concerning the accident which occurred on jun 26th …...the caanission then continued their study...

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F I N A L R E P O R T concerning the acciden t which occurred on Jun 26th 198 8 at M li ouse-Habsheim (68 ) to the Airbus A 320, registered F-GFKC Nvvsnber 29th 1989

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Page 1: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

F I N A L R E P O R T

concerning the accident

which occurred on Jun 26th 198 8

at M li ouse-Habsheim (68 )

to the Airbus A 320, registered F-GFKC

Nvvsnber 29th 1989

Page 2: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

FOREWOR D

This report is a technical document which reflects the point o fview of the Investigation Cb nnission set up by the Minister o fTransport to investigate the circumstances in which theaccident occurred, its causes and its consequences .

In compliance with Appendix 13 to the Convention, o nInternational Civil Aviation, the investigation in no way triesto establish faults or responsibilities . It has been conductedwithout necessarily using contradictory proceedings and withthe basic aim of preventing future accidents .

SPECIAL FE tD 10 EMLISH EDITIQd

This report has been translated and published by the FrenchBureau Erquêtes Accidents to make its reading easier fo rEnglish speaking people . As accurate as the translation may be ,please refer to the original text in French .

Page 3: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

CONTENT S

SYNOPSIS

COMPOSITION OF THE INVESTIGATION CCMMIISSICN AND SUMMARY OF WOR K

1 - FACTUAL INFORMATION

1 .1 - History of the flight

1 .2 - Injuries to persons

1 .3 - Damage to aircraft

1.4 - Other damage

1 .5 - Personnel information

1 .6 - Ai rcrraft information

1 .7 - Meteorological information

1 .8 - Aids to navigation

1 .9 - Camunications

1 .10 -Aerodrome information

1.11 - Flight recorders

1.12 - Wreckage

1 .13 - Medical and pathological informatio n

1 .14 - Fire

1 .15 - Survival aspects

1 .16 - Tests and research

2-ANALYSIS

2 .1 - General considerations

2 .2 - Flight preparation

2 .3 - Sequence of events

3 - CONM SIOIS

3.1 - Findings

3.2 - Probable causes

4 - SAFETY

APPEDDIC'FS

Page 4: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

SYNOPSIS

Date of accident

Sunday June 26th 1988at 12 h 45 tTIC (1 )

Place of accident

300 m beyond the end of rumway34 R at the LISE I ABSHEIMaerodr me (68) and on runwayaxis .

Type of flight

Chartered flightPublic transport of passengersincluding a low altitudeflyover .Flight No . and radio telephonecode :ACF296Q

Aircraft

Airixrs A 320NSN : 9Registration : F-GFKC

Owner

DURUS VERWALTUNGSGESELLSHAFTMi Co MOBILIEN KG

Operator

AIR FRAME

Occupants

* Flight crew : 2* Cabin attendants : 4* Passengers : 130

Summary of accident

As part of an airshow, the aircraft flew over rummy 34 R at a heigh tof approximately 30 feet, engines at idle, with an angle of attacki ncreasing up to the meximan possible taking into account the decelerationrate of the aircraft. During the go-around, the aircraft touched the tree sa short wry beyond the end of the runway, sank into the forest, carne t orest and caught fire . Evacuation was undertaken immediately but threepassengers died in the fire .

Consequences

PERSONS

Unhurt

Aircraft Third partydamage

Killed Injured

crew 0 2 4Tbtalloss

Approximatel ytwo hectares

Passengers 3 34 (*) 93 of forestdestroyed

Third parties 0 0

(*) Passengers taken to hospital .

(1) The times given in this report are in universal time coordinated (UIC) .Add two hours to obtain legal French time .

Page 5: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 .

OCMPC1SITICN OF THE INVFSMGATION COMMISSION AND SUMMARY OF WORK

C urceition of the Investigation Ccunission

By order dated June 27th 1988, the Minister of Transport set up anInvestigation C tinissi on coed of :

Messrs Claude BEGET -

PresidentCaptainBureau Enquêtes Accidents

Frarrois Q) IN -

Ingenieur General de 1'Aa[ementVice-President

Robert AIWFRFT -

Médecin GeneralManber of the Civil Aviation Medical Counci l

Bernard FARTH T - Ingénieur General de la Météorologi e

Paul ARSLANIAN -

Ingénieur en Chef de 1'Aviation Civile

Philippe

k7CHM - Pilot Inspector

Jean-Paul de VILLE EUVE - Engineer Bureau Enquêtes Accidents

whose mission was to study the circurrstarces and find the causes of, andrelease information relevant to, the accident which occurred on June 26th1988 at Iiltr.me-Habsheim to an Air France A 320 aircraft .

In accordance with the provisions of the protocol concernin g

technical investigations of accidents involving aircraft equipped with CF M56 engines, signed jointly on March 21st 1985 by the Accident InvestigationBureau (BEA) of the Civil Aviation General Inspectorate and the NationalTransportation Safety Board (NISB-USA), a delegate of the country co -manufacturing the Meals engines, assisted by three technical advisers, wa scalled on to participate in the Commission's work .

Page 6: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

2 .

Also, in a decision taken by the President of the Commission, MrJean-Claude %%MIER, general engineer armament, joined in the Cao<nission'swork as an expert in human factors .

Sunreryof work

The French Accident Investigation Bureau (BEM was informed of theaccident around 13 h 30 on Sunday June 26th. After having taken allmeasures to safeguard the evidence, two investigators from this office wer esent immediately to the site of the accident . They arrived there around16 h.

On their arrival at the Mulixn1se-Habsheim aerodrome, they got i ncontact with the local aeronautical, prefectorial and judicial authoritie sand started work in collaboration with these authorities .

The recorders had been recovered by the rescuers . They weretransferred overnight to Paris, as their analysis required specializedinstallations and technicians .

Tuesday June 28th : the President of the Cannission held a firsthearing with the flight crew and listened in their presence to th erecordings made on the cockpit voice recorder .

The first full session of the Commission was held in Paris o nWednesday June 29th. All the members of the Cannission were present.

This session permitted all the research and study work to be sharedout between the Ccirmission members .

%b e following day, Thursday June 30th, two members of the Commissionflew to llhouse ilabsheim in a light aircraft belonging to th eadministration and made around ten flights over the wreckage under theflight conditions of the accident .

On this occasion, contacts were also made with the Colmarprefectorial authorities and the examining Judge in charge of the affair .

A second full session was held on FridayJuly 1st during whichparticipation of NTSB was confirmed in accordance with the protocolmentioned above .

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3 .

Fran July 4th to 7th, the accredited representative from the USA andhis three technical advisers participated in the work of the Commission ,became acquainted with the reading out of the flight data recorder and al linfoanation that was available at this stage in the investigation .

This delegation left for Washington on July 7th 1988 without leavinga delegate in situ as had been proposed.

The following weeks were devoted to studying the circmnstances of theaccident . The work especially consisted in examining the recordings ,hearing the pilots and the authorities concerned and reconstructing th eparanE*ers of the accident in the simulator and in flight on July 20th and21st. This led to the writing of the preliminary report which was handedover to the Minister of Transport on July28th 1988 .

The Caanission then continued their study and analysis of th eaccident.

Full sessions of the Commission were held on July 19th 1988 ,September 6th 1988, October 27th 1988, December 20th 1988, April27th 1989 ,June 21st 1989, June 26th 1989 and September 13th 1989 . The Commission alsoreleased an official statement on November 2nd 1988 giving the progres smade in their work . to Ca:mission approved the present final report duringtheir session held on November 29th .

In ca:Qliacce with the clauses of the inbmamirdstexial order datedJanuary 3rd 1953, the Commission carried out all their work in clos ecooperation with the judicial authorities (Public Prosecutor*, ExaminingJudge, judicial experts, Air Transport Police, Air and Frontier Police) .Judicial experts were invited to all the Commission's sessions an dparticipated in much of its work .

In compliance with the terns of the order dated November 3rd 197 2relevant to investigation commissions, the draft of the final report wa ssubmitted, for comments, to the following persons and organizations :

- Crew neuters (flight =wand cabin attendants )- Air France- Airbus Industrie- CFirII- Mulhouse flying club- Direction Generale de 1'Aviation Civile (D .G .A .C. )- Haut Rhin prefecture

'r a two flight crew members declared that they wished to reserv etheir comments for the judicial representatives .

* American equivalent is the Attorney General

Page 8: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

4 .

1 - FACTUAL INFORMATION

1.1 - HIS'IOHI OF THE FLIGHT

On June 26th 1988, the Air France A 320 F-GF C was to perform for AirCharter a series of flights with passengers on behalf of the Mulhouseflying club .

The program included the following flights : Paris-Charles deGa1111e/Basle-Mulhouse, 2 round trips from Basle-Mulhouse and theBasle-Mulhouse/Paris-Charles de Gaulle return flight .

At the start of each of the two round trips, initially planned to th eVosges area, then, for meteorological reasons, to the Alps, the cre wwas, at the request of the Mulhouse flying club, to overfly theMulhouse-Habsheii aerodrome as part of the air show organized by thisflying club .

The regional Air France delegation at Mulhouse, acting as contac tbetween the organizer of the air show and the carrier Air Charter ,had made the administrative preparation for the flight .

In Paris, Air Charter took charge of the commercial aspects, definin gthe general flight conditions (route, choice of aircraft on the basi sof Air France availabilities) and preparing the contract .

Lastly, the technical preparation was undertaken by the "ServiceLigne et Régions de la Direction des Opérations d'Air France" who, o nthe basis of ociunercial requests, studied the conditions under whic hthe flight was to be perforned and prepared the technical file forthe crew .

According to the declarations made by the airline, this preparatio nwas made with respect to the specific airline directives (internalnote DOND 50420 dated October 19th 1987 shown in appendix), takinginto account the obstacles and with a planned low altitude flyover o frunway 02 .

On completion of this study, on Friday June 24th in the afternoon ,

the A 320 Flight Division, i .e. the department responsible for crewmanagement, received the following file intended for the crew

together with verbal =rants :

- IGN (National Geographical Institute) map, scale 1/100,00 0- visual flight chart, scale 1/500,000- visual landing chart (VAL) of )tilhouse Habsheim airfield

- scheduled flight plan- copy of various massages .

In this documentation, there were no instructions either concernin g

runway axis ar height of overflight .

Page 9: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

5 .

On Sunday morning, June 26th, during their flight pmer~a~tion, thecrew become acquainted with the file . No verbal comments were made tothem .

The flight from Paris-Charles de Gaulle to Basle-Mulhouse wasachieved mrmally .

After a short stop, the aircraft departed shortly before 12 h 30 fo rthe first round trip .

For this flight, the pilot in the left seat was the designatedCaptain, and he had the controls .

During taxiing, as confirmed by the recording of on-boar dconversations, he explained in detail the program of the flyby to b emade at Habsheim (first overflight at low speed, with landing gearand flaps extended, at a height of 100 feet, then overflight at hig hspeed in clean configuration) . The intention to make two overflightswas transmitted to air traffic control by radio .

Take-off was made at 12h 41, immediately followed by a right turn t oreach Mulhouse Habsheim at an altitude of 2000 feet QtH (i .e . aheight of approximately 1000 feet above the ground) achieved at 12 h42 .

During the level flight at 1000 feet above the ground, theautothrottle was disengaged to permit manual control of the thrust ,and two warning sequences, related to the landing gear retractedconfiguration and two indications of radio altimeter height less tha n1000 feet, weme heard . The motorway was used as the first visua lnavigation landmark then a track, parallel to the motorway, leadingto the Habsheim aerodrome .

At 12h 44, the aircraft left this level flight altitude and descendedtowards the aerodrome which was identified visually. The engines werethrottled back. Flap and landing gear were extended at start ofdescent.

Setting of the pressure at aerodrome level (i .e . 984 hPa) was madeand counterchecked by the two pilots .

The vertical speed during descent was 600 feet per minute .

Confirmation of Habsheim aerodrare identification was made at 45 0feet above the ground .

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6 .

A warning related to the radio altitude and flap 3 configuration wa srecorded before a first aural altimeter message "200 feet" at 12 h45mn 06s . A second aural message "200 feet" interrupted a personalremark made by the First Officer at 12h 45mn 11s . The First Officerinformed the Captain that the aircraft was reaching 100 feet at 12 h45mn 14s and simultaneously the radio altimeter emitted a "100 feet "message, the vertical speed still being 600 feet per minute .

The descent continued at a slightly lower rate down to 50 feet ,reached 8 seconds after passing through 100 feet agl*, then at a ver ylow rate down to 30 o 35 feet above the ground, the aircraft the nremaining more or less in level flight .

Throughout the whole descent and at the start of level flight mad ewith engines set to flight idle, the aircraft decelerated and it spitch up increased during the last 25 seconds of flight . The end ofthe descent and the level flight were made above rummy 34R. Between12h 45mn 34s and 12h 45mn 35s, the engine controls were set toinitiate go around (the acceleration of the engines can be seen o nthe flight data recorder at 12h 45mn 35s) .

The aircraft touched the trees shortly after the end of the runway a t12h 45mn 40s ; at this time, engine speed was around 83 % Ni, thepitch attitude of the aircraft was 14° .

The first contact between the aircraft and the trees was made by th erear section of the fuselage, the tailplane then the engine nacellesand the main landing gear . The aircraft sank slowly into the forest .The tip of the right wing then the right wing itself broke, fuel wa sprojected forward and fire immediately broke out and penetrated th ecabin as soon as the aircraft came to rest.

Evacuation was made immediately via the left side . The forward lef tdoor could not be opened completely because of the trees . The leftaft door opened correctly and the escape slide deployed normally bu twas perforated by the broken trees as soon as used by the firs tevacuees .

A woman and two children, including one physically handicapped, die din the fire .

* above ground level

Page 11: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

7 .

1 .2 - INJURIES TO PERSONS .

Crew

Passengers

Thirdparty

Killed 0 3 0Injured . . . .

2 34 (1) 0Unhurt 4 93

(1) Passengers taken to hospital

1 .3 - DAMAGE '10 AIRCRAFT

The aircraft was totally destroyed by the successive impacts and th every violent fire which followed .

1 .4 - Ófl ERDAMAGE

Approximately two hectares of forest (5 acres) (young oak and birch )were destroyed. The trees were broken, torn or burnt . Others were cutduring the rescue and wreck recovery operations .

1.5 - PERSONNEL INFORMATION

The crew included two pilots, in accordance with the aircraftoperating rules, both Captains and with management responsibilities .

1 .5 .1 - Captain

Michel ASCINE, born May 5th 1944 in Paris (75 )

* Certificates and lames :

Airline pilot's licence obtained on June 25th 1969 ,Licence valid till November 30th 1988 ,Last medical check-up on May 24th 1988 performed by the AirFran Chew Medical Examination Center (CEMPN) .

* ('�v41 ificati.ons :

Airline pilot instructor's qualification obtained in 197 9Type qualifications : Caravelle SE 210 ; Boeing 707, 727, 737 ;Airbus A 300, A 310Airbus A 320 qualification delivered March 11th 1988

Page 12: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

8 .

:em ark : the A 320 course followed by Michel Asseline wasperformed in accordance with a special program for the nberson the pilot's executive staff within Air France participatingin placing the A 320 into in-service operation .

The proposed program, personalized to suit the role of eac hperson within the management team, was considered acceptable b ythe ad mi nistration provided that flight training was added, an dthis was in fact performed .

The assessment sheets show a very satisfactory level .

* Experience :

Total flight hours : 10,463 (end of May )on A 320 : 138 hours

* Aeronautical career :

1962 : Admitted by competitive examination to the NationalCivil Aviation School (ENAC )

Theoretical and practical training from autumn 1962 to 196 6

June 1966 to February 1967 : trainee at Air France

March 1967 : engaged by Air France as copilot on Caravelle S E210 .

May 1968 to August 1969 : military service in the air force ,final ranking second lieutenant (reserve lieutenant )

September 1969 :

returned to Air France as copilot onCaravelle then on Boeing 707

May 1979 : named as Captain on Caravelle then airlineinstructor on Caravelle then on Boeing 727 .

December 1982 : promoted to managerial level during the puttinginto service of the Boeing 737 piloted by two crew members

From January 1985 to November 1987 : Airbus A 300 and A 31 0qualifications

Promoted to a higher level with :

Responsibility for the preparation of the choices regardingflight simulators (B 737 and A 320 project) ; to this end, flewapproximately 150 hours on the A 320 simulator at Aeroformationand Thorson .

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9 .

Technical missions related to training of pilots (computer-assisted teaching, company policy related to training) .

Deer 1987 : promoted to Head of A 320 training subdivisionwith responsibility for :

- development of type qualification, participation in theestablishment of the aircraft utilization method andtraining (in cooperation with the manufacturer) of th efirst crews ,

- airline aircraft acceptance flights (including F-GFKC) .

* Flying activities in the last 48 hauls before the accident :ferrying of F-GFKC on Friday horning June 24th then flight a sobserver on an Airbus Industrie A 320 to supervise the traininggiven to Air France trainees .

* Previous air accidents : none .

1 .5 .2 . First Officer

Pierre MAZIERES, born January 12th 1943 in Castelnaudary (11 )

* Certificates and Licences :

Airline pilot's licence obtained on August 28th 196 9Licence valid till September 30th 1988Last Tires check-up March 14th 1988 with Air France CEMPN .

* Qualifications :

Airline pilot instructor's qualification obtained in 1982 .Type qualification : Caravelle SE210 ; Boeing 707, 73 7A 320 qualification obtained March 29th 1988 .

Remark : A 320 course performed in accordance with the standardAerofomnation program approved by the DCAC ; the resultingassessment sheets showed a very satisfactory level .

* Experience :

Total flight hours : 10,853 (end of May 1988 )on A 320 : 44 hours .

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10 .

* Aeronautical career :

1962 : Admitted by competitive examination to the NationalCivil Aviation School (same year as Michel Asseline) .

Theoretical and practical training at HNC from autumn 1962 t o1968 .

Training delayed in carparison with Michel Asseline following acar accident .

December 1969 : engaged as copilot by Air France .

1972 : copilot on Boeing 707 .

July 1980 : Promoted to Captain on Boeing 727 .

Dec rber 1982 : Promoted to instructor on Boeing 727 thenBoeing 737 in March 1983 .

January 1986 : Promoted to managerial level on Boeing 737 .

March 25th 1988 : Pramted to a higher position to participatein the placing into service of the A 320 .

* Flying activities in the last 48 hours before the accident : none .

* Previous air accidents : noon.

