(95) to the Concorde Registered F-BTSC Operated by Air France
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E -- FRANCE Accident on 25 July 2000 at La Patte d’Oie in Gonesse (95) to the Concorde EAU D’ENQUETES ET D’ANALYSES POUR LA SECURITE DE L’AVIATION CIVIL registered F-BTSC operated by Air France REPORT translation f-sc000725a MINISTERE DE L'EQUIPEMENT DES TRANSPORTS ET DU LOGEMENT -- BUR FOREWORD This report presents the technical conclusions reached by the BEA on the circumstances and causes of this accident. In accordance with Annex 13 of the Convention on International Civil Aviation, with EC directive 94/56 and with Law No 99-243 of 29 March 1999, the analysis of the accident and the conclusions and safety recommendations contained in this report are intended neither to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. In accordance with Law No 78-753 of 17 July 1978, this document is released subject to literary and artistic copyright. Copying, distribution or the use of this document for commercial purposes is forbidden. SPECIAL FOREWORD TO ENGLISH EDITION This report has been translated and published by the Bureau Enquêtes-Accidents to make its reading easier for English-speaking people. As accurate as the translation may be, the original text in French is the work of reference. F-BTSC - 25 july 2000 - 2 - Table of contents FOREWORD__________________________________________________________________ 2 LIST OF ILLUSTRATIONS_______________________________________________________ 9 GLOSSARY _________________________________________________________________ 11 SYNOPSIS __________________________________________________________________ 14 ORGANISATION OF THE INVESTIGATION ________________________________________ 15 1 - FACTUAL INFORMATION ___________________________________________________ 17 1.1 History of the Flight _______________________________________________________ 17 1.2 Injuries to Persons ________________________________________________________ 18 1.3 Damage to Aircraft ________________________________________________________ 18 1.4 Other Damage ____________________________________________________________ 18 1.5 Personnel Information _____________________________________________________ 18 1.5.1 Flight Crew____________________________________________________________ 18 1.5.1.1 Captain ___________________________________________________________ 18 1.5.1.2 First Officer ________________________________________________________ 19 1.5.1.3 Flight Engineer _____________________________________________________ 20 1.5.2 Cabin Crew ___________________________________________________________ 20 1.5.2.1 Cabin Services Director_______________________________________________ 20 1.5.2.2 Flight Attendants ____________________________________________________ 20 1.6 Aircraft Information________________________________________________________ 21 1.6.1 Airframe ______________________________________________________________ 21 1.6.1.1 Information ________________________________________________________ 21 1.6.1.2 Maintenance _______________________________________________________ 21 1.6.2 Landing Gear __________________________________________________________ 22 1.6.2.1 General ___________________________________________________________ 22 1.6.2.2 Landing Gear Retraction ______________________________________________ 22 1.6.2.3 Braking ___________________________________________________________ 25 1.6.2.4 Deflectors _________________________________________________________ 25 1.6.2.5 Wheels and Tyres ___________________________________________________ 26 1.6.3 Fuel _________________________________________________________________ 27 1.6.4 Engines ______________________________________________________________ 28 1.6.4.1 General ___________________________________________________________ 28 1.6.4.2 CONTINGENCY Mode _______________________________________________ 29 1.6.4.3 Reheat Cutout ______________________________________________________ 29 1.6.4.4 Fire Protection______________________________________________________ 29 1.6.4.5 Engine Maintenance _________________________________________________ 30 1.6.5 Weight and balance _____________________________________________________ 31 1.6.5.1 Weight ____________________________________________________________ 31 F-BTSC - 25 july 2000 - 3 - 1.6.5.2 CG_______________________________________________________________ 32 1.6.5.2.1 CG Determined during Flight Preparation _____________________________ 32 1.6.5.2.2 CG Determined from Investigation Data ______________________________ 32 1.6.6 Takeoff Performance ____________________________________________________ 33 1.6.7 Aircraft systems ________________________________________________________ 34 1.6.7.1 Flight