F I N A L R E P O R T
concerning the accident
which occurred on Jun 26th 198 8
at M li ouse-Habsheim (68 ) to the Airbus A 320, registered F-GFKC
Nvvsnber 29th 1989 FOREWOR D
This report is a technical document which reflects the point o f view of the Investigation Cb nnission set up by the Minister o f Transport to investigate the circumstances in which the accident occurred, its causes and its consequences .
In compliance with Appendix 13 to the Convention, o n International Civil Aviation, the investigation in no way tries to establish faults or responsibilities . It has been conducted without necessarily using contradictory proceedings and with the basic aim of preventing future accidents .
SPECIAL FE tD 10 EMLISH EDITIQd
This report has been translated and published by the Frenc h Bureau Erquêtes Accidents to make its reading easier fo r English speaking people . As accurate as the translation may be , please refer to the original text in French . CONTENT S
SYNOPSIS
COMPOSITION OF THE INVESTIGATION CCMMIISSICN AND SUMMARY OF WORK
1 - FACTUAL INFORMATION 1 .1 - History of the flight 1 .2 - Injuries to persons 1 .3 - Damage to aircraft 1.4 - Other damage 1 .5 - Personnel information 1 .6 - Ai rcrraft information
1 .7 - Meteorological information 1 .8 - Aids to navigation 1 .9 - Camunications
1 .10 -Aerodrome information
1.11 - Flight recorders 1.12 - Wreckage 1 .13 - Medical and pathological information 1 .14 - Fire 1 .15 - Survival aspects 1 .16 - Tests and research 2-ANALYSIS 2 .1 - General considerations 2 .2 - Flight preparation 2 .3 - Sequence of events 3 - CONM SIOIS 3.1 - Findings 3.2 - Probable causes
4 - SAFETY
APPEDDIC'FS SYNOPSIS Date of accident Aircraft
Sunday June 26th 198 8 Airixrs A 32 0 at 12 h 45 tTIC (1 ) NSN : 9 Registration : F-GFKC
Place of accident Owner
300 m beyond the end of rumway DURUS VERWALTUNGSGESELLSHAFT 34 R at the LISE I ABSHEIM Mi Co MOBILIEN KG aerodr me (68) and on runway axis . Operator
AIR FRAME
Type of flight Occupants
Chartered flight Flight crew : 2 Public transport of passengers Cabin attendants : 4 including a low altitude Passengers : 130 flyover . Flight No . and radio telephone code :ACF296Q
Summary of accident
As part of an airshow, the aircraft flew over rummy 34 R at a heigh t of approximately 30 feet, engines at idle, with an angle of attac k i ncreasing up to the meximan possible taking into account the deceleration rate of the aircraft . During the go-around, the aircraft touched the tree s a short wry beyond the end of the runway, sank into the forest, carne t o rest and caught fire . Evacuation was undertaken immediately but thre e passengers died in the fire .
Consequences
PERSONS Aircraft Third party damage Killed Injured Unhurt crew 0 2 4 Tbtal Approximately loss two hectares Passengers 3 34 ( ) 93 of forest destroyed Third parties 0 0
( ) Passengers taken to hospital .
(1) The times given in this report are in universal time coordinated (UIC) . Add two hours to obtain legal French time .
1 .
OCMPC1SITICN OF THE INVFSMGATION COMMISSION AND SUMMARY OF WORK
C urceition of the Investigation Ccunission
By order dated June 27th 1988, the Minister of Transport set up an Investigation C tinissi on coed of :
Messrs Claude BEGET - President Captain Bureau Enquêtes Accident s
Frarrois Q) IN - Ingenieur General de 1 Aa[ement Vice-President
Robert AIWFRFT - Médecin General Manber of the Civil Aviation Medical Counci l
Bernard FARTH T - Ingénieur General de la Météorologi e
Paul ARSLANIAN - Ingénieur en Chef de 1 Aviation Civile
Philippe k7CHM - Pilot Inspector
Jean-Paul de VILLE EUVE - Engineer Bureau Enquêtes Accidents
whose mission was to study the circurrstarces and find the causes of, and release information relevant to, the accident which occurred on June 26th 1988 at Iiltr.me-Habsheim to an Air France A 320 aircraft .
In accordance with the provisions of the protocol concernin g technical investigations of accidents involving aircraft equipped with CF M 56 engines, signed jointly on March 21st 1985 by the Accident Investigatio n Bureau (BEA) of the Civil Aviation General Inspectorate and the National Transportation Safety Board (NISB-USA), a delegate of the country co - manufacturing the Meals engines, assisted by three technical advisers, wa s called on to participate in the Commission s work . 2 .
Also, in a decision taken by the President of the Commission, Mr Jean-Claude %%MIER, general engineer armament, joined in the Cao Sunreryof work The French Accident Investigation Bureau (BEM was informed of the accident around 13 h 30 on Sunday June 26th. After having taken all measures to safeguard the evidence, two investigators from this office wer e sent immediately to the site of the accident . They arrived there around 16 h. On their arrival at the Mulixn1se-Habsheim aerodrome, they got i n contact with the local aeronautical, prefectorial and judicial authoritie s and started work in collaboration with these authorities . The recorders had been recovered by the rescuers . They were transferred overnight to Paris, as their analysis required specialize d installations and technicians . Tuesday June 28th : the President of the Cannission held a first hearing with the flight crew and listened in their presence to th e recordings made on the cockpit voice recorder . The first full session of the Commission was held in Paris o n Wednesday June 29th. All the members of the Cannission were present. This session permitted all the research and study work to be shared out between the Ccirmission members . %b e following day, Thursday June 30th, two members of the Commission flew to llhouse ilabsheim in a light aircraft belonging to th e administration and made around ten flights over the wreckage under the flight conditions of the accident . On this occasion, contacts were also made with the Colmar prefectorial authorities and the examining Judge in charge of the affair . A second full session was held on FridayJuly 1st during which participation of NTSB was confirmed in accordance with the protocol mentioned above . 3 . Fran July 4th to 7th, the accredited representative from the USA and his three technical advisers participated in the work of the Commission , became acquainted with the reading out of the flight data recorder and al l infoanation that was available at this stage in the investigation . This delegation left for Washington on July 7th 1988 without leaving a delegate in situ as had been proposed. The following weeks were devoted to studying the circmnstances of the accident . The work especially consisted in examining the recordings , hearing the pilots and the authorities concerned and reconstructing th e paranE ers of the accident in the simulator and in flight on July 20th and 21st. This led to the writing of the preliminary report which was handed over to the Minister of Transport on July28th 1988 . The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July 19th 1988 , September 6th 1988, October 27th 1988, December 20th 1988, April27th 1989 , June 21st 1989, June 26th 1989 and September 13th 1989 . The Commission also released an official statement on November 2nd 1988 giving the progres s made in their work . to Ca:mission approved the present final report during their session held on November 29th. In ca:Qliacce with the clauses of the inbmamirdstexial order dated January 3rd 1953, the Commission carried out all their work in clos e cooperation with the judicial authorities (Public Prosecutor*, Examining Judge, judicial experts, Air Transport Police, Air and Frontier Police) . Judicial experts were invited to all the Commission's sessions an d participated in much of its work. In compliance with the terns of the order dated November 3rd 1972 relevant to investigation commissions, the draft of the final report was submitted, for comments, to the following persons and organizations : - Crew neuters (flight =wand cabin attendants ) - Air France - Airbus Industrie - CFirI - Mulhouse flying club - Direction Generale de 1'Aviation Civile (D .G .A .C. ) - Haut Rhin prefecture 'r a two flight crew members declared that they wished to reserv e their comments for the judicial representatives . * American equivalent is the Attorney General 4 . 1 - FACTUAL INFORMATION 1.1 - HIS'IOHI OF THE FLIGHT On June 26th 1988, the Air France A 320 F-GF C was to perform for Air Charter a series of flights with passengers on behalf of the Mulhouse flying club . The program included the following flights : Paris-Charles de Ga1111e/Basle-Mulhouse, 2 round trips from Basle-Mulhouse and the Basle-Mulhouse/Paris-Charles de Gaulle return flight . At the start of each of the two round trips, initially planned to th e Vosges area, then, for meteorological reasons, to the Alps, the cre w was, at the request of the Mulhouse flying club, to overfly the Mulhouse-Habsheii aerodrome as part of the air show organized by thi s flying club . The regional Air France delegation at Mulhouse, acting as contac t between the organizer of the air show and the carrier Air Charter , had made the administrative preparation for the flight . In Paris, Air Charter took charge of the commercial aspects, definin g the general flight conditions (route, choice of aircraft on the basi s of Air France availabilities) and preparing the contract . Lastly, the technical preparation was undertaken by the "Service Ligne et Régions de la Direction des Opérations d Air France" who, o n the basis of ociunercial requests, studied the conditions under whic h the flight was to be perforned and prepared the technical file for the crew. According to the declarations made by the airline, this preparatio n was made with respect to the specific airline directives (internal note DOND 50420 dated October 19th 1987 shown in appendix), taking into account the obstacles and with a planned low altitude flyover o f runway 02 . On completion of this study, on Friday June 24th in the afternoon , the A 320 Flight Division, i .e. the department responsible for crew management, received the following file intended for the crew together with verbal =rants : - IGN (National Geographical Institute) map, scale 1/100,00 0 - visual flight chart, scale 1/500,000 - visual landing chart (VAL) of )tilhouse Habsheim airfield - scheduled flight plan - copy of various massages . In this documentation, there were no instructions either concernin g runway axis ar height of overflight . 5 . On Sunday morning, June 26th, during their flight pmer~a~tion, the crew become acquainted with the file . No verbal comments were made to them. The flight from Paris-Charles de Gaulle to Basle-Mulhouse was achieved mrmally . After a short stop, the aircraft departed shortly before 12 h 30 fo r the first round trip . For this flight, the pilot in the left seat was the designated Captain, and he had the controls . During taxiing, as confirmed by the recording of on-boar d conversations, he explained in detail the program of the flyby to b e made at Habsheim (first overflight at low speed, with landing gear and flaps extended, at a height of 100 feet, then overflight at hig h speed in clean configuration) . The intention to make two overflights was transmitted to air traffic control by radio . Take-off was made at 12h 41, immediately followed by a right turn t o reach Mulhouse Habsheim at an altitude of 2000 feet QtH (i .e . a height of approximately 1000 feet above the ground) achieved at 12 h 42 . During the level flight at 1000 feet above the ground, the autothrottle was disengaged to permit manual control of the thrust , and two warning sequences, related to the landing gear retracted configuration and two indications of radio altimeter height less tha n 1000 feet, weme heard . The motorway was used as the first visua l navigation landmark then a track, parallel to the motorway, leading to the Habsheim aerodrome . At 12h 44, the aircraft left this level flight altitude and descende d towards the aerodrome which was identified visually. The engines were throttled back. Flap and landing gear were extended at start of descent. Setting of the pressure at aerodrome level (i .e . 984 hPa) was made and counterchecked by the two pilots . The vertical speed during descent was 600 feet per minute . Confirmation of Habsheim aerodrare identification was made at 45 0 feet above the ground. 6 . A warning related to the radio altitude and flap 3 configuration wa s recorded before a first aural altimeter message "200 feet" at 12 h 45mn 06s . A second aural message "200 feet" interrupted a personal remark made by the First Officer at 12h 45mn 11s . The First Officer informed the Captain that the aircraft was reaching 100 feet at 12 h 45mn 14s and simultaneously the radio altimeter emitted a "100 feet " message, the vertical speed still being 600 feet per minute . The descent continued at a slightly lower rate down to 50 feet , reached 8 seconds after passing through 100 feet agl , then at a ver y low rate down to 30 o 35 feet above the ground, the aircraft the n remaining more or less in level flight . Throughout the whole descent and at the start of level flight mad e with engines set to flight idle, the aircraft decelerated and it s pitch up increased during the last 25 seconds of flight . The end of the descent and the level flight were made above rummy 34R . Between 12h 45mn 34s and 12h 45mn 35s, the engine controls were set to initiate go around (the acceleration of the engines can be seen o n the flight data recorder at 12h 45mn 35s) . The aircraft touched the trees shortly after the end of the runway a t 12h 45mn 40s ; at this time, engine speed was around 83 % Ni, the pitch attitude of the aircraft was 14° . The first contact between the aircraft and the trees was made by th e rear section of the fuselage, the tailplane then the engine nacelle s and the main landing gear . The aircraft sank slowly into the forest . The tip of the right wing then the right wing itself broke, fuel wa s projected forward and fire immediately broke out and penetrated th e cabin as soon as the aircraft came to rest. Evacuation was made immediately via the left side . The forward lef t door could not be opened completely because of the trees . The left aft door opened correctly and the escape slide deployed normally bu t was perforated by the broken trees as soon as used by the firs t evacuees . A woman and two children, including one physically handicapped, die d in the fire . above ground level 7 . 1 .2 - INJURIES TO PERSONS . Crew Passengers Third party Killed 0 3 0 Injured . . . . 2 34 (1) 0 Unhurt 4 93 (1) Passengers taken to hospital 1 .3 - DAMAGE 10 AIRCRAFT The aircraft was totally destroyed by the successive impacts and th e very violent fire which followed . 1 .4 - Ófl ERDAMAGE Approximately two hectares of forest (5 acres) (young oak and birch ) were destroyed. The trees were broken, torn or burnt . Others were cut during the rescue and wreck recovery operations . 1.5 - PERSONNEL INFORMATION The crew included two pilots, in accordance with the aircraft operating rules, both Captains and with management responsibilities . 1 .5 .1 - Captain Michel ASCINE, born May 5th 1944 in Paris (75 ) Certificates and lames : Airline pilot s licence obtained on June 25th 1969 , Licence valid till November 30th 1988 , Last medical check-up on May 24th 1988 performed by the Air Fran Chew Medical Examination Center (CEMPN) . * (' v41 ificati.ons : Airline pilot instructor s qualification obtained in 197 9 Type qualifications : Caravelle SE 210 ; Boeing 707, 727, 737 ; Airbus A 300, A 310 Airbus A 320 qualification delivered March 11th 1988 8 . :em ark : the A 320 course followed by Michel Asseline was performed in accordance with a special program for the nbers on the pilot s executive staff within Air France participating in placing the A 320 into in-service operation . The proposed program, personalized to suit the role of eac h person within the management team, was considered acceptable b y the ad mi nistration provided that flight training was added, an d this was in fact performed . The assessment sheets show a very satisfactory level . Experience : Total flight hours : 10,463 (end of May) on A 320 : 138 hours Aeronautical career : 1962 : Admitted by competitive examination to the National Civil Aviation School (ENAC ) Theoretical and practical training from autumn 1962 to 196 6 June 1966 to February 1967 : trainee at Air France March 1967 : engaged by Air France as copilot on Caravelle S E 210 . May 1968 to August 1969 : military service in the air force , final ranking second lieutenant (reserve lieutenant ) September 1969 : returned to Air France as copilot on Caravelle then on Boeing 707 May 1979 : named as Captain on Caravelle then airline instructor on Caravelle then on Boeing 727 . December 1982 : promoted to managerial level during the putting into service of the Boeing 737 piloted by two crew members From January 1985 to November 1987 : Airbus A 300 and A 31 0 qualifications Promoted to a higher level with : Responsibility for the preparation of the choices regarding flight simulators (B 737 and A 320 project) ; to this end, fle w approximately 150 hours on the A 320 simulator at Aeroformation and Thorson . 9 . Technical missions related to training of pilots (computer- assisted teaching, company policy related to training) . Deer 1987 : promoted to Head of A 320 training subdivisio n with responsibility for : - development of type qualification, participation in the establishment of the aircraft utilization method and training (in cooperation with the manufacturer) of th e first crews , - airline aircraft acceptance flights (including F-GFKC) . Flying activities in the last 48 hauls before the accident : ferrying of F-GFKC on Friday horning June 24th then flight a s observer on an Airbus Industrie A 320 to supervise the training given to Air France trainees . Previous air accidents : none . 1 .5 .2 . First Officer Pierre MAZIERES, born January 12th 1943 in Castelnaudary (11 ) Certificates and Licences : Airline pilot s licence obtained on August 28th 196 9 Licence valid till September 30th 1988 Last Tires check-up March 14th 1988 with Air France CEMPN . Qualifications : Airline pilot instructor s qualification obtained in 1982 . Type qualification : Caravelle SE210 ; Boeing 707, 73 7 A 320 qualification obtained March 29th 1988 . Remark : A 320 course performed in accordance with the standard Aerofomnation program approved by the DCAC ; the resulting assessment sheets showed a very satisfactory level . Experience : Total flight hours : 10,853 (end of May 1988 ) on A 320 : 44 hours . 10 . Aeronautical career : 1962 : Admitted by competitive examination to the National Civil Aviation School (same year as Michel Asseline) . Theoretical and practical training at HNC from autumn 1962 t o 1968 . Training delayed in carparison with Michel Asseline following a car accident . December 1969 : engaged as copilot by Air France . 1972 : copilot on Boeing 707 . July 1980 : Promoted to Captain on Boeing 727 . Dec rber 1982 : Promoted to instructor on Boeing 727 then Boeing 737 in March 1983 . January 1986 : Promoted to managerial level on Boeing 737 . March 25th 1988 : Pramted to a higher position to participate in the placing into service of the A 320 . Flying activities in the last 48 hours before the accident : none . * Previous air accidents : noon. 1 .5.3 Cabinattendants Jean Claude BARCE IQJ, born May 15th 1948 was performing the purser s functions and was on the seat located beside the lef t forward door. Safety-rescue certificate No. 5861 obtained on June 23rd 1972 . Last medical check-up : June 15th 1988 . A 320 specialization certificate : April 14th 1988 . Zbtal flight hours : 8969 hours On A 320 : 11h 23 . Last flight on A 320 : June 25th 1988 . 11 . Chantalde CHALCNGE, born March 9th 1951, occupied, in the cabin, seat 12 R level with the wing emergenCY exit . Safety-rescue certificate No . 