Egyptair 804 crash cause according to BEA

[A0283]

... a fire in the cockpit, French investigators said on Friday July 6, 2018.

They said onboard recorders suggested that the blaze had spread rapidly through the plane.

The findings contradict Egypt's earlier statements that explosives had been found on victims' remains, suggesting the aircraft had been bombed.
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FULL BEA TEXT BELOW
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Accident to the Airbus A320, registered SU-GCC and operated by Egyptair, on 05/19/2016 in cruise off the Egyptian coast [Investigation led by AIB / Egypt] - 06/07/18 18H15

- Download the full press release (https://www.bea.aero/fileadmin/user_upload/BEA_-_Press_Release_060718_18H15.pdf)

Review of situation on 6 july 2018 18H15

Following the accident on 19 May 2016 over the Mediterranean Sea involving an Airbus A320 registered SU-GCC operated by EgyptAir, a safety investigation was immediately opened. In compliance with the international texts in force, as the accident occurred in international waters, Egypt, as the State of Registry and State of the Operator of the aeroplane, is in charge of carrying out this investigation. The BEA appointed an Accredited Representative to represent France as the State of Design of the aeroplane, assisted by technical advisers from the aircraft manufacturer, Airbus. The NTSB (1) also appointed an Accredited Representative to represent the United States as the State of Manufacture of the engine.

France contributed to the safety investigation from the very outset. Initially, the BEA’s work consisted in acting as advisor to its Egyptian counterpart and then in participating in sea search operations for the aircraft wreckage. At the same time, the three States collaborated in collecting and analysing the first elements available - in particular the ACARS (2) messages.

Once the wreckage had been found, the debris was inspected and the flight recorders were located, retrieved and immediately sent to Cairo in order to start the initial work to recover and read the data. These operations, collectively decided on and carried out by the Egyptian, American and French specialists, did not succeed in reading the recorded data due to the severe damage to the data media. Advanced repair work was then necessary and the BEA was asked to carry it out in its laboratory in France.

The work on the flight recorders was carried out under the authority of the Egyptian Investigator In Charge, on the BEA premises, and at the beginning of July 2016 the data from the two flight recorders was extracted, read and decoded.

During this work, the Egyptian authorities published the following elements about the accident:

- The flight recorders stopped operating while the aircraft was in cruise at an altitude of 37,000 feet;

- The aircraft systems sent ACARS messages indicating the presence of smoke in toilets and the avionics bay;

- The data from the data recorder confirms these messages;

- The playback of the cockpit voice recorder reveals, in particular, that the crew mentioned the existence of a fire on board;

- Several pieces of debris were retrieved from the accident site. Some of these had signs of having been subject to high temperatures, and traces of soot.

Once the data from the flight recorders had been retrieved, the Egyptian authorities continued their work in Egypt.

In addition, the BEA had collected the following elements:

- A signal from an emergency locator transmitter was sent at 00:37 (source CNES (3) ) i.e. around eight minutes after the transmission of the last ACARS message;

- Data from a Greek primary radar (sent by the Greek authorities to the BEA) shows that the aeroplane had descended in a turn until collision with the surface of the water.

Based on these elements, the BEA considers that the most likely hypothesis is that a fire broke out in the cockpit while the aeroplane was flying at its cruise altitude and that the fire spread rapidly resulting in the loss of control of the aeroplane.

For its part, the BEA’s Egyptian counterpart announced in December 2016, the discovery of traces of explosive on human remains. It stated that, in accordance with Egyptian legislation, this finding led it to transfer the file to the Egyptian Attorney General who would from now on be responsible for carrying out the investigation.

The BEA’s proposals concerning further work on the debris and recorded data were not, as far as the BEA knows, followed up. The technical elements of the investigation already collected by Egypt, including those provided by the BEA, are protected by the Egyptian judicial investigation.

In an effort to continue the safety investigation mission, the BEA asked to meet the Egyptian Attorney General. This took place at the end of May 2018. In this meeting, the Egyptian authorities explained that as it had been determined that there had been a malicious act, the investigation now fell within the sole jurisdiction of the judicial authorities.

The BEA’s Egyptian counterpart did not publish the final report which would have allowed the BEA to set out its differences of opinion as authorized by the international provisions.

The BEA considers that it is necessary to have this final report in order to have the possibility of understanding the cause of the accident and to provide the aviation community with the safety lessons which could prevent future accidents.

As mentioned above, the BEA considers that the most likely hypothesis is the rapid spread of a fire and would like investigations into this hypothesis to be continued in the interests of aviation safety.

The BEA is ready to continue its collaboration with its Egyptian counterpart should the latter restart the safety investigation into this accident.



(1) National Transportation Safety Board: the BEA’s counterpart in the United States.

(2) ACARS: system for sending messages between the aeroplane and the operator, allowing, in particular, the transmission of information for maintenance operations.

(3) Centre National d’Etudes Spatiales (National Centre for Space Studies.

[SRS]

What can anyone expect from the useless Egyptian authorities. Same pattern of denying any wrong doing. The 767 out of JFK an example. A possible fire on board is too important to ignore.

[The Ancient Geek]

Evidence of an explosion and of a fire are not mutually exclusive, a fire could easily have caused a small explosion and vice versa. Which came first is a more difficut question to answer.

[atakacs]

Am I the only one to have an SR111 redux feeling?

[framer]

Fire in the flight deck?
What are the European regulations around power banks and charging tablet EFB’s / smart phones in the cruise? Anyone from that part of the world know?

[edmundronald]

Evidence of an explosion and of a fire are not mutually exclusive, a fire could easily have caused a small explosion and vice versa. Which came first is a more difficut question to answer.

