Flight AF 4590

UCLA - Managing Project Quality - JM.G.

Air France Concorde at JFK Airport in 2003

� The history of supersonic commercial air travel

has its roots in the 1950s and 1960s. (Context

of cold war)

� Britain and France wanted air travel faster than

the speed of sound—faster than commercial

flights had ever flown.

1. The Concorde (Overview)1.1 Context and History

flights had ever flown.

� In January 1976, Concorde celebrated its first

commercial flight.

� Up until an incident described in the following

slides, the Concorde was considered among

the world's safest planes.

� Role: Supersonic airliner (turbojet-powered

supersonic passenger jet airliner )

� National origin: United Kingdom and France

� Manufacturer: Aerospatiale and EADS (now

Airbus Group)

1. The Concorde (Overview)1.1 Key data (1/2)

Airbus Group)

� First flight: 2 March 1969 (21 January 1976)

� Status: Retired from service (26 November

2003)

� Primary users: British Airways and Air France

� Produced: 1965–1979

� Number built: 20 (including 6 non-airline

aircraft)

� Unit cost: €174 million (~$226 million)

� Cruising speed: Break the sound barrier ; 2

1. The Concorde (Overview)1.2 Key data (2/2)

� Cruising speed: Break the sound barrier ; 2

times the speed of sound ; Mach 2.04 (about

1155 knots (2140 km/h or 1334 mph)

� Passengers: Seating for 92 to 128 passengers

� Competitor: Only two, Concorde and the

Tupolev Tu-144, were ever designed for civil

use as airliners

� An aircraft departed (Concorde AF 4590) France on

July 25, 2000, at 4:45p.m., Air France Flight 4590

from Paris to New York

� The flight lasted just under two minutes

2. The incident2.1 What happened ?

� The flight lasted just under two minutes

� Just after liftoff, the supersonic jet crashed into a

hotel near the airport in Gonesse, France.

� Video timeline: Seconds From Disaster (National Geographic documentary).

� Video simulation: https://youtu.be/sgii3zPeFYY

1. Problem: Concorde crash (What?)

2. Date: July 25th, 2000 at 4.45p.m (When?)

3. Location: Paris Charles de Gaulle Airport, runway

26R, Gonesse hotel (Where?)

3. Root cause analysis3.1 Definition of the problem

26R, Gonesse hotel (Where?)

4. Impact-safety: Air France Concorde + 100

passengers + All 9 crew, 4 people on ground

(Who?)

5. Impact-property: First Concorde lost in 40000

flights. Loss of aircraft ($125 million)

1. Why? – 113 fatalities occurred

2. Why? – 2 engines failed

3. Why? – Flames behind aircraft (First visible

effect). Why “The fuel cell ruptured”?

3. Root cause analysis3.2 5-Whys analysis

effect). Why “The fuel cell ruptured”?

4. Why? –Tire disintegrated and exploded

5. Why? – Debris on the runway

� There were multiple re-laminations of

the tires (worn tires)

� Titanium wear strip debris was on the

runway dropped by other airplane

3. Root cause analysis3.3 A Closer Look at the Cause (The Disintegrated Tire)

runway dropped by other airplane

� Tire rolled over debris tilted on its edge

� A stressed tire exploded with a piece of

it striking the underside of the wing on

Fuel Cell 5

� The impact of debris from the exploded tire

resulted in a shock wave in the tank

� The shock wave caused a rupture in a

forward location of the fuel tank

3. Root cause analysis3.4 A Closer Look at the Cause (Fuel Cell 5)

forward location of the fuel tank

� Fuel entered the intakes of Engines 1 and 2

on the left side of plane

� The fuel choked the air flow

� The engines experienced a flame-out due to

3. Root cause analysis3.5 A Closer Look at the Cause (Loss of Two Engines)

� The engines experienced a flame-out due to

the entering fuel

� The fuel pouring from Fuel Cell 5 also

ignited

� The pilot, while attempting to avoid a

Boeing 747 aircraft, veered sideways off

runway

� The aircraft needed 3 of the 4 engines to

3. Root cause analysis3.5 A Closer Look at the Cause (The Pilot)

� The aircraft needed 3 of the 4 engines to

function

� There wasn’t sufficient thrust to keep it aloft

3. Root cause analysis3.6 The Fishbone analysis

Standard fishbone diagram to investigate on Aircraft accident causes

NTSB: National Transportation Safety Board

B.E.A: French aircraft investigation agency

Concorde

Flight 4590

Machine

Flying debris from

blown tire hit Fuel

Tank 5

MethodsTime MaterialsLeft tire from Flight 4590

was cut and ruptured by

titanium alloy debris

Shockwaves in the

fuel tank caused a

rupture

Flight 4590 veered

sideways off runway to

avoid a Boeing 747 flight

Flight 4590 was one

hour behind schedule

Missing spacer was later

found in airline’s repair

shop

The first fatal crash

in 31-year history

(Complacency led

to a false sense of

security)

