Air France Flight 4590 An Accident Investigation Report

Running head: Air France Flight 4590 1
Air France Flight 4590 an Accident Investigation Report
Captain De Vere Michael Kiss, ATP, Ph.D.

Air France Flight 4590 2
Abstract
This paper focuses on the causes that led to the accident of Air France 4590 which crashed
during an attempted takeoff from runway 26R at Charles de Gaulle Airport in Paris late
afternoon July 25, 2000. Specifically, discussion will involve: background information, causal
elements of the crash, damage/casualties, impact/results/changes to regulation, procedures,
and/or operations. Discussion will show the human factor components which caused this
accident and that causal aspects were not isolated to any one specific individual; that a multitude
of entities share equal responsibility for the human factor errors involved. Subject matter will
discuss how a chain of events (links in a chain) combined together led to the accident. In
addition, the paper also describes how procedures and policies changed as result of this accident.
Further, dialog will encourage critical thinking of the findings of France’s Bureau Enquêtes-
Accidents which appear to have disregarded the importance of specific causal factors leading to
this accident.

Air France Flight 4590, an Accident Report
History
At 16:44 on July 25, 2000, a BAE Systems/EADS (European Aeronautic
Defense and Space Co.) Concorde, operated by Air France as Flight 4590, struck
terrain in Gonesse, France, after receiving foreign-object damage during takeoff from
Runway 26R at Charles de Gaule Airport in Paris. The nine crewmembers and 100
passengers were killed. Four people on the ground were killed, and six people were
injured.The aircraft was destroyed.
The Captain:
The captain, 54, held an airline transport-transoceanic and polar (ATP-TOP) license in
type ratings in the Airbus A 300, A320, and A340; the Boeing 727 and 737; and the Concorde.
He earned the Concorde type rating in August 1999. The captain had 13,477 flight hours,
including 317 flight hours (284 flight hours as captain) in the Concorde.
The First Officer:
The first officer, 50, held an ATP – TOP license and type ratings in the A300,
Aerospatiale Caravelle, Concorde, Morane Saulnier 760 and Nord 262. He earned the Concorde
type rating in January 1989. The first officer had 10,035 flight hours, including 2,698 flight
hours as first officer in the Concorde.
The Flight Engineer:
The flight engineer, 58, held a flight engineer license with ratings in the Boeing 727 and
747, Caravelle and Concorde. He had 12,532 flight hours, including 937 flight hours in the
Concorde.

The Aircraft
The aircraft, serial no. 3, entered airline service in October 1979 and had accumulated
11,989 flight hours in 4,873 cycles. During a scheduled maintenance check in July 2000, a
spacer was omitted when the aircraft left main landing gear assembly was replaced to correct a
defect in the tire – under-inflation – detection system. The aircraft completed four flights after
the maintenance check. The report said that the omission of the spacer did not contribute to the
accident. Concorde pilots disagree with that statement. This will be addressed later. “The aircraft
was airworthy, and there were no acceptable deferred defects for flight 4590,” the report said.
When the aircraft arrived in Paris that morning, the number two engine thrust reverser was
inoperable and the captain elected to have it repaired prior to departure.
Meteorological Information
Visual meteorological conditions prevailed at the airport. Visibility was nine statute
miles, and there were scattered cumulus clouds with bases at 1,800 feet. Temperature was 66°F.
The winds at the runway 26 threshold were from 090° at 8 knots.
Aerodrome Information
Runway 26R was 13,829 feet long and 148 feet wide. Airport elevation is 390 feet.
The Accident
After push back and engine start, the flight crew taxied Air France flight 4590 to runway
26R. During the taxi, all checklists were accomplished and the V speeds were determined (V1 =
150kts, VR = 198kts, V2 = 220kts). In addition the captain conducted a thorough departure
briefing using good CRM by including the other two crewmembers. In addition, upon being
cleared for takeoff, the captain asked “is everyone ready;” demonstrating further concern that all
were prepared and there were no discrepancies.
The dispatcher had calculated the takeoff weight at 407,586 pounds (the weight was
incorrect and the air craft was more than 2,200 lbs. over MTOW). The controller gave takeoff
clearance and said, “The wind was from 090° at 8 knots” (Tailwind). The captain advanced the
thrust levers and the takeoff roll began. At 100 knots, the first officer gave the “100 knots” call