Internal fire may sound better than a bomb, but iis often unsurvivable, and the A320 is a workhorse airframe. An indication that an airframe can catch fire "spontaneously" in cruise is much worse news than an indication of failure of ground security. The lag in finding and publicising the cause of accidents due to political constraints is not helping the safety process.

Edmund

[hoss183]

I believe from the evidence we have this fits. IMO BEA gets it right (for once). There have been several cases of O2 fires in cockpits, some fortunately on the ground. I would also remind people theres a photograph of SU-GCC at the gate with the F/O's perfume purchases sitting on the glare shield.

[Timmy Tomkins]

It's a tragedy that dictatorships like that one can get away with putting others at risk in that manner. There should be international sanctions against them if they do not cooperate with an independent investigation.

[PAXboy]

Simple. A flight deck fire is probably the fault of the airline. A bomb is not. Just as Egypt 990 crashed into the Atlantic due to a mechanical failure by the Boeing aircraft. Not!

[lomapaseo]

It's a tragedy that dictatorships like that one can get away with putting others at risk in that manner. There should be international sanctions against them if they do not cooperate with an independent investigation.

But Egyptians had already filed exceptions form "norms" when agreeing to abide by ICAO investigation rules when judicial investigation were performed. Many other states file similar exceptions.

Sanctions ??"? .there is no such avenue other than not to fly in those states. There of course can be behind the scenes cooperation (identifying shortfalls) as long as it doesn't interfere in an judicial investigations.

The issue to the rest of us is the presumption that the product airworthiness has not been impacted as long as "our" flight operating procedures are followed

[FIRESYSOK]

Evidence of an explosion and of a fire are not mutually exclusive, a fire could easily have caused a small explosion and vice versa. Which came first is a more difficut question to answer.

Evidence of “explosive” is not the same as evidence of an explosion.

[NWA SLF]

What constitutes explosive residue? One reason for asking is ever since I had a heart blockage in 2000 resolved by inserting a stent to keep the blockage open, I have carried nitroglycerin tablets. I've never needed to use one but they are with me. With all the shaking during travel, the tablets often turn to powder. In addition the bottle cap often comes off and the powder is distributed around my pocket, backpack, or wherever I happen to be carrying them. In an explosive residue test would nitro tablets, carried by thousands of Americans, show as an explosive residue? Now that I'm retired my hobby is farming and one of the products I use is ammonium nitrate fertilizer. It ends up on my clothes and I'm not sure washing removes all traces. Will this also result in explosive residue? I have only heard of explosive residue being found - has there ever been further identification of the exact residue to verify it is from an explosive device being detonated? There has been a lot of finite evidence released regarding a fire.

[DaveReidUK]

As far as I'm aware, the Egyptian view that there was an explosion on board was not based on having detected explosive residue, but rather on the fact that none of the body parts recovered from any of the passengers or crew were larger than the size of a hand, and the only identification possible was via DNA.

[andrasz]

What constitutes explosive residue?

Basically any trace amounts of cemicals that may be used in an ED. You are quite right in pointing out that many of these chemicals have perfectly legitimate everyday uses. A friend of mine who runs a carpentry shop was picked up on a random test at Frankfurt for alledgedly having explosive residues on hs clothes. The ensuing hassle resulted in him missing his flight, he was let go after an hour with no formal explanation (nor apology or compensation), he had to buy a new ticket.

[metro301]

As far as I'm aware, the Egyptian view that there was an explosion on board was not based on having detected explosive residue, but rather on the fact that none of the body parts recovered from any of the passengers or crew were larger than the size of a hand, and the only identification possible was via DNA.


From the article above: "For its part, the BEA’s Egyptian counterpart announced in December 2016, the discovery of traces of explosive on human remains. It stated that, in accordance with Egyptian legislation, this finding led it to transfer the file to the Egyptian Attorney General who would from now on be responsible for carrying out the investigation."

No one else found these "traces" except the Egyptians

[DaveReidUK]

From the article above: "For its part, the BEA’s Egyptian counterpart announced in December 2016, the discovery of traces of explosive on human remains. It stated that, in accordance with Egyptian legislation, this finding led it to transfer the file to the Egyptian Attorney General who would from now on be responsible for carrying out the investigation."

No one else found these "traces" except the Egyptians

Yes, I've read the BEA statement.

The pronouncements from various sources are contradictory, to say the least:

"A forensics official has said human remains retrieved from the area where EgyptAir flight 804 crashed point to an explosion on board.

The anonymous official is part of Egypt's investigative team and has examined victims' remains at a morgue in Cairo.

He told the Associated Press that all 80 body parts retrieved so far are small and that 'there isn't even a whole body part, like an arm or a head', adding: 'The logical explanation is that an explosion brought it down...but I cannot say what caused the blast.'

Egypt's al-Watan newspaper quoted another unnamed forensics official as saying the plane blew up in mid-air, leaving remains 'no larger than the size of a hand', but that it has yet to be determined whether an explosive device was to blame.

The head of Egypt's forensics authority denied there was evidence of an explosion later on Tuesday.

'Everything published about this matter is completely false, and mere assumptions that did not come from the forensics authority,' Dr Hisham Abdel Hamid said in a statement quoted by Mena news agency."

EgyptAir crash: Remains retrieved from flight MS804 crash site 'point to an explosion on board aircraft' (https://www.independent.co.uk/news/world/africa/egyptair-flight-ms804-crash-explosion-cause-latest-who-live-updates-mediterranean-sea-a7044546.html)

[EDLB]

IMHO finding only small body parts are most likely if the airframe was intact but hit the water with high speed close to the mach range. You find airplanes smashed to small pieces by high speed impacts into the ground. The same will happen if it hits water head on at high speed.
A midair explosion would separate seats from the airframe and they will have a much smaller terminal velocity <200kn with larger pieces remaining on water impact.

