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(WHAT HAPPENED?? (IT IS AN AIR FRANCE FLIGHT, CHARTERED FOR PETER DEILMANN…
WHY IT HAPPENED???
LOSS OF AIRCRAFT AND DEATH OF 113 PEOPLE-
9 CREW
100 PASSENGERS
4 HOTEL STAFF
CONCORDE CRASHES INTO HOTEL AT GONESSE
DEBRIS ON RUNWAY
MANAGEMENT-
LATENT FAILURE ON BEHALF OF AIRPORT MANAGEMENT TO NOT CHECK RUNWAY PRIOR TO CONCORDES TAKE OFF KNOWING OF THE PRESSURES PUT ON ITS TYRES AT TAKE OFF AND THERE IMPORTANCE TO THE SYSTEMS SAFE FUNCTIONING
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
SYSTEM PARTS/PEOPLE
- ACTIVE FAILURE OF MATERIALS USED ON DC10, POSSIBLY TO WEAK FOR APPLICATION OR NOT SECURED PROPERLY BY MAINTENANCE STAFF.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
DESIGN LIFE CYCLE
- LATENT FAILURE, DC10/OTHER PLANE TYPES PRONE TO HAVE DEBRIS COME OFF THEM AFTER X AMOUNT OF FLYING HOURS DUE TO STRUCTURAL PRESSURRES AND WEARING DURING FLIGHTS.
Terry Bahill, A, Henderson, S 2005, Requirements development, verification, and validation exhibited in famous failures, Systems Engineering, vol. 8, no.1, pp.1-14.
FUEL CELL RUPTURED
DESIGN
- LATENT FAILURE, DELTA WING NOT DESIGNED TO TAKE IMPACT OF THE MAGNITUDE EXPERIENCED ON 25TH OF JULY, NO DEFENCE OR TOLERANCE BUILT IN FOR RESISTING A SHOCKWAVE IN THE FUEL TANK
Ritter, N, Mitschang, B, Harder, T, Gesmann, M and Schoning, H 1994,
Capturing design dynamics/spl minus/the CONCORD approach. In Data Engineering
, Proceedings from 10th International Conference, pp. 440-451.
SYSTEM PART/DESIGN LIFE CYCLE
- LATENT FAILURE, TYRES INCORRECTLY DESIGNED. IT WAS BELIEVED THAT IF THEY BURST THE LARGEST PIECE THAT WOULD SHEAR FROM THEM WOULD ONLY BE 1 KILO IN WIEGHT AND THEREFORE NOT RUPTURE THE STRUCTURE OF THE PLANE OR ITS FUEL TANKS.
Dekker, S., 2016. Drift into failure: From hunting broken components to understanding complex systems. CRC Press.
PEOPLE/MANAGEMENT
- ACTIVE FAILURE, FUEL OVER FILLED AS FUELS WERE SPECIFIED BY WEIGHT AND NOT BY VOLUME (ALTHOUGH THIS WAS NOT CITED AS A CONTRIBUTING FACTOR IT WAS SEEN AS AN AREA THAT COULD CONTRIBUTE TO FUTURE DISASTERS) AND MAY HAVE CONTRIBUTED TO THE SHOCK WAVE.
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
RUNWAY TO SHORT UNABLE TO ABORT TAKEOFF
DESIGN/WORKPLACE/MANAGEMENT
- LATENT FAILURE, THAT THE LENTH OF THE RUNWAY FOR CONCORD PLANES WAS NOT CONSIDERED AND EXTENDED FOR THE EVENT OF AN EMERGENCY AND THE NEED TO ABORT TAKEOFF.
Terry Bahill, A, Henderson, S 2005, Requirements development, verification, and validation exhibited in famous failures, Systems Engineering, vol. 8, no.1, pp.1-14.
DESIGN
- LATENT FAILURE, THE CONCORDE WAS A SUPERSONIC JET WHICH REQUIRED A HIGH SPEED AT TAKE OFF, YET NONE OF THE RUNWAYS ON WHICH IT WAS TO OPERATE ON WHERE FACTORED INTO ITS DESIGN INCASE OF AN EMERGENCY ON THE RUNWAY OR THE NEED TO ABORT TAKE-OFF
Gann, D, Salter, A 2000,
Innovation in project-based, service-enhanced firms: the construction of complex products and systems
, Research policy, vol. 29, no.7, pp.955-972.