6741 obtained on July 16th 1973 . Last medical check-up : September 10th 1987 . A 320 specialization certificate : April 14th 1988 . Dotal flight hours : 6784 On A 320 : 21h 50 Last flight : June 25th 1988 on Boeing 72 7 June 23th 1988 on A 320 . Previous events : wes cabin attendant on the A 300 highjacked at Brindisi . MurielDAGER, born June 3rd 1957, occupied a crew seat on the left in the aft galley . Safety-rescue certificate No . 9648 obtained on May 16th 1972 . Last medical check-up : September 11th 1987 . A 320 specialization certificate : April 15th 1988 . 1bta1 flight hours : 3022 On A 320 : 22h 50 Last flight A 320 : June 25th 1988 . Brurn PICHJT, born February 23rd 1951, occupied the seat on th e right level with the aft galley. Safety-rescue certificate No . 7085 obtained September 20t h 1973 . Last medical check-up : January 7th 1988 . A 320 specialization certificate : April 28th 1988 . Total flight hours : 8223 Ca A 320 : 20h 20 Last flight on A 320 : June 24th 1988 . Previous accidents : Was cabin attendant during the evacuation of damaged Boeing 74 7 at Bombay (India) in 1975 ; the aircraft was totally destroyed by fire during this accident. 12 . 1 .6 -AIRCRAFT INFORMATION Owner and Operator : Owner : DURUS VERWALTUNGSGESELLSCENET MBH Co MJBILIEN K G Operator : AIR FRANCE - Airframe : . Manufacturer : AIRBUS IN1 JSTRIE . Type : AIRBUS A 320-10 0 . MSN : 009 This aircraft obtained Airworthiness Certificate No . 109 099 and noise certificate No. 109 099 on June 22nd 1988 . It was delivered on June 24th 1988 . . total flight hours : 22h 30 . number of operating cycles : 18 - Engines . Manufacturer : CFM International - engine manufactured i n cooperation by General Electric (USA) and SN CAA (France ) . Type CFMI 56-5A1 engine No. 1 (left) : Serial No . 731 122 engine No . 2 (right) : Serial No . 731 120 . delivered to Airbus Industrie on October 6th 1987 . operating hours : S/N 731122 : 27h 20 S/N 731120 : 33h 45 . - Information given on engineering reports Due to the recent delivery date, the remarks made by the crews ar e limited. Ihe significant reports are as follows : - June 25th and 26th 1988, it was reported that the flight managemen t and guidance computer (FM3C) No. 2 did not have the same data bas e as caputer No. 1 , - June 26th 1988, altimeter setting changed to a new incorrect value during a DEL (display management computer) transfer . - June 25th 1988, occurrences of a warnir . related to a nr whee l steering valve (this warning can be heard in the CVR bF re the GEMS (2) "too low, terrain" message) . (1)under a leasing contract with Air Franc e (2)GPM : Ground Proximity ,urning System (warning system o f proximity to ground, based on radio-altitude) . 13 . These anomalies had not been corrected before June 26th 1988 . After an in-depth study, the Commission concluded that none of these had played a role in the accident (note that the second anomaly did no t recur) . Weight and balance These were 6 crew mernbers and 130 passengers, 2 of the passengers (air hostesses) being in the cockpit, for a total number of 15 3 passenger seats available in the cabin . The seats had not been attributed because it was a charter flight ; consequently, the Commission could not determine with exactitude the position of each passenger in the cabin . The weight and balance on take-off calculated after the acciden t were : - weight : 59,635 kg - CG : 30 .7 % The weight and CG calculated before the flight were marked in the logbook as being : - weight : 59,040 kg - CG : 25 .8 % This difference is due to several consecutive errors : - At Paris-Charles de Gaulle, on the balance chart, 3 cabi n attendants were given instead of 4, leading to an error in weight (- 80 kg) and index (-1) . - Then, in Mulhouse, the list of passengers, completed by a last minute change, mentioned only 126 passengers (respectively 110 and 16) instead of 130, i .e. an error of 300 kg . The aircraft tool kit, weighing 215 kg, and located in the cargo compartment, had been forgotten . In the balance calculation, a scale error had been made in reading the graph used to determine the influence of the weight of the passengers . This last error was in part campen.sated for by those made in weight and mentioned above and by the fact that the last minute change had not led to a correction of the CG . 14 . 1 .7 - METEORCOLOGICAL I RNATION 1 .7 .1 - General situation At high altitude, there was a depression above Germany giving a weak north-easterly to northerly flaw on its western side . In the lower levels of the atmosphere, there was a wea k gradient area with, over the Alsacian plain, sky covered by 6 to 8/8 stratocumulus plus locally 1 to 3/8 cunulus and a northerly wind of 5 to 10 kt. 1 .7 .2 - Conditions over flightarea The meteorological center of Basle-Mulhouse, 10 nautical miles from the accident, observed the following conditions : - at 12h20 : Wind : 010 0 /6 kt Visibility : 8 km Cloud : 1/8 Cu at 780 m and 7/8 Sc at 1500 m Temperature : 20°C Dew point : 13°C QtH : 1013 hPa I73SIG - at 12h50 : Wind : 330 0 /6 kt Visibility : 8 km Cloud : 1/8 Cu at 780 m and 7/8 Sc at 1500 m Temperature : 21°C Dew point : 14°C Q[H : 1014 hPa At 12h 41, the Mulhouse-Habsheim controller transmitted the reference pressure by radio to the A 320 pilot before the flyover was made : -QNH : 1012 hPa - QFE : 984 hPa After the accident, the controller reported to the investigators that wind speed was lower than 5 kt . The study of the video tape on which the complete flyover o f the A 320 was recorded, from 160° to 340° in a westward sense , showed that the sky was covered : the stratoctmulus layer wa s sufficiently thin for the resulting luminosity to cast a very clear shadow of the aircraft during the lowest part of thi s overflight. 15 . 1 .8 - AIDS TO NAVIGATION Because visual landmarks were used for the flight between the Basle - Hillhouse and the Mulhouse-Habsheim aerodromes and because of th e absence of radioelectrical facilities at Habsheim, the navigation aids played no part in the accident . 1 .9 - MrJNIGATIONS The transcriptions of the radio cats unications between the aircraft , ground control and the Basle-Mulhouse control tower, then th e Mulhouse-Habsheim control tower, were made and are given in th e appendix. Before take-off from Basle-Mulhouse, the First Officer requested a n altitude of 1000 feet agl for the transit to Mullaase-Habsheim wher e the two flyovers were to be made . At the sane time, he also requested control clearance for th e remainder of the flight to Hericourt . After reception of the 2000 feet QNH transfer flight clearance, h e specified that he would make a first low-altitude flight headin g North then a second one heading South . Then, in contact with the Habsheim tower, he specified "we are caning into view" and "going in for the low-altitude, low speed flyover" . The controller then gave the QNH and the QFE . The First Officer acknowledged reception at 12h 44 non 31s, and thi s was the last radio transmission . 16 . 1 .10 - AERODROME INFORMATION The accident occurred at the northern limit of the Mulhouse-Habshei m aerodrome . The aerodrome is located 10 nautical miles north-north- west of the Basle-Mulhouse airport . The Mulhouse-Habsheim aerodrome (see aerodrome chart in the appendix ) has two sets of two parallel runways, none of which is capable o f receiving an A 320 mainly due to the runway strength : - one, oriented north-east/south-west (02 4° -204°) has a 1000 m by 20 m hard runway and a grass strip , - the other, oriented north-north-west/south-south-east (164° - 344°) comprises two grass strips without clearance to the north-north-west, because they are immediately bordered by a forest of oak and birch . It was runway 34 R, one of these two grass runways, 640 m long, which was acting as the base for the show, the visitors being massed to the west of thes e strips, along the front of the hangars . The aerodrome which is located 6 }an to the east of the city o f Mulhouse (coordinates : lat . 47 .44 .17 N - Long . 07 .25 .58 E), is bordered on the west by a motorway, a high voltage transmission lin e and a railway line, on the north and the east by the forest . It stands out clearly from its surroundings . Its reference altitude is 240 m (787 feet) which corresponds to a difference in standard pressure of 28 hPa, with respect to sea level . The thresholds of strips 16-34 which served as the A 32 0 demonstration axis are at an altitude of 239 m for threshold 34 an d 238 m for threshold 16 . The Hardt forest starts immediately after the road which borders the end of runway 34 . The distance between the end of runway 34 R and the forest is 60 m and the average height of the trees is 12 m. The aerodrome has a 12 m-high control tower located in the angl e formed by the two sets of two runways . It was operating on the day o f the accident and its equipment was in good working order . Its orthogonal projection on axis 16-34 is located 250 m from the end o f runway 34 . The Habsheim control tower barometers were checked by the National Meteorological service and showed no malfunction of the instruments , the difference with respect to the reference barometer being lowe r than 0 .5 hPa, within the tolerances for this type of instrument . 17 . 1 .11 - FLIGHT RECORDERS In ccmpliance with the regulations in force, the A 320 F-GFKC wa s equipped with a cockpit voice recorder (CVR) and a digital flight data recorder (DFDR) . These two recorders, made by Fairchild, were found in the wreckage of the aircraft on their mounts located in th e aft section of the fuselage, and were transferred to Paris in th e evening of June 26th for read-out . 1 .11 .1 - Read-out of recorders 1 .11 .1 .1 - C .V.R. (Fairchild A100 ) The C .V.R was opened and the first reading of the tape made during the night from the 26th to 27th June on the facilities of the French Accident Investigation Bureau (BEA) . The transcription was then made with assistance from th e pilots . Tb obtain an accurate chronology, the tape feed speed wa s initially set using the 400 Hz frequency of the on-board electrical power supply which appeared in the recorde d spectrum. Then, the recordings of the radio transmissions were correlated with those of the air traffic control frequencies (the latter included a time track) . The part of the recording corresponding to the end of th e flight (fram the descent through 200 feet agl) was studied b y spectral analysis : the continuous recording of frequencies has permitted a very accurate chronology of the end of the fligh t to be obtained with an error of less than 0 .1 of a second, in using events with precise time and frequency signatures (synthetic voice of the radio-altimeter, characteristic noises , voices, etc .) . The spectral analysis also permitted the engine speeds to be determined, their characteristic frequencies being recorde d on the CVR via the cockpit microphones . It also enabled correlation to be made with a video tape of the accident, the sound track of which was submitted to the same type o f analysis . 1 .11 .1 .2 - DFDR (Fairchild F 800 ) The DFDR was read out by the Br6tigny sur Orge Flight Test Center (CEV) during the night from the 26th to the 27th o f June by designated persons from this establishment . 18 . The normal validation work made by the BEA on the first listing supplied by CEV revealed that, in spite of the care taken during reading, certain data had been misread. The anomalies observed concerned : - incorrect reading of the information during a period of 8 seconds (starting 17 seconds before the end of the recording and 10 before the engine throttle levers were placed in the go-aroun d position) 4 seconds of which had been rejected by the reader checkin g program and therefore were not printed , - certain errors in the A 320 parameter reproduction softwar e used by the CEV (inversion of the sign for the positions of the righ t and left ailerons for example) . The initially incorrect reproduction of the data was no doub t due to an interruption of contact between the reading head and th e recorded tape, caused by a fold in the tape and/or by dust . The following readings, made after cleaning and smoothing out of the tape, permitted correct reproduction of all data . A bit by bit analysis of the recording for the last part of the flight confirmed the validity of the data obtained . The parameter reproduction software errors (signs, constant values, etc .) were easily corrected . 1 .11 .2 - Operation of recorders The operation of the recorders was perfectly correct throughout th e whole flight itself, i .e. until first impact with the trees . As concerns the CVR, the conversations and aural warnings wer e correctly recorded as well as all the noises in the cockpit . As concerns the DFDR, all parameters were oorre 21y recorded . lastly, the consistency of th data obtained from the reading out o f the CVR and the DPDR and ce .ain outside meedia (photographs, video tapes, etc .) can be describer. as excellent . 19 . After the first impact with the trees, the CVR continued to operat e for around 1 .5 seconds and then stopped . The DFDR continued to operate for around one second then gave incoherent data for aroun d two seconds . This is followed by the data of a previous flight . The exact moment when the aircraft came to rest cannot be accuratel y specified . The only cause that can explain this almost simultaneou s shutdown of the two recorders is the breaking under tension of thei r paver supply cables located in the rear section of the fuselage . The inspection of the tail cone where the recorders are installed showe d that the break of the power supply cables could not have occurred i n this section of the aircraft which suffered little damage ; it is probable that the break occurred forward of this area, doubtless i n the landing gear well, which is the most exposed area for the bundl e of wires considered . However, this assumption could not be checke d due to the condition of the wreckage . The other causes liable to result in shutdown of these recorders were studied, the most probable being simultaneous cut off of the electrical p er supply to the two recorders either by shedding or by ejection from their mounts . These assumptions could not be retained in this case as : - The busbars of each of the recorders can not be simultaneously shed when the AC generators operate correctly, as was the case judging b y the engine speeds at the time when the recorders stopped, a s determined by the spectral analysis of the video recording sound track, - The recorders were found on their mounts . 1 .11 .3 - Read-out of the conversations and the aural warnings (CVR) : The transcription of the CVR recordings is given in the appendix ; it starts with the start-up of the engines at Basle-Mulhouse and stops at the end of the recording (shortly after the first impacts with the trees) . The start of the recording, of a total length of 30mn , concerns the arrival of the previous flight from Paris-Charles de Gaulle . The CVR recording is very easy to follow especially because the cre w were working with headsets . 20 . The following points can be noted concerning the flight sequence : - On start of taxiing at 12h 29, the First Officer requested th e Captain to confirm the items planned for the ovE:flights at Habsheim. The Captain indicated that he would make the first demonstration in Flap configuration 3, landing gear extended, at 100 feet, with maximum angle of attack, alpha floor function (1) disengaged, First Officer adjusting thrust to maintain flight-level ; when requested by the Captain, the First Officer was to select maximum engine power , whilst the Captain carried out a climbing turn . The second overflight was the% scheduled, also at 100 feet, with the First Officer at th e controls, in clean configuration and at high speed (340 knots) . - The Captain then outlined the programme to the Purser and the Firs t Officer specified that it would be best to remain seated during the demonstration (passengers and crew strapped in) . - Take-off was made at 12h 41, the autothrottle was disengaged a s soon as the landing gear had been retracted and flaps placed i n position 1 . - Radio contact was established with the Habsheim tower at 12h 44 an d F- KC was cleared to make its overflight . During the descent, the crew selected the altimeter setting for Habsheim (QFE 984 hPa), then extended the landing gear and the flaps (position 2 then 3) . - The radio altimeter called 200 feet, then 100 feet at the exact moment when the First Officer told the Captain that the aircraft ha d reached this height. - The radio altimeter continued to announce the heights (40 then 50 then 40 feet) . Between 50 and 40 feet, the Captain confirmed th e disengagement of the autothrottle . The First Officer drew the Captain s attention to the presence of pylons ahead . - Full application of power (throttle-levers forward) was made by th e Captain immediately before the radio altimeter announced 30 feet three tines consecutively . Next, the increase in engine speed can be clearly heard before the raise of the impacts with the trees which progressively covers tha t of the engines . 