Crash of Air France Flight 358: penny wise, pound foolish

11

F-GLZQ, the aircraft involved in the incident, at Charles de Gaulle Airport.

1 AF 358

1d There are 297 Paxs and 12 crew members

The above two images are computer generated re-enactment

Accident Summary

Date August 2, 2005
Aircraft type Airbus A340-313E
Registration F-GLZQ
Operator Air France
Flight origin Charles de Gaulle Airport, Paris France
Destination Toronto Pearson International Airport, Mississauga Ontario Canada
Summary Weather-induced runway overshoot, lack of company procedures, and pilot error
Site Toronto Pearson International Airport, Mississauga Ontario Canada
Coordinates N 43°39′23.2″; W79°37′29.0″
Passengers 297
Crew 12
Fatalities 0
Injuries (non-fatal) 43 (42 minor; 12 serious)
Survivors 309 (all)

 

 

22

Path of Flight 358. Dotted lines indicate the normal landing trajectory.

Air France Flight 358 was an Airbus A340-313E, registration F-GLZQ, on a scheduled international flight from Paris, France, to Toronto, Ontario, Canada, on August 2, 2005. While landing at Toronto Pearson International Airport at 1602 hours EDT, it overshot the end of runway 24 Left by approximately 300 metres (980 feet) and came to rest in a small ravine 300 metres (980 feet) past the end of the runway.  All 309 passengers and crew aboard survived, with 12 people sustaining serious injuries.The rest suffered minor or no injuries. A post-crash fire destroyed the aircraft.  The accident highlighted the role played by highly trained flight attendants during an emergency. 

The flight landed during an active thunderstorm at the airport—severe winds, heavy rain, and localized thunderstorms near the airport (see weather below)—and touched down almost half way down the runway. Some passengers report that the plane was rocking from side to side before landing, possibly due to turbulence and gusting winds associated with the storm systems. One passenger described the crash as like a “car accident, but it keeps going and going, non-stop.”

1k YYZ

Due to inclement weather, 540 flights departing and arriving at Pearson were cancelled. Many small and mid-size aircraft due to arrive were diverted to other Canadian airports in Ottawa, London, Hamilton, and Winnipeg. Most of the larger aircraft were diverted to Montreal, Syracuse, New York(NY) and  Buffalo (NY). Flights from Vancouver were turned back. The crash of Air France Flight 358 was the biggest crisis to hit Toronto Pearson since the airport’s involvement in Operation Yellow Ribbon.

Jean Lapierre, the Canadian Minister of Transport, referred to Flight 358 as a “miracle”because everybody survived. Other press sources described the accident as the “miracle in Toronto”, the “Toronto miracle”, the “Miracle” Escape, and the Miracle of Runway 24 Left”. The accident was investigated by the Transportation Safety Board of Canada (TSB), with a final report issued on December 13, 2007.

Aircraft

The aircraft operating Flight 358 was a 6-year-old Airbus A340-313E, powered by 4 CFM International CFM56 engines. With Manufacturer Serial Number (MSN) 289 and registration F-GLZQ, the aircraft made its first flight on August 3, 1999, and was delivered to Air France on September 7, 1999. There were 297 passengers and 12 crew members onboard the Airbus. On this flight, it was flown by Captain Alain Rosaye, age 57, and First Officer Frédéric Naud, 43. Rosaye was a seasoned pilot with 15,411 total flight hours and Naud had 4,834 hours of flight time.

Out of the 297 passengers, there were 168 adult males, 118 adult females, 8 children and 3 infants. Among them, 3 passengers were seated in crew seats, one a third occupant seat of the flight deck and two in the flight crew rest area. The passengers consisted of business persons, vacationers and students.

Accident

33-1

Highway 401 is next to the airport 

The airplane was cleared to land at 1601 EDT on Runway 24L (Runway Two Four Left), which, at 9,000 feet (2,700 metres) in length, is the shortest runway at Pearson Airport. After touchdown, the aircraft did not stop before the end of the runway but continued for 300 metres (980 feet) until it slid into the Etobicoke Creek ravine with a speed of 148 km/h (92 mph), on the western edge of the airport near the interchange of Dixie Road and Highway 401.