DESIGN
- LATENT FAILURE, THE CONCORD NEEDED A 12.9 DEGREE ANGLE TO TAKE OFF WHICH REQUIRED HIGH SPEEDS TO ACHIEVE. THIS COMBINED WITH RUNWAY LENGTHS MEANT THAT ABORTING TAKEOFF WAS VIRTUALLY IMPOSSIBLE ONCE IT COMMENCED TAKEOFF PROCEDURES.
Ritter, N, Mitschang, B, Harder, T, Gesmann, M and Schoning, H 1994,
Capturing design dynamics/spl minus/the CONCORD approach. In Data Engineering
, Proceedings from 10th International Conference, pp. 440-451.
DESIGN- LATENT FAILURE THE DELTA WING CONFIGERATION ALLOWED SUPERSONIC FLIGHT BUT ALSO MEANT GREATER SPEEDS AT TAKE OFF WHICH INEVITABLY COMPROMISED ITS SAFETY AND PROFORMANCE IN AN EMERGENCY SITUATION SUCH AS SEEN IN THE DISASTER.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
TYRE EXPLODED/DISINTERGRATED
DESIGN
- ACTIVE FAILURE, A RISK OF TYRE EXPLOSION WAS SIGHTED 18 YEARS PRIOR TO THE ACCIDENT BUT THE BELIEF WAS THAT THE BIGGEST PIECE THAT COULD BREAK OFF WOULD BE NO MORE THAN 1KG (APPARENTLY PROVEN UNDER TEST CONDITIONS) AND UNABLE TO DO DAMAGE TO THE STRUCTURE OF THE PLANE THAT WOULD HAVE LEAD TO LOSS OF FUNCTION
Ritter, N, Mitschang, B, Harder, T, Gesmann, M and Schoning, H 1994,
Capturing design dynamics/spl minus/the CONCORD approach. In Data Engineering
, Proceedings from 10th International Conference, pp. 440-451.
MANAGEMENT/PEOPLE/WORKPLACES
- ACTIVE/LATENT FAILURE, THE RUNWAY IS NOT CHECKED FOR DEBRIS AS NO REGULATIONS EXIST AT THE ROISSY CHARLES DE GAULLE AIRPORT PRIOR TO THE DISASTER DESPITE THE SENSITIVE NATURE OF CONCORDS TYRES.
Reason, J 1990,
The contribution of latent human failures to the breakdown of complex systems
, Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences, pp.475-484.
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
MANAGEMENT/PEOPLE
- ACTIVE FAILURE, ISSUES SUFFERED BY THE CONCORDE IN THE 1970'S HIGHLIGHTS PROBLEMS WITH THE TYRES SUCH AS EXTREME TEMPERATURES AND EXCESSIVE "TOE IN" WHICH PROMPTS INCREASED SERVICE CHECKS HOWEVER THIS DOES NOT INCREASE ENOUGH TO NEGATE THE ISSUE.
Reason, J 1990,
The contribution of latent human failures to the breakdown of complex systems
, Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, pp.475-484.
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
DESIGN/SYSTEM PART
- LATENT FAILURE, TYRES ARE PRONE TO BURST AT HIGH INFLATION. SERVICE CHECKS WERE INCREASED, HOWEVER THERE WERE STILL OVER 50 TYRE BURSTS RECORDED ON CORCORDE FLIGHTS IN A 24 YEAR PERIOD LEADING TO THE BELIEF THAT THIS SHOULD HAVE BEEN INCREASED.
Terry Bahill, A. and Henderson, S.J., 2005. Requirements development, verification, and validation exhibited in famous failures. Systems Engineering, 8(1), pp.1-14.
