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Category: <span>BEA</span>

Egyptair Flight MS804 Almost A Year Later

Elements of this image are furnished by NASA

Egyptair Flight MS804 (AKA EgyptAir Flight 804) was a Paris to Cairo flight that ended in the Mediterranean on May 19, 2016. Sixty-six people lost their lives: three security crew, fifty-six passengers, seven crew.

Egyptian authorities published a progress report on 28/06/16 that the BEA repaired the recorders. On 17/06 that the Technical Investigation Committee of the A320 accident studied FDR data as well as performing time correlation between FDR and CVR data and cockpit voice recordings before the occurrence of the accident where the existence of a “fire” was mentioned. That report did not determine the reason or location where that fire occurred. Smoke was reported during the flight in the bathroom and the avionics bay.

The investigation has been fraught with controversy. On 22 May, 2016, M6 (French TV) reported that a pilot told Cairo air traffic control about smoke in the cabin, and the pilot consequently made an emergency descent.

On May 20th 2016 The Aviation Herald received information from three independent channels, that ACARS (Aircraft Communications Addressing and Reporting System) messages with following content were received from the aircraft:

  • 00:26Z 3044 ANTI ICE R WINDOW
  • 00:26Z 561200 R SLIDING WINDOW SENSOR
  • 00:26Z 2600 SMOKE LAVATORY SMOKE
  • 00:27Z 2600 AVIONICS SMOKE
  • 00:28Z 561100 R FIXED WINDOW SENSOR
  • 00:29Z 2200 AUTO FLT FCU 2 FAULT
  • 00:29Z 2700 F/CTL SEC 3 FAULT
  • no further ACARS messages were received.

No sooner did the report come out that the Egyptian Civil Aviation Ministry dismissed it as false.

One truism I have found in accident investigation is that it takes time to find the truth. Another is that facts can be misleading. Reportage from official sources moves slowly; reportage from commercial, so-called “news,” or social sources is frequently speculative, unsourced, or purely imaginary. Sometimes it is actually correct. It is difficult to tell the difference. Contradictions are a frequent finding, such as this:

  • Le Figaro reported that no explosives were found on Egyptair flight MS804 French victims’ bodies. The flight crashed in the Mediterranean in 2016.
  • On Dec 15th 2016 Egypt’s Civil Aviation Authority announced that forensic examination on behalf of the Accident Investigation Commission found traces of explosives with some of the human remains recovered. In accordance with Egypt law, the states prosecutor was informed, and a technical commission formed by the prosecution office opened their investigation into the crime.

How does a close reader respond to a statement that “traces of explosives were found WITH human remains?” A close reader finds more questions. With the remains is not ON the remains. But it could be either way since we are dealing with languages. In English, WITH the remains could mean a bomb was floating in the water near the bodies, or ashes, or gasoline or TNT residue. And what constitutes near? Inches? Miles? It all is relative. Or if the original report is loosely translated, did the original document use a preposition such as ON the remains? And then, there are the forensic questions. Were explosive remains washed off of bodies that were submerged in the ocean?

If the case goes to court, the court will want to know if something failed on the plane, and if so, what it was. Manufacturers of failed components are considered responsible parties. No matter what the cause, international treaty determines carrier responsibility to the victims of the crash.

The determination of failed components provides additional responsible parties. The discovery of a bomb would make airport security one of the potential responsible parties. In addition, international treaty provides guidelines for what carriers owe to the families. (Which treaty is involved depends on which treaty/treaties the involved country/countries are signatory to. If it sounds like it can get complicated, you are correct.)

It has been nearly a year since the accident, and though some things may be believed in the court of public opinion to be one way or another, questions remain unanswered. How grievous and how difficult for the families that must wait so long to find out what brought about this tragedy that took their loved ones.

Lufthansa: Safekeeping Profits or Passengers?

crash site image

Accident to the Airbus A320-211, registered D-AIPX and operated by Germanwings, flight GWI18G, on 03/24/15 at Prads-Haute-Bléone

According to the BEA, they will release the final report on Germanwings 9525 on Sunday, March 13, 2016 during a press briefing. I plan to be there.

