INFORME FINAL DEL ACCIDENTE DEL VUELO AF447 RÍO DE JANEIRO - PARÍS

La BEA (Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile), la autoridad francesa responsable de las investigaciones de los accidentes e incidentes de aviación civil, ha publicado el informe final del accidente del vuelo AF447, que cubría el trayecto con origen Río de Janeiro y destino París, y que ocurrió sobre el océano Atlántico el día 1 de junio de 2009.

Adjuntamos los enlaces de los artículos publicados en Las mentiras de Barajas sobre este accidente:

• TRAGEDIA AÉREA EN EL ATLÁNTICO

• TRAGEDIA AÉREA EN EL ATLÁNTICO: ANÁLISIS METEOROLÓGICO

• ALGO DE LUZ SOBRE LA TRAGEDIA AÉREA EN EL ATLÁNTICO

• INFORME PRELIMINAR DE LA BEA SOBRE LA TRAGEDIA AÉREA EN EL ATLÁNTICO

• EN ESPAÑOL: INFORME PRELIMINAR DE LA BEA SOBRE LA TRAGEDIA AÉREA EN EL ATLÁNTICO

• ÚLTIMOS DATOS DE LA INVESTIGACIÓN DEL ACCIDENTE DEL AF447

• TERCER INFORME INTERINO DEL ACCIDENTE DEL AF447

En el siguiente enlace se puede acceder a toda la información elaborada por la BEA sobre el accidente del vuelo AF447. Y el enlace del Informe final.

Del informe destacamos la sección 3 en el que se enumeran en detalle las conclusiones de la investigación y las causas del accidente.

3 - CONCLUSION

3.1 Findings

3.2 Causes of the Accident

The obstruction of the Pitot probes by ice crystals during cruise was a phenomenon that was known but misunderstood by the aviation community at the time of the accident. From an operational perspective, the total loss of airspeed information that resulted from this was a failure that was classified in the safety model. After initial reactions that depend upon basic airmanship, it was expected that it would be rapidly diagnosed by pilots and managed where necessary by precautionary measures on the pitch attitude and the thrust, as indicated in the associated procedure.

The occurrence of the failure in the context of flight in cruise completely surprised the pilots of flight AF 447. The apparent difficulties with aeroplane handling at high altitude in turbulence led to excessive handling inputs in roll and a sharp nose-up input by the PF. The destabilisation that resulted from the climbing flight path and the evolution in the pitch attitude and vertical speed was added to the erroneous airspeed indications and ECAM messages, which did not help with the diagnosis. The crew, progressively becoming de-structured, likely never understood that it was faced with a “simple” loss of three sources of airspeed information.

In the minute that followed the autopilot disconnection, the failure of the attempts to understand the situation and the de-structuring of crew cooperation fed on each other until the total loss of cognitive control of the situation. The underlying behavioural hypotheses in classifying the loss of airspeed information as “major” were not validated in the context of this accident. Confirmation of this classification thus supposes additional work on operational feedback that would enable improvements, where required, in crew training, the ergonomics of information supplied to them and the design of procedures.

The aeroplane went into a sustained stall, signalled by the stall warning and strong buffet. Despite these persistent symptoms, the crew never understood that they were stalling and consequently never applied a recovery manoeuvre. The combination of the ergonomics of the warning design, the conditions in which airline pilots are trained and exposed to stalls during their professional training and the process of recurrent training does not generate the expected behaviour in any acceptable reliable way.

In its current form, recognizing the stall warning, even associated with buffet, supposes that the crew accords a minimum level of “legitimacy” to it. This then supposes sufficient previous experience of stalls, a minimum of cognitive availability and understanding of the situation, knowledge of the aeroplane (and its protection modes) and its flight physics. An examination of the current training for airline pilots does not, in general, provide convincing indications of the building and maintenance of the associated skills.

More generally, the double failure of the planned procedural responses shows the limits of the current safety model. When crew action is expected, it is always supposed that they will be capable of initial control of the flight path and of a rapid diagnosis that will allow them to identify the correct entry in the dictionary of procedures. A crew can be faced with an unexpected situation leading to a momentary but profound loss of comprehension. If, in this case, the supposed capacity for initial mastery and then diagnosis is lost, the safety model is then in “common failure mode”. During this event, the initial inability to master the flight path also made it impossible to understand the situation and to access the planned solution.