1 .11 .4 - Read-out of the parameters recorded on the DFDR (se e appendix ) The number of parameters (200) recorded on the A 320 - 141 of which are discrete (yes/no) - and the quality of the recording permitte d the flight sequence to be reconstructed with high accuracy up to th e moment of impact with the trees . (1) see paragraph 1 .16 .1 .2 21 . Take-off was made at 12h 41, heading 15 50 , and the aircraft left the ground at an IAS of 153kt . Turn was started in the second tha t followed. Four seconds later, roll control passed through a maximum and at this time the radio altimeter indicated 76 feet . The bank angle was then stabilized at 34° approx. The right turn was held for one minute until heading 010 was reached, at the end of the turn th e aircraft entered level flight at 1900 feet QH (approximately 900 to 1000 feet above the ground) at a speed of 200 kt. Progressively, the heading changed to the left to 335°/340° . At 12h 43nn 44s, the aircraft, which had reached 2000 feet QNH (1) started its descent . Descent rate was initially low, 300 feet per minute . At 12h 44mn 14s , the engines were set to idle, the speed, which was 200kt at this time, slowed by approximately lkt per second . Three seconds later , larding gear extension was commanded and a further ten second s later, the flaps, which had remained in position 1, extended t o position 2 . At 12h 44mn 45s, the flaps were extended to position 3 , the aircraft descerxied through 500 feet with a speed of 177kt, mean heading still 334, which was maintained until 90 feet in the descent to Habsheim. At 12h 45ím 06s, aircraft speed was 155kt, as it passed the radio- altimeter height of 200 feet . The barometric altitude decreased continuously, the radio-altimeter height oscillated around 200 fee t between 12h 45mn 06s and 12h 45mn 09s (the terrain over which the aircraft was flying was not flat) . Between 12h 45mn 15s and 12h 45mn 23s, the aircraft made a gentle right turn to line up with runway 34 R, maximum bank angle reached was 13° and heading coming out of the turn was 344° . The speed dropped from 149 to 141kt and the height decreased from 90 to 46 feet . A fluctuation in the radio altimeter height can be seen during this alignment manoeuvre (32 feet at 12h 45mn 18s and 24 feet at 12 h 45mn 19s) corresponding to flight over a clump of trees located i n fiunL of the runway . Before and after this fluctuation, there is perfect agreement between the readings of the radio altimeter an d those of the bararetric altimeter . At 12h 45mn 26s, the aircraft reached 40 feet, still descending , speed was 132kt, still falling, the engines were still at idle (29% of Ni) . At this time, the pilot started a flare to level off close to the ground, the side stick pitch noveients being of low amplitude (o n average, 4° rose up) . lbe lowest points in the flight path were around 30 feet in height : between 12h 45nß 32s and 12h 45mn 39s, the radio altimeter indicated 32, 32, 32, 32, 30, 30, 24 and 34 feet (one value per second) . During this level flight : - The side stick, previously at 4° rose up until 12h 45mn 30s, was brought to and held at 6/7° nose up until 12h 45mn 36s . (1) lbe Q NH altitude readings are the result of a calculation . The one recorded on the DFDR corresponding to altitude pressures set a t 1013.2 hPa. 22 . - The throttle levers were placed in the TOGA (take-off/Go-around) detent ketween 12h 45m1 34s and 12h 45mn 35s . At 12h 45mn 34s speed was 122kt and angle of attack 13 0 . At 12h 45mn 35s, the fuel-flow of engine 1 (recorded at the end of each second on the DFDR) had already increased (from 406 to 682kg/h), its speed N2 had varied from 71 to 72% . The increase in power on the two engines was uniform and at 12 h 45mn 39s the Ni speeds were respectively 83 and 84 % . - From 12h 45mn 35s, the angle of attack reached values of 14 an d 15° . - At 12h 45mn 37s, the stick was set nose-up to 13° then to ful l nose-up in the two seconds which followed . Between 12h 45mn 39s and 12h 45mn 40s, the aircraft touched th e trees ; as shown by a decrease in longitudinal acceleration . After 12h 45mn 40$, the data recorded on the DFDR is incoherent for approximately two seconds, and this followed by the data relevant t o the flight preceding the one in which the accident occurred (closed loop operation of the flight data recorder) . To sum up, the flight was completely reconstructed up to impact wit h the trees . No particular comments need to be made on the initial flight phase . The final flight phase can be summarised as follows , taking "t" as the time reference 12h 45mn 39s : . t-25 sec Aircraft passes 100 feet in descent at a speed of 151kt . t-17 sec Aircraft passes 50 feet at a speed of 141kt . t-13 sec Aircraft passes 40 feet at a speed of 132kt reaches 32 feet at a speed of 123 kt ▪ t-7 sec Aircraft t-6 sec Aircraft is still at 32 feet at a speed of 122kt , • the throttles are still in idle position . t-4 sec The throttles have been brought to the TOGA detent, the Ni and the fuel flow rates start to increase . t-1 sec The stick is in full nose-up position, speed i s 112kt, engine Nls are 67 % . t sec Stick is still in full nose-up position, speed i s 114kt, engine Nis are 83 % and 84 % . . t + 1 sec The aircraft has already touched the trees The work conducted by the Cotmission to verify that the aircraft response to the =wands given by the crew, through the flight and engine controls, showed no ananalies, and is covered by paragrap h 1 .16 below. 23 . 1 .12 - WRECKAGE (see sketch in appendix ) 1 .12 .1 - Flight path A forest of young oak and birch of an average height of 12m an d a base diameter of 20 to 30 can is located at approximately 60 meters from the end of runway 34 R . The A 320 hit the top of these trees at the edge of the fores t with the rear section of the fuselage and the horizonta l stabilizer . Due to the engine thrust, the trees are broken i n the opposite direction to that of the aircraft s movement . The aircraft touched the trees in line with the runwa y centreline. Its path in the forest was practically straight and always in line with the runway centreline . The wreckage itself was located on the extension of this centreline. Fifty meters beyond the edge of the forest, the marks left by the landing gear and the engines can be seen in the tops of the trees . Further on still, the wing leading edges cut off the tops of the trees at lower and lower levels as the aircraft sank into the forest . Judging by the way the tops of the trees were cut off, the aircraft was banked in flight slightly to the right. The evacuation of the various elements of the wreckage (especially for the investigation) required that these trees b e felled. The heights of fracture were measured and plotted on a dimensioned drawing . This enabled an accurate path of the entry of the aircraft into the trees to be plotted . 1 .12 .2 - Wreckage The wreckage was grouped together . Its rear end was found 270 m fran the road which separates the runway from the forest . Upstream, the first large pieces of wreckage were found 230 m from the road : the tip of the right wing with a portion o f aileron and, slightly further away, a portion of slat . On approaching the wreckage, several pieces of flight control surface (slats and flaps, ailerons), and of empennage, cowlings and engine accessories were found together with small pieces o f skin. The main part of the wreckage was surrounded by a jumble of torn and broken trees . The aircraft was largely destroyed b y the fire which followed the accident : the fuselage was caipletely burnt out, except for the empennage and the zone located aft of the pressurized bulkhead where the recorders were found intact . 24 . The right wing, broken into several portions, was also destroyed by the fire . The right engine, torn from its pylon, lay slightly to the rea r of the wing, with the air intake facing towards the tail of th e aircraft . The air intake sound-proofing panels were wrappe d around the fan vanes which suffered practically no damage fro m the accident. The position of the variable stator vanes (VSV) corresponded t o a low engine speed . The low pressure ccanpressor bleed valve s (VBV) that were visible were damaged . The left wing was complete and remained attached to th e fuselage . The leading edge had been crushed in by the trunks of the trees and many branches had stuck there . On the left engine, the position of the VSVs also corresponded to a low engine speed, the visible VBVs were also damaged . The expert investigation of the engines described in paragraph 1 .16 permitted these points to be more accurately defined. Slightly forward and to the right of the aircraft, many trees were burnt indicating that burning fuel was projected forward s from the right wing . The examination of the trim screw showed that the trimnabl e horizontal stabilizer (TSS) was set to approximately 4 .5° which is consistent with the DFDR indications (last recorded valu e was 4 .4°) . 1 .13 - MEDICAL ANDPAO-OLOGICALINFORMATION 1 .13 .1 - Pilot s a - Study of medical files The examination of the medical files of the Crew Medica l Examination Centres (CEMPN) revealed no medical evidence whic h could have influenced the accident . The two pilots had successfully passed their routine radical check-ups every six months since 1962 . 25 . b - Injuries caused by the accident Michel ASSELINE - Various bruises with no signs of bone fracture visible on the X - rays . Bruising of the collarbone (shoulder harness in place) , - Inhalation of smoke and emotional shock , - Kept in hospital one day at Mulhouse , - Absence fran work fran June 26th 1988 to end of November 1988 . Pierre MAZIERES - Injuries to the head, without true loss of consciousness, bu t with clouding of vision, with no signs of bone fracture visibl e on the X-rays - Forehead wound (stitched in hospital ) - Bruising of both collarbones (shoulder harness in place) , - Kept in hospital for one day at Mulhouse , - Returned to hospital for 10 days in August 1988 , - Absence from work from June 26th 1988 to end of November 1988 . c - Timetable before the accident MichelASSELINE The day before the accident, the Captain made training flights on the A 320 with three trainees . He went home around 17h00 U1C (19h00 local tine) and spent a renal night and slept well . On June 26th 1988, he had breakfast around 4h00 (6h00 local) before leaving for Roissy-Charles de Gaulle, where he arrived around 6h1 5 (8h15 local) for the briefing and flight preparation . During a reception with the Authorities and the reporters at Basle-Mulhous e airport, before the demonstration flight, he drank a fruit juice an d ate nothing . PierreMAZIERES The day before the accident, he led a normal life in Paris spent a good night and slept well . On June 26th 1988 on the day of the accident, he got up around 3h0 0 (5h00 local) and had a full breakfast at home . He arrived at Roissy- Charles de Gaulle around 5h30 (7h30 local) then prepared his fligh t following another light breakfast . During the Basle-Nulhause reception, he drank a fruit juice and ate a piece of cake. 26 . d - Alcohol measurement An alcohol level measurement was made on the two pilots by th e Police by means of a breathalyser. As the tests were negative , blood sample alcohol measurements were not performed . 1 .13 .2 - Cabin attendants The 4 cabin attendants suffered from various bruises, withou t bone injuries, and psychological traumas justifying grounding. 1 .13 .3 - Passengers ▪ 110 persons passed through the screening centre and the hospitals (Basle included) . Amongst these passengers, 76 wer e allowed to go tome and 34 were hospitalized . . 12 days after the accident, 8 passengers were still i n hospital . . 42 persons were given leave from work or granted certificate s of temporary inability to work for 7 days or more . . 41 persons suffered from facial or cerebral cranial traumatism with face injuries, broken noses, nose bleeding . These injuries were caused by impact with the seat located in front of the passenger during the accident . . Other injuries and pathological facts included the following : - 2 broken upper arms - 1 broken thigh-bone - 6 bruised rib cages and broken ribs - 2 dislocated shoulder: - 2 fractures of the spTee by compression - 8 cases of immediate t .i marked emotional shocks . . The traumatic injuries were, for the most part, caused by the evacuation (escapes slides c:;maged by the trees or badly deployed because of obstacles, rapid evacuation, with the passengers pilling on top of each other, and violent contact with the ground) . The three deaths were not caused by acceleration effects durin g impacts but by the fire which also caused burns on four other passengers (one of than suffered 23% burns) . 27 . 1 .14 - FIRE 1 .14 .1 - Development of the fire During the inpacts with the trees, the right wing was torn off , the fuel was projected forwards by inertia and immediately ignited causing a very violent fire, from the moment when th e aircraft stopped, to the right and forward of the fuselage . Passengers (see paragraph 1 .15) also report that fire broke out on the left of the fuselage, level with the wings, an d penetrated into the left section of the cabin through th e broken windows at the level of rows 8 and 9, and in the right section through the holes in the floor between rows 10 and 15 . The fire spread throughout the cabin . Later on, fuel flowed out of the left wing and fed the fire i n the fuselage . Only the left wing and the tail of the aircraft (where the flight recorders were located) were not destroyed by the fire , mainly due to the intervention of the fireman . 1 .14 .2 - Fire fighting Six firemen and 2 vehicles were standing by at the Basle - ),l se aerodrome to cover the airshow . They drove immediately to the place of the accident to fight the fire . The alert wns given immediately and, 10 minutes later, the first group of 8 fire fighting vehicles from Saint Louis , Ottmarsheim, Mann, Altkizch and Colmar arrived at the accident site . Note that only small vehicles were able to reach the wreckage , the other vehicles were blocked by the trees and this considerably hindered the fire fighting . 28 . 1 .15 - SURVIVAL ASPECTS - EVACUATION 1 .15 .1 - Evacuation sequence (1 ) Before the Paris-Charles de Gaulle/BasleMUlhouse flight, the cabi n attendants made the terminal turnaround inspection without detectin g defects other than a broken mirror in the aft galley . This mirror permits the cabin attendant to observe the cabin from his seat . During the Basle-Mulhouse line stop, a tetraplegic boy was installe d in seat 4D (aisle), reserved for handicapped persons, then, fo r cam ercial reasons on the request of his family, in seat 4F (window) . After the take-off, the signs asking the passe ngers and the cabin attendants to keep their seat belts attached were illuminated a s planned. During the impacts with the trees and the ground, most of th e passengers hit their heads on the seat in front of them causing man y facial injuries and dizziness . At the aft galley, obje- `s fell onto the cabin attendants . Before the aircraft cane to rest, all the lights went out ; it seem; that the emergency lighting, apart from the exit signs, did not cam e on . Also, breakages gust have occurred in the laser right section of the fuselage forward of the wing because, as soon as the aircraft came to rest, passengers saw flames and smoke caning out of the floor on the right-hand side fuselage hetween rows 10 and 15 . Several seconds at nr after the aircraft came to rest, the fir e entered the cabin thr- h the broken windows on the left side at th e level of rows 8 and 9 . Also, several passengers reported short circuits with sparks around the forward galley and smoke coming from this area . As soon as the aircraft cane to rest, the stewards stationed at the forward and aft doors, seeing the fire on the right of the aircraft , opened the left doors . lbe Captain declared that he made seve attempts to trigger th e evacuation signal ; but it seems that t. .s signal did not work as rxabody in the cabin heard it . (1) This sequence of events is essentially based on reports made b y the cabin attendants and passengers . 29 . A passenger stated that he had wanted to open the left wing c .ergency exit but could not reach it . The commission observed that the opening of this exit, without prior check, would have been very dangerous a s fire was raging around the left wing level . The left forward door was blocked by branches after it had started to open correctly. The escape slide started to deploy partly outside an d partly inside the cabin . The purser, with the help of at least one passenger and an ai r hostess from another airline (who was in the cockpit as a passenger during the flight), pushed the door . The door opened suddenly and th e purser and the passenger fell out of the aircraft and were covered b y the escape slide . The passengers started to panic and push in the front part of th e cabin . The passenger hostess mentioned previously then started to evacuat e the passengers, but the first ones were blocked by branches in the escape slide . The other passengers junped out beside the escape slide but they very quickly piled up on top of each other again due to th e branches . The hostess then stopped evacuation for a short while s o that the passengers who had already junped had tine to extricat e themselves . She thinks that she was helped by another perso n (unidentified) . Meanwhile, on the outside, the purser with the help of another ai r hostess, also passenger in the cockpit and who was no doubt lef t during the pushing, tore away the branches from across the escape slide to free the blocked passengers . After a certain time, the first passenger hostess herself left the aircraft suffering from the effects of the smoke . The hostess stationed in the center of the aircraft at 12D was pushe d into the aisle by the passenger in 12F who was seriously burnt, the n was carried forwards whilst at the same time helping a passenge r whose clothes were on fire . She arrived at the left forward door (1G), no doubt after the evacuation of the previous hostess, and took her place . After the evacuation of the last persons to arrive at this door, she called into the cabin to find out if anyone was still there but did not ge t any reply ; by this time, the smoke, very thick, and flames made any visual inspection impossible . 30 . On the order of the Captain, who had just evacuated the injured Firs t Officer, she then left the aircraft . The Captain then returned to the cockpit to get an anti- spoke mask with the intention of going through the cabin, but in turn had t o leave, before he could don the equipment, suffering from the effect s of the fumes . Note that the cabin attendants either were not able to use the anti - smoke masks during the evacuation or did not think of doing so . They were, in fact, more occupied in opening the doors as quickly a s possible so as to speed up passenger evacuation . The left aft door was opened without any problems and the escape slide was correctly deployed . The steward ordered the passengers t o cane towards him to evacuate and at the same time reassured the m verbally . This, combined with the absence of smoke at the rear of th e cabin, certainly contributed towards the good evacuation via thi s door . After several passengers had used the escape slide it was punctured on the branches . The steward asked his colleague to descend to hel p to receive the passengers . Evacuation continued without panic with spontaneous help from one passenger, especially for the evacuation of an elderly person who ha d difficulty in moving. After the last passengers had left the aircraft, the hostess returne d to go through the cabin but the flames and smoke had reached th e galley ; she was only able to shout out in the direction of the cabin. During the evacuation, the stewards and hostesses could not see wha t was happening at the other end of the aircraft due to the fire aroun d the left wing. Therefore, after the end of evacuation via their door , they went round the wing towards the front or the rear to see if they could be of any help at the other door . It has not been possible to determine the time it took to evacuat e the survivors . 31 . All passengers were able to leave the aircraft, except three : - the young handicapped boy in seat 4F who seams to have remained in his seat ; - a little girl located at 8C who, according to her youn g brother (carried away by the flow of the other passengers) , had not been able to open her seat belt and was blocked by the back of her seat which wes tilted over onto her ; - a wanan travelling in seat 10B, who according to her husband , had reached the left forward or ; as her body was found near to that of the little girl, we can reasonably assume that she went back into the cabin to help the little girl an d was overcame by the fumes . It appears that some of the safety equipment proved to be deficient or inoperative : . As we have seen above, before the aircraft came to rest, the normal lighting went off and the emergency lighting did not came on, due to a design error in its automatic illumination pia, . There was no evacuation signal in spite of several attempt s made by the Captain ; this fault is doubtless related to the other observed electrical problems , . Wei the aircraft cane to rest, the purser wished to broadcast a message via the public address but could not find the handset which, apparently, had been torn from its support, maybe due to the fragility of this support and o f the attachment of the electrical lead . One doctor, one aambulance and 10 first-aid workers were present at the aerodrome for the air show. As soon as the accident occurred , they alerted both the fire brigade and the hospital emergenc y services (the various services had been informed of the air show an d had emergency services ready in accordance with the usual arrangements for this type of meeting) . They arrived on the scene o f the accident and participated in the first examination of the injured and gave first aid while awaiting reinforcements from Mulhouse . The setting-up, 25 minutes after the accident, of an ambulance evacuation circuit and the organization of the examination centre were performe d under the guidance of the fire brigade doctor. On the whole, the hospitalization wes achieved without great difficulty, due to th e minor character of the injuries, the small hunter of persons injured, the geographical location of the accident, near to a large town, th e good cooperation between the medical emergency teams and the goo d operation of the hospital emergeny plan. 32 . Also, around twenty passer . iers stated that they got home or went to the hospital by thumbing a lift on the nearby road without passing via the emergency station . Because of this, they were initiall y reported missing, which complicated the task of the rescuers . 