Embed Size (px)
Citation preview
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz1
annexe 1Liste des événements de type PARG issus des différentes bases internationales
PAR
G O
AC
I
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
09/0
1/19
85
KAN
SAS
CIT
Y,K
S -
Eta
ts-U
nis
Tran
spor
t pub
lic -
Serv
ice
non
régu
lier
- Int
érie
ur -
Car
go
N35
7Q -
LOC
KH
EE
D -
188
ELE
CTR
A
Turb
opro
puls
eur
ALL
ISO
N U
SA
- 50
1 FA
MIL
Y
Mor
telle
s D
étru
it
Acci
dent
M
: 3
B: 0
LOC
-I: P
erte
de
cont
rôle
en
vol
THE
A/C
WAS
VE
CTO
RED
FO
R A
VO
R R
WY
03
AP
P, T
HE
N T
O C
IRC
LE A
ND
LAN
D O
N R
WY
36
AT
KA
NS
AS
CIT
Y A
/P. O
N F
INA
L A
PP
TH
E A
/C W
AS
TO
O
HIG
H A
ND
WA
S C
LEA
RE
D T
O C
IRC
LE L
EFT
FO
R A
NO
THE
R A
PP
. TH
E P
ILO
T B
EG
AN
CIR
CLI
NG
LEF
T. T
HE
CO
NTR
OLL
ER
CA
UTI
ON
ED T
HA
T H
E M
IGH
T B
E L
ININ
G U
P F
OR
FA
IRFA
X A
/P. T
HE
PIL
OT
WE
NT
AR
OU
ND
AN
D W
AS
INS
TRU
CTE
D T
O T
UR
N T
O 3
60 D
EG
AN
D C
LIM
B T
O 3
000
FT. T
HE
A/C
CLI
MB
ED
S
TEE
PLY
, STA
LLE
D A
ND
IMP
AC
TED
A W
ATE
R T
RE
ATM
EN
T P
LAN
T. >
NO
EV
IDE
NC
E O
F A
IRFR
AME
OR
PO
WE
RPL
AN
T PR
OB
LEM
S, N
OR
OF
CAR
GO
S
HIF
TIN
G. >
DR
N: C
VR
IND
ICA
TES
TH
AT
THE
CO
-PIL
OT
WA
S F
LYIN
G T
HE
A/C
AN
D T
HA
T TH
E P
ILO
T TO
OK
CO
NTR
OL
DU
RIN
G T
HE
MIS
SE
D A
PP
.
Acc
iden
t
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
18/0
1/19
85 ZH
AN
GZH
UA
NG
/JIN
AN
- C
hine
Tran
spor
t pub
lic -
Serv
ice
régu
lier
- Int
érie
ur -
Pass
ager
s
B43
4 - A
NTO
NO
V -
AN
-24
Turb
opro
puls
eur
ZZ
Mor
telle
s D
étru
it
Acci
dent
M
: 38
B
: 2
LO
C-I:
Per
te d
e co
ntrô
le e
n vo
l D
UR
ING
AP
P IN
DR
IZZL
E A
ND
FO
G T
HE
CR
EW
SW
ITC
HE
D O
N T
HE
LA
ND
ING
LIG
HTS
. TH
E R
WY
WA
S P
RO
BAB
LY N
OT
CLE
AR
LY V
ISIB
LE A
ND
TH
E A
/C
MA
DE
A M
ISS
ED
AP
P D
UR
ING
WH
ICH
IT C
RA
SHE
D. >
INS
TRU
CTI
ON
S H
AV
E B
EE
N IS
SU
ED
RE
GA
RD
ING
EX
EC
UTI
ON
OF
MIS
SE
D A
PP
PR
OC
ED
UR
ES
FO
R A
N-2
4.
Acc
iden
t
Prél
imin
aire
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz2
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
12/0
3/19
85
BA
RTE
R
ISLA
ND
,AK
- E
tats
-Uni
s
Tran
spor
t pub
lic -
Serv
ice
non
régu
lier
- Int
érie
ur -
Pass
ager
s
N54
0N -
DE
HA
VIL
LAN
D -
DH
C6-
300
Turb
opro
puls
eur
PR
ATT
& W
HIT
NE
Y (C
ANA
DA
) - P
T-6
FAM
ILY
Gra
ves
Impo
rtant
s
Acci
dent
M
: 0
B: 2
SC
F-N
P: D
éfai
llanc
e sy
stèm
e
THE
A/C
CR
AS
HE
D D
UR
ING
A M
ISS
ED
AP
P T
O A
TE
MP
OR
ARY
WIN
TER
LA
ND
ING
STR
IP. W
EA
THE
R: M
AR
GIN
AL
WIT
H IC
ING
.
Acc
iden
t
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
07/0
1/19
87
MIL
ES
CIT
Y,M
T -
Eta
ts-U
nis
Tran
spor
t pub
lic -
Serv
ice
non
régu
lier
- Int
érie
ur -
Pass
ager
s
N57
133
- NO
RTH
AM
ERIC
AN
- C
OM
MAN
DER
690
/168
5 Tu
rbop
ropu
lseu
r G
AR
RE
T A
IRE
SE
AR
CH
- TP
E 3
31
FAM
ILY
Gra
ves
Impo
rtant
s
Acci
dent
M
: 0
B: 1
ON
FIN
AL
APP
TH
E P
ILO
T S
ELE
CTE
D A
PP
RO
ACH
AN
D A
LTIT
UD
E H
OLD
MO
DE
S O
N T
HE
AU
TOP
ILO
T. A
T TH
E M
ISS
ED
AP
P P
OIN
T, H
E S
TAR
TED
TO
M
AK
E A
GO
-AR
OU
ND
BU
T A
PA
X, S
EA
TED
IN T
HE
CO
-PIL
OT'
S S
EA
T, A
NN
OU
NC
ED T
HA
T H
E H
AD T
HE
RW
Y IN
SIG
HT.
TH
E P
ILO
T R
EDU
CE
D P
OW
ER
TO
D
ES
CE
ND
, BU
T TH
E N
OSE
OF
THE
A/C
PIT
CH
ED U
P. T
HE
A/C
STA
LLE
D A
ND
MU
SH
ED T
O T
HE
GR
OU
ND
. >D
RN
: TH
E A
/C H
IT H
AR
D A
ND
SK
IDD
ED
OFF
TH
E R
WY
.
Acc
iden
t
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
09/0
2/19
88 S
PR
ING
FIE
LD,O
H
- Eta
ts-U
nis
Tran
spor
t pub
lic -
Opé
ratio
ns n
on
paya
ntes
- En
traî
nem
ent/c
ontr
ôle
N82
3JS
- BR
ITIS
H A
ER
OS
PA
CE
- 31
JE
TSTR
EA
M
Turb
opro
puls
eur
GA
RR
ET
AIR
ES
EA
RC
H -
TPE
331
FA
MIL
Y
Mor
telle
s D
étru
it
Acci
dent
M
: 3
B: 0
LOC
-I: P
erte
de
cont
rôle
en
vol
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz3
THE
A/C
WAS
ON
SH
OR
T FI
NA
L W
HE
N IT
AR
RES
TED
ITS
DE
SC
EN
T, S
TAR
TED
A C
LIM
B A
ND
BE
GA
N T
O O
SCIL
LATE
IN B
OTH
YA
W A
ND
RO
LL. I
T TH
EN
P
ITC
HED
UP
AN
D R
OLL
ED T
O T
HE
RIG
HT
AN
D E
NTE
RED
A V
ER
TIC
AL
DE
SC
EN
T. T
HE
A/C
HA
D C
OM
PLE
TED
AB
OU
T 27
0 D
EG O
F R
OLL
WH
EN IT
IM
PA
CTE
D T
HE
GR
OU
ND
NO
RTH
OF
THE
RW
Y IN
A S
TEE
P N
OS
E D
OW
N A
TTIT
UD
E. >
DR
N: T
HE
RIG
HT
EN
GIN
E W
AS
OP
ER
ATI
NG
BU
T A
T R
ED
UC
ED
PO
WE
R. T
HE
LE
FT E
NG
INE
WA
S A
T FU
LL P
OW
ER. T
HE
RE
WA
S N
O E
VID
EN
CE
OF
SYS
TEM
MA
LFU
NC
TIO
N. O
THE
R C
OM
PAN
Y P
ILO
TS IN
DIC
ATE
D T
HA
T TH
E P
ILO
T H
AD
A H
ISTO
RY
OF
DEM
EA
NIN
G C
OC
KP
IT B
EH
AV
IOU
R A
ND
RO
UG
HN
ES
S W
ITH
STU
DEN
TS. T
HE
CO
-PIL
OT
WA
S S
MA
LL IN
STA
TUR
E. H
E
HA
D 1
00 H
RS
OF
MU
LTIE
NG
INE
TIM
E A
ND
NO
TU
RB
OPR
OP
TIM
E. T
HE
CO
MP
AN
Y P
ILO
TS R
EP
OR
TED
TH
E C
O-P
ILO
T TR
AIN
EE
WA
S C
ON
SIS
TEN
TLY
B
EH
IND
TH
E A
/C IN
PR
IOR
FLI
GH
TS. >
THE
FLA
PS
WE
RE
FO
UN
D IN
TH
E R
ETR
AC
TED
PO
SIT
ION
CO
NTR
AR
Y T
O T
HE
A/C
HA
ND
BO
OK
. CO
MP
ANY
PIL
OTS
FU
RTH
ER IN
DIC
ATE
D T
HA
T TH
E P
ILO
T H
AD
A H
ISTO
RY
OF
RE
QU
IRIN
G L
OW
ALT
ITU
DE
ON
E E
NG
INE
GO
-AR
OU
ND
S A
ND
DEL
AY
ING
OFF
ER
S O
F A
SS
ISTA
NC
E T
O S
TUD
ENTS
.
Acc
iden
t
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
11/0
2/19
91
MO
SC
OW
- U
RS
S
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
D-A
OA
C -
AIR
BU
S -
A31
0 Tu
rbor
éact
eur d
oubl
e flu
x Z
Z
Auc
un
Auc
un
Inci
dent
M
: 0
B: 0
LOC
-I: P
erte
de
cont
rôle
en
vol
ON
REQ
UE
ST O
F A
TC T
HE
PIL
OT
INIT
IATE
D G
O-A
RO
UN
D A
T 1,
400
FT. T
HE
CR
EW F
ELT
THA
T TH
E A
/C P
ITC
H A
TTIT
UD
E IN
CR
EA
SE
D A
BN
OR
MA
LLY
A
ND
TR
IED
TO
OV
ER
RID
E T
HE
NO
SE
-UP
TE
ND
ENC
Y B
Y M
OV
ING
TH
E C
ON
TRO
L C
OLU
MN
FO
RW
AR
D. T
HIS
CA
US
ED
AU
TOP
ILO
T N
O.1
TO
DIS
EN
GA
GE
. D
ISE
NG
AG
EME
NT
OF
THE
AU
TOP
ILO
T D
ISA
BLE
D T
HE
AU
TOTR
IM A
ND
TH
E S
TAB
ILIZ
ER
RE
MA
INED
IN T
HE
FU
LL N
OS
E-U
P P
OS
ITIO
N W
HIL
E T
HE
C
ON
TRO
L C
OLU
MN
WA
S M
OV
ED
FO
RW
AR
D.>
THE
A/C
PIT
CH
ED
-UP
AN
D S
PE
ED
WA
S R
ED
UC
ED. A
T 4,
000
FT T
HE
A/C
STA
LLE
D T
HE
N C
LIM
BE
D A
ND
S
TALL
ED
AG
AIN
AT
5,70
0 FT
. AT
11,7
55 F
T, A
FTER
TW
O A
DD
ITIO
NA
L ST
ALL
S C
ON
TRO
L W
AS
RE
GA
INED
BY
RE
DU
CIN
G T
HR
US
T A
ND
MA
NU
AL
TRIM
.>TH
E A
/C L
AN
DED
SA
FELY
US
ING
MA
NU
AL
CO
NTR
OL.
>LA
CK
OF
CR
EW
CO
-OR
DIN
ATI
ON
AN
D C
OC
KP
IT R
ES
OU
RC
E M
AN
AG
EM
ENT
CO
NTR
IBU
TED
TO
TH
E E
VE
NT.
Inci
dent
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
15/0
2/19
92 S
WA
NTO
N,O
H
- Eta
ts-U
nis
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
térie
ur -
Car
go
N79
4AL
- MC
DO
NN
ELL
-DO
UG
LAS
- D
C-8
-63
Turb
oréa
cteu
r dou
ble
flux
PR
ATT
& W
HIT
NE
Y, U
SA -
JT-1
2
Mor
telle
s D
étru
it
Acci
dent
M
: 4
B: 0
LOC
-I: P
erte
de
cont
rôle
en
vol
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz4
THE
A/C
WAS
ON
ITS
SE
CO
ND
MIS
SED
AP
P W
HE
N C
ON
TRO
L W
AS
LO
ST
AN
D IT
CR
ASH
ED
INTO
A F
IELD
.>D
RN
: TH
E C
O-P
ILO
T H
AD
MA
DE
TW
O IL
S
AP
PS
, BU
T, F
OR
UN
DE
TER
MIN
ED
RE
AS
ON
S, F
AIL
ED
TO
PR
OP
ER
LY C
APTU
RE
TH
E IL
S L
OC
ALI
ZER
AN
D/O
R G
LID
ES
LOPE
. DU
RIN
G T
HE
SE
CO
ND
M
ISS
ED
AP
P, T
HE
PIL
OT
TOO
K C
ON
TRO
L O
F TH
E A
/C, H
OW
EVE
R, H
E A
PP
AR
EN
TLY
BE
CA
ME
SP
ATI
ALL
Y D
ISO
RIE
NTE
D, A
ND
INAD
VE
RTE
NTL
Y
ALL
OW
ED
AN
UN
USU
AL
ATT
ITU
DE
TO
DE
VE
LOP
WIT
H B
AN
K A
NG
LES
UP
TO
80
DE
G A
ND
PIT
CH
AN
GLE
S U
P T
O 2
5 D
EG
. TH
E C
O-P
ILO
T A
SS
UM
ED
C
ON
TRO
L AN
D B
EG
AN L
EV
ELL
ING
TH
E W
ING
S A
ND
RA
ISIN
G T
HE
NO
SE
OF
THE
A/C
, BU
T IM
PA
CT
OC
CU
RR
ED B
EFO
RE
RE
CO
VE
RY
WA
S C
OM
PLE
TED
. TH
E O
PE
RAB
ILIT
Y O
F TH
E P
ILO
T'S
ATT
ITU
DE
DIR
EC
TOR
IND
ICA
TOR
, AT
THE
TIM
E C
ON
TRO
L W
AS
LO
ST,
IS U
NC
ER
TAIN
.
Acc
iden
t
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
26/0
4/19
94
NA
GO
YA
- Ja
pon
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
B-1
816
- AIR
BU
S -
A30
0-60
0 Tu
rbor
éact
eur d
oubl
e flu
x Z
Z
Mor
telle
s D
étru
it
Acci
dent
M
: 264
B
: 7
LO
C-I:
Per
te d
e co
ntrô
le e
n vo
l TH
E A
/C W
AS C
LEA
RE
D F
OR
AN
ILS
AP
P T
O R
WY
34
AT
NA
GO
YA
A/P
AFT
ER
RE
PO
RTI
NG
AT
THE
OU
TER
MA
RK
ER
. TH
E C
REW
RE
POR
TED
MA
KIN
G A
G
O-A
RO
UN
D, A
FTE
R W
HIC
H T
HE
A/C
MA
DE
AN
AB
NO
RM
AL
MA
NO
EUV
RE
. TH
E A
/C IM
PA
CTE
D N
EA
R T
AX
IWA
Y E
ON
TH
E E
AS
T S
IDE
OF
THE
TH
RE
SHO
LD O
F R
WY
34
AN
D C
AUG
HT
FIR
E.
Acc
iden
t
Prél
imin
aire
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
29/1
0/19
95
SA
N
FRA
NC
ISC
O,C
A
- Eta
ts-U
nis
Tran
spor
t pub
lic -
Aut
re -
Aut
re
N90
4UA
- BO
EIN
G -
737-
500
Turb
oréa
cteu
r dou
ble
flux
CFM
INTE
RN
ATI
ON
AL -
CFM
56
Auc
un
Auc
un
Inci
dent
M
: 0
B: 0
FOLL
OW
ING
A T
ES
T FL
IGH
T TH
E P
ILO
T W
AS
GIV
EN
A G
O-A
RO
UN
D B
Y A
PP
CO
NTR
OL.
HE
SE
LEC
TED
TH
E T
AK
E-O
FF A
ND
GO
-AR
OU
ND
SW
ITC
H A
ND
E
NG
INE
PO
WE
R IN
CR
EA
SE
D. T
HE
A/C
BE
GA
N T
O P
ITC
H U
P A
ND
DID
NO
T S
TOP
AT
THE
GO
-AR
OU
ND
ATT
ITU
DE
. PIT
CH
INC
RE
AS
ED
TO
45
DE
G N
OS
E-
UP
AN
D T
HE
STI
CK
SH
AK
ER
AC
TIV
ATE
D. T
HE
PIL
OT
CO
ULD
NO
T O
VER
CO
ME
TH
E IN
CR
EA
SE
IN P
ITC
H. T
HE
A/C
STA
LLE
D, T
HE
NO
SE D
RO
PP
ED
AN
D
THE
A/C
RO
LLE
D. T
HE
PIL
OT
INC
REA
SE
D T
HE
RO
LL. A
S T
HE
NO
SE
DR
OP
PE
D T
HR
OU
GH
TH
E H
OR
IZO
N A
IRS
PE
ED
INC
RE
AS
ED
AN
D T
HE
PIL
OT
RE
CO
VER
ED T
O W
ING
S-LE
VE
L.
