Report: hard landing and pitch-up after touchdown factors in A321 tailstrike accident

April 22, 2011

The Japan Transport Safety Board (JTSB) released the final report of their investigation into a tailstrike accident involving an Airbus A321 at Osaka-Kansai International Airport (KIX/RJBB), Japan. An improper flare, hard landing and pitch-up after touchdown  were factors.

On October 28, 2009, an Airbus A321-200, registered HL7763, operated by Asiana Airlines, took off from Seoul-Gimpo International Airport (SEL), the Republic of Korea, as a non-scheduled flight OZ1125.

The first officer was pilot flying during the approach to runway 06L of Kansai International Airport. The descent rate of 544 ft/min at the time of touchdown was high and the aircraft contacted the runway hard with a vertical acceleration of 1.91G. The nose-up stick input  was continued after touchdown, while the extension of the spoilers further produced a nose-up effect. As a result the aircraft’s pitch angle of 4.6 degrees at the time of touchdown increased to 10.2 degrees. This angle was in excess of the maximum allowable pitch attitude of 9.7 degrees.

The first officer decided to make a go-around and moved the thrust lever in the TOGA position about four seconds after touchdown. The airplane circled and landed safely eleven minutes later. There were 147 persons on board, consisting of the Captain, 8 other crewmembers, and 138 passengers. No one was injured. The aircraft sustained substantial damage, but there was no outbreak of fire.

JTSB concluded:

In this accident, it is considered highly probable that, during the landing on Kansai International Airport, the Aircraft sustained damage in the aft part of the fuselage which contacted the runway, since the pitch angle became excessively large after the touchdown on the runway.
It is considered highly probable that the Aircraft’s pitch angle became excessive because the First Officer continued inputting pitch-up signals even after touchdown.
The flare by the First Officer was inappropriate and as a result, the sink rate of the Aircraft did not fully decrease, causing the Aircraft to land with a strong impact on the ground. It is considered probable that, that the First Officer became upset by the impact contributed to his continuous input for pitch-up after touchdown.


TSB critices Transport Canada on slow implementation of safety recommendation

April 11, 2011

A TSB investiation into a cabin smoke and passenger evacuation incident revealed that Transport Canada had not yet implemented an actual regulatory change after accepting a safety recommendation dated December 2007. The recommendation called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation.

On March 23, 2010 an Air Canada Airbus A320-211 (registration C-FTJO), operating as flight AC433, departed Montréal/Pierre Elliot Trudeau International Airport, Québec, for Toronto/Lester B. Pearson International Airport, Ontario, with 98 passengers and 6 crew members on board.
In cruise, 1 of the 3 hydraulic systems failed. The flight continued toward destination where the flight made an uneventful landing. While stopped on the runway awaiting a tow, smoke entered the cabin and an evacuation was ordered. Two crew members and 2 passengers received minor injuries during the evacuation.

The TSB concluded that:

  1. A leak from the number 1 yaw damper caused fluid to be ingested into the auxiliary power unit and sent through the air conditioning system, resulting in smoke entering the cabin.
  2. When the crew ordered the evacuation as a result of the smoke, several persons received minor injuries while exiting the aircraft via the emergency slides.

It appeared that many passengers deplaned with their carry-on luggage. It could not be determined whether this was due to the fact that they were not aware of the instructions given by the flight attendants and included in the safety card, or if they were aware, but chose to disregard them. Passengers would have been more aware of this restriction if information was included during the pre-takeoff and pre-landing passenger briefings, as per TSB recommendation A07-07.

The few injuries that did occur may have been aggravated by the fact that the slides were wet from the rain, and the resultant speed of the exiting persons was higher than normal. While the baggage did cause some minor injuries and delays at the bottom of the slides, it did not appreciably increase the evacuation time. Were this a higher level of threat or emergency, however, even a slight delay could have resulted in more serious consequences.

Transport Canada agreed with the Board’s recommendation (A07-07) that called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation. However, to date, no regulatory change has been implemented. Due to the extensive delay between TC’s acceptance of this recommendation and the implementation of actual regulatory change, identified safety dificiencies continue to persist.