1 .15 .2 - Investiqation a) Definition of the questionnair e Due to the conditions of the accident (snake, workload, etc .) , the cabin attendants could not give in their evidence a complete and exact description of the evacuation procedure . Consequently, the Investigation Cottmission decided to send a questionnaire to each passenger with the aim of clarifying th e following points : 1) the conditions relevant to the opening of the left forward door, 2) the entry of stroke and fire into the cabin (as it had onl y been established that smoke had very quickly entered the cabin and that the hair of one woman passenger in row 12 had caught fire) , 3) the injuries sustained during the impacts with the trees and the ground, then during evacuation , 4) the position of each passenger in the cabin and th e emergency exit through which he left the aircraft , 5) and more generally, the evacuation procedure from the point of view of the passengers and their impressions . The Commission decided to avoid all technical terms and to use , as far as possible, multiple choice questions ; this also facilitated the processing of the replies . Also, at the end of the form, a general and narrative questio n permitted the passengers to give all their opinions . A plan of the cabin was appended to help the passengers make their replies. b) Results Of the 127 questionnaires sent to the surviving passengers, the Investigation Catmission received 99 replies (78%) for the most part very accurate and well thought out . The replies to questions 1, 2 and 5 were largely covered in th e previous section, 1 .15 .1 . 33. The replies to question 3 are covered by paragraph 1 .13 . Concerning the 4th question, it appears that the passengers correctly remembered their position in the aircraft and had left by the door nearest to their seat : the dividing line , between the passengers who left by the forward door and those who left by the aft door was located around rows 12 to 1 5 (there is no row 13) ; the only real exception concerns a passenger who was located in raw 18 and who exited the aircraft via the front, without doubt to join his family who were seate d further forward. Also, the evidence of the passengers has permitted their individual behaviour during the evacuation to be established : - The special character of the flight (round trip and first flight for most passengers) had several consequences : . the passengers had practically no hand luggage and los t no time trying to recover it , . they had been particularly attentive during the presentation of the safety cards . - It was also confirmed that the reassuring yet firm words o f the steward at the rear were of a great help for the passengers and clearly limited the panic at the rear of th e aircraft . - Also, 11 passengers clearly stated (even though the questio n had not been asked) that they had had difficulty in openin g their seat belts and that sane of them required help ; it is almost certain that this is not due to the opening mechanism but to a lack of knowledge of the system . As we have seen , this seems to be one of the reasons for the death of the young girl whose brother declared "she could not open her seat belt" . 34 . 1 .16 - TESTS ANDRESEARCH The main objective of the tests and investigations conducted by th e Investigation Commission was to check if the sequence of flight events could have been affected by a malfunction of the aircraft, its engines o r its equipment . They mainly concern : - analysis of the operation of the flight controls and verification o f the conformity of aircraft F-GFKC to the definition covered by th e airworthiness type certificate . - investigation of the engines and analysis of their operation durin g the flight and especially during go-around . Also, the radio-altimeter announcement sequence, which on firs t investigation could seem to be abnormal, was also especially studied . 1 .16 .1 - Analysis of the operation of the flight controls 1 .16 .1 .1 - General The AIRBUS A 320 is equipped with a new generation flight control system : it is the first civil transport aircraft to b e equipped with digital fly-by-wire controls . Two main characteristics distinguish a fly-by-wire contro l system : - the commands given by the crew are transmitted in electrical form to the computers and are not directly transmitted to the servomontrols by mechanical means , - the flight control computers also receive, as input data, th e information delivered by the on-board sensors and can, fro m this, generate the optimized flight control deflection commands for each flight phase . This second point permits an improvement in the flying qualities and reduces the pilot s workload as can be seen by the two following examples : - the system is designed to compensate automatically for external disturbances due, for example, to turbulence : if it detects a movement of the aircraft when the pilot has not given the =amend, it will itself compensate for thi s movement . - the system can incorporate automatic limitations preventin g the aircraft from going beyond predetermined values stored in memory, for example : load factor, angle of attack or rol l rate. The result is that, unlike older aircraft, there are no one-to - one relations between the position of the controls and th e position of the control surfaces . 35 . 1 .16 .1 .2 - AIRBUSA320 fliqht control laws The Investigation Commission particularly studied the final fligh t phase, from the passage through 300 feet agl . On the AIRBUS A 320, in the aircraft configuration during this flight phase, the longitudina l flight control laws change in the following way during an approac h (for reference, the lateral flight control laws do not change) : . Throughout the flight phase preceding the t«aatzlt when the aircraft reaches a height of 50 feet, measured by the radio altimeters, the flight control law is the usual law designate d C : this consists in controlling the load factor around the value 1, with dalping corrective terns for the angular rate o f pitch and the derivative of conventional speed . The effects of the load factors and of these terns are constant for speeds lower than 150 kt . . During the descent phase between 50 and 30 feet, the fligh t control law is modified to gradually take into account (1) a longitudinal attitude term (difference between detecte d attitude on passing through the 50 feet agl, called referenc e attitude, and the actual instantaneous attitude), instead o f the load-factor tern► . . On passing through the 30 feet agl, an additional comman d intended to simulate a conventional ground effect is introduced to supplement the previous pitch attitude control law : this command gradually brings the reference attitude (detected at 5 0 feet) to -2° in 8 seconds creating a nosedawn pitching momen t that the pilot must counter ("derotation") . If at any time, the angle of attack reaches 14 .5°, the flight control law is modified and the load factor term or the attitude ter m (modified or not by the derotation law) is replaced by an angle o f attack term (difference between measured angle of attack and 14 .5° value) . This flight control law ensures, in particular, an automatic protection preventing the aircraft from reaching an angle of attac k greater than 17 .5 to retain a sufficient margin in relation to a stall, even if the pilot holds the control in full nose-up position . This above mentioned flight control mode, named Alpha Prot (hig h angle-of-attack protection) is a priority node as soon as angle of attack reaches 14 .5° . It is not a degraded node and cannot be deactivated by the crew. Lastly, remember that when the radio altimeter height is greater than 100 feet, power is automatically applied if the angle of attac k reaches 15° . This function, called Alpha Floor, intended mainly t o counteract the effect of high wind gradients during approach, can b e inhibited by the crew : (1) this occurs progressively ; the change of law is made in on e second . 36 . . either each time an increasing angle of attack goes beyond 15 ° by acting on one of the instinctive disconnect pushbuttons on the throttle levers, or by disengaging the autothrottle, or by placing the throttles in the idle position . . or permanently by pressing, for more than 30 seconds, on one o f the instinctive disconnect pushbuttons . For the flight made on June 26th 1988, it is possible to reproduce the flight control laws which must have been effectively in operation during the approach and the flight over Habsheim aerodrome on the basis of the information recorded by the DFDR, taking same time reference "t" : 12h 45mn 39s . . before t-22 sec : usual C law, . between t-21 sec and t-20 sec, change to pitch attitude contro l law (corresponding to a jump in the radio altimeter informatio n during this time interval) , . between t-20 sec and t-18 sec, gradual return to C law, . between t-18 sec and t-4 sec, pitch attitude control la w (difference with respect to measured 6° value during passage through 50 feet) , . at t-4 sec, switching to high angle-of-attack protection law, as 14 .5° was reached, this law then being maintained . During runway flyover, since the 30 foot height was not reache d before the 14 .5° angle of attack, the derotation law could not hav e been activated . This point is confirmed by the fact that the pitc h control was practically stable (6 to 7° nose-up) whereas the pitch attitude and the angle of attack increased. If the ground effect simulation law had been activated, the attitude hold and, a fortiori , its increase, would have required nose-up action on the pitch control and this is not shown on the recordings . 1 .16 .1 .3 - Investigations carried out The normal operation of the flight controls was never questioned b y the crew of the A 320 involved in the accident . The Investigation Commission nevertheless judged that this point must be checked out i n detail. 37 . This check was carried out on the basis of flight sinulations wit h the aim of checking if the behaviour of the aircraft F -GFKC could b e considered normal during the flight made on June 26th 1988 . To this end, the Commission had flight simulation tests performed on a representative ground-based simulator (1) and on the A 320 No . 3 (flights No . 260 on July 27th and No . 355 on November 14th 1988) . Some of the members of the Commission themselves performed several o f these tests . Each of these means (simulator and actual aircraft) presente d advantages and disadvantages vis-a-vis the required objective : . the ground simulator permitted very high angle of attack manoeuvres to be made at very low speeds near to the ground but did not permit exact reproduction of the flight environment (outside display limited, different piloting sensations) . Also, it is inpossible to exactly reproduce the flight from the DFD R information as the recording rates are too low for this . . the real aircraft is of course highly representative, but fo r flight safety reasons, we could not go too close to the actua l conditions of the accident . In neither case, was it possible to represent exactly the atmospheri c conditions present during the flight which led to the accident but, á priori, this aspect had only a very marginal influence in the case considered (the atmosphere was calm at }íabsheim on June 26th) . The tests carried out were as follows : - on ground-based simulator : The simulator having been placed in initial conditions from which i t was possible to reach a point in the flight envelope (altitude - speed) measured on the recording of the approach of June 26th, th e pilot at the controls of the simmulator attempted to reach this point then to pass through the same flight envelope point values (altitud e - speed) in a certain number of cases measured on the DFDR . During this test, in which several attempts were required to obtain correc t simulations, the aircraft configuration was fixed (aircraft weigh t and CG position in compliance with those of the flight, landing gear extended, slats 220 , flaps 20 0 ) . During the major part of the approach, engines were at idle and the pilot used only the pitc h control to perform the test . (1) the accuracy of the simulator in representing the aircraft was checked by specialists tram the Flight Test Center who had participated in the A 320 type certification tests . 38 . - in flight . . study of the behaviour of the aircraft at very low speeds , . assessment of the influence of the modifications of the fligh t control laws at very low height during flights over the runway at Toulouse in the approach configuration of the F-GFKC on Jun e 26th 1988 . 1.16 .1 .4 - Results 1 .16 .1 .4 .1 - Reconstruction of performance (variation of altitude and speed ) The two tests on the simulator considered as the most representativ e were retained for the analysis which mainly concerned the final phas e of the flight (from 50 feet) . In both cases, the altitude and speed parameters were very wel l reproduced and the agreement with the flight in which the acciden t occurred can be considered as excellent from this point of view. In the first case ("nominal" case), the differences of the speed i n relation to tine are in general less than ]kt (carpared with the accuracy of this parameter during the DFDR recording : - 0 .5 kt), the diffexem:es in altitude are small (+ 10 feet naximan 13 to 14 seconds before the time of impact, - 5 feet on average during the las t seconds) (1) . It must be underlined that the pilot at the controls tried to pass via given altitude-speed pairs identical to those recorded in flight but that the moment when he reached them result s only from the simulation calculations . The fact that the altitude and sP However, a slight difference must be noted in this case : at t-12s and t-13s, the speed repriced on the simulator was slightly higher than that of the flight of the accident (+ 2 to 3 kt) . In the second case, when the President of the Investigatio n Commission piloted the simulator, the agreement of the variation of speed with respect to time is also excellent, the flight altitud e simulated was very slightly higher than that of the actual flight ( + 8 to 10 feet) . The same difference also exists with the real flight on the radio altimeter altitude between t-21s and t-20s . (1) We can however note between t-21s and t-20 seconds a significant difference between the altitude measured by the radio altimeter an d the altitude of the simulated flight : this is, in fact, a short phase during which the radio altimeter information was wrong (se e paragraph 1 .16 .3) ; the comparison with the barometric altitude shows excellent agreement between the flight made on June 26th and th e simulated flight . 39 . We also have the same discrepancy as in the previous case : at t-12s and t-13s, the speed reproduced in the simulator is slightly higher than that of the flight in which the accident occurred (+ 1 to 2kt) . This discrepancy can be explained by a low amplitude atmospheri c disturbance during the flight, not reproduced by the simulator . The behaviour of the aircraft after t-10s is however in compliance wit h the model, which indicates that this disturbance only had a ver y minor effect on the aircraft flight path . In flight tests, the performance comparison between flight No . 260 and the flight of the accident is good (see sheet given in appendix) . This fact enables us to conclude that the aircraft configuration wa s indeed the same and correctly reproduced . 1 .16 .1 .4 .2 - Response of the aircraft to a pitch actuation at very low speed : The difficulty of ie cing a manoeuvre arises from the fact that we mist place ourselves in identical or nearly identical fligh t control law conditions implying the observance of all relevan t parameters (load factor or attitude, angle of attack, speed gradient , positions of sidestick in pitch) but these parameters are recorde d only at a low rate on the DFDR (in general, one point per second ) whereas an exact reconstruction would require around 40 points pe r second. In the majority of the tests conducted on the simulator an d in flight to assess the behaviour of the aircraft at very high angl e of attack, the pitch control was brought to the rear stop more rapidly than during the flight on June 26th in the phase immediatel y preceding impact with the trees . However, specific tests relevant to this last flight phase permitte d us to check that the response of the aircraft to the pitch comman d given by the Captain was also in compliance with the certificatio n data : on the simulator, the sheet given in the appendix shows that , for the test performed with a stick deflection rate identica l to that of the flight on June 26th, the attitude response is perfectly in catpliance on the simulator and during flight , after resynchronising from the time when the Alpha Prot law was activated, it was also possible to make a reconstruction in flight during flight No. 355 on A 320 No. 3 : l parameters recorded during this test are ccupared on the sheet w :Yu those of the flight of June 26th . The differences between th e two cases are as follows : . flight test No . 355 was made at a speed lower than that of th e flight on June 26th, the weight of the aircraft was lower, th e angles of attack were more or less the same , . the variation of attitude and altitude was different (aircraft descending during flight No . 355, in level flight for th e flight on June 26th), 40 . . the pitch control was brought to the rear stop more slowly than on the flight of June 26th, but from a balance position neare r to neutral , . lastly, during flight No . 355, made at altitude, control was b y the C law (load factor) before changing to the angle-of-attac k protection law whereas for the flight on June 26th, control wa s by the pitch attitude control law before changing to the angle - of-attack protection law . As the objective is to compare the response of the aircraft when it was under the angle-of-attack protection law (in the last seconds o f the flight), the effect of these differences can be considered to b e marginal, especially as the average deceleration of the aircraft is very close in both cases . We can see that the variations in the angle of attack were also ver y similar : the increase in the measured angle of attack is almos t identical during the last two seconds (1°) . The other calculations made also show that if the pitch control had been moved back more rapidly or earlier during the flight in which the accident occurred, an angle of attack greater than 15° could hav e been obtained before inpact with the trees . They also show that , without earlier initiation of go-around, such a manoeuvre would hav e led to an increase in the instantaneous drag of the aircraft an d would not have prevented inpact with the trees . 1 .16 .1.4 .3 - Analysis of the aircraft response for the different flight control laws active during the approach Certain members of the Investigation Commission, themselves pilots , wished to assess personally the behaviour of the aircraft during manoeuvres made near to the ground to check if the switchover of th e flight control laws could lead to handling difficulties . To this end, tests were carried out above the Toulouse runway in level fligh t between 100 and 50 feet (C law), between 50 and 30 feet (pitc h attitude law) and below 30 feet (attitude and de- cation law) . These flight cases, which did not correspond to normal .pproaches, reveale d no handling problems : the switchover from C w to pitch attitude law had no noticeable effect on the behaviour of the aircraf t observed by the pilot, the effect of the derotation term was perceptible (increasing pressure rust be applied rearward to kee p level flight) without this being tricky and it rust be remembered that this rode was not activated during the flight on June 26th . Switchover to the angle-of-attack protection law also had no effect s on the behaviour of the aircraft as felt by the pilot . 