Inci
dent
Prél
imin
aire
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz5
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
27/0
4/19
98 N
EA
R B
RE
ME
N
- Alle
mag
ne
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
D-A
HLN
- BO
EIN
G -
737-
500
Turb
oréa
cteu
r dou
ble
flux
ZZ
Auc
un
Auc
un
Inci
dent
M
: 0
B: 0
DU
RIN
G F
INA
L A
PP
AN
UN
SA
FE N
OS
E G
EA
R IN
DIC
ATIO
N L
ED
TO
A G
O-A
RO
UN
D. D
UR
ING
CLI
MB
-OU
T B
OTH
FLI
GH
T D
IRE
CTO
RS
AN
D A
UTO
THR
US
T W
ER
E O
N. A
FTE
R G
EA
R R
ETR
ACTI
ON
FLA
PS
WER
E S
ET
AT
15 D
EG
. A F
UR
THER
FLA
P R
ETR
AC
TIO
N W
AS
DEL
AY
ED
BY
DIS
CU
SS
ION
S W
ITH
GR
OU
ND
C
ON
TRO
L R
EGAR
DIN
G C
HAN
GIN
G T
HE
DEP
ARTU
RE
PRO
CED
UR
E BE
CAU
SE O
F TH
E W
EATH
ER. H
IGH
TH
RU
ST A
ND
LO
W A
/C W
EIG
HT
RES
ULT
ED IN
A
CLI
MB
RA
TE U
P T
O 4
,800
FT/
MIN
. TH
E A
LTIT
UD
E C
AP
TUR
E F
OR
A 3
,000
FT
LEV
EL
OFF
WA
S A
T 1,
500
FT A
GL
WH
EN T
HE
TO
GA
MO
DE
SW
ITC
HED
TO
M
CP
SP
EE
D M
OD
E. P
ITC
H A
TTIT
UD
E H
AD
NO
W IN
CR
EA
SE
D T
O 2
4 D
EG
NO
SE
UP
. TH
ER
EA
FTER
, TH
E F
LIG
HT
DIR
EC
TOR
PIT
CH
BA
R C
OM
MAN
DED
A
NO
SE
DO
WN
, WH
ICH
TH
E P
ILO
T FO
LLO
WED
BY
MA
NU
AL
NO
SE
DO
WN
TR
IM IN
PU
T. T
HIS
LA
STE
D 4
SE
C D
UE
TO
TH
E S
LOW
RE
ACTI
ON
OF
THE
A/C
. TH
E P
ILO
T W
AS
NO
T AW
AR
E T
HA
T W
ITH
FLA
PS A
T 15
DE
G, T
HE
HO
RIZ
ON
TAL
STA
BILI
ZER
MA
NU
AL
TRIM
SP
EE
D O
PE
RA
TES
AT
A M
AX
IMU
M V
ALU
E
OF
0.6
DE
G/S
EC
. TH
E S
TAB
ILIZ
ER
RA
N IN
TO F
ULL
NO
SE
DO
WN
TR
IM. T
HE
PIT
CH
ATT
ITU
DE
WAS
PA
SS
ING
10
DE
G N
OSE
-UP
WH
EN
FD
R S
HO
WED
A
SH
OR
T-TI
ME
NO
SE
-DO
WN
ELE
VA
TOR
DE
FLE
CTI
ON
AN
D A
RE
DU
CTI
ON
OF
THR
UST
LEV
ER A
NG
LE. T
HE
PIL
OT
SA
ID T
HA
T H
E T
HE
N D
ISE
NG
AG
ED
TH
E
AU
TOTH
RU
ST
BU
T TH
ERE
WA
S N
O S
UC
H IN
DIC
ATIO
N F
RO
M T
HE
FD
R. W
HEN
TH
E P
ILO
T N
OTI
CE
D T
HE
NO
SE
DO
WN
TR
IM H
E P
ULL
ED
TH
E C
ON
TRO
L W
HE
EL
VE
RY
HA
RD
AN
D R
ETA
INED
FU
LL C
ON
TRO
L A
FTER
SO
ME
SE
CO
ND
S. T
HE
FOLL
OW
ING
WER
E R
ECO
RD
ED: P
ITC
H A
LTIT
UD
E -2
4 D
EG
, AN
GLE
O
F A
TTA
CK
-12
DEG
, VE
RTI
CA
L G
-0.4
. AFT
ER
FIX
ING
TH
E U
NS
AFE
GE
AR
IND
ICA
TIO
N B
Y C
HA
NG
ING
TW
O B
ULB
S T
HE
A/C
LA
ND
ED
SAF
ELY
.
Inci
dent
Dat
a
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
11/1
2/19
98
NE
AR
S
UR
ATT
HA
NI
- Tha
ïland
e
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
térie
ur -
Pass
ager
s
HS-
TIA
- A
IRB
US
- A
310
Turb
oréa
cteu
r dou
ble
flux
GE
NE
RA
L EL
EC
TRIC
USA
- C
F6
SE
RIE
S
Mor
telle
s D
étru
it
Acci
dent
M
: 101
B
: 30
LOC
-I: P
erte
de
cont
rôle
en
vol F
-PO
ST:
Ince
ndie
/fum
ée (a
près
impa
ct)
ON
TH
E T
HIR
D L
AND
ING
ATT
EM
PT,
TH
E A
/C C
RA
SH
ED
INTO
A S
WA
MP
. On
11 D
ecem
ber 1
998
at a
bout
17
: 54
hour
s, A
IRB
US
A31
0-20
4 be
long
ing
to T
hai
Airw
ays
Inte
rnat
iona
l Pub
lic C
ompa
ny L
imite
d, o
f nat
iona
lity
and
regi
stra
tion
HS
-TIA
, dep
arte
d on
flig
ht T
G 2
61 fr
om B
angk
ok In
tern
atio
nal A
irpor
t to
Sur
at T
hani
A
irpor
t. Th
e pi
lot h
ad re
ques
ted
Sur
at T
hani
air
traffi
c co
ntro
l for
app
roac
h to
land
on
runw
ay 2
2. A
fter t
ryin
g fo
r thr
ee a
ppro
ache
s, th
e ai
rcra
ft cr
ashe
d 70
0 m
etre
s so
uth
of S
urat
Tha
ni A
irpor
t at a
bout
19
: 08
hour
s de
stro
ying
itse
lf co
mm
plet
ely.
Fro
m 1
46 c
rew
and
pas
seng
ers
on b
oard
: 10
1 di
ed,3
5 w
ere
serio
usly
inju
red
and
10 s
uffe
red
min
or in
jurie
s.
Pro
babl
e C
ause
s A
fter c
aref
ul c
onsi
dera
tion,
the
Airc
raft
Acc
iden
t Inv
estig
atio
n C
omm
ittee
of t
he K
ingd
om o
f Tha
iland
ulti
mat
ely
cam
e to
the
conc
lusi
on th
at th
e ac
cide
nt o
ccur
red
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz6
beca
use
the
airc
raft
ente
red
into
sta
ll co
nditi
on w
hich
mig
ht b
e ca
used
by
the
follo
win
gs :
- 3.
2.1
The
pilo
t atte
mpt
ed to
apr
roac
h th
e ai
rpor
t in
low
er th
an m
inim
um v
isib
ility
with
rain
.
-
3.2.
2 Th
e pi
lot c
ould
not
mai
ntai
n th
e V
OR
cou
rse
as s
et fo
rth in
the
appr
oach
cha
rt. T
he a
ircra
ft fle
w le
ft of
VO
R c
ours
e on
eve
ry a
ppro
ach.
-
3.2.
3 Th
e pi
lots
suf
fere
d fro
m th
e ac
cum
ulat
ion
of s
tress
and
wer
e no
t aw
are
of th
e si
tuat
ion
until
the
airc
raft
ente
red
into
the
upse
t con
ditio
n.
-3.2
.4 T
he p
ilots
had
not
bee
n in
form
ed o
f the
doc
umen
t con
cern
ing
the
wid
e-bo
dy a
irpla
ne u
pset
reco
very
pro
vide
d by
AIR
BU
S In
dust
rie fo
r usi
ng in
pilo
t tra
inin
g.
-3.2
.5 T
he li
ghtin
g sy
stem
and
app
roac
h ch
art d
id n
ot fa
cilit
ate
the
low
vis
ibili
ty a
ppro
ach.
-3
.2.6
Sta
ll w
arni
ng a
nd p
itch
trim
sys
tem
s m
ight
not
fully
func
tion
as d
escr
ibed
in th
e FC
OM
and
AM
M;
Acc
iden
t
Prél
imin
aire
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
27/0
6/20
00
OV
ER
DU
BA
I A
/P -
Em
irats
A
rabe
s U
nis
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
A6-
EKG
- A
IRB
US
- A
310
Turb
oréa
cteu
r dou
ble
flux
GE
NE
RA
L EL
EC
TRIC
USA
- C
F6
SE
RIE
S
Auc
un
Auc
un
Inci
dent
M
: 0
B: 0
PR
N: A
T 50
0 FT
AG
L O
N F
INA
L A
PP
TO
DU
BA
I A/P
, TH
E T
RIM
MA
BLE
HO
RIZ
ON
TAL
STA
BILI
SE
R (T
HS
) TR
IM M
OV
ED
TO
MA
XIM
UM
DE
FLE
CTI
ON
NO
SE
U
P. T
HE
A/C
WA
S B
EIN
G F
LOW
N M
ANU
ALL
Y B
Y T
HE
FIR
ST
OFF
ICER
. SH
OR
TLY
AFT
ER
WAR
DS
A G
O-A
RO
UN
D W
AS
MA
DE
DU
E T
O B
EIN
G H
IGH
AN
D
FAS
T O
N A
PP
. DU
RIN
G T
HE
GO
-AR
OU
ND
, TH
E A
/C P
ITC
HED
UP
TO
46
DEG
PIT
CH
AN
D S
TALL
ED
, DE
SP
ITE
FU
LL F
OR
WAR
D N
OS
E D
OW
N E
LEV
ATO
R.
RE
CO
VER
Y A
CTI
ON
WAS
MA
DE
BY
RE
DU
CIN
G T
HR
US
T TO
IDLE
. TH
E L
OW
SP
EE
D P
RO
TEC
TIO
N S
YS
TEM
OP
ER
ATE
D N
OR
MA
LLY
BU
T TH
E IN
CR
EA
SE
IN
TH
RU
ST
RE
SU
LTED
IN A
FU
RTH
ER H
IGH
NO
SE A
TTIT
UD
E A
ND
STA
LL F
RO
M W
HIC
H T
HE
CA
PTA
IN R
EC
OVE
RE
D U
SIN
G S
AM
E R
EC
OV
ER
Y A
CTI
ON
. N
O T
EC
HN
ICA
L R
EA
SO
N F
OR
TH
E T
HS
MO
VE
ME
NT
HAS
BEE
N F
OU
ND
.
Inci
dent
Prél
imin
aire
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
23/0
8/20
00
NE
AR
B
AH
RA
IN A
/P
- Bah
rein
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
A4O
-EK
- A
IRB
US
- A
320
Turb
oréa
cteu
r dou
ble
flux
CFM
INTE
RN
ATI
ON
AL -
CFM
56
Mor
telle
s D
étru
it
Acci
dent
M
: 143
B
: 0
C
FIT:
Col
lisio
n/qu
asi-c
ollis
ion
avec
relie
f/obs
tacl
e sa
ns p
erte
de
cont
rôle
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz7
PR
N: A
T 1
NM
FR
OM
TO
UC
HD
OW
N A
ND
ALT
ITU
DE
600
FT,
TH
E C
REW
RE
QU
ES
TED
A L
EFT
-HAN
D O
RB
IT, A
ND
INIT
IATE
D A
MIS
SE
D A
PP
. TH
E A
TC
OFF
ER
ED A
RA
DAR
VE
CTO
R W
HIC
H T
HE
CR
EW
AC
CE
PTE
D. T
HE
A/C
CR
OS
SE
D T
HE
RW
Y O
N A
NO
RTH
-EA
STE
RLY
HE
AD
ING
WIT
H A
SH
ALL
OW
CLI
MB
TO
1 0
00 F
T. T
HE
MA
STE
R W
ARN
ING
SO
UN
DED
(FO
R E
XC
EED
ING
FLA
PS
SP
EE
D).>
>DR
N: D
UR
ING
TH
E G
O-A
RO
UN
D, T
HE
FLI
GH
T C
RE
W P
RO
BA
BLY
E
XP
ER
IEN
CE
D A
SP
ATI
AL D
ISO
RIE
NTA
TIO
N, W
HIC
H L
ED
TH
E P
ILO
T TO
FA
LSE
LY P
ER
CE
IVE
A "P
ITC
H-U
P".
HE
RE
SP
ON
DED
BY
MA
KIN
G A
NO
SE
-DO
WN
IN
PU
T, R
ESU
LTIN
G IN
A D
ES
CE
NT.
TH
E G
PW
S V
OIC
E A
LAR
M S
OU
ND
ED
AN
D R
EP
EAT
ED
EV
ER
Y S
EC
ON
D F
OR
NIN
E S
EC
ON
DS
, UN
TIL
THE
A/C
IM
PA
CTE
D T
HE
SH
ALL
OW
SE
A. >
>A C
OM
BIN
ATI
ON
OF
IND
IVID
UA
L A
ND
SY
STE
MIC
ISS
UE
S W
ER
E ID
EN
TIFI
ED
: NO
N-A
DH
ER
EN
CE
TO
STA
ND
ARD
O
PE
RA
TIN
G P
RO
CED
UR
ES
; SP
ATI
AL
DIS
OR
IEN
TATI
ON
AN
D IN
FOR
MA
TIO
N O
VE
RLO
AD; N
ON
-EFF
EC
TIV
E R
ES
PO
NS
E T
O G
PW
S W
ARN
ING
S; L
AC
K O
F A
CR
M T
RA
ININ
G P
RO
GR
AM
ME
; IN
AD
EQ
UAC
IES
IN T
HE
A32
0 FL
IGH
T C
RE
W T
RA
ININ
G P
RO
GR
AMM
ES
, IN
FLI
GH
T D
ATA
AN
ALY
SIS
SY
STE
M A
ND
IN
THE
FLI
GH
T S
AFE
TY D
EP
AR
TME
NT;
AN
D S
AFE
TY O
VE
RS
IGH
T FA
CTO
RS
BY
TH
E R
EG
ULA
TOR
. TW
ELV
E S
AFE
TY R
EC
OM
ME
ND
ATIO
NS
AD
DR
ESS
ED
TO
VA
RIO
US
STA
TES
AN
D IN
TER
NA
TIO
NA
L O
RG
AN
IZA
TIO
NS
WE
RE
MA
DE
.
Acc
iden
t
Dat
a O
AC
I - N
otifi
catio
n in
itial
e O
AC
I O
AC
I - A
DR
EP p
rélim
inai
re O
AC
I O
AC
I - A
DR
EP c
ompl
et O
AC
I O
AC
I - R
appo
rt fi
nal O
AC
I
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
11/1
0/20
01 S
HA
MA
TTAW
A,
1NM
N
,MA
NIT
OB
A -
Can
ada
Tran
spor
t pub
lic -
Serv
ice
non
régu
lier -
Inté
rieur
- Pa
ssag
ers
C-G
YPA
- SW
EA
RIN
GEN
- S
A22
6 TC
M
ETR
O II
Tu
rbop
ropu
lseu
r Z
Z
Mor
telle
s D
étru
it
Acci
dent
M
: 2
B: 1
CFI
T: C
ollis
ion/
quas
i-col
lisio
n av
ec re
lief/o
bsta
cle
sans
per
te d
e co
ntrô
le
Per
imet
er A
irlin
es F
light
PA
G96
2, a
Fai
rchi
ld S
A22
6TC
(Met
rolin
er),
with
two
pilo
ts a
nd a
flig
ht n
urse
on
boar
d, d
epar
ted
God
s La
ke N
arro
ws,
Man
itoba
, at
appr
oxim
atel
y 23
00 c
entra
l day
light
tim
e, o
n a
ME
DE
VA
C fl
ight
to S
ham
atta
wa.
App
roac
hing
Sha
mat
taw
a, th
e cr
ew b
egan
a d
esce
nt to
the
100
naut
ical
mile
m
inim
um s
afe
altit
ude
of 2
300
feet
abo
ve s
ea le
vel (
asl)
and,
whe
n cl
ear o
f an
over
cast
clo
ud la
yer a
t abo
ut 3
000
feet
asl
, atte
mpt
ed a
nig
ht, v
isua
l app
roac
h to
R
unw
ay 0
1. T
he a
ircra
ft w
as to
o hi
gh a
nd to
o fa
st o
n fin
al a
ppro
ach
and
the
crew
ele
cted
to c
arry
out
a m
isse
d ap
proa
ch. A
ppro
xim
atel
y 30
sec
onds
afte
r the
pow
er
was
incr
ease
d, a
t 233
3, th
e ai
rcra
ft fle
w in
to tr
ees
slig
htly
to th
e le
ft of
the
runw
ay c
entre
line
and
abou
t 260
0 fe
et fr
om th
e de
partu
re e
nd o
f Run
way
01.
The
airc
raft
was
equ
ippe
d w
ith a
coc
kpit
voic
e re
cord
er (C
VR) t
hat i
ndic
ated
the
crew
wer
e in
con
trol o
f the
airc
raft;
they
did
not
exp
ress
any
con
cern
prio
r to
impa
ct. T
he a
ircra
ft br
oke
apar
t alo
ng a
wre
ckag
e tra
il of
abo
ut 8
50 fe
et. O
nly
the
cabi
n af
t of t
he c
ockp
it re
tain
ed s
ome
stru
ctur
al in
tegr
ity. T
he c
apta
in a
nd fi
rst o
ffice
r wer
e fa
tally
in
jure
d on
impa
ct. T
he fl
ight
nur
se w
as s
erio
usly
inju
red
but w
as a
ble
to e
xit t
he w
reck
age
of th
e ca
bin.
A p
ost-c
rash
fire
was
con
fined
to th
e w
ings
whi
ch h
ad
sepa
rate
d fro
m th
e ca
bin
and
cock
pit w
reck
age.
Fin
ding
s as
to C
ause
s an
d C
ontri
butin
g Fa
ctor
s Th
e ai
rcra
ft w
as fl
own
into
terr
ain
durin
g an
ove
rsho
ot b
ecau
se th
e re
quire
d cl
imb
angl
e w
as n
ot s
et a
nd m
aint
aine
d to
ens
ure
a po
sitiv
e ra
te o
f clim
b. D
urin
g th
e go
-aro
und,
con
ditio
ns w
ere
pres
ent f
or s
omat
ogra
vic
illus
ion,
whi
ch
mos
t lik
ely
led
to th
e ca
ptai
n lo
sing
situ
atio
nal a
war
enes
s. T
he fi
rst o
ffice
r did
not
mon
itor t
he a
ircra
ft in
stru
men
ts d
urin
g a
criti
cal s
tage
of f
light
; it i
s po
ssib
le th
at h
e w
as a
ffect
ed b
y so
mat
ogra
vic
illus
ion
and/
or d
istra
cted
by
the
non-
dire
ctio
nal b
eaco
n to
the
exte
nt th
at h
e lo
st s
ituat
iona
l aw
aren
ess.
Oth
er F
indi
ngs
The
abse
nce
of
appr
oach
aid
s lik
ely
decr
ease
d th
e cr
ew's
abi
lity
to fl
y an
app
roac
h fro
m w
hich
a la
ndin
g co
uld
be e
xecu
ted
safe
ly. T
he c
ompa
ny s
tand
ard
oper
atin
g pr
oced
ures
(S
OP
s) d
id n
ot d
efin
e ho
w p
ositi
ve ra
te is
to b
e de
term
ined
.
Acc
iden
t
Prél
imin
aire
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz8
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
22/0
1/20
02
Gar
derm
oen
- N
orvè
ge
Tran
spor
t pub
lic
TF-F
IO -
BO
EIN
G -
757-
200
Turb
oréa
cteu
r dou
ble
flux
Auc
un
Auc
un
Inci
dent
gra
ve
M:
B:
AD
RM
: Aér
odro
me
AM
AN
: Man
oeuv
re b
rusq
ue in
tent
ionn
elle
LA
LT: C
ollis
ion/
quas
i-col
lisio
n lo
rs d
'un
vol à
faib
le h
aute
ur L
OC
-I: P
erte
de
cont
rôle
en
vol S
CF-
NP:
D
éfai
llanc
e sy
stèm
e U
SO
S: A
tterr
issa
ge à
pro
xim
ité d
e la
pis
te C
FIT:
Col
lisio
n/qu
asi-c
ollis
ion
avec
relie
f/obs
tacl
e sa
ns p
erte
de
cont
rôle
D
RN
: Ice
land
air B
757
with
regi
stra
tion
TF-F
IO, w
as a
ppro
achi
ng E
NG
M fr
om K
efla
vik.