Thus, the accident resulted from the following succession of events:

• Temporary inconsistency between the airspeed measurements, likely following the obstruction of the Pitot probes by ice crystals that, in particular, caused the autopilot disconnection and the reconfiguration to alternate law;

• Inappropriate control inputs that destabilized the flight path;

• The lack of any link by the crew between the loss of indicated speeds called out and the appropriate procedure;

• The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;

• The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;

• The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it.

These events can be explained by a combination of the following factors:

• The feedback mechanisms on the part of all those involved that made it impossible:

- To identify the repeated non-application of the loss of airspeed information procedure and to remedy this,

- To ensure that the risk model for crews in cruise included icing of the Pitot probes and its consequences;

• The absence of any training, at high altitude, in manual aeroplane handling and in the procedure for ”Vol avec IAS douteuse”;

• Task-sharing that was weakened by:

- Incomprehension of the situation when the autopilot disconnection occurred,

- Poor management of the startle effect that generated a highly charged emotional factor for the two copilots;

• The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers;

• The crew not taking into account the stall warning, which could have been due to:

- A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet,

- The appearance at the beginning of the event of transient warnings that could be considered as spurious,

- The absence of any visual information to confirm the approach-to-stall after the loss of the limit speeds,

- The possible confusion with an overspeed situation in which buffet is also considered as a symptom,

- Flight Director indications that may led the crew to believe that their actions were appropriate, even though they were not,

- The difficulty in recognizing and understanding the implications of a reconfiguration in alternate law with no angle of attack protection.

Los medios de comunicación, entre los que destacamos Aviación Digital, de la prensa especializada, y El País y El Mundo, de la prensa de información general, se han hecho eco de la publicación del informe.

El avión de Air France se estrelló el 1 de junio de 2009 durante un vuelo nocturno que cubría la ruta de Río de Janeiro a París. No sobrevivió ninguna de las 228 personas que viajaban a bordo.

Tras varias fases de investigación, se logró recuperar cuerpos de las víctimas, buena parte del fuselaje del avión y las cajas negras, que registraron los incidentes de vuelo El avión se estrelló en aguas del Atlántico, a 1.296 kilómetros de la ciudad brasileña de Recife, casi cuatro horas después de haber despegado del aeródromo Galeão con 216 pasajeros a bordo, la mayor parte de ellos franceses y brasileños, y doce miembros de la tripulación.

El informe final atribuye el accidente del vuelo París-Río en 2009 a fallos mecánicos y humanos. En él se emiten 41 recomendaciones de seguridad, entre ellas 25 nuevas respecto a su anterior, y atribuye el accidente a fallos en la ergonomía del avión (un Airbus A330), y a las acciones inapropiadas de los pilotos que estaban sometidos a un fuerte estrés. La tripulación se vio superada por los acontecimientos al romperse el indicador de velocidad de la aeronave, según los investigadores. La investigación sugiere, además, la necesidad de mejoras en la señalización dentro de la cabina de los pilotos.

En la presentación, el director de la BEA recordó que con esta investigación no se buscan responsabilidades sobre el accidente y se remitió a la investigación judicial en marcha, en la que tanto Air France como Airbus fueron procesadas por homicidio involuntario en febrero de 2011, para depurar aquéllas. El informe que será presentado el 10 de julio a los familiares de las víctimas, ha sido filtrado ya, llega a similares conclusiones, aunque suma a los fallos técnicos y humanos la deficiencia de los protocolos seguidos y la meteorología adversa. Entre otros, el estudio de los expertos judiciales señala estos fallos y carencias:

• Trayectoria sin control. La pérdida de altura del aparato empezó por “una trayectoria no controlada”, causada por la pérdida de datos sobre la presión total que a su vez fue provocada por la formación de hielo en las sondas Pitot, acompañada por alarmas y degradación de los sistemas asociados. El déficit de información a la tripulación sobre el hielo en las sondas y sobre la altitud contribuyó al efecto sorpresa.

• Protocolos de emergencia inadecuados. Las condiciones de aplicación del protocolo en caso de alarma de caída “no se adaptaron a la urgencia de la situación”.

• Condiciones de vuelo desfavorables. “De noche, con turbulencias y sin referencias visuales”, con fenómenos de cristales de hielo, y la tripulación fatigada.