1 .5.3 Cabinattendants

Jean Claude BARCE'IQJ, born May 15th 1948 was performing thepurser's functions and was on the seat located beside the lef tforward door.

Safety-rescue certificate No. 5861 obtained on June 23rd 1972 .

Last medical check-up : June 15th 1988 .

A 320 specialization certificate : April 14th 1988 .

Zbtal flight hours : 8969 hoursOn A 320 : 11h 23 .

Last flight on A 320 : June 25th 1988 .

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11 .

Chantalde CHALCNGE, born March 9th 1951, occupied, in thecabin, seat 12 R level with the wing emergenCY exit .

Safety-rescue certificate No . 6741 obtained on July 16th 1973 .

Last medical check-up : September 10th 1987 .

A 320 specialization certificate : April 14th 1988 .

'Dotal flight hours : 6784On A 320 : 21h 50

Last flight : June 25th 1988 on Boeing 72 7June 23th 1988 on A 320 .

Previous events : wes cabin attendant on the A 300 highjackedat Brindisi .

MurielDAGER, born June 3rd 1957, occupied a crew seat on theleft in the aft galley .

Safety-rescue certificate No . 9648 obtained on May 16th 1972 .

Last medical check-up : September 11th 1987 .

A 320 specialization certificate : April 15th 1988 .

'1bta1 flight hours : 3022On A 320 : 22h 50Last flight A 320 : June 25th 1988 .

Brurn PICHJT, born February 23rd 1951, occupied the seat on th eright level with the aft galley .

Safety-rescue certificate No . 7085 obtained September 20t h1973 .

Last medical check-up : January 7th 1988 .

A 320 specialization certificate : April 28th 1988 .

Total flight hours : 8223Ca A 320 : 20h 20Last flight on A 320 : June 24th 1988 .

Previous accidents :

Was cabin attendant during the evacuation of damaged Boeing 74 7at Bombay (India) in 1975 ; the aircraft was totally destroyedby fire during this accident.

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12 .

1 .6 -AIRCRAFT INFORMATION

Owner and Operator :

Owner : DURUS VERWALTUNGSGESELLSCENET MBH Co MJBILIEN KG

Operator : AIR FRANCE

- Airframe :

. Manufacturer : AIRBUS IN1 JSTRIE

. Type : AIRBUS A 320-10 0

. MSN : 009

This aircraft obtained Airworthiness Certificate No . 109 099 andnoise certificate No. 109 099 on June 22nd 1988 .

It was delivered on June 24th 1988 .

. total flight hours : 22h 30

. number of operating cycles : 18

- Engines

. Manufacturer : CFM International - engine manufactured i ncooperation by General Electric (USA) and SN CAA (France )

. Type CFMI 56-5A1engine No. 1 (left) : Serial No . 731 122engine No . 2 (right) : Serial No . 731 120

. delivered to Airbus Industrie on October 6th 1987

. operating hours : S/N 731122 : 27h 20S/N 731120 : 33h 45 .

- Information given on engineering reports

Due to the recent delivery date, the remarks made by the crews ar elimited. 'Ihe significant reports are as follows :

- June 25th and 26th 1988, it was reported that the flight managementand guidance computer (FM3C) No. 2 did not have the same data bas eas caputer No. 1 ,

- June 26th 1988, altimeter setting changed to a new incorrect valueduring a DEL (display management computer) transfer .

- June 25th 1988, occurrences of a warnir . related to a nr whee lsteering valve (this warning can be heard in the CVR bF re theGEMS (2) "too low, terrain" message) .

(1)under a leasing contract with Air Franc e(2)GPM : Ground Proximity ,urning System (warning system ofproximity to ground, based on radio-altitude) .

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13 .

These anomalies had not been corrected before June 26th 1988 . Afteran in-depth study, the Commission concluded that none of these hadplayed a role in the accident (note that the second anomaly did no trecur) .

Weight and balance

These were 6 crew mernbers and 130 passengers, 2 of the passengers(air hostesses) being in the cockpit, for a total number of 15 3passenger seats available in the cabin .

The seats had not been attributed because it was a charter flight ;consequently, the Commission could not determine with exactitude theposition of each passenger in the cabin .

The weight and balance on take-off calculated after the acciden twere :

- weight : 59,635 kg- CG : 30 .7 %

The weight and CG calculated before the flight were marked in thelogbook as being :

- weight : 59,040 kg- CG : 25 .8 %

This difference is due to several consecutive errors :

- At Paris-Charles de Gaulle, on the balance chart, 3 cabi nattendants were given instead of 4, leading to an error in weight(- 80 kg) and index (-1) .

- Then, in Mulhouse, the list of passengers, completed by a lastminute change, mentioned only 126 passengers (respectively 110 and16) instead of 130, i .e. an error of 300 kg .

The aircraft tool kit, weighing 215 kg, and located in the cargocompartment, had been forgotten .

In the balance calculation, a scale error had been made in readingthe graph used to determine the influence of the weight of thepassengers .

This last error was in part campen.sated for by those made in weightand mentioned above and by the fact that the last minute change hadnot led to a correction of the CG .

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14 .

1 .7 - METEORCOLOGICAL I RNATION

1 .7 .1 - General situation

At high altitude, there was a depression above Germany giving aweak north-easterly to northerly flaw on its western side .

In the lower levels of the atmosphere, there was a wea kgradient area with, over the Alsacian plain, sky covered by 6to 8/8 stratocumulus plus locally 1 to 3/8 cunulus and anortherly wind of 5 to 10 kt.

1 .7 .2 - Conditions over flightarea

The meteorological center of Basle-Mulhouse, 10 nautical milesfrom the accident, observed the following conditions :

-

at 12h20 : Wind : 010 0 /6 ktVisibility : 8 kmCloud : 1/8 Cu at 780 m and 7/8 Sc at 1500 mTemperature : 20°CDew point : 13°CQtH : 1013 hPaI73SIG

-

at 12h50 : Wind : 330 0 /6 ktVisibility : 8 kmCloud : 1/8 Cu at 780 m and 7/8 Sc at 1500 mTemperature : 21°CDew point : 14°CQ[H : 1014 hPa

At 12h 41, the Mulhouse-Habsheim controller transmitted thereference pressure by radio to the A 320 pilot before theflyover was made :

-QNH : 1012 hPa- QFE : 984 hPa

After the accident, the controller reported to theinvestigators that wind speed was lower than 5 kt .

The study of the video tape on which the complete flyover o fthe A 320 was recorded, from 160° to 340° in a westward sense ,showed that the sky was covered : the stratoctmulus layer wa ssufficiently thin for the resulting luminosity to cast a veryclear shadow of the aircraft during the lowest part of thi soverflight .

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15 .

1 .8 - AIDS TO NAVIGATION

Because visual landmarks were used for the flight between the Basle -Hillhouse and the Mulhouse-Habsheim aerodromes and because of th eabsence of radioelectrical facilities at Habsheim, the navigationaids played no part in the accident .

1 .9 - MrJNIGATIONS

The transcriptions of the radio cats unications between the aircraft ,ground control and the Basle-Mulhouse control tower, then th eMulhouse-Habsheim control tower, were made and are given in th eappendix.

Before take-off from Basle-Mulhouse, the First Officer requested a naltitude of 1000 feet agl for the transit to Mullaase-Habsheim wherethe two flyovers were to be made .

At the sane time, he also requested control clearance for th eremainder of the flight to Hericourt .

After reception of the 2000 feet QNH transfer flight clearance, h especified that he would make a first low-altitude flight headin gNorth then a second one heading South .

Then, in contact with the Habsheim tower, he specified "we are caninginto view" and "going in for the low-altitude, low speed flyover" .

The controller then gave the QNH and the QFE .The First Officer acknowledged reception at 12h 44 non 31s, and thi swas the last radio transmission .

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16 .

1 .10 - AERODROME INFORMATION

The accident occurred at the northern limit of the Mulhouse-Habshei maerodrome . The aerodrome is located 10 nautical miles north-north-west of the Basle-Mulhouse airport .

The Mulhouse-Habsheim aerodrome (see aerodrome chart in the appendix )has two sets of two parallel runways, none of which is capable o freceiving an A 320 mainly due to the runway strength :

- one, oriented north-east/south-west (02 4° -204°) has a 1000 mby 20 m hard runway and a grass strip ,

- the other, oriented north-north-west/south-south-east (164° -344°) comprises two grass strips without clearance to thenorth-north-west, because they are immediately bordered by aforest of oak and birch . It was runway 34 R, one of these twograss runways, 640 m long, which was acting as the base forthe show, the visitors being massed to the west of thes estrips, along the front of the hangars .

The aerodrome which is located 6 }an to the east of the city o fMulhouse (coordinates : lat . 47 .44 .17 N - Long. 07 .25 .58 E), isbordered on the west by a motorway, a high voltage transmission lin eand a railway line, on the north and the east by the forest . Itstands out clearly from its surroundings .

Its reference altitude is 240 m (787 feet) which corresponds to adifference in standard pressure of 28 hPa, with respect to sea level .The thresholds of strips 16-34 which served as the A 32 0demonstration axis are at an altitude of 239 m for threshold 34 an d238 m for threshold 16 .

The Hardt forest starts immediately after the road which borders theend of runway 34 .

The distance between the end of runway 34 R and the forest is 60 mand the average height of the trees is 12 m .

The aerodrome has a 12 m-high control tower located in the angl eformed by the two sets of two runways . It was operating on the day o fthe accident and its equipment was in good working order . Itsorthogonal projection on axis 16-34 is located 250 m from the end o frunway 34 .

The Habsheim control tower barometers were checked by the NationalMeteorological service and showed no malfunction of the instruments ,the difference with respect to the reference barometer being lowe rthan 0 .5 hPa, within the tolerances for this type of instrument .

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1 .11 - FLIGHT RECORDERS

In ccmpliance with the regulations in force, the A 320 F-GFKC wa sequipped with a cockpit voice recorder (CVR) and a digital flightdata recorder (DFDR) . These two recorders, made by Fairchild, werefound in the wreckage of the aircraft on their mounts located in th eaft section of the fuselage, and were transferred to Paris in th eevening of June 26th for read-out .

1 .11 .1 - Read-out of recorders

1 .11 .1 .1 - C .V.R. (Fairchild A100 )

The C .V.R was opened and the first reading of the tapemade during the night from the 26th to 27th June on thefacilities of the French Accident Investigation Bureau (BEA) .

The transcription was then made with assistance from th epilots .

Tb obtain an accurate chronology, the tape feed speed wa sinitially set using the 400 Hz frequency of the on-boardelectrical power supply which appeared in the recordedspectrum. Then, the recordings of the radio transmissions werecorrelated with those of the air traffic control frequencies(the latter included a time track) .

The part of the recording corresponding to the end of th eflight (fram the descent through 200 feet agl) was studied b yspectral analysis : the continuous recording of frequencies haspermitted a very accurate chronology of the end of the fligh tto be obtained with an error of less than 0 .1 of a second, inusing events with precise time and frequency signatures(synthetic voice of the radio-altimeter, characteristic noises ,voices, etc .) .

The spectral analysis also permitted the engine speeds tobe determined, their characteristic frequencies being recorde don the CVR via the cockpit microphones . It also enabledcorrelation to be made with a video tape of the accident, thesound track of which was submitted to the same type o fanalysis .

1 .11 .1 .2 - DFDR (Fairchild F 800 )

The DFDR was read out by the Br6tigny sur Orge FlightTest Center (CEV) during the night from the 26th to the 27th o fJune by designated persons from this establishment .

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The normal validation work made by the BEA on the first listingsupplied by CEV revealed that, in spite of the care taken duringreading, certain data had been misread. The anomalies observedconcerned :

- incorrect reading of the information during a period of 8seconds (starting 17 seconds before the end of the recording and 10before the engine throttle levers were placed in the go-aroun dposition) 4 seconds of which had been rejected by the reader checkin gprogram and therefore were not printed ,

- certain errors in the A 320 parameter reproduction softwar eused by the CEV (inversion of the sign for the positions of the righ tand left ailerons for example) .

The initially incorrect reproduction of the data was no doub tdue to an interruption of contact between the reading head and th erecorded tape, caused by a fold in the tape and/or by dust . Thefollowing readings, made after cleaning and smoothing out of thetape, permitted correct reproduction of all data .

A bit by bit analysis of the recording for the last part of theflight confirmed the validity of the data obtained .

The parameter reproduction software errors (signs, constantvalues, etc .) were easily corrected .

1 .11 .2 - Operation of recorders

The operation of the recorders was perfectly correct throughout th ewhole flight itself, i .e. until first impact with the trees .

As concerns the CVR, the conversations and aural warnings wer ecorrectly recorded as well as all the noises in the cockpit .

As concerns the DFDR, all parameters were oorre 21y recorded .

lastly, the consistency of th' data obtained from the reading out o fthe CVR and the DPDR and ce .ain outside meedia (photographs, videotapes, etc .) can be describer. as excellent .

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After the first impact with the trees, the CVR continued to operat efor around 1 .5 seconds and then stopped . The DFDR continued tooperate for around one second then gave incoherent data for aroun dtwo seconds . This is followed by the data of a previous flight . Theexact moment when the aircraft came to rest cannot be accuratelyspecified . The only cause that can explain this almost simultaneou sshutdown of the two recorders is the breaking under tension of theirpaver supply cables located in the rear section of the fuselage . Theinspection of the tail cone where the recorders are installed showe dthat the break of the power supply cables could not have occurred i nthis section of the aircraft which suffered little damage ; it isprobable that the break occurred forward of this area, doubtless i nthe landing gear well, which is the most exposed area for the bundleof wires considered . However, this assumption could not be checke ddue to the condition of the wreckage .

The other causes liable to result in shutdown of these recorders werestudied, the most probable being simultaneous cut off of theelectrical p er supply to the two recorders either by shedding or byejection from their mounts . These assumptions could not be retainedin this case as :

- The busbars of each of the recorders can not be simultaneously shedwhen the AC generators operate correctly, as was the case judging bythe engine speeds at the time when the recorders stopped, a sdetermined by the spectral analysis of the video recording soundtrack,

- The recorders were found on their mounts .

1 .11 .3 - Read-out of the conversations and the aural warnings(CVR) :

The transcription of the CVR recordings is given in the appendix ; itstarts with the start-up of the engines at Basle-Mulhouse and stopsat the end of the recording (shortly after the first impacts with thetrees) . The start of the recording, of a total length of 30mn ,concerns the arrival of the previous flight from Paris-Charles deGaulle .

The CVR recording is very easy to follow especially because the cre wwere working with headsets .

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The following points can be noted concerning the flight sequence :

- On start of taxiing at 12h 29, the First Officer requested th eCaptain to confirm the items planned for the ovE:flights at Habsheim.The Captain indicated that he would make the first demonstration inFlap configuration 3, landing gear extended, at 100 feet, withmaximum angle of attack, alpha floor function (1) disengaged, FirstOfficer adjusting thrust to maintain flight-level ; when requested bythe Captain, the First Officer was to select maximum engine power ,whilst the Captain carried out a climbing turn . The second overflightwas the% scheduled, also at 100 feet, with the First Officer at th econtrols, in clean configuration and at high speed (340 knots) .

- The Captain then outlined the programme to the Purser and the Firs tOfficer specified that it would be best to remain seated during thedemonstration (passengers and crew strapped in) .

- Take-off was made at 12h 41, the autothrottle was disengaged a ssoon as the landing gear had been retracted and flaps placed i nposition 1 .

- Radio contact was established with the Habsheim tower at 12h 44 an dF- KC was cleared to make its overflight . During the descent, thecrew selected the altimeter setting for Habsheim (QFE 984 hPa), thenextended the landing gear and the flaps (position 2 then 3) .

- The radio altimeter called 200 feet, then 100 feet at the exactmoment when the First Officer told the Captain that the aircraft ha dreached this height .

- The radio altimeter continued to announce the heights (40 then 50then 40 feet) . Between 50 and 40 feet, the Captain confirmed thedisengagement of the autothrottle . The First Officer drew theCaptain's attention to the presence of pylons ahead .

- Full application of power (throttle-levers forward) was made by theCaptain immediately before the radio altimeter announced 30 feetthree tines consecutively .

Next, the increase in engine speed can be clearly heard before theraise of the impacts with the trees which progressively covers tha tof the engines .

1 .11 .4 - Read-out of the parameters recorded on the DFDR (se eappendix )

The number of parameters (200) recorded on the A 320 - 141 of whichare discrete (yes/no) - and the quality of the recording permitte dthe flight sequence to be reconstructed with high accuracy up to th emoment of impact with the trees .

(1) see paragraph 1 .16 .1 .2

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Take-off was made at 12h 41, heading 15 50 , and the aircraft left theground at an IAS of 153kt . Turn was started in the second tha tfollowed. Four seconds later, roll control passed through a max imumand at this time the radio altimeter indicated 76 feet . The bankangle was then stabilized at 34° approx. The right turn was held forone minute until heading 010 was reached, at the end of the turn th eaircraft entered level flight at 1900 feet QH (approximately 900 to1000 feet above the ground) at a speed of 200 kt. Progressively, theheading changed to the left to 335°/340° . At 12h 43nn 44s, theaircraft, which had reached 2000 feet QNH (1) started its descent .Descent rate was initially low, 300 feet per minute . At 12h 44mn 14s ,the engines were set to idle, the speed, which was 200kt at thistime, slowed by approximately lkt per second . Three seconds later ,larding gear extension was commanded and a further ten secondslater, the flaps, which had remained in position 1, extended toposition 2 . At 12h 44mn 45s, the flaps were extended to position 3 ,the aircraft descerxied through 500 feet with a speed of 177kt, meanheading still 334, which was maintained until 90 feet in the descentto Habsheim.

At 12h 45ím 06s, aircraft speed was 155kt, as it passed the radio-altimeter height of 200 feet . The barometric altitude decreasedcontinuously, the radio-altimeter height oscillated around 200 fee tbetween 12h 45mn 06s and 12h 45mn 09s (the terrain over which theaircraft was flying was not flat) .

Between 12h 45mn 15s and 12h 45mn 23s, the aircraft made a gentleright turn to line up with runway 34 R, maximum bank angle reachedwas 13° and heading coming out of the turn was 344° . The speeddropped from 149 to 141kt and the height decreased from 90 to 46feet . A fluctuation in the radio altimeter height can be seen duringthis alignment manoeuvre (32 feet at 12h 45mn 18s and 24 feet at 12 h45mn 19s) corresponding to flight over a clump of trees located i nfiunL of the runway. Before and after this fluctuation, there isperfect agreement between the readings of the radio altimeter an dthose of the bararetric altimeter .