Clo
se to
Sol
berg
ND
B, t
he fl
ight
cre
w b
ecam
e aw
are
that
the
RW
Y h
ad b
een
chan
ged
from
01R
to 0
1L d
ue to
sno
w c
lear
ing.
In a
dditi
on, t
here
wer
e st
rong
tailw
inds
at 2
000-
3000
ft u
p to
45
kts.
ILS
app
roac
h w
as in
itial
ly c
ondu
cted
by
auto
pilo
t, bu
t as
the
A/C
nev
er b
ecam
e pr
oper
ly s
tabi
lized
on
GP,
the
auto
pilo
t was
dis
conn
ecte
d. T
he c
omm
ande
r fle
w th
e A
/C m
anua
lly, a
nd c
ompl
aine
d ab
out h
is
GP
dat
a fre
quen
tly m
issi
ng. T
he F
/O d
id n
ot ta
ke a
ny a
ctio
ns to
this
. His
inst
rum
ents
wer
e fu
nctio
ning
nor
mal
ly. A
t 580
ft, a
ppro
ach
was
stil
l not
sta
biliz
ed (a
bove
G
P),
and
PIC
initi
ated
mis
sed
appr
oach
. Pitc
h w
as in
crea
sed
to 2
0 de
g., a
nd s
peed
dec
reas
ing
to it
s pe
ak o
f 137
kt.
To a
void
sta
lling
the
A/C
the
PIC
low
ered
the
nose
abr
uptly
, to
gain
mor
e sp
eed.
The
con
trol c
olum
n w
as re
turn
ed to
neu
tral f
or a
sho
rt m
omen
t. Th
en a
noth
er a
brup
t nos
e-do
wn
cont
rol m
ovem
ent w
as m
ade,
ca
usin
g a
pitc
h at
titud
e to
-49
deg.
Thi
s di
ve w
as n
ot re
cove
red
until
321
ft A
GL
and
251
kt a
irspe
ed. D
urin
g th
is in
cide
nce,
aur
al w
arni
ngs
had
been
pre
sent
, lik
e "te
rrai
n" a
nd "t
oo lo
w te
rrai
n". T
he re
cove
ry o
f the
div
e co
ntin
ued
with
a p
itch
attit
ude
of a
ppro
x. +
40 d
eg.,
and
the
fligh
t con
tinue
d no
rmal
ly, b
ut w
ith s
ever
al a
brup
t co
ntro
l inp
uts.
Loa
d fa
ctor
s du
ring
thes
e ab
norm
al m
aneu
vers
wer
e m
easu
red
to b
e -0
.6 a
nd +
3,59
g's
. The
A/C
mad
e a
norm
al la
ndin
g on
the
2. a
ttem
pt.
Con
clus
ions
from
AIB
N: G
ener
al a
. The
flig
ht fr
om K
efla
vik
airp
ort t
o O
slo
airp
ort G
arde
rmoe
n w
as u
neve
ntfu
l unt
il th
e de
scen
t was
sta
rted.
b. T
he d
esce
nt a
nd
appr
oach
was
mad
e in
stro
ng ta
ilwin
d. c
. The
airc
raft
over
shot
of t
he L
LZ in
itial
ly. d
. The
airc
raft
desc
ende
d on
the
LLZ
unst
abili
zed
in h
eigh
t and
spe
ed. e
. Afte
r the
C
omm
ande
r sta
rted
the
mis
sed
appr
oach
, the
airc
raft
ente
red
a dr
amat
ic m
anoe
uvre
with
exc
eede
nces
in p
itch,
spe
ed a
nd lo
ad fa
ctor
s. f.
Afte
r the
land
ing,
the
Com
man
der w
as c
once
rned
prim
arily
rega
rdin
g th
e IL
S ra
w d
ata
failu
res
and
not s
o m
uch
rega
rdin
g th
e ex
ceed
ence
s. g
. The
flig
ht c
ontin
ued
to S
tock
holm
airp
ort
Arla
nda
and
back
to K
efla
vik
airp
ort w
ithou
t a th
orou
gh te
chni
cal i
nspe
ctio
n to
be
perfo
rmed
. The
airc
raft
a. T
he a
ircra
ft ha
d be
en m
aint
aine
d an
d w
as s
ervi
ceab
le
with
no
sign
ifica
nt d
efec
ts. T
he e
quip
men
t not
bei
ng o
pera
tive
upon
dep
artu
re K
efla
vik
did
not h
ave
any
effe
ct re
gard
ing
this
inci
dent
. b. T
he ra
w d
ata
info
rmat
ion
of
the
ILS
on
the
Com
man
der's
flig
ht in
stru
men
ts d
isap
pear
ed in
term
itten
tly a
t tim
es d
urin
g th
e ap
proa
ch to
Gar
derm
oen.
c. T
he m
ass
and
bala
nce
of th
e ai
rcra
ft w
ere
with
in th
e no
rmal
ope
ratin
g lim
its a
t the
tim
e of
the
inci
dent
. d. T
he a
ircra
ft di
d no
t rec
eive
any
dam
age
durin
g th
e "u
pset
" in
spite
of t
he e
xcee
denc
es o
f bot
h sp
eed
and
load
fact
ors.
As
a pr
ecau
tion
som
e co
mpo
nent
s w
ere
late
r rep
lace
d. F
light
Ope
ratio
ns a
. A c
ompr
ehen
sive
Flig
ht O
pera
tions
Man
ual,
supp
lem
ente
d by
A
erop
lane
Ope
ratin
g M
anua
l, R
oute
Man
ual a
nd T
rain
ing
Man
ual c
ontro
ls th
e di
ffere
nt a
spec
ts o
f Flig
ht O
pera
tions
. b. C
rew
sel
ectio
n, in
itial
tech
nica
l- an
d fli
ght
train
ing
and
recu
rren
t tra
inin
g sa
tisfy
the
requ
irem
ents
from
the
auth
oriti
es. c
. The
Com
pany
was
at t
he ti
me
of th
e in
cide
nt n
ot u
tiliz
ing
a sy
stem
atic
ana
lysi
s of
flig
ht
reco
rder
dat
a of
all
fligh
ts fo
r sup
ervi
sion
, con
trol a
nd m
onito
ring
of th
e C
ompa
ny's
ope
ratio
nal s
tand
ard.
d. A
mor
e cl
ear d
ocum
enta
tion
of th
e ph
iloso
phy
and
the
polic
ies
in th
e di
ffere
nt m
anua
ls w
ould
be
of a
dvan
tage
to p
erso
nnel
at a
ll le
vels
of t
he C
ompa
ny. T
he c
rew
a. T
he c
rew
mem
bers
wer
e pr
oper
ly li
cens
ed. b
. Wor
king
ho
urs
and
rest
per
iods
prio
r to
the
inci
dent
wer
e w
ithin
the
limits
pre
scrib
ed b
y re
gula
tions
. c. T
he p
rofic
ienc
y ch
ecks
for b
oth
pilo
ts w
ere
valid
. d. B
oth
pilo
ts h
ad
gone
thro
ugh
the
com
pany
's te
chni
cal a
nd o
pera
tiona
l flig
ht tr
aini
ng w
ithou
t wai
vers
. e. B
oth
pilo
ts h
ad re
ceiv
ed th
e pl
anne
d C
RM
com
pany
trai
ning
. Org
anis
atio
n an
d m
anag
emen
t a. I
cela
ndai
r is
orga
nize
d an
d m
anag
ed in
acc
orda
nce
with
the
requ
irem
ents
of J
AR
-OPS
1 a
nd th
e Ic
elan
dic
CA
A. b
. A m
ore
clea
r doc
umen
tatio
n of
the
philo
soph
y an
d th
e po
licie
s w
ould
be
of a
dvan
tage
to p
erso
nell
in th
e co
mpa
ny.
Inci
dent
gr
ave
Abn
orm
al m
aneu
verin
g on
app
roac
h D
ata
OA
CI -
AD
REP
com
plet
OA
CI
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz9
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
21/0
7/20
07
Mel
bour
ne
Aer
odro
me
- A
ustra
lie
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
VH-V
QT
- AIR
BU
S -
A32
0 Tu
rbor
éact
eur d
oubl
e flu
x
Auc
un
Auc
un
Inci
dent
gra
ve
M:
B:
OTH
R: A
utre
D
RN
: On
21 J
uly
2007
, an
Airb
us In
dust
rie A
320-
232
airc
raft
was
bei
ng o
pera
ted
on a
sch
edul
ed in
tern
atio
nal p
asse
nger
ser
vice
bet
wee
n C
hris
tchu
rch,
New
Ze
alan
d an
d M
elbo
urne
, Aus
tralia
. At t
he d
ecis
ion
heig
ht o
n th
e in
stru
men
t app
roac
h in
to M
elbo
urne
, the
cre
w c
ondu
cted
a m
isse
d ap
proa
ch a
s th
ey d
id n
ot h
ave
the
requ
ired
visu
al re
fere
nce
beca
use
of fo
g. T
he p
ilot i
n co
mm
and
did
not p
erfo
rm th
e go
-aro
und
proc
edur
e co
rrec
tly a
nd, i
n th
e pr
oces
s, th
e cr
ew w
ere
unaw
are
of
the
airc
raft'
s cu
rren
t flig
ht m
ode.
The
airc
raft
desc
ende
d to
with
in 3
8 ft
of th
e gr
ound
bef
ore
clim
bing
. The
airc
raft
oper
ator
had
cha
nged
the
stan
dard
ope
ratin
g pr
oced
ure
for a
go-
arou
nd a
nd, a
s a
resu
lt, th
e cr
ew w
ere
not p
rom
pted
to c
onfir
m th
e ai
rcra
ft's
fligh
t mod
e st
atus
unt
il a
num
ber o
f oth
er p
roce
dure
item
s ha
d be
en
com
plet
ed. A
s a
resu
lt of
the
airc
raft
not i
nitia
lly c
limbi
ng, a
nd th
e cr
ew b
eing
dis
tract
ed b
y an
incr
ease
d w
orkl
oad
and
unex
pect
ed a
lerts
and
war
ning
s, th
ose
item
s w
ere
not c
ompl
eted
. The
ope
rato
r had
not
con
duct
ed a
risk
ana
lysi
s of
the
chan
ge to
the
proc
edur
e an
d di
d no
t sat
isfy
the
inci
dent
repo
rting
requ
irem
ents
of i
ts
safe
ty m
anag
emen
t sys
tem
(SM
S) o
r of t
he T
rans
port
Saf
ety
Inve
stig
atio
n A
ct 2
003.
As
a re
sult
of th
is o
ccur
renc
e, th
e ai
rcra
ft op
erat
or c
hang
ed it
s go
-aro
und
proc
edur
e to
refle
ct th
at o
f the
airc
raft
man
ufac
ture
r, an
d its
SM
S to
requ
ire a
form
al ri
sk m
anag
emen
t pro
cess
in s
uppo
rt of
any
pro
posa
l to
chan
ge a
n ai
rcra
ft op
erat
ing
proc
edur
e. In
add
ition
, the
ope
rato
r is
revi
ewin
g its
flig
ht tr
aini
ng re
quire
men
ts, h
as in
voke
d a
num
ber o
f cha
nges
to it
s do
cum
ent c
ontro
l pro
cedu
res,
and
ha
s re
vise
d th
e in
cide
nt re
porti
ng re
quire
men
ts o
f its
SM
S. I
n ad
ditio
n to
the
safe
ty a
ctio
n ta
ken
by th
e ai
rcra
ft op
erat
or th
e ai
rcra
ft m
anuf
actu
rer h
as, a
s a
resu
lt of
th
e oc
curr
ence
, enh
ance
d its
pub
lishe
d go
-aro
und
proc
edur
es to
em
phas
ise
the
criti
cal n
atur
e of
the
fligh
t cre
w a
ctio
ns d
urin
g a
go-a
roun
d. P
RN
: Whi
le th
e cr
ew
was
con
duct
ing
a go
aro
und
the
airc
raft
faile
d to
go
into
spe
ed re
fere
nce
syst
em (S
RS
) mod
e. T
he in
vest
igat
ion
is c
ontin
uing
.
Inci
dent
gr
ave
Ser
ious
Inci
dent
200
7055
76 V
H-V
QT:
Go-
arou
nd e
vent
, Mel
bour
ne A
erod
rom
e 21
Jul
y 20
07
Dat
a O
AC
I - N
otifi
catio
n in
itial
e O
AC
I O
AC
I - A
DR
EP p
rélim
inai
re O
AC
I O
AC
I - A
DR
EP c
ompl
et O
AC
I O
AC
I - R
appo
rt fi
nal O
AC
I
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
31/0
7/20
08
Ow
aton
na,
Min
neso
ta -
Eta
ts-U
nis
Tran
spor
t pub
lic -
Serv
ice
non
régu
lier
- Int
érie
ur -
Pass
ager
s
N81
8MV
- BR
ITIS
H A
ER
OS
PA
CE
- 12
5 S
ER
IES
800
Tu
rbor
éact
eur d
oubl
e flu
x
Mor
telle
s D
étru
it
Acci
dent
M
: 8
B:
LOC
-I: P
erte
de
cont
rôle
en
vol
IN: L
oss
of c
ontro
l and
impa
ct fo
llow
ing
go-a
roun
d at
tem
pt d
urin
g la
ndin
g, a
/c d
estro
yed.
Acc
iden
t
Not
ifica
tion
initi
ale
OA
CI -
Not
ifica
tion
initi
ale
OA
CI
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz10
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
27/1
1/20
08
Au
larg
e de
C
anet
-Pla
ge
(66)
- Fr
ance
Avi
atio
n gé
néra
le -
Aut
re -
Essa
i/exp
érim
enta
l/con
trôl
e ap
rès
mai
nten
ance
D-A
XLA
- A
IRB
US
- A
320
Turb
oréa
cteu
r dou
ble
flux
INTE
RN
ATI
ON
AL
AE
RO
EN
GIN
ES
(IA
E) -
V25
00 IN
TER
NA
TIO
NA
L A
ER
O
EN
GIN
ES
(IAE
) IN
TER
NAT
ION
AL
AE
RO
E
NG
INE
S (I
AE)
Mor
telle
s D
étru
it
Acci
dent
M
: 7
B:
UN
K: I
ncon
nu o
u in
déte
rmin
é LO
C-I:
Per
te d
e co
ntrô
le e
n vo
l In
: Col
lisio
n w
ith s
ea d
urin
g th
e ap
proa
ch to
RW
Y 3
3.
Acc
iden
t C
ollis
ion
avec
la m
er e
n ap
proc
he
Prél
imin
aire
O
AC
I - N
otifi
catio
n in
itial
e O
AC
I O
AC
I - A
DR
EP p
rélim
inai
re O
AC
I
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
13/1
2/20
08
near
Lon
don
Gat
wic
k -
Roy
aum
e U
ni
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
G-M
ON
K -
BO
EIN
G -
757-
200
Turb
oréa
cteu
r dou
ble
flux
RO
LLS-
RO
YCE
RB
211-
535E
4
Auc
un
Auc
un
Inci
dent
gra
ve
M:
B:
UN
K: I
ncon
nu o
u in
déte
rmin
é
IN: S
tick
shak
er a
ctiv
ated
dur
ing
app
to L
ondo
n, G
atw
ick.
The
a/c
wen
t aro
und
and
stic
k sh
aker
act
ivat
ed a
sec
ond
time.
The
a/c
reco
vere
d fo
r ano
ther
app
and
la
nded
.
Inci
dent
gr
ave
N
otifi
catio
n in
itial
e O
AC
I - N
otifi
catio
n in
itial
e O
AC
I
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
30/0
6/20
09
App
roac
h to
M
oron
i Hah
aia
- Com
ores
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
7O-A
DJ
- AIR
BU
S -
A31
0 Tu
rbor
éact
eur d
oubl
e flu
x P
RA
TT &
WH
ITN
EY
, USA
- P
W 4
000
Mor
telle
s D
étru
it
Acci
dent
M
: 152
B
: 1
U
NK
: Inc
onnu
ou
indé
term
iné
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz11
PR
N: A
t the
exp
ecte
d tim
e of
arri
val t
o ap
proa
ch fi
x fo
r rw
y 20
, the
con
trolle
r cal
led
the
crew
of f
light
IY62
6 w
ithou
t obt
aini
ng a
resp
onse
. Rem
ains
of t
he p
lane
wer
e fo
und
at s
ea. I
N: C
rash
ed o
n se
a. U
noffi
cial
Fro
m th
e B
BC
: Yem
en je
t cra
shes
in In
dian
Oce
an -
A Y
emen
i airl
iner
with
153
peo
ple
on b
oard
has
cra
shed
in th
e In
dian
Oce
an n
ear t
he C
omor
os a
rchi
pela
go. S
ome
bodi
es h
ave
been
spo
tted,
a Y
emen
i avi
atio
n of
ficia
l sai
d, a
nd w
reck
age
of th
e pl
ane
loca
ted.
It is
not
cle
ar
whe
ther
ther
e w
ere
surv
ivor
s. T
he A
irbus
310
flig
ht IY
626,
ope
rate
d by
Yem
eni c
arrie
r Yem
enia
Air,
was
flyi
ng fr
om th
e Y
emen
i cap
ital S
anaa
. It i
s no
t cle
ar w
hat
caus
ed th
e cr
ash
but o
ffici
als
say
ther
e w
as b
ad w
eath
er in
the
area
at t
he ti
me.
Fre
nch
Tran
spor
t Min
iste
r Dom
iniq
ue B
usse
reau
told
Fre
nch
radi
o th
e w
eath
er
rath
er th
an th
e pl
ane
itsel
f was
the
likel
y pr
oble
m. "
They
are
say
ing
the
plan
e w
as m
akin
g its
app
roac
h, th
at it
pul
led
out o
f the
app
roac
h an
d th
en tr
ied
anot
her
appr
oach
that
wen
t wro
ng,"
he to
ld F
renc
h ra
dio.
Rep
orts
say
the
plan
e w
as d
ue in
the
Com
oros
cap
ital M
oron
i at a
bout
023
0 (2
230G
MT
on M
onda
y). M
ost o
f the
pa
ssen
gers
had
trav
elle
d to
San
aa fr
om P
aris
or M
arse
ille
on a
diff
eren
t airc
raft.
The
flig
ht o
n to
Mor
oni w
as a
lso
thou
ght t
o ha
ve m
ade
a st
op in
Djib
outi.
The
re w
ere
147
pass
enge
rs, i
nclu
ding
thre
e ba
bies
, and
11
crew
on
boar
d. A
n ai
rpor
t sou
rce
told
AFP
new
s ag
ency
that
66
of th
e pa
ssen
gers
wer
e Fr
ench
, alth
ough
man
y ar
e th
ough
t to
have
dua
l Fre
nch-
Com
oran
citi
zens
hip.
Thi
s is
the
seco
nd a
ir tra
gedy
this
mon
th in
volv
ing
larg
e nu
mbe
rs o
f Fre
nch
citiz
ens.