• Fallos humanos. Los expertos subrayan que el comandante de abordo no asumió sus responsabilidades e inhibió la voluntad de hacerlo bien del copiloto. No hubo, dice el informe, reacción apropiada a la alarma de pérdida de altura.

• La formación del copiloto. “No era suficiente para asumir la función de suplente del comandante”.

• Falta de seguimiento desde 2004. Los incidentes con pérdidas de indicación de la velocidad señalados desde 2004 no fueron seguidos de respuestas efectivas.

Desde Las mentiras de Barajas expresamos nuestra solidaridad con los familiares de los fallecidos y destacamos la independencia de la BEA y la valentía y celeridad de la investigación judicial, especialmente si la comparamos con la CIAIAC, el informe final del accidente de Barajas y la investigación judicial en marcha.

¡ES EL AEROPUERTO, ESTÚPIDO!

Recordamos unos párrafos del Informe técnico A032-2008, informe final, publicado en Julio de 2011 por la Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC)sobre el accidente del vuelo JK5022 de Spanair que tuvo lugar en el Aeropuerto de Madrid-Barajas el día 20 de agosto de 2008.

1. INFORMACIÓN SOBRE LOS HECHOS

1.1 Antecedentes del vuelo

...

Una vez que despegó la aeronave inmediatamente anterior, a las 14:23:09 h Control (DEP) comunicó: «SPANAIR 5022 VIENTO 210 05 AUTORIZADO A DESPEGAR, PISTA 36 IZQUIERDA». La tripulación colacionó a las 14:23:14 h: «AUTORIZA A 36 IZQUIERDA SPANAIR EHHHH 5022».

...

Durante la carrera de despegue se oyeron los anuncios en voz alta (call outs) «SIXTY», «ONE HUNDRED», «V1», «POWER CHECK» y «ROTATE14». En el momento en que se oyó «V1» la velocidad15 grabada en el DFDR fue de 154 KCAS y al oírse «ROTATE» se registró una velocidad de 157 KCAS.

A las 14:24:10 h en el DFDR quedó registrado el cambio de la señal de modo tierra a modo vuelo procedente del sistema de sensación de tierra de la pata de morro. La carrera de despegue tuvo una longitud aproximada de 1.950 m.

...

A las 14:24:14 h se activó la vibración de la palanca de control del sistema avisador de pérdida (stall warning stick shaker) y la bocina y la voz sintética de aviso de pérdida simultáneamente. El copiloto dijo «FALLO DE MOTOR» en tono interrogativo y un segundo más tarde, a las 14:24:15 h el comandante, en un tono de voz muy elevado, preguntó cómo se apagaba la voz. En ese momento la velocidad era de 168 KCAS, había 25 ft de radio altura, un ángulo de asiento (pitch) de 15,5° y un alabeo (bank) a la derecha de 4,4°.

El alabeo a la derecha se incrementó hasta un máximo de 20°. En este momento quedó registrada una variación de la posición de las palancas de empuje de unos 4° la izquierda y 32° la derecha, en el sentido de disminuir el empuje, durante un segundo.
Como consecuencia de ello, el valor de EPR se redujo dos segundos después a un valor en torno a 1,65 en ambos motores, observándose variaciones de los parámetros de motor. Inmediatamente las palancas se movieron hasta su posición más adelantada posible, alcanzándose unos valores de EPR en torno a 2,20. Estos valores se mantuvieron constantes hasta el final.

A partir de ese momento se escucharon los avisos de «bank angle» procedente del sistema de aviso de proximidad al terreno (EGPWS) y en cabina sonaron alternativamente en tres (3) ocasiones la bocina y la voz sintética anunciando la condición de pérdida: «[bocina]stall, [bocina]stall, [bocina]stall», a veces solapados con el aviso del EGPWS. La vibración de la palanca de control del sistema avisador de pérdida permaneció activa hasta el primer impacto con el suelo.

A las 14:24:19 h se alcanzaron los máximos valores de ángulo de asiento (18,3°) y de radio altura (40 ft). A las 14:24:24 h se escuchó el primer impacto contra el terreno alcanzándose una aceleración vertical de 3,17 g. En ese momento la actitud registrada de la aeronave era de 10,4° de pitch y 5,3° de alabeo a la derecha. La velocidad era de 154 KCAS.

A las 14:24:30 h finalizó la grabación de datos de vuelo en el DFDR.

