Narrative:Air France flight AF358 departed Paris at 13:32 local time for a scheduled flight to Toronto. Weather conditions were poor as the aircraft approached Toronto with heavy thunderstorms and rain. Around 15:52 the crew contacted Toronto Approach. The controller replied: "Air France 3-5-8 Heavy roger, 2-4 Left is your runway, the altimeter 3-0-0-0 and when you are able fly heading 2-10 and intercept the localizer." The Air France pilot then responded: "When able within.... five nautical miles we can intercept the localizer, Air France 3-5-8." The crew then received further instructions to descend to 5000 and to reduce their speed to 190 knots. About 15:55 they were cleared down to 4000 feet and one minute later the controller cleared the flight for the ILS approach to runway 24 Left. Within less than a minute the controller asked "...Air France 3-5-8 reduce speed now to 1-60 knots", which was correctly read back. Thirty seconds later the controller radioed: "Air France 3-5-8 slow to your final approach speed". Then, about, 15:58 they were instructed to contact the Toronto Tower: "Air France 3-5-8 contact Toronto tower at the KIREX fix on frequency 1-18 point 3-5". The KIREX fix is located at 6.0 DME. After being cleared to land, the Airbus touched down on runway 24L, a 9000 feet (2743 m) runway. The airplane was not able to stop before the end of the runway and overran. It careened to the left, down a slope, ending up in a gulley. The airplane caught fire, but everyone on board was evacuated safely.
|Date:||Tuesday 2 August 2005|
|C/n / msn:|| 289|
|First flight:|| 1999|
|Total airframe hrs:||28418|
|Engines:|| 4 CFMI CFM56-5C4|
|Crew:||Fatalities: 0 / Occupants: 12|
|Passengers:||Fatalities: 0 / Occupants: 297|
|Total:||Fatalities: 0 / Occupants: 309 |
|Airplane damage:|| Destroyed|
|Airplane fate:|| Written off (damaged beyond repair)|
|Location:||Toronto-Pearson International Airport, ON (YYZ) ( Canada)
|Crash site elevation:|| 173 m (568 feet) amsl |
|Phase:|| Landing (LDG)|
|Nature:||International Scheduled Passenger|
|Departure airport:||Paris-Charles de Gaulle Airport (CDG/LFPG), France|
|Destination airport:||Toronto-Pearson International Airport, ON (YYZ/CYYZ), Canada|
FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1. The crew conducted an approach and landing in the midst of a severe and rapidly changing thunderstorm. There were no procedures within Air France related to distance required from thunderstorms during approaches and landing, nor were these required by regulations.
2. After the autopilot and autothrust systems were disengaged, the pilot flying (PF) increased the thrust in reaction to a decrease in the airspeed and a perception that the aircraft was sinking. The power increase contributed to an increase in aircraft energy and the aircraft deviated above the glide path.
3. At about 300 feet above ground level (agl), the surface wind began to shift from a headwind component to a 10-knot tailwind component, increasing the aircraft's groundspeed and effectively changing the flight path. The aircraft crossed the runway threshold about 40 feet above the normal threshold crossing height.
4. Approaching the threshold, the aircraft entered an intense downpour, and the forward visibility became severely reduced.
5. When the aircraft was near the threshold, the crew members became committed to the landing and believed their go-around option no longer existed.
6. The touchdown was long because the aircraft floated due to its excess speed over the threshold and because the intense rain and lightning made visual contact with the runway very difficult.
7. The aircraft touched down about 3800 feet from the threshold of Runway 24L, which left about 5100 feet of runway available to stop. The aircraft overran the end of Runway 24L at about 80 knots and was destroyed by fire when it entered the ravine.
8. Selection of the thrust reversers was delayed as was the subsequent application of full reverse thrust.
9. The pilot not flying (PNF) did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This further contributed to the delay in the PF selecting the thrust reversers.
10. Because the runway was contaminated by water, the strength of the crosswind at touchdown exceeded the landing limits of the aircraft.
11. There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto/Lester B. Pearson International Airport (CYYZ).
12. Despite aviation routine weather reports (METARs) calling for thunderstorms at CYYZ at the expected time of landing, the crew did not calculate the landing distance required for Runway 24L. Consequently, they were not aware of the margin of error available for the landing runway nor that it was eliminated once the tailwind was experienced.
13. Although the area up to 150 m beyond the end of Runway 24L was compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond this point, along the extended runway centreline, contributed to aircraft damage and to the injuries to crew and passengers.
14. The downpour diluted the firefighting foam agent and reduced its efficiency in dousing the fuel-fed fire, which eventually destroyed most of the aircraft.
FINDINGS AS TO RISK:
1. In the absence of clear guidelines with respect to the conduct of approaches into convective weather, there is a greater likelihood that crews will continue to conduct approaches into such conditions, increasing the risk of an approach and landing accident.
2. A policy where only the captain can make the decision to conduct a missed approach can increase the likelihood that an unsafe condition will not be recognized early and, therefore, increase the time it might otherwise take to initiate a missed approach.
3. Although it could not be determined whether the use of the rain repellent system would have improved the forward visibility in the downpour, the crew did not have adequate information about the capabilities and operation of the rain repellent system and did not consider using it.
4. The information available to flight crews on initial approach in convective weather does not optimally assist them in developing a clear idea of the weather that may be encountered later in the approach.
5. During approaches in convective weather, crews may falsely rely on air traffic control (ATC) to provide them with suggestions and directions as to whether to land or not.
6. Some pilots have the impression that ATC will close the airport if weather conditions make landings unsafe; ATC has no such mandate.
7. Wind information from ground-based measuring systems (anemometers) is critical to the safe landing of aircraft. Redundancy of the system should prevent a single-point failure from causing a total loss of relevant wind information.
8. The emergency power for both the public address (PA) and EVAC alert systems are located in the avionics bay. A less vulnerable system and/or location would reduce the risk of these systems failing during a survivable crash.
9. Brace commands were not given by the cabin crew during this unexpected emergency condition. Although it could not be determined if some of the passengers were injured as a result, research shows that the risk of injury is reduced if passengers brace properly.
10. Safety information cards given to passengers travelling in the flight decks of Air France Airbus A340-313 aircraft do not include illustrations depicting emergency exit windows, descent ropes or the evacuation panel in the flight deck doors.
11. There are no clear visual cues to indicate that some dual-lane slides actually have two lanes. As a result, these slides were used mostly as single-lane slides. This likely slowed the evacuation, but this fact was not seen as a contributing factor to the injuries suffered by the passengers.
12. Although all passengers managed to evacuate, the evacuation was impeded because nearly 50 per cent of the passengers retrieved carry-on baggage.
» Air France
» TSB Investigation Update Number A05H0002
METAR Weather report:
20:00 UTC / 16:00 local time: CYYZ 022000Z 29011KT 4SM +TSRA BKN051TCU BKN140 23/22 A3002 RMK TCU6AC1 CB ASOCTD LTGCC VIS LWR SW-NW 2 SLP164=
wind 290 degrees at 11 kts visibility 4 miles heavy thunderstorms containing rain 5-7 oktas cloud at 5100ft with towering cumulus 5-7 oktas cloud at 14000ft temperature 23C dewpoint 22C QNH 30.02in and a.o. Cumulonimbus clouds with cloud to cloud lightning)
Follow-up / safety actions
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Paris-Charles de Gaulle Airport to Toronto-Pearson International Airport, ON as the crow flies is 5976 km (3735 miles).