At 12h 45mn 26s, the aircraft reached 40 feet, still descending ,speed was 132kt, still falling, the engines were still at idle (29%of Ni) . At this time, the pilot started a flare to level off close tothe ground, the side stick pitch noveients being of low amplitude (onaverage, 4° rose up) .

lbe lowest points in the flight path were around 30 feet in height :between 12h 45nß 32s and 12h 45mn 39s, the radio altimeter indicated32, 32, 32, 32, 30, 30, 24 and 34 feet (one value per second) . Duringthis level flight :

- The side stick, previously at 4° rose up until 12h 45mn 30s, wasbrought to and held at 6/7° nose up until 12h 45mn 36s .

(1) lbe Q NH altitude readings are the result of a calculation . Theone recorded on the DFDR corresponding to altitude pressures set a t1013.2 hPa.

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- The throttle levers were placed in the TOGA (take-off/Go-around)detent ketween 12h 45m1 34s and 12h 45mn 35s . At 12h 45mn 34s speedwas 122kt and angle of attack 13 0 . At 12h 45mn 35s, the fuel-flow ofengine 1 (recorded at the end of each second on the DFDR) had alreadyincreased (from 406 to 682kg/h), its speed N2 had varied from 71 to72% . The increase in power on the two engines was uniform and at 12 h45mn 39s the Ni speeds were respectively 83 and 84 % .

- From 12h 45mn 35s, the angle of attack reached values of 14 an d15° .

- At 12h 45mn 37s, the stick was set nose-up to 13° then to ful lnose-up in the two seconds which followed .

Between 12h 45mn 39s and 12h 45mn 40s, the aircraft touched th etrees ; as shown by a decrease in longitudinal acceleration .

After 12h 45mn 40$, the data recorded on the DFDR is incoherent forapproximately two seconds, and this followed by the data relevant t othe flight preceding the one in which the accident occurred (closedloop operation of the flight data recorder) .

To sum up, the flight was completely reconstructed up to impact wit hthe trees . No particular comments need to be made on the initialflight phase . The final flight phase can be summarised as follows ,taking "t" as the time reference 12h 45mn 39s :

.

t-25 sec Aircraft passes 100 feet in descent at a speed of151kt

. t-17 sec Aircraft passes 50 feet at a speed of 141kt

. t-13 sec Aircraft passes 40 feet at a speed of 132kt

▪ t-7 sec Aircraft reaches 32 feet at a speed of 123 kt

t-6 sec Aircraft is still at 32 feet at a speed of 122kt ,the throttles are still in idle position

.

t-4 sec The throttles have been brought to the TOGA

detent, the Ni and the fuel flow rates start to

increase

.

t-1 sec The stick is in full nose-up position, speed i s

112kt, engine Nls are 67 %

.

t sec Stick is still in full nose-up position, speed i s114kt, engine Nis are 83 % and 84 % .

. t + 1 sec The aircraft has already touched the trees

The work conducted by the Cotmission to verify that the aircraft

response to the =wands given by the crew, through the flight and

engine controls, showed no ananalies, and is covered by paragrap h

1 .16 below.

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1 .12 - WRECKAGE (see sketch in appendix )

1 .12 .1 - Flight path

A forest of young oak and birch of an average height of 12m an da base diameter of 20 to 30 can is located at approximately 60meters from the end of runway 34 R .

The A 320 hit the top of these trees at the edge of the forestwith the rear section of the fuselage and the horizonta lstabilizer . Due to the engine thrust, the trees are broken i nthe opposite direction to that of the aircraft's movement .

The aircraft touched the trees in line with the runwaycentreline. Its path in the forest was practically straight andalways in line with the runway centreline . The wreckage itselfwas located on the extension of this centreline.

Fifty meters beyond the edge of the forest, the marks left bythe landing gear and the engines can be seen in the tops of thetrees . Further on still, the wing leading edges cut off thetops of the trees at lower and lower levels as the aircraftsank into the forest . Judging by the way the tops of the treeswere cut off, the aircraft was banked in flight slightly to theright.

The evacuation of the various elements of the wreckage(especially for the investigation) required that these trees b efelled. The heights of fracture were measured and plotted on adimensioned drawing . This enabled an accurate path of the entryof the aircraft into the trees to be plotted .

1 .12 .2 - Wreckage

The wreckage was grouped together . Its rear end was found 270 mfran the road which separates the runway from the forest .

Upstream, the first large pieces of wreckage were found 230 mfrom the road : the tip of the right wing with a portion o faileron and, slightly further away, a portion of slat .

On approaching the wreckage, several pieces of flight controlsurface (slats and flaps, ailerons), and of empennage, cowlingsand engine accessories were found together with small pieces o fskin .

The main part of the wreckage was surrounded by a jumble oftorn and broken trees . The aircraft was largely destroyed b ythe fire which followed the accident : the fuselage wascaipletely burnt out, except for the empennage and the zonelocated aft of the pressurized bulkhead where the recorderswere found intact .

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The right wing, broken into several portions, was alsodestroyed by the fire .

The right engine, torn from its pylon, lay slightly to the rea rof the wing, with the air intake facing towards the tail of th eaircraft . The air intake sound-proofing panels were wrappe daround the fan vanes which suffered practically no damage fro mthe accident.

The position of the variable stator vanes (VSV) corresponded t oa low engine speed . The low pressure ccanpressor bleed valve s(VBV) that were visible were damaged .

The left wing was complete and remained attached to thefuselage .

The leading edge had been crushed in by the trunks of the treesand many branches had stuck there .

On the left engine, the position of the VSVs also correspondedto a low engine speed, the visible VBVs were also damaged . Theexpert investigation of the engines described in paragraph 1 .16permitted these points to be more accurately defined .

Slightly forward and to the right of the aircraft, many treeswere burnt indicating that burning fuel was projected forward sfrom the right wing .

The examination of the trim screw showed that the trimnabl ehorizontal stabilizer (TSS) was set to approximately 4 .5° whichis consistent with the DFDR indications (last recorded valu ewas 4 .4°) .

1 .13 - MEDICAL ANDPAO-OLOGICALINFORMATION

1 .13 .1 - Pilots

a - Study of medical files

The examination of the medical files of the Crew MedicalExamination Centres (CEMPN) revealed no medical evidence whic hcould have influenced the accident . The two pilots hadsuccessfully passed their routine radical check-ups every sixmonths since 1962 .

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b - Injuries caused by the accident

Michel ASSELINE

- Various bruises with no signs of bone fracture visible on the X -rays . Bruising of the collarbone (shoulder harness in place) ,

- Inhalation of smoke and emotional shock ,- Kept in hospital one day at Mulhouse ,- Absence fran work fran June 26th 1988 to end of November 1988 .

Pierre MAZIERES

- Injuries to the head, without true loss of consciousness, bu twith clouding of vision, with no signs of bone fracture visibl eon the X-rays

- Forehead wound (stitched in hospital )- Bruising of both collarbones (shoulder harness in place) ,- Kept in hospital for one day at Mulhouse ,- Returned to hospital for 10 days in August 1988 ,- Absence from work from June 26th 1988 to end of November 1988 .

c - Timetable before the accident

MichelASSELINE

The day before the accident, the Captain made training flights on theA 320 with three trainees . He went home around 17h00 U1C (19h00 localtine) and spent a renal night and slept well .

On June 26th 1988, he had breakfast around 4h00 (6h00 local) beforeleaving for Roissy-Charles de Gaulle, where he arrived around 6h1 5(8h15 local) for the briefing and flight preparation . During areception with the Authorities and the reporters at Basle-Mulhous eairport, before the demonstration flight, he drank a fruit juice andate nothing .

PierreMAZIERES

The day before the accident, he led a normal life in Paris spent agood night and slept well .

On June 26th 1988 on the day of the accident, he got up around 3h0 0(5h00 local) and had a full breakfast at home . He arrived at Roissy-Charles de Gaulle around 5h30 (7h30 local) then prepared his fligh tfollowing another light breakfast .

During the Basle-Nulhause reception, he drank a fruit juice and ate apiece of cake .

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d - Alcohol measurement

An alcohol level measurement was made on the two pilots by thePolice by means of a breathalyser. As the tests were negative ,blood sample alcohol measurements were not performed .

1 .13 .2 - Cabin attendants

The 4 cabin attendants suffered from various bruises, withou tbone injuries, and psychological traumas justifying grounding .

1 .13 .3 - Passengers

▪ 110 persons passed through the screening centre and thehospitals (Basle included) . Amongst these passengers, 76 wer eallowed to go tome and 34 were hospitalized .

. 12 days after the accident, 8 passengers were still i nhospital .

. 42 persons were given leave from work or granted certificate sof temporary inability to work for 7 days or more .

. 41 persons suffered from facial or cerebral cranialtraumatism with face injuries, broken noses, nose bleeding .These injuries were caused by impact with the seat located infront of the passenger during the accident .

. Other injuries and pathological facts included thefollowing :

- 2 broken upper arms- 1 broken thigh-bone- 6 bruised rib cages and broken ribs- 2 dislocated shoulder:- 2 fractures of the spTee by compression- 8 cases of immediate t .i marked emotional shocks .

. The traumatic injuries were, for the most part, caused by theevacuation (escapes slides c:;maged by the trees or badlydeployed because of obstacles, rapid evacuation, with thepassengers pilling on top of each other, and violent contactwith the ground) .

The three deaths were not caused by acceleration effects durin gimpacts but by the fire which also caused burns on four otherpassengers (one of than suffered 23% burns) .

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1 .14 - FIRE

1 .14 .1 - Development of the fire

During the inpacts with the trees, the right wing was torn off ,the fuel was projected forwards by inertia and immediatelyignited causing a very violent fire, from the moment when th eaircraft stopped, to the right and forward of the fuselage .

Passengers (see paragraph 1 .15) also report that fire broke outon the left of the fuselage, level with the wings, an dpenetrated into the left section of the cabin through th ebroken windows at the level of rows 8 and 9, and in the rightsection through the holes in the floor between rows 10 and 15 .The fire spread throughout the cabin .

Later on, fuel flowed out of the left wing and fed the fire inthe fuselage .

Only the left wing and the tail of the aircraft (where theflight recorders were located) were not destroyed by the fire ,mainly due to the intervention of the fireman .

1 .14 .2 - Fire fighting

Six firemen and 2 vehicles were standing by at the Basle -),l se aerodrome to cover the airshow .

They drove immediately to the place of the accident to fightthe fire .

The alert wns given immediately and, 10 minutes later, thefirst group of 8 fire fighting vehicles from Saint Louis ,Ottmarsheim, 'Mann, Altkizch and Colmar arrived at the accidentsite .

Note that only small vehicles were able to reach the wreckage ,the other vehicles were blocked by the trees and thisconsiderably hindered the fire fighting .

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1 .15 - SURVIVAL ASPECTS - EVACUATION

1 .15 .1 - Evacuation sequence (1 )

Before the Paris-Charles de Gaulle/BasleMUlhouse flight, the cabi nattendants made the terminal turnaround inspection without detectin gdefects other than a broken mirror in the aft galley. This mirrorpermits the cabin attendant to observe the cabin from his seat .

During the Basle-Mulhouse line stop, a tetraplegic boy was installe din seat 4D (aisle), reserved for handicapped persons, then, fo rcam ercial reasons on the request of his family, in seat 4F (window) .

After the take-off, the signs asking the passe ngers and the cabinattendants to keep their seat belts attached were illuminated a splanned.

During the impacts with the trees and the ground, most of th epassengers hit their heads on the seat in front of them causing man yfacial injuries and dizziness .

At the aft galley, obje- `s fell onto the cabin attendants .

Before the aircraft cane to rest, all the lights went out ; it seem;that the emergency lighting, apart from the exit signs, did not cameon . Also, breakages gust have occurred in the laser right section ofthe fuselage forward of the wing because, as soon as the aircraftcame to rest, passengers saw flames and smoke caning out of the flooron the right-hand side

fuselage hetween rows 10 and 15 .

Several seconds at nr after the aircraft came to rest, the fir eentered the cabin thr- h the broken windows on the left side at th elevel of rows 8 and 9 .

Also, several passengers reported short circuits with sparks aroundthe forward galley and smoke coming from this area .

As soon as the aircraft cane to rest, the stewards stationed at theforward and aft doors, seeing the fire on the right of the aircraft ,opened the left doors .

lbe Captain declared that he made seve attempts to trigger th eevacuation signal ; but it seems that t . .s signal did not work asrxabody in the cabin heard it .

(1) This sequence of events is essentially based on reports made b ythe cabin attendants and passengers .

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A passenger stated that he had wanted to open the left wing c .ergencyexit but could not reach it . The commission observed that the openingof this exit, without prior check, would have been very dangerous asfire was raging around the left wing level .

The left forward door was blocked by branches after it had started toopen correctly. The escape slide started to deploy partly outside an dpartly inside the cabin .

The purser, with the help of at least one passenger and an ai rhostess from another airline (who was in the cockpit as a passengerduring the flight), pushed the door . The door opened suddenly and th epurser and the passenger fell out of the aircraft and were covered bythe escape slide .

The passengers started to panic and push in the front part of th ecabin .

The passenger hostess mentioned previously then started to evacuat ethe passengers, but the first ones were blocked by branches in theescape slide . The other passengers junped out beside the escape slidebut they very quickly piled up on top of each other again due to th ebranches . The hostess then stopped evacuation for a short while s othat the passengers who had already junped had tine to extricat ethemselves . She thinks that she was helped by another perso n(unidentified) .

Meanwhile, on the outside, the purser with the help of another ai rhostess, also passenger in the cockpit and who was no doubt lef tduring the pushing, tore away the branches from across the escapeslide to free the blocked passengers .

After a certain time, the first passenger hostess herself left theaircraft suffering from the effects of the smoke .

The hostess stationed in the center of the aircraft at 12D was pushe dinto the aisle by the passenger in 12F who was seriously burnt, the nwas carried forwards whilst at the same time helping a passenge rwhose clothes were on fire .

She arrived at the left forward door (1G), no doubt after theevacuation of the previous hostess, and took her place . After theevacuation of the last persons to arrive at this door, she calledinto the cabin to find out if anyone was still there but did not ge tany reply ; by this time, the smoke, very thick, and flames made anyvisual inspection impossible .

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On the order of the Captain, who had just evacuated the injured FirstOfficer, she then left the aircraft .

The Captain then returned to the cockpit to get an anti- spoke maskwith the intention of going through the cabin, but in turn had t oleave, before he could don the equipment, suffering from the effect sof the fumes .

Note that the cabin attendants either were not able to use the anti -smoke masks during the evacuation or did not think of doing so . Theywere, in fact, more occupied in opening the doors as quickly a spossible so as to speed up passenger evacuation .

The left aft door was opened without any problems and the escapeslide was correctly deployed. The steward ordered the passengers t ocane towards him to evacuate and at the same time reassured the mverbally . This, combined with the absence of smoke at the rear of th ecabin, certainly contributed towards the good evacuation via thi sdoor .

After several passengers had used the escape slide it was puncturedon the branches . The steward asked his colleague to descend to hel pto receive the passengers .

Evacuation continued without panic with spontaneous help from onepassenger, especially for the evacuation of an elderly person who haddifficulty in moving .

After the last passengers had left the aircraft, the hostess returnedto go through the cabin but the flames and smoke had reached th egalley ; she was only able to shout out in the direction of thecabin.

During the evacuation, the stewards and hostesses could not see wha twas happening at the other end of the aircraft due to the fire aroundthe left wing. Therefore, after the end of evacuation via their door ,they went round the wing towards the front or the rear to see if they

could be of any help at the other door .

It has not been possible to determine the time it took to evacuatethe survivors .

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All passengers were able to leave the aircraft, except three :

- the young handicapped boy in seat 4F who seams to haveremained in his seat ;

- a little girl located at 8C who, according to her youn gbrother (carried away by the flow of the other passengers) ,had not been able to open her seat belt and was blocked bythe back of her seat which wes tilted over onto her ;

- a wanan travelling in seat 10B, who according to her husband ,had reached the left forward or ; as her body was foundnear to that of the little girl, we can reasonably assumethat she went back into the cabin to help the little girl an dwas overcame by the fumes .

It appears that some of the safety equipment proved to be deficientor inoperative :

.As we have seen above, before the aircraft came to rest, thenormal lighting went off and the emergency lighting did notcame on, due to a design error in its automatic illuminationpia,

.There was no evacuation signal in spite of several attempt smade by the Captain ; this fault is doubtless related to theother observed electrical problems ,

. Wei the aircraft cane to rest, the purser wished tobroadcast a message via the public address but could notfind the handset which, apparently, had been torn from itssupport, maybe due to the fragility of this support and o fthe attachment of the electrical lead .

One doctor, one aambulance and 10 first-aid workers were present atthe aerodrome for the air show. As soon as the accident occurred ,they alerted both the fire brigade and the hospital emergencyservices (the various services had been informed of the air show an dhad emergency services ready in accordance with the usualarrangements for this type of meeting) . They arrived on the scene o fthe accident and participated in the first examination of the injuredand gave first aid while awaiting reinforcements from Mulhouse . Thesetting-up, 25 minutes after the accident, of an ambulance evacuationcircuit and the organization of the examination centre were performe dunder the guidance of the fire brigade doctor. On the whole, thehospitalization wes achieved without great difficulty, due to theminor character of the injuries, the small hunter of persons injured,the geographical location of the accident, near to a large town, th egood cooperation between the medical emergency teams and the goo doperation of the hospital emergeny plan .

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Also, around twenty passer. iers stated that they got home or went tothe hospital by thumbing a lift on the nearby road without passingvia the emergency station . Because of this, they were initiallyreported missing, which complicated the task of the rescuers .

1 .15 .2 - Investiqation

a) Definition of the questionnair e

Due to the conditions of the accident (snake, workload, etc .) ,the cabin attendants could not give in their evidence acomplete and exact description of the evacuation procedure .Consequently, the Investigation Cottmission decided to send aquestionnaire to each passenger with the aim of clarifying th efollowing points :

1) the conditions relevant to the opening of the left forwarddoor,

2) the entry of stroke and fire into the cabin (as it had onl ybeen established that smoke had very quickly entered thecabin and that the hair of one woman passenger in row 12had caught fire) ,

3) the injuries sustained during the impacts with the treesand the ground, then during evacuation ,

4) the position of each passenger in the cabin and th eemergency exit through which he left the aircraft ,

5) and more generally, the evacuation procedure from thepoint of view of the passengers and their impressions .

