par l’AESA 84 4.2 Recommandations de sécurité 91 4.2.1 Homogénéité des données de masses manipulées 91 4.2.2 Procédures opérationnelles 92 4.2.3 Poursuite du vol après la survenue d’un incident grave 92 4.2.4 Protections contre l’insertion de vitesses erronées sur Boeing 777 93 4.2.5 Gestion du risque par les autorités de l’aviation civile 93 ANNEXES 98 5 F-GUOC - 22 mai 2015 Glossaire AESA Agence Européenne de la Sécurité Aérienne AFM Aircraft Flight Manual (Manuel de vol) AMC Acceptable Means of Compliance (Moyens acceptables de mise en conformité) AP AutoPilot (Pilote automatique) ARMS Aviation Risk Management Solutions ARO Authority Requirement for Air Operations (Exigences applicables aux autorités en matière d’opérations aériennes) ASDA Acceleration Stop Distance Available (Longueur utilisable pour l’accélération arrêt) ASR Air Safety Report (Compte rendu de sécurité des vols) ATSB Australian Transport Safety Bureau (Organisme d’enquête de sécurité de l’Australie) BST Bureau de la Sécurité des Transports (Organisme d’enquête de sécurité du Canada) CAP Circulation Aérienne Publique CAS Calibrated Air Speed (Vitesse Conventionnelle) CASIA Civil Aviation Safety Investigation Authorities (Autorités d’enquête de sécurité de l’aviation civile) CDB Commandant de Bord CDU Control Display Unit (Tableaux de commande et d’affichage) CRM Crew Resource Management (Gestion des ressources de l’équipage) CTA Certificat de Transporteur Aérien CVR Cockpit Voice Recorder (Enregistreur phonique) DAC Directions de l’Aviation Civile DCS Direction du Contrôle de la Sécurité DGAC Direction Générale de l’Aviation Civile DSAC Direction de la Sécurité de l’Aviation Civile DSB Dutch Safety Board (Organisme d’enquête des Pays-Bas) DO Direction des Opérations (Air France) DOW Dry Operating Weight (Masse à vide en ordre d’exploitation) ECD État de Charge Définitif 6 F-GUOC - 22 mai 2015 ECR European Central Repository (Base de données européenne des événements de sécurité d’aviation civile) EFB Electronic Flight Bag (Système de documentation électronique) EICAS Engine Indication and Crew Alerting System (Système d’affichage des paramètres moteurs et des alarmes sur les deux écrans centraux du poste de pilotage) EUROCAE EURopean Organisation for Civil Aviation Equipment (Organisation européenne pour l’équipement de l’aviation civile) FAA Federal Aviation Administration (Agence américaine en charge de l’aviation civile) FCOM Flight Crew Operations Manual (Manuel d’exploitation des équipages) FCTM Flight Crew Training Manual (Manuel de formation des équipages) FDM Flight Data Monitoring (Programme de collecte de données de vol) FDR Flight Data Recorder (Enregistreur de paramètres) FL Flight Level (Niveau de vol) FMC Flight Management Computer (Calculateur de gestion de vol) FMS Flight Management System (Système de gestion du vol) FOB Fuel On Board (Quantité de carburant embarqué) FOI Flight Operation Inspector (Inspecteur en vol) FORDEC Faits Options Risques Décision Exécution Contrôles ft Feet (Pieds) GM Guidance Material (Document d’orientation) GPS Global Positioning System (Système de positionnement par satellite) GW / GR WT Gross Weight (Masse brute totale au départ) kt Knot (Nœud) LEF Livret d’Entraînement et de Formation LINTOP Lido Integrated Takeoff Performance Tool (Système de calcul de performance au décollage de Lido) LOSA Line Operations Safety Audit (Audit de sécurité des opérations en ligne) MCT Manuel de Contrôle Technique MEP Mise en Place MMS Minimum Maneuvering Speed (Vitesse minimale de manœuvre) MOPS Minimum Operational Performance Standards (Spécifications de performances opérationnelles minimales) 7 F-GUOC - 22 mai 2015 MTOW Maximum Take-Off Weight (Masse maximale au décollage) NASA National Aeronautics and Space Administration (Agence aéronautique et spatiale américaine) NOTAM Notice To AirMen (Avis aux navigants aériens) NPA Notice of Proposed Amendment (Avis de proposition de modification de réglement) NTSB National Transportation Safety Board (Organisme d’enquête de sécurité des USA) OFP Operational Flight Plan (Plan de vol exploitation) OPL Officier Pilote de Ligne OPT On-board Performance Tool (Outil de calcul des performances) ORO Organisation Requirement for Air Operators (Exigences applicables aux organismes pour les opérations aériennes) OSV Officier de Sécurité des Vols OBWBS On-Board Weight and Balance Systems (Systèmes de pesée autonomes) PA Pilote Automatique PF Pilot Flying (Pilote aux commandes) PFD Primary Flight Display (Écran de vol primaire) PIA Preliminary Impact Assessment (Analyse préliminaire d’impact) PLD PayLoad (Charge utile) PLI Pitch Limit Indicator (Indicateur de limite d’assiette) PNS Programme National de Sécurité PNT Personnel Navigant Technique PM Pilot Monitoring (Pilote non en fonction) PPV Préparation du Plan de Vol QAR Quick Access Recorder (Enregistreur de paramètres à déchargement rapide) RMT Rule Making Task (Tâche réglementaire) QRH Quick Reference Handbook QT Qualification de Type SGS Système de Gestion de la Sécurité SIB Safety Information Bulletin (Bulletin d’information de sécurité) SRM Safety Risk Management (Processus de gestion des risques de sécurité de l’AESA) 8 F-GUOC - 22 mai 2015 TAIC Transport Accident Investigation Commission (Organisme d’enquête de sécurité de Nouvelle-Zélande) TODA Take-Off Distance Available (Distance utilisable au décollage) TOGA Take-Off Go-Around (Décollage / Remise des gaz) TORA Take-Off Runway Available (Longueur de roulement au décollage utilisable) TOM Take-Off Monitoring (Système de surveillance du décollage) TOS Take-Off Securing (Système de détection d’erreurs d’insertion au décollage) TOW Take-Off Weight (Masse au décollage) TOPMS Take-Off Performance Monitoring System (Système de surveillance des performances au décollage) TRE Type Rating Examiner (Examinateur de qualification de type) TSP Tail Strike Protection (Protection contre le toucher de queue) UTC Coordinated Universal Time (Temps universel coordonné) VR Vitesse de Rotation WG Working Group (Groupe de travail) ZFW Zero Fuel Weight (Masse sans carburant) 9 F-GUOC - 22 mai 2015 n° codé : BEA2015-0225 Synopsis Heure À 10 h 25(1) (1)Sauf précision contraire, les Exploitant Air France heures figurant Nature du vol Vol cargo dans ce rapport sont exprimées en Personnes à bord CDB (PM) ; OPL (PF) ; Deux OPL de renfort heure en UTC.
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