ROYAL JORDANIAN AIRLINES FLIGHT OPERATIONS DEPARTMENT / FLIGHT SAFETY FLIGHT SAFETY NEWSLETTER ( AUGUST 2011 )

Transcription

1 ROYAL JORDANIAN AIRLINES FLIGHT OPERATIONS DEPARTMENT / FLIGHT SAFETY FLIGHT SAFETY NEWSLETTER ( AUGUST 2011 ) Prepared by: F/O. Marwan Al-Dayaflah Manager Flight Safety 1

2 Table of content SUBJECT Hard landing and pitch-up after touchdown factors in A321 PAGE 3 tailstrike accident Poor CRM factor in cargo plane takeoff incident 5 Airline, airport and controller were factors in A320 taxiway takeoff 7 at Oslo Unreliable airspeed indication incident involving an Airbus A330 9 Premature thrust during rolling takeoff caused B737 runway 11 excursion. Fatigued Crew Lands on Taxiway 12 2

3 Hard landing and pitch-up after touchdown factors in A321 tailstrike accident On October 28 th, 2009, an Airbus A , registered HL7763, operated by Asiana Airlines, took off from Seoul-Gimpo International Airport (SEL), the Republic of Korea, as a non-scheduled flight OZ1125. The first officer was pilot flying during the approach to runway 06L of Kansai International Airport. The descent rate of 544 ft/min at the time of touchdown was high and the aircraft contacted the runway hard with a vertical acceleration of 1.91G. The nose-up stick input was continued after touchdown, while the extension of the spoilers further produced a nose-up effect. As a result the aircraft s pitch angle of 4.6 degrees at the time of touchdown increased to 10.2 degrees. This angle was in excess of the maximum allowable pitch attitude of 9.7 degrees. The first officer decided to make a go-around and moved the thrust lever in the TOGA position about four seconds after touchdown. The airplane circled and landed safely eleven minutes later. There were 147 persons on board, consisting of the Captain, 8 other crewmembers, and 138 passengers. No one was injured. The aircraft sustained substantial damage, but there was no outbreak of fire. 3

4 The investigators concluded: In this accident, it is considered highly probable that, during the landing on Kansai International Airport, the Aircraft sustained damage in the aft part of the fuselage which contacted the runway, since the pitch angle became excessively large after the touchdown on the runway. It is considered highly probable that the Aircraft s pitch angle became excessive because the First Officer continued inputting pitchup signal seven after touchdown. The flare by the First Officer was inappropriate and as a result, the sink rate of the Aircraft did not fully decrease, causing the Aircraft to land with a strong impact on the ground. It is considered probable that, that the First Officer became upset by the impact contributed to his continuous input for pitch-up after touchdown. 4

5 Poor CRM factor in cargo plane takeoff incident Blue Dart Aviation Flight No. BD-201, a Boeing F, operated on a cargo flight from Kolkata to Delhi, Mumbai and Bangalore. The flight departed on schedule from Kolkata at 22:25 hrs and was uneventful till Mumbai. At Mumbai, the aircraft taxied out from Bay No G-4 via Papa, Echo, and was cleared to proceed to holding point N1 for runway 27. The flight was cleared to line up after an arrival of Kuwait Airways Boeing 777 aircraft. The Captain was PF and the FO was Pilot Monitoring for the departure. While lining up, the Captain lined up on the right of centerline of the runway. The FO promptly drew the attention of the Captain by stating that the centerline was on the left. This was acknowledged by the Captain. On being cleared for take off the thrust levers were opened by the Captain and the aircraft commenced its roll. The FO at this stage called out to the Captain that he was on the right, twice in quick succession. The Captain carried out a correction to the left to return to the centerline. The take off was continued with and the aircraft took off at 05:15 hours at the correct speed and carried out a standard departure. The flight to Bangalore i.e climb, cruise, decent and approach were normal. The aircraft carried out an uneventful landing with FO as PF. The aircraft taxied to the bay at 06:45 hours. On arrival at the bay, the Engineer observed that there were damages to the right hand wheels. No. 3 main wheel tyre was deflated. There were deep incisions on No. 3, 4 & 8 main wheel tyres 5