The Commission decided to avoid all technical terms and to use ,as far as possible, multiple choice questions ; this alsofacilitated the processing of the replies .

Also, at the end of the form, a general and narrative questio npermitted the passengers to give all their opinions .

A plan of the cabin was appended to help the passengers maketheir replies.

b) Results

Of the 127 questionnaires sent to the surviving passengers, theInvestigation Catmission received 99 replies (78%) for the mostpart very accurate and well thought out .

The replies to questions 1, 2 and 5 were largely covered in th eprevious section, 1 .15 .1 .

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The replies to question 3 are covered by paragraph 1 .13 .

Concerning the 4th question, it appears that the passengerscorrectly remembered their position in the aircraft and hadleft by the door nearest to their seat : the dividing line ,between the passengers who left by the forward door and thosewho left by the aft door was located around rows 12 to 1 5(there is no row 13) ; the only real exception concerns apassenger who was located in raw 18 and who exited the aircraftvia the front, without doubt to join his family who were seate dfurther forward .

Also, the evidence of the passengers has permitted theirindividual behaviour during the evacuation to be established :

- The special character of the flight (round trip and firstflight for most passengers) had several consequences :

. the passengers had practically no hand luggage and los tno time trying to recover it ,

. they had been particularly attentive during thepresentation of the safety cards .

- It was also confirmed that the reassuring yet firm words o fthe steward at the rear were of a great help for thepassengers and clearly limited the panic at the rear of th eaircraft .

- Also, 11 passengers clearly stated (even though the questio nhad not been asked) that they had had difficulty in openin gtheir seat belts and that sane of them required help ; it isalmost certain that this is not due to the opening mechanismbut to a lack of knowledge of the system . As we have seen ,this seems to be one of the reasons for the death of theyoung girl whose brother declared "she could not open herseat belt" .

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1 .16 - TESTS ANDRESEARCH

The main objective of the tests and investigations conducted by th eInvestigation Commission was to check if the sequence of flight eventscould have been affected by a malfunction of the aircraft, its engines o rits equipment . They mainly concern :

- analysis of the operation of the flight controls and verification o fthe conformity of aircraft F-GFKC to the definition covered by th eairworthiness type certificate .

- investigation of the engines and analysis of their operation durin gthe flight and especially during go-around .

Also, the radio-altimeter announcement sequence, which on firs tinvestigation could seem to be abnormal, was also especially studied .

1 .16 .1 - Analysis of the operation of the flight controls

1 .16 .1 .1 - General

The AIRBUS A 320 is equipped with a new generation flightcontrol system : it is the first civil transport aircraft to b eequipped with digital fly-by-wire controls .

Two main characteristics distinguish a fly-by-wire contro lsystem :

- the commands given by the crew are transmitted in electricalform to the computers and are not directly transmitted to theservomontrols by mechanical means ,

- the flight control computers also receive, as input data, th einformation delivered by the on-board sensors and can, fro mthis, generate the optimized flight control deflectioncommands for each flight phase .

This second point permits an improvement in the flyingqualities and reduces the pilot's workload as can be seen bythe two following examples :

- the system is designed to compensate automatically for

external disturbances due, for example, to turbulence : if itdetects a movement of the aircraft when the pilot has notgiven the =amend, it will itself compensate for thi s

movement .

- the system can incorporate automatic limitations preventin g

the aircraft from going beyond predetermined values stored in

memory, for example : load factor, angle of attack or rol l

rate.

The result is that, unlike older aircraft, there are no one-to -

one relations between the position of the controls and th e

position of the control surfaces .

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1 .16 .1 .2 - AIRBUSA320 fliqht control laws

The Investigation Commission particularly studied the final fligh tphase, from the passage through 300 feet agl . On the AIRBUS A 320, inthe aircraft configuration during this flight phase, the longitudina lflight control laws change in the following way during an approac h(for reference, the lateral flight control laws do not change) :

. Throughout the flight phase preceding the t«aatzlt when theaircraft reaches a height of 50 feet, measured by the radioaltimeters, the flight control law is the usual law designate dC* : this consists in controlling the load factor around thevalue 1, with dalping corrective terns for the angular rate o fpitch and the derivative of conventional speed . The effects ofthe load factors and of these terns are constant for speedslower than 150 kt .

. During the descent phase between 50 and 30 feet, the fligh tcontrol law is modified to gradually take into account (1) alongitudinal attitude term (difference between detectedattitude on passing through the 50 feet agl, called referenc eattitude, and the actual instantaneous attitude), instead o fthe load-factor tern► .

. On passing through the 30 feet agl, an additional comman dintended to simulate a conventional ground effect is introducedto supplement the previous pitch attitude control law : thiscommand gradually brings the reference attitude (detected at 5 0feet) to -2° in 8 seconds creating a nosedawn pitching momen tthat the pilot must counter ("derotation") .

If at any time, the angle of attack reaches 14 .5°, the flight controllaw is modified and the load factor term or the attitude ter m(modified or not by the derotation law) is replaced by an angle o fattack term (difference between measured angle of attack and 14 .5°value) . This flight control law ensures, in particular, an automaticprotection preventing the aircraft from reaching an angle of attac kgreater than 17 .5' to retain a sufficient margin in relation to astall, even if the pilot holds the control in full nose-up position .

This above mentioned flight control mode, named Alpha Prot (hig hangle-of-attack protection) is a priority node as soon as angle ofattack reaches 14 .5° . It is not a degraded node and cannot bedeactivated by the crew.

Lastly, remember that when the radio altimeter height is greater than100 feet, power is automatically applied if the angle of attac kreaches 15° . This function, called Alpha Floor, intended mainly tocounteract the effect of high wind gradients during approach, can beinhibited by the crew :

(1) this occurs progressively ; the change of law is made in on esecond .

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. either each time an increasing angle of attack goes beyond 15 °by acting on one of the instinctive disconnect pushbuttons onthe throttle levers, or by disengaging the autothrottle, or byplacing the throttles in the idle position .

. or permanently by pressing, for more than 30 seconds, on one o fthe instinctive disconnect pushbuttons .

For the flight made on June 26th 1988, it is possible to reproducethe flight control laws which must have been effectively in operationduring the approach and the flight over Habsheim aerodrome on thebasis of the information recorded by the DFDR, taking same timereference "t" : 12h 45mn 39s .

. before t-22 sec : usual C* law,

. between t-21 sec and t-20 sec, change to pitch attitude contro llaw (corresponding to a jump in the radio altimeter informatio nduring this time interval) ,

. between t-20 sec and t-18 sec, gradual return to C* law,

. between t-18 sec and t-4 sec, pitch attitude control la w(difference with respect to measured 6° value during passagethrough 50 feet) ,

. at t-4 sec, switching to high angle-of-attack protection law, as14 .5° was reached, this law then being maintained .

During runway flyover, since the 30 foot height was not reachedbefore the 14 .5° angle of attack, the derotation law could not hav ebeen activated . This point is confirmed by the fact that the pitc hcontrol was practically stable (6 to 7° nose-up) whereas the pitchattitude and the angle of attack increased. If the ground effectsimulation law had been activated, the attitude hold and, a fortiori ,its increase, would have required nose-up action on the pitch controland this is not shown on the recordings .

1 .16 .1 .3 - Investigations carried out

The normal operation of the flight controls was never questioned b ythe crew of the A 320 involved in the accident . The InvestigationCommission nevertheless judged that this point must be checked out indetail.

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This check was carried out on the basis of flight sinulations wit hthe aim of checking if the behaviour of the aircraft F -GFKC could b econsidered normal during the flight made on June 26th 1988 . To thisend, the Commission had flight simulation tests performed on arepresentative ground-based simulator (1) and on the A 320 No . 3(flights No . 260 on July 27th and No . 355 on November 14th 1988) .Some of the members of the Commission themselves performed several ofthese tests .

Each of these means (simulator and actual aircraft) presente dadvantages and disadvantages vis-a-vis the required objective :

. the ground simulator permitted very high angle of attackmanoeuvres to be made at very low speeds near to the ground butdid not permit exact reproduction of the flight environment(outside display limited, different piloting sensations) . Also,it is inpossible to exactly reproduce the flight from the DFD Rinformation as the recording rates are too low for this .

. the real aircraft is of course highly representative, but fo rflight safety reasons, we could not go too close to the actua lconditions of the accident .

In neither case, was it possible to represent exactly the atmospheri cconditions present during the flight which led to the accident but, ápriori, this aspect had only a very marginal influence in the caseconsidered (the atmosphere was calm at }íabsheim on June 26th) .

The tests carried out were as follows :

- on ground-based simulator :

The simulator having been placed in initial conditions from which i twas possible to reach a point in the flight envelope (altitude -speed) measured on the recording of the approach of June 26th, th epilot at the controls of the simmulator attempted to reach this pointthen to pass through the same flight envelope point values (altitud e- speed) in a certain number of cases measured on the DFDR . Duringthis test, in which several attempts were required to obtain correctsimulations, the aircraft configuration was fixed (aircraft weigh tand CG position in compliance with those of the flight, landing gearextended, slats 220 , flaps 20 0 ) . During the major part of theapproach, engines were at idle and the pilot used only the pitc hcontrol to perform the test .

(1) the accuracy of the simulator in representing the aircraft was checkedby specialists tram the Flight Test Center who had participated in the A320 type certification tests .

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- in flight .

. study of the behaviour of the aircraft at very low speeds ,

. assessment of the influence of the modifications of the fligh tcontrol laws at very low height during flights over the runwayat Toulouse in the approach configuration of the F-GFKC on Jun e26th 1988 .

1.16 .1 .4 - Results

1 .16 .1 .4 .1 - Reconstruction of performance(variation of altitude and speed )

The two tests on the simulator considered as the most representativ ewere retained for the analysis which mainly concerned the final phas eof the flight (from 50 feet) .

In both cases, the altitude and speed parameters were very wel lreproduced and the agreement with the flight in which the acciden toccurred can be considered as excellent from this point of view .

In the first case ("nominal" case), the differences of the speed i nrelation to tine are in general less than ]kt (carpared with theaccuracy of this parameter during the DFDR recording : - 0 .5 kt), thediffexem:es in altitude are small (+ 10 feet naximan 13 to 14 secondsbefore the time of impact, - 5 feet on average during the las tseconds) (1) . It must be underlined that the pilot at the controlstried to pass via given altitude-speed pairs identical to thoserecorded in flight but that the moment when he reached them result sonly from the simulation calculations . The fact that the altitude andsP<ed curves are practically in compliance with the data obtainedLan the recorder with respect to time shows that the real aircraf tbehaved in this respect in the same way as the certificated aircraft(the characteristics of which are integrated into the simulator) .

However, a slight difference must be noted in this case : at t-12sand t-13s, the speed repriced on the simulator was slightly higherthan that of the flight of the accident (+ 2 to 3 kt) .

In the second case, when the President of the InvestigationCommission piloted the simulator, the agreement of the variation ofspeed with respect to time is also excellent, the flight altitud esimulated was very slightly higher than that of the actual flight ( +8 to 10 feet) . The same difference also exists with the real flighton the radio altimeter altitude between t-21s and t-20s .

(1) We can however note between t-21s and t-20 seconds a significantdifference between the altitude measured by the radio altimeter an dthe altitude of the simulated flight : this is, in fact, a shortphase during which the radio altimeter information was wrong (se eparagraph 1 .16 .3) ; the comparison with the barometric altitude showsexcellent agreement between the flight made on June 26th and thesimulated flight .

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We also have the same discrepancy as in the previous case : at t-12sand t-13s, the speed reproduced in the simulator is slightly higherthan that of the flight in which the accident occurred (+ 1 to 2kt) .

This discrepancy can be explained by a low amplitude atmospheri cdisturbance during the flight, not reproduced by the simulator . Thebehaviour of the aircraft after t-10s is however in compliance wit hthe model, which indicates that this disturbance only had a ver yminor effect on the aircraft flight path .

In flight tests, the performance comparison between flight No . 260and the flight of the accident is good (see sheet given in appendix) .

This fact enables us to conclude that the aircraft configuration wasindeed the same and correctly reproduced .

1 .16 .1 .4 .2 - Response of the aircraft to a pitch actuation atvery low speed :

The difficulty of ie cing a manoeuvre arises from the fact thatwe mist place ourselves in identical or nearly identical flightcontrol law conditions implying the observance of all relevan tparameters (load factor or attitude, angle of attack, speed gradient ,positions of sidestick in pitch) but these parameters are recorde donly at a low rate on the DFDR (in general, one point per second )whereas an exact reconstruction would require around 40 points pe rsecond. In the majority of the tests conducted on the simulator an din flight to assess the behaviour of the aircraft at very high angl eof attack, the pitch control was brought to the rear stop morerapidly than during the flight on June 26th in the phase immediatel ypreceding impact with the trees .

However, specific tests relevant to this last flight phase permitte dus to check that the response of the aircraft to the pitch comman dgiven by the Captain was also in compliance with the certificatio ndata :

on the simulator, the sheet given in the appendix shows that ,for the test performed with a stick deflection rate identica lto that of the flight on June 26th, the attitude response isperfectly in catpliance on the simulator and during flight ,after resynchronising from the time when the Alpha Prot law wasactivated,

it was also possible to make a reconstruction in flight duringflight No. 355 on A 320 No. 3 :

'l parameters recorded during this test are ccupared on the sheetw :Yu those of the flight of June 26th . The differences between th etwo cases are as follows :

. flight test No . 355 was made at a speed lower than that of th eflight on June 26th, the weight of the aircraft was lower, th eangles of attack were more or less the same ,

. the variation of attitude and altitude was different (aircraftdescending during flight No . 355, in level flight for th eflight on June 26th),

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. the pitch control was brought to the rear stop more slowly thanon the flight of June 26th, but from a balance position neare rto neutral ,

. lastly, during flight No . 355, made at altitude, control was b ythe C* law (load factor) before changing to the angle-of-attac kprotection law whereas for the flight on June 26th, control wa sby the pitch attitude control law before changing to the angle -of-attack protection law .

As the objective is to compare the response of the aircraft when itwas under the angle-of-attack protection law (in the last seconds o fthe flight), the effect of these differences can be considered to b emarginal, especially as the average deceleration of the aircraft isvery close in both cases .

We can see that the variations in the angle of attack were also ver ysimilar : the increase in the measured angle of attack is almos tidentical during the last two seconds (1°) .

The other calculations made also show that if the pitch control hadbeen moved back more rapidly or earlier during the flight in whichthe accident occurred, an angle of attack greater than 15° could havebeen obtained before inpact with the trees . They also show that ,without earlier initiation of go-around, such a manoeuvre would hav eled to an increase in the instantaneous drag of the aircraft an dwould not have prevented inpact with the trees .

1 .16 .1.4 .3 - Analysis of the aircraft response for thedifferent flight control laws active duringthe approach

Certain members of the Investigation Commission, themselves pilots ,wished to assess personally the behaviour of the aircraft duringmanoeuvres made near to the ground to check if the switchover of th eflight control laws could lead to handling difficulties . To this end ,tests were carried out above the Toulouse runway in level fligh tbetween 100 and 50 feet (C* law), between 50 and 30 feet (pitc hattitude law) and below 30 feet (attitude and de- 'cation law) . Theseflight cases, which did not correspond to normal .pproaches, reveale dno handling problems : the switchover from C* w to pitch attitudelaw had no noticeable effect on the behaviour of the aircraf tobserved by the pilot, the effect of the derotation term wasperceptible (increasing pressure rust be applied rearward to kee plevel flight) without this being tricky and it rust be rememberedthat this rode was not activated during the flight on June 26th .

Switchover to the angle-of-attack protection law also had no effect son the behaviour of the aircraft as felt by the pilot .

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These tests also enabled us to establish that the very ncuentaryswitchovers of the flight control laws which occurred between t-21 sand t-20s due to the erratic indications given by the radio altimeterduring the flight over a clump of trees were not of a nature toaffect the behaviour of the aircraft .

Tb sum up, the Investigation Commission established that th eperformance of the flight controls was in compliance with thecertification data during the flight made on June 26th 1988 and theyconsider that the flight control laws of the aircraft show nocharacteristics liable to create any specific handling difficultie seven under the conditions of this flight which differed noticeabl yfrom those of a normal approach .

1.16 .2 - Engine operation

Unlike the flight controls, the behaviour of the engines wasquestioned by the crew immediately after the accident : they declaredthat, after initiating go-around, engine thrust was not achieved .

From the very first investigations made on the recorders (CVR andDFDR), it was however established that the engines had responded t othe go-around initiation made between 5 and 5 .5 seconds before theimpact with the trees (variation of engine speeds, temperatures andfuel flow rates on the two engines recorded on the DFDR ; noisescharacteristic of changes in engine speeds recorded on the CVR) .

The Commission therefore concentrated their work on checking thecirmmstances of the go-around by :

- reproducing as accurately as possible the engine parameters ,

- comparing the observed behaviour with the normal certificatio ncharacteristics .

The Commission also participated in the engine examination made bythe manufacturer CFMI (in the SIX► premises at Melun-Villaroche) .

1 .16 .2 .1 - Reproduction of the engineparametersduring go-around

The characteristic engine acceleration parameters after go-around initiation were reproduced from three independentsources :

- the engine parameters recorded on the DFDR ,

- the spectral analysis of the last seconds of the CVRrecording, the characteristic frequencies of the enginespeeds having been recorded by the cockpit area microphone,

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- the spectral analysis of the sound track of a video film shotby . a spectator on the ground .

The results of these analyses are perfectly in agreement and sho wthat the engines increased in power as soon as go-around wasinitiated .

The last engine speeds recorded by the CVR and the DFDR were 84 .4 %Ni on the CVR, 83 and 84 % Ni on the DFDR. The sound track of thevideo film permitted reproduction of several additional seconds afte rthe impact with the trees (when the flight recorders were no longeroperating) : the last maximum speed value, clearly identified fromthis source, was 91 % NI .

1 .16 .2 .2 - Comparison with basic certification dat a

As the engine responses had been reproduced without ambiguity, th eCommission checked their conformity with the basic certificationdata.

The certification regulations in particular require that the climbgradient of the aircraft in landing configuration, all enginesoperating, Host be at least equal to 3 .2 % with thurst available 8seconds after initiating go-around . This statutory requirement i sreflected by a minimum thrust value and, therefore a minimum Nispeed, taking into account the aircraft drag characteristics . In theflight conditions of June 26th, this minimum Ni speed value was 94 %(value which must be obtained 8 seconds after initiating go-around) .