41 . These tests also enabled us to establish that the very ncuentary switchovers of the flight control laws which occurred between t-21 s and t-20s due to the erratic indications given by the radio altimeter during the flight over a clump of trees were not of a nature to affect the behaviour of the aircraft . Tb sum up, the Investigation Commission established that th e performance of the flight controls was in compliance with the certification data during the flight made on June 26th 1988 and they consider that the flight control laws of the aircraft show no characteristics liable to create any specific handling difficultie s even under the conditions of this flight which differed noticeabl y from those of a normal approach . 1.16 .2 - Engine operation Unlike the flight controls, the behaviour of the engines was questioned by the crew immediately after the accident : they declared that, after initiating go-around, engine thrust was not achieved . From the very first investigations made on the recorders (CVR and DFDR), it was however established that the engines had responded t o the go-around initiation made between 5 and 5 .5 seconds before the impact with the trees (variation of engine speeds, temperatures and fuel flow rates on the two engines recorded on the DFDR ; noises characteristic of changes in engine speeds recorded on the CVR) . The Commission therefore concentrated their work on checking the cirmmstances of the go-around by : - reproducing as accurately as possible the engine parameters , - comparing the observed behaviour with the normal certificatio n characteristics . The Commission also participated in the engine examination made by the manufacturer CFMI (in the SIX► premises at Melun-Villaroche) . 1 .16 .2 .1 - Reproduction of the engineparametersduring go- around The characteristic engine acceleration parameters after go- around initiation were reproduced from three independen t sources : - the engine parameters recorded on the DFDR, - the spectral analysis of the last seconds of the CVR recording, the characteristic frequencies of the engine speeds having been recorded by the cockpit area microphone, 42 . - the spectral analysis of the sound track of a video film sho t by . a spectator on the ground . The results of these analyses are perfectly in agreement and sho w that the engines increased in power as soon as go-around was initiated . The last engine speeds recorded by the CVR and the DFDR were 84 .4 % Ni on the CVR, 83 and 84 % Ni on the DFDR. The sound track of th e video film permitted reproduction of several additional seconds afte r the impact with the trees (when the flight recorders were no longer operating) : the last maximum speed value, clearly identified from this source, was 91 % NI . 1 .16 .2 .2 - Comparison with basic certification dat a As the engine responses had been reproduced without ambiguity, th e Commission checked their conformity with the basic certification data. The certification regulations in particular require that the climb gradient of the aircraft in landing configuration, all engines operating, Host be at least equal to 3 .2 % with thurst available 8 seconds after initiating go-around . This statutory requirement i s reflected by a minimum thrust value and, therefore a minimum Ni speed, taking into account the aircraft drag characteristics . In the flight conditions of June 26th, this minimum Ni speed value was 94 % (value which must be obtained 8 seconds after initiating go-around) . In the case of this flight, the inpact with the trees occurred before 8 seconds had elapsed after initiation of go-around (see below) . The Commission therefore sought the minimum Ni engine speed values for the period between 5 and 8 seconds after initiation of go-around i n the conditions of the flight and corresponding to go arounds whic h would satisfy the regulations . These values are given on the curve a t the end of the paragraph . The exact moment when go-around was initiated by the pilot during th e Habeheim overflight was determined as follows : - The position of the throttles recorded by the DFDR, every tw o seconds, indicated : flight idle position at 12h 45mn 33s , TOGA position at 12h 45mn 35s . Between 12h 45mn 34s and 12 h 45mn 35s, engine 1 N2 speed and flow started to increase (this information is taken in the middle of the cycle) . - The recording made in the cockpit by the CVR shows that th e throttles were placed in TOGA position at 12h 45mn 34s 5/10 . 43 . - The eye-witness reports refer to a definitive and rapid application of go-around power . From these considerations, it can be estimated that go-around was initiated between 12h 45mn 34s and 12h 45mn 34s 4/10 . The N1 speeds recorded on the DFDR at 12h 45mn 39s ar e respectively 83 and 84 % for engines 1 ani 2 (i .e . 5 to 5 .4s after initiation of ga-arourxi) . The speeds measured by external means are 91 % 0 .6s after having reached 83 % . Under these conditions, the curve below compares these recorded speeds to the minimum speeds required to meet the certification requirements . We can conclude that the engine acceleration was in compliance with these requirements . N1 speed (%) 94 Mini s nn N1 90 . Measured N1 .. Uncertainty concerning exac t 80 go-around initiation time 70. I I I time ( s ) 5 6 7 after go-aroun d initiatio n It was thus verified that the engine acceleration defec t sometimes reported in certain low altitude flight cases on the A 320 did not occur during the flight on June .26th . Also, the conditions required for this to occur were not present (speed much lower than 250kt) . 44 . 1 .16 .2 .3 - Detailed engine investigatio n The engine investigation showed that the engines wer e practically stopped during final impact on the basis of th e following : no signs of fan rotation were found even though, after the impact, moving blades were in contact with fixed parts , signs of low speed rotation of HP system are visible at time of impact with the ground , all the undamaged variable bleed valves (VBV) of the low pressure compressors were in the open position, i .e . corresponding to idle speed or shut-down . It was also found that the combustion chambers were alnos t completely blocked by a compact mixture of partially burnt wood and leaf debris . With these elements established, it mist be underlined that th e fact that the =t.ors were practically stopped during final impact does not contradict the fact that they were operatin g normally before impact with the trees : the falling of the airs ,;_aft into the forest led to passive ingestion of branches and leaves via the air intakes and this caused the engines to stop by obstructing the combustion chambers . The engine speed fell rapidly and the regulation system, mainly controlled by N2 speed, brought the VW and the VBV into a position compatibl e with a low N2 speed, and this explains why the VW and VBV wer e found in a position corresponding to idle speed . 1 .16 .2 .4 - Conclusions concerning engine operatio n Zb sum up, the Investigation Commission established that the engine acceleration during the flight in which the acciden t occurred was perfectly in compliance with the basi c certification data and that their operation was normal up to the accent when, after impact with the trees, they started to absorb the vegetation debris during the final falling of th e aircraft into the forest . 1.16 .3 -Additional investigations In their investigations to check if the operation of the aircraft had been correct on June 26th, the Commission was also led to study th e reasons which could explain the apparently irregular radio altimete r announcement sequence : 200 feet, 100 feet followed by 40 feet then 50 feet . . .(whereas 50 feet should have been broadcast before 4 0 feet) . 45 . On the aircraft intended for AIR FRANCE, the aural announcement s provided for in the program are (height in feet) : - 200, 100, 50, 40, 30, 20, 10, 5 , - and for approaches for which the crew has selected a decisio n height DH (approach in low visibility conditions) : HUNDRED ABOVE when passing through DH + 100 feet and NIININUM on passage throug h III . The predetermined announcements are triggered 10 feet above th e altitudes to be announced for those greater than or equal to 100 fee t and 2 feet above for those less than 100 feet . The time required to generate an announcement from the trigge r threshold is on average 0 .4 seconds . If an announcement is started (synthetic voice starts to speak), it is pronounced entirely . If, another height, associated with another announcement, is detecte d before the first announcement begins, the first announcement is no t broadcast, as priority is given to the second value to be announced . The aural announcement is also inhibited if the two radio altimeters are inoperative, if radio altimeter altitude is lower than 3 feet o r if radio altimeter altitude increases . Above 50 feet, intermediate announcements (repetition of sam e announcement when the following threshold is not crossed) ar e generated every 11 seconds . Below 50 feet, this time is reduced to 4 seconds . In case of the flight made on June 26th, when the actual height o f the aircraft was decreasing continuously from 100 to 50 feet betwee n 12h 45mn 15s and 12h 45mn 23s, there was a discontinuity in the radi o altimeter information between 12h 45mn 18s and 12h 45mn 19s . The evolution of these readings was in compliance with the curve below : 46 . eT<0,4 s 10, time ( s ) I 1 T T i I I 1 I This discontinuity comes from flight over a clump of trees located shortly before the runway . The 50 feet announcanent, triggered b y passing through a height of 52 feet, was inhibited as the 40 fee t announcenent was triggered, by passing through a height of 42 feet , less than 0 .4 sec . after the 50 feet annoummnent had been triggered . The 40 feet annourcenent was therefore made without the 50 feet announcenent having been made and before the 30 feet announcement wa s triggered . This 30 feet announcement was inhibited as at the tim e when it should have been announced, the radio altimeter altitude was increasing . After time 12h 45mn 20s, the announcenent sequence presented no irregularities . Note, however, the repetition of the 30 fee t announcements at very short intervals during the last flight phase . Ttnese repetitions can be explained only by very low oscillations o f the radio altimeter height around the 30 feet value, the announcement being triggered each time that the 32 feet height was passed after a n increase in altitude even very brief, had been recorded (these very low altitude oscillations may have been flying oscillations or th e result of a very low altitude variations in the terrain flown over : an 8 an height variation 3 .5m wide is sufficient to rearm th e 47 . 2 - ANALYSIS 2 .1 - (iAL CONSIDERATIONS The Camtission found that the aircraft was airworthy, that the weight and CG were within the authorized limits and, more generally, that there was no evidence of any mechanical or instrumental failure (before the first impacts with the trees), liable to reduce safety . On the contrary the Cannission became convinced that the behaviour o f the aircraft had been, from all points of view, in compliance with the certification data and that the flight path followed was i n accordance with the flight control contends given by the crew via th e flight controls . They also determined that the weather conditions and lightin g conditions and also the aerodrome infrastructure, navigation aids an d telecommunications played no part in the accident . The crew, normally quali fied to fly Airbus A 320s, shoved no medical or pathological evidence which may have been liable to influence the flight . The Commission were thus led to concentrate their study on th e circumstances of the preparation for the flight and on the element s liable to have influenced the behaviour of the crew during the flight as they flew the aircraft on a flight path appreciably different fro m the one that they had explicitly planned before the flight . 2 .2 - FLIGEfT PREPARATION 2 .2 .1 - Study of the feasibility of the flight over Habshei m aerodrome According to the departments of AIR FRANCE responsible for the flight preparation, the low altitude overflights had bee n studied as provided for in AIR FRANCE's internal note DO ND 50420 . This study would mainly have consisted in checking obstacle clearance in case of engine failure . According to the airline, these flybys were studied for fligh t over runway 02 . This declaration led the Commission to make the following renarks : 1) The hard runway 02 at NUlhouse-Habsheim cannot be used by the A 320, due mainly to the fact that its strength is too low, 48 . 2) The runway to be used could not have been foreseen at the tim e when the flight was prepared by the department concerned (weathe r conditions unknown and AIR FRANCE not notified of the runway selected by the organizers) . Note DO ND 50420 was drawn up by AIR FRANCE to prevent demonstratio n flights from being made at heights which are too law . This note specifies, inter alia, that all or part of a tourist or demonstration flight mist be subject to : "accurate definition of the way in which the flight will be carried out 'distance, altitude, configuration , etc .) and the corresponding task snaring" . These directives should have been drawn up by the flight division but : • It was only on the Friday afternoon that the flight file was handed over, by the employee responsible for its preparation , to the technical assistant of the division at the moment whe n he was leaving . Reception of this document therefore seems to have been fortuitous . • Also, the persons responsible within the flight division did no t deal with this earlier probably due to their workload related to the entry into service of the aircraft . . Fran the file (which did not indicate any particular difficulties), they estimated that Michel ASSEGINE wa s perfectly capable of planning this flight himself given his position in time company and his strong personal which resulted in h., 'n having a field of actio°• mach gr .er than appears in the airline's organization chart. Consequently, the file was handed over as it stood to the crew . It included none of the items required by note DO ND 50420 nor an y indication of height or overflight axis to be observed or any direct means of contact with the air show organizers . The Commission considered that, as no such indications were given , the crew should have referred to DO ND 50420 . This note specifies that 'e minimum runway overflight height of 100 feet in landing configuration' rust be observed . The Commission remarked that : 1) Time note was not appended to file handed over to the c' »w even if its existence is recalled in a assage . 2) Time 100 feet height was not applicable to the Mulhouse-Habshei m overflight as none of the runways was usable by the A 320 . 49 . 3) Also, the choice of a height of 100 feet is in contradiction with the French air safety regulations which impose a miniman overflight height of 170 feet using VFR (this flight phase was carried out unde r VFR even though under an IFR flight plan) . The Commission also observed that within the scope of touristic or demonstration flights, the 100 feet agl height had already been use d by AIR F1MCE to perform many overflights, including over grass runways, (more than twenty since 1987), during air shows in Franc e and abroad. The Investigation Commission noted that the overflight height abov e the aerodromes where the air shows were held, even though not in compliance with the regulations, had not led to reactions from th e Administration, or from the air show organizers (except on one occasion where the flyover conditions and height, lower than the fixed minimum, had given rise to actions from the competent intenninisterial (Hare, Defence, Civil Aviation) control =mission) . 2 .2 .2 - Distribution of the results of the study and provision of information to the crew The Department who made the study informed the Air Operation s Directorate and the Flight Safety Department of AIR FRANC, as wel l as the Regional Air Traffic Control (East) and the Basle-Mulhouse tower by Telex. Then they handed over the file to the A 320 flight division. Due to the short period of time available, the technical assistant did not have time to make verbal ccuments on the file to the Captain who was on flying duty on June 25th . The First Officer, who that day was resting, was not contacted . e pilots were chosen for this flight as they had managerial responsibilities . Reconnaissance of the Habsheim aerodrome by the crew was at no time considered . The meeting provided for in the regulations, on its initiative , between the air show flight manager and the crew did not take place onus depriving them of information which could have been useful (special features of the terrain, axis used, location of public , etc.) . The organizer had held that same morning a preparation meeting with all the other pilots concerned but was not worried by the absence o f the A 320 crew due to the correct performance of flights made during AIR FRAM= participation in previous air straws at Habsheimn and the freeing of the airspace planned from the moment when the aircraft was to take off from Basle-Mulhouse. The crew, therefore, had received rop information or verbal comments on th file drawn up for them. 50 . 2 .2 .3 - Flight preparation by the cre w 2 .2 .3 .1 - The study of the file (including the prefectora l authorization number, photocopies of the 1/500,000 scale VFR flight chart, IGN 1/100,000 scale map, VAL chart of the Mulhouse-Habsheim terrain) was only made by the two pilots on Sunday morning June 26th . They therefore made the flight preparation only from items differin g from their normal working documentation and describing an aerodrome and its surroundings which they did not know and on which, due to lack of directives, they had free manoeuvre choice . Neither of the two pilots had previously performed a demonstratio n flight. The Commission noted that they seemed not to have tried to obtain additional information concerning these overflights . It is probable that the Captain, on seeing the file, judged that th e flyovers presented no difficulties and that he had no need fo r additional information. Also, the AIR FRANCE personnel directly concerned would no doubt not have been easy to contact on a Sunday . 2 .2 .3 .2 - At BASLE-NEE, during taxiing, the Captain made a briefing on the two low altitude flyovers at the Habsheim airfield. The axis of the runway which was finally chosen because of th e terrain and the public was not mentioned. The two flyovers were planned without a previous flight over the aerodrome, one at low speed, the other at high speed . The flyover conditions were also explained as follows : First flyover to be performed : 1) at 100 feet, 2) with flaps in position 3 and landing gear extended , 3) in level flight decelerating to maximum angle of attac k permitted by the A 320 flight control system, 4) after disengagement of automatic go-around protection at hig h angle of attack (alpha-floor) , 5) with assistance to control the aircraft required of the First Officer if holding the load on the stick became uncomfortabl e (" . . .If I tell you it is hard . . .") , 6) maintaining level flight with the aid of the engines by th e First Officer , 7) with go-around initiated by the First Officer on order from th e Captain. 