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Flight 203

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by

Ellen Cummings

on 27 February 2013

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Transcript of Flight 203

History of Concorde Air France Flight 4590 Main Event Lesson Learned Striking similarities to the fateful Air France crash in 2000

Tire exploded takeoff
Fuel and Hydraulic fluid leak Root causes Preparation of the aircraft.
Exceeding the MTOW
Loaded in the wrong way
Number 5 wing tank overfilled
Miss-reported weather
Missed runway inspection Relating Other related incidents 1962 Separate French and British projects joined forces.
1967 First prototype at Toulouse.
1969 First flight from Toulouse
Concord 002 near Bristol
First supersonic flight
1973 Concord 002 first visit to USA
1974 First double transatlantic journey in one day
1976 First commercial flights (Heathrow to Bahrain) June 1979 Washington DC - Tyres 5 and 6 blew out
July 1979 Dulles Airport - Tyre blown
October 1979 New York JFK - Tyres 7 and 8 failed
February 1981 Mexico City- Tyres blew out
August 1981 New York - Aborted takeoff Tyre incidents Concorde Incidents 12 June 1979 - Two tyres blew
21 July 1979 - A tyre blew, probably due to foreign object damage
16 Sept 1980 - Tyre blew on takeoff
19 July 1988 - Two hydraulic system failures
15 July 1993 - Debris caused damage to the wing The general layout used in aircraft design in recent times is linked to prevention FOD. In comparison to 2000:
Higher melting point alloys
Reinforced and hidden landing gear wiring
Engine's location not directly behind landing gear

Accident prevention at design stage influences future maintenance costs It is important to recognise how human factors are directly linked to System Management Safety. Accidents often occur when there is failure to adopt SMS procedures and the subsequent consequences Program to be adopted by Organization to reduce cases of foreign object damage. It comprises of 3 main stages:
Awareness
- posters, publications

Training Staff
Inspection/Maintenance Missed runway inspection Shredded tyre Punctured fuel tank Fuel leakage Engine failure 1 The piece of titanium alloy which started the chain of disaster A 4.5kg piece of debris left the tyre at speeds around
310 mph A shock wave traveling trough the number 5 fuel tank caused it to rupture at its weakest point The leaking fuel was ignited causing a large plume of flames to follow the aircraft Loss of fuel caused engines one and two to surge and shut down There was no not enough power with the three remaining engines for a successful take off due to the overloading and the faulty undercarriage Lack of power Unable to accelerate or climb so remained at 230 mph and 200 ft Fire damage The fire caused the left wing to disintegrate Engine failure 2 Engine one failed causing an imbalance in power and causing the aircraft to bank The crash Group BB3 An important cause of the crash was that Concorde was over the aft Centre of Gravity limit. We have encountered Centre of Gravity throughout technological science, and here is a brief explanation of why it is important for flight stability. In the business module last year, we learnt the importance of RISK MANAGEMENT and HEALTH AND SAFETY. This is particularly important for air safety. The risk of damage from debris on the runway was not managed, as a titanium strip from another aeroplane punctured one of Concorde’s tires.
The first action taken by the head of the French Transport Authority immediately grounded Air France Concorde flights
As a result of this accident, and many less severe accidents, more effort has been put into managing foreign object damage. An example of this is the TREX system which uses high definition radar mounted to a truck to inspect runways for debris. Trex foreign object detection system From case studies such as Silver Bridge, the forensics module has taught us the importance of redundancy. There are contingency plans for engine failure; they can be re-started and are built to legislative codes as part of HEALTH AND SAFETY. However, at take-off, the Concorde needs all available engines to provide necessary thrust. As the Concorde must take-off at high speeds, if an engine fails at take-off, there is no contingency plan as no runway would be long enough to allow the Concorde to reach 200mph and then stop. This is one risk that cannot be managed. The ruptured fuel tank caused the fire damage and engine failure. This was caused by a hydrodynamic pressure surge when the tire fragment hit it, because as we know from technological science, liquids are incompressible so transfer a load to the fuel tank through convection and shock waves. FEA shows high stress near area of impact. We are familiar with FEA modeling from the design module. This diagram shows how the pressure surge causes a deformation near the point of impact To determine this, the debris was examined and experimental tests were carried out – which as we have learnt is an important part of all forensic investigations. For the same reason, tests were carried out to determine the failure mechanism for the burst tire. The selection of materials is an important part of design for durability, and influenced the rupture of the fuel tank. The wings were constructed from an aluminium alloy which was chosen as it was light weight, resistant to conditions high up in the atmosphere and resistant to cyclic loading, it could not resist the tire impact. As a result, they were upgraded with a Kevlar lining. Kevlar is a composite material – specifically it is made of woven aramid fibres. Kevlar is used for F1 fuel tanks as its fibrous structure is resistant to puncture – the failure mode of Kevlar is shown in the diagram compared to a brittle failure of something like the aluminium fuel tank. Picture showing the woven fibres of kevlar This image of Kevlar's molecular structure shows the molecular bond (circled in red) which is exploited to give kevlar its strength. The chain molecules fibres are oriented along the fibres axis, making them exceptionally strong The burst tire was a cause of the accident, and was already a known problem of the Concorde. Because it failed at high speed and pressure, the debris had very high energy (KE=mv2). At 4.5 kg and 400 km/h this means it had about 56kJv of kinetic energy. A lesson was learnt however, and new materials were chosen by Michelin, who replaced the nylon thread with another material so that the tires are

