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REPORTS > AVIATION > 2005 > A05H0002

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  AVIATION Reports - 2005 - A05H0002

Table of Contents

  1. 1.0 Factual Information
    1. 1.1 History of the Flight
    2. 1.1.1 Departure
    3. 1.1.2 En Route
    4. 1.1.3 Descent and Approach
    5. 1.1.4 Landing
    6. 1.2 Injuries to Persons
    7. 1.3 Damage to the Aircraft
    8. 1.4 Other Damage
    9. 1.5 Personnel Information
    10. 1.5.1 Captain Information
    11. 1.5.2 First Officer Information
    12. 1.5.3 Cabin Crew Information
    13. 1.6 Aircraft Information
    14. 1.6.1 General Information
    15. 1.6.2 Aircraft Weight and Balance
    16. 1.6.3 Landing Speeds
    17. 1.6.4 Landing Distance Calculations
    18. 1.6.5 Stopping Performance
    19. 1.6.6 Aircraft Seats and Restraint Systems
    20. 1.6.7 Emergency Exits
    21. 1.6.8 Evacuation Escape Devices
    22. 1.6.9 Evacuation Alert System
    23. 1.6.10 Cabin Emergency Lighting
    24. 1.6.11 Public Adress System
    25. 1.6.12 Emergency Equipment
    26. 1.6.13 Automatic Flight System
    27. 1.6.14 Fuel Management and Monitoring
    28. 1.6.15 Weather Radar
    29. 1.6.16 Windshear Detection and Prediction
    30. 1.6.17 Aircraft Communications Addressing and Reporting System
    31. 1.6.18 Ground Spoilers
    32. 1.6.19 Brake System and Antiskid
    33. 1.6.20 Engine Controls
    34. 1.6.21 Rain Removal System
    35. 1.7 Meteorological Information
    36. 1.7.1 General
    37. 1.7.2 Graphic Area Forecasts
    38. 1.7.3 Aerodrome Forecasts
    39. 1.7.3.1 Toronto/Lester B. Pearson International Airport (CYYZ)
    40. 1.7.3.2 Niagara Falls International Airport, New York (KIAG)
    41. 1.7.3.3 Ottawa/Macdonald-Cartier International Airport (CYOW)
    42. 1.7.4 Aviation Routine Weather Reports
    43. 1.7.4.1 Toronto/Lester B. Pearson International Airport (CYYZ)
    44. 1.7.4.2 Ottawa/Macdonald-Cartier International Airport (CYOW)
    45. 1.7.4.3 Niagara Falls International Airport, New York (KIAG)
    46. 1.7.5 Significant Meteorological Information
    47. 1.7.6 Toronto/Lester B. Pearson International Airport (CYYZ) Wind Information
    48. 1.7.7 Recorded Rainfall Rates
    49. 1.7.8 Thunderstorms
    50. 1.7.9 Lightning
    51. 1.7.10 Red Alerts
    52. 1.7.11 Weather Conditions on the Ground
    53. 1.8 Aids to Navigation
    54. 1.8.1 Air Traffic Control Radar
    55. 1.8.2 Runway 24L Instrument Approach
    56. 1.9 Communications
    57. 1.9.1 General
    58. 1.9.2 External Communication
    59. 1.9.3 Internal Communication
    60. 1.10 Aerodrome Information
    61. 1.10.1 General
    62. 1.10.2 Airport Closure
    63. 1.10.3 Use of Runway 24L
    64. 1.10.4 Runway 24L Physical Description
    65. 1.10.5 Runway 24L Lighting and Markings
    66. 1.10.6 Water-Contaminated Runways
    67. 1.10.7 Hydroplaning
    68. 1.10.8 Runway Grooving
    69. 1.10.9 Runway Friction
    70. 1.10.10 Runway Certification Requirements
    71. 1.10.11 Runway End Safety Area Alternatives
    72. 1.10.12 Previous Runway Overrun Accident at Toronto
    73. 1.10.13 Automated Terminal Information System Broadcasts
    74. 1.10.14 Notice to Airmen
    75. 1.11 Flight Recorders
    76. 1.11.1 Cockpit Voice Recorder
    77. 1.11.2 Flight Data Recorder
    78. 1.11.2.1 General