On
1 Ju
ne a
n A
ir Fr
ance
A
irbus
330
trav
ellin
g fro
m R
io d
e Ja
neiro
to P
aris
plu
nged
into
the
Atla
ntic
, kill
ing
all 2
28 p
eopl
e on
boa
rd. '
Abo
rted
land
ing'
A s
earc
h is
und
er w
ay, w
ith th
e Fr
ench
m
ilita
ry a
ssis
ting
with
the
oper
atio
n. O
ffici
als
told
AFP
that
wre
ckag
e fro
m th
e pl
ane,
an
oil s
lick
and
bodi
es h
ad b
een
spot
ted
in th
e w
ater
a fe
w k
ilom
etre
s fro
m
Mor
oni,
on th
e is
land
of N
jazi
dja
(Gra
nde
Com
ore)
. "Th
e w
eath
er c
ondi
tions
wer
e ro
ugh;
stro
ng w
ind
and
high
sea
s," Y
emen
ia o
ffici
al M
oham
mad
al-S
umai
ri to
ld
Reu
ters
new
s ag
ency
. The
BB
C's
Will
Ros
s, in
Ken
ya, s
ays
that
giv
en th
e fa
ct th
e cr
ash
happ
ened
dur
ing
the
nigh
t and
in th
e se
a, th
e ch
ance
s of
find
ing
any
surv
ivor
s ar
e sl
im. T
he th
ree
Com
oros
isla
nds
are
abou
t 300
km (1
90 m
iles)
nor
thw
est o
f Mad
agas
car i
n th
e M
ozam
biqu
e ch
anne
l. A
resi
dent
nea
r the
airp
ort t
old
the
BB
C a
bout
100
peo
ple
wer
e try
ing
to g
et in
to th
e ai
rpor
t to
find
out m
ore
info
rmat
ion,
but
with
out m
uch
succ
ess.
The
airl
ine
Yem
enia
is 5
1% o
wne
d by
the
Yem
eni
gove
rnm
ent a
nd 4
9% b
y th
e S
audi
gov
ernm
ent.
In 1
996,
a h
ijack
ed E
thio
pian
airl
iner
cam
e do
wn
in th
e sa
me
area
- m
ost o
f the
175
pas
seng
ers
and
crew
wer
e ki
lled.
Uno
ffici
al F
rom
Avi
atio
n H
eral
d: A
Yem
enia
Airb
us A
310-
300,
regi
stra
tion
7O-A
DJ
perfo
rmin
g fli
ght I
Y-6
26 (d
ep J
un 2
9th) f
rom
San
a'a
(Yem
en) t
o M
oron
i H
ahai
a (C
omor
es) w
ith 1
47 p
asse
nger
s an
d 11
cre
w, d
isap
pear
ed fr
om ra
dar w
hile
on
appr
oach
to M
oron
i abo
ut 6
min
utes
prio
r to
estim
ated
arr
ival
at a
roun
d 1:
30am
(Jun
29th
22:
30Z)
. The
airp
lane
was
on
the
outb
ound
leg
of th
e in
stru
men
t app
roac
h an
d du
ring
the
turn
bac
k to
war
ds th
e ru
nway
, whe
n it
disa
ppea
red.
On
Tues
day
mor
ning
(Jun
30th
aro
und
05:0
0Z) a
boa
t dis
cove
red
debr
is o
f the
mis
sing
airl
iner
in th
e In
dian
Oce
an. T
here
are
no
sign
of s
urvi
vors
, sev
eral
bod
ies
have
be
en s
ight
ed. T
he a
irlin
e re
ports
142
pas
seng
ers
and
11 c
rew
. The
Com
ores
For
eign
Min
istry
sai
d ho
wev
er, t
hat n
umbe
r was
inco
rrec
t and
147
pas
seng
ers
wer
e on
bo
ard.
The
airp
lane
had
dep
arte
d S
ana'
a w
ith a
del
ay o
f 90
min
utes
at 2
1:30
L.
Acc
iden
t C
rash
: A31
0 ne
ar M
oron
i, im
pact
ed o
cean
Pr
élim
inai
re
OA
CI -
Not
ifica
tion
initi
ale
OA
CI
OA
CI -
AD
REP
pré
limin
aire
OA
CI
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
23/0
9/20
09
AD
Par
is C
DG
- F
ranc
e
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
F-G
RH
U -
AIR
BU
S -
A31
9 Tu
rbor
éact
eur d
oubl
e flu
x C
FM IN
TER
NA
TIO
NAL
- C
FM 5
6
Auc
un
Auc
un
Inci
dent
gra
ve
M:
B:
CFI
T: C
ollis
ion/
quas
i-col
lisio
n av
ec re
lief/o
bsta
cle
sans
per
te d
e co
ntrô
le
PR
N: V
ol M
osco
u - P
aris
CD
G. E
n ap
proc
he fi
nale
pis
te 2
7 R
de
l'aér
odro
me
de P
aris
CD
G, a
ux m
inim
a, le
com
man
dant
de
bord
exé
cute
une
rem
ise
des
gaz
en
rais
on d
es c
ondi
tions
mét
éoro
logi
ques
. La
perte
d'a
ltitu
de q
ui s
'ens
uit e
ntra
îne
le d
écle
nche
men
t de
l'ala
rme
GP
WS
"SIN
K R
ATE
". Le
pilo
te e
n fo
nctio
n dé
conn
ecte
to
utes
les
aide
s au
pilo
tage
et r
écup
ère
l'avi
on. L
e po
int b
as d
e la
traj
ecto
ire e
st e
nreg
istré
à 7
6 pi
eds.
Inci
dent
gr
ave
Per
te d
'alti
tude
en
rem
ise
de g
az, a
larm
e G
PW
S
Prél
imin
aire
B
ulle
tin T
P
OA
CI -
AD
REP
pré
limin
aire
OA
CI
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz12
PAR
G S
UPP
LEM
ENTA
IRES
ISSU
ES D
E LA
BA
SE B
EA
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
25/0
2/20
09
AD A
mst
erda
m
- Pay
s-B
as
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal
TC-J
GE
- BO
EIN
G -
737-
800
Turb
oréa
cteu
r dou
ble
flux
Mor
telle
s D
étru
it
Acci
dent
M
: 9
B:
CFI
T: C
ollis
ion/
quas
i-col
lisio
n av
ec re
lief/o
bsta
cle
sans
per
te d
e co
ntrô
le
Vol
AD
Ista
nbul
(Tur
quie
) - A
D A
mst
erda
m (P
ays-
Bas)
En
final
e po
ur la
pis
te 1
8R, l
'avi
on h
eurte
le s
ol 1
000
mèt
res
envi
ron
avan
t le
seui
l.
Acc
iden
t C
ollis
ion
avec
le s
ol e
n fin
ale
Clô
turé
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
09/0
3/20
08
Kim
po
Inte
rnat
iona
l A
irpor
t -C
orée
, R
épub
lique
de
Tran
spor
t pub
lic
HL7
242
- AIR
BU
S -
A30
0-60
0
Auc
un
Lége
rs
Inci
dent
M
: B
: 11
AR
C: C
onta
ct a
norm
al a
vec
la p
iste
/le s
ol L
OC
-I: P
erte
de
cont
rôle
en
vol
Vol
Che
ju -
Séo
ul/K
impo
. Lor
s de
l'at
terr
issa
ge e
n pi
ste
32L,
l'av
ion
rebo
ndit.
Les
des
truct
eurs
de
porta
nce
se d
éplo
ient
. Le
com
man
dant
de
bord
(PF)
app
lique
la
pous
sée
inve
rse.
Jug
eant
que
le re
bond
est
impo
rtant
, il d
écid
e d'
effe
ctue
r une
rem
ise
de g
az, q
u'il
initi
e al
ors
que
les
les
inve
rseu
rs d
e po
ussé
e so
nt to
ujou
rs e
n tra
nsit,
que
la p
ouss
ée e
st to
ujou
rs s
ur ID
LE e
t que
la v
itess
e es
t fai
ble
(VLS
-20
kts)
. La
queu
e de
l'av
ion
touc
he la
pis
te. L
e de
uxiè
me
atte
rris
sage
s'e
ffect
ue s
ans
autre
pro
blèm
e. C
i-apr
ès, s
ont r
epris
des
ext
raits
du
rapp
ort p
ublié
par
l'or
gani
sme
d'en
quêt
e co
réen
. Exe
cutiv
e S
umm
ary
On
Mar
ch 9
, 200
8, a
bout
17:
23, K
orea
n A
ir fli
ght 1
250
(her
eina
fter r
efer
red
to a
s "fl
ight
125
0"),
A30
0?60
0 (R
egis
tratio
n H
L724
2), t
ook
off f
rom
Jej
u In
tern
atio
nal A
irpor
t for
Gim
po In
tern
atio
nal A
irpor
t (h
erei
nafte
r ref
erre
d to
as
"Gim
po A
irpor
t"). A
bout
18:
07, w
hile
atte
mpt
ing
to la
nd o
n ru
nway
32L
of G
impo
Airp
ort,
fligh
t 125
0 ha
ppen
ed to
be
a no
se u
p te
nden
cy
follo
win
g a
roug
h la
ndin
g. T
he c
apta
in th
ough
t it a
sev
ere
boun
ce a
nd c
ondu
cted
the
go?a
roun
d pr
oced
ures
. How
ever
, the
airc
raft
pitc
h at
titud
e ex
ceed
ed it
s ge
omet
ry li
mits
dur
ing
the
proc
ess,
cau
sing
the
airc
raft
tail
to s
trike
the
runw
ay s
urfa
ce. F
light
125
0 w
as a
regu
larly
sch
edul
ed d
omes
tic p
asse
nger
ser
vice
flig
ht
oper
atin
g un
der i
nstru
men
t flig
ht ru
les
(IFR
). O
ne c
apta
in, o
ne fi
rst o
ffice
r, an
d si
x fli
ght a
ttend
ants
, and
260
pas
seng
ers
wer
e on
boa
rd a
t the
tim
e of
the
inci
dent
, but
th
ere
wer
e no
inju
ries
to p
erso
ns d
ue to
this
inci
dent
. Con
clus
ions
Fin
ding
s R
elat
ed to
Pro
babl
e C
ause
s Th
e ca
ptai
n ju
dged
the
nose
up
tend
ency
of t
he a
ircra
ft af
ter
touc
hdow
n as
a h
igh
boun
ce a
nd c
ondu
cted
the
go�
]aro
und
proc
edur
es, a
nd d
urin
g th
e pr
oces
s, th
e ai
rcra
ft ta
il ha
d st
roke
the
runw
ay d
ue to
the
pitc
h at
titud
e of
ai
rcra
ft ex
ceed
ing
the
airc
raft
geom
etry
lim
its. F
indi
ngs
Rel
ated
to R
isk
1. T
he g
o�]a
roun
d co
ntro
l was
con
duct
ed in
the
cond
ition
that
the
airc
raft
touc
hed
dow
n on
ru
nway
and
the
thru
st re
vers
er is
initi
ated
. 2. T
he p
itch
attit
ude
was
incr
ease
d to
mor
e th
an 1
1.2°
bef
ore
the
engi
ne th
rust
reac
hed
to a
take
off p
erfo
rman
ce. 3
. The
fir
st o
ffice
r did
not
pro
vide
any
adv
ice
at a
ll w
hile
the
capt
ain
mad
e th
e w
rong
judg
men
ts a
nd c
ondu
cted
the
impr
oper
con
trols
. Oth
er F
indi
ngs
1. T
he fl
ight
cre
w o
f fli
ght 1
250
held
app
ropr
iate
lice
nses
to th
e fli
ght a
nd th
e ai
rcra
ft he
ld th
e va
lid a
irwor
thin
ess
certi
ficat
e an
d th
e op
erat
ing
limita
tions
spe
cific
atio
n. 2
. The
flig
ht c
rew
of
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz13
fligh
t 125
0 to
ok a
n ad
equa
te re
st b
efor
e th
e fli
ght a
nd it
was
con
firm
ed th
at th
ere
wer
e no
fact
ors
whi
ch m
ay a
ffect
the
fligh
t med
ical
ly. 3
. The
regu
late
d m
aint
enan
ce
was
per
form
ed o
n fli
ght 1
250
and
ther
e w
ere
no d
efec
ts in
the
airfr
ame
or s
yste
m fo
und
befo
re th
e oc
curr
ence
of a
ccid
ent.
4. T
he in
cide
nt fl
ight
land
ed in
the
limits
of
the
Land
ing
Wei
ght C
ente
r of G
ravi
ty P
erce
ntag
e M
ean
Aer
odyn
amic
Cho
rd (L
DW
C.G
% M
AC
) with
the
appr
opria
te fu
els.
5. F
or th
e w
eath
er a
t Gim
po A
irpor
t, th
e vi
sual
met
eoro
logi
cal c
ondi
tion
prev
aile
d at
the
time
whe
n fli
ght 1
250
land
ed a
nd th
ere
was
no
gust
or w
ind
exce
edin
g th
e cr
ossw
ind
limits
. 6. F
light
125
0 ke
pt th
e no
rmal
app
roac
h sp
eed
in th
e fin
al a
ppro
ach
phas
e fo
r lan
ding
and
did
not
mak
e ha
rd la
ndin
g. 7
. The
pitc
h at
titud
es o
f airc
raft
that
the
airc
raft
tail
of A
300�
]600
to
uche
s th
e ru
nway
sur
face
are
11.
2° fo
r mai
n la
ndin
g ge
ar w
ith th
e ai
rcra
ft w
eigh
t and
12.
8° fo
r mai
n la
ndin
g ge
ar w
ithou
t the
airc
raft
wei
ght.
8. A
ccor
ding
to
A30
0�]6
00 P
OM
, the
go�
]aro
und
proc
edur
es s
hall
be c
ondu
cted
for h
igh
boun
ce e
xcee
ding
5 fe
et d
urin
g la
ndin
g. 9
. The
cap
tain
of f
light
125
0 ha
d ex
perie
nced
the
touc
h &
go
and
the
goar
ound
with
the
sim
ulat
or d
urin
g th
e up
grad
e tra
inin
g to
the
capt
ain
of A
300�
]600
. 10.
Due
to th
e st
rike
of a
ircra
ft ta
il w
ith ru
nway
, tai
l ski
d sh
oe, d
rain
mas
ter,
airc
raft
skin
, low
er s
kin
skid
and
rive
t, an
d ke
el b
eam
sup
port
in th
e bo
th s
ide
of in
ner a
ircra
ft ta
il w
ere
dam
aged
. Saf
ety
Rec
omm
enda
tions
U
nder
the
findi
ngs
of th
e fli
ght 1
250
inci
dent
, the
AR
AIB
dev
elop
e sa
fety
reco
mm
enda
tions
to K
orea
n A
ir as
follo
ws:
Kor
ean
Air
1. R
evie
w th
e pl
an to
rein
forc
e th
e go
�]a
roun
d tra
inin
g in
the
capt
ain
upgr
ade
train
ing
prog
ram
. �] C
ondu
ct th
e in
tens
ive
go�
]aro
und
train
ing
usin
g th
e si
mul
ator
trai
ning
pro
vide
d ad
ditio
nally
bef
ore
the
oper
atio
n ex
perie
nce.
(AIR
080
5-1)
�] P
rovi
de th
e op
portu
nitie
s to
exp
erie
nce
the
go�
]aro
und
in th
e va
rious
poi
nts
durin
g ap
proa
ch a
nd la
ndin
g. (A
IR 0
805�
]2)
? E
mph
asiz
e du
ring
train
ing
that
"a fu
ll-st
op la
ndin
g m
ust b
e co
mpl
eted
afte
r rev
erse
thru
st is
sel
ecte
d."(
AIR
080
5?3)
Inci
dent
H
eurt
du fu
sela
ge lo
rs d
'un
atte
rris
sage
inte
rrom
pu
Clô
turé
A
utre
- N
atio
nal
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
30/0
3/20
07
AD
Abi
djan
- C
ôte
d'Iv
oire
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
F-G
ZCC
- A
IRB
US
- A
330-
200
Turb
oréa
cteu
r dou
ble
flux
GE
NE
RA
L EL
EC
TRIC
USA
- C
F6
SE
RIE
S
Auc
un
Auc
un
Inci
dent
gra
ve
M:
B:
CFI
T: C
ollis
ion/
quas
i-col
lisio
n av
ec re
lief/o
bsta
cle
sans
per
te d
e co
ntrô
le
- Vol
Par
is C
DG
- A
bidj
an. A
l'ar
rivée
à A
bidj
an, l
'équ
ipag
e pr
épar
e un
e pr
océd
ure
ILS
pou
r la
pist
e 21
. Il f
ait n
uit,
l'env
ironn
emen
t est
ora
geux
mai
s le
terr
ain
déga
gé. P
enda
nt la
fina
le, l
'équ
ipag
e co
nsta
te u
n ve
nt a
rrièr
e si
gnifi
catif
. Ver
s 10
0 ft,
le v
ent a
rrièr
e au
gmen
te e
t dép
asse
10
noeu
ds. L
e co
mm
anda
nt d
e bo
rd, P
F,
déci
de d
'inte
rrom
pre
l'app
roch
e. L
'alti
tude
de
rem
ise
de g
az ra
pide
men
t atte
inte
, le
PF
agit
sur l
a co
mm
ande
de
prof
onde
ur p
our d
imin
uer l
'ass
iette
pui
s ré
duit
la
pous
sée.
La
vite
sse
augm
ente
rapi
dem
ent e
t l'in
dica
tion
LVR
CLB
clig
note
sur
le F
MA
. Pen
dant
ce
tem
ps, d
'aut
res
actio
ns à
piq
uer s
ont e
nreg
istré
es e
t l'a
ssie
tte
dim
inue
ver
s de
s va
leur
s né
gativ
es. L
e va
rio a
ttein
t -40
00 p
ieds
/min
ute.
Le
PF
réag
it pa
r une
act
ion
à ca
brer
, le
PN
F in
terv
ient
éga
lem
ent.
Des
ala
rmes
Sin
k R
ate
et
Pul
l Up
sont
déc
lenc
hées
par
le G
PWS
. Apr
ès a
naly
se d
e la
mét
éo e
t du
vent
sur
le te
rrai
n, l'
équi
page
pré
pare
et r
éalis
e un
e ap
proc
he c
lass
ique
pou
r la
pist
e 03
. Le
rest
e du
vol
et l
'atte
rris
sage
se
déro
ulen
t nor
mal
emen
t.
Inci
dent
gr
ave
Ala
rme
GPW
S S
ink
Rat
e et
Pul
l Up
suite
à p
erte
d'a
ltitu
de lo
rs d
e la
rem
ise
de g
az.