and the captain verified by stating “checked” (per procedures); the flight engineer announced
“four greens,” indicating all engines were operating normally. A few seconds later, the no. 2
(right front) tire on the left main landing gear disintegrated after impacting with a piece of metal
from a Continental DC-10 that had taken off 5 minutes before. This is what the BAE claims.
However, many Air France pilots argued against this assessment.
Debris from the tire penetrated the fuel cell of the left-wing and also entered the intake of
the no. 2 engine and, possibly, the no. 1 engine. The no. 2 engine immediately lost power and the
no. 1 engine thrust was reduced to about 75% of normal takeoff thrust. At this point, the aircraft
velocity was beyond V1 (150 knots) but below VR (198 knots). Calibrated airspeed was 183
knots when the captain began rotation at a rate less than normal rotation rate. This was 15 knots
below VR and 37 knots below V2. (V2=220 KIAS)
The tower reported, “Concorde 4590 you have flames; you have flames behind you.” The
controller's transmission was acknowledged by the first officer. The engine no. 1 “go light”
illuminated, indicating the engine had recovered and was producing nearly nominal thrust. The
no.2 engine fire warning system activated and the engineer shut it down. Then the captain gave
instructions to accomplish the engine fire procedure checklist. Shortly thereafter, the no. 1 engine
again lost power and was reduced to 4% of normal takeoff thrust. Several times thereafter, the
first officer gave warning to watch the airspeed as the indicated airspeed was only 200 knots.
(V2-20) The captain commanded for the gear to be retracted. However, the first officer was
unable to accomplish gear retraction (WHY). Again, the first officer gave another warning for
airspeed which was still at 200 knots. Then the no. 1 Engine recovered one more time but again
decelerated rapidly, resulting in total loss of trust.
The aircraft angle of attack increased from 12° to more than 25°, and left bank increased
from 2° to 113°. The captain then reduced thrust on engines 3 and 4 (BEA). The accident report
does not clearly indicate the airspeed at this time. However, it can be assumed the left-wing lost
lift, and the captain lost directional control due to thrust asymmetry and loss of airflow over the
vertical fin. The aircraft continued the bank to the left completely rolling over and struck the
ground in an upside down and flat position.

The French Bureau Enquêtes-Accidents (BEA) Findings
The probable causes of the accident were the following:
• High-speed passage of a tire over a part lost by an aircraft that had taken a 5 min. earlier
and the destruction of the tires:
• The ripping out a large piece of fuel tank in the complex process of transmission of the
energy (shock wave in the fuel tank) produced by the impact of a piece of tire and
another point on the tank; this transmission involved the deformation of the tank skin and
the movement of the fuel, with perhaps the contributory effect of other more minor
shocks and/or a hydrodynamic pressure search; and,
• Ignition of the leaking fuel by an electric arc in the wiring for the landing – gear break
ventilators; continuing through contact with the hot parts of the engine, emitting forward
propagation of the flames; causing a very large fire under the aircraft wing and severe
loss of thrust on engine no. 2, then engine no 1.
• In addition, the impossibility of retracting the landing gear probably contributed to the
retention and stabilization of the flame throughout the flight. (The gear probably allowed
for longer directional control due to induced drag).
• The report also stated that although the aircraft was 2,205 pounds over the maximum
takeoff weight; this factor was not contributory to the accident.
• “The crew experienced a totally unknown (Creative Based Decision), highly dynamic
situation with no pre-established solution to face it in a phase of flight where, having
passed V1, they were mentally prepared for rotation (Why, because the organizational
structure had no procedures for such an event; I.e. no dual-engine failure procedures). In
this exceptional and unknown environment, the decision to take off as soon as possible
appears to have become compelling. The rate of rotation also appears to confirm that the
pilot was conscious of taking off at a speed below VR” (BEA).
• Finally, the report placed the blame for this accident entirely on Continental Airlines and
one of that company's mechanics, John Taylor. Indeed, France conducted a criminal suit
against Continental and Mr. Taylor and both were found guilty.