    79. 1.11.2.2 Relevant Flight Data Recorder Information
    80. 1.12 Wreckage and Impact Information
    81. 1.12.1 Impact Damage
    82. 1.12.2 Fuselage
    83. 1.12.3 Wings
    84. 1.12.4 Stabilizers
    85. 1.12.5 Aircraft Engines and Auxiliary Power Unit
    86. 1.12.6 L2 Emergency Exit Door
    87. 1.12.7 Cockpit Seats
    88. 1.12.8 Cockpit
    89. 1.12.9 Tires and Brakes
    90. 1.13 Medical Information
    91. 1.14 Fire
    92. 1.14.1 Fire Initiation and Spread
    93. 1.14.2 Aircraft Rescue and Fire Fighting
    94. 1.14.3 Aircraft Familiarization Charts
    95. 1.15 Survival Aspects
    96. 1.15.1 General
    97. 1.15.2 Runway Excursion
    98. 1.15.3 The Evacuation
    99. 1.15.4 Use of Emergency Exits
    100. 1.15.5 Exit Slides
    101. 1.16 Tests and Research
    102. 1.16.1 Simulator Trials
    103. 1.16.2 Testing of Aircraft Brakes
    104. 1.16.3 Passenger Questionnaire
    105. 1.17 Organizational and Management Information
    106. 1.17.1 Air France Human Factors Training
    107. 1.17.2 Air France No-Blame Policy
    108. 1.17.3 Air France Airbus A340 Training
    109. 1.17.4 Air France Manuals, Policies, and Procedures
    110. 1.17.5 Flight Planning
    111. 1.17.6 Air France Procedures for Approach and Landing
    112. 1.17.7 Weather Radar
    113. 1.17.8 Air France Calculation of Landing Distance
    114. 1.17.9 Air France Policy on the Use of Reverse Thrust on Landing
    115. 1.17.10 Air France Procedures for Dealing with Windshear
    116. 1.17.11 Air France Information on Thunderstorms
    117. 1.17.12 Air France - Fatigue Management
    118. 1.17.13 Air France - Previous Safety Initiatives Concerning Landing Accidents
    119. 1.17.14 Emergency Procedures
    120. 1.17.15 Air France Differences from Airbus Manuals, Procedures, and Recommendations
    121. 1.17.16 Recurrent Emergency Training for Cabin Crew
    122. 1.18 Additional Information
    123. 1.18.1 Weather-Related Landing Occurrences - Internal Air France Investigations
    124. 1.18.2 Weather-Related Landing Occurrences - Other Operators
    125. 1.18.2.1 Hawaiian Airlines at Tahiti
    126. 1.18.2.2 American Airlines at Little Rock, Arkansas
    127. 1.18.2.3 Australian Transportation Safety Board
    128. 1.18.3 Study of Go-Around Events
    129. 1.18.4 Studies of Penetrations into Convective Weather
    130. 1.18.5 Research into Pilot Decision Making - Assessment of Risk and Weather
    131. 1.18.6 Flight Safety Foundation - Approach and Landing Accident Reduction Report
    132. 1.18.7 Research into Crew Management of Risk
    133. 1.18.8 Public Address System
    134. 1.18.9 Evacuation Alert System
    135. 1.18.10 Aircraft Emergency Lighting
    136. 1.18.11 Viewing Windows - Assessing Exterior Hazards in an Evacuation
    137. 1.18.12 Safety Briefing Cards for Passengers Travelling on the Flight Deck
    138. 1.18.13 Brace-for-Impact Commands
    139. 1.18.14 Provision of Safety Information - Recommended Brace-for-Impact Positions
    140. 1.18.15 Provision of Safety Information Regarding Carry-on Baggage
    141. 1.18.16 Provision of Safety Information During an Emergency - Language
    142. 1.18.17 Portable Emergency Equipment - Smoke Hoods and Megaphones
    143. 1.18.18 Dual-Lane Slides
    144. 1.19 Useful or Effective Investigation Techniques