SYSTEM PART
- ACTIVE FAILURE, TYRES ON CONCORDES WERE SOMETIMES RELAMINATED. THERE WERE NO GUIDELINES AROUND HOW MANY TIMES THIS COULD BE PREFORMED AND NO GUIDELINES AROUND PERMISSIBLE REPAIRS THAT COULD BE CARRIED OUT ON ITS TYRES. LEADING TO DIFFERENT STANDARDS BEING PREFORMED BY DIFFERENT SERVICE DIVISIONS IN DIFFERENT LOCATIONS IN WHICH CONCORDE FLEW.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
LOSS OF POWER TO ENGINES
SYSTEM PART/DESIGN LIFE CYCLE
- LATENT FAILURE, THE CABLE IN THE LANDING GEAR BAY WAS NOT SUFFICIENTLY INSULATED TO PROTECT IT FROM TYRE DEBRIS: IT SHOULD BE NOTED THAT THIS CAUSE IS ESTABLISHED FROM THE INABILITY OF THE CREW TO RETRACT THE LANDING GEAR. THIS LEAD TO THE FIRE AND SUBSEQUENT LOSS OF ENGINE POWER
Terry Bahill, A, Henderson, S 2005, Requirements development, verification, and validation exhibited in famous failures, Systems Engineering, vol. 8, no.1, pp.1-14
PEOPLE/MANAGEMENT
- ACTIVE FAILURE, PILOTS FOLLOW FIRE PROCEDURES AND SHUT DOWN ENGINE 2 IN AN ATTEMPT TO PUT OUT THE FIRE HOWEVER THIS PLACES GREAT STRAIN ON THE REMAINING 2 ENGINES.CONCORDE REQUIRES AT LEAST 3 WORKING ENGINES TO CORRECTLY FUNCTION, GAIN SPEED AND ALTITUDE
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
DESIGN-
LATENT FAILURE, TESTS INDICATED THAT IN THE EVENT OF A FUEL TANK RUPTURE THE FUEL SHOULD EMINATE AWAY FROM THE ENGINES AND OUT TOWARD THE WING EDGES, HOWEVER IGNITED FUEL WAS NOT FACTORED IN TO THE TESTS WHICH ALLOWED THE INTAKES FOR THE ENGINES TO BECOME CHOKED AND LOSE FUNCTION/POWER.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
SYSTEM PART
-ACTIVE FAILURE, THE DELTA WING DESIGN BEING LONG AND WIDE TO ALLOW FOR SUPERSONIC FLIGHT ENABLED THE HEAT FROM THE IGNITED FUEL TO HOLD UNDER THE WING AND SUBSEQUENTLY BEGIN THE DISINTAGRATION OF THE WING FASTER THAN IT WOULD HAVE WITH OTHER TYPES OF WING DESIGN.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
THE DC-10
SYSTEM PART/PEOPLE/WORKPLACES
- LATENT AND ACTIVE FAILURE, STRIPA RIVET WAS MISSING ON THE LOWER RIGHT WEAR STRIP WHICH WAS DEFORMED AND THERE WAS PLAY OF SIX MILLIMETRESIN RELATION TO THE SUPPORT,THIS WOULD INDICATE INCORRECT OR CARELESS INSTALLATION MAY HAVE CONTRIBUTED TO THE STRIP BREAKING OFF WHICH CAUSED THE DISASTER
Reason, J 1990,
The contribution of latent human failures to the breakdown of complex systems
, Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences, pp.475-484.
SYSTEM PART/PEOPLE/WORKPLACES/DESIGN LIFECYCLE
- ACTIVE FAILURE,THE LEVEL OF WEAR ON THE STRIP ADJACENT TO THE MISSING STRIP HAD CLEARLY EXCEEDED THE TOLERANCES ACCEPTED BY THE MANUFACTURE LEADING TO THE CONCLUSION THAT SO WOULD HAVE THE ONE ON THE RUNWAY THAT CAUSED THE INCIDENT
SYSTEM PART/PEOPLE/MANAGEMENT
- ACTIVE FAILURE,THE LEFT WEAR STRIPS HAD BEEN REPLACED AND DID NOT APPEAR TO BE ORIGINAL PARTS WHICH MAY HAVE CONTRIBUTED TO ITS BREAKING AWAY FROM THE PLANE.