Human Factors Involved
Fatal airline accidents do not occur because of one single event. In analyzing tens of
airline accidents since the late 1970s, the author cannot recall one accident that did not result
without the occurrence of a chain of events commonly called “links in a chain.” With all due
respect, the BEA is somewhat flagrant in its findings. Let's look at the links in the chain of
events causing this accident.
Regardless of what the BEA claims, any time an aircraft is flown in excess of its
maximum takeoff weight, the aircraft is now beyond its certification envelope and becomes an
experimental aircraft. Remember, during the certification process, the aircraft is brand-new, the
engines are brand-new, the test pilots are of the most qualified, and the conditions are favorable
for the best results. At the time of this accident, the aircraft was 21 years old and had logged
11,980 hours of flying time.
In addition, the certification of the max takeoff weight (of the Concorde) was based on
just one engine failing; the critical engine. In this case, both the no. 2 and then the no. 1 engines
failed. This certification was based on only one engine as the engineers felt that the probability
of two engines failing simultaneously was so low that certification for takeoff with dual engine
failure was not necessary (Physically not possible) (this is true for all four-engine aircraft).
“Concorde is certified to take off with only three engines functioning, but not two. If one
motor can destroy another, that means Concorde has to take off on two engines, and that's
physically impossible,” says Françoise Grangier, an Airbus 320 pilot and air crash
investigator. “The aviation industry has been misled by redundancy before: British
Airways on June 24 1982 (four engine flameout, volcanic ash), and United 232 (DC-10
total hydraulic failure) on July, 1989” (Downer, 2009, page 2).
Certifying the aircraft for just one engine failure rather than two engines also affects an
even more important variable; determining V1. V1 as a decision speed (a go/no go speed in
regards to safety of flight items). I.e., when taking off, if anything happens prior to 80 knots
(100kts with Concorde), the crew is to abort the takeoff. Between 80 knots and V1, only “safety

of flight items,” such as an engine fire or loss of directional control, would mandate a rejection
of takeoff. Beyond V1, company procedures, regulations, and statistics mandate that the aircraft
continue the takeoff and return for landing.
The problem with this is that, under engineering terms, V1 is the same as VCEF (Critical
Engine Failure Speed) (Dole, & Lewis, 2000). VCEF is the speed at which the aircraft has
enough kinetic energy, that in the event of an engine failure (two engine aircraft), it can continue
to accelerate beyond V1 and reach VR and then V2 (the speed the aircraft must be accelerated at
before reaching a 35 foot obstacle above the end of the runway, Dole & Lewis, 2000, 195) and
continue the climb to a safe altitude.
Additionally, V2 provides stall protection at 15° of bank with a failed engine. When you
intentionally lower V1 below the required speed (in this case the failure of two engines), you risk
making a decision to continue when the aircraft does not have the velocity to accelerate to VR
and V2 and fly safely (V1 of 150 was not fast enough to accelerate to V2 in this case). Had there
been procedures for dual engine failure, V1 would have been just a few knots below VR and the
decision would have been to abort the takeoff. Runway 26R was 13,500 feet long. Calibrated
airspeed was 183 knots when the captain began rotation. If V1 had been predicated on VCEF, the
decision would have been to abort. In any case, there should be procedures for the possibility of
a dual engine failure at takeoff.
A most controversial finding concerned a spacer which normally holds two lateral rings
in position on the oleo/bogie coupling (maintains directional control of the main wheel
assembly) of the left main gear and is vital to wheel alignment. An Air France maintenance error,
the spacer was not reinstalled after routine maintenance work performed four days before the
crash. Nonetheless, the BEA rolled out the missing spacer as a cause of the crash (Harris, J.,
2001).
“The truth is that because of that missing spacer, the left main gear was slightly skewed
on the takeoff roll. Skidding heated and wore down the tire, cause the plane to drift to the left
side of the runway, and captive from accelerating normally,” charges Jean-Marie Chauve, a 37
year Air France veteran and retired Concorde pilot who has drawn his own calculations – and

