Mar 24, 2015 — The BEA is the French Civil Aviation Safety Investigation Authority. Its investigations are conducted with the sole objective of improving
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Ministère de l™Ecologie, du Développement durable et de l™Energie Bureau d™Enquêtes et d™Analyses pour la sécurité de l™aviation civile Preliminary ReportAccident on 24 March 2015 at Prads-Haute-Bléone (Alpes-de-Haute-Provence, France) to the Airbus A320-211 registered D-AIPX operated by Germanwings This is a courtesy translation into English by the BEA of the Preliminary Report on the Safety Investigation. As accurate as the translation may be, the original text in French is the work of˜reference.Published May 2015
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D-AIPX – 24 mars 2015 2The BEA is the French Civil Aviation Safety Investigation Authority. Its investigations are conducted with the sole objective of improving aviation safety and are not intended to apportion blame or liability.BEA investigations are independent, separate and conducted without prejudice to any judicial or administrative action that may be taken to determine blame or liability.This document is a Preliminary Report and has been prepared on the basis of the initial information gathered in the course of the investigation, without any analysis. Some of the points covered may evolve with time. Nothing in the presentation of this document or in any of the points raised therein should be interpreted as an indication of the conclusions of the investigation.SPECIAL FOREWORD TO ENGLISH EDITIONThis is a courtesy translation into English by the BEA of the Preliminary Report on the Safety Investigation. As accurate as the translation may be, the original text in French is the work of reference.Foreword
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D-AIPX – 24 mars 2015 3Table of ContentsFOREWORD 2GLOSSARY 4ORGANISATION OF THE INVESTIGATION 51 ˜ FACTUAL INFORMATION 71.1 History of Flight 71.2 Injuries to Persons 111.3 Damage to Aircraft 111.4 Personnel Information 111.4.1 Captain 111.4.2 Co-pilot 121.5 Aircraft Information 131.5.1 Airframe 131.5.2 Engines 141.5.3 Maintenance 141.5.4 Cockpit door locking system 151.5.5 Communication from the passenger cabin to the cockpit 181.5.6 OPEN DESCENT Mode 191.7 Telecommunications 201.8 Flight Recorders 201.8.1 Type of equipment 201.8.2 Opening and readout operations 211.8.3 Synchronization of recordings 221.8.4 Previous Flight 221.8.5 Work carried out on the Quick Access Recorder (QAR) 231.9 Wreckage and Impact Information 241.10 Survival Aspects 251.11 Organizational and Management Information 261.12 Additional Information 261.12.1 Testimony 261.12.2 Previous Events 261.12.3 EASA Safety Information Bulletin 272 ˜ INITIAL FINDINGS 28 3 ˜ THE ONGOING SAFETY INVESTIGATION 29
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D-AIPX – 24 mars 2015 4GlossaryACPAudio Control PanelACARSAircraft Communication Addressing and Reporting SystemAMEAero-Medical ExaminerATCAir Traffic ControlBFUGerman Federal Bureau of Aircraft Accident(Bundesstelle für Flugunfalluntersuchung)CIAIACSpanish safety investigation authority (Comisión de Investigación de Accidentes e Incidentes de Aviación Civil)CVRCockpit Voice RecorderDGACFrench general civil aviation directorate (Direction Générale de l™Aviation Civile)EASAEuropean Aviation Safety AgencyFCUFlight Control UnitFDRFlight Data RecorderGPWSGround Proximity Warning SystemICAOInternational Civil Aviation OrganisationLBAGerman civil aviation authority (Luftfahrt-BundesAmt)MELMinimum Equipment ListPFPilot FlyingPFDPrimary Flight DisplayPMPilot MonitoringQARQuick Access RecorderREVMedical certificate issued after review procedure