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
SYSTEM PART/DESIGN LIFECYCLE/MANAGEMENT/PEOPLE
- ACTIVE AND LATENT FAILURE, THE LEFT FAN DOOR ON THE INSIDE WAS FOUND TO HAVE DEEP WEAR MARKS ON IT, IN PARTICULAR ON THE PART WHICH RESTS ON THE STRIPS IN QUESTION.
Davidson, G and Labib, A 2003,
Learning from failures: design improvements using a multiple criteria decision-making process
, Proceedings of the Institution of Mechanical Engineers, Journal of Aerospace Engineering, vol.217, no.4, pp.207-216.
DESIGN LIFE CYCLE/PEOPLE/SYSTEMPART
- ACTIVE AND LATENT FAILURE, TO THE RIGHT OF THE BEARING POINT OF THE STRIP ADJACENT TO THE MISSING STRIP, SEVERE WEAR OF AROUND 2 MILLIMETRES WAS OBSERVABLE ON THE PLANES COWL.
Terry Bahill, A, Henderson, S 2005, Requirements development, verification, and validation exhibited in famous failures, Systems Engineering, vol. 8, no.1, pp.1-14.
DESIGN
- LATENT FAILURE, WHEN CLOSED THE FAN/REVERSER COWL ASSEMBLY MADE IT PRACTICALLY IMPOSSIBLE TO NOTE THE ABSENCE OF THE LOWER STRIP.
Ritter, N, Mitschang, B, Harder, T, Gesmann, M and Schoning, H 1994,
Capturing design dynamics/spl minus/the CONCORD approach. In Data Engineering
, Proceedings from 10th International Conference, pp. 440-451.
WORKPLACES/PEOPLE/MANAGEMENT- ACTIVE FAILURE, WERE THE CORRECT PROCEDURES AND METHODS FOR MAINTENANCE UNDERSTOOD BY THE TECHNICIANS AND ALL WHO WORK ON AND MAINTAIN THE DC-10 BASED ON THE EVIDENCE THE FOLLOWING FACTORS MAY HAVE CONTRIBUTED TO THE STRIP BREAKING AWAY FROM THE DC-10
Under skilled technician
Change in operation routine i.e. timing systems and methods
rogue operator, lack of care or vision toward consequences
new or overseas parts being used or replacement part being "suited" to role
New or forign labels on system without adequate training on equipment type.
Time pressures and deadlines leading to use of unauthorized part
Reason, J 1990,
The contribution of latent human failures to the breakdown of complex systems
, Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences, pp.475-484.
Turner, B 1994,
Causes of disaster: sloppy management
, British Journal of management, vol. 5, no.3, pp.215-219.
WHAT HAPPENED??
IT IS AN AIR FRANCE FLIGHT, CHARTERED FOR PETER DEILMANN CRUISES. THE FLIGHT HAS 9 CREW AND 100 PASSENGERS ON BOARD HEADING TO NEW YORK AS PART OF A 16 DAY CRUISE TO SOUTH AMERICA
SHORTLY BEFORE ROTATION, AS IT GAINS SPEED AND HEADS DOWN THE RUNWAY CONCORDES FRONT RIGHT TYRE (NO.2) OF THE LEFT LANDING GEAR STRIKES A METAL STRIP ON THE RUNWAY WHILST TRAVELLING AT APPROX. 323KMH WHICH BURSTS CONCORDES TYRE
CONCORDE SUPER-SONIC PASSENGER JET REGISTERED - F-BTSC, ATTEMPTS TO TAKE-OFF FROM RUNWAY 26 AT ROISSY CHARLES DE GAULLE AIRPORT @ 16:43 ON 25TH OF JULY
METAL STRIP WAS 43.5CM LONG AND HAD BROKEN OFF A DC-10 PLANES ENGINE MOUNT THAT HAD TAKEN OFF ON THE SAME RUNWAY, 5MINS BEFORE CONCORD
DEBRIS FROM THE TYRE (A 4.5 KILOGRAM PIECE) STRIKES THE UNDER SIDE OF CONCORDES DELTA SHAPED WING