51 . The second flyover was to be performed : 8) by the First Officer, also at 100 feet, at high speed and in clea n configuration. These 8 points lead to the following comments : 1) As we have seen in paragraph 2 .2 .1, the 100 feet flyover height, also not in compliance with regulations, does comply with internal note DO ND 50420 . For the crew, flying at this height could therefor e be considered as authorized and therefore as normal . Note that no mention is made of the reference selected for the 10 0 feet : barometric height (QFE) or radio altimeter height . 2) This flap and landing gear configuration is one of the norma l landing configurations . 3) The deceleration in level flight was planned down to minimum flight speed corresponding to the maaiman angle of attack permitted by the aircraft fly-by-wire system . This shows, on the part of the Captain, his desire to highlight the value of the A 320 by demonstrating its specific possibilities . The training given to the pilots erphasized all the protections from which the A 320 benefits with respect to its lift which could have given then the feeling, which indeed is justified, of increase d safety. In particular, the demonstration of the activation of the safety features and protection of this aircraft may lead one t o consider flight approaching one of the limitations (especially th e one related to angle of attack) as a foreseeable flight condition since lift is guaranteed. However, etphasis was perhaps not sufficiently placed on the fact that, if the limit cannot be exceeded, it nevertheless exists and still affects the perfoanance, i .e . the ability to change the aircraft flight path. As on conventional aircraft, the load factor available at minimum speed in level flight is only one (zero manoeuvrability in recovery and turn) and the drag at this speed is very high (back side of the drag curve) which greatly limits th e climb gradients as the available excess thrust is naturally low . During training on previous generation aircraft, pilots are mad e aware of the dangers of flight at low speed, and the basic rule whic h consists in observing a margin with respect to a minimum speed is driven hone . The pilots would therefore probably not have considered such a manoeuvre at a speed so close to stall on these types o f aircraft. However, for the flight of the accident, the crew did no t hesitate to plan a low height flyover at a speed lower than approac h speed (normal minimum operating speed) without realizing that , because of the protection, the aircraft limits were reached without risk of exceeding than, but that performance was reduced in the sam e way as on conventional aircraft . 52 . 4) The choice to inhibit the autocratic go-around protection (Alpha Floor) resulted from the need to eliminate this protection if flight at 100 feet or above is planned at an angle of attack higher than th e one activating this protection. The inhibition in this case can only be achieved in practice by pressing and holding the two switches placed on the throttles . After 30 seconds, inhibition beca as permanent for the rest of the flight . This decision is compatible with the objective expressed by th e Captain to maintain a height of 100 feet and seems to confirm tha t the incursion below 100 feet was not considered by him at this stage . In effect, below 100 feet, this protection is not active . 5) The request for help to control the aircraft made to the Firs t Officer can only be explained by concern about the discomfort cause d by a sustained rose-up action, which seems to indicate that th e Captain thought that he had time to make a prolonged level flight above the runway at maximan stabilized angle of attack. 6) The request made to the First Officer to maintain level flight b y adjusting the engine speed confirms the previous remark . 7) The application of power was planned to be made by the Firs t Officer on the order ("au TOP") of the Captain . The latter was therefore envisaging a go-around starting from the power settin g necessary to maintain level-flight, in other words from a high power- setting. On the A 320, the training demonstrations of the behaviour of the aircraft at low speed are only made from stabilized level flight at a speed near to minim= speed and therefore with a thrust near to the equilibrium thrust at maximum angle of attack . In this case, go- around is made from a high engine speed and gain in altitude appear s immediate and the aircraft remains in maximum angle of attack . Note that this type of demonstration is highly impressive : climb with pitch control set to full nose-up while making roll manoeuvres give s the feeling of great safety . 8) The height of 100 feet planned for the second high speed flyove r is not in compliance with note DO ND 50420 which specifies a minimu m height of 300 feet for this type of overflight . The choice of the height of 100 feet was perhaps made due to only partial knowledge o f this rote . The Commission observes that : - the prolonged level flight mentioned in 5 could not be achieve d (length of runway) . There is also a lack of precision concerning the go-around initiation point . These two points show the incomplete character of the fligh t preparation. 53 . - the task sharing concerning look out and monitoring of th e instrun ents is not mentioned ; even if this task sharing could seem obvious for each of the pilots, this aspect shoul d have been dealt with due to the character of the flight (demonstration flight and, moreover, crew made up of tw o instructor Captains) . - the comment made by the Captain indicating that he had already made this manoeuvre 20 times is probably pertinent a s concerns the number, but not as concerns the height at which the Alpha protection was activated during his training flights as instructor or trainee . 2 .3 - SEQUENCEOFEVENTS After a 6-minute wait due to the traffic, the aircraft lined up on the runway and took off at 12h 41 . It turned right immediately to head towards the Habsheim aerodrome . The take off and climb to 200 0 feet (dui lasted 2 minutes during which the pilots were occupied b y the management of the flight and by unwanted warnings leading, on the part of the Captain, to remarks confirming his profound knowledge of the aircraft . These the crew tried to identify the Habsheim aerodrome which they did not know ; the descent was only started (with an initial speed o f 190kt) at 5 .5 Nm from the aerodrane, a distance which turned out to be too short to achieve the desired loss of height and deceleratio n sufficiently quickly to permit stabilized level flight . During the descent, the First Officer made contact with the Habsheim tower and specified : "we re going in for the low altitude low spee d flyover" which corresponded to the briefing and did not incite a remark from the Captain ; the controller gave the QFE altimeter setting ; the two pilots repeated this and indicated that they had selected and checked it . The Captain asked the First Officer to confirm if that was indeed the airfield when they passed 450 feet measured on the radio altimeter . This request can be explained by the habit of making checks for al l flight phases, especially during approach . Also, at this time, the Captain is, without doubt, trying to find th e runway above which the manoeuvre is to be made . It is only when he sees the crowd of spectators that he decides, in accordance with hi s declarations, to overfly 34R without however telling the First Officer. 54 . The GFh1S announcement at 300 feet radio altimeter cares from the fac t that it was not in "flaps 3" node . The chime which follows corresponds, according to the crew, to the switching off of the GPWS . This was done, instead of selecting "flaps 3" node, probably to prevent further warnings during the demonstration . At 12h 45mn 11s, the First Officer made a comment concerning the AI R FRANCE flight safety officer whose function consists, among othe r things, of studying the flights for which the safety margins have no t been observed. This comment can be interpreted . in different ways : either anticipated self satisfaction before the planned demonstratio n or, more likely, according to the Cc:mission, a warning for the Captain. It can be seen that the First Officer stops in the middle of hi s remark when the "200 feet" aural announcement of the radio altimete r is made. The pilots therefore heard this announcement (maybe withou t identifying it) the volume of which is sufficient to justify interruption of the phrase being spoken even though both of them are using headsets (the radio altimeter announcement is only broadcast b y the cockpit loudspeaker and not in the headsets but these, being lightweight, enable the raises in the cockpit to be heard) . At 12h 45mmn 14s, the First Officer notifies the Captain that they are reaching the height planned for level flight : "OK, you re at 100 feet there, watch, watch . . ." . Here again, the First Officer interrupted his sentence at the 10 0 feet radio altimeter announcenent which shows that he heard thi s sound. Also, this coincidence indicates that, either he was using th e radio altimeter as the height reference or that the altimeter indications were consistent with those of the radio altimeter . Due to the remark made at 12h 45nn 32s ("watch out for the pylon s ahead . . .") we can consider that the "watch, watch corresponde d to the start of a new warning, as the aircraft was arriving at the selected height with a still significant descent rate (600 feet/mn approx .) . The Captain at the controls did not react either to the radi o altimeter announcements of fifty and forty feet or to a possibl e reading of the instruments and as concerns the warning about the pylons, he dismisses it with a short phrase ("Yeah, Yeah, don t worry") . Since, for the reminder of the flight, the radio altimeter was registering less than 100 feet, Alpha Floor protection wa s autanatically deactivated . 55 . A problem of reference is raised for the 100 feet flyover margin : the radio altimeter readings are only valid for flat terrain or ove r a topographically known contour with electrically well flagged points (IIS approaches) . On the other hand, the barometric altimeter is a n instrument whose intrinsic accuracy at low altitude is around 3 0 feet . The altimeter reference pressure is supplied to within 0 .5 hPa which corresponds to 15 feet . A low flyover based on the baruetric altimeter cannot then, a priori, be accurately achieved . These considerations may have led the crew to have only limite d confidence in the readings of these two instrunents . If the descent observed below the planned height was not mad e voluntarily, this supposes that the Captain was flying by sight an d that he had not registered the aural anmuncenents made by the radi o altimeter as he was occupied with other tasks . It is interesting to specify the various factors which could have led to error : - he was flying over a terrain that he did not know and had not ha d the possibility of studying as he had not made prior reconnaissanc e (either from the ground or in flight) . Also, he had only had a short time to consult his file which, moreover, was very brief . Be therefore had no accurate geographical landmarks . - whereas he was accustomed to use 2 to 3000 m long runways wit h approx. 100-foot high control towers, he found himself on an 800 m long grass strip with a 40-foot high tower ; the scale effect may have created a false impression making him think that he was at th e planned height . - the to the high nose-up attitude of the aircraft, the pilot s eye level was much higher than the rear section of the fuselage an d this gave him a false ingression of the height margin of th e aircraft with respect to the obstacles . - also, at the start of the overflight the trees were perceived onl y as a change in colour with respect to the grass of the runway an d not as a change in contour ; the crew no doubt only identified tha n as an obstacle at a very late stage as indicated by the remark made by the First Officer who was concerned about the pylons which were approximately 1 .5Jan distant but not about the nearby trees . 56 . Also, by the reply made to the previous warning :"Yeah, yeah, don t worry", and his irk during the briefing : "I ve done it 20 times" , the pilot appeared very confident . We can try to explain this frame of mind by the following considerations : - Because of his work on the A 320 simulators and his participation in the development of the aircraft, he knew the A 320 better tha n most of his colleagues . - He had often performed similar manoeuvres at high altitude and on the simulator ; he knew all the special protections introduced int o the A 320 flight control laws especially the stall protection an d he could, therefore, have thought himself fully protected for hi s high angle of attack flyover, even at a very low altitude . - As these same manoeuvres were generally made with a stabilized engine speed well above idle, the thrust was established ver y quickly permitting immediate increase in height . Also, an air show is the ideal occasion to demonstrate the possibilities of the A 320 of which he was an ardent advocate . The choice of a flyover at Y rum angle of attack may also have been the result of the atmosphere created by the "air show festivities" on th e ground and on-board and the presence of female passengers in th e cockpit . At 12h 45nn 26s, when he placed the aircraft in level flight, the Captain indicated that he was disconnecting the autothrottle ; this operation had already been performed at 12h 41nn 58s . The Captain later stated that, in this case, it was "a safety measure" intended to guarantee full application of thrust when required by him . We can zsierk that this action was of no use for the intended objective : irrespective of the autothrottle situation, engine powe r increase is identical when the throttles are brought to TOGA position. At 12h 45an 34s 5/10, when the aircraft passed in front of th e control tower, the Captain rapidly placed the throttles in the position corresponding to max . thrust (TOGA) . This was not in compliance with the program which specified gradual and partia l application of power made by the First Officer to keep level flight at maximum angle of attack then throttle up to TOGA also by the First Officer . Three seconds after having applied go-around thrust, the pilot gradually brought the pitch control to full nose-up position. 57 . It is probable that these actions of the Captain (application of go - around thrust and nose-up command) were motivated by a sudden awareness of danger. At this moment in time, the aircraft was at low speed and at very lo w height ; it had no energy reserves, neither kinetic nor potential . Also, the engines, at flight idle when go-around was i nitiated, could not instantly supply high thrust due to their inertia . One can very easily explain the pilots impression of a lack of response of th e engines (this ingression was also felt by the members of the CaRmission during the reproduction flights carried out in the cours e of the investigation) . Engine acceleration is slower at low speeds : 4 seconds are required to go from 29 % Ni to 67 % Ni and only 1 second to go from 67 % Ni to 83 % Ni, the engine speed which had bee n reached when first contact with the trees was made 5 seconds after initiating go-around . The engine speeds increased at least up to 91 % (last value obtaine d by spectral analysis of the sound track of the video recording of th e accident) but, at that time, the rear section of the fuselage had already hit the trees, creating additional drag which prevented th e aircraft from gaining height . Following this, the engines ingested a high quantity of leaves and branches which were mashed up in th e =p essor and clogged the entry to the cambustion chambers causin g shutdown of the two engines . The aircraft sank into the trees and was rapidly slowed down. 58 . 3 - ammnslms 3 .1 - FACTS ES BEISHED BY THE INVESTIGATION - The aircraft was in a flightworthy condition - The weight and balance were within authorized limits ; the errors in their calculation did not in anyway influence the flight . - The Commission found no malfunction of the aircraft or its equipment which could have contributed towards a reduction in safety or an increase in the crew s workload during the fina l flight phase . - The crew held the valid certificates and licences and had the qualifications required to operate the aircraft . - The two pilots held management positions in their airline an d participated, at various stages, in the development and the entr y into service of the A320 . - Neither of the two pilots had previously made a demonstratio n flight . - As concerns the crew, no physiological factor or medical histor y was fount that could have played a role in the accident . - The planned flight programme included flybys over the Mulhouse- Habeheim aerodrome as part of an airshow. - Mo prepare for this flight, the crew were in possession of a shor t brief for the part concerning the overflights . - The crew had only partial information on the organization of the airshow, particularly because of the absence of prior contact between the organizers and the crew . - During taxiing at Basle-Mulhouse, before take-off, the Captai n specified his it -►tions for the overflights at Habsheim overflight at 10( .Net with flaps in position 3 and landing gear extended, deceler :,tion in level flight down to minimum airspee d corresponding to maximum angle of attack, stabilization at thi s minima speed, then application of full power on the Captain s order. Then a second flyover at high speed also at 100 feet . - Locating of the aerodreme was late . 59 . - Descent was started at 12h 43nn 44s at 5 .5 nautical miles from the aerodrome, the engines were throttled back to flight idle throughout the descent, with the speed reducing . - %ten 100 feet agl was reached, the descent rate was still about 600 feet/min . - The pilot levelled off at a height of about 30 feet, engines a t flight idle, attitude increasing . He did not have the time to stabilize the angle of attack at the maxim= value that he had selected . - Rapid application of full power occurred between 12h 45mn 34s an d 12h 45mn 35s ; the angle of attack was at this tine 15° and th e speed 122 knots . - The response of the engines was normal and in compliance with certification requirements . - The aircraft touched the trees between 12h 45mn 39s and 12h 45mn 40s with the rear section of the fuselage and then slowly sank int o the forest as a result of the inked drag and the loss of engine power caused by ingestion of leaves and branches . - A very violent fire broke out innediately, mainly at the right o f the aircraft, and flames penetrated the cabin as soon as th e aircraft came to rest . - Evacuation was begun immediately by the cabin attendants via the forward and rear left-side doors . - Three passengers were unable to leave the cabin and died in the fire . 3 .2 - PROBABLECALF 3 .2 .1 - Cause The Commission believes that the accident resulted from the combination of the following conditions : - very low flyover height, lower than surrounding obstacles . - speed very slow and reducing to reach maximum possible angle o f attack. - engine speed at flight idle . - late application of go-around power . 60 . This combination of conditions led to intact of the aircraft with th e trees . The Catmission also believes that if the descent below 100 feet was not deliberate, it may have resulted from failure to take proper account of the visual and aural information intended to give th e height of the aircraft . 