[Hotel Tango]

IMHO finding only small body parts are most likely if the airframe was intact but hit the water with high speed close to the mach range.

Precisely. And that is exactly what was believed to have been the case according to earlier facts published (which I can't find now).

[birdspeed]

It’s shameful that a report has not been released yet. We have all the evidence that we need. Important recommendations for the industry must be published before another incident like this happens again. Time is of the essence.

Just using amateur deductions, this looks very similar to the ground incident at Cario ironically with EgyptAir MS667. Fire accidentally started probably by the charging of an Apple device, then the O2 hose gets involved causing a blowtorch effect spreading down into the electrics bay.

[DaveReidUK]

It’s shameful that a report has not been released yet. We have all the evidence that we need. Important recommendations for the industry must be published before another incident like this happens again. Time is of the essence.

It's entirely conceivable that there will never be a report released into the public domain, now that the investigation has been removed from the Egyptian AIB and become a judicial responsibility.

As for the need for timely safety recommendations, I think the lessons from this event have already been learned.

[birdspeed]

Davereiduk,
What lessons might that be? I’m not aware of them. What have we learned? Has anything changed since MS804?

Thanks

[NWA SLF]

Was there not indication of a fire at the first officer windshield heating element connection? I can't remember now the places where I saw that mentioned and how that was identified - ACARS? Then the lavatory and equipment bay heat and smoke. A short at the windshield should have been protected by its circuit breaker but that is where I first saw someone suspect the first officer had placed their iPad near there. I don't know the design of the location, if there is some place to place an iPad, but most airplane knowledgeable people talked about a cockpit fire. I do remember that within minutes of the incident Trump Tweeted "There the Islamists go taking down another one." That is about as far as I read certifying it was an act of terrorism.

[DaveReidUK]

Correct me if I'm wrong, but I understand that a number of European operators (and possibly others) have imposed prohibitions on non-company-supplied portable electronic devices on the flight deck.

While we could argue as to whether or not that was a "lesson learned" from MS804, given that no probable cause has yet been determined, I don't think it's a coincidence.

[flash8]

Well it would suit the French to accept this narrative, after all no more looking at a CDG security breach.

This feels like an entirely politically driven conclusion to suit various parties. The truth as it were will never see the light of day, even if it were a fire, it could have been induced by somebody on board with nefarious motives (and tools), and then become uncontained, thus being a terrorist activity in reality.

[aixois]

Was there not indication of a fire at the first officer windshield heating element connection? I can't remember now the places where I saw that mentioned and how that was identified - ACARS? .

Hello,
It was on AVHERALD (article=4987fb09) :
On May 20th 2016 The Aviation Herald received information from three independent channels, that ACARS (Aircraft Communications Addressing and Reporting System) messages with following content were received from the aircraft:
00:26Z 3044 ANTI ICE R WINDOW
00:26Z 561200 R SLIDING WINDOW SENSOR
00:26Z 2600 SMOKE LAVATORY SMOKE
00:27Z 2600 AVIONICS SMOKE
00:28Z 561100 R FIXED WINDOW SENSOR
00:29Z 2200 AUTO FLT FCU 2 FAULT
00:29Z 2700 F/CTL SEC 3 FAULT
no further ACARS messages were received.
Early May 21st 2016 the French BEA confirmed there were ACARS messages just prior to break down of communications warning however that they are insufficient to understand the causes of the accident until flight data or cockpit voice recorders have been found

Good evening to everyone.

[birdspeed]

As well as these ACARS messages we have the CVR. We know the pilots were fighting a fire with halon extinguishers to no avail. So all we have to do is ask ourselves—what fire won’t be put out with halon extinguishers? Answer— incendiary device, lithium battery and oxygen fed fires.

[Christodoulidesd]

A Weak Circumstantial Theory by French Investigators Points to Fiery Apple Device Bringing Down Air Egypt - Patently Apple (http://www.patentlyapple.com/patently-apple/2017/01/a-weak-circumstantial-theory-by-french-investigators-points-to-fiery-apple-device-bringing-down-air-egypt.html)

[ZeBedie]

As far as I'm aware, the Egyptian view that there was an explosion on board was not based on having detected explosive residue, but rather on the fact that none of the body parts recovered from any of the passengers or crew were larger than the size of a hand, and the only identification possible was via DNA.

Yes, the 'explosion' was the energy released when it hit the sea at high speed. I pity the French investigators having to deal with that level of ignorance.

[rcsa]

From the current edition of The Economist - the journalist's story of cigarette smoke emanating from the cockpit exactly fits my experience the last three times I flew with EgyptAir. I wouldn't fly with them again. I try to avoid stereotypes, but probably more than any country I can think of, every time something goes wrong the Egyptian official narrative defaults to 'it wasn't our fault, must have been someone else'.

https://www.economist.com/gulliver/2018/07/14/what-really-happened-to-egyptair-flight-804

