Concorde AF4590 Crash Reports

The article discusses the Concorde AF4590 Crash and the systematic errors that led to the tragedy. It also explores how Crew Resource Management (CRM) could have been employed to mitigate the tragedy. The official report is compared to the information presented by John Hutchison.

Concorde AF4590 Crash 1
CONCORDE AF4590 CRASH REPORTS
By (Name)
The Name of the Class (Course)
Professor (Tutor)
The Name of the School (University)
The City and State where it is located
The Date

Concorde AF4590 Crash 2
Concorde AF4590 Crash Reports
According to John Hutchinson, any aircraft related accident or tragedy is normally
attributed to a series of systematic errors; and the same can be said for Air France Flight
Concorde AF4590. The aircraft had been undergoing maintenance for the past 2 to 3 days and
the reassembly of the left-hand undercarriage was not properly conducted. The missing
component that was overlooked during the reassembly is referred to as a spacer(John Hutchinson
on Air France Flight 4590, 2017). Failure to put the spacer in its purpose position meant that the
wheels on the left-hand undercarriage where not appropriately spaced and they were also not
held firmly in place. In addition, the pilot ordered that the fuel tanks be completely filled to
maximum capacity; without living any air space in all tanks. Company policy mandates that the
tanks should only be filled within 70% and 80%, and the remaining percentage should be allotted
to air. John also speculates that due to the fact that a significant proportion of the passengers
were going on a cruise; he may have been in a hurry to leave mainly because he had delayed the
flight by two hours after he ordered for repairs to be made on a problematic reverser (John
Hutchinson on Air France Flight 4590, 2017).
Hutchison also tells the interviewer that the pilot was warned by the dispatcher that they
were critically overweight and adding more cargo would severely detriment the plane's centre of
gravity. The pilot chose to ignore the warning and demanded that the remaining nineteen
passenger bags be put in the space available in the back storage space. In addition, the plane had
not used up a significant amount of the taxing fuel by the time the flight was ready to take off.
As such, the plane is estimated to have been overweight by 2 or 3 tonnes. Due to this reason the
pilot asked to use an extra section of the runway that had been closed off because resurfacing
was being done. Therefore, the transition point between the two sections of runway had a bump

Concorde AF4590 Crash 3
like partition. The plane was cleared for takeoff with tail wind and this greatly increased the
overweight factor by 4 or more tonnes. The wise option would have been to takeoff on a
difficult runway with front wind thus allowing for significant fuel consumption and weight
reduction before the plane took flight. This was however not done and Flight Concorde AF4590
maintained its projected takeoff trajectory. During the actual takeoff take off the wheels on the
left-hand undercarriage were crippled when the plane hit the ledge between the operational
runaway and the segment that was undergoing resurfacing. As a result, the tyres locked and they
began to slide on top of the runway, leading to a considerable amount of friction that caused the
wheels to emit smoke as the plane run down the runway (John Hutchinson on Air France Flight
4590, 2017).
As the plane continued down the runway at 200miles/hr, one of the wheels on the left-
hand undercarriage hit a piece of titanium rod that took off a considerably large chuck of rubber
and throw it towards one of the plane tanks. The impact was so great that the energy had no way
of being dissipated so the fuel tank ruptured to relieve the tension. A fire erupted from the fuel
tank as a result of faulty wiring in the braking mechanism of the plane. The flight engineer
switched of the left engine without consulting with pilot this lead to a considerable loss in thrust.
The plane took off skewed to the left narrowly missing another plane waiting for clearance (John
Hutchinson on Air France Flight 4590, 2017). It never reached speeds of 220 knots and the final
nail on the casket was the loss of centre of gravity (due to spillage of large quantities of fuel on
the front end of the plane) this caused Concorde AF4590 to tilt upwards by about 35 degrees
before slamming down into the Relais Bleu hotel. The tragedy resulted in the 113 deaths (109
passengers and 4 hotel residents).

Concorde AF4590 Crash 4
The official report is to a large extent similar to the information presented by John Hutchison the
only differences are in the manner in which the engines where damaged by debris and the degree
of human error that resulted in the accident. Moreover, the official report does not clearly
indicate the lack of teamwork and proper interaction between the cabin crew (BEA, 2000). There
are therefore a few through which Crew Resource Management (CRM) could have been
employed to mitigate the tragedy. For instance, company safety policies and culture should be
aligned with CRM practices to better the level of care and duty given by the flight crew.
Secondly, CRM aids in the identification of precursors that can be associated with accidents and
potentially harmful incidents. Moreover, CRM practices will prevent the incorporation and
employment of organizational factors in the handling of flight matters. With regard to how crew
member interact with each other and perform their respective duties (FORD, Jane et al., 2014).
CRM creates a channel of communication that allows the pilot to interact and converse
effectively with the cabin crew and first officer. CRM ensures that the leadership role of the pilot
is nurtured fully since he/she is expected to enhance intra-communication amongst the cabin
crew members, and ensure that crew member participate in decision making by offering them
mutual monitoring and coordination responsibilities(FORD, Jane et al., 2014).

Concorde AF4590 Crash 5
References
BEA. 2000. Accident on 25 July 2000 at La Patte d’Oie in Gonesse (95) to the Concorde
registered F-BTSC operated by Air France. Bureau Enquêtes-Accidents (BEA).
FORD, Jane, Robert HENDERSON, and David O'HARE. 2014. The effects of Crew Resource
Management (CRM) training on flight attendants' safety attitudes. Journal of safety research.
IIIL(3), pp.49-56.
John Hutchinson on Air France Flight 4590. Online Media (Youtube). Aircrew Interview. 2017.