have been verified by independent experts- based on published information from the flight data
and cockpit voice recorders. His version is seconded by Michael Suaud, a retired Concorde flight
engineer. The two men spent several months preparing a detailed report on the crash, which they
have presented to the investigating magistrate of the judicial inquiry (Harris, J., 2001).
These two men present an argument that states the aircraft was moving to the left at the
start of the takeoff roll, before the tire blowout and loss of engines 1 and 2. “The tire burst at
around 174 knots and only after the blowout did it strike the metal strip. If acceleration had been
nominal, the plane would have been airborne about 50 yards before reaching the strip.” Further,
the two former crew members also cited that had the space been in place, the aircraft would not
have drifted to the left. The BEA believes the leftward yaw was caused by loss of thrust from the
left engines, not by the skewed bogie. “They have never shown us where our figures are wrong.
They are under pressure to make this look like a freak accident caused by that piece of metal on
the runway. That would cover up Air France's failure in letting a plane take off that wasn't ready”
(Jean-Marie Chauve).
“It's true that, due to regrettable maintenance error, the spacer had not been replaced. But
our investigation shows that its absence, though its slightly affected alignment of the left main
gear, had no influence on the way the tires were worn, are on the plane's trajectory acceleration”
(BEA chief Paul-Louis Arslanian).
In order for a crew to be affective as a team towards threat management, the crew must
be able to quickly and correctly identify the threat, evaluate it, and act upon it with the least
amount of cognitive resources (Kanki, B., 2010). This must be done in a timely manner
especially when operating in a critical environment such as takeoff. This crew was exceptional at
performing to the level of the SOPs presented by the organization. Indeed, there was good crew
resource management throughout the entire flight leading up to the accident. However, a false
hypothesis was presented to the crew through the valiant efforts of others outside the aircraft.
The control tower and, supposedly, another pilot radioed they were not sure where the
fire was generated. This would cause some ambiguity in determining the cause. Of course, there

was no way that anyone from a distance could identify that the fuel cell had been compromised
and that the flames originated there. Knowing this, a different hypothesis might have been
formed; possibly leading to different procedures by the crew. This can only be speculated.
However, it is important to note that the ability to correctly identify the problem, and act
accordingly in a timely fashion is paramount in a successful outcome. Not identifying in a timely
manner is another link in the chain of this accident. It should be noted that the crew was unaware
of a problem until notified by the tower. The BAE report states, “The official transcript of the
black box recorder of Air France 4590 shows that the crew was unaware anything was wrong
until alerted by the tower.”
The fire resulting from the ruptured fuel cell created higher density altitudes for the no. 1
and no 2. engines and the performance of the left wing. While the engines most likely ingested
tire debris, specifically the no. 2 engine; the increased density altitude from the fire would have
created an unstable aircraft during recovery. Most likely, the aircraft rolled to the left at the end
because of this increased density altitude and loss of directional control.
In 1981, The United States National Transportation Safety Board (NTSB) issued
recommendations to both Air France and British Airways as there had been four separate
incidents at Washington's Dulles airport where the number two tire on the Concorde had
disintegrated. Two of these incidents resulted in penetration of the left fuel cell. During one of
these flights, where the cell had not been penetrated, the crew continued on to Paris knowing
they had blown tires. A second crew, made an attempt to fly to Paris, however, they later realized
they needed to land and touchdown in New York's Kennedy airport. In a third incident, the tire
did penetrate the fuel cell. However, the crew was only aware they had blown a tire. There was a
passenger on board sitting next to the left wing. He visually saw something depart the airplane
through the left wing leaving a 12 square foot hole. The passenger had to forcibly convince a
flight attendant to inform the flight crew. Upon this information, the flight engineer went to the
passenger. Upon seeing the hole in the wing and fuel seeping from it, the flight engineer turned
ashen gray (Harris, J., 2001).