3 .2 .2 - Other factors The Commission also remarked that the following factors contributed towards placing the crew in a situation that they were not able t o fully control : - The flight preparation was insufficient, especially due to th e brevity and late provision of the brief and of the informatio n about the airshow. - The task sharing planned for the flyover by the crew wa s irxxluplete and was not followed . - The holiday atmosphere for the passengers and the spectators could have been transmitted to the Captain . - The A 320 has new features which may have inspired som e overconfidence in the mind of the Captain . - These new features of the aircraft had satetines been criticize d ani the Captain wanted to defend the aircraft . - Neither of the two pilots had previous experience of demonstration flights . - The late identification of the aerodrome led to a rush of events, and the making of the descent and then the ccnplet e flyover above the runway with the engines at flight idle, and without stabilizing the flight parameters . - Neither of the two ilots had previous experience of applying go-around power furor :light idle in similar conditions . 61 . 4 - CKS 4 .1 - AffiriINISTRATIVEAND TECHNICALPREPARATICTiFOR FLIGHT 4 .1 .1 - The Investigation Commission remarked that the flight which led to the accident had only been briefly prepare d without real consultation either between the departments concerned, or with the crew . The Cannission recamends that : - the preparation of such flights (participation in air shows ) includes as a minimal and in addition to the actions already e illicitly provided for in the regulations : -the drawing-up of a ocr:sive flight safety brief specifying the flight parameters to be oteerved and the ptooediires to be followed in case of a failure, - a meting between the crew and the departments which participated in the flight ptepar t en, organized within good time before the scheduled date of flight, - effective recommaimmance of the place wbet+e the flight is to be made, ani if possible : - one or more practice flights on a representative fligh t simulator including special attention to the critical aspects which may result from non-observanoe of the flight parameters, especially incase of a failure . 4 .1 .2 - The presence of passengers on-board, provided for i n the charter contract for this flight, contributed, during th e accident, to the aggravation of the consequences for th e persons . The Investigation Commission reams that : - this type of flight (participation in air shows) be node without passengers and with minimum crew including only th e persons required to carry out the flight, the only manoeuvre s authorized with passengers an-board being these laid down in the operating manual . 4 .1.3 - The Commission remarked that the internal Air-Franc e note EC ND 50420 laid an certain rules which were not i n compliance with regulations . 62 . The Cartinission recatmends : - that the internal rules of the airlines be checked for conformity with official regulations. 4 .2 - TRAIN= OF PERSONNEL { .2 .1 - Flight crews 4 .2 .1 .1 - The Investigation Camtission remarked that the pilots planned to carry out a manoeuvre at the limits of the fligh t envelope and that the role of each crew member had not bee n precisely planned. The Ca:mission recommends that : - airline pilots be reminded that their job consists of strictly applying standard and well-defined procedures ; - consequently, their training be more oriented towards safety which requires that standard flight conditions be permanentl y maintm ne i• - for the A320 training in particular, the pilots are made aware that the performance limitations still stand, as an any other aircraft, in spite of the many automatic protections (especially with respect to stall and with shear) ; - for flights made with crew musts of the same rank, the functions of each and the task sharing be especially wel l defined. 4 .2 .1 .2 - The investigation showed that neither of the crew metfers had previously node demonstration flights nor followed specific training for this . The Ooaai.ssirn reoa mmrC s that : - crews performing demonstratim flights receive special and well-adapted training, which is not within the scope of th e basic training or type Q alifirs+ticxi . 63 . 4 .2 .2 - Cabin attendants 4 .2 .2 .1 - During discussions meld with cabin attendants , whether or not involved in the accident, it became clear that after the A320 specialization training course, certain cabi n attendants still had doubts relevant to certain canninicatio n and safety equipment, these doubts being alleviated only afte r in-service practice from explanations given by other personne l and practical training on the aircraft during line stops . The Conmissi an retamends that : - the aircraft gpRlifi rLion stage be reinforced and that emphasis be placed an the location and the use of the safety equipment ( Y exits, communication system, megaphone , anti,emd a masks, etc .) . Bach trainee must handle all the safety equipment on the actual aircraft arm a demonstration mock gyp. 4 .2 .2 .2 - The evacuation was achieved better at the rear tha n at the front of the aircraft . The experience of the cabin attendants present, who had already had experience of a simila r situation, no doubt contributed significantly . The Commission reea:cnerrls that : - means of simulating a realistic envixament for training cabin attendants be studied . 4 .2 .2 .3 - Several passengers said in their statement that th e confidence of the cabin attendants and their reassuring word s helped than to evacuate the aircraft rapidly and calmly. The Commission suggests that : - cabin attendants be made more aware of the psychologica l effect that their remarks and behaviour can have on th e pgEO:8 . 64 . 4 .3 - AIRCRAFT 4 .3 .1 - The Commission remarked that certain operating defects, which played no part in the accident (defects mentioned in the mechanical reports), have since been corrected on the in-service aircraft . The Commission believes therefore that no recatmendations need be mad e concerning these. 4 .3 .2 - The Commission remarked that the aural anmuncements made b y the radio altimeter and the aural warnings were transmitted only via the cockpit loudspeakers and not via the pilots headsets . The Commission recommends : - that studies be made to see if it would not be judicious to transmit all warnings and aural announcemants via the pilots headsets. 4 .3 .3 - During the accident, the two recorders stopped almos t simultaneously before the ai rcraft finally came to rest and was destroyed by the fire : the exact cause of this could not be determined, however, the most probable supposition is that the power supply cables of the 2 recorders broke . They are located in the sam e cable bundle . The Commission recammerds that : - when these are separate voice and flight data recorders, the cable routes should also be separated . 4 .3 .4 - Due to the circa u tares of the accident, the communications equipment was not used . However, study of the cabin furnishin g reports and discussions with various cabin attendants led the Commission to recammerl thht : - the system attaching the handset to the cabin well be reinforced . 65 . - tie cabin interphone and the Cabin AttendanttFLight Crew/Cabi n Attendant Call system be returned autaaaticaf ty to the "Public Address" function each time that the handset is hung up cm it s support, so that the flight attendants can broadcast urgent messages very quickly to the passengers using only one hand (a t present, the system is reset after each use, bwo operations are therefore required to talk : select required function then pres s handset switch to talk) . Also, the Commission remarked that the emergency lighting automati c illumination programming error has been corrected ; they therefore consider that no recommendation relevant to this are required . 4 .3 .5 - In their response to the evacuation questionnaire , 11 passengers indicated that they had had some trouble in openin g their seat belts and that some required help ; these difficulties were due to a lack of kmnwledge of the seat belt opening procedure . Also, it must be noted that, to open this type of belt, the flap mast be raised then the two halves of the belt separated . Consequently, the Commission recommends that : - during the safety demonstrations before each flight, use of the seat belt be demonstrated (closing, tightening, opening) . - t1 a prooechrres be also indicated in the leaflet giving safety instructions for the passengers . - the attention of the seat belt nmmfacturers be drawn to th e advantage of providing unlocking systems 4:ere a single simple action causes both unlocking and separation of the two halves of the belt. 4 .3 .6 - Fran among the passengers who answered the questionnair e mentioned above, 50% (i .e . 49 persons) declared that they hit their head an the back of the seat in front of than leading, for same, to partial loss of oonacirousress . Mme (commission reoocmwrds that : - studies be undertaken so that the design of future seats takes thi s potential problem into account . 66 . 4 .4 - ORGANIZATION OAF HELP After the accident, the fire fighting and first aid vehicles ha d difficulties in getting to the accident area, the only access road t o the place where the air sham was held (and also the place o f accident) being congested by many private vehicles . Also, the fire-fighting trucks could not gain access to the wreckag e as they were too wide for the forest tracks, and only small vehicle s could reach the aircraft . The investigation commission recommends that : when air shows are organized : -access to the aerodrome is kept open for fire-fighting and first aid vehicles, - the safety facilities in-situ be adapted to the envircmuent . 67 . 5 -APPIOVAL OF THE REPORT This report has been accepted unanimously by the members of the Investigation Commission, November 30th 1989 . President of the Camiission Claude BECH T Vice-President of the Commission Frangois GOWN L Ingénieur Généxal de la Météorologie Bernard FARTfiI7MT Le MedecinGenéral Robert AUFFRET L Ingénieur en Che f de 1 Aviation Civile Paul ARSLANIAN Pilot Inspector, !9e[ber of the Organism e du Cantrále en Vol Philippe GOURGUEC EEN L Ingénieur du Bureau Enquêtes Accident Jean-Paul de VIIL,IINEUVE A P P E N D I C E S 1 - Map of the region with path tracked by aircraft rada r 2 - Plate of the Mulhouse-Fíabsheim aerodrome 3 - Photographs 4 - Perspective view showing the way the trees were cut 5 - Transcript of the radio communications 6 - CVR transcript 7 - DFDR-CVR correlation 8 - Reproduction of DFDR parameters 9 - Air France Note DO ND 5042 0 10 - Flight Zest Sheets Us ydro-Elec / : . ~ s,a a~~~ ssa Accident , DISIIpM • 1:71% ~~ ~ ~~• ; s .. -~ M P~r •aáaa ►~o r wptsna►r APPENDIX 2 - Mulhouse-Habsheim aerodralle plate - CARTE O ATTERRISSAGE A VUE MULHOUSE- Heb:helm LFG B Lei : 474417 N Long : 007255$ E Alt 240 n1 - 787 Ft NMI - 88 - NAIR-NM Situation : d tm E 6 (28 hPa) RR : ►mm ACC : BEMIS Idures+ml 124.100 - OEIMS tomb 124.l50 AOp : IY Twr : muumuu Tow 125.áO ST elt~tmar COUMA141hwM CU1721.i (iMAM141111riia C~w avdWs M - 7iSSI11NOM y r..a - 00r O , , M .Y 7 :1 ♦ 9 Position 2S 0 ~ ofo+ Wreckage °j 4 2 2 ~ 4r _ ~ Nip /i t. q .1 46 4.. ! 4 ~. !. • ~/ / ~ . ,• / .~ 23f ! r // • _ ~ ~ / ~~~ ~ ) ~ ,y0 ~ % / , \ / ~A t 40 • It741 Y/ A 26r \\♦\ ~~ , o , ew i % , `/ 301 i 24 1 24 s • o ~ AI X J .~ \♦ ` ~ ~ r / ~ / ßS41 ~~ 240 ~i► 2 1+ . ~ b e :00 Ir 44 - AIL w. .ww .2 6 ) 7 =Few , ~ \ ~ . 21 NIIrL01TIR Au Q]J 4 eul SOLI- OI Zs NA us • :mt = ewr..~ R~1CDO1m r~10n : A/ .. .r m Adl ow ..w . 4. ad mme.aum Ool Ad. 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AI SW wam rAT2 dib-Midop ß 0501700 w AI L CORRECTIONS : RmbietitNt - Cmuiples - Midis - AC! ~ Nr 108 S ~ 88 02 11 SERVICE OE LWFORMAT10N AERONAUT10UE — FRANCE MULHOUSE-Hebeheim LFG B A' APPENDIX 4 FUSELAGE ENGINE + LANDING GEA ENGINE + LANDING GEAR R PERSPECTIVE VIEW SHOWING THE WAY THE TREES WERE CM' APPENDIX 5 RADI0C7QNIlM .INICATI( N RECORDINGS BEIinIEEN BASLE-M[ü HOUSE AND ACF 296 Q ON JUNE 26th 198 8 Time GMT Stations Text 12h 25m OOs ACF296Q Basle from Air charter two nine six 25m 04s Basle Air charter two nine six over 25m 06s ACF296Q life request start-up clearanc e 25m 08s Basle Roger two nine six I ll call you 25m 10s ACF296Q Roger 12h 25m 15s Basle - Air charter two nine six clear to star t up 25m 18s ACF296Q - OK two nine six 12h 25m 24s Basle - Two nine six confirm that on departure you re doing a flyover at Habsheim 25m 27s ACF296Q - That s right so if it is OK by you we l l do anti-noise procedure on sixteen turn right fly towards BLM then straight t o Habsheim and than leave for Hericourt as normal flight plan 25m 37s Basle - Roger you are taking sixteen 25m 40s ACF296Q - Roger that s fine thank you 12h 29m 12s ACF296Q Charter . . air charter two nine six taxi clearance please 29m 20s Basle Air charter two nine six Quebec taxi holding point sixteen 29m 23s ACF296Q For holding point sixteen air charter two nine six Quebec 12h 30m 50s Basle Charter t%v nine six Quebec can you tell what altitude you want 12h 31m 09s Basle - Air charter two nine six Basle 31m lls ACF296Q - Go ahead 31m 12s Basle - Two nine six Quebec can you tell me what altitude you want 31m 17s ACF296Q - Yes after take-off we ll take a righ t turn one thousand feet to the flying club then there we make two flyovers . The second at high speed and then we l l negotiate clearance with you to g o straight to Hericourt 31m 35s Basle - Roger two nine six Quebec 31m 39s ALr296Q - Well it would be good if we could have clearance before second flyover as we ll be passing at high speed like that we could climb quickly 31m 45s Basle - I\o nine six Quebec you confirm on e thousand feet above ground then 31m 48s ACF296Q - One thousand feet above ground and by right turn there and then after we l l descend for low altitude flyover of the airfield over there 31m 53s Basle - Roger I ll contact you 31m 55s ACF296Q - Roger 12h 32m 40s Basle - Air charter two nine six Quebec ready to copy 32m 42s ACF296Q - Go ahead 32m 43s Basle - OK two nine six Quebec after take-off on sixteen right turn to Bravo Sierra climb to two thousand feet Ql! H one thousand an d thirteen QVH and transponder six fou r four three 32m 55s ACF296Q - Roger six four four three right turn to Bravo Sierra from Bravo Sierra and two thousand feet QiH air franee oh sorry air charter two nine six Quebec eh then we g o straight to the flying club and flyover over going north at low altitude and the n the second flying south towards you and at that time we need one nine zero clearance to Hericourt 33m 23s Basle - Roger and clearance will be regiven by approach therefore it s correct contact tower on one one eight three good-bye 33m 28s ACF296Q - One one eight three good-bye two nine six Quebec 12h 34m 55s ACF296Q - Air charter two nine six Quebec at holding point sixteen 34m 58s Basle - Hello air charter two nine six Quebec hold before runway sixteen 35m 02s ACF296Q - OK we re holding before runway sixteen 12h 36m 10s ACF296Q - Two nine six Quebec we ll line up whe n you like 36m 14s Basle ¶ D nine six Quebec hold before runway sixteen we still have an IFR to land , like that you can go straight to Habsheim at low altitude 36m 20s ACF296Q - Thank you two nine six Quebec we hold 12h 38m 34s Basle - Air charter two nine six Quebec a cityliner on final sixteen call when you see it 38m 38s ACF296Q - Roger we can see it two nine six Quebec 38m 40s Basle - Roger behind the cityliner on fina l sixteen line up behind and hol d 38m 43s ACF296Q OK behind the aircraft on final we line up and hold two nine six Quebec 12h 40m 40s Basle - Air charter two nine six Quebec clear for take-off runway sixteen wind calm 40m 44s ACF296Q - Rolling two nine six Quebec 12h 43m 34s ACF296Q - After take-off for air franse we re practically in sight of the airfield there 43m 41s Basle - Roger air charter two nine six you can contact Habsheim on one two five two five good-bye 43m 45s ACF296Q - One two five two five good-by e END OF RDCORDING TRA1SCRIP1ZCN OF RADIOCOMMUNICATIQZS EXCHANGED ON JUNE 26 1988 ON FREQUENCY/125 .250 MHZ P = Pilot A/C ACF 296 Q C = Mulhouse-Habsheim controlle r 1244 P Air Charter Quebec Hello 124404 C 296 Q Hello P We re caning into view of the airfield for flyove r C Yes I can see you, you re cleared, sky clear 124415 P CSC we re going in for the low altitude low speed flyove r Air Charter Quebec C Roger 124425 C Quebec November Hotel Habsheim 1012 Fox Echo 98 4 P Roger Call Fox Alpha Bravo Quebe c 124551 (not identified) : Achtung Feuer Feuer the 320 the 32 0 has caught fire Achtung Achtung 1246 C Basle Basle the 320 has crashed the 320 has crashed Basle You repeat, it has crashed C Affirmative 34 200 meters 300 meters north of the runway Basle North of your runway C Repeat 124616 UG Alouette Uniform Golf, I ll take off for AERf EDICAL EVACUATION if you like C OK Basle Basle Approach repeat Mulhouse here Basle Approach repeat where did the AIRBUS crash 124625 C Affirmative it crashed north of the airfield after flyover 124630 Basle North of the Mulhouse-Habsheim airfield Basle How many kilometers about 124641 C Try to warn the airport if you can send someon e 124643 Basle Roger all right we ll do what we have to then C OK A P P E N D I% 6 lItANbCRIIMON CF THE COCKPIT VOICE RECCRDER AM) WARNIWS CF THE AIRBUS A 320 AIRCRAFT registered F-(FEC involved in the accident on June 26th 1988 at . Capt . : Captain F/O : First Officer Purser : Purser F D nine Vbioe TOWER : Local aerodrosie control tower GROM) : Line mechanic : Word, Group of words, not understood or omitted REMARKS Only the last 19 minutes of the CVR have been transcribed as only thes e concern the flight during which the accident occurred . They have been subjected to a spectral analysis which was more exhaustive for the last 3 6 seconds . Therefore, the conversations, have been accurately identified an d timed in this transcription . 1 NOISE S TIME I FROM CONVERSATIONS RADI O WARNING S COMMENTS Remark : Start of tape corresponds to end of previous flight (not transcribed ) 12 H 27 15" I GROUND I Good ~ Clack 1 1 OK ready for push back then ~ Capt . OK 12 H 27 32" I Capt . I Ready for start-up of 1 ~ I GROUN D OK I I Capt . I Roge r 12 H 27 37" Capt . you see 1 how it got it there are 2 signals, there s boost APU which gives th e signal and closure of packs, the pack s I they ve already got their signal as wel l Whoop . . . Whoop . . . Whoo p I When we start 12 H 27 46" ~ Capt . There s a prehistoric one 1 (Laughter and joke s Feminin e -~ concerning a firs t I Voic e I generation aircraf t arriving at adjacen t I parking area) . F/0 OK, Ignition A and oil pressure I Clack 1 Personal discussion 12 H 28 11" Capt . I OK, start-up completed you can unplug and I signal on left I think good-bye I I Gong 1 I Gong 1 12 H 28 17" I GROUND I OK, good trip, see you later, Capt . Yeah I Adios mat e I (doubtful ) I Right away, got to do it, Click, Clic k Click 1 Click 1 You press it Hop I I Many switching noise s 1 There I I Click I Click 1 Sorry, thank you 2 12 H 28 33" I Capt . I Control surfaces clack 1 clack 1 Like tha t I I ll hear yo u F/0 1 Yes but I Capt . I There you are, do you want to try ? (blowing twice into the microphone ) I F/0 I It s very good . . . 12 H 28 46" I Feminine You managed to find a mechanic after all l Voic e 12 H 28 50" I Capt . I After start check list (Laughter ) I F/0 "After start" Ignition l 12 H 28 53" 1 Capt . I NORMAL I I F/0 I ECAM Status . They re there 1 I Capt . They re there and we know them Click Al l 1 blac k 12 H 29 01" I F/ 0 1 O K I F/0 Anti ice ? Capt . I OFF 1 12 H 29 04" I F/ 0 Gen 1 and 2 ? I Capt . I ON 1 I F/ 0 I Flight controls ? 