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D-AIPX – 24 mars 2015 5d-px150324.enORGANISATION OF THE INVESTIGATION On 24 March 2015, at around 10 h 15, the Marseille en-route control centre informed the BEA of the accident to an Airbus A320, registered D-AIPX that had occurred while overflying the French Alps. In accordance with the provisions of European regulation (EU) n°996/2010 of the European Parliament and Council of the 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation, a Safety Investigation was immediately initiated by the BEA.A team of seven investigators from the BEA travelled to the accident site on the afternoon of 24 March. In coordination with the authorities in charge of the judicial investigation, and with helicopter transport provided by the Gendarmerie, the safety investigators were able to access the site the following day. The CVR was found on the afternoon of 24 March 2015 and transferred the following day to the BEA for readout. After reading out the data, it appeared to the BEA that an act of unlawful interference was probably involved in the accident. European Regulation (EU) n°996/2010 and the advance arrangement ‚‚relating to Safety Investigations between the French ministry of Justice and the BEA™™ of 16 September 2014, specify that, in such a situation, the relevant elements gathered during the Safety Investigation must be communicated immediately to the judicial authorities, and the BEA can decide to continue the Safety Investigation, which it did. The BEA associated the following foreign counterparts with the Safety Investigation, which then appointed Accredited Representatives: the BFU (Germany), the aeroplane being registered in Germany and operated by a German airline. This made it possible to obtain the assistance of technical advisers from Germanwings; the CIAIAC (Spain). This made it possible to obtain information relating to the aeroplane™s stop at Barcelona and data from the Spanish ATC service.Controlled descent on autopilot, collision with terrainAircraftAirbus A320-211 registered D-AIPXDate and time24 March 2015 at 09 h 41(1)OpertorGermanwingsPlacePrads-Haute-Bléone (04)Type of flightPublic transportPersons on boardCaptain (PM), co-pilot (PF), 4 cabin crew, 144˜passengersConsequences and damageCrew and passengers fatally injured, aeroplane destroyed(1)Except where otherwise indicated, all times in this report are UTC. One hour should be added to obtain the legal time in metropolitan France on the day of the event.
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D-AIPX – 24 mars 2015 6The BEA also associated technical advisers from EASA, the DGAC, Snecma (on hehalf of CFM) and Airbus.The Safety Investigation is organised with three working groups in the following areas: aircraft, aeroplane systems and operations. The Accredited Representatives and the technical advisers were divided between the three groups.At the time of the publication of this report, Australia, Israel and Japan appointed experts to follow the Safety Investigation, in accordance with standards and recommended practices in ICAO Annex 13, since some of the victims came from these countries.The BEA™s Safety Investigation, whose sole objective is to prevent accidents and incidents, will include the collection and analysis of data, a statement of conclusions, including the determination of the causes and/or contributing factors and, where appropriate, the issuing of Safety Recommendations.
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D-AIPX – 24 mars 2015 8At 9 h 30 min 24 (point), noises of the opening then, three seconds later, the closing of the cockpit door were recorded. The Captain was then out of the cockpit.At 9 h 30 min 53 (point), the selected altitude on the FCU changed in one second from 38,000 ft to 100 ft(2). One second later, the autopilot changed to ‚‚OPEN DES™™(3) mode and autothrust changed to ‚‚THR IDLE™™ mode. The aeroplane started to descend and both engines™ rpm decreased.At 9 h 31 min 37, noises of a pilot™s seat movements were recorded.At 9 h 33 min 12 (point ), the speed management changed from ‚‚managed™™ mode to ‚‚selected™™(4) mode. A second later, the selected target speed became 308 kt while the aeroplane™s speed was 273 kt. The aeroplane™s speed started to increase along with the aeroplane™s descent rate, which subsequently varied between 1,700 ft/min and 5,000 ft/min, then was on average about 3,500 ft/min.At 9 h 33 min 35, the selected speed decreased to 288 kt. Then, over the following 13 seconds, the value of this target speed changed six times until it reached 302 kt. At 9 h 33 min 47 (point), the controller asked the flight crew what cruise level they were cleared for. The aeroplane was then at an altitude of 30,000 ft in descent. There was no answer from the co-pilot. Over the following 30 seconds, the controller tried to contact the flight crew again on two occasions, without any answer.At 9 h 34 min 23, the