In the case of this flight, the inpact with the trees occurred before8 seconds had elapsed after initiation of go-around (see below) . TheCommission therefore sought the minimum Ni engine speed values forthe period between 5 and 8 seconds after initiation of go-around i nthe conditions of the flight and corresponding to go arounds whic hwould satisfy the regulations . These values are given on the curve a tthe end of the paragraph .

The exact moment when go-around was initiated by the pilot during th eHabeheim overflight was determined as follows :

- The position of the throttles recorded by the DFDR, every tw oseconds, indicated : flight idle position at 12h 45mn 33s ,TOGA position at 12h 45mn 35s . Between 12h 45mn 34s and 12 h45mn 35s, engine 1 N2 speed and flow started to increase(this information is taken in the middle of the cycle) .

- The recording made in the cockpit by the CVR shows that th ethrottles were placed in TOGA position at 12h 45mn 34s 5/10 .

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43 .

- The eye-witness reports refer to a definitive and rapidapplication of go-around power .

From these considerations, it can be estimated that go-aroundwas initiated between 12h 45mn 34s and 12h 45mn 34s 4/10 .

The N1 speeds recorded on the DFDR at 12h 45mn 39s ar erespectively 83 and 84 % for engines 1 ani 2 (i .e . 5 to 5 .4safter initiation of ga-arourxi) .

The speeds measured by external means are 91 % 0 .6s afterhaving reached 83 % .

Under these conditions, the curve below compares these recordedspeeds to the minimum speeds required to meet the certificationrequirements . We can conclude that the engine acceleration wasin compliance with these requirements .

N1 speed (%)

Minis nn N1

Measured N1Uncertainty concerning exac t

go-around initiation time

90 .

80..

70..

I

I

I5

6

7time ( s )after go-around

initiatio n

It was thus verified that the engine acceleration defec tsometimes reported in certain low altitude flight cases on theA 320 did not occur during the flight on June .26th . Also, theconditions required for this to occur were not present (speedmuch lower than 250kt) .

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1 .16 .2 .3 - Detailed engine investigation

The engine investigation showed that the engines wer epractically stopped during final impact on the basis of th efollowing :

no signs of fan rotation were found even though, after theimpact, moving blades were in contact with fixed parts ,

signs of low speed rotation of HP system are visible at timeof impact with the ground ,

all the undamaged variable bleed valves (VBV) of the lowpressure compressors were in the open position, i .e .corresponding to idle speed or shut-down .

It was also found that the combustion chambers were alnos tcompletely blocked by a compact mixture of partially burnt woodand leaf debris .

With these elements established, it mist be underlined that th efact that the =t.ors were practically stopped during finalimpact does not contradict the fact that they were operatin gnormally before impact with the trees : the falling of theairs ,;_aft into the forest led to passive ingestion of branchesand leaves via the air intakes and this caused the engines tostop by obstructing the combustion chambers . The engine speedfell rapidly and the regulation system, mainly controlled by N2speed, brought the VW and the VBV into a position compatiblewith a low N2 speed, and this explains why the VW and VBV wer efound in a position corresponding to idle speed .

1 .16 .2 .4 - Conclusions concerning engine operation

Zb sum up, the Investigation Commission established that theengine acceleration during the flight in which the acciden toccurred was perfectly in compliance with the basiccertification data and that their operation was normal up tothe accent when, after impact with the trees, they started toabsorb the vegetation debris during the final falling of th eaircraft into the forest .

1.16 .3 -Additional investigations

In their investigations to check if the operation of the aircraft hadbeen correct on June 26th, the Commission was also led to study th ereasons which could explain the apparently irregular radio altimete rannouncement sequence : 200 feet, 100 feet followed by 40 feet then50 feet . . .(whereas 50 feet should have been broadcast before 4 0feet) .

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On the aircraft intended for AIR FRANCE, the aural announcement sprovided for in the program are (height in feet) :

- 200, 100, 50, 40, 30, 20, 10, 5 ,

- and for approaches for which the crew has selected a decisio nheight DH (approach in low visibility conditions) : HUNDRED ABOVEwhen passing through DH + 100 feet and NIININUM on passage throug hIII .

The predetermined announcements are triggered 10 feet above thealtitudes to be announced for those greater than or equal to 100 feetand 2 feet above for those less than 100 feet .

The time required to generate an announcement from the trigge rthreshold is on average 0 .4 seconds . If an announcement is started(synthetic voice starts to speak), it is pronounced entirely . If,another height, associated with another announcement, is detecte dbefore the first announcement begins, the first announcement is no tbroadcast, as priority is given to the second value to be announced .The aural announcement is also inhibited if the two radio altimetersare inoperative, if radio altimeter altitude is lower than 3 feet orif radio altimeter altitude increases .

Above 50 feet, intermediate announcements (repetition of sam eannouncement when the following threshold is not crossed) ar egenerated every 11 seconds . Below 50 feet, this time is reduced to 4seconds .

In case of the flight made on June 26th, when the actual height o fthe aircraft was decreasing continuously from 100 to 50 feet between12h 45mn 15s and 12h 45mn 23s, there was a discontinuity in the radi oaltimeter information between 12h 45mn 18s and 12h 45mn 19s . Theevolution of these readings was in compliance with the curve below :

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eT<0,4 stime ( s )

I

1

T

T

i

I

I

1

I

This discontinuity comes from flight over a clump of trees locatedshortly before the runway . The 50 feet announcanent, triggered b ypassing through a height of 52 feet, was inhibited as the 40 fee tannouncenent was triggered, by passing through a height of 42 feet ,less than 0 .4 sec . after the 50 feet annoummnent had been triggered .

The 40 feet annourcenent was therefore made without the 50 feetannouncenent having been made and before the 30 feet announcement wa striggered. This 30 feet announcement was inhibited as at the timewhen it should have been announced, the radio altimeter altitude wasincreasing .

After time 12h 45mn 20s, the announcenent sequence presented noirregularities . Note, however, the repetition of the 30 fee tannouncements at very short intervals during the last flight phase .Ttnese repetitions can be explained only by very low oscillations o fthe radio altimeter height around the 30 feet value, the announcementbeing triggered each time that the 32 feet height was passed after a nincrease in altitude even very brief, had been recorded (these verylow altitude oscillations may have been flying oscillations or th eresult of a very low altitude variations in the terrain flown over :an 8 an height variation 3 .5m wide is sufficient to rearm th e

10,

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2 - ANALYSIS

2 .1 - (iAL CONSIDERATIONS

The Camtission found that the aircraft was airworthy, that the weightand CG were within the authorized limits and, more generally, thatthere was no evidence of any mechanical or instrumental failure(before the first impacts with the trees), liable to reduce safety .On the contrary the Cannission became convinced that the behaviour o fthe aircraft had been, from all points of view, in compliance withthe certification data and that the flight path followed was inaccordance with the flight control contends given by the crew via theflight controls .

They also determined that the weather conditions and lightin gconditions and also the aerodrome infrastructure, navigation aids an dtelecommunications played no part in the accident . The crew, normallyquali fied to fly Airbus A 320s, shoved no medical or pathologicalevidence which may have been liable to influence the flight .

The Commission were thus led to concentrate their study on th ecircumstances of the preparation for the flight and on the element sliable to have influenced the behaviour of the crew during the flightas they flew the aircraft on a flight path appreciably different fro mthe one that they had explicitly planned before the flight .

2 .2 - FLIGEfT PREPARATION

2 .2 .1 - Study of the feasibility of the flight over Habshei maerodrome

According to the departments of AIR FRANCE responsible for theflight preparation, the low altitude overflights had bee nstudied as provided for in AIR FRANCE's internal note DO ND50420 . This study would mainly have consisted in checkingobstacle clearance in case of engine failure .

According to the airline, these flybys were studied for fligh tover runway 02 .

This declaration led the Commission to make the followingrenarks :

1) The hard runway 02 at NUlhouse-Habsheim cannot be used bythe A 320, due mainly to the fact that its strength is too low,

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2) The runway to be used could not have been foreseen at the tim ewhen the flight was prepared by the department concerned (weathe rconditions unknown and AIR FRANCE not notified of the runway selecte dby the organizers) .

Note DO ND 50420 was drawn up by AIR FRANCE to prevent demonstratio nflights from being made at heights which are too law . This notespecifies, inter alia, that all or part of a tourist or demonstrationflight mist be subject to : "accurate definition of the way in whichthe flight will be carried out 'distance, altitude, configuration ,etc .) and the corresponding task snaring" .

These directives should have been drawn up by the flight divisionbut :

• It was only on the Friday afternoon that the flight file washanded over, by the employee responsible for its preparation ,to the technical assistant of the division at the moment whe nhe was leaving . Reception of this document therefore seems tohave been fortuitous .

• Also, the persons responsible within the flight division did no tdeal with this earlier probably due to their workload relatedto the entry into service of the aircraft .

. Fran the file (which did not indicate any particulardifficulties), they estimated that Michel ASSEGINE wa sperfectly capable of planning this flight himself given hi sposition in time company and his strong personal whichresulted in h., 'n having a field of actio°• mach gr .er thanappears in the airline's organization chart .

Consequently, the file was handed over as it stood to the crew. Itincluded none of the items required by note DO ND 50420 nor an yindication of height or overflight axis to be observed or any directmeans of contact with the air show organizers .

The Commission considered that, as no such indications were given ,the crew should have referred to DO ND 50420 .

This note specifies that 'e minimum runway overflight height of 10 0feet in landing configuration' rust be observed .

The Commission remarked that :

1) Time note was not appended to

file handed over to the c' »w evenif its existence is recalled in a assage .

2) Time 100 feet height was not applicable to the Mulhouse-Habshei moverflight as none of the runways was usable by the A 320 .

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3) Also, the choice of a height of 100 feet is in contradiction withthe French air safety regulations which impose a miniman overflightheight of 170 feet using VFR (this flight phase was carried out unde rVFR even though under an IFR flight plan) .

The Commission also observed that within the scope of touristic ordemonstration flights, the 100 feet agl height had already been use dby AIR F1MCE to perform many overflights, including over grassrunways, (more than twenty since 1987), during air shows in Franc eand abroad.

The Investigation Commission noted that the overflight height abov ethe aerodromes where the air shows were held, even though not incompliance with the regulations, had not led to reactions from th eAdministration, or from the air show organizers (except on oneoccasion where the flyover conditions and height, lower than thefixed minimum, had given rise to actions from the competentintenninisterial (Hare, Defence, Civil Aviation) control =mission) .

2 .2 .2 - Distribution of the results of the study and provisionof information to the crew

The Department who made the study informed the Air Operation sDirectorate and the Flight Safety Department of AIR FRANC, as wel las the Regional Air Traffic Control (East) and the Basle-Mulhousetower by Telex. Then they handed over the file to the A 320 flightdivision.

Due to the short period of time available, the technical assistantdid not have time to make verbal ccuments on the file to the Captainwho was on flying duty on June 25th . The First Officer, who that daywas resting, was not contacted .

e pilots were chosen for this flight as they had managerialresponsibilities . Reconnaissance of the Habsheim aerodrome by thecrew was at no time considered .

The meeting provided for in the regulations, on its initiative ,between the air show flight manager and the crew did not take plac eonus depriving them of information which could have been useful(special features of the terrain, axis used, location of public ,etc.) .

The organizer had held that same morning a preparation meeting wit hall the other pilots concerned but was not worried by the absence o fthe A 320 crew due to the correct performance of flights made duringAIR FRAM= participation in previous air straws at Habsheimn and thefreeing of the airspace planned from the moment when the aircraft wasto take off from Basle-Mulhouse.

The crew, therefore, had received rop information or verbal commentson th file drawn up for them.

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2 .2 .3 - Flight preparation by the crew

2 .2 .3 .1 - The study of the file (including the prefectora lauthorization number, photocopies of the 1/500,000 scale VFR flightchart, IGN 1/100,000 scale map, VAL chart of the Mulhouse-Habsheimterrain) was only made by the two pilots on Sunday morning June 26th .They therefore made the flight preparation only from items differin gfrom their normal working documentation and describing an aerodromeand its surroundings which they did not know and on which, due tolack of directives, they had free manoeuvre choice .

Neither of the two pilots had previously performed a demonstrationflight.

The Commission noted that they seemed not to have tried to obtainadditional information concerning these overflights .

It is probable that the Captain, on seeing the file, judged that th eflyovers presented no difficulties and that he had no need fo radditional information. Also, the AIR FRANCE personnel directlyconcerned would no doubt not have been easy to contact on a Sunday .

2 .2 .3 .2 - At BASLE-NEE, during taxiing, the Captain made abriefing on the two low altitude flyovers at the Habsheim airfield.The axis of the runway which was finally chosen because of th eterrain and the public was not mentioned. The two flyovers wereplanned without a previous flight over the aerodrome, one at lowspeed, the other at high speed .

The flyover conditions were also explained as follows :

First flyover to be performed :

1) at 100 feet ,2) with flaps in position 3 and landing gear extended ,3) in level flight decelerating to maximum angle of attack

permitted by the A 320 flight control system,4) after disengagement of automatic go-around protection at hig h

angle of attack (alpha-floor) ,5) with assistance to control the aircraft required of the First

Officer if holding the load on the stick became uncomfortabl e(" . . .If I tell you it is hard . . .") ,

6) maintaining level flight with the aid of the engines by th eFirst Officer ,

7) with go-around initiated by the First Officer on order from th eCaptain.

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The second flyover was to be performed :

8) by the First Officer, also at 100 feet, at high speed and in clea nconfiguration .

These 8 points lead to the following comments :

1) As we have seen in paragraph 2 .2 .1, the 100 feet flyover height ,also not in compliance with regulations, does comply with internalnote DO ND 50420 . For the crew, flying at this height could therefor ebe considered as authorized and therefore as normal .

Note that no mention is made of the reference selected for the 10 0feet : barometric height (QFE) or radio altimeter height .

2) This flap and landing gear configuration is one of the norma llanding configurations .

3) The deceleration in level flight was planned down to minimumflight speed corresponding to the maaiman angle of attack permittedby the aircraft fly-by-wire system . This shows, on the part of theCaptain, his desire to highlight the value of the A 320 bydemonstrating its specific possibilities .

The training given to the pilots erphasized all the protections fromwhich the A 320 benefits with respect to its lift which could havegiven then the feeling, which indeed is justified, of increase dsafety. In particular, the demonstration of the activation of thesafety features and protection of this aircraft may lead one t oconsider flight approaching one of the limitations (especially th eone related to angle of attack) as a foreseeable flight conditionsince lift is guaranteed .

However, etphasis was perhaps not sufficiently placed on the factthat, if the limit cannot be exceeded, it nevertheless exists andstill affects the perfoanance, i .e . the ability to change theaircraft flight path. As on conventional aircraft, the load factoravailable at minimum speed in level flight is only one (zeromanoeuvrability in recovery and turn) and the drag at this speed isvery high (back side of the drag curve) which greatly limits th eclimb gradients as the available excess thrust is naturally low .

During training on previous generation aircraft, pilots are mad eaware of the dangers of flight at low speed, and the basic rule whichconsists in observing a margin with respect to a minimum speed isdriven hone . The pilots would therefore probably not have consideredsuch a manoeuvre at a speed so close to stall on these types o faircraft. However, for the flight of the accident, the crew did no thesitate to plan a low height flyover at a speed lower than approachspeed (normal minimum operating speed) without realizing that ,because of the protection, the aircraft limits were reached withoutrisk of exceeding than, but that performance was reduced in the sam eway as on conventional aircraft .

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4) The choice to inhibit the autocratic go-around protection (AlphaFloor) resulted from the need to eliminate this protection if flightat 100 feet or above is planned at an angle of attack higher than th eone activating this protection. The inhibition in this case can onlybe achieved in practice by pressing and holding the two switchesplaced on the throttles . After 30 seconds, inhibition beca aspermanent for the rest of the flight .

This decision is compatible with the objective expressed by th eCaptain to maintain a height of 100 feet and seems to confirm tha tthe incursion below 100 feet was not considered by him at this stage .In effect, below 100 feet, this protection is not active .

5) The request for help to control the aircraft made to the Firs tOfficer can only be explained by concern about the discomfort cause dby a sustained rose-up action, which seems to indicate that th eCaptain thought that he had time to make a prolonged level flightabove the runway at maximan stabilized angle of attack .

6) The request made to the First Officer to maintain level flight byadjusting the engine speed confirms the previous remark .

7) The application of power was planned to be made by the Firs tOfficer on the order ("au TOP") of the Captain . The latter wastherefore envisaging a go-around starting from the power settin gnecessary to maintain level-flight, in other words from a high power-setting.

On the A 320, the training demonstrations of the behaviour of theaircraft at low speed are only made from stabilized level flight at aspeed near to minim= speed and therefore with a thrust near to theequilibrium thrust at maximum angle of attack . In this case, go-around is made from a high engine speed and gain in altitude appear simmediate and the aircraft remains in maximum angle of attack . Notethat this type of demonstration is highly impressive : climb withpitch control set to full nose-up while making roll manoeuvres give sthe feeling of great safety .

8) The height of 100 feet planned for the second high speed flyove ris not in compliance with note DO ND 50420 which specifies a minimu mheight of 300 feet for this type of overflight . The choice of theheight of 100 feet was perhaps made due to only partial knowledge o fthis rote .

The Commission observes that :

- the prolonged level flight mentioned in 5 could not be achieve d(length of runway) . There is also a lack of precisionconcerning the go-around initiation point .

These two points show the incomplete character of the flightpreparation .

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- the task sharing concerning look out and monitoring of th einstrun ents is not mentioned ; even if this task sharingcould seem obvious for each of the pilots, this aspect shoul dhave been dealt with due to the character of the flight(demonstration flight and, moreover, crew made up of tw oinstructor Captains) .

- the comment made by the Captain indicating that he hadalready made this manoeuvre 20 times is probably pertinent a sconcerns the number, but not as concerns the height at whichthe Alpha protection was activated during his trainingflights as instructor or trainee .

2 .3 - SEQUENCEOFEVENTS

After a 6-minute wait due to the traffic, the aircraft lined up onthe runway and took off at 12h 41 . It turned right immediately tohead towards the Habsheim aerodrome . The take off and climb to 200 0feet (dui lasted 2 minutes during which the pilots were occupied b ythe management of the flight and by unwanted warnings leading, on thepart of the Captain, to remarks confirming his profound knowledge ofthe aircraft .