Load-bearing shear bushes

were out of alignment by 7

inches

Undercarriage of aircraft

was out of alignment

Balding tires—all tires had

multiple re-laminations

Five minutes before

Flight 4590 departed, a

Continental flight lost a

titanium alloy strip on

the runway

Rotation error; raising

of the plane’s nose

during take-off was

done incorrectly

Fuel spill from the

ruptured tank choked

the airway of two

engines causing fire

Flight 4590

Crash

PeopleEnvironmentEnergy Measurement

Cockpit Flight

Engineer shut down

the ailing 2nd engine

prematurely; flight

was 25 feet off

ground

Flight Captain should

have decided if an

engine was to be

shut down

There was a change in

wind conditions; flight

departure factors

should be been

recalculated

The Concorde reached

a velocity were it could

not abort take off; it

had to lift off with

flames from left wing

Flight 4590 was 6 tons

overweight for wind

conditions

Flight 4590 was

flying too slowly; 188 knots

instead of recommended

199 knotsA full runway

inspection was not

completed as was

protocol Center of gravity for

Flight 4590 was beyond

54% due to error in

weight distribution; plane

was rear-heavy

Industry-required

strength of tire was not

stringent enough

Shutting down an engine

is safe after elevation of

400 feet, not 25 feet, as

was done

Three of the four engines

were needed for the plane

to function properly

Flight 4590 hit a

landing strip light

during take off

� 1. Problem Outline -what, when, where

� 2. Analysis – review cause techniques

3. Root cause analysis3.8 Cause mapping analysis (Problem Solving Steps)

� 3. Solutions –

� Possible Solutions

� BEST Solutions

� Action Plan

� Impact

Safety 100 passengers fatalities

9 crew members fatalities

4 fatalities on the ground

Compliance Runway inspection not complete

3. Root cause analysis3.9 Cause mapping analysis (Problem Outline: The Cause)

Compliance Runway inspection not complete

Property Property—Loss of aircraft valued at

$125,000,000, Hotel destroyed

Operations Loss of revenue, grounded and eventually

retired Concorde fleet

Frequency 1st Concorde lost in 40,000 flights or 900,000

hours

3. Root cause analysis3.9 Cause mapping analysis (The Concorde case)

� After 9/11 attacks, market for flights

dropped. Last Concorde flight was in

October 2003.

� New Supersonic airliners?

4. The Concorde crash4.1 In the aftermath…

� New Supersonic airliners?

� Unlikely, exorbitant fuel costs made the

Concorde uneconomical

� In 1989, a round-trip ticket from London to New

York cost about $6,500. By 2003, airfare had

soared to as high as $12,000 for a round trip

between New York and Paris

� Bless the Checklist

� Without a checklist, an organization begins to

lack order. Like in much of what we do, it’s the

little things that count.

� Mandatory protocol for a full runway

4. The Concorde crash4.2 Lesson learned

� Mandatory protocol for a full runway

inspection before takeoff

� Modifications were made to Concorde:

� more secure electrical controls

� Kevlar lining to the fuel tanks

� burst-resistant tires

� “Concorde forty-five ninety you have

flames, you have flames behind you!”- Last sentence from flight recorder

4. The Concorde crash4.2 Cost of poor Quality

� Christian Marty, Pilot and famous windsurfer

� Jean Marcot, Co-pilot

� 7 crew members, 100 passengers, and 4

people

Tribute

Gonesse memorial

� http://en.wikipedia.org/wiki/Air_France_Flight_4590

� http://en.wikipedia.org/wiki/Concorde

� http://en.wikipedia.org/wiki/Supersonic_aircraft

� http://www.thinkreliability.com/

� https://www.youtube.com/watch?v=AxydOEd8oQQ

� https://www.youtube.com/watch?v=sgii3zPeFYY

� http://www.planecrashinfo.com/lastwords.htm

References

� http://www.planecrashinfo.com/lastwords.htm

� 9 crew members, 100 passengers, and 4 people