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After the aircraft stopped, the crew saw fire outside and began evacuation. When the emergency exits were opened, one of the right middle exit slides (R3) deflated after being punctured by debris from the aircraft, while one of the left slides (L2) failed to deploy at all for unknown reasons. The two rear left exits remained closed due to the fire.  A number of passengers were forced to jump from the aircraft to exit. The actions of the flight attendants, who ensured that all the passengers quickly evacuated, contributed to the safe escape of all passengers. The first officer was the last to leave the plane, which was evacuated within the required 90 second time frame.

Emergency response teams responded to the incident and were on site within 52 seconds of the crash occurring. The TSB official report states that “the first response vehicle arrived at the scene within one minute of the crash alarm sounding”.

After the crash, some passengers—including those who were injured—scrambled up the ravine to Highway 401 which runs almost parallel to the runway. Peel Regional Police located the first officer and several passengers along Highway 401, receiving assistance from motorists who were passing the airport when the crash occurred. Some motorists took injured people, including the pilot, directly to hospitals. Other motorists took non-injured passengers to the airport. The main fire burned for two hours, ending just before 18:00 EDT. All fires were out by early afternoon on 3 August 2005, and investigators were able to begin their work.

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33

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The accident caused the cancellation or diversion of hundreds of flights, with ripple effects throughout the North American air traffic system. By that night, four of the five runway surfaces at Pearson were back in service, but the flight and passenger backlog continued through the next day.

The accident also caused heavy traffic congestion throughout Toronto’s highway system. Highway 401, one of the world’s busiest highways, is the main route through the Greater Toronto Area, and the crash occurred near the highway’s widest point where 18 lanes of traffic travel between Highway 403, Highway 410 and Highway 427. Though the fire was extinguished within hours, there was considerable congestion on the highway for days after the crash due to motorists slowing down or pulling over to view the wreckage. This created numerous traffic collisions, prompting the Ontario Provincial Police to increase patrols along that part of the highway.

  • In 1978, Air Canada Flight 189 slid into Etobicoke Creek, the site of the AF358 crash, resulting in two deaths. The Air Canada DC-9 used the 24R-06L runway, crashing north of the AF358 crash scene and deeper into the ravine.
  • The runway the Air France plane landed on, 24L-06R, is an east-west runway with a length of 2.7 kilometres (9,000 feet), so the plane did not land very far off the runway. After the crash of AF358, there were some calls for the ravine to be filled or spanned by a bridge. Others said that such an undertaking would have been prohibitively expensive.
  • Runway 24L-06R did not yet exist, and runway 24R-06L was numbered 24L-06R.
  • The current runway 23-05 was at that time numbered 24R-06L

This was the first time an Airbus A340 series was involved in a crash, ending its 14-year clean record. The aircraft involved entered service in 1999 and had had its last maintenance check in France on 5 July 2005. It made 3,711 flights for a total of 28,426 flight hours.

One passenger took four photographs of the evacuation with his camera, which were released to the media. The final Transportation Safety Board of Canada report refers to the photographs and draws conclusions about the nature of the disaster based on the photographs. Mark Rosenker, the acting chairman of the National Transportation Safety Board, criticized the concept of passengers taking photographs of disasters, stating, “Your business is to get off the airplane. Your business is to help anybody who needs help.” According to Rosenker, taking photographs during an evacuation of an airliner is irresponsible. Helen Muir, an aerospace psychology professor at Cranfield University in the United Kingdom, stated that pausing during evacuations “is just what we don’t want people to do.” However, Muir added that photographs are “very valuable to accident investigators“.

Weather

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A METAR (weather observation) for Pearson was released almost exactly at the time of the accident. It stated that the weather at 1601 EDT (2001 UTC) consisted of:

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  • Wind from 340° True at 44 km/h) gusting to 61 km/h (Variation is 10 degrees West at Pearson Airport, so the wind direction actually on the runway (runways are magnetic) would be 330 degrees magnetic, a difference of 110 degrees from the runway heading of 237 degrees. So we have a strong crosswind blowing of 28 knots, which is gusting to 38 knots. In fact we have a tail wind, which will increase the landing distance. The crosswind reported may have been beyond the laid out limitation capability of the airplane).
  • Visibility 1 1⁄4 miles (2.0 km) in
  • Weather: thunderstorms and heavy rain, towering cumulus clouds.
  • Ceiling was overcast at 4,500 feet (1,400 m) above ground level
  • Temperature was 23 °C (73 °F)