    145. 1.19.1 Use of Flight Data Recorder and Cockpit Voice Recorder Animation as an Interview Tool
  2. 2.0 Analysis
    1. 2.1 Introduction
    2. 2.2 Aircraft
    3. 2.2.1 Emergency Exit Door L2
    4. 2.2.2 Aircraft Air Data Inertial Reference System - Wind Calculation
    5. 2.3 Airports
    6. 2.3.1 Runway End Safety Areas
    7. 2.3.2 Adequacy of Aircraft Rescue and Fire Fighting Aircraft Familiarization Charts (TP 11183)
    8. 2.3.3 Adequacy of Wind Information
    9. 2.4 Weather
    10. 2.4.1 Adequacy of Meteorological Data
    11. 2.4.2 Weather Information Provided by Air Traffic Control
    12. 2.5 Flight Operations
    13. 2.5.1 Crew Rest
    14. 2.5.2 The Accident Flight
    15. 2.5.3 Autopilot and Autothrust Use
    16. 2.5.4 Approaches in Convective Weather
    17. 2.5.5 Weather Information for Predicting Convective Weather
    18. 2.5.6 Landing on Contaminated Runways
    19. 2.5.7 Crew Resource Management / Threat and Error Management
    20. 2.5.8 Use of Rain Repellent
    21. 2.5.9 Captain-Only Missed Approach Call
    22. 2.5.10 Decision-Making Training for Difficult Approaches
    23. 2.6 Survivability
    24. 2.6.1 General
    25. 2.6.2 Fire
    26. 2.6.3 Aircraft Seats
    27. 2.6.4 Passenger Safety and Evacuation
    28. 2.6.4.1 Cockpit Safety Briefing Checklist
    29. 2.6.4.2 Pre-Landing Safety Briefings
    30. 2.6.4.3 Brace Position
    31. 2.6.4.4 Passenger Cabin and Baggage
    32. 2.6.4.5 Evacuation Slides
    33. 2.6.4.6 Cabin Crew Actions and Communications
  3. 3.0 Conclusions
    1. 3.1 Findings as to Causes and Contributing Factors
    2. 3.2 Findings as to Risk
    3. 3.3 Other Findings
  4. 4.0 Safety Action
    1. 4.1 Action Taken
    2. 4.1.1 Air France
    3. 4.1.1.1 Rain Repellent
    4. 4.1.1.2 Red Alert
    5. 4.1.1.3 Thunderstorms
    6. 4.1.1.4 Captain-Only Missed Approach
    7. 4.1.2 Transport Canada
    8. 4.1.3 Airbus
    9. 4.2 Action Required
    10. 4.2.1 Approaches into Convective Weather
    11. 4.2.2 Pilot Decision Making
    12. 4.2.3 Landing Distance Considerations
    13. 4.2.4 Runway End Safety Area Requirements
    14. 4.2.5 Carry-on Baggage
  5. Appendices
    1. Appendix A - Air France Runway 24L Approach Chart
    2. Appendix B - Airport Diagram - CYYZ
    3. Appendix C - Summary of Weather
    4. Appendix D - Airbus A330/A340 Location of Safety Equipment
    5. Appendix E - Runway End Safety Areas for Runway 24L
    6. Appendix F - Flight Data Recorder Values
    7. Appendix G - Landing Distance Required Chart - Contaminated
    8. Appendix H - Landing Distance Required Chart - Autobrake Full
    9. Appendix I - Glossary
  6. Photos
    1. Photo 1 - Weather at Threshold About Two Minutes Before Landing
    2. Photo 2 - AFR358 on Short Final
    3. Photo 3 - Weather Shortly After Landing
    4. Photo 4 - Accident Site
    5. Photo 5 - Aircraft Wreckage
    6. Photo 6 - Aircraft Stabilizers
    7. Photo 7 - Cockpit Seats
    8. Photo 8 - Aircraft Fire in Progress
    9. Photo 9 - Slide Training Device
  7. Figures
    1. Figure 1 - Landing Sequence Key Events
    2. Figure 2 - Aircraft Cabin and Exits
    3. Figure 3 - Weather Intensity Information Displayed to the Controller
    4. Figure 4 - Emergency Exits

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Date Modified: 2008-07-31
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