More information:

 


Report on UPS B747F in-flight fire accident: captain likely incapacitated

April 5, 2011

track data drived from the digital flight data recorder (DFDR) (image: GCAA)

The UAE General Civil Aviation Authority (GCAA) published a Preliminary Report of their investigation into the September 2010 fatal accident involving a UPS Boeing 747-400F. The report amongst others indicates that the captain had to leave his seat in search for portable oxygen in the smoke-filled flight deck. After which there was no further CVR information that indicated any further interaction from the Captain for the remainder of the flight.

Also, the report stated that there were no declared shipments of hazardous materials onboard the airplane. However, at least three of the shipments contained lithium ion battery packs that met the Class 9 hazardous material criteria.

A Boeing 747-44AF (SCD) cargo plane, registered N571UP, was destroyed in an accident shortly after takeoff from Dubai Airport (DXB), UAE. Both crew members were killed in the crash.
On September 3rd 2010, Flight UPS6 arrived from Hong Kong on a scheduled cargo service flight into Dubai (DXB) carrying among other items consignments of cargo that included lithium batteries.
There were no declared shipments of hazardous materials onboard the airplane. However, at least three of the shipments contained lithium ion battery packs that met the Class 9 hazardous material criteria, according to the report.
The aircraft was parked at the loading position at 15:35 local time. Several Unit Load Devices (ULD) were offloaded and new ULDs were loaded onto the plane. The flight then took from Dubai at 18:51. The First Officer was the Pilot Flying, the Captain was the Pilot Non Flying (PNF) for the sector to Köln/Bonn-Konrad Adenauer Airport (CGN), Germany.
The take off and climb out from Dubai was uneventful with the exception of a PACK 1 fault which was reset by the PNF at 18:55.
The flight transited from UAE airspace into Bahrain Airspace where, at 19:12, the fire bell alarm sounded on the flight deck. The airplane was approaching top of climb (FL320) at the time.
Following the fire bell annunciation, the Captain assumed control of the aircraft as PF, and the First Officer reverted to PNF while managing the fire warnings and cockpit checklists. The Captain advised Bahrain Air Traffic Control (BAH-C) that there was a fire indication on the main deck of the aircraft. The crew informed BAH-C that they needed to land as soon as possible. BAH-C advised the crew that Doha International Airport (DOH) was at the aircraft’s 10 o’clock position at 100 NM DME. DOH was the nearest airport at the time the emergency was declared, Dubai (DXB) was approximately 148 NM DME. The Captain elected to return to DXB, and following the request to land as soon as possible to BAH-C, the crew declared an emergency. BAH-C acknowledged the request, cleared the aircraft for a series of right hand heading changes back to DXB onto a heading of 106°.
At approximately 19:14, the Auto Pilot (AP) disconnected, followed at 19:15 by a second audible alarm similar to the fire bell. At about this time the flight crew put on the oxygen masks and goggles. The crew experienced difficulties communicating via the intercom with the masks on, which interfered with the Cockpit Resource Management (CRM).
Following the initiation of the turn back to DXB, having been cleared to 27,000 ft, the crew requested an expedited, immediate descent to 10,000 feet. Following ATC clearance, the flight crew initiated a rapid descent to 10,000 ft. BAH-C advised the crew that the aircraft was on a direct heading to DXB and cleared for landing on DXB runway 12 left at their discretion.
The Fire Main Deck checklist was activated. According to the system logic, the cabin began to depressurise, PACKS 2 and 3 shut down automatically, and PACK 2 and 3 positions were then manually selected to OFF on the overhead panel in accordance with the checklist instructions.
At 19:15, PACK 1 shut down, with no corresponding discussion recorded on the CVR. A short interval after the AP was disengaged, the Captain informed the F/O that there was limited pitch control of the aircraft in the manual flying mode, the Captain then requested the F/O to determine the cause of the pitch control anomaly.
During the turn back to DXB, the AP was re-engaged, and the aircraft descent was stabilised at 19:17. The Captain told the F/O to pull the smoke evacuation handle. This was not part of the Fire Main Deck Non-Normal checklist.