According to the Canada Air Pilot, Runway 24L has a heading of 227° true (237° magnetic)

Runway 24L, Minima Instrument Landing System (ILS) approach

  • Decision Height 200 feet (61 m) above ground level
  • Visibility 1⁄2 mile (0.80 km) or
  • Runway visual range (RVR) of 2,600 feet (790 m)

The METAR for 21:00 UTC (17:00 EDT), nearly an hour after the accident, shows wind backing to the south and improving conditions generally, while noting smoke aloft from the burning plane.

  • The Canadian Broadcasting Corporation reported that the crash occurred two hours after a ground stop was declared at the airport because of severe thunderstorms in the area (“red alert” status, which, for safety reasons, halts all ground activity on the apron and gate area. Aircraft can still land and take off if still in queue).
  • Visibility at the time of the accident was reported to be very poor. There was lightning, strong gusty winds, and hail at the time and the rain just began as the plane was landing. Within two hours the winds increased from 5 to 30 km/h (3 to 20 mph) and the temperature dropped from 30 to 23 °C (86 to 73 °F).
  • A severe thunderstorm warning was in effect since 11:30 a.m. and all outbound flights and ground servicing operations had been canceled but landings were still permitted.

Injuries

The following table summarizes the injuries as reported by the Transportation Safety Board.

  Crew Passengers Total
Fatal 0 0 0
Serious 2 10 12
Minor/None 10 287 297
  12 297 309

Out of the twelve passengers who suffered major injuries, nine suffered the injuries from the impact and three suffered the injuries from the evacuation. Most of the injuries occurred to passengers and crew located in the flight deck and forward cabin. According to passenger reports, the leap from the aircraft to the ground caused many of the injuries, including broken legs, and ruptured vertebrae. The Captain sustained back and head injuries during the impact of the crash when his seat was wrenched out of place by the force of the impact, causing him to hit his head against the overhead controls. Minor injuries included twisted ankles, sore necks, bruises and effects from smoke inhalation. A total of 33 persons were taken to various hospitals within and outside Toronto for treatment, of which 21 were treated for minor injuries and released. The York-Finch campus of the Humber River Regional Hospital treated seven people for smoke inhalation. William Osler Health Centre, Etobicoke General Hospital, Credit Valley Hospital, and Peel Memorial Hospital were additional nearby hospitals that had admitted victims of the crash.

In addition to the Greater Toronto Airport Authority, on-site emergency services were also provided by

  • Peel Regional Paramedic Services
  • Peel Regional Police
  • Mississauga Fire
  • Emergency Services
  • Toronto EMS
  • Royal Canadian Mounted Police
  • Ontario Provincial Police patrolled Highway 401.
  • The Toronto Transit Commission provided two of its transit buses to act as shelter for victims.

Investigation

44

Panoramic picture of the aftermath of Flight 358

29 airplane burning

30 Crash

Representation

The Transportation Safety Board of Canada (TSB) took control of the accident site once emergency response teams had finished their work. The TSB led the investigation, with the cooperation of several other organizations:

  • Transport Canada as the country of occurrence’s representative
  • Air France as the operator
  • Airbus as the airframe manufacturer
  • GE Aviation as the engine manufacturer
  • French Department of Transport representing the country of operator and airframe manufacturer
  • United States National Transportation Safety Board representing the country of the engine manufacturer

Evidence

The flight data recorder and cockpit voice recorder were sent to France for analysis. Preliminary results indicated that the plane landed 4,000 feet (1,220 metres) from the start of the 9000 feet (2,743 metres) runway, much further along than normal, at a ground speed of 148 knots (274 km/h; 170 mph) – 140 knots being considered normal – with a tailwind, skidded down the runway and was traveling over 70 knots (130 km/h; 81 mph) as it overran the tarmac and fell into the ravine. Tire marks extended 1,610 feet (490 metres) indicating emergency braking action.