selected speed increased up to 323 kt. The aeroplane™s speed was then 301 kt and started to increase towards the new target.At 9 h 34 min 31 (point), the buzzer to request access to the cockpit was recorded for one second. At 9 h 34 min 38, the controller again tried to contact the flight crew, without any answer.At 9 h 34 min 47 then at 9 h 35 min 01, the Marseille control centre tried to contact the flight crew on 133.330 MHz, without any answer. The aeroplane was then at an altitude of 25,100 ft, in descent.At 9 h 35 min 03 (point), the selected speed increased again to 350 kt(5). Subsequently, and until the end of the recording: the selected speed remained at 350 kt and the aeroplane™s speed stabilised around 345 kt; the autopilot and autothrust remained engaged; the cockpit call signal from the cabin, known as the cabin call, from the cabin interphone, was recorded on four occasions between 9 h 35 min 04 and 9 h 39 min 27 for about three seconds; noises similar to a person knocking on the cockpit door were recorded on six occasions between 9 h 35 min 32 (point) and 9 h 39 min 02; muffled voices were heard several times between 9 h 37 min 11 and 9 h 40 min 48, and at 9 h 37 min 13 a muffled voice asks for the door to be opened;(2)This is the minimum value that it is possible to select on A320.(3)This mode is described in paragraph 1.5.6.(4)When the speed is said to be ‚‚ selected ‚‚, the target speeds are chosen by the ˚ight crew. When the speed is said to be ‚‚managed™™, it is the ˚ight management system (FMS) that automatically determines the target speeds.(5)This value is the maximum speed that the ˚ight crew can select. It corresponds to VMO (maximum operating speed).
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D-AIPX – 24 mars 2015 9 between 9 h 35 min 07 and 9 h 37 min 54, the Marseille control centre tried to contact the flight crew on three occasions on 121.5 MHz, and on two occasions on 127.180 MHz, without any answer; between 9 h 38 min 38 (point) and 9 h 39 min 23, the French Air Defence system tried to contact the flight crew on three occasions on 121.5 MHz, without any answer; noises similar to violent blows on the cockpit door were recorded on five occasions between 9 h 39 min 30 (point) and 9 h 40 min 28; low amplitude inputs on the co-pilot™s sidestick were recorded between 9 h 39 min 33 and 9 h 40 min 07(6); the flight crew of another aeroplane tried to contact the flight crew of GWI18G at 9 h 39 min 54, without any answer.At 9 h 40 min 41 (point), the ‚‚Terrain, Terrain, Pull Up, Pull Up™™ aural warning from the GPWS triggered and remained active until the end of the flight.At 9 h 40 min 56, the Master Caution warning was recorded, then at 9 h 41 min 00 the Master Warning triggered and remained active until the end of the flight.At 9 h 41 min 06, the CVR recording stopped at the moment of the collision with the terrain.(6)Low amplitude inputs on the co-pilot™s sidestick were recorded between 9 h 39 min 33 and 9 h 40 min 07.
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D-AIPX – 24 mars 2015 111.2 Injuries to PersonsInjuriesFatalSeriousMinor/noneCrew members6–Passengers144–Others—1.3 Damage to AircraftThe aeroplane was destroyed.1.4 Personnel Information1.4.1 CaptainMale, aged 34, German nationality. air transport pilot™s licence ATPL(A) issued on 28 January 2014; A320 type rating revalidated on 9 July 2014; last class 1 medical check-up performed on 31 October 2014 and valid until 12˜December 2015. Experience: total: 6,763 flying hours; on type: 3,811 flying hours, of which 259 as Captain; in the previous 3 months: 108 hours; in the previous month: 18 hours; in the last 24 hours: 7 hours. Flying career: from March 2001 to June 2003, he undertook Air Transport pilot training at the˜‚‚Lufthansa Flight Training Pilot School™™ in Bremen (Germany) and the ‚‚Airline Training Center™™ in Phoenix (Arizona, USA)˜ in March 2005, he obtained his A320 type rating˜ from June 2005 to January 2010, he worked as a co-pilot on Airbus A320 for the Condor Berlin airline in April 2010, he obtained his A340 type rating, and his type rating for the A330 in February 2011 from April 2010 to May 2014, he worked as a co-pilot on Airbus A330/A340 for Lufthansa on 6 May 2014, he joined Germanwings as a Captain on A320.
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