Concord / Air France Flight 4590 Trial Verdict 2

[YoungTurk]

A French court recently ruled that Continental Airlines and a mechanic in their employ are guilty of involuntary manslaughter and liable for the deaths of 119 in the crash of Air France flight 4590.

At issue in the guilty verdict was an incorrectly fabricated / installed wear strip which is believed to have separated from a DC-10 on the Concord's runway and caused a tire puncture leading to the chain of failures which resulted in the final crash.

The French engineers and regulators named in the suit, as well as the Continental mechanic's supervisor, were acquitted.

The following link includes a trial summary and a link to the official crash report - very interesting read.

The US media take seems to be that the Americans were scapegoated for the crash. I'm curious what those here think of the verdict.

http://avstop.com/news_december_201...l_airlines_responsible_for_concorde_crash.htm

 

[hokie66]

Concorde had a lot of near misses with tire blowouts. Continental will appeal, but in a French court, don't like their chances.

 

[MintJulep]

From the investigation report:

Further, in-service experience shows that the destruction of a tyre during taxi, takeoff or
landing is not an improbable event on Concorde and that such an event may cause
damage to the structure and systems. However, such destruction had never caused a fuel
fire.
The accident which occurred on July 25 2000 showed that the destruction of a tyre - a
simple event which may recur - had catastrophic consequences in a very short time
without the crew being able to recover from the situation.
Consequently, without prejudice to further evidence that may come to light in the course of
the investigation, the BEA and the AAIB recommend to the Direction Générale de
I'Aviation Civile of France and the Civil Aviation Authority of the United Kingdom that:
• the Certificates of Airworthiness for Concorde be suspended until
appropriate measures have been taken to guarantee a satisfactory level of
safety with regard to the risks associated with the destruction of tyres.”

Concorde was not tolerant of a probable and predictable event. Tires sometimes fail. Seems that a share of the culpability lies with the designers and manufacturer.

Continental and the mechanic deserve a share of culpability as well. Not supposed to make up your own modifications.

 

[dik]

I had understood that the repair used titanium which supposedly was a brittle material and it was the fragment from this repair that caused the damage to the Concord.

Dik

 

[RPstress]

@Dik: do you have a ref for that? (Hadn't seen it myself; just curious.)

 

[YoungTurk]

That is correct, look at the accident report in the above link on page 60 and later starting on page 103 (IIRC). The wear strip was supposed to be made from SS (per the maintenance manual) and Titanium was used. There also appears to have been an incorrect installation of the rivets used to retain it, though that part is not made totally clear to me.

Having not worked in transport or power plants, I can't speak to how egregious the repair was. Finding the mechanic criminally liable is an extreme precedent, I would hope the magnitude of the mistake called for such a harsh response.

On the other hand we have the Concord designers and certification authority, who may have put an un-airworthy aircraft into service and left it there until this happened. They have been exonerated. I'm not sure how I feel about that. It gives some confidence to me as an engineer (and potentially a certification approver) that I would not be held criminally liable for my work. But it also leaves the question unanswered of who is ultimately responsible for un-airworthy designs.

 

[YoungTurk]

I should add - the strip was found to have caused the tire blowout. The fire and engine failure apparently resulted from the tire blowout and not directly from the titanium strip.

 

[MintJulep]

In this age of "it's not my fault" and general lack of accountability for one's actions I actually find holding the mechanic liable for the consequences of his work rather refreshing.

If an engineer designs a structure that fails and the collapse kills people then the engineer is held liable. If a doctor leaves something inside a patient during an operation the doctor is held liable. Why should a professional A&P mechanic be held to a lesser standard of accountability?

Having said that, it seems that the DC-10 manuals where somewhat ambiguous, and that the shimming procedure as-written was widely known to be impossible to perform as-written.

There's no shortage of culpability.

 

[thruthefence]

"Why should a professional A&P mechanic be held to a lesser standard of accountability?"

I'm sure the work was done "in the docks", thus under 14 CFR 145, Certified Repair Stations. And at this level, the Airlines all have engineers "on staff" that have the make changes as necessary, even manufacturing their own parts, toward the end of safe and airworthy aircraft. (14 CFR 21.303 (b)(2)) These processes are well defined, and contain quality control at every turn.

Should the A&P be held accountable? Of course, if there are issues of poor workmanship & execution. I doubt, however, that a "professional A&P" simply walked by the scrap barrel, choose a strip of titanium, and said "this oughta work" and completed the repair.

If he, on his own, "designed" and installed the repair, he is liable. If the "system", eg the certified repair station, signed off on it at any step in the process, be it engineering, or QC, they are culpable as well.

 

[WKTaylor]

BA & AF were aware that FOD posed a hazard to tires, engines and the underside of the acft... with the under-slung after-buring engines being particularly vulnerable to sucking up expensive FOD [Duhhh]. Runways and taxiways for "heavies" are notorious for accumulating FOD, such as fasteners, tire bits-n-pieces, aircraft components, oil/fluids, etc.

One simple fact that appears to be overlooked by the court was that there was a standing requirement by BA and AF for a taxiway and runway FOD sweep [ground vehicle check] ahead of the Concorde for all movements [powered taxi, take-offs and landings]. This was NOT accomplished for the mishap flight, for whatever reasons, by AF or the CDG airport authorities. IF it had been accomplished, and the debris was found/removed, then this would have been a "non-event".

The fundamental problem, was like the NASA space shuttle program, was that there were glaring "red-flag incidents" that were occurring... but ignored by leadership... that should have prompted deadly serious safety reviews and corrective actions. Even if corrective actions appear "costly", the fact of how costly a major accident would be was NEVER factored in.

Regards, Wil Taylor

 

[KENAT]

This came up elsewhere and Johners gave this link.

http://www.iasa.com.au/folders/Safety_Issues/others/concordespacer.html

Posting guidelines faq731-376

http://eng-tips.com/market.cfm?

(probably not aimed specifically at you)
What is Engineering anyway: faq1088-1484​

 

[kontiki99]

Did they use recapped tires?