GULLIVER (https://www.economist.com/gulliver/2018/07/14/what-really-happened-to-egyptair-flight-804GULLIVER) is not the type of person to kick up a fuss on his travels, least of all when lucky enough to be at the front of the plane. But his patience was pushed to the limit a couple of years ago, when his EgyptAir flight from Cairo to London was blighted by the near-constant stench of cigarette smoke wafting in from the cockpit. Shackled by British meekness and an unwillingness to challenge a flight crew, your asthmatic correspondent suffered the coughs and tried instead to focus on work. Conversations with Egyptian friends later revealed that on-board cigarette smoke is hardly a rarity when flying with the North African flag-carrier. Naturally, anecdotes such as this provide only a snapshot of an airline’s safety standards. But it is a deeply disturbing snapshot given the stalled investigation into EgyptAir Flight 804, which crashed into the Mediterranean Sea during a routine flight from Paris to Cairo in 2016, killing all 66 people aboard. This month, France’s air-crash investigation agency, BEA, took the unusual step of criticising the official Egyptian investigation into the disaster. The French body rejects Egypt’s conclusion that a “malicious act” likely brought down the plane. When BEA was shown supposed evidence of explosive traces on the remains of some of the victims two years ago, it suggested that the test results may have been tampered with. It believes that a fire likely brought down the aircraft, basing its conclusion on three pieces of evidence: electronic signals sent from the plane indicating that smoke alarms were activated in the toilet and avionics bays; cockpit voice recordings that show the flight crew discussing an on-board fire; and wreckage that bears signs of high temperatures and soot.Unearthing the truth about Flight 804 will not bring back the 66 victims. But it may bring some closure to their relatives. And, if lessons can be learned, it probably will help save lives in future. BEA notes that Egypt ignored requests to conduct further tests relating to the fire theory and then failed to publish a final report into the crash. Without this, it says it has no platform on which “to set out its differences of opinion, as authorised by the international provisions”. This response, like Gulliver's, is too timid. The French body should take its concerns directly to the European Aviation Safety Agency (EASA), which has the power to ban EgyptAir from the European Union’s skies if it believes the airline’s regulator is failing to abide by international norms for air crash investigations.

[DaveReidUK]

https://www.economist.com/gulliver/2018/07/14/what-really-happened-to-egyptair-flight-804 (https://www.economist.com/gulliver/2018/07/14/what-really-happened-to-egyptair-flight-804GULLIVER)

Bad link.

Economist: What really happened to EgyptAir Flight 804? (https://www.economist.com/gulliver/2018/07/14/what-really-happened-to-egyptair-flight-804)

[Trav a la]

Why do EASA need to have this issue brought to their attention before taking any interest/action in the interest of the safety of all?

I would have thought that they should take some form of action if they suspected there was more to this accident than there appears to be on the face of it. In other words, how can they allow a countries self interest, such as Egypt, to supersede that of the wider aviation community?

[SLF3]

"Star Alliance Member Airlines 28 airlines working in harmonyOur member airlines include many of the world’s top aviation companies as well as smaller regional airlines. Together, they offer easy connections to almost any destination in the world.Each airline maintains its own individual style and cultural identity, bringing the richness of diversity and multiculturalism to the alliance. At the same time each airline shares a common dedication to the highest standards of safety and customer service."
So why would I fly Lufthansa in preference to Egyptair? They codeshare.........

[rcsa]

So here's a question; how resistant is an A-320 cockpit to a dropped cigarette? Back in the day when every Sky God (and half the passengers) smoked, presumably there were dropped cigarette ends all over the place; yet I don't know of cases where an aircraft was brought down by an ensuing fire. But is a relatively modern aircraft designed on the assumption that there will be no such dropped hot coals? Is there an ashtray provided in the cockpit, or do illicit smokers use a plastic cup with a bit of water in the bottom? If such an arrangement was balanced on the top of the cockpit coaming (where the fire/smoke warnings first appeared on the ACARS messages), and tipped or fell over, what would happen if water and a burning cigarette fell down the air-vents below the windshield?

We'll never know, I guess. Although the iPad/phone LiOn fire theory remains a prime suspect, it would be very interesting to hear answers to these questions from someone who knows the A320 flight deck and systems.

Dave - thanks for fixing the link. I cut-and-pasted the article because I suspected the link might not work, but thanks for tidying it up.

[hoss183]

So here's a question; how resistant is an A-320 cockpit to a dropped cigarette?

Just a dropped cigarette - pretty resistant to zero problem
An ignition source (whether it be cigarette or ipad etc) + an oxygen leak - almost impossible to extiguish

[infrequentflyer789]

So here's a question; how resistant is an A-320 cockpit to a dropped cigarette? Back in the day when every Sky God (and half the passengers) smoked, presumably there were dropped cigarette ends all over the place; yet I don't know of cases where an aircraft was brought down by an ensuing fire. But is a relatively modern aircraft designed on the assumption that there will be no such dropped hot coals? Is there an ashtray provided in the cockpit, or do illicit smokers use a plastic cup with a bit of water in the bottom? If such an arrangement was balanced on the top of the cockpit coaming (where the fire/smoke warnings first appeared on the ACARS messages), and tipped or fell over, what would happen if water and a burning cigarette fell down the air-vents below the windshield?


Maybe better to ask what happens if burning flammable liquid went down there. From: https://www.thetimes.co.uk/article/pilot-s-ipad-may-have-started-fire-that-brought-down-jet-say-experts-37sgdkd5p

CCTV from the gate at Charles de Gaulle airport showed that Mohamed Mamdouh Ahmed Assem, the co-pilot on flight MS804, put his Apple iPhone 6S, his iPad mini and four bottles of cologne on the dashboard before the Airbus A320 took off for Cairo on May 19,

So, that's batteries/igniters, timers (integral to phone/ipad), and accelerant (of type favoured by some terrorists: https://www.mirror.co.uk/news/uk-news/exclusive-scent-from-hell-550498 ), now unless I'm being terminally dumb that's just one tiny trivial to hide short-circuit-switch away from an incendiary bomb, isn't it? Maybe the Egyptians are right after all ? :\

[rcsa]

On that evidence I don't think you're the one who's being 'terminally dumb', habibi. I think it's the bloke who put all that stuff up there in the first place, and his Captain who didn't think it might be a good idea to exercise command authority and tell him not to be so dumb...

