Air France crash in Toronto (2 months ago) was avoidable disaster

http://www.thestar.com/NASApp/cs/Con...=1020852955095

Oct. 2, 2005. 08:44 AM
Pearson disaster was avoidable

SCOTT SIMMIE, KEVIN MCGRAN AND CATHERINE PORTER
STAFF REPORTERS

At least once a day, the image — unbidden, unwanted, indelible —
seizes the mind's eye of Philippe Lacaille.

Like an endless and cruel loop, the Aurora resident and his wife and
his two youngest children are again aboard Air France Flight 358,
bound from Paris to Toronto. It is, once more, August 2. Nothing
changes.

After a tumultuous descent, during which the Airbus A340 heaves and
rattles and groans through a non-stop maelstrom of lightning, rain and
wind, they are finally approaching the runway.

But something is very, very wrong. Lacaille can feel the wind pushing
the plane forward, feel the pilot fighting to keep the plane in line
with the runway.

The landing gear makes sudden contact with the wet asphalt. Hurtling
forward, Lacaille senses the right wing tip dip to the ground. Then he
feels the right engine explode and the right wing go back up. There's
an enormous boom and a sound — fwoompf — "like a deep subwoofer kind
of thing with an enormous glow on the right side."

When all 309 people aboard escaped with their lives from the burning
and broken A340 two months ago today, the media was quick to dub it
"The Miracle of Runway 24L."

And, given the catastrophe that might have happened, there's no doubt
it could have been much, much worse. Passengers departed quickly.
Emergency services responded rapidly. No one died.

But the trauma to passengers and destruction of the
multimillion-dollar plane needn't have happened at all.

A Star investigation shows that — despite the plane landing so late
there was little chance of it stopping in those conditions — a series
of safety improvements at the airport could have saved the plane.
Experts say the runway should be longer and should have special
grooves to mitigate wet conditions, and the end of the runway should
be surrounded with an apron of special concrete designed to stop
runaway planes.

"It was completely preventable," says Mary Schiavo

(haven't we had enough "Schiavo's" in the news lately?)

former director general of the United States Department of
Transportation, a pilot, author, and widely acknowledged authority on
aviation accidents.

Schiavo is an interested party — the South Carolina-based lawyer is
involved in a class action suit on behalf of passengers of Flight 358
— but numerous other aviation authorities in Canada and the U.S. have
told the Star, repeatedly, that runway 24L, and Pearson in general,
could have been made safer with some simple steps common at many
American airports.

Blue skies greeted Flight 358 when it passed into Ontario airspace.
But then the 57-year-old captain (Air France has not named any of the
crew) got on the intercom and said the plane would have to circle for
a bit — probably for 20 minutes, Lacaille recalls — because of severe
weather in the Toronto area.

A thunderstorm had been pounding the area from Newmarket to the
Niagara region intermittently through the afternoon. By the time Air
France Flight 358 was lining up to land, the storm was fiercer at the
airport than anywhere else in the region. Rain was hammering the
runways. The wind was quickly changing direction and blasting in
powerful 60 km/h gusts.

At 12:20 p.m., a lightning advisory had halted operations of the
ground crews, who were at risk of being struck. Planes were backed up
on the tarmac, unable to load or unload.

As the weather worsened, the Greater Toronto Airports Authority, which
operates Pearson, issued a news release saying the two north-south
runways were to be used only as a last resort due to the storm. The
northernmost east-west runway — the longest at Pearson — had been
taken out of operation the day before for maintenance.

The airport was down to 24R and 24L, two shorter runways that are
roughly parallel to Highway 401 at the southernmost point of the
airport.

Runway 24L is the airport's shortest, at 2.74 kilometres, and the
newest. Before it could open the runway in 2002, the GTAA had to buy
the Regal Constellation, a hotel on the east side of Airport Rd., and
slice the top off it to give planes enough clearance.

Pearson's critics don't have any issues with the hotel end of the
runway, but they're not happy with the other end. Just 200 metres from
the end of the tarmac, past a stretch of open grass and a service
road, lies a steep, tree-filled gully and the winding waters of
Etobicoke Creek. Proposals to do something about the creek hazard have
been made at least since 1972, when engineering consultant Robert
Choma approached the airport with a scheme to fill it in. He says his
plan was dismissed as too expensive.

