Representation Once the emergency response teams had finished their work, the
Transportation Safety Board of Canada (TSB) took control of the accident site and led the investigation, with the cooperation of several other organizations in accordance with the provisions of ICAO Annex 13: •
Transport Canada as the country of occurrence's representative •
Air France as the operator •
Airbus as the airframe manufacturer •
GE Aviation as the engine manufacturer •
French Department of Transport representing the country of operator and airframe manufacturer • United States
National Transportation Safety Board representing the country of the engine manufacturer
Mark Rosenker, the acting chairman of the
National Transportation Safety Board (NTSB), criticized the concept of passengers taking photographs of disasters, stating, "Your business is to get off the airplane. Your business is to help anybody who needs help." • Passenger oxygen tanks supposedly exploded in the heat of the fire. (
Emergency passenger oxygen is provided via a
chemical oxygen generator but the aircraft would have been carrying
therapeutic oxygen for passengers requiring a constant supply throughout the flight and first aid situations.) • The copy of the "E.R.S. Aircraft Crash Chart" at Pearson International Airport did not include blueprints for the Airbus A340 model of planes at the time of the accident. The blueprints would have contained vital information with regard to search and rescue efforts, and would have provided the location of fuel and pressurized gas tanks so that rescue crews could avoid them. Other irregularities that were not confirmed nor denied by officials: • 12 seconds elapsed between the moment the plane touched down and when pilots applied the
thrust reversers, which are used to assist braking • One of the aircraft doors opened on its own during the landing, according to witnesses. Black boxes are unable to reveal this data.
Conclusions The TSB concluded in its final report that the pilots had missed cues that would have prompted them to review their decision to land, and also that: • Air France had no procedures related to distance required from thunderstorms during approaches and landings. • After the autopilot had been disengaged, the pilot flying increased engine thrust in reaction to a decrease in 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 flight path. • At above ground level, the wind changed from a headwind to a tailwind. • While approaching the threshold, the aircraft entered an intense downpour and the forward visibility became severely reduced. • When the aircraft was near the threshold, the crew members committed to the landing and believed their
go-around option no longer existed. • The pilot not flying did not make the standard callouts concerning the spoilers and thrust reversers during the landing roll. This contributed to the delay in the pilot flying selecting the thrust reversers. • There were no landing distances indicated on the operational flight plan for a contaminated runway condition at the Toronto / Lester B. Pearson International Airport. • The crew did not calculate the landing distance required for runway 24L despite aviation routine weather reports (METARs) calling for thunderstorms. The crew was not aware of the margin of error. • The topography at the end of the runway and the area beyond the end of Runway 24L contributed to aircraft damage and injuries to crew and passengers. The TSB advised changes to bring Canadian runway standards in line with those used abroad, either by extending them to have a
runway end safety area (RESA) or, where that is not possible, providing an equivalently effective backup method of stopping aircraft. Other recommendations made by the TSB included having the
Canadian Department of Transport establish clear standards limiting approaches and landings in convective weather for all operators at Canadian airports, and mandate training for all pilots involved in Canadian air operations to better enable them to make landing decisions in bad weather. ==Litigation==