I tend towards the cock-up rather than the conspiracy. Sounds to me like this is just the same complacent ignorance and disregard of risk one sees every minute of the day in Cairo traffic, rather than the calculated plot you seem to imply...

Good grief.

[tupungato]

Recent report determined the crash was caused by pilot smoking cigarette (supposedly it was allowed in Egyptair), and faulty setting of an oxygen mask (set by maintenance to emergency and emitting oxygen, should have been checked before flight). From what I understand it is a 134-page independent report by French aviation experts, not by Egyptian authorities. Here is a summary:

https://nypost.com/2022/04/27/egyptair-flight-ms804-fatal-crash-caused-by-pilot-mohamed-said-ali-ali-shoukairs-cigarette/


I think Italian Corriere Della Sera was the first news outlet reporting, and they have most details. You can Google translate it.

https://www.corriere.it/cronache/22_aprile_26/volo-egyptair-incendio-piloti-fumo-fb725f4c-c4d3-11ec-8db2-dfe15c68e9dd.shtml

[A0283]

<just a webtranslation - only minor rewriting/improving>

--/--

EgyptAir flight crashed in the Mediterranean, six years of silence and no final report

The EgyptAir plane then crashed in the Mediterranean


25 Apr 2022



On 19 May 2016 the Airbus A320 departed from Paris and headed for Cairo with 66 people crashes into the sea. Egypt has not published the results of the investigation. Relatives of the victims: "We want the truth"

Immediately after that flight Quentin Heslouin, a 41-year-old French engineer, wants to take his dad Pierre, 75, to the Abu Simbel archaeological site in Egypt. A trip together, just the two of them. Although where they are seated - the first in seats 31C, the second at 31B - you would have seen little or nothing of the night landing in Cairo: the row is level with the wings. But Quentin and Pierre will never have the chance to see either the metropolis or the ruins that are a World Heritage Site. The plane on which they travel, an EgyptAir Airbus A320 departed from Paris-Charles de Gaulle and headed for the Egyptian capital, sank into the Mediterranean on 19 May 2016, 290 kilometers from Alexandria in Egypt. There are 66 people on board: 56 passengers, 7 crew members and 3 security officers.

The alarms

Before disappearing from the radar - and shortly after leaving Greek airspace - Flight MS804 reports through the automatic system the presence of smoke in the front bathroom and in the lower part of the nose. The pilots do not launch any may days. The Airbus A320 is one of the most used and safest aircraft in the world. Thousands fly every day. But six years after that tragedy, the Egyptian authorities - leading the investigations by jurisdiction - have never produced any final investigation report, as desired by international treaties. Nor is it preliminary.

Foto A debris from EgyptAir's Airbus A320 spotted in the Mediterranean

The news to families

“Since May 2016 we have only had questions and no answers. We want to understand why we lost our loved ones and we still don't know it today, ”Julie Heslouin, elementary school teacher, sister of Quentin and daughter of Pierre, tells Corriere della Sera on the phone. Julie animates the committee of relatives of the victims of flight MS804. The moment when life changed for her she remembers it very well. "In the morning I saw on TV that an EgyptAir plane had crashed, but I didn't immediately connect the fact to the trip of my brother and my father", she reconstructs. "At that point my sister Aude called the emergency number for the family and that's where we found out."

The terrorism alarm

Flight MS804 - with Mohammed Saied Ali Shokair and first officer Mohammed Ahmed Mamdouh Assem at the controls - takes off from "Charles de Gaulle" in Paris at 23.09 on 18 May 2016. It is a particular period in Europe with alarm thresholds at the highest. The autumn before, in the French capital, there were the attacks of the Bataclan and its surroundings (130 dead, 368 injured). On 22 March, a couple of months before the flight, a terrorist group organized the attacks in the Brussels area and at the airport (32 victims, 340 injured). So when the Airbus A320 disappears, the first thought is of a terrorist attack.

Foto The two "black boxes" of the aircraft that sank in 2016

Above Italy

At 00.11 on 19 May the jet enters the Italian airspace above Livigno, a few minutes later it leaves the country from Veneto, then runs along the entire Balkans and continues further south. At 01.24 - they reconstruct the routes of the specialized site Flightradar24 - enter the Greek airspace, but an hour later neither the Greek nor the Egyptian controller managed to get in touch. At 2.30am the Airbus disappears from the radars of both area control centers after veering a couple of times, first to the left, then immediately to the right.

Foto The two pilots at the controls of flight MS804

The seven signals

Shortly before sinking, it turns out later, the plane sent 7 "dispatches" in just 2 seconds through the "Acars", a data communication system with ground stations: they report problems with the anti-ice sensors, the windows of the cockpit, the presence of smoke in the front bathroom and in the avionics compartment (under the cockpit), the stop of the functioning of 2 computer systems crucial for flight and of the one that maneuvers the wings. Neither the commander nor the FO mentions it or asks for assistance.

Foto The Bea detective office hangar near Paris

The start of the investigation

Relations with the Egyptians are immediately problematic. The incident, for Cairo, is an act of terrorism and for this reason the investigation requires the documents to be kept secret. The transalpine authorities find it hard to support these theses. The dynamics of the debris recovered around the impact area, according to Western experts, excludes the explosion at high altitude. The truth lies in the 2 black boxes, found and analyzed in the laboratories near Paris of the French detective agency Bea. But the intergovernmental agreement stipulates that Bea cannot disclose the information because she is not responsible for the investigation. A search warrant from the French judiciary is needed to obtain the data of the black boxes which remain known only to a very few people. «From the Egyptians we received only the condolences of the rite and the remains of our loved ones. Then silence, ”Julie says.

foto The one on the 2016 flight is missing from the list of investigations into accidents in Egypt

No document

Cairo stops confronting Paris a few weeks after the accident, they let the transalpines filter out. Since then, it's just silences, omissions and tensions. Egyptian investigators have never published a preliminary report - which international standards usually indicate to do within 30 days of the incident - or a definitive one. "We have not received any final document on flight MS804, but to find out the reasons we invite you to ask the state that set up the investigation commission," a spokesman for ICAO, the UN civil aviation agency, explained to the Courier.