The creek became an issue in 1978 when a DC-9 skidded off runway 23L
(now known as runway 24R). After an aborted take-off, the plane
skidded into the gully, killing two passengers. Two of the nine
recommendations from the coroner's jury involved covering over
Etobicoke Creek, but it never happened.

In 1996, Transport Canada handed control of the airport to the GTAA,
an autonomous, not-for-profit, private operator. The GTAA embarked on
a $4.4 billion redevelopment of the airport that included building a
fifth runway — 24L, parallel to 24R, both leading toward the creek.
Brian Lackey, vice president of operations for the GTAA, says filling
in the creek wasn't considered and the new runway was built to meet
Transport Canada safety standards. But Transport Canada standards
don't meet International Civil Aviation Organization standards.

ICAO, a branch of the United Nations, sets runway standards, but
leaves it to national authorities to implement them. ICAO standards
must ultimately fit into local realities, said Denis Chagnon from
ICAO's Montreal headquarters.

ICAO recommends a 300-metre safety zone at the end of all runways
handling international traffic, but will settle for a 150-metre safety
zone as an international standard. Transport Canada's standard calls
for a 60-metre over-run, with a recommendation for an additional 90
metres.

Pearson's runway 24L meets the 60-metre Transport Canada standard, but
not all of the additional 90-metre recommendation (the GTAA would not
divulge how much extra safety overrun space it has). It couldn't reach
the 90-metre mark without filling in the creek, a move deemed by some
to be too costly, and by others to be environmentally insensitive.

As one aviation official put it, if you don't have the extra 90
metres, "you just live with whatever you have."

While Flight 358 burned up time and fuel waiting for clearance to
land, many passengers watched the global positioning system relaying
the route in real time on the overhead monitors. Lacaille thinks they
might have spent 10 minutes or so before the captain — with 15,000
hours flying time and a 20-year career with Air France — again got on
the intercom. It was time, he said, to descend.

But Philippe Lacaille was starting to feel unsettled.

"I have flown 27 or 28 years around the world as an executive. I've
flown through very severe weather. I have never seen anything like
that.

"The clouds were dark and dense ... and the deeper we were going, it
started turning yellowish. (Yet) it was so dark they had to turn on
the lights in the plane," Lacaille says, still sounding in disbelief.

"Incredible turbulence, lightning all around the plane — every second,
almost. The plane was going absolutely insane. I'm not a pilot, but I
don't know how anyone in their right mind could have let the pilot
land in this weather."

Some experts have also questioned why the pilot chose to land. Other
planes had, but conditions were worsening. Mary Schiavo, the aviation
expert retained by a group suing the airline, speculates the plane was
virtually out of fuel and had no option but to put down.

The decision to land ultimately rests with the pilot, who relies on
information fed to the cockpit from the tower, from planes that landed
earlier, and onboard weather monitoring systems. But minutes before
Flight 358 came in to land, a lightning strike disabled runway 24L's
anemometer, a gauge for recording the speed and direction of wind —
vital information for a pilot landing in a storm.

Another tool for transmitting weather information — something Pearson
doesn't have — is Doppler radar, which can predict severe wind shears.
The airport, through Environment Canada, can tell pilots precise
weather patterns as they are; with Doppler, they can tell what's
coming.

"One thing that's missing at Pearson is some sort of wind-shear alert
system," said Bob Perkins, an Air Canada Jazz captain and the head of
the Canadian safety branch of the Air Line Pilots Association. "What
they have is reactive to what is there right now. It's looking at wind
speed, how much rain has fallen."

But what's needed "is more predictive, looking out beyond the
airports, seeing what's happening, translating that into motion to be
decoded by algorithms in the programs and be turned into an alerting
function that is usable by air traffic controllers, usable by flight
crews to give us some warning of the fact that things are not going
the way they should be."

Most major U.S. airports have it. So do a lot of American and Canadian
TV stations, for forecasting weather. But not Pearson. Lackey says
with its weather stations and radars, the airport feels it has the
information it needs to operate safely.