A 14:24:36 h una aeronave comunicó a Torre en frecuencia de Rodadura Central-Sur (GND C-Sur), que acababa de haber un accidente.

La aeronave acabó destruida a consecuencia de los impactos con el suelo y el incendio posterior.

3.2. Causas

La CIAIAC ha determinado que el accidente se produjo porque:

La tripulación perdió el control del avión como consecuencia de la entrada en pérdida inmediatamente después del despegue, por no haber configurado el avión correctamente, al no realizar la acción de despliegue de los flaps/slats, tras una serie de fallos y omisiones, junto con la ausencia de aviso de la configuración incorrecta de despegue.

La tripulación no identificó los avisos de pérdida ni corrigió dicha situación después del despegue —retrasó momentáneamente las palancas de potencia del motor, aumentó el ángulo de asiento y no corrigió el alabeo— produciéndose un deterioro de la condición de vuelo en pérdida.

La tripulación no detectó el error de configuración al no utilizar adecuadamente las listas de comprobación que contienen los puntos para seleccionar y comprobar la posición de flaps/slats en las labores de preparación de vuelo, en concreto:

• No llevó a cabo la acción de seleccionar flaps/slats con la correspondiente palanca de mando (en «After Start Cheklist»);

• No realizó la comprobación cruzada de la posición de la palanca y el estado de las luces indicadoras de flaps y slats al ejecutar la lista de comprobación «After Start»;

• Omitió la comprobación de flaps y slats en el punto «Take Off Briefing» de la lista de comprobación de taxi;

• En la comprobación visual realizada en la ejecución al punto «Final Items» correspondiente a la lista «Take Off Inminent» no se realizó una confirmación real de la posición de los flaps y slats, tal como mostraban los instrumentos de la cabina de vuelo.

...

Y también unos párrafos del Informe definitivo del incidente del MD-83 de Mapjet acontecido el 5 de junio de 2007 en el Aeropuerto de Lanzarote.

1. INFORMACIÓN factual

1.1 Historial del vuelo

1.1.2. Vuelo Lanzarote-Barcelona

El despegue desde Lanzarote se produjo a las 10:45 hora local, desde la pista 03 utilizando “autothrottle”. El piloto a los mandos era el copiloto. Después de la rotación, que se realizó a una velocidad aproximada de 145 kt, se activó el “stick shacker” y la aeronave empezó a alabear a la izquierda y derecha hasta alcanzar ángulos de 63º al lado derecho y 60º al izquierdo. El comandante retrajo el tren de aterrizaje aprox. 25 a 30 segundos después del despegue mientras la aeronave continuaba oscilando a ambos lados del eje longitudinal. La aeronave continuó alabeando hasta alcanzar una velocidad superior a 200 kt.

La aeronave ascendió hasta 5.000 ft y la tripulación, en un primer momento, decidió continuar con el vuelo, decisión que rectificó inmediatamente y la aeronave regresó a Lanzarote. La tripulación no declaró emergencia. El aterrizaje se realizó normalmente sin que existiera incidencia.

No se produjeron daños ni a personas ni a la aeronave. El desembarque del pasaje se realizó con normalidad.

Y esto es lo que ocurrió el 20 de marzo de 2009 en Melbourne: Un A-340 de Emirates Airlines que realizaba el vuelo de Melbourne a Dubai se golpeó con la cola en la pista durante el despegue, y no remontó el vuelo hasta que sobrepasó el final de la pista 16 del Aeropuerto de Melbourne por la noche y con visibilidad normal.

Ninguno de los 275 ocupantes sufrió ningún daño; el avión sí, en la parte baja trasera del fuselaje. También resultaron afectados algunos elementos del final de pista.

Tres accidentes y dos resultados. El viento salvó al Mapjet de Lanzarote y un diseño adecuado salvó a los 275 pasajeros del A-340 en Melbourne. En Barajas el viento lanzó al JK5022 contra el suelo y errores de diseño del aeropuerto lo despeñaron por un barranco que aún despide a los vuelos que despegan en configuración norte. Desgraciadamente, el JK55022 no intentó el despegue desde Lanzarote o desde Melbourne.

¿Hay quién todavía cree que la culpa fue del relé? No, la culpa fue del aeropuerto. Sin dudarlo, una nueva investigación que contemple todos los aspectos concurrentes es necesaria.