Clô
turé
A
vril
2008
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz14
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
03/0
5/20
06
Mer
Noi
re -
R
ussi
e,
Fédé
ratio
n de
Tran
spor
t pub
lic -
Serv
ice
régu
lier -
In
tern
atio
nal -
Pas
sage
rs
EK-3
2009
- A
IRB
US
- A
320
Turb
oréa
cteu
r dou
ble
flux
CFM
INTE
RN
ATI
ON
AL -
CFM
56
Mor
telle
s D
étru
it
Acci
dent
M
: 113
B
: C
FIT:
Col
lisio
n/qu
asi-c
ollis
ion
avec
relie
f/obs
tacl
e sa
ns p
erte
de
cont
rôle
Fi
ndin
gs 1
. The
A-3
20 E
K-3
2009
airc
raft
was
ow
ned
by th
e FU
NN
EL
com
pany
(Cay
man
Isla
nds)
and
was
ope
rate
d by
Arm
avia
. The
airc
raft
had
valid
regi
stra
tion
and
airw
orth
ines
s ce
rtific
ates
issu
ed b
y th
e A
viat
ion
Adm
inis
tratio
n of
the
Rep
ublic
of A
rmen
ia. 2
. Airc
raft
mai
nten
ance
was
car
ried
out b
y S
aben
a Te
chni
cs
(Bel
gium
) spe
cial
ists
in a
ccor
danc
e w
ith th
e ag
reem
ent w
ith A
rmav
ia. A
dditi
onal
wor
k w
as c
arrie
d ou
t by
Arm
avia
mai
nten
ance
per
sonn
el. N
o de
ficie
ncie
s in
the
mai
nten
ance
ser
vice
wer
e re
veal
ed th
at c
ould
hav
e in
fluen
ced
the
outc
ome
of th
e la
st fl
ight
. 3. T
he a
ircra
ft, it
s sy
stem
s an
d en
gine
s w
ere
serv
icea
ble
on d
epar
ture
fro
m Y
erev
an. T
he In
vest
igat
ion
Com
mis
sion
did
not
brin
g to
ligh
t any
evi
denc
e of
any
airc
raft
syst
em o
r eng
ine
failu
re d
urin
g th
e la
st fl
ight
. 4. T
he a
ircra
ft's
mov
emen
ts w
ere
com
plet
ely
dete
rmin
ed b
y ch
ange
s in
the
cont
rol s
urfa
ces
and
the
engi
ne m
odes
. The
aut
opilo
t was
wor
king
acc
ordi
ng to
the
esta
blis
hed
wor
k lo
gic.
Aer
odyn
amic
and
thru
st p
erfo
rman
ce o
f the
airc
raft
corre
spon
ded
to th
e ch
arac
teris
tics
of th
e ai
rcra
ft ty
pe. T
here
wer
e no
ext
erna
l inf
luen
ces
on th
e ai
rcra
ft (w
ind
shea
r, et
c.).
5. T
he a
ircra
ft ha
d a
suffi
cien
t am
ount
of t
he c
orre
ct fu
el fo
r saf
e co
mpl
etio
n of
the
fligh
t. Th
e ta
ke-o
ff, la
ndin
g w
eigh
t and
bal
ance
of t
he a
ircra
ft di
d no
t exc
eed
the
limita
tions
spe
cifie
d in
the
A32
0 FC
OM
. 6. T
here
was
no
disi
nteg
ratio
n of
the
airc
raft
in th
e ai
r. A
ll ai
rcra
ft st
ruct
ural
dam
age
resu
lted
from
the
impa
ct w
ith th
e w
ater
. 7. T
he c
rew
had
val
id p
ilot's
lice
nses
and
med
ical
cer
tific
ates
. The
ir qu
alifi
catio
ns a
nd s
tate
of h
ealth
cor
resp
onde
d to
the
char
acte
r of t
he
mis
sion
per
form
ed a
nd a
llow
ed s
afe
exec
utio
n of
the
fligh
t. A
ccor
ding
to th
e do
cum
ents
pre
sent
ed, t
he p
rofe
ssio
nal s
kill
leve
l of t
he fl
ight
cre
w m
embe
rs w
as in
ac
cord
ance
with
Arm
enia
n C
AA
regu
latio
ns. 8
. Arm
avia
doe
s no
t exe
rcis
e op
erat
iona
l sup
ervi
sion
of t
he A
320
airc
raft
crew
s' fl
ight
s by
usi
ng fl
ight
reco
rder
in
form
atio
n, w
hich
mad
e it
impo
ssib
le to
fully
eva
luat
e th
e pr
ofes
sion
al s
kill
leve
l of t
he fl
ight
cre
w m
embe
rs. 9
. Acc
ordi
ng to
the
data
pre
sent
ed, t
he p
re-fl
ight
rest
of
the
crew
prio
r to
the
depa
rture
to th
e S
ochi
airp
ort c
onsi
sted
of o
ver 2
4 ho
urs
at h
ome.
How
ever
, the
cre
w's
coc
kpit
conv
ersa
tions
indi
cate
d th
eir f
atig
ue, w
hich
cou
ld
have
influ
ence
d th
e ou
tcom
e of
the
fligh
t. Th
e fli
ght w
as p
erfo
rmed
at n
ight
, whe
n th
e pr
obab
ility
of m
ista
kes
is e
spec
ially
hig
h. 1
0. T
he m
eteo
rolo
gica
l and
air
navi
gatio
n su
ppor
t for
the
fligh
t met
the
requ
irem
ents
of t
he e
xist
ing
regu
lato
ry d
ocum
ents
. Air
traffi
c co
ntro
l ser
vice
per
sonn
el, i
nclu
ding
per
sonn
el fr
om th
e ar
eas
of
resp
onsi
bilit
y in
Soc
hi, Y
erev
an, T
bilis
i and
Ros
tov,
had
val
id li
cens
es a
s ci
vil a
viat
ion
spec
ialis
ts w
ith th
e re
quire
d ra
tings
. 11.
At t
he ti
me
of th
e ac
cide
nt th
e m
eteo
rolo
gica
l con
ditio
ns w
ere
com
plic
ated
and
did
not
cor
resp
ond
to th
e m
eteo
rolo
gica
l min
ima
of th
e ru
nway
06
of th
e S
ochi
airp
ort d
ue to
the
«clo
ud c
eilin
g»
para
met
er. I
n th
e tim
e be
fore
the
acci
dent
, the
wea
ther
con
ditio
ns a
t Soc
hi a
irpor
t wer
e un
stab
le. T
he c
rew
was
info
rmed
of t
he w
eath
er c
hang
es b
y th
e ai
r tra
ffic
cont
rolle
r in
a tim
ely
man
ner.
Inac
cura
cies
com
mitt
ed b
y th
e ai
r tra
ffic
cont
rolle
r whi
le re
porti
ng th
e w
eath
er w
ere
not d
irect
ly c
onne
cted
with
the
caus
e of
the
airc
raft
acci
dent
, but
they
influ
ence
d th
e in
itial
dec
isio
n of
the
crew
to re
turn
to th
e de
partu
re a
erod
rom
e . 1
2. T
he e
mot
iona
l rea
ctio
n of
the
crew
to th
e ai
r tra
ffic
cont
rolle
r's
info
rmat
ion
abou
t the
act
ual w
eath
er c
hang
es b
elow
the
esta
blis
hed
met
eoro
logi
cal m
inim
a w
as n
egat
ive
and
coul
d ha
ve le
d to
an
incr
ease
in th
e ps
ycho
-em
otio
nal
stra
in o
f the
cre
w m
embe
rs d
urin
g th
e fin
al s
tage
of f
light
. 13.
The
app
roac
h fo
r a la
ndin
g on
runw
ay 0
6 w
as m
ade
with
the
use
of IL
S in
an
auto
mat
ic m
ode.
The
re
was
no
devi
atio
n of
the
airc
raft
from
the
esta
blis
hed
glid
e sl
ope
prof
ile. A
ll th
e ra
dio
navi
gatio
n ai
ds a
t Soc
hi a
irpor
t wer
e fu
lly s
ervi
ceab
le. 1
4. T
he to
wer
con
trolle
r's
inst
ruct
ion
to a
bort
the
desc
ent a
nd p
erfo
rm a
righ
than
d cl
imbi
ng tu
rn to
600
m th
at w
as g
iven
to th
e cr
ew a
fter t
he c
loud
cei
ling
decr
ease
d be
low
the
esta
blis
hed
min
ima
for R
W 0
6, d
id n
ot fu
lly c
ompl
y w
ith th
e pr
ovis
ions
of t
he c
ontro
ller's
ope
ratio
nal m
anua
l, th
ough
it d
id n
ot d
irect
ly in
fluen
ce th
e ou
tcom
e of
the
fligh
t. A
ccor
ding
to th
e A
IP o
f Rus
sia
the
cont
rolle
r had
a ri
ght t
o re
fuse
the
land
ing.
It s
houl
d be
not
ed th
at a
num
ber o
f AIP
item
s co
ntra
dict
eac
h ot
her a
nd a
re
ambi
guou
s. 1
5. A
ccor
ding
to th
e A
rmav
ia O
pera
tions
Man
ual,
the
crew
mus
t ini
tiate
the
goar
ound
man
oeuv
re o
n re
ceiv
ing
wea
ther
info
rmat
ion
belo
w th
e m
inim
a,
even
if th
e re
liabl
e vi
sual
con
tact
is e
stab
lishe
d w
ith th
e ru
nway
or w
ith la
ndm
arks
. 16.
At t
he b
egin
ning
of t
he a
borte
d-ap
proa
ch m
anoe
uvre
the
crew
did
not
com
ply
with
the
stan
dard
go-
arou
nd p
roce
dure
stip
ulat
ed b
y th
e FC
OM
, reg
ardi
ng a
pply
ing
take
off t
hrus
t, re
tract
ing
flaps
by
one
step
and
retra
ctin
g la
ndin
g ge
ar. T
he c
limb
in th
e O
PE
N C
LIM
B m
ode
and
the
right
-han
d tu
rn in
the
HD
G m
ode
wer
e ca
rrie
d ou
t und
er a
utop
ilot c
ontro
l in
the
land
ing
conf
igur
atio
n w
ith th
e au
toth
rust
wor
king
in
the
spee
d-ho
ld m
ode.
The
land
ing
gear
was
ext
ende
d un
til th
e en
d of
the
fligh
t. Th
e m
ode
in q
uest
ion
is n
ot d
escr
ibed
in th
e A
320
AFM
. 17.
Dur
ing
fligh
t und
er
auto
pilo
t con
trol,
the
LOW
EN
ER
GY
WA
RN
ING
sig
nal w
as a
ctiv
ated
. The
cre
w h
ad p
rope
rly re
acte
d to
this
war
ning
by
setti
ng th
e th
rust
leve
rs in
the
take
off p
ositi
on
in fu
ll co
mpl
ianc
e w
ith th
e A
FM. I
t mus
t be
note
d th
at th
e cr
ew a
ctio
ns o
n ac
tivat
ion
of th
is w
arni
ng a
re s
peci
fied
in th
e A
BN
OR
MA
L P
RO
CE
DU
RE
sec
tion
of th
e A
320
QR
H. 1
8. S
imul
tane
ousl
y w
ith a
n in
crea
se in
eng
ine
pow
er th
e cr
ew (t
he C
apta
in) s
witc
hed
off t
he a
utop
ilot i
n th
e no
rmal
man
ner u
sing
the
take
-ove
r pu
shbu
tton
on th
e si
de s
tick.
Mos
t pro
babl
y, th
e ca
use
of th
e au
topi
lot d
isen
gage
men
t was
the
fact
that
the
airc
raft
dyna
mic
s an
d at
titud
e du
ring
this
man
oeuv
re
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz15
wer
e un
expe
cted
by
the
Cap
tain
: pitc
h an
gle
+21º
, rol
l ang
le +
25º,
decr
ease
in s
peed
, the
act
ivat
ed «
SP
EE
D S
PE
ED
SP
EE
D»,
war
ning
as
wel
l as
the
fact
that
he
coul
d no
t pre
dict
furth
er c
hang
es in
thes
e pa
ram
eter
s. T
hrou
ghou
t the
rest
of t
he fl
ight
the
airp
lane
was
con
trolle
d m
anua
lly, w
ith th
e bo
th F
Ds
switc
hed
on. 1
9. A
fter
dise
ngag
emen
t of t
he a
utop
ilot t
he C
apta
in w
as p
ilot f
lyin
g. H
is a
ctio
ns, o
rigin
ally
, led
to th
e pl
ane
mak
ing
a st
abili
zed
turn
to th
e rig
ht w
ith a
roll
of a
bout
20
degr
ees,
cl
imbi
ng a
t a ra
te o
f 2-3
m/s
and
acc
eler
atin
g. T
he s
tabi
lized
turn
pro
ceed
ed u
ntil
the
mag
netic
hea
ding
atta
ined
the
valu
e di
fferin
g fro
m th
e ru
nway
hea
ding
by
90
degr
ees.
Sub
sequ
ently
the
Cap
tain
con
trolle
d th
e pl
ane
to d
esce
nd w
ith a
pitc
h an
gle
up to
12
degr
ees
pitc
h do
wn
and
a ro
ll an
gle
up to
40
degr
ees
to th
e rig
ht,
whi
ch a
t max
imum
con
tinuo
us p
ower
resu
lted
in a
sub
stan
tial i
ncre
ase
in IA
S a
nd th
e ve
rtica
l rat
e of
des
cent
, as
wel
l as
in a
ctiv
atio
n of
EG
PW
S a
nd C
RC
war
ning
s (e
xces
sive
spe
ed in
flig
ht w
ith h
igh-
lift d
evic
es e
xten
ded)
. The
act
ual r
easo
n of
suc
h ac
tions
by
the
Cap
tain
cou
ld n
ot b
e de
term
ined
. Pro
babl
y, s
uch
inad
equa
te
pilo
ting
was
cau
sed
by th
e la
ck o
f mon
itorin
g of
suc
h fli
ght p
aram
eter
s as
pitc
h, a
ltitu
de a
nd ro
ll, a
t nig
ht in
diff
icul
t wea
ther
con
ditio
ns w
ith a
bac
kgro
und
of fa
tigue
an
d ps
ycho
-em
otio
nal s
tress
. 20.
Afte
r the
act
ivat
ion
of th
e E
GP
WS
war
ning
, bot
h pi
lots
mad
e co
ntro
l inp
uts
sim
ulta
neou
sly.
The
take
-ove
r but
ton
was
not
pre
ssed
by
eith
er o
f the
pilo
ts. T
he c
ontro
l inp
uts
by th
e C
apta
in a
nd th
e co
-pilo
t, bo
th in
roll
and
pitc
h w
ere
not c
oord
inat
ed a
nd m
ade
in o
ppos
ite d
irect
ions
. The
DU
AL
INP
UT
war
ning
was
not
act
ivat
ed b
ecau
se o
f its
low
er p
riorit
y co
mpa
red
to th
e E
GP
WS
war
ning
. Bef
ore
the
airp
lane
col
lided
with
the
wat
er th
e cr
ew h
ad a
lmos
t co
mpl
eted
retra
ctio
n of
the
win
g hi
gh-li
ft de
vice
s in
sev
eral
ste
ps (t
he s
lats
wer
e st
ill m
ovin
g). N
eith
er o
f the
pilo
ts w
as m
onito
ring
the
airc
raft
desc
ent p
aram
eter
s or
fu
lfille
d th
e FC
OM
requ
irem
ents
for c
rew
act
ions
afte
r EG
PW
S w
arni
ng a
ctiv
atio
n, w
hich
are
sta
ted
in th
e "E
ME
RG
EN
CY
PR
OC
EDU
RE
" Sec
tion
of th
e A
320
QR
H.
The
crew
's a
ttent
ion
mig
ht h
ave
been
dis
tract
ed b
y a
long
20-
seco
nd c
ontro
ller's
mes
sage
rega
rdin
g a
chan
ge in
the
appr
oach
pro
cedu
re, w
hich
was
reco
rded
by
the
CV
R a
long
with
the
EG
PW
S a
nd C
RC
war
ning
s th
at w
ere
soun
ding
in th
e ba
ckgr
ound
. The
con
trolle
r iss
ued
the
mes
sage
in a
ccor
danc
e w
ith th
e co
ntro
ller's
op
erat
iona
l man
ual,
afte
r the
cre
w c
onta
cted
him
. 21.
Exp
erim
ents
on
the
sim
ulat
ors
show
ed: -
Pro
vide
d th
at th
e st
anda
rd «
GO
AR
OU
ND
» an
d «M
ISS
ED
AP
P»
proc
edur
es p
resc
ribed
by
the
FCO
M a
re fo
llow
ed, t
he a
ircra
ft pe
rform
s th
e go
-aro
und
man
oeuv
re w
ith n
o di
fficu
lties
, in
both
the
auto
mat
ic a
nd d
irect
or m
odes
. - In
th
e ca
se w
here
the
auto
pilo
t rem
ains
eng
aged
, whi
le th
e ai
rcra
ft is
per
form
ing
a m
anoe
uvre
sim
ilar t
o th
at in
the
acci
dent
flig
ht, t
he a
utop
ilot n
orm
ally
com
plet
es th
e go
-aro
und
proc
edur
e, w
ith a
max
imum
pitc
h an
gle
not e
xcee
ding
21.
5º, t
he s
hort-
time
decr
ease
of s
peed
not
exc
eedi
ng 1
0-12
kt,
with
act
ivat
ion
of th
e «S
PE
ED
S
PE
ED
SP
EE
D»
war
ning
, and
with
out a
ctiv
atio
n of
the
á - F
LOO
R fu
nctio
n. -
If af
ter a
ctiv
atio
n of
the
«PU
LL U
P»
war
ning
the
FCO
M re
com
men
datio
ns a
re
impl
emen
ted,
for t
he p
aram
eter
s si
mila
r to
thos
e in
the
acci
dent
flig
ht (i
ndic
ated
airs
peed
270
…28
0 kt
, pitc
h an
gle
-5.5
º…-6
.5º,
roll
angl
e ab
out z
ero
and
the
win
g hi
gh-li
ft de
vice
s in
the
18º/0
º pos
ition
), th
e de
crea
se in
alti
tude
dur
ing
airc
raft
reco
very
from
des
cent
is a
bout
200
…23
0 ft.
Con
clus
ion
The
fata
l cra
sh o
f the
"Arm
avia
" A
-320
EK
-320
09 w
as a
CFI
T ac
cide
nt th
at h
appe
ned
due
to c
ollis
ion
with
the
wat
er w
hile
car
ryin
g-ou
t a c
limbi
ng m
anoe
uvre
afte
r an
abor
ted
appr
oach
to S
ochi
ai
rpor
t at n
ight
with
wea
ther
con
ditio
ns b
elow
the
esta
blis
hed
min
ima
for r
unw
ay 0
6. W
hile
per
form
ing
the
clim
b w
ith th
e au
topi
lot d
isen
gage
d, th
e C
apta
in, b
eing
in a
ps
ycho
emot
iona
l stre
ss c
ondi
tion,
mad
e no
se d
own
cont
rol i
nput
s du
e to
the
loss
of p
itch
and
roll
awar
enes
s. T
his
star
ted
the
abno
rmal
situ
atio
n. S
ubse
quen
tly th
e C
apta
in's
inpu
ts in
the
pitc
h ch
anne
l wer
e in
suffi
cien
t to
prev
ent d
evel
opm
ent o
f the
abn
orm
al s
ituat
ion
into
the
cata
stro
phic
one
. Alo
ng w
ith th
e in
adeq
uate
con
trol
inpu
ts o
f the
Cap
tain
, the
con
tribu
ting
fact
ors
to d
evel
opm
ent o
f the
abn
orm
al s
ituat
ion
into
the
cata
stro
phic
one
wer
e al
so th
e la
ck o
f nec
essa
ry m
onito
ring
of th
e ai
rcra
ft de
scen
t par
amet
ers
(pitc
h at
titud
e, a
ltitu
de, v
ertic
al s
peed
) by
the
co-p
ilot a
nd th
e ab
senc
e of
pro
per r
eact
ion
by th
e cr
ew to
the
EG
PW
S w
arni
ng.