Air traffic controllers signalled Flight 358 to come in on runway 24L
and slow to final approach speed. At the same time, controllers were
keeping their eyes on another flight of lightning nearby. They told
Air Canada Flight 1105 to change position to "get you around some of
the heavier weather."

What happened in the cockpit is not clear, as investigators have not
publicly released audio recordings and released only partial black box
data. But some details are known.

As the shuddering jet descended to 300 feet, the autopilot and
autothrust were disconnected. The pilots would land the jet manually —
standard operating procedure for most airlines in poor weather.

At 300 feet, the pilots set the braking system to medium and brought
the plane in.

When planes land, most of the braking action is done by the wheels,
with spoilers and reverse thrust only helping to slow the aircraft.

The runway came in sight, 2.74 kilometres of slick, rain-soaked
asphalt, but to the Lacailles it seemed too far below. As it came
closer, Philippe and Veronique recall a sudden shift in wind blasting
the jet from behind. It felt like the wind was making the plane
accelerate through the air.

Pilots should touch down in the first third of a runway to give the
maximum distance for braking. For some reason — wind shear, human
error, other factors — the Airbus touched down almost half way down
the runway. There was very little room to stop. When the wheels hit
the runway the plane was travelling at 274 kilometres per hour,
slightly faster than it should have been.

The Airbus barrelled along the runway, and to many of the passengers
it felt like the plane was speeding up to take off again. Shortly
after touchdown, the pilots effectively stepped on the brakes hard.
Braking data released by Airbus shows the pilots quickly overrode the
autobrake and applied full braking power. One unconfirmed report in
the French media has the pilots delaying 12 seconds before activating
reverse thrusters. If true, experts say that was simply too late.

If there was indeed a delay in the reverse thrust engaging, there's
speculation it may have been software-related. There have been
incidents with other aircraft where the computer appeared to be
thinking one thing and not immediately responding to pilot inputs.

Gunnar Kuepper, a director of the International Association of
Emergency Managers and a member of the advisory board of the Canadian
Center for Emergency Preparedness, has studied the crash at Pearson,
and sees similarities with an accident in Warsaw in 1993.

A plane was attempting to land in heavy weather with severe rain and a
strong tailwind. When the tires hydroplaned, Kuepper says, they didn't
begin the normal rotation that would occur with a regular landing. The
computer didn't "think" the jet was down and — despite efforts by the
pilot — delayed the application of reverse thrust and brakes for nine
seconds. The jet skidded off the end of the runway; two of the 70 on
board died and many others were injured.

"The computer didn't realize the plane was on the ground. The pilot
didn't know what the computer was doing," says Kuepper. "My
speculation is that, indeed, something like that happened in Toronto.

-------------------------------------------------------------------
`If you had this crumbling runway stuff at the end of the runway, this
for sure would have saved the airplane.'

Gunnar Kuepper, emergency management expert
-------------------------------------------------------------------

"Therefore it had something to do with the interaction between the
computers and the pilot, and perhaps the pilot did not react properly,
the computer did not react properly, the plane landed very late, and
so on."

Soon after the crash, Real Levasseur, lead investigator for the
Transportation Safety Board, said he doubted hydroplaning was a
factor. There were skid marks on the runway. But experts interviewed
by the Star say the aircraft likely hydroplaned at least briefly,
dramatically reducing the braking potential of the wheels.

By the time it reached the end of the runway the plane had slowed
down, but not nearly enough. It skidded past the end of the runway,
beyond a 60-metre safety over-run and across a stretch of grass,
smashed through chain-link fence, skidded over a service road, smashed
through another steel fence, and fell down the tree-filled gully of
Etobicoke Creek.

With investigations under way, neither Air France nor Airbus will
comment on any aspect of the accident. In a statement by Airbus soon
after the crash, the aircraft manufacturer said information gleaned
from the preliminary investigation showed all of the aircraft's
systems worked, but the runway was simply too wet. The statement,
based on partial data, did not mention any software problems.

Given it landed 1,200 metres up a 2.74-kilometre runway, the pilot
should have abandoned the landing, says Doug Seagrim, a retired Air
Canada pilot.

