Interim report on the accident on 1st June 2009 to the Airbus A330-203

航空发表于 2010-10-1 16:36:04

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航空发表于 2010-10-1 16:36:34

Interim report f-cp090601ae on the accident on 1st June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro – Paris F-GZCP - 1st June 2009 1 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. Foreword
F-GZCP - 1st June 2009 3 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 F-GZCP - 1st June 2009 4 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 F-GZCP - 1st June 2009 5 Glossary AAIB Air Accident Investigation Branch ACARS Aircraft Communications Addressing and Reporting System ACP Audio Control Panel ADIRU Air Data and Inertial Reference Unit ADM Air Data Module ADR Air Data Reference ADS-C Automatic Dependent Surveillance-Contract AFS Automatic Flight System AIC Aeronautical Information Circular AMU Audio Management Panel AOC Airline Operational Control ASECNA Air Traffic Safety Agency for Africa and Madagascar ATA Air Transport Association of America ATC Air Traffic Control ATPL Airline Transport Pilot License ATSU Air Traffic Service Unit BFU German accident investigation board (Bundesstelle für Flugunfalluntersuchung) BITE Built-In Test Equipment SB Service Bulletin CAS Calibrated Airspeed CAT Clear Air Turbulence OCC Operations Coordination Centre ECC En-route Control Centre RCC Rescue Coordination Centre CDL Configuration Deviation List CECLANT Atlantic Command CENIPA Brazilian accident investigation board (CENtro de Investigação e Prevenção de Acidentes aeronãuticos) CFR Current Flight Report CG Centre of Gravity CMC Central Maintenance Computer CMS Central Maintenance System CNOA French national operations centre CPDLC Controller-Pilot DataLink Communications CPL Commercial Pilot’s Licence DGAC French civil aviation directorate (Direction Générale de l'Aviation Civile) DMC Display Management Computer F-GZCP - 1st June 2009 6 ECAM Electronic Centralized Aircraft Monitoring EFCS Electronic Flight Control System ETOPS Extended-range Twin-engine OPerationS EWD Engine Warning Display FADEC Full Authority Digital Engine Control FCDC Flight Control Data Concentrator FCL Flight Crew Licensing FCMS Fuel Control Monitoring System FCOM Flight Crew Operating Manual FCPC Flight Control Primary Computer FCSC Flight Control Secondary Computer FCTM Flight Crew Training Manual FD Flight Director FIR Flight Information Region FL Flight Level FM Flight Management FMGEC Flight Management Guidance and Envelope Computer FMS Flight Management System FPV Flight Path Vector FWS Flight Warning System GNSS Global Navigation Satellite System GPS Global Positioning System GPWS Ground Proximity Warning System HF High Frequency IATA International Air Transport Association IFPS Initial Flight plan Processing System IR Inertial Reference IRME Multi Engine Instrument Rating ISIS Integrated Standby Instrument System kHz kilo Hertz kt knot LMC Last Minute Change MAC Mean Aerodynamic Chord MEL Minimum Equipment List METAR METeorological Airport Report MHz Mega Hertz MRCC Maritime Rescue Coordination Centre MTOW Maximum Takeoff Weight ND Navigation Display NM Nautical Mile NOTAM NOTice to AirMen F-GZCP - 1st June 2009 7 NTSB National Transportation Safety Board (USA) ICAO International Civil Aviation Organisation PF Pilot Flying PFD Primary Flight Display PFR Post Flight Report RCC Rescue Coordination Centre RMP Radio Management Panel ROV Remotely Operated Vehicle SAR Search and Rescue SD System Display SELCAL SELective CALling system SIGMET SIGnificant METeorological information TAF Terminal Area Forecast TCAS Traffic alert and Collision Avoidance System TEMSI Significant weather chart TPL Towed Pinger Locator ULB Underwater Locator Beacon USCG US Coast Guard UTC Universal Time Coordinated VHF Very High Frequency ITCZ Inter-Tropical Convergence Zone

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Interim report on the accident on 1st June 2009 to the Airbus A330-203