Réal Levasseur Shedalin, the TSB’s lead investigator for the accident, said the plane landed too far down the runway to have been able to stop properly on such wet pavement. Investigators have found no evidence of engine trouble, brake failure, or problems with the spoilers or thrust reversers. Why evacuation chutes failed to deploy from two exits remains under study. Some fleeing passengers were forced to jump some 6.6 feet (2 metres) to the ground.

Irregularities

The final report of the TSB states: “During the flare, the aircraft entered a heavy shower area, and the crew’s forward visibility was significantly reduced as they entered the downpour.” This suggests the possibility that the plane was hit in heavy weather by a wet downburst, causing the Airbus to land long. Based on the Air France A340-313 Quick Reference Handbook (QRH), page 34G, Landing Distance Without Autobrake, the minimum distance of 3,789 feet (1,155 metres) would be used in dry conditions to bring the aircraft to a complete stop. In wet conditions the braking distance increases with a 5-knot tailwind, reversers operative, and a 6.3 mm (0.25 in) of downpour on the runway to 6,614 feet (2,016 metres). There was not enough remaining runway available at the touch down point of AF 358.

Other possible irregularities mentioned in a government report on the accident:

  • Passenger oxygen tanks supposedly exploded in the heat of the fire. (Emergency passenger oxygen is provided via a chemical oxygen generator, but the aircraft would have been carrying therapeutic oxygen for passengers requiring a constant supply throughout the flight and first aid situations.)
  • The copy of the “E.R.S. Aircraft Crash Chart” at Pearson International Airport did not include blueprints for the Airbus A340 model of planes at the time of the crash. The blueprints would have contained vital information about search and rescue efforts and provide the location of fuel and pressurised gas tanks so that rescue crews could avoid them.

24 Over beginning of the runway

25 Floating over the runway

26 Continues to eat the runway

27 runs out of room

28 runs out of room

These images are computer generated re-enactment

Conclusions

  • The TSB concluded in its final report that the pilots had missed cues that would have prompted them to review their decision to land.
  • Air France had no procedures related to distance required from thunderstorms during approaches and landings.
  • After the autopilot had been disengaged, the pilot flying increased engine thrust in reaction to a decrease in airspeed and a perception that the aircraft was sinking. The power increase contributed to an increase in aircraft energy and the aircraft deviated above the flight path.
  • At 300 feet above ground level, the wind changed from a headwind to a tailwind.
  • While approaching the threshold, the aircraft entered an intense downpour and the forward visibility became severely reduced.
  • When the aircraft was near the threshold, the crew members committed to the landing and believed their go-around option no longer existed.
  • The pilot not flying did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This contributed to the delay in the pilot flying selecting the thrust reversers.
  • There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto / Lester B. Pearson International Airport.
  • The crew did not calculate the landing distance required for runway 24L despite aviation routine weather reports (METARs) calling for thunderstorms. The crew were not aware of the margin of error.
  • The topography at the end of the runway beyond the area and the end of Runway 24L contributed to aircraft damage and injuries to crew and passengers.

The TSB advised changes to bring Canadian runway standards in line with those used abroad, either by extending them to have a 300 m runway safety area (or Runway End Safety Area) or, where that is impossible, providing an equivalently effective backup method of stopping aircraft. Other recommendations that the TSB made includes having the Department of Transport establish clear standards limiting approaches and landings in convective weather for all operators at Canadian airports, and mandate training for all pilots involved in Canadian air operations to better enable them to make landing decisions in bad weather.

Compensation

Within one week of the crash, cash payments ranging from $1,000 to $3,700 (all figures in this article in Canadian dollars unless otherwise stated) were given to passengers for interim emergency use. These funds were given to passengers through an emergency centre set up in the Novotel Hotel in Mississauga, near the airport. These payments were independent of the claims process, which has been started for passengers who have not retained counsel. It is expected that the insurers of Air France will pay for all damages as well as extra compensation for having passengers go through the ordeal; however, only amounts of €6,000 to €9,000 have been offered, prompting passengers to turn to the lawsuit to seek legal action. The insurance is handled by the Societé de Gestion & D’Expertises D’Assurances in France. All passengers have also been offered a free round-trip ticket to any Air France destination in the world in the same fare class in which they were originally booked on AF358.

