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ASN Wikibase Occurrence # 195212
Last updated: 15 August 2019
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Date:11-MAR-2017
Time:18:55 LT
Type:Silhouette image of generic A343 model; specific model in this crash may look slightly different
Airbus A340-313
Owner/operator:Air France
Registration: F-GLZU
C/n / msn: 377
Fatalities:Fatalities: 0 / Occupants: 281
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Bogotá-Eldorado Airport (BOG/SKBO) -   Colombia
Phase: Take off
Nature:International Scheduled Passenger
Departure airport:Bogotá-Eldorado Airport (BOG/SKBO)
Destination airport:Paris-Charles de Gaulle Airport (CDG/LFPG)
Investigating agency: BEA
Narrative:
Air France flight AF423, an Airbus A340-313, made an abnormally long takeoff from runway 13R at Bogotá-Eldorado Airport in Colombia.
The Captain was the pilot in flying (PF) on this stage. The take-off was carried out at night on runway 13R, which is 3,800 m long and has a 300 m clearway (CWY). The crew applied a 50% thrust on brakes and then took off at full thrust (TOGA).
The PF initiated rotation when rotation speed (VR) was reached. At that pouint the aircraft was 2,760 m from the runway 13R threshold. The aircraft's rotation rate was low. The three crew members reported that they heard the audio alarm "PITCH PITCH". The main landing gears left the ground while the aircraft was 140 m from the opposite runway threshold.
The aircraft crossed the opposite runway threshold at 6 feet. The end of the CWY was reached at 20 feet. The speed at that point was V2 + 9 kt. The aircraft passed 12 ft over the ILS antennas. The climb was then continued without further issues and the regulatory obstacle clearance margins on the climb path of the second segment were respected.

Causes of the serious incident:
The serious incident resulted from inadequate PF pitch-up orders that increased the TOD by 424 m over the certified theoretical TOD plus the regulatory safety margins under the operational conditions of the day. This significantly increased the risk of longitudinal runway excursion or collision with obstacles.
The investigation showed that the order of rotation of the PF during the rotation of the event was at the lower limit of the values observed in operations in several companies operating A340-300s. It was lower than the order to be rotated recommended in the FCTM in effect at the time of the occurrence.
Under the conditions of the serious incident, the application of an initial pitch-up order by a typical amplitude of 2/3 of travel as mentioned by the MTCT and then maintained at this deflection value did not achieve the rate of rotation of 3°/s mentioned in the same document and retained in the certified performance established at the end of the certification flight test phase.
There was no flight data processing process to monitor take-offs at the time of the occurrence and no take-off performance notification had not been made by European crews on the A340-300 by the date of the event.

BEA noted that prior to this occurrence, the difference between the rotation rates obtained in operations and those used in the performance calculations had not been identified by Airbus A340-300 operators due to the lack of crew reporting and take-off performance monitoring during flight analyses.
In October 2017, all Air France A340 crews had received training in rotation techniques. The first results of the flight analysis (about 600 flights) show that the crews have modified their rotation technique, which has had the effect of increasing the average rotation rate (from 1.8°/s to 2.2°/s) and reducing the rotation time.
Both Air France and Lufthansa has also implemented a precautionary measure which consists of introducing a fictitious reduction in the available runway length of 280 m (Lufthansa) and 380 m (Air France) for performance calculations for all A340-300 take-offs from Bogota.

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/serious-incident-to-the-airbus-a340-registered-f-glzu-operated-by-air-france-on-11032017-at-bogota/
https://www.bfu-web.de/DE/Publikationen/Bulletins/2017/Bulletin2017-03.pdf?__blob=publicationFile
https://translate.google.fr/translate?sl=auto&tl=en&js=y&prev=_t&hl=fr&ie=UTF-8&u=http%3A%2F%2Fwww.lepoint.fr%2Feconomie%2Fair-france-entre-le-bea-et-l-inspection-du-travail-apres-des-decollages-critiques-a-bogota-06-12-2017-2177639_28.php&edit-text=&authuser=0
_________________
https://flightaware.com/live/flight/AFR423/history/20170311/2330Z/SKBO/LFPG/tracklog
https://www.flightradar24.com/data/flights/af423#cb5fdfd
https://ad.easa.europa.eu/ad/2017-20

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration: 2 years and 4 months
Download report: Final report


Images:



Revision history:

Date/timeContributorUpdates
04-May-2017 08:03 harro Added
04-May-2017 08:03 harro Updated [Narrative]
21-Jun-2017 11:23 harro Updated [Source, Narrative]
27-Nov-2017 21:02 harro Updated [Time, Source, Photo, ]
06-Dec-2017 10:37 Iceman 29 Updated [Source, Narrative]
13-Dec-2017 10:30 AF5541 Updated [Total occupants, Source]
31-Aug-2018 17:44 harro Updated [Registration, Operator, Source]
15-Jul-2019 14:05 harro Updated [Total occupants, Narrative, Photo, Accident report, ]
24-Jul-2019 15:59 harro Updated [Source, Accident report, ]

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