Although the public has not seen the final report, and indeed, as the investigation has not yet even been completed, the world already understands what happened aboard this tragic flight. What we really do not understand—and perhaps never will—is what drove Germanwings co-pilot Andreas Lubitz to research cockpit door security and methods of committing suicide. We do not know what drove a depressed human being to impel the plane and all the lives in his safekeeping into the side of a French mountain, condemning every soul aboard that plane to death. We do not know the devils that hounded him into this cold-blooded act. We only mourn, perhaps, his loss of humanity, as we mourn alongside the grieving families who have been robbed of their loved ones and their rightful lives.

All passenger/families received a total of 8 million euros, divided equally among them. Media reports on what passengers received from Lufthansa varies.

In the German media, the Rheinische Post claimed officials of the German airline said families of the 144 passengers have obtained different compensation amounts. It is also reported that Lufthansa group has paid 11.2 million euros ($12.48 million) to the families. Additional “uncalculated” compensation in “property damages” is still coming from Lufthansa to the families.

This compensation…coming from Lufthansa, whose 2014 profit was declared “flat” at a mere $31.7 billion, announced in October of 2015 a nine-month net profit of €1.75 billion ($ 1.97 billion), up 262.7% from €482 million. The tragedy which destroyed 150 lives, and crippled all of their families appears to have left Lufthansa’s bottom line untouched.

Do we also mourn and grieve and condemn Lufthansa? The depth of the ethics and principals of this many billion dollar company—the largest airline in Europe—remains to be seen. We can ask ourselves if this is a high-principled company of good repute, of sterling honor. We need not conjecture long. A tangible answer will be obvious when these decisions are made. We will see where lie their priorities when we learn how they treat the families whose lives hang in the balance in their custodianship.

Jan 18: TAM Airbus Emergency was Slow Suffocation

Image of A320 Interior
Image of A320 Interior
On January 18, 2016, a TAM Linhas Aereas Airbus A320-200 was on a scheduled flight from Brasilia to Aracaju Brazil when the pilots decided to return to Brasilia. They made a safe landing and were in the air ten minutes short of an hour. Incident investigations always take time. So it was a couple weeks later, on Feb 5th when the BEA reported this notice. (Note that the BEA is Le Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation, France’s Governmental aviation authority.) The BEA reported Brazil’s CENIPA notice why the pilots decided to return.

The Airbus was climbing. Cabin crew told the flight crew that passengers and cabin crew were suffering from significant hypoxia. Hypoxia means inadequate oxygenation of the blood, or deficiency in the amount of oxygen delivered to the body tissues. Web MD says this about hypoxia:

“When your body doesn’t have enough oxygen, you could get hypoxemia or hypoxia. These are dangerous conditions. Without oxygen, your brain, liver, and other organs can be damaged just minutes after symptoms start.”

“Hypoxemia (low oxygen in your blood) can cause hypoxia (low oxygen in your tissues) when your blood doesn’t carry enough oxygen to your tissues to meet your body’s needs. The word hypoxia is sometimes used to describe both problems. Symptoms can vary from person to person, the most common hypoxia symptoms are Changes in the color of your skin, ranging from blue to cherry red, Confusion,Cough, Fast heart rate, Rapid breathing, Shortness of breath, Sweating, Wheezing. If you have symptoms of hypoxia, call 911.”

On the Tam flight in question, the flight crew manually released the passenger oxygen masks. After returning to Brasilia, the incident was rated serious. CENIPA is investigating. CENIPA’s acronym is in Portuguese: Centro de Investigação e Prevenção de Acidentes Aeronáuticos. CENIPA is a unit of the Brazilian Air Force that investigates aviation accidents and incidents in Brazil.

The flight under investigation was JJ-3538 flown by the Airbus registered as #PR-MAA on a standard flight from Brasilia,DF to Aracaju, SE in Brazil.