What does Annex 13 of the Icao regulations on air accidents say

International rules

Annex 13 of the ICAO regulation provides that "the state conducting the investigation must make the final report available to the public as soon as possible or, in any case, within 12 months of the accident". If this is not possible then "the state must publish a provisional report on the occasion of each anniversary of the accident". Which Egypt has never done. The civil aviation authorities and local investigative offices have never responded to the Courier's requests. No comment also from EgyptAir, while the French judicial authority - which has opened a file because there are compatriots among the victims - prefers secrecy.

EgyptAir's maintenance hangar (photo by the airline)

The counter-investigation

A 76-page document, prepared between 2018 and 2019 by 2 French experts, claims that in the previous 5 flights that aircraft recorded about 20 warnings for more or less important technical problems - from the air intake system in the engines to the smoke detection sensors on board - "but were not reported by the pilots and therefore not analyzed by the maintenance of EgyptAir," it says. Egyptian civil aviation denies the existence of technical problems. "Before its penultimate flight (from Cairo to Paris, ed.) The plane should not have taken off without extensive control," write the 2 experts. However, they conclude that it is not possible to identify a root cause.

Foto Some of the faces of the 66 victims of the plane crash in Cairo, Egypt

The French version

A spokesperson for Bea, contacted by Corriere, explains that the official position of the French detective remains that of 6 July 2018. With a press release - at times very harsh - the agency claims that "the most probable hypothesis of the accident is that it was caused by a fire that broke out in the cockpit during the cruise phase, which spread quickly leading to the loss of control of the aircraft ". Bea also stresses that "it is necessary to have a final report of the incident in order to be able to present the differences of opinion to the Egyptians as established by international standards". Having this document also serves to improve safety in the sector as it always happens after every tragedy in the skies.

Foto Relatives of the victims of flight MS804 in front of the Egyptian embassy in Paris

The family members

"6 years later we are torn between hoping to know the truth and feeling tired because things are not going as they should," says Julie Heslouin. Will the truth ever be found out? «I don't know - she replies -, I myself oscillate between optimism and pessimism. The French authorities, whom we have met several times, have listened to us, but the fact is that there is no progress. Without an effective collaboration from Egypt, without being able to hear the people involved in the maintenance, it becomes almost impossible to get to the bottom of this story ".

[A0283]

<just a webtranslation - only minor rewriting/improving>

--/--

26 Apr 2022

A confidential report of French experts on flight MS804 Paris-Cairo in 2016 with 66 people on board: "Plane crashed in a fire caused by the leak of oxygen"

EgyptAir flight MS804 Paris-Cairo crashed in the Mediterranean on 19 May 2016 with 66 people on board due to a fire that broke out in the cockpit due to the escape of oxygen from the co-pilot's mask - changed 3 days earlier and set to mode "Emergency" - at a time when the commander or FO was probably smoking at 11,278 m AMSL. Six years after that disaster, some of the world's leading experts shed light, perhaps once and for all, on what happened to the A320 of which the Egyptian authorities - responsible for the investigation - have never made known neither a preliminary report nor a definitive one. . A 134-page document - which Corriere della Sera has viewed exclusively - now reconstructs the last moments. The dossier was sent a month ago to the Paris Court of Appeal which is investigating for "manslaughter" because among the victims there are also 12 compatriots.

The route

Flight MS804 takes off from "Charles de Gaulle" in Paris at 11.21 pm on May 18, 2016. At 12.11 am the jet enters the Italian airspace above Livigno, flies over Veneto, then skirts the Balkans and proceeds south. At 2.27 am the Greek controller invites the pilots to get in touch with their Egyptian colleague because the Airbus is entering the airspace of the African country, "but it gets no response," writes the French investigation. At 2.34am the aircraft disappears from the radars of both area control centers after turning first to the left, then immediately to the right and without sounding any alarm. Shortly before the crash, it turns out, the plane sent 7 "dispatches" in 2 seconds: they signal problems with the anti-ice sensors, the cockpit windows, they indicate the presence of smoke in the front bathroom and in the avionics compartment (under the cockpit), the stop to the functioning of 2 systems crucial for flight and wings.

The investigations

On 16 and 17 June, a month later, the 2 "black boxes" are recovered (one records the technical parameters of the flight, the other the audio of the pilots) then sent to France to be examined by the investigative agency Bea, which delivers the results - as established by the rules - to those responsible for the investigation: Cairo. Relations with the Egyptians are problematic. The accident, for them, is an act of terrorism. Paris does not agree: the debris recovered around the impact area excludes the explosion. In autumn 2018, with an unprecedented act, the French judicial police came to the offices of the Bea to collect the data from the "black boxes". To draw up the current report, the experts met 23 times between Aug 2021 and Feb 2022. They put pen to paper that on board that aircraft the pilots tended to smoke a lot (something not forbidden at the time by EgyptAir) and that in previous trips there The plane experienced several technical problems "but none so serious as to require its grounding".

The beginning of the tragedy

On May 16, 2016, a EgyptAir maintenance worker replaced the co-pilot's oxygen mask. The reason is also not clear why Egypt does not cooperate. When putting away the new mask, the attendant leaves the cursor that manages the air flow in the "emergency" position. According to the report, this is the beginning of the chain of events leading to the crash: the Airbus manual writes that in emergency mode "an oxygen leak may occur". This is what happened on board flight MS804. To confirm this are the audio of the pilots.