“The BEA’s list of 57 tire-related incidents from 1976 to 2000, 30 of which were on Air
France flights and 27 on British Airways, documented that 32 blowouts damaged the aircraft’s
structure, engines, or hydraulics, and six resulted in penetration of one or more fuel cells”
(Harris, J., 2001).
Engineers had an opportunity back in the early 1980s to reinforce the fuel cells on the
Concorde. In addition, they also had the opportunity to develop tires that could better withstand
the forces encountered at the higher velocities on the runway experienced by the Concorde. They
knew about this problem for nearly 20 years before the accident of Air France 4590. Had the
changes occurred back in the 1980s, as suggested by the U.S. NTSB, it is possible that flight
4590 would have continued to JFK without incident.
One change that resulted from the NTSB recommendations was inspecting the runway
for debris prior to the Concorde using the runway for takeoff. The procedure developed was for
the runway to be inspected three different times in a 24 hour period. However, on this day, it had
been more than 12 hours since the runway had been inspected. “The report shows that the
runway was not fully inspected for more than 12 hours before the doomed plane took off” (Paul
Arslanian, BEA director). “It was usual for Charles de Gaulle airport to carry out its three
inspections a day at relatively flexible times. If anything wrong would have existed, it would
have been noticed immediately,” (Didier Hamon, Airport Authority Spokesman). The BEA did
not find this a factor in the accident.
In addition, because the aircraft was rotated below VR, the resulting induced drag
required by the higher angle of attack, due to the slower airspeed, created more drag preventing
the aircraft from accelerating to V2. When an aircraft is flying faster, the angle of attack is lower.
When an aircraft is flying slower the angle of attack is higher. When the aircraft velocity is
slower, because of this induced drag of the higher angle of attack, it requires more thrust to
maintain flight.

When the thrust required is greater than the thrust available, the pilot needs to lower the
nose to maintain the airspeed providing both lift and directional control. In this accident, because
of the situation, the thrust required was greater than the thrust available, and the aircraft could
not accelerate to V2; as discussed above. There is no “blue line” for minimum controllable
airspeed in a transport category aircraft. However, V2 is above minimum controllable airspeed
(VMCG). When flying below V2, during the climb out, you risk losing directional control. The
result is to roll over and impact the ground upside down. Therefore, if one cannot maintain V2
after engine failure, it is better to lower the nose and plan an emergency landing as if you had
lost all engines than continue to decelerate further. This is most likely why the captain reduced
the thrust on the no. 3 and no. 4 engines as he was losing directional control. However, the action
was too late; the inertia from the operating engine torque was too great and the airflow over the
vertical fin was disrupted.
One more factor. The aircraft departed with a tail wind of 8 knots. The BEA stated this
was not a factor. However, taking off with the tail wind further complicated the aircraft’s ability
to reach V2. In addition, the aircraft needed more runway length to reach V1 changing the
geographical position of the aircraft on the runway. Had the flight departed from runway 6L,
they would have reached V1 sooner and the aircraft would have had an advantage in reaching V2
that it did not have with the tail wind. Remember, although it was only 8 knots, you are talking
about a total difference of 16 knots. (The aircraft velocity reached 200 KIAS; 20 knots below

V2. The 16 knot difference would have put the aircraft at 216 KIAS, just 4 knots below V2.
Therefore, the tailwind was a factor).
Conclusion
Portraying the metal strip as the cause of the accident and Continental and one of its
employees as the sole guilty parties shows the determination of the French authorities to a shift
attention and blame away from Air France, which was government – owned at the time and
operated and maintained the aircraft, as well as from the French authorities responsible for the
Concorde’s airworthiness and safety.
“To find any crime was committed in this tragic accident is not supported either by the
evidence at trial or by aviation authorities and experts around the world,” (Continental Airlines).
Upon investigation, the facts prove a different story than what is presented in the accident report
by the French Bureau Enquêtes-Accidents. There was not one single element that caused this
accident. For anyone to suggest that it was the result of just one element shows they do not
understand the total equation. In fact, I have listed several variables that were “links in the chain”
because this accident (The report is subjective and not objective). Had any one of those links
been broken, odds are the outcome would have been different.
Those links are:
• Exceeding Maximum Takeoff Weight
• Failing to certify the aircraft to operate with two failed engines instead of only one engine
in a four engine aircraft. There should have been procedures for a dual-engine failure on
takeoff (I.e. Abort the takeoff).
▪ A better definition of V1 in regards to VCEF should also have been incorporated into
the taxonomy of the takeoff realm of flight allowing the pilots better knowledge of a
true hypothesis in that regard.
• Tire skidding and heat developed from the missing ole/bogie spacer.
• Failure to inspect the runway for debris prior to Concorde departure.