The Captain informed BAH-C that the cockpit was ‘full of smoke’ and commented to the F/O about the inability to see the instruments. The Captain instructed the F/O to input DXB into the Flight Management System (FMS). The F/O acknowledged the request and commented about the increasing flight deck temperature. It was not clear from the CVR if the FMS was programmed for DXB, although the DFDR indicated that the ILS/VOR frequency was changed to 110.1 MHz which was the frequency for DXB RW12L. Based on the information available to date, it is likely that less than 5 minutes after the fire indication on the main deck, smoke had entered the flight deck and intermittently degraded the visibility to the extent that the flight instruments could not effectively be monitored by the crew.
At approximately 19:19, during the emergency descent, at approximately 20,000 ft cabin altitude, the CAPT, as PF, declared a lack of oxygen supply. Following a brief exchange between the Captain and F/O regarding the need for oxygen, the Captain transferred control of the aircraft to the F/O as PF. Portable oxygen is located on the flight deck and in the supernumerary area, aft of the flight crew’s positions when seated. At this point the recorded CVR is consistent with the Captain leaving his seat, after which there is no further CVR information that indicates any further interaction from the Captain for the remainder of the flight.
The normal procedural requirement of transiting into the Emirates FIR, inbound for DXB was a radio frequency change from BAH-C to UAE-C. At 19:20, BAH-C advised the crew to contact UAE-C. At approximately the same time, the PF transmitted ‘mayday, mayday, mayday can you hear me?’.
The PF advised BAH-C that due to the smoke in the flight deck, the ability to view the cockpit instruments, the Flight Management System (FMS), Audio Control Panel (ACP) and radio frequency selection displays had been compromised. At 19:21, the PF advised BAH-C that they would stay on the BAH-C frequency as it was not possible to see the radios. The PF elected to remain on the BAH-C radio frequency for the duration of the flight. At approximately 19:22 the aircraft entered the Emirates FIR heading east, tracking direct to the DXB RW12L intermediate approach fix. The aircraft was now out of effective VHF radio range with BAH-C. In order for the crew to communicate with BAH-C, Bahrain advised transiting aircraft that they would act as a communication relay between BAH-C and the emergency aircraft.
At 19:22, the F/O informed the relay aircraft that he was ‘looking for some oxygen’.
Following the rapid descent to 10,000 ft the aircraft leveled off at the assigned altitude approximately 84NM from DXB. At approximately 19:26, the PF requested immediate vectors to the nearest airport and advised he would need radar guidance due to difficulty viewing the instruments.
At around 19:33, approximately 26 NM from DXB, the aircraft descended to 9000 ft, followed by a further gradual descent as the aircraft approached DXB, inbound for RW12L. The speed of the aircraft was approximately 340 kts.
19:38, approximately 10NM from RW12L, BAH-C, through the relay aircraft, advised the crew the aircraft was too high and too fast and requested the PF to perform a 360° turn if able. The PF responded ‘Negative’. At this time the DFDR data indicated the gear lever was selected down, the speed brake lever moved toward extend and at approximately the same time there was a sound consistent with the flap handle movement; shortly afterward the PF indicated that the landing gear was not functioning.
The aircraft over flew the DXB northern airport boundary on a heading of 117°, the aircraft speed and altitude, was 340 kts at an altitude of 4500 ft and descending. Following the over flight of DXB, on passing the south eastern end of RW12L, the aircraft was cleared direct to Sharjah Airport (SHJ) as an immediate alternate – SHJ was to the aircraft’s left and the SHJ runway was a parallel vector.
The relay pilot asked the PF if it was possible to perform a left hand turn. The PF responded requesting the heading to SHJ.
The PF was advised that SHJ was at 095° from the current position at 10 NM and that this left hand turn would position the aircraft on final approach for SHJ (RW30). The PF acknowledged the heading change for SHJ. The PF selected 195° degrees on the Mode Control Panel (MCP).
The AP disconnected at 19:40, the aircraft then entered a descending right hand turn at an altitude of 4000 ft as the speed gradually reduced to 240 kts until the impact.
Several Ground Proximity Warning System (GPWS) caution messages were audible on the CVR indicating: Sink Rate, Too Low Terrain and Bank Angle warnings. Radar contact was lost at approximately 19:41. The aircraft crashed 9nm south of DXB onto a military installation near Minhad Air Force Base.