These the crew tried to identify the Habsheim aerodrome which they didnot know ; the descent was only started (with an initial speed o f190kt) at 5 .5 Nm from the aerodrane, a distance which turned out tobe too short to achieve the desired loss of height and deceleratio nsufficiently quickly to permit stabilized level flight .

During the descent, the First Officer made contact with the Habsheimtower and specified : "we're going in for the low altitude low spee dflyover" which corresponded to the briefing and did not incite aremark from the Captain ; the controller gave the QFE altimetersetting ; the two pilots repeated this and indicated that they hadselected and checked it .

The Captain asked the First Officer to confirm if that was indeed theairfield when they passed 450 feet measured on the radio altimeter .

This request can be explained by the habit of making checks for al lflight phases, especially during approach .

Also, at this time, the Captain is, without doubt, trying to find therunway above which the manoeuvre is to be made . It is only when hesees the crowd of spectators that he decides, in accordance with hisdeclarations, to overfly 34R without however telling the FirstOfficer.

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The GFh1S announcement at 300 feet radio altimeter cares from the factthat it was not in "flaps 3" node . The chime which followscorresponds, according to the crew, to the switching off of the GPWS .This was done, instead of selecting "flaps 3" node, probably toprevent further warnings during the demonstration .

At 12h 45mn 11s, the First Officer made a comment concerning the AI RFRANCE flight safety officer whose function consists, among othe rthings, of studying the flights for which the safety margins have no tbeen observed. This comment can be interpreted . in different ways :either anticipated self satisfaction before the planned demonstratio nor, more likely, according to the Cc:mission, a warning for theCaptain.

It can be seen that the First Officer stops in the middle of hi sremark when the "200 feet" aural announcement of the radio altimete ris made. The pilots therefore heard this announcement (maybe withou tidentifying it) the volume of which is sufficient to justifyinterruption of the phrase being spoken even though both of them areusing headsets (the radio altimeter announcement is only broadcast bythe cockpit loudspeaker and not in the headsets but these, beinglightweight, enable the raises in the cockpit to be heard) .

At 12h 45mmn 14s, the First Officer notifies the Captain that they arereaching the height planned for level flight : "OK, you're at 100feet there, watch, watch . . ." .

Here again, the First Officer interrupted his sentence at the 10 0feet radio altimeter announcenent which shows that he heard thi ssound. Also, this coincidence indicates that, either he was using th eradio altimeter as the height reference or that the altimeterindications were consistent with those of the radio altimeter .

Due to the remark made at 12h 45nn 32s ("watch out for the pylon sahead . . .") we can consider that the "watch, watch corresponde dto the start of a new warning, as the aircraft was arriving at theselected height with a still significant descent rate (600 feet/mnapprox .) .

The Captain at the controls did not react either to the radi oaltimeter announcements of fifty and forty feet or to a possibl ereading of the instruments and as concerns the warning about thepylons, he dismisses it with a short phrase ("Yeah, Yeah, don' tworry") .

Since, for the reminder of the flight, the radio altimeter wasregistering less than 100 feet, Alpha Floor protection wasautanatically deactivated .

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A problem of reference is raised for the 100 feet flyover margin :the radio altimeter readings are only valid for flat terrain or overa topographically known contour with electrically well flagged points(IIS approaches) . On the other hand, the barometric altimeter is a ninstrument whose intrinsic accuracy at low altitude is around 3 0feet . The altimeter reference pressure is supplied to within 0 .5 hPawhich corresponds to 15 feet . A low flyover based on the baruetricaltimeter cannot then, a priori, be accurately achieved .

These considerations may have led the crew to have only limitedconfidence in the readings of these two instrunents .

If the descent observed below the planned height was not mad evoluntarily, this supposes that the Captain was flying by sight an dthat he had not registered the aural anmuncenents made by the radi oaltimeter as he was occupied with other tasks . It is interesting tospecify the various factors which could have led to error :

- he was flying over a terrain that he did not know and had not ha dthe possibility of studying as he had not made prior reconnaissanc e(either from the ground or in flight) . Also, he had only had ashort time to consult his file which, moreover, was very brief . Betherefore had no accurate geographical landmarks .

- whereas he was accustomed to use 2 to 3000 m long runways wit happrox. 100-foot high control towers, he found himself on an 800 mlong grass strip with a 40-foot high tower ; the scale effect mayhave created a false impression making him think that he was at th eplanned height .

- the to the high nose-up attitude of the aircraft, the pilot's eyelevel was much higher than the rear section of the fuselage an dthis gave him a false ingression of the height margin of th eaircraft with respect to the obstacles .

- also, at the start of the overflight the trees were perceived onl yas a change in colour with respect to the grass of the runway andnot as a change in contour ; the crew no doubt only identified tha nas an obstacle at a very late stage as indicated by the remark madeby the First Officer who was concerned about the pylons which wereapproximately 1 .5Jan distant but not about the nearby trees .

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Also, by the reply made to the previous warning :"Yeah, yeah, don' tworry", and his irk during the briefing : "I've done it 20 times" ,the pilot appeared very confident . We can try to explain this frameof mind by the following considerations :

- Because of his work on the A 320 simulators and his participationin the development of the aircraft, he knew the A 320 better tha nmost of his colleagues .

- He had often performed similar manoeuvres at high altitude and onthe simulator ; he knew all the special protections introduced int othe A 320 flight control laws especially the stall protection an dhe could, therefore, have thought himself fully protected for hi shigh angle of attack flyover, even at a very low altitude .

- As these same manoeuvres were generally made with a stabilizedengine speed well above idle, the thrust was established ver yquickly permitting immediate increase in height .

Also, an air show is the ideal occasion to demonstrate thepossibilities of the A 320 of which he was an ardent advocate . Thechoice of a flyover at Y rum angle of attack may also have been theresult of the atmosphere created by the "air show festivities" on theground and on-board and the presence of female passengers in th ecockpit .

At 12h 45nn 26s, when he placed the aircraft in level flight, theCaptain indicated that he was disconnecting the autothrottle ; thisoperation had already been performed at 12h 41nn 58s . The Captainlater stated that, in this case, it was "a safety measure" intendedto guarantee full application of thrust when required by him .

We can zsierk that this action was of no use for the intendedobjective : irrespective of the autothrottle situation, engine powe rincrease is identical when the throttles are brought to TOGAposition.

At 12h 45an 34s 5/10, when the aircraft passed in front of thecontrol tower, the Captain rapidly placed the throttles in theposition corresponding to max . thrust (TOGA) . This was not incompliance with the program which specified gradual and partialapplication of power made by the First Officer to keep level flightat maximum angle of attack then throttle up to TOGA also by the FirstOfficer .

Three seconds after having applied go-around thrust, the pilotgradually brought the pitch control to full nose-up position .

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It is probable that these actions of the Captain (application of go-around thrust and nose-up command) were motivated by a suddenawareness of danger .

At this moment in time, the aircraft was at low speed and at very lo wheight ; it had no energy reserves, neither kinetic nor potential .

Also, the engines, at flight idle when go-around was i nitiated, couldnot instantly supply high thrust due to their inertia . One can veryeasily explain the pilots' impression of a lack of response of th eengines (this ingression was also felt by the members of theCaRmission during the reproduction flights carried out in the cours eof the investigation) . Engine acceleration is slower at low speeds :4 seconds are required to go from 29 % Ni to 67 % Ni and only 1second to go from 67 % Ni to 83 % Ni, the engine speed which had bee nreached when first contact with the trees was made 5 seconds afterinitiating go-around .

The engine speeds increased at least up to 91 % (last value obtaine dby spectral analysis of the sound track of the video recording of theaccident) but, at that time, the rear section of the fuselage hadalready hit the trees, creating additional drag which prevented th eaircraft from gaining height . Following this, the engines ingested ahigh quantity of leaves and branches which were mashed up in th e=p essor and clogged the entry to the cambustion chambers causingshutdown of the two engines . The aircraft sank into the trees and wasrapidly slowed down .

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3 - ammnslms

3 .1 - FACTS ES BEISHED BY THE INVESTIGATION

- The aircraft was in a flightworthy condition

- The weight and balance were within authorized limits ; the errorsin their calculation did not in anyway influence the flight .

- The Commission found no malfunction of the aircraft or itsequipment which could have contributed towards a reduction insafety or an increase in the crew's workload during the fina lflight phase .

- The crew held the valid certificates and licences and had thequalifications required to operate the aircraft .

- The two pilots held management positions in their airline an dparticipated, at various stages, in the development and the entr yinto service of the A320 .

- Neither of the two pilots had previously made a demonstratio nflight .

- As concerns the crew, no physiological factor or medical histor ywas fount that could have played a role in the accident .

- The planned flight programme included flybys over the Mulhouse-Habeheim aerodrome as part of an airshow .

- Mo prepare for this flight, the crew were in possession of a shor tbrief for the part concerning the overflights .

- The crew had only partial information on the organization of theairshow, particularly because of the absence of prior contactbetween the organizers and the crew .

- During taxiing at Basle-Mulhouse, before take-off, the Captai nspecified his it -►tions for the overflights at Habsheimoverflight at 10( .Net with flaps in position 3 and landing gearextended, deceler :,tion in level flight down to minimum airspee dcorresponding to maximum angle of attack, stabilization at thi sminima speed, then application of full power on the Captain' sorder. Then a second flyover at high speed also at 100 feet .

- Locating of the aerodreme was late .

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- Descent was started at 12h 43nn 44s at 5 .5 nautical miles from theaerodrome, the engines were throttled back to flight idlethroughout the descent, with the speed reducing .

- %ten 100 feet agl was reached, the descent rate was still about600 feet/min .

- The pilot levelled off at a height of about 30 feet, engines a tflight idle, attitude increasing . He did not have the time tostabilize the angle of attack at the maxim= value that he hadselected .

- Rapid application of full power occurred between 12h 45mn 34s an d12h 45mn 35s ; the angle of attack was at this tine 15° and th espeed 122 knots .

- The response of the engines was normal and in compliance withcertification requirements .

- The aircraft touched the trees between 12h 45mn 39s and 12h 45mn40s with the rear section of the fuselage and then slowly sank int othe forest as a result of the inked drag and the loss of enginepower caused by ingestion of leaves and branches .

- A very violent fire broke out innediately, mainly at the right o fthe aircraft, and flames penetrated the cabin as soon as th eaircraft came to rest .

- Evacuation was begun immediately by the cabin attendants via theforward and rear left-side doors .

- Three passengers were unable to leave the cabin and died in thefire .

3 .2 - PROBABLECALF

3 .2 .1 - Cause

The Commission believes that the accident resulted from thecombination of the following conditions :

- very low flyover height, lower than surrounding obstacles .

- speed very slow and reducing to reach maximum possible angle o fattack.

- engine speed at flight idle .

- late application of go-around power .

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This combination of conditions led to intact of the aircraft with th etrees .

The Catmission also believes that if the descent below 100 feet wasnot deliberate, it may have resulted from failure to take properaccount of the visual and aural information intended to give th eheight of the aircraft .

3 .2 .2 - Other factors

The Commission also remarked that the following factors contributedtowards placing the crew in a situation that they were not able tofully control :

- The flight preparation was insufficient, especially due to th ebrevity and late provision of the brief and of the informationabout the airshow.

- The task sharing planned for the flyover by the crew wa sirxxluplete and was not followed .

- The holiday atmosphere for the passengers and the spectatorscould have been transmitted to the Captain .

- The A 320 has new features which may have inspired som eoverconfidence in the mind of the Captain .

- These new features of the aircraft had satetines been criticize dani the Captain wanted to defend the aircraft .

- Neither of the two pilots had previous experience ofdemonstration flights .

- The late identification of the aerodrome led to a rush ofevents, and the making of the descent and then the ccnplet eflyover above the runway with the engines at flight idle, andwithout stabilizing the flight parameters .

- Neither of the two ilots had previous experience of applyinggo-around power furor :light idle in similar conditions .

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4 - CKS

4 .1 - AffiriINISTRATIVEAND TECHNICALPREPARATICTiFOR FLIGHT

4 .1 .1 - The Investigation Commission remarked that the flightwhich led to the accident had only been briefly prepare dwithout real consultation either between the departmentsconcerned, or with the crew .

The Cannission recamends that :

- the preparation of such flights (participation in air shows )includes as a minimal and in addition to the actions alreadye illicitly provided for in the regulations :

-the drawing-up of a ocr:sive flight safety briefspecifying the flight parameters to be oteerved and theptooediires to be followed in case of a failure ,

- a meting between the crew and the departments whichparticipated in the flight ptepar ten, organized within goodtime before the scheduled date of flight ,

- effective recommaimmance of the place wbet+e the flight is tobe made,

ani if possible :

- one or more practice flights on a representative fligh tsimulator including special attention to the critical aspectswhich may result from non-observanoe of the flightparameters, especially incase of a failure .

4 .1 .2 - The presence of passengers on-board, provided for i nthe charter contract for this flight, contributed, during th eaccident, to the aggravation of the consequences for thepersons .

The Investigation Commission reams that :

- this type of flight (participation in air shows) be nodewithout passengers and with minimum crew including only th epersons required to carry out the flight, the only manoeuvre sauthorized with passengers an-board being these laid down inthe operating manual .

4 .1.3 - The Commission remarked that the internal Air-Franc enote EC ND 50420 laid an certain rules which were not i ncompliance with regulations .

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The Cartinission recatmends :

- that the internal rules of the airlines be checked forconformity with official regulations .

4 .2 - TRAIN= OF PERSONNEL

{ .2 .1 - Flight crews

4 .2 .1 .1 - The Investigation Camtission remarked that the pilot splanned to carry out a manoeuvre at the limits of the fligh tenvelope and that the role of each crew member had not bee nprecisely planned .

The Ca:mission recommends that :

- airline pilots be reminded that their job consists ofstrictly applying standard and well-defined procedures ;

- consequently, their training be more oriented towards safetywhich requires that standard flight conditions be permanentl ymaintm ne •i

- for the A320 training in particular, the pilots are madeaware that the performance limitations still stand, as an anyother aircraft, in spite of the many automatic protections(especially with respect to stall and with shear) ;

- for flights made with crew musts of the same rank, thefunctions of each and the task sharing be especially wel ldefined.

4 .2 .1 .2 - The investigation showed that neither of the crew

metfers had previously node demonstration flights nor followed

specific training for this .

The Ooaai.ssirn reoa mmrC s that :

- crews performing demonstratim flights receive special andwell-adapted training, which is not within the scope of th ebasic training or type Q'alifirs+ticxi .

Page 67: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

63 .

4 .2 .2 - Cabin attendants

4 .2 .2 .1 - During discussions meld with cabin attendants ,whether or not involved in the accident, it became clear thatafter the A320 specialization training course, certain cabi nattendants still had doubts relevant to certain canninicatio nand safety equipment, these doubts being alleviated only afterin-service practice from explanations given by other personne land practical training on the aircraft during line stops .

The Conmissi an retamends that :

- the aircraft gpRlifi rLion stage be reinforced and thatemphasis be placed an the location and the use of the safetyequipment ( Y exits, communication system, megaphone ,anti,emd a masks, etc .) . Bach trainee must handle all thesafety equipment on the actual aircraft arm a demonstrationmock gyp.

4 .2 .2 .2 - The evacuation was achieved better at the rear tha nat the front of the aircraft . The experience of the cabinattendants present, who had already had experience of a simila rsituation, no doubt contributed significantly .

The Commission reea:cnerrls that :

- means of simulating a realistic envixament for trainingcabin attendants be studied .

4 .2 .2 .3 - Several passengers said in their statement that th econfidence of the cabin attendants and their reassuring word shelped than to evacuate the aircraft rapidly and calmly .

The Commission suggests that :

- cabin attendants be made more aware of the psychologicaleffect that their remarks and behaviour can have on th e

pgEO:8 .

Page 68: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

64 .

4 .3 - AIRCRAFT

4 .3 .1 - The Commission remarked that certain operating defects, whichplayed no part in the accident (defects mentioned in the mechanicalreports), have since been corrected on the in-service aircraft . TheCommission believes therefore that no recatmendations need be mad econcerning these .

4 .3 .2 - The Commission remarked that the aural anmuncements made b ythe radio altimeter and the aural warnings were transmitted only viathe cockpit loudspeakers and not via the pilots' headsets .

The Commission recommends :

- that studies be made to see if it would not be judicious totransmit all warnings and aural announcemants via the pilots 'headsets.

4 .3 .3 - During the accident, the two recorders stopped almos tsimultaneously before the ai rcraft finally came to rest and wasdestroyed by the fire : the exact cause of this could not bedetermined, however, the most probable supposition is that the powersupply cables of the 2 recorders broke . They are located in the sam ecable bundle .

The Commission recammerds that :

- when these are separate voice and flight data recorders, the cableroutes should also be separated .

4 .3 .4 - Due to the circa u tares of the accident, the communicationsequipment was not used . However, study of the cabin furnishingreports and discussions with various cabin attendants led theCommission to recammerl thht :

- the system attaching the handset to the cabin well be reinforced .

Page 69: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

65 .

- tie cabin interphone and the Cabin AttendanttFLight Crew/Cabi nAttendant Call system be returned autaaaticaf ty to the "PublicAddress" function each time that the handset is hung up cm it ssupport, so that the flight attendants can broadcast urgentmessages very quickly to the passengers using only one hand (a tpresent, the system is reset after each use, bwo operations aretherefore required to talk : select required function then pres shandset switch to talk) .

Also, the Commission remarked that the emergency lighting automati cillumination programming error has been corrected ; they thereforeconsider that no recommendation relevant to this are required .

4 .3 .5 - In their response to the evacuation questionnaire ,11 passengers indicated that they had had some trouble in openingtheir seat belts and that some required help ; these difficultieswere due to a lack of kmnwledge of the seat belt opening procedure .

Also, it must be noted that, to open this type of belt, the flap mastbe raised then the two halves of the belt separated .

Consequently, the Commission recommends that :

- during the safety demonstrations before each flight, use of theseat belt be demonstrated (closing, tightening, opening) .

- t1 a prooechrres be also indicated in the leaflet giving safetyinstructions for the passengers .

- the attention of the seat belt nmmfacturers be drawn to th e

advantage of providing unlocking systems 4:ere a single simpleaction causes both unlocking and separation of the two halves ofthe belt .

4 .3 .6 - Fran among the passengers who answered the questionnair ementioned above, 50% (i .e . 49 persons) declared that they hit theirhead an the back of the seat in front of than leading, for same, topartial loss of oonacirousress .

Mme (commission reoocmwrds that :

- studies be undertaken so that the design of future seats takes thi spotential problem into account .