After a lawsuit lasting four and a half years, Air France settled the compensation lawsuit with 184 of the 297 passengers (no crew members included) aboard Flight 358. The compensation is for a total of $12 million. Air France will pay $10 million and have been released from passengers’ claims stemming from the incident, according to the judgment’s summary. Airbus and Goodrich, the company that made the emergency evacuation system on the plane will pay $1.65 million and claims against them in a lawsuit have been released.

J.J. Camp, a Vancouver lawyer representing claimants, says passengers seriously harmed with either physical or psychological injuries will be eligible for the maximum payout of $175,000. Passengers who weren’t seriously harmed in the crash will receive the minimum payment of between $5,000 and $10,000.

Litigation

Within a few days after the accident, a class action suit was filed on behalf of all passengers on board by representative plaintiff Suzanne Deak to the Ontario Superior Court of Justice. The attorneys representing Deak and the passengers are Gary R. Will and Paul Miller from Will Barristers in Toronto. The plaintiffs sought payments for general and aggravated damages in the amount of $75 million, and payments for special damages and pecuniary damages in the amount of $250 million. A second-class action lawsuit was also filed by plaintiffs Sahar Alqudsi and Younis Qawasmi (her husband) for $150 million a few days later. However, both suits had since merged as only one lawsuit was allowed to proceed to court.

 In December 2009, a $12 million settlement agreement was reached between Air France and the class. The settlement resolved the claims of 184 passengers and their families. Forty-five other passengers had opted out of the suit, while 68 others have already agreed to a settlement with Air France.

Air France stated that it would not lose any money from the lawsuits as it is covered by its insurers. Air France did not provide further contacts and assistance to those who retained counsel of the lawsuit until an agreement has been made between both sides’ lawyers.

Air France lawsuit

In June 2008, almost 3 years after the accident, Air France filed a lawsuit against the Greater Toronto Airports Authority, NAV Canada, and the Government of Canada for $180 million.  In the statement of claim filed with the Ontario Superior Court of Justice, Air France alleged that the “GTAA failed to provide a safe environment for the conduct of civil air operations.” The statement also claims that “The overrun and the consequent injuries to persons and damage to property were caused solely by the negligence of the defendants“. Air France says Transport Canada was “negligent” by not implementing the recommendations of a coroner’s inquest into the 1978 crash that urged the creation of a 300-metre safety area to give aircraft more room to stop after landing.

Aftermath

An inquiry by the Transportation Safety Board of Canada found runway safety zones at the end of runways at some Canadian airports are below accepted international standards. The report highlighted that Toronto Pearson’s runways meet current Canadian standards, and that runway 24L has a de facto 150-metre RESA. The TSB also suggested precautions are needed to be taken by airlines when landing in bad weather.

Courtesy of: Wikipedia.org; TSB of Canada; NTSB; AirSafe.com

One thought on “Crash of Air France Flight 358: penny wise, pound foolish

  1. The captain went into the holding pattern for over thirty minutes, northeast of Pearson Airport awaiting improvement in weather. He had been regularly getting weather updates enroute, the last one being that it was raining with chance of thunderstorm on arrival.
    An active thunderstorm was hitting Pearson Airport at the time of his arrival with winds reported at 28 knots with gusts up to 38 knots.
    The captain was concerned with putting the aircraft down at Pearson Airport and did not contemplate a diversion to Ottawa or Montreal His reasons may have been economic factors for the company since the logistics of hotel accommodation and food at the alternate airport outweighed.everything. This was flawed reasoning as the subsequent accident highlighted. A diversion became mandatory considering the weather..
    The captain allowed his copilot to conduct the approach and landing as per mutual understanding on departure from Paris, France.
    The captain did not take over controls from the First Officer when he saw the aircraft floating almost past the middle of the landing distance available. The aircraft overran the runway at a speed of 146 kilometres per hour.
    During the prolonged flare the captain cautioned the First Officer to put it down at least two or three times but did not take over the controls.
    The reverse thrust was activated 17 seconds after the wheels hit the ground. This delay is inexcusable as they had lost all the stopping distance available due to the wet runway also.
    The Captain or First Officer could have executed an overshoot anytime during the flare when they realized that it would be impossible to stop in the available distance.
    I regret that the Captain did not fly after the accident due to injuries sustained. The First Officer was suspended for three months.

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