The investigation is on-going.

More information:


Lebanon releases progress report on fatal Ethiopian Boeing 737-800 accident investigation

March 28, 2011

Flight ET409 flight profile

The Lebanese Ministry of Public Works & Transport released their investigation progress report regarding the January 2010 fatal accident involving a Ethiopian Flight 409 off the coast of Beirut.

On January 25, 2010 a Boeing 737-8AS(WL) passenger jet, registered ET-ANB, was destroyed in an accident 6 km southwest off Beirut International Airport (BEY), Lebanon. All 82 passengers and eight crew members were killed. The airplane operated on Ethiopian Airlines flight ET409 from Beirut International Airport (BEY) to Addis Ababa-Bole Airport (ADD).

The progress report indicated that IMC prevailed for the flight, and the flight was on an instrument flight plan. It was night in dark lighting conditions with reported isolated cumulonimbus clouds and thunderstorms in the area.
Flight ET409 was initially cleared by ATC on a LATEB 1 D Standard Instrument Departure (SID) from runway 21. Just before take-off, ATC changed the clearance to an “immediate right turn direct Chekka”.
The Boeing 737 took off from runway 21 at 02:36. After take-off ATC instructed ET409 to turn right on a heading of 315° and change frequencies and contact Beirut Control. ET409 acknowledged the clearance and continued a right turn. ATC instructed ET409 to turn left heading 270°, which was acknowledged. The flight continued the climbing left turn to heading 270° but did not maintain that heading. The aircraft continued on a southerly track. Just prior to reaching  altitude of 7700 feet, the stick shaker activated, sounding for a period of 29 seconds. Meanwhile the airplane reached an angle of attack (AOA) of 32° and began a descent to 6000 feet. When the stick shaker ceased, the aircraft began to climb again. At 02:40:56, just prior to reaching 9000 feet, the stick shaker activated again, sounding for a period of 26 seconds.

After reaching 9000 feet the aircraft made a sharp left turn and descended rapidly. The maximum registered bank angle was 118° left and the airplane reached a maximum registered speed was 407.5 knots at a G load of  4.412. The airplane disappeared from the radar screen and crashed into the Mediterranean Sea at 02:41:30.

Additional preliminary facts established by the investigators:

  • The aircraft weight and balance record was reviewed and no deficiencies or anomalies were noted.
  • No defect or deferred maintenance item was reported on the technical log after the arrival and before departure of the plane from Beirut.
  • The examination of the maintenance documents on this aircraft did not reveal any significant anomalies.
  • Based on the elements recovered up to 24 Feb, 2011 and the visual observation, no evidence of fire has been brought up.
  • The Flight Crew and Cabin Crew were licensed in accordance with the ECAA regulations.
  • The documents received by the Flight Crew prior to departure, including weather information, were in accordance with the relevant requirements.
  • The Captain had a total flying experience of 10,233 hours of which 188 hours on B 737-700/800.
  • The First Officer  had a total flying experience of 673 hours of which 350 hours as F/O on B 737-700/800.

The investigation is on-going.

More information:


Report: UK CAA publishes task forces’ recommendations on 7 top safety risks

March 28, 2011

The U.K. CAA launched a task force initiative in June 2009 to address the seven top safety risks.

The Paper pubsihed by the CAA consolidates the findings and recommendations of the task forces into one document.

The ‘Significant Seven’ safety risks cover:

  • loss of control;
  • runway overrun or excursion;
  • controlled flight into terrain (CFIT);
  • runway incursion and ground collision;
  • airborne conflict;
  • ground handling operations;
  • airborne and post-crash fire.