Page 70: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

66 .

4 .4 - ORGANIZATION OAF HELP

After the accident, the fire fighting and first aid vehicles ha ddifficulties in getting to the accident area, the only access road t othe place where the air sham was held (and also the place o faccident) being congested by many private vehicles .

Also, the fire-fighting trucks could not gain access to the wreckag eas they were too wide for the forest tracks, and only small vehicle scould reach the aircraft .

The investigation commission recommends that : when air shows areorganized :

-access to the aerodrome is kept open for fire-fighting and firstaid vehicles,

- the safety facilities in-situ be adapted to the envircmuent .

Page 71: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

67 .

5 -APPIOVAL OF THE REPORT

This report has been accepted unanimously by the members of theInvestigation Commission, November 30th 1989 .

President of the Camiission

Claude BECHT

Vice-President of the Commission

Frangois GOWN

L'Ingénieur Généxal de laMétéorologie

Bernard FARTfiI7MT

Le MedecinGenéral Robert AUFFRET

L'Ingénieur en Che fde 1'Aviation Civile

Paul ARSLANIAN

Pilot Inspector ,!9e[ber of the Organismedu Cantrále en Vol

Philippe GOURGUEC EEN

L'Ingénieur du BureauEnquêtes Accident

Jean-Paul de VIIL,IINEUVE

Page 72: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July
Page 73: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

A P P E N D I C E S

1 - Map of the region with path tracked by aircraft rada r

2 - Plate of the Mulhouse-Fíabsheim aerodrome

3 - Photographs

4 - Perspective view showing the way the trees were cut

5 - Transcript of the radio communications

6 - CVR transcript

7 - DFDR-CVR correlation

8 - Reproduction of DFDR parameters

9 - Air France Note DO ND 5042 0

10 - Flight Zest Sheets

Page 74: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

Us ydro-Elec / : .

s,a a

ssa~~~~Accident

,DISIIpM •

*1:71%~~

MP~r

~ ~~• ; s .. -~

•aáaa

►~o r 'wptsna►r

Page 75: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

APPENDIX 2

- Mulhouse-Habsheim aerodralle plate -

CARTE O'ATTERRISSAGE A VUE

MULHOUSE- Heb:helm LFG BLei : 474417 N Long : 007255$ E

Alt 240 n1 - 787 Ft

NMI - 88 - NAIR-NMSituation : d tm E 6 ' (28 hPa)

ACC : BEMIS Idures+ml 124.100 - OEIMS tomb 124.l50AOp : IY

Twr : muumuu Tow 125.áOST elt~tmar COUMA141hwM CU1721.i

(iMAM141111riia C~w avdWs M- 7iSSI11NOM

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9

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RelltepnenlMff COmplMlerlteitt: : bob*. Amt pes d TwtAimNa/ifia. Obi 1 r616 M.AI SW wam rAT2 dib-Midop ß 0501700 w AI L

CORRECTIONS : RmbietitNt - Cmuiples - Midis - AC!

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RR : ►mm

SERVICE OE LWFORMAT10N'AERONAUT10UE — FRANCE MULHOUSE-Hebeheim LFG B

Page 76: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July
Page 77: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

A'

Page 78: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

APPENDIX 4FUSELAGE

ENGINE + LANDING GEARENGINE + LANDING GEAR

PERSPECTIVE VIEW SHOWIN GTHE WAY THE TREES WERE CM'

Page 79: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

APPENDIX 5

RADI0C7QNIlM .INICATI( N RECORDINGS

BEIinIEEN BASLE-M[ü HOUSE AND ACF 296 Q

ON JUNE 26th 198 8

Time GMT Stations Text

12h 25m OOs ACF296Q Basle from Air charter two nine six25m 04s Basle Air charter two nine six over25m 06s ACF296Q life request start-up clearance25m 08s Basle Roger two nine six I'll call you25m 10s ACF296Q Roger

12h 25m 15s Basle

- Air charter two nine six clear to star tup

25m 18s ACF296Q

- OK two nine six

12h 25m 24s Basle

- Two nine six confirm that on departureyou're doing a flyover at Habsheim

25m 27s ACF296Q

- That's right so if it is OK by you we'lldo anti-noise procedure on sixteen turnright fly towards BLM then straight t oHabsheim and than leave for Hericourt asnormal flight plan

25m 37s Basle

- Roger you are taking sixteen25m 40s ACF296Q

- Roger that's fine thank you

12h 29m 12s ACF296Q Charter . . air charter two nine six taxiclearance please

29m 20s Basle Air charter

two

nine

six Quebec

taxiholding point sixteen

29m 23s ACF296Q For holding point sixteen air charter twonine six Quebec

12h 30m 50s Basle Charter t%v nine six Quebec can you tellwhat altitude you want

Page 80: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12h 31m 09s

Basle

-

Air charter two nine six Basle31m lls ACF296Q

-

Go ahead31m 12s

Basle

-

Two nine six Quebec can you tell me whataltitude you want

31m 17s ACF296Q - Yes after take-off we'll take a righ tturn one thousand feet to the flying clubthen there we make two flyovers . Thesecond at high speed and then we'l lnegotiate clearance with you to g ostraight to Hericourt

31m 35s

Basle

-

Roger two nine six Quebec31m 39s ALr296Q - Well it would be good if we could have

clearance before second flyover as we'llbe passing at high speed like that wecould climb quickly

31m 45s

Basle

-

'I\o nine six Quebec you confirm on ethousand feet above ground then

31m 48s ACF296Q - One thousand feet above ground and byright turn there and then after we'l ldescend for low altitude flyover of theairfield over there

31m 53s

Basle

-

Roger I'll contact you31m 55s ACF296Q

-

Roger

12h 32m 40s

Basle

-

Air charter two nine six Quebec ready tocopy

32m 42s

ACF296Q

-

Go ahead32m 43s Basle - OK two nine six Quebec after take-off on

sixteen right turn to Bravo Sierra climbto two thousand feet Ql! H one thousand an dthirteen QVH and transponder six fourfour three

32m 55s ACF296Q - Roger six four four three right turn toBravo Sierra from Bravo Sierra and twothousand feet QiH air franee oh sorry aircharter two nine six Quebec eh then we g ostraight to the flying club and flyoverover going north at low altitude and the nthe second flying south towards you andat that time we need one nine zeroclearance to Hericourt

33m 23s Basle - Roger and clearance will be regiven byapproach therefore it's correct contacttower on one one eight three good-bye

33m 28s ACF296Q

-

One one eight three good-bye two nine sixQuebec

Page 81: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12h 34m 55s ACF296Q

-

Air charter two nine six Quebec atholding point sixteen

34m 58s

Basle

-

Hello air charter two nine six Quebechold before runway sixteen

35m 02s ACF296Q

-

OK we're holding before runway sixteen

12h 36m 10s

ACF296Q

-

Two nine six Quebec we'll line up whe nyou like¶ D nine six Quebec hold before runwaysixteen we still have an IFR to land ,like that you can go straight to Habsheimat low altitudeThank you two nine six Quebec we hold

12h 40m 40s

Basle

-

Air charter two nine six Quebec clear fortake-off runway sixteen wind calm

40m 44s

ACF296Q

-

Rolling two nine six Quebec

12h 43m 34s ACF296Q - After take-off for air franse we'repractically in sight of the airfieldthere

43m 41s Basle - Roger air charter two nine six you cancontact Habsheim on one two five two fivegood-bye

43m 45s

ACF296Q

-

One two five two five good-by e

END OF RDCORDING

36m 14s

Basle

36m 20s

ACF296Q

-

12h 38m 34s

Basle

-

38m 38s

ACF296Q

-

38m 40s

Basle

-

38m 43s

ACF296Q

Air charter two nine six Quebec acityliner on final sixteen call when yousee itRoger we can see it two nine six QuebecRoger behind the cityliner on fina lsixteen line up behind and hol dOK behind the aircraft on final we lineup and hold two nine six Quebec

Page 82: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

TRA1SCRIP1ZCN OF RADIOCOMMUNICATIQZS EXCHANGED

ON JUNE 26 1988 ON FREQUENCY/125 .250 MHZ

P = Pilot A/C ACF 296 Q

C = Mulhouse-Habsheim controller

Air Charter Quebec Hello

296 Q Hello

We're caning into view of the airfield for flyover

Yes I can see you, you're cleared, sky clear

CSC we're going in for the low altitude low speed flyove rAir Charter Quebec

C

Roger

1244

124404

124415

P

C

P

C

P

124425 Quebec November Hotel Habsheim 1012 Fox Echo 98 4C

P

C

Basle

C

Basle

C

UG

124551

1246

124616

Roger

Call Fox Alpha Bravo Quebe c

(not identified) : Achtung Feuer Feuer the 320 the 32 0has caught fire Achtung Achtung

Basle Basle the 320 has crashed the 320 has crashed

You repeat, it has crashed

Affirmative 34

200 meters 300 meters north of therunway

North of your runway

Repeat

Alouette Uniform Golf, I'll take off for AERf EDICAL

EVACUATION if you like

Page 83: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

C

Basle

OK

Basle Approach repeat Mulhouse here Basle Approach repeatwhere did the AIRBUS crash

124625 C Affirmative it crashed north of the airfield afterflyover

124630

124641

124643

Basle

Basle

C

Basle

C

North of the Mulhouse-Habsheim airfield

How many kilometers about

Try to warn the airport if you can send someon e

Roger all right we'll do what we have to then

OK

Page 84: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

A P P E N D I% 6

lItANbCRIIMON CF THE COCKPIT VOICE RECCRDERAM) WARNIWS CF THE AIRBUS A 320 AIRCRAFT registeredF-(FEC involved in the accident on June 26th 1988

at

.

Capt .

: Captain

F/O

: First Officer

Purser

: Purser

F D nine Vbioe

TOWER

: Local aerodrosie control tower

GROM)

: Line mechanic

: Word, Group of words, not understood oromitted

REMARKS

Only the last 19 minutes of the CVR have been transcribed as only thes econcern the flight during which the accident occurred . They have beensubjected to a spectral analysis which was more exhaustive for the last 3 6seconds . Therefore, the conversations, have been accurately identified an dtimed in this transcription .

Page 85: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

I

FROMNOISESWARNING S

COMMENTS

1

TIME RADI OCONVERSATIONS

Remark : Start of tape corresponds to end of previous flight (not transcribed )

12 H 27'15" I GROUND I

Good ~ Clack

11 OK ready for push back then ~

12 H 27'32"

Capt . OK

I

Ready for start-up of 1 ~I

Capt .

12 H 27'37"

I GROUND

I

Capt .

OK

I

Roge r

you see 1

how it got it

there are

I

Capt .

12 H 27'46" ~

Capt .

2 signals,

there's boost APU which gives thesignal and closure of packs,

the pack sI

they've already got their signal as wel lI

When we start

There's a prehistoric one

1-~

Whoop . . . Whoop . . . Whoop

(Laughter and joke sFeminine

I

Voice

F/0 OK,

Ignition A and oil pressure

concerning a firs tI

generation aircraf tarriving at adjacent

I

parking area) .

I

Clack

1

12 H 28'11" I OK,

start-up completed you can unplug and

Personal discussion

Capt .

12 H 28'17" I GROUND

I

signal on left I think good-bye

I

I

OK,

good trip,

see you later,

I

Gong

1

I

Gong

1

Capt . Yeah

I Adios mateI

Right away,

got to do it,

Click,

ClickYou press it Hop

I1

There

I

Sorry,

thank you

I

(doubtful )

Click

1 Click

1

I Many switching noise sI

Click

I

Click

1

Page 86: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

2

12 H 28'33" I

Capt .

F/0

I

Control surfaces

clack

1

clack

1 Like tha t

I

I'll hear you

1

Yes but

I

Capt . I There you are, do you want to try ? (blowing twice into the

microphone )

I

F/0 I

It's very good . . .

12 H 28'46" I Feminine You managed to find a mechanic after all l

Voice

12 H 28'50" I

Capt . I

After start check list (Laughter )

I

F/0 "After start"

Ignition

l

12 H 28'53" 1

Capt . I

NORMAL

I

I

F/0 I

ECAM Status .

They're there

1

They're there and we know them Click Al l1 blac k

1 O K

Anti ice ?

I OFF 1

Gen 1 and 2 ?

I ON 1

I Flight controls ?

Checked 1

On right as well I Rudder trim t

I Capt .

12 H 29'01" I F/ 0

I F/0

Capt .

12 H 29'04" I F/ 0

I Capt .

I F/ 0

1 Capt .

F/0

Page 87: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

3

Laughter and joke s

concerning previously

mentioned "prehistoric "

aircraft - Clack I

Clack t

I

Capt . I

It's

at

zero

t

12 H 29'10" I

F/0 I

and the pitch ?

I

Capt . I Everything's fine

I

F/0 . . You checked everything it's OK ?

I

"After start" completed

t

12 H 29'13" I

F/0 We are on

one

That's O K

I

F/0 Wait,

I'll do it,

I'll speak

I

Capt . OK

12 H 29'16" I

F/0 - ACF 296 taxi

clearance please ?

12 H 29'20" I TOWER - ACF 296 Q taxi to l

holding point 16

I

12 H 29'23" I

F/0 I

For holding point

16 the Air Charte r

1296 Q

12 H 29'26" I

Capt . Right ?

F/0 All clear to right

I

--------------------------- -

--------------------------- -

Eh, we've not extended flaps 1 l

One

We have, it's OK I

I and spoilers armed I

I There we are

I Anyway it's there for that it'll tell you .

F/ 0

I Capt .

12 H 30'13"

F/ 0

I Capt .

Page 88: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12 H 30'16"

F/ 0

12 H 31'13" 1 TOWER

I OK, you, you, you . . . you explain your speed, I

12 H 30'20" I Capt .

12 H 30'51" I TOWER

12 H 30'56" I F/ 0

I Capt .

I F/ 0

12 H 30'59" I Capt .

4

altitude, etc .

I

1 OK then, take-off right turn, leave the flap

at 1, anyway we do normal take-off, retrac tI the landing gear and with flaps at 1, we go

I

I nice and easy to find our thing . As soon as we lI have formally identified it, we extend the

I

I flaps to 3, landing gear extended, do the

I

I flyover at 100 feet, landing gear out and then )

you leave it to me . I'll give it alpha max ,1 I'll disengage the alpha floor and then, if I

I tell you it is hard you help me and you hold I

I the power to keep zero vertical rate

I

Zero vertical rate and me I'll hold it at

- ACF 296 Basle, can

alpha max . At the signal you give it TOGA and I you tell me wha t

I I'll pull the stick and if you're there I bank

altitude you woul d

I away

I like ?

You want to get off there then 7

That, I've done it twenty times, that one .

I OK, we're agreed 1

And then, after, we bring everything in, mov eoff and give it all its got to 340 knots an d

the second, you also go over at 100 feet, an d

there, no need to pull 2 .5 g as back there ,

they won't like it .

OK all tha t12 H 31'09" I F/ 0

12 H 31'09"

TOWER

12 H 31'11" 1 F/0

ACF 296 Q Basle ?

I Go ahead 1

Yes, 296 Q, can

I you tell me wha t

I altitude you want ?

Page 89: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

F/ 0

12 H 31'18" I Capt .

12 H 31'19" I F/0

5I

1 2000 1

I

Roger, 1000 feet to get there

1000 feet to

get there, 1000 feet ground

I

I Yes, after take -

I off, we'll take a

I right turn 100 0

I feet to the flyin g

I club then there

I we'll make 2

I flyovers the second

at high speed and

I then we'l l

1

I negotiate clearanc e

1

I with you to go t o

1

1 hmmm

. . . Hbricourt

I Héricourt .12 H 31'35" I Capt .

12 H 31'35" 1 TOWER Roger 296 Q

So it's 1000 feet Fox Ech o

1000 feet/groun d

I Capt .

12 H 31'39" I F/ 0

12 H 31'45" I TOWER

12 H 31'49" I Capt .

Well, it would b e

1 good if we coul dhave clearanc e

1 before the secon d

I flyover as we'll b e

I passing at high

I speed, like that ,

we could climb

quickly

I Roger, 296 Q, yo u

confirm 1000 fee t

I above ground then ?

Page 90: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

One thousand fee tabove ground and by eright turn there, I

then we'll descend I

for low altitud eflyover of theairfield there

~ Clack 1

OK I'll call you

6

OK

I Clack 1

12 H 31'49" ~

F/0

1

II

12 H 31'53" ~ TOWER

12 H 31'55" 1

F/ 0

12 H 31'58" I

Capt . Autobrake max

I

F/0 Yes

1

1

Capt . Take-off config tes t

1

F/0 Yes then

t

eh

t OK t

Have you already seen what the take-off configtest does . . . watch, if you put it thereWait there

Wait sh . . . . Imagine that it' sI like tha tGo on7he take-off confi g

I That's it

it must move a littl eI That's it, do it now t Go on .

I . . .(reply incomprehensible t )

I Yeh

Yeh

Put it . . . put it on 1 so that we won't get itwrong .

The detents are too well don e

Well then 1 Between the two there when I tak eit for the high speed flyover you negotiatethe 190 clearance so that we can get out o f

I there and do a pull-out at 2g for STS .

12 H 32'03"

Capt .

F/ 0

Capt .

Capt .

12 H 32'22" I Capt .

12 H 32'25" ~ F/0

Clack l Clack 1

Clack l

Page 91: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

712 H 32'35"

Capt .

12 H 32'40" 1 TOWER

1 Capt .

12 H 32'42" I F/ 0

12 H 32'44" I TOWER

Purse r

12 H 32'55" I F/ 0

12 H 32'59" ~ Capt .

Purse r

12 H 33'16" ~ Capt .

12 H 33'23" I TOWER

No, don't pull-out at 2 .5 g as yesterday w edid 2 g

2 .5 g in training and I've hadenough of that I have

ACF296, ready t ocopy ?

- Yes, he's ready 1

Go ahead 1

I OK 296 Q aftertake-off on 16

I right turn toI Bravo Sierra climbto 2000 feet QNH ,QNH 1013 andtransponder 644 3

In short, what are we doing ?

Roger, then 644 3right turn to Bravo s

We take off, fly to the Habsheim airfield,

I Sierra, from Bravothere we do a low altitude flyover, bank,

Sierra and 2000

~accelerate, flyover at top speed and get out I feet QNH AIR FRANCEof there .

I oh sorry . . .ACF 296 I

I Q, eh then we go

I

to the Mont-Blanc ?