Porque esto es lo que pensamos de la CIAIAC, al menos por lo que respecta a su informe sobre el accidente de Barajas del 20 de agosto de 2008.



Adjuntamos el informe publicado en SKYbrary.

A340 Overrun on Take Off

Source: www.skybrary.aero

The ATSB has published the final report into the March 2009 tail strike and runway overrun by an Airbus A340-500, caused by insufficient thrust having been set because of incorrect flight crew data entry in performance calculations.

A345, Melbourne Australia, 2009 (RE HF)

Category: Accidents and Incidents

Description

On 20 March 2009 an Airbus A340-500 being operated by Emirates Airline on a scheduled passenger flight from Melbourne to Dubai with an augmented (relief) crew occupying the two flight deck observer seats suffered a tail strike and did not become airborne until after the end of take off runway 16 at Melbourne at night in normal ground visibility. Only subsequently, when an ECAM (Electronic Centralized Aircraft Monitoring) annunciation of a tail strike was apparent and ATC called, did the crew realise that a tail strike and overrun had occurred and it was decided to return to land to “assess the damage” with a ‘PAN’ was subsequently declared. An unusual noise accompanied by a cabin report of smoke in the rear cabin area just after completion of fuel dumping led to a precautionary request to ATC for a landing as soon as possible but a full inspection after coming to a stop on the runway founds no signs of fire and a normal taxi in to a gate was then made for disembarkation. None of the 275 occupants were injured but the aircraft rear lower fuselage and ground installations beyond the end of the departure runway struck by it were damaged.

Investigation

An Investigation was carried out by the Australian Transport Safety Bureau (ATSB). FDR data recording was found to have ceased as the aircraft had become airborne and this was attributed to the dislodgement of the FDR from its mounting rack immediately behind the rear pressure bulkhead to where it was found after the flight, lying (undamaged) on the lower fuselage skin below and slightly to the rear of the mounting rack. Fortunately, a DAR (Digital ACMS Recorder) was also fitted and had recorded most of the FDR parameters as well as others in Non-Volatile Memory (NVM).

The trajectory of the aircraft during the take off was established from the evidence available. The aircraft rear lower fuselage had contacted the 3657 metre long runway at three locations, starting at 265 metres, 173 metres and 110 metres from the end of the runway. It had then overrun the end of the runway onto the stopway and across the grassed clearway, becoming airborne three seconds after the selection of TOGA thrust. However, before gaining altitude, the aircraft had struck a Runway 34 lead-in sequence strobe light and several antennae, the latter impacts having disabled the Runway 16 ILS. A small depression at the end of the 60 metre stopway had resulted in the rear fuselage briefly losing contact with the ground and the final ground contact mark had ended 148 metres beyond the end of the paved runway surface (and beyond the 120 metre Clearway).



Figure 1 - Graphical representation of Digital Aircraft Condition Monitoring System Recorder (DAR) data showing position of aircraft at a computed airspeed corresponding to V1 used by the crew, initial tail contact with ground, and final tail ground contact witness mark. Source: ATSB AO-2009-012 Final Report.

Inspection of the aircraft lower rear fuselage found the lower skin to have been abraded by contact with the runway surface and in some areas worn through its full thickness with grass and soil caught in the airframe structure. One service panel had been dislodged and was subsequently found beyond the end of the take off runway along with numerous pieces of metal from the abraded skin panels.

It was established that performance calculations for the take off had been made using the Airbus Less Paper Cockpit (LPC) system on a single EFB. In accordance with the Operator’s SOP, the second EFB carried was used only as a backup in the event of a malfunction in the one being used. An aircraft take off weight of 100 tonnes less than the actual weight available to the flight crew was inadvertently entered into the EFB and the effects of that error on speeds and thrust settings were not subsequently noticed by any of the four pilots present. When the aircraft failed to become airborne after two ‘Rotate’ calls using the reduced thrust calculated, the aircraft commander had applied TOGA thrust and a few seconds later the aircraft had become airborne. Whilst still airborne, the crew had established for themselves the origin of the difficulty getting airborne as the gross error in the entered take off weight when the EFB was accessed to begin the landing performance calculations.

