Root cause analysis of The Concorde (Air France Flight 4590) crash, that occurred in Paris in 2000. This document will be updated. Air France Flight 4590 was a Concorde flight operated by Air France which was scheduled to fly from Charles de Gaulle Airport near Paris, to John F. Kennedy International Airport in New York City. On 25 July 2000, it crashed into a hotel in Gonesse, France. All one hundred passengers and nine crew members on board the flight died. On the ground, four people were killed and one critically injured.

1. Flight AF 4590
UCLA - Managing Project Quality - JM.G.

2. Air France Concorde at JFK Airport in 2003

3. The history of supersonic commercial air travel
has its roots in the 1950s and 1960s. (Context
of cold war)
Britain and France wanted air travel faster than
the speed of sound—faster than commercial
flights had ever flown.
1. The Concorde (Overview)
1.1 Context and History
flights had ever flown.
In January 1976, Concorde celebrated its first
commercial flight.
Up until an incident described in the following
slides, the Concorde was considered among
the world's safest planes.

4. Role: Supersonic airliner (turbojet-powered
supersonic passenger jet airliner )
National origin: United Kingdom and France
Manufacturer: Aerospatiale and EADS (now
Airbus Group)
1. The Concorde (Overview)
1.1 Key data (1/2)
Airbus Group)
First flight: 2 March 1969 (21 January 1976)
Status: Retired from service (26 November
2003)
Primary users: British Airways and Air France

5. Produced: 1965–1979
Number built: 20 (including 6 non-airline
aircraft)
Unit cost: €174 million (~$226 million)
Cruising speed: Break the sound barrier ; 2
1. The Concorde (Overview)
1.2 Key data (2/2)
Cruising speed: Break the sound barrier ; 2
times the speed of sound ; Mach 2.04 (about
1155 knots (2140 km/h or 1334 mph)
Passengers: Seating for 92 to 128 passengers
Competitor: Only two, Concorde and the
Tupolev Tu-144, were ever designed for civil
use as airliners

6. An aircraft departed (Concorde AF 4590) France on
July 25, 2000, at 4:45p.m., Air France Flight 4590
from Paris to New York
The flight lasted just under two minutes
2. The incident
2.1 What happened ?
The flight lasted just under two minutes
Just after liftoff, the supersonic jet crashed into a
hotel near the airport in Gonesse, France.
Video timeline: Seconds From Disaster (National Geographic documentary).
Video simulation: https://youtu.be/sgii3zPeFYY

7. 1. Problem: Concorde crash (What?)
2. Date: July 25th, 2000 at 4.45p.m (When?)
3. Location: Paris Charles de Gaulle Airport, runway
26R, Gonesse hotel (Where?)
3. Root cause analysis
3.1 Definition of the problem
26R, Gonesse hotel (Where?)
4. Impact-safety: Air France Concorde + 100
passengers + All 9 crew, 4 people on ground
(Who?)
5. Impact-property: First Concorde lost in 40000
flights. Loss of aircraft ($125 million)

8. 1. Why? – 113 fatalities occurred
2. Why? – 2 engines failed
3. Why? – Flames behind aircraft (First visible
effect). Why “The fuel cell ruptured”?
3. Root cause analysis
3.2 5-Whys analysis
effect). Why “The fuel cell ruptured”?
4. Why? –Tire disintegrated and exploded
5. Why? – Debris on the runway

9. There were multiple re-laminations of
the tires (worn tires)
Titanium wear strip debris was on the
runway dropped by other airplane
3. Root cause analysis
3.3 A Closer Look at the Cause (The Disintegrated Tire)
runway dropped by other airplane
Tire rolled over debris tilted on its edge
A stressed tire exploded with a piece of
it striking the underside of the wing on
Fuel Cell 5

10. The impact of debris from the exploded tire
resulted in a shock wave in the tank
The shock wave caused a rupture in a
forward location of the fuel tank
3. Root cause analysis
3.4 A Closer Look at the Cause (Fuel Cell 5)
forward location of the fuel tank

11. Fuel entered the intakes of Engines 1 and 2
on the left side of plane
The fuel choked the air flow
The engines experienced a flame-out due to
3. Root cause analysis
3.5 A Closer Look at the Cause (Loss of Two Engines)
The engines experienced a flame-out due to
the entering fuel
The fuel pouring from Fuel Cell 5 also
ignited

12. The pilot, while attempting to avoid a
Boeing 747 aircraft, veered sideways off
runway
The aircraft needed 3 of the 4 engines to
3. Root cause analysis
3.5 A Closer Look at the Cause (The Pilot)
The aircraft needed 3 of the 4 engines to
function
There wasn’t sufficient thrust to keep it aloft