The traces of oxygen

By separating the soundtracks of one of the black boxes, the "CVR", the experts discover 2 rustles at 2.25 and 24 seconds and at 2.25 and 29 coming from the microphone incorporated in the oxygen mask of the co-pilot who at that moment it is in its compartment. Then 2 more blows, at 2.26 and 11 and at 2.26 and 24. Oxygen itself is not flammable, but promotes combustion. For this reason, immediately after there is a beginning of a fire triggered "by a spark or a flame". The finger is pointed at a lit cigarette, yet another in that aircraft if it is true that 2 months earlier in the cockpit the ashtrays were replaced because they are now too used. The document is unable to establish whether the pilots used a fire extinguisher or not.

The planned checks

"When we enter the cockpit, between the various preliminary checks before taking off, there is also the control of the oxygen flow in the side masks," Daniele Veronelli, commander of A320 and member of the technical department of Anpac (National Association commercial aviation pilots). "A door is lifted and the air flow is tested by pressing a button that protrudes from the compartment. By operating the intercom you can hear the oxygen flowing because each mask is equipped with a microphone ". If the crew is the first to set foot on the plane that day - he continues - "then this type of test is also performed. If, on the other hand, one takes over from colleagues, the check is not foreseen, but it does not detract from the fact that this is done anyway, it only takes a few seconds ".

The alarms

Are there any signs of oxygen on board? "When the levels drop, on one of the screens in front of the pilots the indication of the amount of oxygen turns orange. If you are on the ground you do not take off, if you are in flight you have to decide whether to continue or divert to the nearest airport ". The masks have a minimum of 15 minutes of autonomy. "There is a lever: if it is in the normal position, the oxygen flow is on demand. If, on the other hand, it is in the "emergency" position then this releases the air at a higher pressure to throw out the fumes that could enter in the event of a fire or smoke on board.

The tiredness of the pilots

In the document, among many things, there is a passage on the pilots. Between 01.01 and 1.46 at night - when the aircraft passes between the coast of Croatia and over Athens, Greece - the technicians note, hearing the black boxes, that the commander and FO show signs of fatigue. "A yawn is clearly audible at 1.01 and 53 seconds", it reads. Twelve minutes later "captain and FO clearly express that they both feel tired from this night flight and from lack of sleep." Same concept repeated at 1.46. But the documents compiled, the experts explain, "indicate that rest hours have been respected for both".

The reactions

The Egyptian CAA and EgyptAir did not respond to the Courier's questions. ICAO, the UN civil aviation agency, explains that it has not received any final reports from Cairo. Bea, the French investigative agency, confirms the position expressed in 2018: for them the most probable hypothesis remains "a fire that broke out in the cockpit during the cruise phase which led to the loss of control of the jet". "We have been wanting to understand why we have lost loved ones since May 2016," says Julie Heslouin over the phone, who lost her brother Quentin, 41, and her father Pierre, 75, on the phone. he has long wanted the truth. This document could perhaps provide the answers.

[comcomtech]

Evidence of frayed insulation around high-pressure oxygen lines in the cabin was, I believe, presented in this forum shortly after the accident. A similar situation was (in the same post) blamed for a tarmac fire of another Egyptair craft a few years earlier.

[A0283]

Would be interesting to find out if ICAO can find a solution for countries not publishing reports.

One option might be to give interested parties an opportunity to file an official report (in their own language and english) at ICAO if the lead country does not abide by the rules (say for example after 3 or 5 years, which should give the lead country enough time). That official report could then be used by ICAO and the global aerospace community as the default report for that specific case.

[MissChief]

No accident report? No surprises from Egypt. nor Pakistan, nor Cuba, nor a host of other 3rd world countries. Their pilots are never to blame, nor the airline's maintenance, nor anything remotely connected to their country.

Simply a good reason to avoid flying with carriers from the 3rd world. Which I do.

[ATC Watcher]

Simply a good reason to avoid flying with carriers from the 3rd world. Which I do.
Yes if you can, but I think you forgot this is a professional pilots forum , not a travel agency one.
A0283 : Would be interesting to find out if ICAO can find a solution for countries not publishing reports.
Everything in ICAO is " Should" not "shall" and even then there are no sanctions if you do not follow .. A member state is sovereign.. Insurance companies have probably more power there than ICAO.

[Bergerie1]

ATC Watcher is absolutely right. ICAO does a tremendous amount of good work but member states have not given it the right to mandate. States can and do file exemptions and quite often ignore ICAO recommendations.

[DaveReidUK]

ICAO is, of course, an agency of the UN - so it's unreasonable to expect it to have any more power/authority than its parent.

[WillowRun 6-3]

Regarding ICAO, though indeed it exists as an agency within the UN structure overall, and lacks the authority to enforce SARPs or Annexes or the Convention Articles as if it were a court of a sovereign state, IMHO the system it administers has enabled and supported standardization - not universally, but on a very widespread basis.

The suggestion by A0283 would seem to involve some change to Annex 13, such that a process for producing a substitute investigation report would be available. The lack of literal mandatory enforcement powers at ICAO does not make this a pointless effort.

Whether there is an informal, between-the-lines system within ICAO for imposing consequences if not sanctions as such, upon states which depart from Annex 13 processes (or other components of the ICAO system) is a "nice" question -- but its answer doesn't make the idea of a substitute report process - available after a certain lapse of time - an inadvisable idea.