• Failing to act upon multiple past incidences of tire bursting and associated fuel cell
penetration.
▪ This would have required developing procedures to quickly identify fuel-cell
penetration to have a better understanding of the true situation; allowing for a quicker
response.
• The need to develop a better understanding of the relationship between aircraft velocity,
angle of attack, lift and drag and the correlation between thrust required and thrust
available.
• Taking off with a tail wind.
As stated in the beginning of the paper, no one of the above elements would have caused this
accident. They all had to come together in the way they did; making them all causal factors or
“links in a chain.”
Changes Resulting from the Accident:
There were multiple changes to the Concorde and procedures including:
(Question, if Continental had sole responsibility, than why all the other changes)
• Strengthening the fuel cells with Kevlar
• Using Michelin NZG tires for better sustainability and modifications to the anti-skid
computer
• Shielding the electrical wiring on the main landing gear with non-conductive material to
prevent fire ignition
• Inhibition of the power supply to the break ventilators during critical phases of flight
• MMEL revision preventing operations without the tire-under-pressure-detection system
• Mandatory feedback through analysis of in-service incidents and rapid definition of
corrective actions for communication to operators and pilots
• Concorde flight manual stipulates that a red alarm (master caution warning light and
gong) must lead to an immediate reaction by the crew.
• Air France Manual requires no action be taken until reaching 400 feet agl
• Because of the missing spacer, the BEA recommended audits of Air France’s Concorde
operational and maintenance conditions

• Recommended inspections of movement areas (runways and taxiways)
• Recommended the FAA conduct audits of Continental airlines
• Recommended installations of video recorders in cockpits
• Recommended procedures for recording conversations between flight crew and cabin
crew
• Recommended installing devices to provide visual display of parts of the structure hidden
from the crew’s view or devices to detect damage to those parts of the aircraft
• Recommended modifying new flight simulators so they accurately reproduce
accelerations experienced in the cockpit
• Because investigators were exposed to asbestos during examination of the aircraft, the
BEA recommends manufactures immediately identify all potentially dangerous
substances used in the manufacture of their aircraft
While the above recommendations were made to incorporate the return and successful
future of the Concorde, the events of 9/11detirred passenger travel to New York indefinitely
during the immediate years afterward. Because of the economic results, both Air France and
British Airways were forced to discontinue Concorde service. We will never know if the
procedures that where created would have prevented another Concorde accident.

References
ABC, (2006). NTSB Documants on Concorde Tire Incidents. ABC News. Retrieved from:
http://www.abcnews.co.com/International/story?id=83028&page=1
Aviation Safety Network, (2012). Concorde Past Accident History. Concorde Accident
Retrieved from:
http://www.concordesst.com/accident/past.html
BBC, (2000) Concorde, Preliminary Report. BBC. Retrieved from:
http://www.newsbbc.co.uk/2/hi/europe/906545.stm
Dole, C.E., & Lewis, J.E., (2000). Flight Theory and Aerodynamics. 2nd
Edition. New York, NY:
John Wiley & Sons, INC.
Downer, J., (2009). When Failure is an Option: Redundancy, reliability and Regulation in
Complex Technical Systems. Center for Analysis of Risk and Regulation. London School
of Economics and Political Science: London, UK.
Flight Safety Foundation, (2002). Foreign-object Damage Cripples Concorde on Takeoff From
Paris. Retrieved from: http://www.flightsafety.org/ap/ap_apr02.pdf
Hall, J., (2000). Statement of NTSB Chairman Jim Hall on the Crash of the Concorde. NTSB.
Retrieved from: http://www.ntsb.gov/news/2000/000725b.htm
Harris, J., (2001). The Concorde Redemption. Air and Space Magazine. Retrieved from:
http://www.airspacemag.com/flight-today/redemption.html?c=y&page=5
Hawkins, F.H., (1997). Human Factors. 2nd
Edition. Hants, England: Ashgate Publishing
Limited.
Kanki, B., 2010). Crew Resource Management. 2nd
Edition. San Diego, CA: Elsevier Inc.
Lightfoot, B., (2012). Yet Another Disaster That Could Have Been Prevented. Retrieved from:
http://www.users.cloud9.net/~bradmcc/concorde.html
NYC Aviation, (2010) Continental Found ‘Criminally Responsible’ for Air France Crash. NYC
Aviation. Retrieved from: http://www.nycaviation.com/2010/12/continental-found-
criminally-responsible-for-airfrance-concorde-crash/
Sancton, T., (2000). Doomed. Time Magazine. Retrieved from:
http://www.time.com/time/world/artical/0,8599,2050152,00.html.

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