13. 3. Root cause analysis
3.6 The Fishbone analysis
Standard fishbone diagram to investigate on Aircraft accident causes
NTSB: National Transportation Safety Board
B.E.A: French aircraft investigation agency

14. Concorde
Flight 4590
Machine
Flying debris from
blown tire hit Fuel
Tank 5
MethodsTime Materials
Left tire from Flight 4590
was cut and ruptured by
titanium alloy debris
Shockwaves in the
fuel tank caused a
rupture
Flight 4590 veered
sideways off runway to
avoid a Boeing 747 flight
Flight 4590 was one
hour behind schedule
Missing spacer was later
found in airline’s repair
shop
The first fatal crash
in 31-year history
(Complacency led
to a false sense of
security)
Load-bearing shear bushes
were out of alignment by 7
inches
Undercarriage of aircraft
was out of alignment
Balding tires—all tires had
multiple re-laminations
Five minutes before
Flight 4590 departed, a
Continental flight lost a
titanium alloy strip on
the runway
Rotation error; raising
of the plane’s nose
during take-off was
done incorrectly
Fuel spill from the
ruptured tank choked
the airway of two
engines causing fire
Flight 4590
Crash
PeopleEnvironmentEnergy Measurement
Cockpit Flight
Engineer shut down
the ailing 2nd engine
prematurely; flight
was 25 feet off
ground
Flight Captain should
have decided if an
engine was to be
shut down
There was a change in
wind conditions; flight
departure factors
should be been
recalculated
The Concorde reached
a velocity were it could
not abort take off; it
had to lift off with
flames from left wing
Flight 4590 was 6 tons
overweight for wind
conditions
Flight 4590 was
flying too slowly; 188 knots
instead of recommended
199 knots
A full runway
inspection was not
completed as was
protocol Center of gravity for
Flight 4590 was beyond
54% due to error in
weight distribution; plane
was rear-heavy
Industry-required
strength of tire was not
stringent enough
Shutting down an engine
is safe after elevation of
400 feet, not 25 feet, as
was done
Three of the four engines
were needed for the plane
to function properly
Flight 4590 hit a
landing strip light
during take off

15. 1. Problem Outline -what, when, where
2. Analysis – review cause techniques
3. Root cause analysis
3.8 Cause mapping analysis (Problem Solving Steps)
3. Solutions –
Possible Solutions
BEST Solutions
Action Plan

16. Impact
Safety 100 passengers fatalities
9 crew members fatalities
4 fatalities on the ground
Compliance Runway inspection not complete
3. Root cause analysis
3.9 Cause mapping analysis (Problem Outline: The Cause)
Compliance Runway inspection not complete
Property Property—Loss of aircraft valued at
$125,000,000, Hotel destroyed
Operations Loss of revenue, grounded and eventually
retired Concorde fleet
Frequency 1st Concorde lost in 40,000 flights or 900,000
hours

17. 3. Root cause analysis
3.9 Cause mapping analysis (The Concorde case)

18. After 9/11 attacks, market for flights
dropped. Last Concorde flight was in
October 2003.
New Supersonic airliners?
4. The Concorde crash
4.1 In the aftermath…
New Supersonic airliners?
Unlikely, exorbitant fuel costs made the
Concorde uneconomical
In 1989, a round-trip ticket from London to New
York cost about $6,500. By 2003, airfare had
soared to as high as $12,000 for a round trip
between New York and Paris

19. Bless the Checklist
Without a checklist, an organization begins to
lack order. Like in much of what we do, it’s the
little things that count.
Mandatory protocol for a full runway
4. The Concorde crash
4.2 Lesson learned
Mandatory protocol for a full runway
inspection before takeoff
Modifications were made to Concorde:
more secure electrical controls
Kevlar lining to the fuel tanks
burst-resistant tires

20. “Concorde forty-five ninety you have
flames, you have flames behind you!”
- Last sentence from flight recorder
4. The Concorde crash
4.2 Cost of poor Quality

21. Christian Marty, Pilot and famous windsurfer
Jean Marcot, Co-pilot
7 crew members, 100 passengers, and 4
people
Tribute
Gonesse memorial

22. http://en.wikipedia.org/wiki/Air_France_Flight_4590
http://en.wikipedia.org/wiki/Concorde
http://en.wikipedia.org/wiki/Supersonic_aircraft
http://www.thinkreliability.com/
https://www.youtube.com/watch?v=AxydOEd8oQQ
https://www.youtube.com/watch?v=sgii3zPeFYY
http://www.planecrashinfo.com/lastwords.htm
References
http://www.planecrashinfo.com/lastwords.htm
9 crew members, 100 passengers, and 4 people