I straight to the1 aeroclub . We flyby

A second flyby southward 1

I going north at low ~I altitude and thenI second flyb yI southward toward sI you and at thattime we need 19 0

I clearance t oI Hericourt .

I Roger and clearance)

Page 92: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

I will be regiven b yI approach therefore

I it's correc t

contact tower on118 .3 good-bye

118 .3, good-bye

286 Q

12 H 33'26" I Capt .

12 H 33'29"

F/ 0

I F/0

1 Purser

I F/0

Purse r

12 H 33'38" I Capt .

Purser

I F/ 0

12 H 33'43" I Capt .

12 H 34'47" I Capt .

There we are . . .

Yes, you were saying 7

- No, but I was saying the cabin was ready . . .

You, you stay seated during the complet e

flyover . . .

About the announcements, you're doin gsomething . . .

1 I'm going to tell them, yes ,I The announcements I'll do them

I . . . OK there are also some . . . in German .

You see

I Ladies and Gentlemen, Hello and welcome aboard )I this AIRBUS 320 No . 3 of the series for AI RI FRANCE and which has only been in service for I

2 days . We shall soon take off for a short

I

I tourist flight starting at the Habsheim flying )I club where we will do 2 flyovers to

II demonstrate the continuity of the French

II Aviation and then we shall make a tour of

I

I Mont-Blanc depending on the weather condition sand air traffic .

II wish you a very agreeable flight .

I Meine Damen Und Herren . . . .

I1 . . . . Ich WUsche Ihnen eine Guten Flug .

IThere we are

good

8

Click !

(Announcement more o r

less identical inI German)

Page 93: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12 H 34'55"

Capt .

12 H 34'58" I TOWER

12 H 35'02" I Capt .

12 H 35'10" 1 Capt .

1 F/ 0

Capt .

F/ 0

I Capt .

I F/ 0

12 H 35'25"

Capt .

I'm going to give C . . . hell . He's not see n

that the data banks are not the same . He' sI gonna be in the sh . . . for a while I

I Alright I

Poor C . . . he'll be in for it

I Eh I We've not done it before take-off 1

I What before take-off we are . . . hold beforeI runway .

Yes l but it's done high up . . .

I Well, autobrake max ,

I Well, ye s

Signs on

I Eh

It makes no difference ; spoilers armed ,

I Eh

yes

If the . . . . it disengages jus tafter the landing gear it's OK .

Flaps 1, take off, take off config normal 1

Normal I Good "pre take-off" completed .

ACF 296 Q at

I (Joke about the Fir9s t

I holding point 16

I Officer )

I Hello ACF 296 Q

~I hold before runwa y16

~

OK I We're holding ~

before 16 .96 Q

~

(Laughter )

Word incomprehensible

Page 94: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12 H 35'42" I Capt .

I F/ 0

I Capt .

F/ 0

I Capt .

12 H 36'10" I F/ 0

12 H 36'14" I TOWER

1 0

Feminine voic e

(jokes concerningjournalists )

Capt .

12 H 36'21" I F/ 0

I F/ 0

12 H 36'29" I Capt .

F/ 0

Capt .

Crate in view t You're lucky aren't you 7

What did you say ?

Super efficient

Did you see that good wor k

Right on time every time 1 Dead on time 1

Ah . . . 296 Q We'll

line up when you

like

I 296 Q hold befor e

I runway 16 we stil l

I have an IFR to land

like that you can

I go straight to

Habsteim at lowI altitud e

GUT I

I GUT 1

~

I Right then you

we keep flaps 1 to go there 1

I and extend when we get there

I Wait take it easy, we descend, we've not muchmargin Cling 1 gling 1 gling t

I Then . . . eh you

you turn above there fl yalmost back over the end of the runway, pic kup the motorway

I've

I've

I've

I've

and you almost didn't have it opposite

OK 296 Q we hold

(Whistling )

(Whistling)

Page 95: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 1Capt .

I F/ 0

12 H 36'45" I Capt .

12 H 36'54" I Capt .

I

12 H 38'24"

F/ 0

Feminine

Voic e

Capt .

12 H 37'32" ~ Capt .

I F/0

and I've

I've all here t

I'm like that t

I'm not really worried about that you know

I I'll put it on NAV, like that I've an overall

I view and I stay on "ARC" - You put it on

1 fort

twenty

forty

twenty miles, so

1 that all's in, me I'll stay on ARC at ten

I miles .

(Question inaudible )

What 1 No, I'll tell you something you're no t

used to cockpits, are you ? but like this whe n

we're really busy as you can see

you should

not speak eh

shouldn't bother not speak

I eh

should'nt bother the pilots, eh ?

I You see how he is 1

. . . You are not used t o

Have you seen what I've selected there ?

Can you remember the clearance over the

motorway 1 eh ? eh 1 Herr Mazière s

What is the minimum clearance over a motorway ?Three hundred meters 1

Eh t And when we get over, Meribel, a littl ebefore

I'll give you the microphone behin dI to call who you want there .

(Whistling )

(Whistling )

Discussions with the

two passengers in the

cockpi t

Personal conversation

Page 96: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

We won't see it very well 1 don't you thinkso 1

Capt .

1 2

1 F/0

12 H 38'34" I TOWER

12 H 38'38" I F/ 0

12 H 38'39" 1 Capt .

12 H 38'40" I TOWER

12 H 38'43" 1 F/0

FeminineVoice

12 H 38'45" 1 Capt .

1 ACQ 296 Q, a

cityliner final

I sixteen call when

I you see it

1 Roger behind the

1 cityliner on fina l116 line up behind

I and hold

OK behind the

I aircraft on fina l

we line up and

1 hold 296 Q

----------------------------- -

I I'll flyover the runway there for eh flat ou t

no, no, no, no, don't pass 1 no, n o

. . . .we've

The radio's OK, that's that's it . . .

That what I want to say . . . on the radio what I

Mustn't do just anything . . .

What 1

Roger, we have seen

it 296 Q

I don't know if you'll be able to see

Page 97: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

Capt .

1 3I That for that you need a special clearance t o

I do what you're going to do but at Meribel . . .

No at Meribel there's not . . .

I Otherwise I'm not going

I If I haven't got clearance we're not going . . .I there, the flyover, the only thing, is at the

I discretion of the crew . . .

12 H 39'03" ~ F/0

F/ 0

12 H 39'39" 1 Capt .

Capt .

I F/ 0

12 H 39'52" I Capt .

Capt .

I F/ 0

12 H 40'16"

Capt .

1 There you know

you if

there you know

I anyway you'll get them on the radio eh

I we'll say . . .

OK, we line up behind

I You'll extend the lights and will keep them s o

that they can see us

All the lights

we

keep them

we'll retract them only passing

Ah . . . leave it on . . .

(illegible)

"WING" they won't see

there's no poin t

In any case, we'll forget them on landing

(Jokes )

(Laughter )

Clack t Clack !

(whistling )

(Sigh, whistling and

German rhyme)

Page 98: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 4

ACF 296 Q, clea rfor take-off runway

I 16 wind calm

We're rolling 296 Q )

I Engine accelerationI noise

Clack Clack

(simultaneously )

Illegibl e

Doubtful

I Clack 1 (L/G operation )

1 (Buzzer) (Alt capture )

I (Reduction in engine1 noise )

I Capt .

I All right then, ready si r

12 H 40'40" I TOWER

12 H 40'44" , F/0

~

12 H 40'48" I Capt .

~ Take-off

Go

12 H 40'59"

F/0 + Capt . Thrust SRS 1 RUNWAY

12 H 41'04"

F/0

I Parameters norma l

I Capt .

12 H 41'16" ( Capt .

1 +

I F/ 0

12 H 41'19" ( F/0I you see that 7

I Yeah, that happens

I know the bug

Yeah yeah

I V1 - V r

It wasn't up

1 Positive climb Gear up

I Alt Star

Gear up

Capt .

I F/ 0

12 H 41'26"

F/ 0

I F/ 0

12 H 41'32" 1 Capt .

12 H 41'47" I F/ 0

12 H 41'52" 1 Capt .

100

It's already requesting "CLIMB" the b

Page 99: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 5

12 H 41'56"

I

FIG Gear up,

flaps 1,

after take-off check list i sI completed except for flap s

12 H 41'58" Capt . I'm dis . . .gaging the autothrottle (word not clear )

I Gong = InstinctiveDisconnec t

12 H 42'00" 1

(declaration by crew )

I

Clack . . .

Clack . . .

Repetitive gong(config . warning )

12 H 42'03" Capt . That's the landing gear that,

it's no timportant, kill

it eh

F/0

I It's below 1000 feet at low altitude you canI be sure

I Shall we extend it eh ?

I No 1 No : don't extend right away, it' sbecause I've throttled back to below a certai n

I N .1 . We know that one

(New repetitive gong 1 )

(second config warning )

Oh 1 kill it

Ah I It gets on my wick tha ton e

12 H 42'06" I Capt .

12 H 42'08" I F/ 0

12 H 42'12" ~ Capt .

12 H 42'27" ~ Capt .

Slight increase i n

engine spee d

Stabilization of engine

speed

Page 100: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 6

I Extend it, it makes no difference to get there

I There we are . . .

Good, it is as if we could see the airfiel d

You're at 8 nautical miles there, you'll soo n

see it, there's the motorwa y

12 H 42'29"

F/0

12 H 42'32" 1 Capt .

12 H 42'54" I Capt .

F/0

Reduction in engin e

spee d

12 H 42'57" 1 Capt .

F/ 0

12 H 43'07" I Capt .

12 H 43'10"

F/0

Capt .

Capt .

We'll leave the motorway to left, won't we . . .

it's to the lef . . . no, to the right of th e

motorway .

It's slightly to the right of the motorwa y

so you . . . you leave the motorway on the lef t

I OK, as soon as we identify we descend ver y

I quickly then ,

Leave everybody fastened in

That's, that's normal for it, it always doe s

I that to start with . You see, it keeps th e

I landing gear the whole thing

I OK, then it is OK I that we've got at th e

start .

Well there's a little way that' s

1 interesting . Yeah

Clack

12 H 43'36" I F/0 After take-off fo r

Air France 296 ,

1 we're practicallyI in view of th eI airfield there

Page 101: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

12 H 43'41 "

12 H 43'46"

I TOWER

~

F/ 0

I

F/ 0

1

Capt .

I

F/0

~

Habzeim 7 That's it no ?

1

Habsheim . Habs

Heim

~

Habsheim

12 H 44'01" 1

F/0

Capt . There's the airfield .

It's there . . .

you go tit, have you ?

12 H 44'05' I TOWER ~

12 H 44'10" Capt . ~

What

?

12 H 44'13" TOWER ~

12 H 44'15" Capt . Gear down

12 H 44'17" ~

F/ 0

12 H 44'22" ~ TOWER

12 H 44'23" I

Capt . Flaps 2

1 7

I Roger ACF 296 yo uI can contac tHabsheim 125 .25good-bye

125 .25 good-bye

Ah 1 Habsheim AirCharter 296 QHello

296 Q Hello

We're coming int oview of theairfield fo rflyove r

Yes, I can see you ,you're cleared ehSky is clear .

1 Clack

OK, we're going in I L/G aerodynamic noise sfor the low

~altitude low speedflyover 296 Q

Clac k

Page 102: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 8

12 H 44'27" TOWER QNH Habsheim 101 2Fox Echo 9 .8 .4 .

1

Capt . OK

12 H 44'31" I

F/0 Roger

12 H 44'32" Capt . 9 .8 .4 .

put

in 9 .8 .4 .

12 H 44'34" I

F/0 9 .8 .4 . QFE selected

t

12 H 44'37" I Good gear is down = flaps 2 t

12 H 44'42" I

Capt . I

Flaps 3

12 H 44'45" I

F/0 I

Flaps

3

t

I

Capt . I

That's the airfield, you confirm 7

12 H 44'48" I

F/0 1

Affirmative

12 H 44'51" I

F/0 You see it LL 01, when we get there thereyou're at 1 nautical mile,

that's right

OK I

P G 1

12 H 44'55" I Capt .

I F/0

12 H 45'04" I

7/10 1

12 H 45'05" 1

7/10 1

12 H 45'11" I F/0

GONG I(Nose Wheel Valv eaccording to the crew )

"Too Low Terrain "1 (GPWS )

I Gong t (GPWS cut-of fI according to the crew )

I "Two hundred t" (radioaltimeter) allusion toairline flight safet y

I office r

Page 103: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

1 9

12 H 45'11 "4/10 1

12 H 45'12" F/0 G is going to . . .

eh

I

12 45'14" I

F/0 OK, you're at 100 feet there, watch, watch

12 H 45'15" I

3/10 1

12 H 45'19" I

1/10 1

12 H 45'23" I

6/10 1

12 H 45'26"

Capt .

12 H 45'27" I

5/10 1

12 H 45'32" I F/ 0

12 H 45'33" I Capt .

12 H 45'34" 1

5/10 1

12 H 45'35" I

3/10 1

12 H 45'36" I

2/10 1

12 H 45'37" 1 F/ 0

12 H 45'38 "3/101

I "Two hundred" (radi oI altimeter )

(continuation of previou spersonal remark )

"One hundred" (radioaltimeter )

I"Forty"(radio altimeter )

"Fifty"(radio altimeter )

"Forty"(radio altimeter )

Clack I Clack 1 Clack l

(power lever detents )

I"Thirty"(radio altimeter )

"Thirty"(radio altimeter )

"Thirty"(radio altimeter )

OK, I'm OK there, disconnect autothrottl e

Watch out for the pylons ahead eh See them 7

Yeah, Yeah, don't worr y

TOGA/SRS

Page 104: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

2 0

12 H 45'39" I F/0

Go around track

Increase in engin espeed

Noises of impact in th etree s

12 H 45'39" I

Capt .

I Sh

9/101

I

12 H 45'41" I

I

5/101

IEND OF TAPE

Page 105: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

17h1S'DO •

I2h1S•OS •two hundred

17h1S•1o •

you arrive at 100 feet there, watch, watc hone hundred

~7h1S'1S •

forty 17h15'70•

rimy +7h 1 S'2S •forty

t7h1S')0 -watch out for the pylons ahead, eh, see tha nyeah, yeah, don't worr yinitiation of qo-aroundthirt ythirt y

mart with the tree sTOGA, SR Cthirty

17hi5'1S -

17h~S 10 '

' .

, . .

, .~ I

~ —

—,~

— ~_ i hii HïL TT

, -- - , ~--

-

,1~ ;~-- ;- ;-~-. ? i

t :=; -

,-

;

~~-

;

~4~; »L

~-i I á I

I I I I i ;I ,

~

I

_= :~ ' ° iiá - ~~'-~ - -

; -- -

~ ~-~-=—

i

~

_ ; :#C► • .___í,oá®®D®®6`~i ;

~~~ 0' i. ~,L

-~•

--~ ~N Á --: '-- - _ .-.~

►► _~ - H ~

ii!-~ ~

1~

i~- -- - ~ ~ 1- - -~ — ~— ,~~NU ~~~~~®~á~i ®,~~~~.~~ ~ .a

—if ' ~: + ~ ~r ;~ '_ • - . .J :.~ ,; . ~ ~ ~ ; ~ ;

i : :1 ~ • ~ ;

, -,_L_ ~ r'-f-~ , - ~~

} -; - --,-~ — ~ ~_~ I-- -~L .~

- . -I

----

- {----~-- ~-

~ -f--Y--~1 ~-- ~ t_14>

I -1 ~

N.,

J

Page 106: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

APPENDIX 8

REPRODUCrION

OF I*M

PARAIClERS

Page 107: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

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Page 125: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

iii'R FRANCE

DIRECTION DES OPERATIONS AERIENNE SCommandement

N . REF . Do.ND 50 420/JG.JSJ

STINATAIRE DO.VB - DO.VH - DO. VA - DO.VN - DO. V5 - CEP. PN - CAR . GN

PUATAIRES DG.DT - DG.GN - DT .TI -

DO.NY

SCOPE : Tburist or demonstration flights (Ref . DO . ND 50 420 )

The study of several law altitude flight cases by the Flight Analysi sCc: mission leads us to remind you that all flights, or parts of flights ,made for touristic or demonstration reasons, must be covered by th efollowing :

1) an accurate definition, by the Flight Division concerned, of th eperformance conditions (distance, altitude, configuration, etc .) andthe corresponding task sharing in accordance with sought objective ,

2)

written authorization from DO .ND with information to DO .NY.

3) meticulous preparation on ground and a carplete briefing of the crewbefore the concerned flight phase is undertaken .

The general rules to be observed are :

. minima manoeuvring height : 600 ft radio altimeter ,

. minima flyover height above runway of 100 ft in landing configuratio nand 300 ft in clean configuration .

Other more restrictive rules taking the conditions into account (weather ,type of aircraft, environment, contour, air traffic, etc .) may be retained.

If any of these rules is not observed, the case shall be presented to th eFlight Analysis Commission .

This, of course, also applies to all Systematic Flight Analysis anomalie sin the normal sense of the term (excessive bank or vertical speed, GPWS ,exceeding limitations (VFE, EGT, etc .)) .

These flights, important for our public image, mist be very carefull yprepared and performed and the rules given above are a contribution toward sthis .

I am convinced that you will do all you can to observe than .

H. Petit

A P P E N D I X 9

missy, le 19 octobre 1987

Page 126: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

APPENDIX 10

Catparison between the performance recordedon A 320 No . 3 (flight No. 260 )

and on A 320 F-G'KC

The following sheet compares the performances measured on the A 320 F-('E Cin the last flight phase of the accident and on the A 320 No . 3 during atest performed in same configuration as the F-( KC in this flight phase .

The comparison concerns the total height versus time variations which ar erepresentative of the aircraft performance report : the total height (H) i sthe sum of the real height (Z) and the V2/2g parameters (the square of thespeed divided by twice the acceleration due to gravity) . The total energyof the aircraft (E) at a given time is the sum of its potential energ y(mgZ) and its kinetic energy (1/2 mV2) ; the performance report can b ereproduced by the variation of the total height which is proportional to E

(E = mgH)

The flight phase of the accident taken into account in this comparison is :

- for the F-( , the final flight phase (descent then deceleratinglevel flight between the 200 feet at 80 m/s and 30 feet at 63 mIs) .

- for the A 320 No . 3, a descent decelerating between 2595 feet at 7 6m/s and 2350 feet at 61 m/s .

The total heights variations (total gradient) during the sane time interva lare practically identical in both cases .

Page 127: concerning the accident which occurred on Jun 26th …...The Caanission then continued their study and analysis of th e accident. Full sessions of the Commission were held on July

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