Sho
rtcom
ings
foun
d du
ring
inve
stig
atio
n 1.
Dur
ing
desc
ent a
nd a
ppro
ach
the
crew
con
stan
tly h
ad ir
rele
vant
con
vers
atio
ns th
at h
ad n
othi
ng to
do
with
the
crew
op
erat
ions
man
ual,
and
ther
efor
e vi
olat
ed th
e re
quire
men
ts o
f RO
LRG
A R
A-2
000,
Sec
tion
8.3.
4. 2
. The
A32
0 FC
TM, w
hich
was
app
rove
d by
the
Civ
il A
viat
ion
Adm
inis
tratio
n of
the
Rep
ublic
of A
rmen
ia a
nd a
ccor
ding
to w
hich
Cap
tain
G.S
. Grig
orya
n pa
ssed
his
trai
ning
bef
ore
star
ting
solo
flig
hts
with
the
airli
ne, d
oes
not
cont
ain
the
requ
irem
ent f
or p
assi
ng th
e U
pgra
de to
Cap
tain
pro
gram
me.
Cap
tain
G.S
. Grig
orya
n di
d no
t pas
s th
is tr
aini
ng. T
his
train
ing
prog
ram
me
was
mad
e m
anda
tory
in th
e ne
xt re
visi
on o
f the
FC
TM. 3
. The
Flig
ht O
pera
tions
Dep
artm
ent o
f Arm
avia
doe
s no
t com
ply
with
the
prov
isio
ns o
f RO
LRG
A R
A S
ectio
n 11
.2 a
nd
ICA
O A
nnex
6 P
art 1
Cha
pter
3, w
hich
requ
ire a
irlin
es to
ana
lyze
figh
t ope
ratio
ns w
ith th
e us
e of
the
FDR
and
CV
R re
cord
ings
for a
ircra
ft w
ith th
e ce
rtifie
d M
TOW
ex
ceed
ing
27 0
00 k
g. 4
. In
viol
atio
n of
RO
LRG
A R
A-2
000
Sec
tions
4.5
.33
and
6.1.
5, A
rmav
ia a
irlin
e do
es n
ot k
eep
reco
rds
on th
e ap
proa
ches
and
land
ings
in
com
plic
ated
wea
ther
con
ditio
ns p
erfo
rmed
by
thei
r Cap
tain
s. 5
. The
follo
win
g de
ficie
ncie
s w
ere
iden
tifie
d in
air
traffi
c m
anag
emen
t: - A
t 21:
16 th
e ap
proa
ch c
ontro
ller
of th
e S
ochi
aer
odro
me
advi
sed
the
crew
of t
he tr
end
wea
ther
fore
cast
for l
andi
ng a
s 15
0 by
150
0 an
d di
d no
t ide
ntify
the
trend
as
"AT
TIM
ES
". Th
is in
accu
racy
co
mm
itted
by
the
cont
rolle
r whi
le re
porti
ng th
e w
eath
er to
the
crew
was
not
dire
ctly
con
nect
ed w
ith th
e ca
use
of th
e ai
rcra
ft ac
cide
nt, b
ut it
influ
ence
d th
e in
itial
de
cisi
on o
f the
cre
w to
retu
rn to
the
depa
rture
aer
odro
me.
- A
t 22:
01:3
7 th
e ap
proa
ch c
ontro
ller a
dvis
ed th
e cr
ew o
f the
obs
erve
d w
eath
er a
t Soc
hi a
erod
rom
e as
at
22:0
0 an
d by
mis
take
sai
d th
e cl
oud
ceili
ng w
as "c
onsi
dera
ble
1800
", in
stea
d of
180
m, h
owev
er th
is d
id n
ot in
fluen
ce th
e C
apta
in's
dec
isio
n. -
At 2
2:03
:29
the
crew
di
d no
t rep
ort,
and
the
hold
ing
cont
rolle
r did
not
requ
est t
he c
rew
to re
port
the
sele
cted
sys
tem
and
mod
e of
app
roac
h, w
hich
doe
s no
t mee
t the
requ
irem
ents
of t
he
Hol
ding
Con
trolle
r's O
pera
tion
Man
ual,
Sec
tion
4, it
em 4
.2.1
, of S
ochi
aer
odro
me.
- A
t 22:
11:3
8 th
e fin
al c
ontro
ller a
t Soc
hi a
erod
rom
e w
as in
form
ed b
y th
e w
eath
er
obse
rver
on
the
actu
al w
eath
er a
t Soc
hi a
erod
rom
e w
ith th
e cl
oud
ceili
ng a
t 100
m, w
hich
was
bel
ow th
e es
tabl
ishe
d m
inim
a (c
loud
cei
ling
170
m, v
isib
ility
250
0 m
). B
ased
on
this
info
rmat
ion,
the
final
con
trolle
r ins
truct
ed th
e cr
ew: "
Abo
rt de
scen
t, cl
ouds
at 1
00 m
, rig
ht-h
and
clim
bing
turn
to 6
00 m
eter
s". T
he c
ontro
ller's
act
ions
di
d no
t com
ply
with
the
requ
irem
ents
of t
he C
ivil
Flig
ht O
pera
tions
Gui
danc
e 85
Sec
tion
6.5.
16 a
nd th
e Fi
nal C
ontro
ller's
Ope
ratio
n M
anua
l, ite
ms
4.3
and
4.3.
1.
How
ever
, acc
ordi
ng to
the
AIP
of R
ussi
a th
e co
ntro
ller h
ad a
righ
t to
forb
id th
e la
ndin
g. It
sho
uld
be n
oted
that
a n
umbe
r of A
IP it
ems
cont
radi
ct e
ach
othe
r and
are
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz16
ambi
guou
s. 6
. Met
eoro
logi
cal s
uppo
rt: -
The
wea
ther
fore
cast
for t
he S
ochi
aer
odro
me
for t
he p
erio
d fro
m 1
8:00
to 0
3:00
was
not
ver
ified
with
rega
rd to
vis
ibilit
y in
th
e "A
t tim
es" g
roup
; - In
vio
latio
n of
the
Gui
danc
e fo
r Met
eoro
logi
cal S
uppo
rt in
Civ
il A
viat
ion
95, S
ectio
ns 4
.3.1
and
4.4
.1 d
) and
the
Inst
ruct
ion
for m
eteo
rolo
gica
l su
ppor
t at S
ochi
aer
odro
me,
the
obse
rver
did
not
com
plet
e th
e sp
ecia
l wea
ther
repo
rt at
22:
11, w
hen
the
clou
d ce
iling
desc
ende
d to
100
m, i
.e. t
o a
valu
e st
ipul
ated
in
Ann
ex 8
of t
he C
riter
ia F
or Is
suan
ce o
f a S
peci
al W
eath
er R
epor
t; - T
he re
com
men
datio
n fo
r ATI
S b
road
cast
con
tent
stip
ulat
ed in
the
join
t Ord
er N
o. 6
2/41
"On
appr
oval
and
impl
emen
tatio
n of
Inst
ruct
ion
for A
TIS
bro
adca
st c
onte
nt in
Eng
lish
and
Rus
sian
lang
uage
s" o
f 20.
03.2
000
issu
ed b
y th
e Fe
dera
l Air
Tran
spor
t A
dmin
istra
tion
and
Hyd
rom
eteo
rolo
gy a
nd E
nviro
nmen
t Mon
itorin
g S
ervi
ce w
as n
ot e
ntire
ly fu
lfille
d. 7
. A32
0 ai
rcra
ft: -
In c
ours
e of
read
ing
out t
he F
DR
dat
a, a
nu
mbe
r of d
iscr
epan
cies
wer
e fo
und
in th
e do
cum
enta
tion
desc
ribin
g th
e lo
gic
of b
inar
y si
gnal
reco
rdin
gs; -
Whi
le p
erfo
rmin
g m
anoe
uvre
s in
the
land
ing
conf
igur
atio
n w
ith th
e au
topi
lot a
nd a
utot
hrus
t eng
aged
, the
LO
W E
NE
RG
Y W
ARN
ING
may
sou
nd, w
hich
Airb
us c
onsi
ders
as
an a
bnor
mal
situ
atio
n. 5
. SA
FETY
R
EC
OM
ME
ND
ATI
ON
S 5
.1 T
o av
iatio
n ad
min
istra
tions
of t
he C
IS c
ount
ries:
- To
con
duct
brie
fings
with
the
fligh
t cre
ws,
con
trolle
rs a
nd te
chni
cal a
nd e
ngin
eerin
g pe
rson
nel t
o re
view
the
circ
umst
ance
s an
d th
e ca
uses
of t
he a
ccid
ent.
- To
ensu
re fu
lfilm
ent o
f the
requ
irem
ents
of I
CAO
Ann
ex 6
Par
t 1 C
hapt
er 3
for m
anda
tory
an
alys
is o
f per
form
ed fl
ight
ope
ratio
ns b
ased
on
the
CV
R a
nd F
DR
reco
rdin
gs fo
r the
airc
raft
with
a c
ertif
ied
MTO
W e
xcee
ding
270
00 k
g. -
To d
raw
the
atte
ntio
n of
A
320
crew
s to
the
nece
ssity
of i
mm
edia
te re
spon
se to
act
ivat
ion
of th
e E
GP
WS
war
ning
(eve
n if
othe
r war
ning
s ar
e on
at t
he s
ame
time)
in th
e ca
se o
f ins
trum
ent
fligh
t, or
flig
ht in
diff
icul
t wea
ther
con
ditio
ns, o
r flig
ht in
the
mou
ntai
ns. T
o in
trodu
ce th
e re
leva
nt e
xerc
ises
in th
e si
mul
ator
trai
ning
pro
gram
mes
to p
ract
ice
thes
e ac
tions
. To
cons
ider
the
advi
sabi
lity
of e
xten
ding
thes
e re
com
men
datio
ns to
oth
er a
ircra
ft ty
pes.
- To
revi
ew th
e ne
cess
ity o
f enh
anci
ng c
rew
sim
ulat
or tr
aini
ng in
the
sect
ion
on fl
ying
in F
light
Dire
ctor
mod
e, e
spec
ially
dur
ing
appr
oach
and
go-
arou
nd. -
To
brin
g th
e co
nten
t of t
he A
IP, a
s w
ell a
s th
e A
TC c
ontro
llers
' job
des
crip
tions
an
d op
erat
ions
man
uals
, int
o co
mpl
ianc
e w
ith th
e st
anda
rds
and
prac
tices
reco
mm
ende
d by
ICA
O, w
ith re
gard
to c
lear
ance
for a
ppro
ach
and
land
ing.
5.2
To
avia
tion
adm
inis
tratio
ns o
f CIS
cou
ntrie
s jo
intly
with
the
indu
stria
l and
sci
entif
ic a
nd re
sear
ch o
rgan
izat
ions
: - T
o or
gani
ze a
nd c
ondu
ct re
sear
ch in
to th
e co
nditi
ons
unde
r whi
ch a
cre
w m
ay lo
se s
patia
l orie
ntat
ion
and/
or u
pset
airc
raft
attit
ude
may
dev
elop
, and
to is
sue
prac
tical
reco
mm
enda
tions
to e
nhan
ce fl
ight
saf
ety.
In
parti
cula
r, to
eva
luat
e th
e ef
fect
of i
n-fli
ght a
ccel
erat
ion
illus
ions
. Bas
ed o
n th
e re
sear
ch, t
o de
velo
p an
d in
trodu
ce a
spe
cial
ized
cou
rse
for r
ecur
rent
trai
ning
of c
rew
s th
at s
houl
d co
ntai
n bo
th c
lass
room
and
flyi
ng tr
aini
ng. 5
.3 T
o th
e C
ivil
Avi
atio
n A
dmin
istra
tion
of th
e R
epub
lic o
f Arm
enia
and
Arm
avia
airl
ine
adm
inis
tratio
n: -
To
incl
ude
in th
e A
320
FCTM
the
man
dato
ry re
quire
men
t for
trai
nee
Cap
tain
s to
pas
s th
e U
pgra
de to
Cap
tain
pro
gram
me.
- To
kee
p re
cord
s on
app
roac
hes
perfo
rmed
in
diff
icul
t wea
ther
con
ditio
ns b
y A
320
crew
s, in
acc
orda
nce
with
the
regu
lato
ry d
ocum
ents
rela
ting
to th
e or
gani
zatio
n of
flig
ht o
pera
tions
in c
ivil
avia
tion
of th
e R
epub
lic o
f Arm
enia
. - T
o or
gani
ze F
DR
and
CV
R re
adou
ts fo
r ana
lysi
s of
A32
0 fli
ght o
pera
tions
, in
orde
r to
reve
al a
ny e
rror
s an
d de
ficie
ncie
s in
cre
ws'
pilo
ting
tech
niqu
e, a
nd to
dev
elop
mea
sure
s fo
r the
ir pr
even
tion.
- To
poi
nt o
ut to
airc
raft
crew
s th
at ir
rele
vant
con
vers
atio
ns in
the
cock
pit,
espe
cial
ly d
urin
g th
e cl
imb
and
desc
ent p
hase
s, a
re p
rohi
bite
d. 5
5 - T
o co
nsid
er th
e ne
cess
ity o
f enh
ance
d si
mul
ator
trai
ning
for A
320
crew
s. -
To d
evel
op a
pro
cedu
re fo
r sto
rage
of A
320
oper
atio
nal d
ocum
enta
tion
that
wou
ld re
gula
te th
e co
nditi
ons
of k
eepi
ng th
e or
igin
als
and
copi
es o
f the
doc
umen
ts b
y bo
th S
aben
a Te
chni
cs a
nd A
rmav
ia a
irlin
e.
5.4.
To
the
Fede
ral A
ir N
avig
atio
n S
ervi
ce o
f the
Rus
sian
Fed
erat
ion:
- To
revi
ew th
e po
ssib
ility
of u
pdat
ing
of A
IP o
f the
RF
and
othe
r reg
ulat
ory
docu
men
ts fo
r the
pu
rpos
e of
uni
ficat
ion
of A
TC p
roce
dure
s fo
r iss
uing
inst
ruct
ions
for g
o-ar
ound
s to
airc
raft
oper
ated
by
dom
estic
and
fore
ign
airli
nes,
and
to in
corp
orat
e th
e re
leva
nt
amen
dmen
ts in
to th
e R
ules
and
Phr
aseo
logy
for I
n-fli
ght R
adio
Com
mun
icat
ions
and
ATC
. - T
o re
view
the
poss
ibili
ty o
f inc
orpo
ratio
n of
the
Air
Traf
fic S
ervi
ce
proc
edur
es in
the
aero
drom
e se
rvic
es p
rovi
ded
in a
ccor
danc
e w
ith IC
AO
reco
mm
enda
tions
(Doc
umen
t 444
4, A
ttach
men
t 11)
and
the
Ord
er N
o. 1
03/D
V-11
6 of
26
.10.
95 is
sued
by
Dep
artm
ent o
f Air
Tran
spor
t. 5.
5. T
o th
e Fe
dera
l Ser
vice
for H
ydro
met
eoro
logy
and
Env
ironm
enta
l Mon
itorin
g: -
To re
view
the
poss
ibilit
y of
pu
rcha
sing
and
inst
allin
g of
a n
ew D
oppl
er w
eath
er ra
dar a
t the
civ
il av
iatio
n m
eteo
rolo
gica
l sta
tion
in S
ochi
. - T
o un
derta
ke m
easu
res
to e
limin
ate
the
shor
tcom
ings
in
the
met
eoro
logi
cal s
uppo
rt to
civ
il fli
ght o
pera
tions
at S
ochi
aer
odro
me
brou
ght t
o lig
ht in
the
cour
se o
f the
inve
stig
atio
n. 5
.6. T
o th
e fe
dera
l sta
te u
nita
ry e
nter
pris
e "S
tate
Cor
pora
tion
for A
ir Tr
affic
Man
agem
ent»
: - T
o re
stor
e co
mpl
ete
ATI
S b
road
cast
ing
for S
ochi
aer
odro
me,
incl
udin
g w
eath
er d
ata.
- To
cla
rify
to c
ontro
llers
of
the
Soc
hi A
ir Tr
affic
Sup
port
of th
e gr
oups
of B
EC
MG
and
TE
MP
O c
hang
es in
the
wea
ther
fore
cast
s fo
r the
aer
odro
me
and
of th
e tw
o-ho
ur "t
rend
" wea
ther
fo
reca
sts.
5.7
. To
Airb
us: -
To
elim
inat
e th
e di
scre
panc
ies
in th
e do
cum
enta
tion
desc
ribin
g th
e lo
gic
of th
e bi
nary
sig
nals
reco
rded
by
the
FDR
. - T
o in
trodu
ce in
the
A32
0 FC
OM
info
rmat
ion
clar
ifyin
g sp
ecifi
c fe
atur
es o
f act
ivat
ion
of th
e O
PE
N C
LIM
B m
ode
in v
ario
us fl
ight
con
ditio
ns. -
To
intro
duce
in th
e A
320
FCO
M a
war
ning
ab
out p
ossi
ble
activ
atio
n of
the
LOW
EN
ER
GY
WAR
NIN
G, w
hen
the
airc
raft
perfo
rms
man
oeuv
res
in th
e la
ndin
g co
nfig
urat
ion
with
con
side
rabl
e ch
ange
s in
pitc
h an
d ro
ll an
gles
. - T
o re
view
the
expe
dien
cy o
f alte
ratio
n of
the
type
and
/or p
riorit
y of
the
EG
PW
S w
arni
ng to
ens
ure
mor
e re
liabl
e pi
lots
' res
pons
e to
its
activ
atio
n.
5.8.
To
elim
inat
e th
e sh
ortc
omin
gs re
veal
ed d
urin
g in
vest
igat
ion
of th
e av
iatio
n ac
cide
nt.
Acc
iden
t C
ollis
ion
avec
la m
er a
près
rem
ise
des
gaz
Clô
turé
O
AC
I - R
appo
rt fi
nal O
AC
I
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz17
Dat
e Li
eu
Expl
oita
tion
Type
d'a
éron
ef
Dom
mag
es
corp
orel
s D
omm
ages
m
atér
iels
To
tal d
es
bles
sure
s à
bord
24/0
9/19
94
AD
Orly
(94)
- Fr
ance
Tr
ansp
ort p
ublic
YR-L
CA
- A
IRB
US
- A
310
Turb
oréa
cteu
r dou
ble
flux
Auc
un
Auc
un
Inci
dent
M
: B
: LO
C-I:
Per
te d
e co
ntrô
le e
n vo
l - V
ol B
ucar
est -
Orly
. Pen
dant
l'ap
proc
he s
ur P
aris
Orly
, par
bon
nes
cond
ition
s m
étéo
rolo
giqu
es, l
'avi
on s
e m
et s
ouda
inem
ent e
n m
onté
e en
pre
nant
une
forte
as
siet
te lo
ngitu
dina
le e
t déc
roch
e. L
'équ
ipag
e pa
rvie
nt à
récu
pére
r le
cont
rôle
de
l'avi
on e
t se
repr
ésen
te à
l'at
terr
issa
ge. C
ause
s pr
obab
les
Les
caus
es d
irect
es d
es
attit
udes
inus
uelle
s et
du
décr
ocha
ge s
ubis
par
l'av
ion
sont
un
mou
vem
ent d
u P
HR
ver
s la
pos
ition
à p
lein
cab
rer e
t une
aug
men
tatio
n ra
pide
de
la p
ouss
ée,
man
oeuv
res
tout
es d
eux
com
man
dées
par
le p
ilote
en
fonc
tion,
à la
sui
te d
'une
réve
rsio
n de
mod
e de
l'A
FS q
ui n
'a p
as é
té c
ompr
ise.
