Concord Accident Afr 4590

Accident Report of Flight AFR 4590

Michael D. Baker

18 May 2011

Embry-Riddle Aeronautical University

SFTY 320

Table of Contents

Cover...........................................................................................................................................................................1

Table of Contents.......................................................................................................................................................2

Crash Summary..........................................................................................................................................................3

Metal Wear Strip........................................................................................................................................................4

Figure 1 (Metal Strip).................................................................................................................................................5

Tire Failure History.....................................................................................................................................................6

Figure 2 (Tire History Failure Chart)........................................................................................................................6

Ruptured Fuel Tank...................................................................................................................................................7

Figure 3 (Hydrodynamic Pressure).........................................................................................................................8

Engine Failure...............................................................................................................................................9

Figure 4......................................................................................................................................................................10

Human Factors.........................................................................................................................................................11

Prevention................................................................................................................................................................12

Conclusion................................................................................................................................................................13

References...............................................................................................................................................................14

Abstract

This report summarizes the unfortunate events that led up to the fatal mishap of flight AFR 4590. Throughout this report explains how human factors directly contributed to the accident. This report describes the details of the findings from the BEA investigation. The author displays what measures that should have been implemented in preventing this accident.

On July 25th, 2000 the aviation industry suffered from another mishap which struck national attention. Flight AFR 4590 operated by Air France was scheduled to depart Roissy Charles de Gaulle Airport and to arrive in New York. During takeoff from runway 26R the aircraft ran over a strip of metal puncturing on of its main landing gear tires. Debris from the shelled out tire caused damage leading up to a punctured fuel tank. The fuel from the punctured fuel tank was ignited. The aircraft then experienced multiple engine failure. The landing gear failed to retract and more engine problems occurred. After a very brief time the aircraft failed to gain altitude and speed. The aircraft crashed into a nearby hotel which killed all 100 passengers onboard and all 9 crew members. Unfortunately 4 people were killed and 6 more injured on the ground. The aircraft was completely destroyed and so was the hotel.

There were several human factors involved that had contributed to this tragic event. Taking the "swiss cheese effect" and comparing it to this accident, we can then evaluate on how AFR 4590 reached its end. First let's take a look at the main culprit which was the strip of metal found on the runway. Where was the strip from and why was it there? The metal strip that punctured the tire originated from a Continental Airlines DC 10 registered N 13067. This aircraft had taken off approximately five minutes prior to AFR 4590 departure at Paris Charles de Gaulle airport. Investigations discovered that on aircraft N 13607, the number 3 engine fan reverser support was missing a wear strip on the lower left side. This wear strip allows the reverser cowl to rest on while in the stowed position. As investigators researched through the maintenance records of the DC 10, it was found that this strip had been replaced during a C phase check on June 11, 2000 by Tel Aviv of Israel Aircraft Industries. Maintenance records also show that this wear strip had replaced once again on July 9, 2000 in Houston, Texas by a Continental Airlines mechanic. The metal strip (see figure 1) found on the runway was made of TA6V alloy consisting of titanium, aluminum, vanadium and iron. The fasteners used were aluminum cherry max type rivets. The spacing on the metal strip seemed to be off center and in a random pattern. The metal strip was repaired on the DC 10, was not repaired in accordance with the manufactures repair manual. The strip should have been constructed out of stainless steel instead of the TA6V alloy. The manual also instructed that a template must be made in order to reuse the existing twelve rivet holes. It was discovered that on the DC 10 the existing holes were not reused. Instead of the twelve factory drilled holes there thirty seven holes. Some of the newly drilled holes overlapped each other. Overtime the rivets failed causing the strip to fall off the aircraft.

Figure 1. (Bertrand, 2010)

Tire failure is no stranger to the supersonic Concorde jet. Statistics show that the Concorde had more than a sixty percent chance of tire failure than the Airbus A340. From 1976 to the retirement of the jet, there have been fifty seven recorded tire failure occurrences (See Figure 2.). Twelve of those occurrences caused damage to the fuel tanks all of which happened during takeoff. Six occurrences of the twelve had punctured the fuel tanks, none of which