"less likely to lose pressure and throw off debris when damaged." LEGAL Finally, there are the legal implications of the accident, i.e. who is responsible. This was determined by the investigation, and resulted in Continental Airlines being charged with full civil responsibility, (but not criminal responsibility) and paying 1.3 million Euros to Air France for damage to their reputation.
Much more was paid out by Air France and others in compensation - an estimated 1 million Euros per passenger. This relates to law regarding health and safety which we were taught in year 1, and as we know, fatal accidents result in serious legal implications. Perrier, the flight test engineer from the 1980 Concorde modification program subject to 11 hours of questioning
The mechanic who fitted the metal strip which punctured Concorde's tire was charged of manslaughter in 2010 and acquitted in the 2010 appeal
Trial didn't happen until 2010, and the appeal in 2012 - a very long case
In an article 'Judging the Judiciary' in Aviation Week and Space technology, the legal investigation is questioned, suggesting that the Paris airports authority were 'let off the hook', and criticizes how the court handles aviation inquiries. Joe Flannery Ellen Cummings Bob Harding Cavin Kaseke Tuesday 25th July 2000
Air France Concorde 203 flight from Paris to New York
100 Passengers. 9 Crew members.
Concorde 203 clocked 11,989 hours of safe flying. 14:42:31
Pilot commences takeoff over an hour behind schedule.

14:43:06
Concorde reaches V1 speed.

14:43:13
Pilot rotates the aircraft. Control Tower informs crew of flames on left wing.

14:43:30
Attempts to retract the landing gear fail. Reheat technology
204 ft in length
07/02/1996 - NYC to London in 2 hours 52mins
100 Passengers
2.5 Tonnes
250 mph Interesting Facts: 14:43:59
Ground Proximity Alert sounds. The crew announces they will try to get to Le Bourget Airport.

Engine 1 fails leading to an uncontrollable asymmetric thrust causing the plane to bank 100 degrees. The crew reduces power to engine 3 and 4 to try to correct.

The fire was melting parts of the left wing, adding to the lack of lift and control.

14:44:03
Concorde crashed into nearby airport hotel killing 4 people and all 109 on board. Cummings, E; Kilcran, J; Flannery, J; Kaseke, C; Harding, B Thank you for listening
Any Questions? James Kilcran 2 most important recommendations
develop stronger tires
reinforce fuel tanks with Kevlar (Ignored) Failure to achieve a high standard maintenance procedures and techniques was evident from both airlines The effects of having a missing spacer:
Slower acceleration
Misaligned wheels may have instigated the asymmetric trajectory Essentially is implementing practices taught in training.

Foreign Object Debris Detection Systems
Uses radar technology
gives co-ordinates of objects (up to 2cm in size)

Example: X-Sight Systems Automated (Bangkok Airport 2012) Aftermath Air France grounded all Concordes following crash whilst BA continued flights.
Crash was widely reported, and shook public's confidence in aircraft.
CAA revoked Concorde's certificate 16th August 2000.
Concorde was only brought back after suitable upgrades had been installed, showing both authorities and public it was safe.
First commercial flight on 7th November 2001 by Air France & BA. Key Message Each event has a lesson linked to:
risk management
health and safety

Accident was ultimately caused by:
Human factors
Crew time pressure
Exceeding MTOW
Missed runway inspection
Failure to adopt to System Management Safety (SMS) Washington Dallas Airport (1979 Incident) Recommendations in the official accident report A number of recommended changes were proposed to improve safety including:

installation of sensors to detect under inflated tires
improved pre-flight tire inspection methods History of Concorde tire events Graph shows a decline but NOT elimination of tire incidents Aircraft Maintenance Continental Airlines Metal piece was high prone to failure due to bad design
Random drilled holes and sharp edges
High stress concentration locations Air France Business Management Accident prevention is vital. Failure can have legal consequences:
Continental paid Air France for damages
Families were compensated

Evidence highlighting the industry is learning - grounding of Boeing 787 Dreamliner Legal Implications Foreign Object Damage Prevention Program Inspection & Maintenance Prevention During Design Module Perspective
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