Brazil investigates incident
BEA reports on BEA2016-0061
Serious incident, Brasilia Federal District, on 18 January 2016, AIRBUS – A320, PR-MAA; click to enlarge image

Fokker 27 Investigation

BEA Fokker 27, registered I-MLVT, 25 October 2013, Roissy Charles de Gaulle Airport, France

INFORMATION ON 27 OCTOBER 2013

The BEA has initiated a Safety Investigation following the accident that occurred to the Fokker 27 Mk 500, operated by the Italian airline Miniliner on behalf of the French airline Europe Airpost.

The cargo aeroplane, with two pilots on board, had taken off at 01h10 (local time) from Roissy Charles de Gaulle Airport bound for Dole, France. A few minutes later, the aeroplane suffered uncontained damage to the left engine. During the accident, a left propeller blade went through the fuselage. At 01h20, the crew made an emergency landing back at Roissy Charles de Gaulle Airport.

A team of three investigators from the BEA went to Roissy on Friday 25 October to begin the first work on the investigation. The flight recorders, along with the propeller, will be sent to the BEA on Monday 28 October.

Organisation of the Investigation

In accordance with the provisions of European Regulation 996/2012, the BEA has associated the following organisations with the Safety Investigation:

ANSV (Agenzia Nazionale per la Sicurezza del Volo, Italy) representing the State of Operation of the aeroplane,
AAIB (Air Accidents Investigation Branch, United Kingdom) representing the State of Manufacture of the aeroplane’s engine and
the Dutch Safety Board (Netherlands) representing the State of Manufacture of the aeroplane.
The preliminary examination of the propeller blade that separated from the engine and the readout of the flight recorders will be undertaken at the BEA at the beginning of this week, in the presence of the BEA’s foreign counterparts and their technical advisers.

The BEA releases the “Final report” on Air France Flight 447


The BEA report (pp 200-201) concluded:

  • The crew possessed the licenses and ratings required to undertake the flight.
  • The aeroplane possessed a valid Certificate of Airworthiness, and had been
    maintained in accordance with the regulations.
  • The aeroplane’s weight and balance were within operational limits.
  • The aeroplane had taken off from Rio de Janeiro without any known technical
    problems, except on one of the three radio management panels.
  • The composition of the crew was in accordance with the operator’s procedures.
  • The meteorological situation was not exceptional for the month of June in the
    inter-tropical convergence zone.
  • There were powerful cumulonimbus clusters on the route of AF 447. Some of
    them could have been the centre of some notable turbulence.
  • An additional meteorological analysis showed the presence of strong
    condensation towards AF 447’s flight level, probably associated with convection
    phenomena.
  • The precise composition of the cloud masses above 30,000 feet is little known,
    in particular with regard to the super-cooled water/ice crystal divide, especially
    with regard to the size of the latter.
  • Several aeroplanes that were flying before and after AF 447, at about the same
    altitude, altered their routes in order to avoid cloud masses.
  • The crew had identified some returns on the weather radar and made a heading
    change of 12° to the left of their route.
  • At the time of the autopilot disconnection, the Captain was taking a rest.
  • The departure of the Captain was done without leaving any specific instructions
    for crossing the ITCZ.
  • There was an implicit designation of a pilot as relief Captain.
  • There was an inconsistency between the speeds measured, likely following the
    blockage of the Pitot probes by ice crystals.
  • The AP then the A/THR disconnected while the aeroplane was flying at the upper
    limit of a slightly turbulent cloud layer.
  • The aeroplane systems detected an inconsistency in the measured airspeeds. The
    flight control law was reconfigured to alternate 2B.
  • No failure message on the ECAM clearly indicates the detection by the system of
    an inconsistency in measured airspeeds.
  • The pilots detected an anomaly through the autopilot disconnection warning
    that surprised them.
  • The engines functioned normally and always responded to the crew’s inputs.
  • The PNF called out imprecise flight path corrections. They were however essential
    and sufficient for short-term management of the situation.
  • The last recorded values were a pitch attitude of 16.2 degrees nose-up, roll of
    5.3#degrees to the left and a vertical speed of -10,912 ft/min.
  • The Pitot probes installed on F-GZCP met requirements that were stricter than
    the certification standards.
  • Analysis of the events related to the loss of airspeed indications had led Airbus
    and Air France to replace C16195AA Pitot probes by the C16195BA model. The
    first aeroplane had been modified on 30 May#2009.
  • EASA had analyzed Pitot probe icing events; it had confirmed the severity of the
    failure and had decided not to make the probe change mandatory.
  • The flight was not transferred between the Brazilian and Senegalese control
    centres.
  • Between 8 h 22 and 9 h 09, the first emergency alert messages were sent by the
    Madrid and Brest control centres.
  • The crew was not able to use the ADS-C and CPDLC functions with DAKAR Oceanic.
    If the connection had been established, the loss of altitude would have generated
    an alert on the controller’s screen.
  • The first floating aeroplane parts were found 5 days after the accident.
  • The flight recorders were recovered 23 months after the accident.