Controls ______________________________________________________ 34 1.6.7.2 Air Conditioning_____________________________________________________ 35 1.6.7.3 Le GPWS _________________________________________________________ 35 1.7 Meteorological Conditions __________________________________________________ 36 1.7.1 General Situation at 12 h 00 ______________________________________________ 36 1.7.1.1 At Altitude _________________________________________________________ 36 1.7.1.2 On the Ground _____________________________________________________ 36 1.7.2 Situation at the Aerodrome _______________________________________________ 36 1.7.3 Documents Supplied to the Crew___________________________________________ 37 1.8 Aids to Navigation_________________________________________________________ 37 1.9 Telecommunications ______________________________________________________ 37 1.9.1 Radar Track ___________________________________________________________ 37 1.9.2 Telecommunications ____________________________________________________ 38 1.9.2.1 ATIS _____________________________________________________________ 38 1.9.2.2 Flight Data Frequency________________________________________________ 38 1.9.2.3 Ground Frequency __________________________________________________ 39 1.9.2.4 Loc South Frequency ________________________________________________ 39 1.10 Aerodrome Information ___________________________________________________ 39 1.10.1 General _____________________________________________________________ 39 1.10.2 Runway Inspections ____________________________________________________ 40 1.10.2.1 Regulations _______________________________________________________ 40 1.10.2.2 The inspections on 25 July 2000_______________________________________ 42 1.11 Flight Recorders _________________________________________________________ 42 1.11.1 Recorder Types and Readout ____________________________________________ 42 1.11.1.1 Cockpit Voice Recorder (CVR) ________________________________________ 42 1.11.1.2 Flight Data Recorder (FDR) __________________________________________ 43 1.11.1.3 QAR ____________________________________________________________ 43 1.11.2 Cockpit Voice Recorder _________________________________________________ 44 1.11.2.1 CVR Readout _____________________________________________________ 44 1.11.2.1.1 Time-base ____________________________________________________ 44 1.11.2.1.2 Software Used _________________________________________________ 45 1.11.2.2 Transcript of the Recording___________________________________________ 47 1.11.2.3 Identification of the Alarms and Noises __________________________________ 50 1.11.2.3 1 Procedure_____________________________________________________ 50 1.11.2.3.2 Supplementary Research_________________________________________ 52 1.11.2.3.2.1 Recordings in flight __________________________________________ 52 1.11.2.3.2.2 400 Hz demodulation ________________________________________ 53 1.11.2.3.3 Research Results_______________________________________________ 54 1.11.3 FDR Readout _________________________________________________________ 54 1.11.3.1 The Flight ________________________________________________________ 54 1.11.3.1.1 Analysis of Parameters __________________________________________ 54 1.11.3.1.2 Values of Parameters____________________________________________ 56 1.11.3.2 Track (end of report) ________________________________________________ 60 1.12 Wreckage and Impact Information __________________________________________ 60 1.12.1 The Runway__________________________________________________________ 60 1.12.1.1 Water Deflector ____________________________________________________ 60 1.12.1.2 Pieces of Tyre _____________________________________________________ 61 1.12.1.3 Piece of Metal _____________________________________________________ 62 1.12.1.4 Structural Element__________________________________________________ 62 F-BTSC - 25 july 2000 - 4 - 1.12.1.5 Brake Servo Valve Cover ____________________________________________ 63 1.12.1.6 Piece of Concrete and Signs of Explosion _______________________________ 63 1.12.1.7 Lighting __________________________________________________________ 63 1.12.1.8 Tyre tracks _______________________________________________________ 63 1.12.1.9 Soot Deposits on Runway____________________________________________ 65 1.12.2 Between Runway 26 Right and the Accident Site _____________________________ 67 1.12.3 The Accident Site ______________________________________________________ 68 1.12.3.1 Description of Site and Plan __________________________________________ 68 1.12.3.2 Instrument Indications _______________________________________________ 72 1.12.3.3 Examination of Engines______________________________________________