"Before the wheels even touched, they should have realized how much
runway had gone by and how wet it was. Airplanes, once they're
traveling above 90 knots, they'll hydroplane. That's just like
waterskiing. The wheels don't actually contact the runway. To even
attempt to land when they're that far down the runway, or continue
with the landing, that's a classic `Don't do it.'"

The U.S. Federal Aviation Authority has a program to battle
hydroplaning. Just about every runway in the United States has grooves
cut into it perpendicular to the runway; the water drains faster, the
wheels get better grip.

The reverse is true in Canada, with only a handful of runways being
grooved. It wasn't always so. In the 1970s, Pearson's runways were
grooved, says Hugh Devitt, the general manager of the airport from
1972-76.

"I had in fact implemented the grooving of the thresholds of the
runway, that is both ends of the runways, with what we call grooving,"
said Devitt, now 84. "I'd proven in 1974 that this was the way to go
to accelerate the moisture leaving."

Lackey, from the GTAA, says grooving would be of no advantage today.

"The runways at that time were concrete surfaced. Our runways at
Pearson now are all asphalt surface. It's our belief we get an
appropriate amount of runway surface friction with an asphalt surface.
The grooving generally corrects problems with polishing of aggregates
and slipperiness of concrete surfaces."

That argument doesn't wash with the FAA. "We groove both concrete and
asphalt runways," says spokeswoman Marcia Alexander-Adams.

There were problems getting out. Several emergency chutes didn't
deploy, leaving passengers to jump three metres to the ground as the
fire grew behind them, stoking fears of an explosion. Passengers fell
on top of other passengers. Almost all of the injuries from the crash
were caused by the leap to the ground — broken legs, twisted ankles,
sore necks and the odd ruptured vertebrae.

So far this year, eight planes have over-shot their runways in North
America, resulting in 33 deaths and more than 150 injuries. But a
January incident at John F. Kennedy Airport International in New York
stands out, because no one was injured. A Boeing 747-200F skidded off
a runway perched over Jamaica Bay, and came to a complete stop. The
runway's very short safety zone was equipped with Engineered Material
Arresting System (EMAS). It's a concrete that crumbles under the
weight of an aircraft, but strong enough to support the weight of
emergency vehicles.

When it crumbles, it slows the plane down, says Pasquale DiFulco,
spokesman for the New York & New Jersey Port Authority, which
installed the world's first EMAS system at JFK in 1996.

"It's essentially concrete that's pumped full of air that's designed
to absorb the energy of a rolling aircraft, crushing the material as
it runs over it," said DiFulco. "Imagine driving a car into gradually
deepening snow, or into gradually deepening sand.

But the "jury's still out" on EMAS, says Lackey. "We understand there
have been concerns about maintenance, particularly in the kind of
climate we have here... It's a material which is susceptible to
moisture. When you get moisture and it freezes, it doesn't necessarily
perform as advertised."

But the FAA reports no problems with EMAS. It's in 18 airports in the
U.S., including six in northern climes — Minneapolis, Boston Logan,
Rochester, N.Y., Binghamton, N.Y., JFK and La Guardia — and one on the
way in Teterborough, N.J.

The GTAA's team of emergency responders from Peel and Toronto run more
than a dozen exercises a year. About a year earlier, the scenario was
a plane in the creek during heavy rain, eerily similar to the Air
France crash. They learned a lot, including that they would need
bulldozers to clear debris and make a path for fire trucks and
ambulances.

The paramedics have been lauded for their quick work that day in
treating passengers and getting them to safety in difficult
conditions. The first fire truck was there in 52 seconds, ambulances
soon after — remarkable considering that just getting to the site was
challenging for some of the paramedics, not because of the crash, but
because of the weather. Power lines were down, roads were flooded, the
highways were bumper-to-bumper.

The Airbus had been completely evacuated within 90 seconds, but
passengers had fled through the rain in all directions. Some headed
north onto the tarmac. Others went south toward the highway, where
they flagged down cars or huddled for cover under bridges. Passengers
were spotted walking the slim divider between the express and commuter
lanes of Highway 401. Still others clustered quietly together in the
ravine, covered in mud.

Four different triage centres were quickly set up to treat passengers
where they were. The rain was still bucketing down, making it
difficult to see. Black smoke billowing from the wreckage carried the
stench of burning plastic, as the fuselage of the Airbus disintegrated
in the intense heat.