The Investigation found that there had been a complete failure of the procedural cross checks to detect the gross error of weight or its effects. The operating First Officer, who had also been PF for the take off, was found to have made the initial weight input error and the required cross check by the aircraft commander of the take-off weight in the FMGS with that used in the take-off performance calculation was then not made. The aircraft commander had entered the EFB performance figures into the FMGS and crosschecked them with the First Officer against the erroneous values that had previously been copied onto the flight plan. He had then handed the EFB back to the First Officer, who had stowed it before they completed the loadsheet confirmation procedure together. During that procedure, it was found that the First Officer had correctly read the weight from the FMGS as 361.9 tonnes but, when reading the same weight from the flight plan, had stated 326.9 tonnes before immediately correcting this to 362.9 tonnes. This procedure also included the First Officer reading out the (wrongly recorded) ‘green dot speed’ (best speed for climb once clean, affected only by aircraft weight and altitude) of 265 knots (490.78 km/h, 136.21 m/s) from the FMGS which was accepted by the aircraft commander.

During the take off roll, using an assumed temperature calculation of reduced thrust which had been produced using the wrong (low) take off weight, the rate of acceleration had not been perceived as lower than required. The rotation rate used was found to have been as prescribed and the tail strike had been the result of continued rotation following the second ‘rotate’ call which led to the aircraft reaching the geometric limit of 9.5° after which TOGA thrust was applied. It was considered “unlikely that the flight crew had time to recognise that the aircraft had not lifted off at the expected pitch attitude of about 8°.” In this respect, it was noted that, at the prevailing rotation rate, it would have taken only about half a second to increase the pitch by 1.5°, making the PFD an ineffective means of identifying the exceedence.

It was noted that, whilst climbing to 7000 feet2,133.6 m to commence fuel dumping, it had become apparent that the aircraft was not pressurising. No specific reason could be established for the apparent sight and smell of smoke in the rear cabin that had accompanied it but it was considered that the change in aircraft attitude as descent was commenced probably led to dust and odours from the earlier damage.

The Investigation distinguished two aspects of the accident as:

• the over rotation which led to the tail strike

• the long take off roll which led to the overrun

The Investigation examined in detail the ways in which a number of cross checks built in to the procedures for establishing take off data had all failed. The “lack of recognition of the degraded take off performance (relative to that needed) until very late in the take off run” was considered to have compounded the use of erroneous take off data which had created the conditions for the accident. However, it was noted that pilots rated for mixed fleet operations, as in this case for the A330-200, A340-300 and A340-500, there was an exposure to a large range of take off weights and (perceived) accelerations. Given that distraction was considered to have played a major part in facilitating error, a detailed examination of the effectiveness of risk management in this area was made. It was considered that:

• The operator had identified other flight phases as critical to the safety of flight, such as taxi, takeoff and climb, and had a sterile cockpit rule for those phases. There was no such management practice to reduce the potential for distraction during the take-off performance calculation and checking process.

• The provision by the operator of briefings to flight crews on distraction management in the months prior to the accident appear to have been ineffective in this accident.

In respect of the augmenting crew, it was considered that:

• The lack of clear direction on the role of, and required input from the augmenting crew during the pre-departure preparation further increased the distraction risk to the operating flight crew.

• The presence of augmenting crew in the cockpit during the pre-departure phase (in itself) created a distraction for the operating crew.

In respect of the SOPs involved, there was concern that, as usual, they were “typically designed on the basis that information flow….is sequential and....procedures are conducted in a linear fashion based on this sequential information flow” whereas research has shown such a linear flow is atypical in line operations which “increases the likelihood that, following a distraction, the flight crew will re-enter a procedure at an incorrect point.”

It was concluded after eliminating all other possible causes and establishing the chain of events with all the available evidence that “the over rotation and tail strike were due to the incorrect rotation speed and flap configuration for the actual weight of the aircraft”.

The preface to the Findings included the remarks that “although there are a number of factors identified directly relating to this accident, the accident needs to be taken in the context of the long history of similar take-off performance events.” Consequently, the recommended safety responses as result of the Investigation are “those that address the whole situation, not just those that address the specific factors identified in this accident”.