1 Capt . Checked 1 F/0 On right as well I Rudder trim t 3 I Capt . I It s at zero t 12 H 29 10" I F/0 I and the pitch ? I Capt . I Everything s fine I F/0 . . You checked everything it s OK ? I "After start" completed t 12 H 29 13" I F/0 We are on one That s O K I F/0 Wait, I ll do it, I ll spea k I Capt . OK 12 H 29 16" I F/0 - ACF 296 tax i clearance please ? 12 H 29 20" I TOWER - ACF 296 Q taxi to l holding point 16 I 12 H 29 23" I F/0 I For holding poin t 16 the Air Charte r 1296 Q 12 H 29 26" I Capt . Right ? F/0 All clear to right I ------Laughter and joke s ------concerning previousl y mentioned "prehistoric " aircraft - Clack I F/ 0 Eh, we ve not extended flaps 1 l I Capt . One We have, it s OK I 12 H 30 13" F/ 0 I and spoilers armed I Clack t I Capt . I There we ar e I Anyway it s there for that it ll tell you . 4 12 H 30 16" F/ 0 I OK, you, you, you . . . you explain your speed, I altitude, etc . I 12 H 30 20" I Capt . 1 OK then, take-off right turn, leave the flap at 1, anyway we do normal take-off, retrac t I the landing gear and with flaps at 1, we go I I nice and easy to find our thing . As soon as we l I have formally identified it, we extend the I I flaps to 3, landing gear extended, do the I I flyover at 100 feet, landing gear out and then ) you leave it to me . I ll give it alpha max , 1 I ll disengage the alpha floor and then, if I I tell you it is hard you help me and you hold I I the power to keep zero vertical rate I 12 H 30 51" I TOWER Zero vertical rate and me I ll hold it at - ACF 296 Basle, ca n alpha max . At the signal you give it TOGA and I you tell me wha t I I ll pull the stick and if you re there I bank altitude you woul d I away I like ? 12 H 30 56" I F/ 0 You want to get off there then 7 I Capt . That, I ve done it twenty times, that one . I F/ 0 I OK, we re agreed 1 12 H 30 59" I Capt . And then, after, we bring everything in, mov e off and give it all its got to 340 knots an d the second, you also go over at 100 feet, an d there, no need to pull 2 .5 g as back there , they won t like it . 12 H 31 09" I F/ 0 OK all tha t 12 H 31 09" TOWE R ACF 296 Q Basle ? 12 H 31 11" 1 F/0 I Go ahead 1 12 H 31 13" 1 TOWER Yes, 296 Q, ca n I you tell me wha t I altitude you want ? 5 I F/ 0 1 2000 1 I 12 H 31 18" I Capt . Roger, 1000 feet to get there 1000 feet to get there, 1000 feet ground I 12 H 31 19" I F/0 I Yes, after take - I off, we ll take a I right turn 100 0 I feet to the flyin g I club then there I we ll make 2 I flyovers the second at high speed an d I then we l l 1 I negotiate clearanc e 1 I with you to go t o 1 1 hmmm 12 H 31 35" I Capt . . . . Hbricourt I Héricourt . 12 H 31 35" 1 TOWER Roger 296 Q I Capt . So it s 1000 feet Fox Ech o 12 H 31 39" I F/ 0 Well, it would b e 1 good if we coul d have clearanc e 1 before the secon d I flyover as we ll b e I passing at high I speed, like that , we could climb quickl y 12 H 31 45" I TOWE R I Roger, 296 Q, yo u confirm 1000 fee t I above ground then ? 12 H 31 49" I Capt . 1000 feet/groun d 6 12 H 31 49" ~ F/0 One thousand fee t above ground and by e right turn there, I then we ll descend I 1 for low altitud e I flyover of the I airfield there ~ Clack 1 12 H 31 53" ~ TOWER OK I ll call you 12 H 31 55" 1 F/ 0 OK I Clack 1 12 H 31 58" I Capt . Autobrake max I F/0 Yes 1 1 Capt . Take-off config tes t 1 F/0 Yes then t eh t OK t 12 H 32 03" Capt . Have you already seen what the take-off config Clack l Clack 1 test does . . . watch, if you put it ther e Wait there Wait sh . . . . Imagine that it s I like tha t Go on7he take-off confi g Clack l I That s it it must move a littl e I That s it, do it now t Go on . F/ 0 I . . .(reply incomprehensible t ) Capt . I Yeh Ye h Capt . Put it . . . put it on 1 so that we won t get i t wrong . 12 H 32 22" I Capt . The detents are too well don e 12 H 32 25" ~ F/0 Well then 1 Between the two there when I tak e it for the high speed flyover you negotiate the 190 clearance so that we can get out o f I there and do a pull-out at 2g for STS . 7 12 H 32 35" Capt . No, don t pull-out at 2 .5 g as yesterday w e did 2 g 2 .5 g in training and I ve had enough of that I have 12 H 32 40" 1 TOWER ACF296, ready t o copy ? 1 Capt . - Yes, he s ready 1 12 H 32 42" I F/ 0 Go ahead 1 12 H 32 44" I TOWER I OK 296 Q afte r take-off on 1 6 I right turn to I Bravo Sierra climb to 2000 feet QNH , QNH 1013 an d transponder 644 3 Purse r In short, what are we doing ? 12 H 32 55" I F/ 0 Roger, then 644 3 right turn to Bravo s 12 H 32 59" ~ Capt . We take off, fly to the Habsheim airfield, I Sierra, from Bravo there we do a low altitude flyover, bank, Sierra and 2000 ~ accelerate, flyover at top speed and get out I feet QNH AIR FRANCE of there . I oh sorry . . .ACF 296 I I Q, eh then we go I Purse r to the Mont-Blanc ? I straight to th e 1 aeroclub . We flyby 12 H 33 16" ~ Capt . A second flyby southward 1 I going north at low ~ I altitude and then I second flyb y I southward toward s I you and at tha t time we need 19 0 I clearance t o I Hericourt . 12 H 33 23" I TOWER I Roger and clearance) 8 I will be regiven b y 12 H 33 26" I Capt . There we are . . . I approach therefore I it s correc t contact tower o n 118 .3 good-by e 12 H 33 29" F/ 0 118 .3, good-by e 286 Q I F/0 Yes, you were saying 7 Click ! 1 Purse r - No, but I was saying the cabin was ready . . . I F/0 You, you stay seated during the complet e flyover . . . Purse r About the announcements, you re doin g something . . . 12 H 33 38" I Capt . 1 I m going to tell them, yes , I The announcements I ll do the m Purse r I . . . OK there are also some . . . in German . I F/ 0 You see 12 H 33 43" I Capt . I Ladies and Gentlemen, Hello and welcome aboard ) I this AIRBUS 320 No . 3 of the series for AI R I FRANCE and which has only been in service for I 2 days . We shall soon take off for a short I I tourist flight starting at the Habsheim flying ) I club where we will do 2 flyovers to I I demonstrate the continuity of the French I I Aviation and then we shall make a tour of I I Mont-Blanc depending on the weather condition s and air traffic . I I wish you a very agreeable flight . I Meine Damen Und Herren . . . . I (Announcement more o r 1 . . . . Ich WUsche Ihnen eine Guten Flug . I less identical i n I German) 12 H 34 47" I Capt . There we are good 9 12 H 34 55" Capt . ACF 296 Q at I (Joke about the Fir s t I holding point 16 I Officer ) 12 H 34 58" I TOWER I Hello ACF 296 Q ~ I hold before runwa y 16 ~ 12 H 35 02" I Capt . OK I We re holding ~ before 16 .96 Q ~ 12 H 35 10" 1 Capt . I m going to give C . . . hell . He s not see n that the data banks are not the same . He s I gonna be in the sh . . . for a while I (Laughter ) 1 F/ 0 I Alright I Capt . Poor C . . . he ll be in for i t F/ 0 I Eh I We ve not done it before take-off 1 I Capt . I What before take-off we are . . . hold before Word incomprehensible I runway . I F/ 0 Yes l but it s done high up . . . 12 H 35 25" Capt . I Well, autobrake max , I Well, ye s Signs o n I Eh It makes no difference ; spoilers armed , I Eh yes If the . . . . it disengages jus t after the landing gear it s OK . Flaps 1, take off, take off config normal 1 Normal I Good "pre take-off" completed . 1 0 12 H 35 42" I Capt . Crate in view t You re lucky aren t you 7 Feminine voic e I F/ 0 What did you say ? I Capt . Super efficien t Did you see that good wor k F/ 0 Right on time every time 1 Dead on time 1 (jokes concernin g journalists ) I Capt . 12 H 36 10" I F/ 0 Ah . . . 296 Q We ll line up when yo u like 12 H 36 14" I TOWER I 296 Q hold befor e I runway 16 we stil l I have an IFR to land like that you ca n I go straight t o Habsteim at lo w I altitud e Capt . GUT I 12 H 36 21" I F/ 0 I GUT 1 ~ OK 296 Q we hold (Whistling ) I F/ 0 I Right then you we keep flaps 1 to go there 1 I and extend when we get ther e 12 H 36 29" I Capt . I Wait take it easy, we descend, we ve not much margin Cling 1 gling 1 gling t F/ 0 I Then . . . eh you you turn above there fl y (Whistling) almost back over the end of the runway, pic k up the motorwa y Capt . I ve I ve I ve I ve and you almost didn t have it opposite 1 1 Capt . I and I ve I ve all here t I F/ 0 I m like that t 12 H 36 45" I Capt . I m not really worried about that you know (Whistling ) 12 H 36 54" I Capt . I I ll put it on NAV, like that I ve an overall I view and I stay on "ARC" - You put it on 1 fort twenty forty twenty miles, s o 1 that all s in, me I ll stay on ARC at te n I miles . (Whistling ) Feminin e (Question inaudible ) Voic e Capt . What 1 No, I ll tell you something you re no t used to cockpits, are you ? but like this whe n we re really busy as you can see you shoul d not speak eh shouldn t bother not spea k I eh should nt bother the pilots, eh ? 12 H 37 32" ~ Capt . I You see how he is 1 I F/0 . . . You are not used t o Discussions with th e two passengers in th e cockpi t Personal conversation Have you seen what I ve selected there ? Can you remember the clearance over th e motorway 1 eh ? eh 1 Herr Mazière s What is the minimum clearance over a motorway ? Three hundred meters 1 12 H 38 24" F/ 0 Eh t And when we get over, Meribel, a littl e before I ll give you the microphone behin d I to call who you want there . 1 2 Capt . We won t see it very well 1 don t you think so 1 1 F/0 What 1 12 H 38 34" I TOWER 1 ACQ 296 Q, a cityliner final I sixteen call whe n I you see i t 12 H 38 38" I F/ 0 Roger, we have see n it 296 Q 12 H 38 39" 1 Capt . I don t know if you ll be able to see 12 H 38 40" I TOWE R 1 Roger behind th e 1 cityliner on fina l 116 line up behin d I and hol d 12 H 38 43" 1 F/0 OK behind th e I aircraft on fina l we line up an d 1 hold 296 Q Feminin e ------Voic e 12 H 38 45" 1 Capt . I I ll flyover the runway there for eh flat ou t no, no, no, no, don t pass 1 no, n o . . . .we v e The radio s OK, that s that s it . . . That what I want to say . . . on the radio what I Mustn t do just anything . . . 1 3 I That for that you need a special clearance t o I do what you re going to do but at Meribel . . . No at Meribel there s not . . . I Otherwise I m not goin g Capt . I If I haven t got clearance we re not going . . . I there, the flyover, the only thing, is at the I discretion of the crew . . . 12 H 39 03" ~ F/0 1 There you know you if there you know I anyway you ll get them on the radio e h I we ll say . . . (Jokes ) F/ 0 OK, we line up behin d (Laughter ) 12 H 39 39" 1 Capt . I You ll extend the lights and will keep them s o Clack t Clack ! that they can see us All the lights we keep them we ll retract them only passin g (whistling ) Capt . Ah . . . leave it on . . . I F/ 0 (illegible) 12 H 39 52" I Capt . "WING" they won t see there s no poin t Capt . In any case, we ll forget them on landing I F/ 0 (Sigh, whistling and 12 H 40 16" Capt . German rhyme) 1 4 I Capt . I All right then, ready si r 12 H 40 40" I TOWER ACF 296 Q, clea r for take-off runway I 16 wind cal m 12 H 40 44" , F/0 ~ We re rolling 296 Q ) 12 H 40 48" I Capt . ~ Take-off Go I Engine acceleratio n I noise 12 H 40 59" F/0 + Capt . Thrust SRS 1 RUNWAY 12 H 41 04" F/0 I Parameters norma l Clack Clac k I Capt . 12 H 41 16" ( Capt . 1 + (simultaneously ) I F/ 0 100 12 H 41 19" ( F/0 It s already requesting "CLIMB" the b I you see that 7 Capt . I Yeah, that happens I know the bug Illegibl e I F/ 0 Yeah yea h 12 H 41 26" F/ 0 I V1 - V r I F/ 0 It wasn t up Doubtful 12 H 41 32" 1 Capt . 1 Positive climb Gear u p I Clack 1 (L/G operation ) 12 H 41 47" I F/ 0 I Alt Star Gear up 1 (Buzzer) (Alt capture ) 12 H 41 52" 1 Capt . I (Reduction in engine 1 noise ) 1 5 12 H 41 56" I FIG Gear up, flaps 1, after take-off check list i s I completed except for flap s 12 H 41 58" Capt . I m dis . . .gaging the autothrottle (word not clear ) I Gong = Instinctive Disconnec t 12 H 42 00" 1 (declaration by crew ) I Clack . . . Clack . . . Repetitive gon g (config . warning ) 12 H 42 03" Capt . That s the landing gear that, it s no t important, kill it e h F/0 12 H 42 06" I Capt . I It s below 1000 feet at low altitude you ca n I be sur e Slight increase i n engine spee d 12 H 42 08" I F/ 0 I Shall we extend it eh ? 12 H 42 12" ~ Capt . I No 1 No : don t extend right away, it s because I ve throttled back to below a certai n I N .1 . We know that one Stabilization of engine speed (New repetitive gong 1 ) (second config warning ) 12 H 42 27" ~ Capt . Oh 1 kill it Ah I It gets on my wick tha t on e 1 6 12 H 42 29" F/0 I Extend it, it makes no difference to get there 12 H 42 32" 1 Capt . I There we are . . . Reduction in engin e spee d 12 H 42 54" I Capt . Good, it is as if we could see the airfiel d F/0 You re at 8 nautical miles there, you ll soo n see it, there s the motorwa y 12 H 42 57" 1 Capt . We ll leave the motorway to left, won t we . . . it s to the lef . . . no, to the right of th e motorway . F/ 0 It s slightly to the right of the motorwa y so you . . . you leave the motorway on the lef t 12 H 43 07" I Capt . I OK, as soon as we identify we descend ver y I quickly then , 12 H 43 10" F/0 Leave everybody fastened i n Capt . That s, that s normal for it, it always doe s I that to start with . You see, it keeps th e I landing gear the whole thing Capt . I OK, then it is OK I that we ve got at th e start . Well there s a little way that s Clac k 1 interesting . Yeah 12 H 43 36" I F/0 After take-off fo r Air France 296 , 1 we re practicall y I in view of th e I airfield there 1 7 12 H 43 41 " I TOWER I Roger ACF 296 yo u I can contac t Habsheim 125 .25 good-bye 12 H 43 46" ~ F/ 0 ~ 125 .25 good-by e I F/ 0 Habzeim 7 That s it no ? 1 Capt . 1 Habsheim . Habs Heim I F/0 ~ Habshei m 12 H 44 01" 1 F/0 Ah 1 Habsheim Air Charter 296 Q Hello Capt . There s the airfield . It s there . . . you go t it, have you ? 12 H 44 05 I TOWER ~ 296 Q Hell o 12 H 44 10" Capt . ~ What ? We re coming int o view of the airfield fo r flyove r 12 H 44 13" TOWER ~ Yes, I can see you , you re cleared eh Sky is clear . 1 Clack 12 H 44 15" Capt . Gear down 12 H 44 17" ~ F/ 0 OK, we re going in I L/G aerodynamic noise s for the low ~ altitude low speed flyover 296 Q 12 H 44 22" ~ TOWE R 12 H 44 23" I Capt . Flaps 2 Clac k 1 8 12 H 44 27" TOWER QNH Habsheim 101 2 Fox Echo 9 .8 .4 . 1 Capt . OK 12 H 44 31" I F/0 Roger 12 H 44 32" Capt . 9 .8 .4 . put in 9 .8 .4 . 12 H 44 34" I F/0 9 .8 .4 . QFE selected t 12 H 44 37" I Good gear is down = flaps 2 t 12 H 44 42" I Capt . I Flaps 3 12 H 44 45" I F/0 I Flaps 3 t I Capt . I That s the airfield, you confirm 7 12 H 44 48" I F/0 1 Affirmative 12 H 44 51" I F/0 You see it LL 01, when we get there there you re at 1 nautical mile, that s right 12 H 44 55" I Capt . GONG I (Nose Wheel Valv e according to the crew ) I F/0 OK I "Too Low Terrain " 1 (GPWS ) 12 H 45 04" I I Gong t (GPWS cut-of f 7/10 1 I according to the crew ) 12 H 45 05" 1 I "Two hundred t" (radio 7/10 1 altimeter) allusion to airline flight safet y I office r 12 H 45 11" I F/0 P G 1 1 9 12 H 45 11 " I "Two hundred" (radi o 4/10 1 I altimeter ) 12 H 45 12" F/0 G is going to . . . eh I (continuation of previou s personal remark ) 12 45 14" I F/0 OK, you re at 100 feet there, watch, watc h 12 H 45 15" I "One hundred" (radi o 3/10 1 altimeter ) 12 H 45 19" I I"Forty"(radio altimeter ) 1/10 1 12 H 45 23" I "Fifty"(radio altimeter ) 6/10 1 12 H 45 26" Capt . OK, I m OK there, disconnect autothrottl e 12 H 45 27" I "Forty"(radio altimeter ) 5/10 1 12 H 45 32" I F/ 0 Watch out for the pylons ahead eh See them 7 12 H 45 33" I Capt . Yeah, Yeah, don t worr y 12 H 45 34" 1 Clack I Clack 1 Clack l 5/10 1 (power lever detents ) 12 H 45 35" I I"Thirty"(radio altimeter ) 3/10 1 12 H 45 36" I "Thirty"(radio altimeter ) 2/10 1 12 H 45 37" 1 F/ 0 TOGA/SR S 12 H 45 38 " "Thirty"(radio altimeter ) 3/101 2 0 12 H 45 39" I F/0 Go around track Increase in engin e spee d Noises of impact in th e tree s 12 H 45 39" I Capt . I Sh 9/101 I 12 H 45 41" I I END OF TAPE 5/101 I . , . . , ,~ . ~ I ~ — — — ~_ i T hii HïL. ? T - , ~ - ,1~ ;~-- ;- ;-~- i - - , -- , ; ~ ; t =: ; - - ~- I ~ 4~; » ~ I á I I I I I i ; I , L -i ~ = :~ _ ° i iá- ~~ -~ - - 17h1S DO• ; - - - ~-~ — ~ = - i _ ; • .___í :#C►~ `~i ; two hundred I2h1S•OS• ~ ,oá ®®D®® 6 J ~~0 i. ,L ~ -~ 17h1S•1o• ' • --~ ~ ► _ : .-N. Á-- -- - 1 ~ you arrive at 100 feet there, watch, watc ~► _~ - H one hundred h ~7h1S 1S• ~ -~ ~ ~ i ii! forty - -- - ~ ~ 1- - -~ — — ~ 17h15 70• NU,~~ ~~~ ,~~~~~~®~á~i.~~® ~ . rimy +7h1S 2S• a forty —i f : ~ t7h1S )0- r _ • -. . + :.~ ,;. ~ ~ ~ ~ ; ~ ; i : : _L_ 1 ;~ J ~ • ~ ; ~ , -, watch out for the pylonsyeah, ahead, yeah, eh, don t see worr thayn ~ r-f-~ , - ~ initiation of qo-arounthirtyd 17hi5 1S- _~ ~ } -; - --,-~ — ~I ~ -~ thirty ~ -- L. _ TOGA,thirty SRC I ---- - I{----~-- ~- ~ -f--Y--~1-. - ~--- ~ t mart with the trees 17h~S 10 114> ~ N., APPENDIX 8 REPRODUCrION OF I*M PARAIClERS ! !u+ 101 . (C l 001 kon ouo OL0 60( 9t.( + lLl LG lLl . l•u uv Lu . . • Ill •la l V . 94 1 wtv- v ,aL SLcI• L .uZ 41 . 1 t Eu+ sof. 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GN PUATAIRES DG.DT - DG.GN - DT .TI - DO.NY SCOPE : Tburist or demonstration flights (Ref . DO . ND 50 420 ) The study of several law altitude flight cases by the Flight Analysi s Cc: mission leads us to remind you that all flights, or parts of flights , made for touristic or demonstration reasons, must be covered by th e following : 1) an accurate definition, by the Flight Division concerned, of th e performance conditions (distance, altitude, configuration, etc .) and the corresponding task sharing in accordance with sought objective , 2) written authorization from DO .ND with information to DO .NY. 3) meticulous preparation on ground and a carplete briefing of the crew before the concerned flight phase is undertaken . The general rules to be observed are : . minima manoeuvring height : 600 ft radio altimeter , . minima flyover height above runway of 100 ft in landing configuratio n and 300 ft in clean configuration . Other more restrictive rules taking the conditions into account (weather , type of aircraft, environment, contour, air traffic, etc .) may be retained. If any of these rules is not observed, the case shall be presented to th e Flight Analysis Commission. This, of course, also applies to all Systematic Flight Analysis anomalie s in the normal sense of the term (excessive bank or vertical speed, GPWS , exceeding limitations (VFE, EGT, etc .)) . These flights, important for our public image, mist be very carefull y prepared and performed and the rules given above are a contribution toward s this . I am convinced that you will do all you can to observe than . H. Petit APPENDIX 10 Catparison between the performance recorded on A 320 No . 3 (flight No. 260) and on A 320 F-G KC The following sheet compares the performances measured on the A 320 F-( E C in the last flight phase of the accident and on the A 320 No . 3 during a test performed in same configuration as the F-( KC in this flight phase . The comparison concerns the total height versus time variations which ar e representative of the aircraft performance report : the total height (H) i s the sum of the real height (Z) and the V2/2g parameters (the square of the speed divided by twice the acceleration due to gravity) . The total energy of the aircraft (E) at a given time is the sum of its potential energ y (mgZ) and its kinetic energy (1/2 mV2) ; the performance report can b e reproduced by the variation of the total height which is proportional to E (E = mgH) The flight phase of the accident taken into account in this comparison is : - for the F-( , the final flight phase (descent then decelerating level flight between the 200 feet at 80 m/s and 30 feet at 63 mIs) . - for the A 320 No . 3, a descent decelerating between 2595 feet at 7 6 m/s and 2350 feet at 61 m/s . The total heights variations (total gradient) during the sane time interva l are practically identical in both cases . fM 0..w:.í • . : `1. ; ., . f: ~ . . . ~.•~dl. ; . .. f ! , 4 r . .! ! f ! ; . . . . . ~! { I { . .. . . i . . .~ ! .~ • , ! . . . . f . . . ! ! e•+ a~ c . . .~... ! ! 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