Platoon manager Ben Addley, the first Peel EMS personnel at the crash
site, arrived to see scores of passengers frantically racing up the
gully toward him, yelling and asking where they should go. Most were
barefoot, as they had been told to remove their shoes before jumping
down the emergency chute.

A delivery truck pulled up out of nowhere. The driver jumped out and
yanked open the door to release about 40 people, including the
Lacailles.

"It was mayhem," Addley says.

The Lacaille family and many others were put on GTAA buses at the
site, where they sat for more than two hours before being taken back
to the airport where Philippe and Veronique's oldest son, Julien, 23,
was waiting for news of them.

(2 hours? is that how uncoordinated they were at YYZ?)

The arrivals monitor in Terminal 3 flashed that Air France Flight
358 had been delayed.

Then a passenger without shoes burst through the Arrivals gate
screaming there had been a fire and everyone on the Air France flight
was dead, Jirjes recalls.

Although all passengers aboard Flight 358 were promised compensation
for their destroyed luggage, Danial says she has yet to see anything
beyond reimbursement for some expenses.

It wasn't long after the crash before there was talk of class action
suits against Air France, the GTAA and Airbus, among others.

Danial has joined a suit organized by lawyer Paul Miller of Will
Barristers, Barristers and Solicitors, seeking damages of $325
million. Some of the 72 passengers in his suit "are terrified of going
into the subway because they're petrified of being in a confined space
with no control of their movement," Miller says. "I have a client who
won't even come into my office, which is on the 30th floor of my
building. She's too terrified."

Another suit, which also names the pilots as defendants, seeks $150
million.

Philippe Lacaille, who already went through one life-altering
experience when he quit his corporate job, seems to believe in second
chances.

"The question is: `What am I going to do with this second chance? How
can I benefit others?'" says Lacaille, who is also in the Miller
lawsuit.

Since the crash, he has opened his own Reiki centre in Oak Ridges and
also runs a hospice. "That's how I see completing the second part of
this life, is to try to be better with other people and serve them as
best I can."

By the end of the day, as a result of the storm and then the crash,
more than 450 flights were cancelled and thousands of passengers
forced to disembark planes that had been preparing for takeoff.

But no one died in this accident, and in a way that gives Transport
Canada and Pearson airport officials a second chance.

To Kuepper, the emergency management expert, the remedies are obvious.

"The Doppler radar would be very helpful to the pilots," says Kuepper.
"If you had this crumbling runway stuff at the end of the runway, this
for sure would have saved the airplane."

The Transportation Safety Board investigation continues. Spokesman
John Cottreau promises it will be "thorough" and if safety
deficiencies are noted, corrections will be recommended.

"If the safety board comes along and says `Gee guys, this has got to
change, or that's got to change, and that's particularly in relation
to grooved runways, or runway-end safety areas, or the arrester
systems' ... that would be first of all aimed at the entire country
and not just us," says John Kaldeway, CEO of the GTAA. "Whatever the
safety board says, we will be reading with a great deal of interest."

Transport Canada says it's looking at upgrading as many as 300 safety
standards, including safety over-runs, to bring Canada in line with
international standards. It may be 2007 before they're implemented.

In the meantime, more than 23 million passengers will move through
Pearson this year. Here's to second chances.

------------

See also:

http://www.tc.gc.ca/CivilAviation/co.../CRFI/menu.htm

Canadian Runway Friction Index

This tool is used to help pilots determine how effective braking will
be with different loads and different surface conditions. Table 4,
Runway Surface Condition and CRFI equivalent, shows that several of
the factors that day (water, crosswinds, etc.) would likely have
diminished the jet’s ability to brake. Interestingly, the very worst
scenario for braking is if the aircraft hydroplanes. There’s much talk
on the various pilots forums that hydroplaning could have been a
factor.

Airline Pilots Association (ALPA) news release. It describes Pearson
as “an international airport that, unfortunately, does not meet
international standards. It is the latest in a series of airline
accidents that highlight the dangers of inadequate runway safety
areas.”

Account of runway overshoot at JFK earlier this year. The craft was
saved by a material that slowed the runway run-away.