More information:


Report: Irish AAIU issues preliminary report on fatal Metro III accident at Cork

March 16, 2011

The Irish Air Accident Investigation Unit (AAIU) released its preliminary report of the investigation into the fatal accident at Cork Airport, February 10, 2011.

A Swearingen SA-227BC Metro III passenger plane, registered EC-ITP, was damaged beyond repair in a landing accident at Cork Airport (ORK), Ireland. There were 10 passengers and two crew members on board. Both crew members and four passengers were killed.

The AAIU report documents the circumstances in which the flight crew attempted three approaches in low visibility conditions. The AOC of the operator contained approval for the aircraft to operate CAT I approaches only. At Cork Airport this meant a decision height of 200 feet at an RVR (touchdown) minimum of 550 m for runway 17 and 750 m for runway 35.

The aircraft first established on the ILS approach to runway 17 at 08:58.  RVRs passed by Cork Tower were 300/400/375.   A missed approach was carried out at 09:03 hrs, the lowest height recorded on this approach was 101 ft radio altitude.

A second ILS approach was then flown, to the reciprocal direction runway 35.  At 09:10 the flight crew reported established on the ILS runway 35.  The RVRs passed by the Tower at this time were 350/350/350.  A missed approach was carried out at 09:14, the lowest height recorded on this approach was 91 ft radio altitude.

The crew then decided to enter a holding pattern to see if the weather would improve. Meanwhile the crew inquired about weather conditions at other airports. Waterford, their alternate, as well as Shannon and Dublin were at or below minima. Weather at Kerry was favourable.

At 09:45 the aircraft reported established on the runway 17 ILS . The RVR (touchdown) improved to 550 m, which was passed to the flight crew by Cork Approach. The final RVRs passed to EC-ITP at 09.46 were 500/400/400 when the aircraft was 9.6 nm from the threshold of runway 17.  At approximately 400 ft radio altitude, recorded data shows the aircraft deviated to the right of the runway centreline, paralleling the centreline track.
The descent was continued below Decision Height (DH).  Power was reduced momentarily before being re-applied. Just below 100 ft radio altitude, a go-around was called by the PNF and was acknowledged by the PF. Recorded data shows that the aircraft rolled significantly to the left as the aircraft tracked towards the runway centreline.  This was immediately followed by a rapid roll to the right which brought the right wingtip into contact with the runway surface. Runway surface contact was made with a roll angle of 97 degrees to the right.  The initial impact mark was located 86 m from the runway threshold, and 2 m left of the centreline.  The aircraft continued to roll rapidly to the right and struck the runway in the fully inverted position 25 m beyond the initial impact point.

The investigation is on-going.

More information:

 


Report: Fatal EMB-120 loss of control accident during a simulated engine failure

May 20, 2010

Aerial view of the accident site at Darwin Airport. Photo: ATSB

A preliminary report released today by the Australian Transport Safety Bureau (ATSB) indicates that the fatal crash of an EMB-120 Brasilia at Darwin occurred during a simulated engine failure.

On 22 March 2010 an Embraer 120ER Brasilia turboprop plane, registered VH-ANB, was destroyed in a takeoff accident at Darwin Airport, NT (DRW), Australia. Both pilots were killed.
The ATSB report states that flight was a training flight to revalidate the captain’s command instrument rating. The supervisory pilot/training captain advised the aerodrome controller that the departure would incorporate asymmetric flight (a simulated engine failure), and was approved by the controller to perform the manoeuvre.
Witnesses reported that the takeoff appeared ‘normal’ until a few moments after becoming airborne, when the aircraft rolled and diverged left from its take-off path. They watched as the aircraft continued rolling left, and entered a steep nose-down attitude. The airplane impacted the ground in a right wing-low, nose-down attitude of about 65 degrees. A high intensity, fuel-fed fire that followed the collision with the ground destroyed most of the fuselage and cabin and right wing.


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