[ATC Watcher]

ICAO was created to get a form of internationally agreed rules in civil Aviation , as well as covering international airspace . It is mainly standardization body ,and some annexes, like Annex 13 are not their priority, The priority is PANS OPS and PANS ATM, and that works relatively well. and keeps us safe when we fly
As to accident investigation reports, although there is a template , there is no guarantee the contents will be useful . I have seen some reports of a few pages but where every question is answered, but tells you absolutely nothing , to 400 pages ones .But in the end , the analysis is what counts. The problem today is that insurance lawyers ( sorry Willow run ) are looking for clues to blame someone to get either their clients off the hook , or just make money for the families ( and themselves) . That explains partially why some recent reports keeps things vague if the investigators are not 100% sure of a fact. Bad for safety and we may be missing important clues as a result.

[DaveReidUK]

Whether there is an informal, between-the-lines system within ICAO for imposing consequences if not sanctions as such, upon states which depart from Annex 13 processes (or other components of the ICAO system) is a "nice" question -- but its answer doesn't make the idea of a substitute report process - available after a certain lapse of time - an inadvisable idea.

Fair point.

However, as in much of life, desirable and feasible aren't the same thing.

[ATC Watcher]

One of the consequences of not having final reports is that the ‘global’ data is not complete
The public one yes, but the people that matter i.e. the ones that propose things and have power to do changes, have the facts and the data
There are closed doors meetings where IATA, the manufacturers and ops people cooperate and solve things, Not always visible but very effective.

[WillowRun 6-3]

ATC Watcher
The effective "coin of the realm" in law and litigation in this area is an LL.M. degree - while there are exceptional cases of successful practices and firms, they prove the rule.
The point is, an LL.M. entails both Public Int'l Air Law, and Privare Int'l Air Law - the latter being where the lawyers live on one side of the fence, or the other, i.e,, they rep either airframers and other OEMs and airlines etc., or families of accident victims. Rare is the legal-eagle repping either, or both.
So, no apologies to yours truly. I'm done with law practice structured by sides of the fence.

[trevelyan]

https://news.sky.com/story/cigarette-in-cockpit-caused-egyptair-passenger-jet-to-crash-killing-all-on-board-investigation-finds-12600173

[DIBO]

Re. the cigarette story, I'm inclined to trust Simon@AVHerald a bit more than the Italian newspaper:
@ antonio bordoni on Saturday, Apr 30th 2022 14:07Z
By Simon Hradecky on Saturday, Apr 30th 2022 18:05Z
Without being able to reveal the sources: the information is contained in the official investigation files and is corroborated by testimonies of close friends and colleagues of the pilots involved.

Pilots non-smokers
By antonio bordoni on Saturday, Apr 30th 2022 14:07Z
if someone can actually confirm that both pilots were non-smokers, I can contact the newspaper in question and highlight the fake news they published

[DaveReidUK]

Re. the cigarette story, I'm inclined to trust Simon@AVHerald a bit more than the Italian newspaper:

I'm confused - are you saying that Avherald has refuted the cigarette-as-an-ignition-source theory ?

[Lonewolf_50]

They appear to be calling it into question, but I don't think they've got the kind of ammo refutation would need, or, if they do, they are playing their cards close to their vests.

[DIBO]

I'm confused - are you saying that Avherald has refuted the cigarette-as-an-ignition-source theory ?
I'm not "saying" only "inclined to trust a bit more", based on the two AvHerald comment lines I quoted (but which are a bit too brief to be unambiguous).
Admittedly, my post was also too brief to be unambiguous, the 'cigarette-as-an-ignition-source theory' as such is not refuted, but blaming the Capt. or F/O, as stated in the Corriere Della Sera newspaper, seems to conflict with the 'information corroborated by testimonies' that both were non-smokers.
With 10 crew on board and smoking in the cockpit not prohibited at the time, the possibility that a cockpit jumpseat was occupied by a smoker, cannot be excluded....

[fdr]

Hello,
It was on AVHERALD (article=4987fb09) :
On May 20th 2016 The Aviation Herald received information from three independent channels, that ACARS (Aircraft Communications Addressing and Reporting System) messages with following content were received from the aircraft:
00:26Z 3044 ANTI ICE R WINDOW
00:26Z 561200 R SLIDING WINDOW SENSOR
00:26Z 2600 SMOKE LAVATORY SMOKE
00:27Z 2600 AVIONICS SMOKE
00:28Z 561100 R FIXED WINDOW SENSOR
00:29Z 2200 AUTO FLT FCU 2 FAULT
00:29Z 2700 F/CTL SEC 3 FAULT
no further ACARS messages were received.
Early May 21st 2016 the French BEA confirmed there were ACARS messages just prior to break down of communications warning however that they are insufficient to understand the causes of the accident until flight data or cockpit voice recorders have been found

Good evening to everyone.

When this happened, it had all the hall marks of a fire originating at the RH window power blocks. The assumption of it being caused by an iPad would only make sense if the fire was detected by the crew some considerable time before the RH window TAI ACARS message. The comments on O2 mask flow noise picked up on the CVR are again only interesting if they led by some time the ACARS fault msgs.

Absent that time data, there is nothing to indicate it was an iPad, or battery pack or O2 mask issue.

As to fighting a fire originating at the power contacts of the window, as long as there is power supplied the item is not going to stop burning once the extinguish ant is removed from the atmosphere.

A descent from cruise to impact in less than 8 minutes, with much of that eestablishing a descent is not likely to result in anything less than massive fragmentation on impact. If ballistic penetration, stippling or other evidence of an explosive device is absent, there is no need for there to have been an explosion.

The seat of the fire may not have been at the window itself, it would merely need to be related to the power supply associated with the RH window, less likelyhood of involvement of a control circuit but all things are possible inthe absence of all of the evidence which does exist but appears to not be released to the public.

Crew smoking is a low probability causation and would have had verbal commentary on a CVR recording.

I would look at power circuits for the window, and where they are not directly observed by the crew from the EE Bay etc.