Le
coup
le c
abre
ur a
pro
voqu
é un
e pr
ise
d'as
siet
te b
ruta
le q
ue l'
équi
page
n'a
pas
pu
et n
e po
uvai
t pas
con
teni
r à la
pro
fond
eur.
Les
élém
ents
sui
vant
s on
t con
tribu
é à
l'inci
dent
: · U
ne a
ppro
che
trop
rapi
de, d
ue à
un
débu
t de
desc
ente
tard
if, s
uivi
e pa
r un
racc
ourc
isse
men
t de
la p
rocé
dure
sta
ndar
d. ·
Un
trava
il in
suffi
sant
en
équi
page
. · L
a sé
lect
ion
prém
atur
ée d
e l'a
ltitu
de d
e re
mis
e de
s ga
z et
la p
rise
préc
ipité
e de
la c
onfig
urat
ion
becs
et v
olet
s à
20-2
0, q
ui o
nt e
ntra
îné
l'act
ivat
ion
de la
pro
tect
ion
en v
itess
e. ·
La d
iffic
ulté
de
com
préh
ensi
on d
e l'a
ctio
n de
l'au
tom
anet
te a
ugm
enta
nt la
pou
ssée
dan
s sa
fonc
tion
de p
rote
ctio
n co
ntre
les
haut
es v
itess
es.
Inci
dent
D
écro
chag
e en
app
roch
e C
lôtu
ré
Rap
port
ble
u
Mar
s 20
00
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz18
DONNEES ISSUES DE LA BASE DU NTSB
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz19
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz20
DONNEES FOURNIES PAR LA FAA INFORMATIONS ISSUES DE LA BASE DE DONNEES ASIAS Data Source: ACCIDENT AND INCIDENT DATABASE Report Number: 20060518009919C Local Date: 18-MAY-06 Local Time: City: FAIRBANKS State: AK Airport Name: FAIRBANKS INTL Event Type: INCIDENT - AIR CARRIER Mid Air Collision: NOT A MIDAIR Aircraft Damage: MINOR Aircraft Make: MCDONNELL-DOUGLAS-BOEING Aircraft Model: MD-80 Aircraft Series: 83 Airframe Hrs: Operator: ALASKA AIRLINES Owner: ALASKA AIRLINES INC (-23) ^PRIVACY DATA OMITTED^ F/O WAS PILOT FLYING, APPROACH BECAME UNSTABLE, AIRCRAFT LINED UP LEFT OF RUNWAY, GO AROUND WAS COMMANDED BY PIC, DURING GO AROUND RIGHT WING STRUCK RUNWAY. INFORMATIONS ISSUES DE LA BASE DE DONNEES ASRS Weather Conditions: VMC Ceiling Single Value (ft): 5000 Light Condition: DAYLIGHT Acft Make/Model Desc: A300 Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: TEST FLIGHT Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: FMS OR FMC Flight Crew Count: 2 Flt Crew Exp (last 90 days): 100 Flt Crew Total Exp: 15000 Flt Crew Exp: 1200
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz21
CONDUCTING A FUNCTIONAL TEST OF THE AUTO GAR FEATURE OF AUTOPLT #2 DURING A POST 'C' CHK ACCEPTANCE FLT. INITIAL PITCH AND AIRSPD NORMAL AT 15 DEGS ANU AND V3 (150 KTS). AT 1000 FT CTL COLUMN NOSE DOWN INPUTS INITIATED, HOWEVER ACFT PITCH INCREASED. AT 3000 FT PITCH EXCEEDED 20 DEGS ANU AND SPD DECREASED BELOW 120 KTS. MAX THRUST WAS APPLIED. TRIM WAS NOT MOVING AT 4.5 DEGS ANU AND ELEVATOR EFFECTIVENESS WAS DIMINISHING. PITCH INCREASED TO 29 DEGS (FROM DIGITAL FLT DATA RECORDER) AT 4000 FT. MANUAL TRIM WHEEL WAS MOVED NOSE DOWN, DISCONNECTING PITCH TRIM AND AUTOPLT. RECOVERY WAS MADE. THRUST WAS REDUCED AFTER 10-15 SECONDS OF OVERTEMP ON CF6-50-C2 ENGS. DECLARED AN EMER AND RETURNED WITHOUT FURTHER EVENT TO ZZZ. INFREQUENCY OF TRAINING IN AUTO GAR CAUSED BREAKDOWN IN SOP. COMPLACENT APCH TO POOR ACFT PERFORMANCE DUE TO ON-GOING MULTIPLE MECHANICAL FAULTS/FAILURES IN TEST FLT. FAILURE TO DISCONNECT AUTOPLT. PF DID NOT QUICKLY AND DEFINITELY ANNOUNCE PITCH CTL PROB ALLOWING ENTIRE CREW TO FOCUS ON RESOLUTION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE FLC WAS NOT PREPARED FOR THE AUTOTRIM AND AUTOPLT TO MALFUNCTION DURING THE GAR. THIS MALFUNCTION IS A RARE OCCURRENCE AND THE HIGH ANGLE OF ATTACK OF THE ACFT WAS VERY UNUSUAL. HE STATED THAT HIS LACK OF COMMUNICATING TO THE OTHER CREW MEMBERS (CRM) WHEN THE MALFUNCTION WAS REALIZED CAUSED FOR A SLOW REACTION TO THE SIT. THE FACT THAT THE AUTOPLT WAS NOT DISCONNECTED IMMEDIATELY WAS A FACTOR. AS THE ACFT ACHIEVED A DANGEROUSLY HIGH ANGLE OF ATTACK THE SIT DETERIORATED AND THE FLC BECAME FIXATED AND DID NOT PERFORM THE SOPS AS PER THE OPERATING MANUAL. Weather Conditions: VMC Light Condition: DAYLIGHT WX Elements Visual (sm): 10 Flt Crew Exp (last 90 days): 210 Flt Crew Total Exp: 7800 Flt Crew Exp: 7000 Acft Make/Model Desc: REGIONAL JET 700 ER/LR (CRJ700) Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: PASSENGER Acft Flight Phase: LANDING Acft Flight Plan: IFR DUE TO AN ACFT NOT BEING ABLE TO EXIT THE RWY, AT GAR WAS INITIATED. ON CLBOUT, PF MADE A TURN TO 090 DEGS AND AT ABOUT 800-900 FT, TWR CLRED US TO LAND ON RWY XX. I CALLED TWR BACK AND VERIFIED THAT THEY WANTED US TO LAND ON RWY XX, AND THEY CONFIRMED IT. AFTER THIS, I LOOKED AT THE AIRSPD AND CONFIGN AND BEGAN TO FORCEFULLY SHOUT OUT COMMENTS/COMMANDS ABOUT THE AIRPLANE BEING SLOW AND THAT WE NEEDED TO ACCELERATE. AT SOME POINT THE CAPT PULLED THE THRUST LEVERS BACK AND BEGAN TO LEVEL AT 900-1000 FT. I NOTICED THE TREND VECTOR DECREASING RAPIDLY AND A SPD OF 150 KTS. I CONTINUED TO SHOUT, 'WATCH YOUR SPD. YOU'RE SLOW, ACCELERATE.' I CONTINUED TO SHOUT 'FLY THE AIRPLANE, FLY THIS AIRPLANE!' I BELIEVE I WAS CALLING OUT MINIMUM SPDS
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz22
AT SOME POINT AS WELL. I WAS ABOUT TO TAKE THE CTLS BUT DIDN'T BECAUSE HE STARTED TO RESPOND TO THE ACFT. DURING THIS TIME THE STICK SHAKER ACTIVATED. THE ACFT WAS ACCELERATED A BIT BUT THERE WERE MANY PITCH, ROLL, AND PWR ADJUSTMENTS. AS HE BANKED THE ACFT TO THE R TO MAKE A TEARDROP BACK TO THE FINAL FOR RWY XX, AND I TOLD TWR WE WERE NOT ABLE TO LAND ON RWY XX, THIS IS WHEN THE PF ALLOWED THE ACFT TO GET SLOW AGAIN AND, IN THE TURN, THE SHAKER ACTIVATED AGAIN FOR ABOUT 1 SECOND. I CONTINUED TO TELL THE CAPT TO FLY THE AIRPLANE. I ALSO RECOMMENDED THAT HE TURN ON THE AUTOPLT TO REDUCE WORKLOAD. AFTER THIS, THE FLT WAS SMOOTH. AS I WAS ABOUT TO CALL THE FLT ATTENDANTS, THEY CALLED ME AND I TOLD THEM THAT I WAS ABOUT TO MAKE A PA TO THE PAX. THE ACFT WAS CONFIGURED PROPERLY FOR LNDG AND WE MADE A SAFE, UNEVENTFUL LNDG IN ZZZ ON RWY XX. AFTER PARKING, I ASKED THE CAPT WHAT HAPPENED AND HE SAID HE WAS WORRIED ABOUT BUSTING ZZZ1'S AIRSPACE. I MADE IT CLR THAT THE ACFT SHOULD NEVER GET THAT SLOW ON A GAR AND THAT THE PROC SHOULD BE FULLY COMPLETED PRIOR TO COMMENCING ANOTHER APCH. I WALKED TO THE CABIN TO TALK TO THE FLT ATTENDANTS AND MAKE SURE THEY WERE OK. THEY WERE SHAKEN UP AND I BRIEFLY EXPLAINED THE SITUATION BUT ASKED THE FORWARD FLT ATTENDANT TO GO GET THE CAPT SO WE COULD DISCUSS IT. HE TOLD HER IT WAS A STANDARD GAR AND STAYED IN THE COCKPIT. TO MY KNOWLEDGE NO CREW DEBRIEF TOOK PLACE OTHER THAN WHAT I HAD SAID TO THE FLT ATTENDANTS. SUPPLEMENTAL INFO FROM CAN 798193: WE WERE APCHING RWY XX AT ZZZ WHEN WE HAD TO DO A GAR DUE TO AN ACFT ON THE RWY. I (THE CAPT) WAS FLYING. I CALLED FOR SET THRUST FLAPS 8 DEGS AND PUSHED THE THRUST LEVERS FORWARD TO THE TOGO DETENT. I NOW BELIEVE THAT I DID NOT PUSH THE TOGO BUTTON ON THE THRUST LEVERS. WE WERE GIVEN A TURN TO 090 DEGS AND CLRED TO 1500 FT. WE LEVELED AT 1500 FT AND WERE CLRED TO LAND ON RWY XX, HOWEVER, WE WERE ALMOST ABEAM THE END OF THE RWY ONLY ABOUT 1 MI TO THE S. BEFORE I REALIZED HOW CLOSE WE WERE, I PULLED THE PWR BACK TO DSND. I BELIEVE THIS IS WHEN THE ACFT SLOWED UP AND THE SHAKER WENT OFF. WE INFORMED THE TWR THAT WE COULD NOT LAND FROM THIS POS. WE WERE TOLD TO TURN R AND LAND OUT OF THE R-HAND TURN. WE TURNED AS INSTRUCTED AS I BELIEVED THIS WAS TO KEEP US OUT OF ZZZ2 AIRSPACE. THE TURN PUT US OVER THE TOP OF ZZZ1 AND WE THEN RECEIVED VECTORS TO A TEARDROP PATTERN TO RWY XX. IN RETROSPECT, I BELIEVE THAT WHAT THEY MEANT WAS TO CONTINUE ON THE 090 DEG HDG FOR A TEARDROP PATTERN TO RWY XX. I BELIEVE THAT I FAILED TO PUSH TO TOGO BUTTON AND THIS LED TO A DELAY IN TURNING THE AUTOPLT ON. THIS WOULD HAVE REDUCED THE WORKLOAD AND ALLOWED ME TO HAVE MORE TIME FOR A BETTER PERSPECTIVE. THE FO TENSED UP AND COM SUFFERED. THIS WAS AN ANOMALY. I HAVE DONE MANY GARS OVER THE YRS AND THEY ALL WENT VERY WELL. I AM EMBARRASSED AND PERPLEXED THAT THIS WENT TOO FAR FROM THE NORMAL. USUALLY, WHEN I SEE A POSSIBLE GAR SITUATION DEVELOPING, I REVIEW THE PROC BRIEFLY WITH THE PNF TO MAKE SURE THAT WE ARE ON THE SAME PAGE. I REALLY THOUGHT THE ACR WOULD MAKE IT OFF THE RWY THIS TIME SO I DID NOT. PERHAPS IF I HAD, IT WOULD HAVE GONE AS SMOOTH AS USUAL. SUPPLEMENTAL INFO FROM ACN 799432: WE WERE IN OUR BRACING POS READY TO LAND IN ZZZ WHEN WE PULLED UP
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz23
Acft Make/Model Desc: COMMERCIAL FIXED WING Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: PASSENGER Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: FMS OR FMC Flight Crew Count: 2 Flt Crew Exp (last 90 days): 200 Flt Crew Total Exp: 6250 Flt Crew Exp: 4200 WE WERE ON THE ILS INTO BZN, MT. AFTER CROSSING MANNI (FAF) WE SWITCHED TO BZN TOWER AND WERE CLEARED TO LAND. THE AIRCRAFT WAS FLYING ON AUTOPILOT AND THE GS AND COURSE WERE CENTERED ON THE CDI. AT ABOUT 6500 FEET MSL ON GS (1500 FEET AGL) WE RECEIVED AN ERRONEOUS GS INDICATION AND THE GS WENT FULL DEFLECTION UP INSTANTLY. WE WERE IN THE PROCESS OF MAKING FINAL CONFIGURATION CHECKS FOR LANDING AND DIDN'T NOTICE IT RIGHT AWAY. SINCE THE AUTOPILOT WAS STILL ON, IT REACTED BY CHASING THE GS AND PITCHING UP RAPIDLY. THE AIRCRAFT APPROACHED CRITICALLY LOW AIRSPEEDS AT THIS HIGH ANGLE OF ATTACK, ENGAGING THE 'STICK SHAKER' (PRE-STALL WARNING). THIS ALL HAPPENED SO FAST WE WERE BOTH STILL IN AWE WONDERING WHAT WAS GOING ON. THE CAPTAIN IMMEDIATELY ATTEMPTED TO FORCE NOSE-DOWN ATTITUDE TO COME OUT OF OUR PRE-STALL CONDITION. THE AUTOPILOT HAD COMMANDED IN SO MUCH NOSE-UP TRIM THE FORCE WAS HARD TO OVERCOME. THE CAPTAIN INITIATED MISSED APPROACH PROCEDURES AND I FOLLOWED HIS LEAD BY COMMENCING PROCEDURES TO GET THE GEAR AND FLAPS UP. OUR STALL RECOVERY PROCEDURES TELL US TO CLIMB AND CONTINUE CLIMBING UNTIL OUT OF A STALL CONDITION. THE AIRCRAFT WAS NOT STALLED, BUT ON THE SIDE OF SAFETY, WE TREATED THE SITUATION AS SUCH. IN THIS HIGH PITCH ATTITUDE, WITH A LIGHT LOAD AND FULL POWER, THIS AIRCRAFT WILL CLIMB OUT AT 5000 TO 6000 FPM. WITH EVERYTHING THAT WAS GOING ON, WE DIDN'T REALIZE THE MISSED APPROACH ALTITUDE ON THE PUBLISHED CHART OF 8000 FEET MSL WAS NOT SET IN THE AIRCRAFT'S ALTITUDE ALERTER. THIS ALL OCCURRED AT ABOUT 6500 FEET MSL, SO UNDERSTANDABLY WE BLEW RIGHT THROUGH 8000 FEET MSL. ONCE IN CONTACT WITH ZLC, WE ADVISED OF OUR MISSED APPROACH AND WERE ASSIGNED 9000 FEET MSL. BY THIS TIME WE ARRESTED OUR CLIMB AT 10800 FEET MSL AND BEGAN DESCENDING TO 9000 FEET MSL. I BELIEVE THE ALTITUDE WAS DEVIATED FROM ON OUR MISSED APPROACH FOR 2 REASONS: 1) WE WERE IN THE PROCESS OF CLEANING UP THE AIRCRAFT AND GETTING IT IN A SAFE CONFIGURATION FOR A MISSED APPROACH. 2) OUR PROCEDURES DON'T ALLOW US TO SET IN THE MISSED APPROACH ALTITUDE INTO THE ALTITUDE ALERTER UNTIL WITHIN 1000 FEET OF FIELD ELEVATION. AT THE TIME OF THIS ANOMALY WE WERE AT 1500 FEET AGL. HENCE, THE PROPER MISSED APPROACH ALTITUDE WAS NOT SET IN THE ALERTER TO REMIND US TO LEVEL AT 8000 FEET MSL. THE PROPER CORRECTIVE ACTIONS WERE TAKEN IN ORDER TO KEEP THE FLIGHT SAFE. WE DID NOT INTENTIONALLY DEVIATE FROM THE MISSED APPROACH ALTITUDE ON THE PUBLISHED CHART, AND AS SOON AS WE REALIZED THE DEVIATION, WE TOOK EVASIVE ACTION TO CORRECT TO THE ASSIGNED ALTITUDE
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz24
