Interim report - Airbus A330-203 - Air France flight AF447 Rio de Janeiro – Paris - 1st June 2009.pdf

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F-GZCP
f-cp090601ae
I nterim report
on the accident on 1 st June 2009
to the Airbus A330-203
registered F-GZCP
operated by Air France
light AF 447 Rio de Janeiro – Paris
Bureau d’Enquêtes et d’Analyses
p our la sécur ité de l ’aviation civile
Ministère de l ’écologie, de l ’énergie, du développ ement durable et de la mer, en charge des technologies ver tes et des négociations sur le climat
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Foreword
This document has been prepared on the basis of the initial information
gathered during the investigation, without any analysis and - given the
continuing absence of wreckage, the flight recorders, radar tracks and
direct testimony - without any description of the circumstances of the
accident. Some of the points covered may evolve with time. Nothing in the
presentation of this interim report or in the points that are raised therein
should be interpreted as an indication of the orientation or conclusions of
the investigation.
In accordance with Annex 13 to the Convention on International Civil
Aviation, with EC directive 94/56 and with the French Civil Aviation Code,
the investigation is not conducted in such a way as to apportion blame
or to assess individual or collective responsibility. The sole objective is
to draw lessons from this occurrence which may help to prevent future
accidents or incidents
SPECIAL FOREWORD TO ENGLISH EDITION
This interim report has been translated and published by the BEA to
make its reading easier for English-speaking people. As accurate as the
translation may be, the original text in French should be considered as the
work of reference.
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F-GZCP - 1 st June 2009
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Table of Contents
FOREWORD
1
GLOSSARY
5
SYNOPSIS
9
ORGANISATION OF THE INVESTIGATION
11
1. FACTUAL INFORMATION
13
1.1 History of Flight
13
1.2 Killed and Injured
14
1.3 Damage to Aircraft
14
1.4 Other Damage
14
1.5 Personnel Information
14
1.5.1 Flight crew
14
1.5.2 Cabin crew
17
1.6 Aircraft Information
19
1.6.1 Airframe
19
1.6.2 Engines
20
1.6.3 Weight and balance
20
1.6.4 Condition of the aircraft before departure
20
1.6.5 Maintenance operations follow-up
21
1.6.6 Information on the airspeed measuring system
21
1.6.7 Checks and maintenance of the Pitot probes
23
1.6.8 ACARS communication system
24
1.6.9 Centralised Maintenance System
25
1.6.10 Radio communications system
28
1.7 Meteorological Conditions
28
1.7.1 Meteorological Situation
28
1.7.2 Comments on the information available
29
1.8 Aids to Navigation
33
1.9 Communications
33
1.9.1 Communications between the control centres
34
1.9.2 Coordination between the control centres
35
1.10 Aerodrome Information
37
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1.11 Flight Recorders
37
1.12 Wreckage and Impact Information
37
1.12.1 Localisation of the bodies and aircraft parts
37
1.12.2 Identification of the items recovered
38
1.12.3 Visual inspection
38
1.12.4 Summary of visual examination
40
1.13 Medical and Pathological Information
40
1.14 Fire
41
1.15 Survival Aspects
41
1.16 Tests and Research
45
1.16.1 Sea Searches
45
1.16.2 ACARS messages
48
1.17 Information on Organisations and Management
57
1.17.1 Preparation of flights within Air France
57
1.17.2 Work cycles and flight crew rest
61
1.17.3 Instruction for use of the on-board weather radar
63
1.17.4 Letters of agreement between air traffic control
organisations
64
1.17.5 Experimental implementation of the ADS-C system
at Dakar
66
1.18 Additional information
66
1.18.1 Events associated with erroneous air speed indications
66
1.18.2 Brief history of the Pitot probes on Airbus A330 / A340
67
1.18.3 Testimony of crews in flight in the vicinity of the accident
zone
67
1.18.4 Procedures to be applied in case an unreliable speed
indication is detected
69
2. INITIAL FINDINGS
70
LIST OF APPENDICES
73
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