6 .THE IMPACT CREATES A SHOCK/PRESSURE WAVE WITHIN THE TANK WHICH BLOWS A PLUG OF WING TANK SKIN OUTWARDS CAUSING FUEL TO CASCADE FROM THE HOLE AND OVER THE ENGINES
CONCORDE IS TRAVELING TO FAST AND THERE IS NOT ENOUGH RUNWAY TO ABORT TAKEOFF- CONCORDE LIFTS INTO THE AIR (CONCORDE WOULD NEED AT LEAST 3000M OF RUNWAY TO SAFELY ABORT ITS TAKE-OFF AT THIS POINT
AN ELECTRICAL WIRE IN THE LANDING GEAR MAY ALSO HAVE BEEN SEVERED BY ANOTHER PIECE OF THE TYRE DEBRIS WHICH TOUCH AND SPARK IGNITING THE FUEL LEAKING FROM CONCORDES WING
CREW ARE NOTIFIED OF THE FIRE BY TOWER AND ENGINE FIRE ALARMS IN THE COCKPIT. THEY ATTEMPT TO CORRECT THE SITUATION BY SHUTTING DOWN ENGINE 2 AND USING ONBOARD FIRE CONTROL MEASURES. THE PLANE IS OPERATING AT VERY LOW POWER
CONCORDE STRUGGLES TO GAIN ALTITUDE AND THEY ARE ALSO UNABLE TO RETRACT THE LANDING GEAR- THEY ARE FLYING AT APPROX. 200FEET AND A SPEED OF 200KM
THE LEFT WING BEGINS TO DISINTERGRATE DUE TO THE HEAT OF THE FIRE, THERE IS A SUDDEN LOSS OF POWER IN THE REMAINING ENGINES (3&4), THE PLANE HEELS OVER TO 110 DEGREES, ROLLS TO THE LEFT AND STALLS
CONCORDE FALLS FROM THE SKY 127 SECONDS AFTER TAKE OFF- CRASHES INTO A HOTEL KILLING ALL 109 ON BOARD AND 4 EMPLOYEES OF THE HOTEL.
PEOPLE
Captain
Male, 54 years old
• Commercial pilot’s licence No 193067 issued 12 July 1967
• First class Commercial pilot’s licence No 208369 issued on 8 August 1969
• Airline transport pilot’s TOP licence No 195176 issued on 19 February 1976
• Total flying hours: 13,477 of which 5,495 as Captain
• Flying hours on Concorde: 317 of which 284 as Captain
• Flying hours in the last six months: 177.91
• Flying hours in the last three months: 95.34
• Flying hours in the last thirty days: 23.86
NO INDICATIONS THAT THE PILOT WAS UNDERTRAINED OR THAT HIS ACTIONS AT THE TIME OF THE INCIDENT CONTRIBUTED TO THE SYSTEMS FAILURE
First Officer
Male, 50 years old
• Commercial pilot’s licence No 411171 issued on 16 December 1971
• First class commercial pilot’s licence No 263672 issued on 9 October 1972
• Airline transport pilot’s TOP licence No 232079 issued on 2 February 1979
• Total flying hours: 10,035 of which 2,698 as FO on Concorde
Flying hours in the previous six months: 127.25
Flying hours in the previous three months: 50.13 Flying hours in the previous thirty days: 7.64
NO INDICATIONS THAT THE FIRST OFFICER WAS UNDERTRAINED OR THAT HIS ACTIONS AT THE TIME OF THE INCIDENT CONTRIBUTED TO THE SYSTEMS FAILURE
Flight Engineer
Male, 58 years old
• Flight Engineer’s Licence No 142568 issued on 22 March 1968, valid until 30 June 2001
• Total flying hours: 12,532 of which 937 as FE on Concorde
• Flying hours in the previous six months: 131.64
• Flying hours in the previous three months: 62.19
• Flying hours in the previous thirty days: 23.62
NO INDICATIONS THAT THE FLIGHT ENGINEER WAS UNDERTRAINED OR THAT HIS ACTIONS AT THE TIME OF THE INCIDENT CONTRIBUTED TO THE SYSTEMS FAILURE