Acft Make/Model Desc: A320 Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: PASSENGER Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: Flight Crew Count: 2 Flt Crew Exp (last 90 days): 160 Flt Crew Total Exp: 9875 Flt Crew Exp: 3600 ON THIS LEG I WAS THE PF THE FO WAS THE PNF. WE HAD BEEN CLRED FOR A VISUAL APCH TO RWY 33L AT ZZZ. THE WX WAS GOOD AND I WAS LETTING THE AUTOPLT FLY US INBOUND AND DOWNSLOPE ON THE ILS. AT ABOUT 7-8 MI OUT THE TWR WARNED US THAT A TRUCK AND MEN WERE WORKING QUICKLY TO GET DEBRIS (DEAD ANIMAL) CLRED OFF THE RWY. HE SAID HE DIDN'T KNOW IF THEY WOULD BE DONE IN TIME SO THERE WAS THE CHANCE HE MIGHT HAVE TO ABORT THE APCH. HE ASKED US TO FLY OUR LOWEST APCH SPD POSSIBLE. I DO THIS WITH FULL FLAPS AND GEAR DOWN. AT APPROX 3 MI AND 900 FT AGL, TWR SAID SOMETHING LIKE 'ACR X SORRY BUT THIS ISN'T GONNA WORK, TURN L TO A HDG OF 190.' 3 SECONDS LATER THE CTLR SAID 'AND ACR X CLB AND MAINTAIN 2000 FT.' AT THE VERY INSTANT OF HIS FIRST 6 WORDS I LEVELED THE PLANE BY ENGAGING THE VERT SPD ZERO FCU BUTTON. THE AUTOPLT AND AUTOTHROTTLE WORKED TOGETHER TO STOP THE DOWNSLOPE TRAJECTORY AND BRING UP THE ENGS TO MORE PWR. THEN I COMMENCED THE TURN USING THE AUTOPLT. NEXT I USED THE FCU TO DIAL IN AND ENGAGE AN AUTOPLT CLB TO 2000 FT. THE ENGS ADVANCE AND THE PLANE BEGINS A CLB. ALL AIRLINE PLTS TRAIN FOR GAR'S THAT PASS OVER THE FIELD. THIS WAS VERY MUCH A NON STANDARD MANEUVER. AT A LOW ALT WE WERE BEING BROKEN OFF THE APCH. THOUGH OUR LOW ALT GETS ONE'S ATTN, IT REALLY IS NOT THAT BIG A DEAL AS NOW ALL WE DO IS GO ABOUT FLYING THE AIRPLANE. THE FO SEEMED SPRING LOADED FOR ACTION. HE ASKED ME 'IS THIS A GAR?' AS HIS L-HAND WAS ON THE FLAP LEVER. I SAID 'NO,...WE AREN'T DOING A GAR OVER THE FIELD.' FO 'DO YOU WANT GAR FLAPS?' CAPT 'NO.' A FEW SECONDS GO BY AND I ASK FOR GEAR BY SAYING THE SOP 'POSITIVE RATE, GEAR UP.' FO LIFTS THE GEAR LEVER. NOW WE ARE IN THE CLB AND ABOUT 1100-1200 FT AGL. I SAY THE SOP PHRASE 'GAR FLAPS' WHICH IN THIS PLANE MEANS THAT RETRACT THE FLAPS ONE STEP. IN OUR CURRENT CONFIGN THIS WOULD BE FROM FULL FLAPS TO FLAPS 3 DEGS. THE PNF IS TO MAKE THE SOP CALL OUT 'SPD CHKED, FLAPS 1' AFTER LOOKING AT THE ECAM. HE DIDN'T MAKE THIS CALLOUT. I AM GENERALLY LOOKING FORWARD AND WORKING THE FCU TO FLY. IN MY LOWER VISION I SEE THE L SIDE PFD TAPE JUMP UP (IT TIES IN WITH THE FLAP LEVER) AND OUR SPD IS NOW PRESENTING AS QUICKLY APCHING THE AREA OF A STALL. I QUICKLY GRAB THE STICK, SHOVE THE NOSE FORWARD AND THE AUTOPLT KICKS OFF. I GRAB THE THRUST LEVERS AND PUSH THEM FORWARD FOR MORE PWR. I TRY TO LEVEL THE BANK SOME AND PERFORM SOMETHING SIMILAR TO AN UPSET RECOVERY PROC. THE FO WAS THINKING THE SAME THING AS HE HAD ALSO PUSHED THE NOSE FORWARD. (DUAL INPUTS WAS CALLED OUT BY THE WARNING SYS.) MY EYES TAKE 1 SECOND TO LOOK AT THE CENTRAL ENG GAUGES AND I SEE THAT THE FLAPS HAVE BEEN COMMANDED TO THEIR LOWEST DETENT WHICH NOW WILL BE A SETTING OF FLAPS 1+F. THE FO
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz25
HAD INAPPROPRIATELY MOVED THE FLAPS FROM THE FULLEST SETTING PAST 2 DETENTS AND F ONE. THIS CAUSES US TO LOSE LIFT ON THE WINGS OF A HVY SWEPT-WING ACFT. THE PLANE IS HERKY-JERKY, THIS ISN'T PRETTY BUT THE ALPHA FLOOR PROTECTION SYS DID NOT ACTIVATE. WE DSND WHAT I GUESS WAS 200-300 FT. I SCOOP IT OUT, WE FLY TO HDG, WE ARE PUT BACK INTO THE LINE UP AND WE LAND. ONCE AT THE GATE THE FO DOESN'T OFFER ANY REFLECTIONS, THOUGHTS, APOLOGIES, OPINIONS UNTIL I INITIATE CONVERSATION ON THE BREAK OUT. IN GENERAL HE JUST COMMENTS THAT 'THAT WHOLE THING WAS SCREWY.' I HAVE SINCE COMMUNICATED WITH HIM AND HE WON'T PARTICIPATE IN CONVERSATION TO REVIEW THE FLYING PARTICULARS OF THE INCIDENT. CONCLUSION: THE FO MOVED THE FLAP LEVER TO AN UNCOMMANDED POS. HE DID NOT MAKE THE SOP CALLOUT WHILE DOING THIS. I HAD TO TAKE AGGRESSIVE ACTION TO AVOID APCHING A STALL REGIME. WHY? I DON'T KNOW. I AM CONTINUING TO PURSUE THE MATTER WITH DEPT HEADS AND THE PLT HIMSELF. POSSIBLY THE FO HAD HIS BRAIN SATURATED WITH THE TYPICAL GAR PROC, BUT EVEN SO HE DID THIS WRONG. ALSO, WE HAVE HAD TO DO MORE THAN THE USUAL NUMBER OF FLAPS 3 DEG TKOFS LATELY AT ZZZ DUE TO CONSTRUCTION ON RWY 28. POSSIBLY HE HAD THAT PROFILE IN HIS BRAIN WHERE WE MOVE THE FLAPS FROM F3 TO F ONE. BUT IF HE WAS THINKING THAT H Acft Make/Model Desc: A300 Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: TEST FLIGHT Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: Flight Crew Count: 3 Flt Crew Exp (last 90 days): 60 Flt Crew Total Exp: 7000 Flt Crew Exp: 6000 I AM A SO, LINE QUALIFIED ON AN A300-B4. I WAS RECEIVING IOE ON A TEST FLT WITH AN ENGINEERING CREW IN ORDER TO CHK OUT ACFT WHEN THEY ARE OUT OF HVY MAINT. I PREFLTED OUR AIRPLANE. WE DID NUMEROUS FLT TESTS FOR APPROX 2 HRS. WE STARTED AN AUTOPLT GAR AND THE PLTS WERE NOT SATISFIED WITH THE RESULTS. SO WE ATTEMPTED A SECOND AUTO GAR. THE AUTO GAR WAS STARTED AT APPROX 50 FT AGL, VFR ON THE #2 AUTOPLT AND THE COPLT WAS DOING THE MANEUVER. HE PULLED THE TOGA TRIGGERS AND I WATCHED THE THROTTLES ADVANCE, NOTED THE FLT PATH INDICATOR N1 AND GAR. I MONITORED ENG SPOOL UP, WATCHED THE FLAPS RETRACT FROM 25 DEGS TO 15 DEGS AND MONITORED GEAR UP. I HAD VISUAL AND AURAL INDICATION OF TRIM ACFT NOSE UP. AFTER GEAR RETRACTION, A PITCH TRIM LIGHT ILLUMINATED ON THE MODE WARNING PANEL AND I ANNOUNCED IT. AS ACFT CLBED, I MONITORED PRESSURIZATION MOMENTARILY AND THEN LOOKED FOR TFC. I RECALL AIRSPD APPROX 140 KTS AND HIGH ANGLE OF ATTACK ABOVE 2000 FT. THERE WAS NO MENTION FROM ANY PLT OF A PROB. I THINK THE COPLT WAS HAVING PROBS LEVELING OFF AT 3000 FT PRESELECTED ALT. WE WERE
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz26
STILL CLBING AND THIS WAS THE FIRST INDICATION HE GAVE, 'I HAVE NO CTL OF THE ACFT' AS HE LOOKED INTO MY EYES. HE ALSO BANGED THE CTL COLUMN FULL FORWARD TO THE STOPS WITH NO ACFT RESPONSE. I NEVER HEARD THE AUTOPLT DISCONNECT NOR DID I HEAR ANYONE ANNOUNCE THEY TRIED. THE COPLT STARTED TO PULL THE THROTTLES BACK. WE HAVE A HIGH ANGLE OF ATTACK, LOW AIRSPD, AND SUPPOSEDLY NO ELEVATOR CTL. I STARTED ADVANCING THROTTLES FORWARD. AIRSPD WAS AROUND 119 KTS, FLAPS 15 DEGS, SLATS 15 DEGS, AT 220000 LBS. WE ALL FIREWALLED THE THROTTLES. I STARTED MOVING THE MANUAL TRIM WHEEL FORWARD AS FAST AS POSSIBLE. I FELT THE NOSE START DOWN AND ASKED IF THE COPLT HAD CTL. HE SAID YES. A LITTLE LATER, I RE-ENGAGED THE PITCH TRIM SWITCHES AND HE COULD THEN TRIM THE ACFT. I THINK THE PLT THOUGHT THE NOSE WOULD DROP IF HE PULLED THE THROTTLES BACK. OUR ANGLE OF ATTACK WAS TOO HIGH AND HE HAD NO ELEVATOR CTL. I THINK DURING THE GAR THE COPLT APPLIED FORWARD PRESSURE ON THE YOKE AND THE AUTOPLT WAS TRIMMING AGAINST HIS COMMAND. HE NEVER CALLED FOR FLT DIRECTOR, HDG, OR ALT ACQUIRE AFTER 500 FT. I THINK THE PROFILE FOR THE GAR WAS DONE IMPROPERLY AND FEEL COM WAS HORRIBLE AND FELT THE PLTS SHOULD HAVE MONITORED THE WHOLE PROCESS A LOT BETTER. THE CAPT NEVER TRIED TO MANIPULATE HIS CTL COLUMN. SOMETHING MAY HAVE BEEN WRONG WITH THE AIRPLANE. WE OVERTEMPED BOTH ENGS AND DECLARED AN EMER AND LANDED THE ACFT. I FEEL THE PLTS GAVE ME VERY LITTLE WARNING ABOUT HOW THE AIRPLANE WAS PERFORMING AND WHEN THEY DID GIVE ME FEEDBACK, I HAD ALMOST NO TIME TO MAKE A DECISION AND REACT. I FEEL IF NOTHING WAS DONE, WE WOULD HAVE STALLED ON DEP AND WE WOULD ALL HAVE DIED. WE WERE SLATS 16 DEGS, FLAPS 15 DEGS, 224000 LBS APPROX. OUR PAPERWORK SHOWS STALL WARNING WOULD HAVE SOUNDED AROUND 108 KTS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE SO WAS ASSIGNED TO RECEIVE SOME OF HIS IOE TRAINING ON A TEST FLT. THE CAPT AND FO ARE LINE PLTS THAT ALSO CONDUCT TEST FLTS FOR THIS COMPANY. THE SO HAD AN IOE CHK AIRMAN WITH HIM. THE RPTR THINKS THAT THE CAPT DID NOT SUPERVISE THE FO OR THE ACFT PROPERLY. HE THINKS THE FO WAS TRYING TO CTL THE ACFT'S HIGH CLB RATE BY PUSHING FORWARD ON THE CTL YOLK WITHOUT DISCONNECTING THE AUTOPLT. HE HEARD AND SAW THE STABILIZER TRIM, TRIM NOSE UP. BOTH THE CAPT AND FO HAVE BEEN REMOVED FROM THE FLT TEST CREW AS A RESULT OF THE INCIDENT. HE ALSO STATED THE CAPT'S AUTOPLT DISCONNECT BUTTON WAS FOUND INTERMITTENT. BOTH ENGS WERE OVERTEMPED AND ONE REQUIRED REPLACEMENT. Acft Make/Model Desc: B737-800 Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: PASSENGER Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: FMS OR FMC Flight Crew Count: 2 Flt Crew Exp (last 90 days): 171 Flt Crew Total Exp: 24965 Flt Crew Exp: 307
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz27
ACFT WAS IN THE FINAL APCH PHASE OF THE APCH TO RWY 8L IN ATL. WE HAD BEEN RADAR VECTORED TO A 17 MI FINAL AT 5000 FT AND 180 KTS. WE WERE THEN ASSIGNED 160 KTS AND CLRED FOR THE ILS RWY 8L APCH. THE 'APCH' MODE WAS SELECTED WITH A SINGLE AUTOPLT ENGAGED AND THE ACFT INTERCEPTED AND TRACKED THE ILS NORMALLY. THE ACFT WAS CONFIGURED FOR A FLAPS 30 DEG LNDG AND NORMAL CHKLISTS WERE ACCOMPLISHED. THE ACFT WAS STABILIZED ON APCH AND SPACING WITH OTHER TFC APPEARED TO BE COMFORTABLY SPACED ON TCASII. XING THE FAF AT 2800 FT, THE TWR CTLR ISSUED A CLRNC TO CLB TO 4000 FT AND TO TURN L TO 360 DEGS. I DID NOT HEAR CLRLY THE CALL SIGN ON THE CLRNC. I LOOKED TO THE FO AND ASKED HIM TO VERIFY THE CLRNC BEING FOR US. MY HANDS WERE ON THE FLT CTLS AS I WAS 'FOLLOWING' THE AUTOPLT ON THE APCH. AS THE FO VERIFIED THE CLRNC, I SELECTED 'TOGA' MODE OF FLT AUTOMATION AND PROCEEDED WITH THE NORMAL GAR CALLOUTS. SELECTING TOGA AUTOMATICALLY DISCONNECTED THE AUTOPLT AND ESTABLISHED NEARLY FULL PWR ON BOTH ENGS. AS I WAS NOT LOOKING DIRECTLY AT THE FLT INSTS WHEN SELECTING TOGA, THE VERY RAPID INCREASE OF PWR CAUSED THE ACFT PITCH TO INCREASE PAST THE DESIRED ATTITUDE OF 15 DEGS TO AN ATTITUDE OF 20 DEGS, OR POSSIBLY SLIGHTLY HIGHER. ALTHOUGH I INSTINCTIVELY PLACED FORWARD PRESSURE ON THE FLT CTLS TO COUNTER THE RAPID CHANGE IN PITCH, THE PRESSURE WAS INSUFFICIENT TO STOP THE PITCH AT THE DESIRED ATTITUDE. IN AN ATTEMPT TO SMOOTHLY LOWER THE NOSE IN THE INTEREST OF PAX COMFORT, THE ACFT EXPERIENCED A 1 OR 2 SECOND STICK SHAKER WARNING AS WE LEVELED AT 4000 FT. CONTRIBUTING FACTORS: 1) AN UNEXPECTED CONDITION: AN UNEXPECTED GAR AT AN UNEXPECTED PHASE OF FLT, 2) AUTOMATION WHICH CONTRIBUTES TO A LARGE 'SURPRISE FACTOR: LARGE AND RAPID PWR CHANGE IN ENGS WELL BELOW THE WING CREATING AN INSTANT PITCH CHANGE, AND THEN DISCONNECTING THE AUTOPLT. 3) THE SELECTION OF TOGA AT A TIME WHEN CONCENTRATION WAS NOT FIRMLY ESTABLISHED ON FLT INSTS.
Acft Make/Model Desc: AIRBUS INDUSTRIE UNDIFFERENTIATED OR OTHER MODEL
Acft Operator Desc: AIR CARRIER Acft Far Part: PART 121 Acft Flight Mission: PASSENGER Acft Flight Phase: LANDING Acft Flight Plan: IFR Acft Nav in Use: Flight Crew Count: 2 Flt Crew Exp (last 90 days): 150 Flt Crew Total Exp: 10000 Flt Crew Exp: 1100 ON APCH INTO ZZZ RWY XXR, TURNING DOWNWIND ON THE STAR, THE FMS DUMPED OUR FLT PLAN. WE WERE VFR SO WE CONTINUED THE APCH ON ATC VECTORS. I HARD TUNED THE RWY XXR ILS INTO THE 'RAD/NAV' ON THE FMS. ON FINAL, MY FLT DIRECTOR DID NOT AGREE WITH THE ILS GS, SO I CALLED TO TURN OFF FLT DIRECTORS. WE DID NOT GET SWITCHED OVER TO THE TWR, THEREFORE, WE DID NOT GET A LNDG CLRNC. SO WE DID A GAR. ON THE GAR WE
Etude sur les pertes de contrôle de la trajectoire en phase d’approche lors de la remise de gaz28
HAD TO FIND THE CORRECT RADIO FREQ AND THEN GET A HDG AND ALT TO FLY. I BELIEVE IT WAS 360 DEGS AND 3000 FT. WE WERE ALSO CLEANING UP THE ACFT AS WE CLBED TO 3000 FT. I STARTED TO LEVEL AT 3000 FT BUT THE ACFT DID NOT SEEM TO WANT TO STAY LEVEL AT 3000 FT. IT TURNS OUT, ATC HAD GIVEN US 5000 FT AND THE CAPT WAS TRYING TO CLB THE PLANE UP TO 5000 FT AND I WAS TRYING TO LEVEL OFF AT 3000 FT—CANCELING OUT EACH OTHER'S INPUTS. I THOUGHT I HAD A CTL PROB AND ASKED THE CAPT TO DECLARE AN EMER. HE DID. I REALIZED THE CAPT WAS TOUCHING THE CTLS AND ASKED HIM TO STOP SO I COULD GET CTL OF THE AIRPLANE. HE DID. THE CAPT THEN PUT MY FLT DIRECTOR ON AND ALSO TURNED THE AUTOPLT ON. WE CLBED TO 5000 FT. GOT VECTOR TO FINAL, RAN THE CHKLIST, AND FLEW ANOTHER ILS XXR INTO ZZZ FOR LNDG. I DON'T EVEN KNOW WHAT CORRECTIVE ACTION SHOULD BE TAKEN. THIS SHOULD NOT HAPPEN, EVER. ONE PERSON FLIES, THE OTHER DOES NOT. INFORMATION ISSUES DU NTSB ET FOURNIES PAR LA FAA AU BEA Data Source: NTSB AVIATION ACCIDENT/INCIDENT DATABASE Event Id: 20040819X01260 Local Date: 07/08/2003 Category of Operation: SCHEDULED Aircraft Type: AIRPLANE Aircraft Homebuilt: NO Aircraft Damage: DESTROYED Phase of Flight: MISSED APPROACH (IFR) Aircraft Make: BOEING Aircraft Model: 737 Aircraft Series: 200C Operator Doing Business As: Operator Name SUDAN AIRWAYS Injury Summary for Aircraft 1 Fatal Serious Minor NoneCrew 9 0 0 0 Pass 104 1 Total 115 1 0 0 AIRCRAFT 1 PRELIMINARY REPORT On July 8, 2003 about 0417 hours local time, Sudan Airways flight 319, a Boeing 737-200 airplane, registry ST-AFK, collided with the ground during a missed approach at Port Sudan Airport, Sudan. Instrument meteorological conditions prevailed. The pilot, copilot, 9 crew members, and 104 passengers were fatally injured. One passenger, a 2-year old child, was seriously injured. The airplane was destroyed, and there was post-crash fire. The departure point was Port Sudan, and the scheduled destination was Khartoum, Sudan. About 15 minutes after takeoff, the pilot reported the loss of power in one engine. The flight returned to Port Sudan and was cleared for the ILS Runway 35 approach. The reported visbility was 2.5 miles in sand. The flightcrew did not sight the runway, and during the missed approach the airplane descended and collided with terrain about 3 miles east of the airport. The aircraft distinegrated during the impact sequence. The wreckage was strewn a distance of about 600 feet, and oriented on a 150 degree magnetic track.