Five Safety Issues were identified:

• The existing take-off certification standards, which were based on the attainment of the take-off reference speeds, and flight crew training that was based on the monitoring of and responding to those speeds, did not provide crews with a means to detect degraded take-off acceleration. [Significant safety issue]

• The operator’s training and processes in place to enable flight crew to manage distractions during the pre-departure phase did not minimise the effect of distraction during safety critical tasks. [Significant safety issue]

• The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check of the speed/weight relationship for their aircraft during takeoff. [Significant safety issue]

• The failure of the digital flight data recorder (DFDR) rack during the tailstrike prevented the DFDR from recording subsequent flight parameters. [Minor safety issue]

• The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure. [Minor safety issue]

Safety Action in response to the accident and the investigation of it by the ATSB itself in initiating and completing a Safety Study on “Take-off performance parameter errors: A global perspective” was noted. After taking account of Safety Action by Emirates, Airbus, EASA and FAA as described in the Report, the ATSB made one Safety Recommendation:

• That the FAA take action to address the existing take-off certification standards, which are based on the attainment of the take-off reference speeds, and flight crew training that was based on the monitoring of and responding to those speeds, and do not provide crews with a means to detect degraded take-off acceleration. (AO-2009-012-SR-079)

In respect of the outstanding concern about the issues raised by ‘Cross Crew Qualification and Mixed Fleet Flying’ the Investigation determined that the best way to progress this matter was to direct ‘Safety Advisory Notices’ to the FSF and to IATA requesting respectively that:

• The Flight Safety Foundation consider developing guidance to assist flight crews form appropriate mental models in respect of the weight and corresponding take-off performance parameters for a particular flight. The use by operators of mixed fleet flying increases the importance of that guidance. (AO-2009-012-SAN-086)

• The International Air Transport Association to encourage its members to develop guidance to assist their flight crews form appropriate mental models in respect of the weight and corresponding take-off performance parameters for a particular flight. The application by operators of mixed fleet flying increases the need for that guidance. (AO-2009-012-SAN-087)

The Final Report of the Investigation was published on 16 December 2011: Aviation Occurrence Investigation AO-2009-012 Final.

Related articles and further readings were not included but are available in the skybrary article.

AUSBAU DER FLUGHÄFEN IN FRANKFURT, MÜNCHEN, BERLIN,…? NEIN, DANKE

La fiebre de la expansión aeroportuaria se ha trasladado de España a Alemania; eso sí, con alguna diferencia; así, mientras en España contaba con el beneplácito de casi todos, en Alemania la mayoría social parece no estar por la labor de convertir las zonas residenciales cercanas en infiernos inhabitables. ¡Ninguna capital de provincia sin aeropuerto ni estación del AVE! Era el eslogan suicida de unos políticos suicidas que convencieron a una sociedad suicida para financiar unos proyectos suicidas por unos bancos suicidas… hasta que llegó alguien y les dio una pistola. Los alemanes son muy cabales, conocen el riesgo al que se enfrentan y actúan preventivamente en la calle, con la movilización social, y en los juzgados, con demandas.

En Alemania, como en España, el diseño y ejecución de los planes de expansión aeroportuaria se llevan a cabo en el ámbito local y regional ¿Nos suena familiar? En ninguno de los dos países ha existido ni existe un debate nacional sobre esta cuestión.

Pero Alemania no es España y la sociedad civil germana no es la española, y los planes de expansión aeroportuaria de Frankfurt, Munich y Berlín se han topado con la oposición de los actuales y futuros afectados por la contaminación acústica.

En España primero se aplaude y se exigen inversiones y luego se lamentan las consecuencias, alguno protesta y decide ir a los juzgados, y si alguien osa ganar una sentencia entonces llega el gobierno y con el apoyo cómplice de la oposición cambia las leyes. En Alemania primero se quejan, se manifiestan y acuden a los juzgados y si ganan una sentencia se ejecuta y se respetan las leyes existentes. Así, en España, desde la aprobación de la reforma de la Ley de Navegación Aérea, es obligatorio soportar el ruido, bien porque reside en zona de servidumbre acústica en cuyo caso no puede hacer nada, bien porque su vivienda no está afectada legalmente y entonces se fastidia igualmente. En Alemania ya han conseguido el cierre nocturno del Aeropuerto de Frankfurt.

En España no hay una movilización nacional contra la locura aeroportuaria y sus consecuencias sobre la salud y la calidad de vida de los residentes en las zonas afectadas. No obstante, hay que reconocer y aplaudir el titánico esfuerzo que lleva a cabo la Asociación Nacional de Afectados por el Impacto del Tráfico Aéreo, ANAITA, en su lucha desigual contra AENA y la Dirección General de Aviación Civil del Ministerio de Fomento.