The accident occurred after the following events:

  1. 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;
  2. Inappropriate control inputs that destabilized the flight path;
  3. The lack of any link by the crew between the loss of indicated speeds called out
    and the appropriate procedure;
  4. The late identification by the PNF of the deviation from the flight path and the
    insufficient correction applied by the PF;
  5. The crew not identifying the approach to stall, their lack of immediate response
    and the exit from the flight envelope;
  6. 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.

Download the complete final report here:

BEA FINAL REPORT on AF 447

BEA release: Human Factors Committee


The BEA has just formed the « Human Factors » working group whose creation was announced at the time of the publication of the third Interim Report on the investigation into the accident to the Rio-Paris flight on 1st June 2009.

This working group’s objective is to analyze all aspects connected to the conduct of the flight:

Crew actions and reactions during the last three phases of the flight described in the third Interim Report, in particular in relation to the stall warning;
Cockpit ergonomics;
Man-machine interfaces.
This working group is made up of seven experts:
Three BEA investigators specializing in human factors;
A psychiatrist specializing in risk analysis;
A human factors aviation consultant;
A type-rated A330 pilot;
An A330 test pilot.

The BEA may call on other experts from time to time and will consult Airbus and Air France when required.

The group’s work will begin very soon and should be completed by the end of December 2011. Its thinking will take into account input from both the «Operations» and the «Airplane Systems» groups.

All of the work carried out will be included in the Final Report, which will establish the causes of the accident, whose publication is planned for the first half of 2012.

Yemenia Flight 626, Comoros, Updated

The BEA sent this letter to the president of the Inquiry committee, the Ministries of Communications of Moroni, New technology, Transportation and tourism (Loosely translated. For the original, click the link below the letter):

Re: Yemenia Flight 626
Monsieur President,

I have read the first progress report on flight IY626 that crashed June 29, 2009 during the landing procedure at the airport in Moroni. This report is dated June 25, 2011 but has not, to my knowledge been released to date.

This report contains the facts that for the most part, were already available three months after the accident.

However, the BEA addressed you in May 2010 regarding the publication of a progress report in the context of the first anniversary of the accident. This note has been taken into consideration after a year.

No action improving safety of flights has been recommended by your Commission which is the Commission’s responsibility.

I recall that France, through the intermediary of BEA, has been deeply involved in this investigation. The underwater research was funded by France for $ 3 M.

The fact that the commission has not yet begun to use the information collected from its recorders, two years after reading them. This is inacceptible.

I urge you that the investigation that you lead henceforth be conducted with diligence and in accordance with international provisions.

I would be grateful for the Chairman of the Commission of Inquiry to please ensure that is has established a plan to lead to the publication of a final report within the best times.

In the meantime, I urge you to accept the assurances of my highest consideration.

Director of the BEA
Jean-Paul Troadec

lettre.commission.d.enquete.comorienne.

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