Concorde Flight 4590: A Healthcare Accident Investigation Report

This report provides an analysis of the Air France Concorde Flight 4590 accident, focusing on the perspective of a Concorde Maintenance stakeholder. It details the mechanical failures, such as improper maintenance guidelines and engine malfunctions, and personnel errors, including inadequate runway inspections. The report highlights the crucial role of maintenance in preventing such disasters and the significant impact the accident had on the Concorde fleet's future. The investigation examines the titanium alloy strip issue and the delayed flight's impact. The conclusion underscores the significance of the accident as the only fatal crash in Concorde's history, attributing it to negligence and ignorance, and leading to the retirement of the fleet. The report references key sources and emphasizes the importance of adherence to safety protocols.

Health Care
Accident Investigation

Introduction
• An Air France Concorde Flight 4590 that was heading to New York from Paris
killed 4 people on the ground and 109 passengers (Riding, 2000 n.d).
• This was the first Concorde crash since the plane which is recognised as the
worlds supersonic undergone through a commercial operation that was
performed in 1976.
• According to the witnesses, either one or both Concorde’s left engine was
seen smoking heavily then burst in a fire as the plane sped down the airstrip.
• The plane is said to have failed to gain an altitude whereby it swayed to the
left and later it crashed and demolished the restaurant and hotel that was
nine miles to the Northeast Paris.
•My job role at Concorde Maintenance as the stakeholder and was to engage in
the periodic checks for concorde and it was the most important to ensure all
damaged parts of concorde were repaired.

Mechanical Failure(Findings and
recommendations)
• The first human error identified is that there was a mechanical failure as the
mechanics did not follow proper maintenance guidelines such as flight controls and
locking mechanisms (Bubbico, Carbone, Ramírez-Camacho, Pastor and Casal, 2016
p.95).
• As the Concorde Maintenance, my most crucial part of the job is to ensure that the
concorde does not have any mechanical problems that would lead to fatal accidents.
• Notably, as the Concorde Maintenance stakeholder, I may have overlooked the fact
that a Concorde needs faster takeoff than other airplanes which caused to the
malfunction of the engine that was beyond the pilot’s control and he opted to take a
sudden emergency landing.
• However, the Airplane France Concorde 4590 had passed the V1 speed which is
considered as unsafe even though it failed to gain enough speed.
• The three engines were damaged and the plane could not accelerate and the
accident investigators argued that safe landing was unlikely to happen for Air France
Concorde Flight 4590.

Personnel Error
• Another human factor that contributed to the Air France
Concorde Flight 4590 is the personnel error (Kozuba, 2011
p.30).
• Notably, the aircraft lost a titanium alloy strip as the usual
protocol for runway inspection was not well undertaken.
• The flight had been delayed by almost an hour hence the
personnel did not have ample time to perform a thorough
runway inspection as expected for a Concorde flight.
• It is reported that the parts of a Continental flight that had
taken off previously cut the Concorde’s left tires that
ruptured causing the fatal crash.

Conclusion
• Air France Flight 4590 is the only Concorde’s fatal accident
recorded in a history of 31 years.
• Concorde had been qualified as one of the safest flight but
ignorance and negligence of the mechanics and personnel
contributed to the fatal accident.
• The accident was a huge blow for my job role as Concorde
Maintenance as it also incurred huge losses.
• It was announced that later the passengers’ numbers
decreased and maintenance costs increased leading to the
British and France Airways to announce the retirement of
the Concorde’s fleet.

Bibliography
Bubbico, R., Carbone, F., Ramírez-Camacho, J.G., Pastor, E. and
Casal, J., 2016. Conditional probabilities of post-release events for
hazardous materials pipelines. Process Safety and Environmental
Protection, 104, pp.95-110.
Casal, J., Gómez-Mares, M., Muñoz, M. and Palacios, A., 2012. Jet
fires: a “minor” fire hazard. Chemical Engineering
Transactions, 26.
Kozuba, J., 2011. Impact of human factor on likelihood of aircraft
accident. Archives of Transport System Telematics, 4, pp.29-36.
Riding, A. (2000, July 26). The Concorde Crash: The Overview; 113
Die in First Crash of a Concorde. Retrieved from
https://www.nytimes.com/2000/07/26/world/the-concorde-cras
h-the-overview-113-die-in-first-crash-of-a-concorde.html