En Alemania, desde las primeras manifestaciones nacionales contra el ruido del pasado mes de octubre, hay una conciencia y un movimiento nacional emergente contra los planes de expansión aeroportuaria. Los números son contundentes: entre 10.000 y 20.000 personas se manifiestan regularmente en Frankfurt, entre 7.000 y 15.000 asisten a las manifestaciones contra el nuevo Aeropuerto de Berlín y 7.000 en Munich contra la construcción de una tercera pista.

Adjuntamos un artículo en el que se informa de las campañas y actuaciones que están llevando a cabo las asociaciones vecinales en defensa de su salud y calidad de vida con un lema claro: progreso sí pero no a cualquier precio.



Desde Las mentiras de Barajas animamos a los alemanes a continuar con las movilizaciones y la batalla judicial hasta que la razón alcance a los políticos y responsables de la locura aeroportuaria por las buenas, o los juzgados la impongan por el peso de la ley.



A new third runway at Munich airport?



The German Spring: Young Friends of the Earth Bavaria opposing airport expansion

Young Friends of the Earth Bavaria in Germany have been campaigning against the expansion of airports in Germany. Florian Sperk tells us about the campaign against a new third runway at Munich airport.

Written by Florien Sperk, Young Friends of the Earth Bavaria

Since the first nationwide anti-noise demonstrations took place last October in Frankfurt, rumours of an emerging national movement against airport expansion have grown. So what's up in Germany?

Over the last few years local protest groups around Germany's three main airports - Frankfurt, Berlin and Munich – have been growing. In Frankfurt about 10,000 to 20,000 people are demonstrating regularly. In Berlin 7,000 to 15,000 people have marched against the new airport. And in Munich up to 7,000 people have taken part in protests. But this spring something new happened.

Something big is coming up

This spring the different groups started noticing each other, and began to recognise the power they can have in working together. In Germany all aviation issues are planned and decided at a local and regional level by town halls, not at a national level. Thus there has been a lack of a national debate around aviation. Germany has never really asked itself key questions: about the value of the different airports to the economy, or whether there should be limits to growth, or what role a reduction in domestic flights could play in the national strategy to stop climate change. Many people are arguing that the time is now right to put the expansion of the aviation industry on the national agenda. And they could be right. The profits of Germany's main airline, Lufthansa, are tumbling. There may be no need for further expansion.

The third runway in Munich!

We now look at the current protest in Munich within the context of the bigger, national picture. In Munich the expansion of the airport is said to be needed to keep possible delays below 4 minutes over the next 20 to 30 years, assuming maximum usage of the airport. Some people might think this is a joke. But is not. It is actually the main justification given for the third runway. The authorities want to make sure maximum delay shall always be less than 4 minutes, even if the demand for flights doubles. The reality is, though, that the demand for flights is decreasing every month. So there is already evidence that the biggest climate-killer of Bavaria simply does not need to expand. The third runway in Munich can and will be stopped.

No third runway in Munich!

The main reasons Young Friends of the Earth Bavaria want to stop the third runway are explained in the following short movie, made by Young Friends of the Earth Bavaria.



But, for those how don't speak German, the reasons are:

1) The airport has debts of about 2.7 billion Euros.

2) The airport has made a profit only three times in its 20 year existence

3) The third runway will cost more than 1.2 billion Euros. And all this money will be spend for a saving of 4 minutes, at a time when the budgets for social projects are cut every year.

4) The airport is Bavaria's biggest climate-killer - with about 10 % of the total emissions of Bavaria.

5) More than 1000 hectares of a conservation area for birds will be destroyed.

6) One of the last big fens in Bavaria will be critically damaged.

7) About 40,000 to 80,000 people will suffer of noise and air-pollution

Munich can become Germany's Heathrow, the London activists say

Young Friends of the Earth Bavaria invited the successful activists of Plane Stupid and AirportWatch to Munich this spring. And guess what: John Stewart, one of the activists, told us that the current situation at Munich is very similar to the situation in London in the years before the third runway at Heathrow was finally stopped. And if the strategic mastermind of the Heathrow third runway campaign says something like this, it's up to us in Young Friends of the Earth to answer with massive campaigning.

Find out more about the movement against airport expansion in Germany