6 and reverted rubber on No. 7 tyre. No. 3 brake assembly had signs of FOD and grease nipple was deformed. At 08:30 hours information was received from Mumbai that a runway inspection was carried out and runway edge lights were damaged. A subsequent report indicated that a total of 15 runway edge lights of runway 27/09 were damaged, nine towards the north side between N1 and N4 and six on the southern side between taxiway E1 and intersection. The investigators concluded: The cause for the incident is incorrect lineup by the Captain on the right side of the RW instead of the Center even after being informed by the FO. Contributory factors: 1. An error in judgment / assessment in determining the extent of displacement to the right of centerline while lining up. 2. Inadequate CRM practices both by the Captain and FO. 3. Lack of assertion on the part of the FO in emphasizing the displacement of the aircraft to the Captain. 4. Inadequate attention on the part of the Captain towards inputs from the FO. 6

7 Airline, airport and controller were factors in A320 taxiway takeoff at Oslo Figure 1; The orange line indicates where the aircraft took off northbound on taxiway M, instead of on runway 01L, west of taxiway M. The serious incident occurred on 25 th February Aeroflot flight number AFL212, an Airbus A320 aircraft, made a taxiing mistake and took off from taxiway M instead of runway 01L. There were three pilots, four cabin crew members and sixty passengers onboard. After the incident, the flight continued as planned to Moscow. The flight crew was not aware that they had taken off from the taxiway until informed of this by the air traffic controller after take-off. 7

8 Under the prevailing conditions, taxiway M was by chance long enough for the aircraft to take off. The taxiway was at the time of the incident also free of other traffic and obstacles. This prevented a more serious outcome of the incident. The investigation has uncovered several causes for AFL212 s taxiing mistake and take-off from the taxiway. The factors which contributed to the events can be found with the parties involved, i.e. the airline, the control tower and the airport. The Accident Investigation Board is of the opinion that deficient procedures and insufficient alertness in the cockpit, in combination with insufficient monitoring from the control tower and insufficient signposting in the maneuvering area, resulted in AFL212 making a taxiing mistake and taking off from taxiway M. 8

9 Unreliable airspeed indication incident involving an Airbus A330 Figure 2; Location of pitot and TAT probes on an A330. On 28 th of October 2009, an Airbus A aircraft, registered VH- EBA, was being operated as Jetstar flight 12 on a scheduled passenger service from Narita, Japan to Coolangatta, Australia. Soon after entering cloud at 39,000 ft, there was a brief period of disagreement between the aircraft s three sources of airspeed information. The autopilot, autothrust and flight directors disconnected, a NAV ADR DISAGREE caution message occurred, 9

10 and the flight control system reverted to alternate law, which meant that some flight envelope protections were no longer available. There was no effect on the aircraft s flight path, and the flight crew followed the operator s documented procedures. The airspeed disagreement was due to a temporary obstruction of the captain s and standby pitot probes, probably due to ice crystals. A similar event occurred on the same aircraft on 15 March The rate of unreliable airspeed events involving the make of pitot probes fitted to VH-EBA (Goodrich 0851HL) was substantially lower than for other probes previously approved for fitment to A330/A340 aircraft. In it s investigation into the June 1 st, 2009 accident involving an Air France A330 (flight AF447), the French investigators found 36 occurrences between the period 12 November 2003 and 7 August 2009 that the aircraft manufacturer concluded were attributable to the blocking of at least two pitot probes by ice. A 27 events involved aircraft fitted with Thales model C16195AA pitot probes, the same model fitted on the AF447. Two events involved aircraft fitted with Goodrich 0851HL probes. Both of the events involving VH-EBA occurred in environmental conditions outside those specified in the certification requirements for the pitot probes. The French investigator has recommended the European Aviation Safety Agency (EASA) to review the certification criteria for pitot probes in icing environments. The operator identified the problem and included unreliable airspeed in its recurrent training program for the A320 and A

11 Premature thrust during rolling takeoff caused B737 runway excursion On August 29 th, 2009 an Air Algrie Boeing 737-8D6 departed the right side of runway 36L at Lyon-Saint-Exupry Airport (LYS/LFLL), France during takeoff. It rolled for about 250 meters on the grass verge alongside the runway. The aircraft joined the track after hitting a runway edge light and continued the takeoff. On arrival in Stif-Ain Arat Airport (QSF/DAAS), Algeria, minor damage was found on the right engine, the airframe and nose gear. There were 39 passengers and 7 crew members on board. The investigators report states: The overrun is due to a non-compliance with the procedure of rolling takeoff by premature application of takeoff thrust as the aircraft, light and with a rear centre of gravity, had not yet entered the runway. A possible tendency of the Pilot Flying to add thrust before the complete alignment of the aircraft on the centerline of the runway contributed to the occurrence of this serious incident. The decision to continue the takeoff after having returned to the track with a speed of less than V1 led the crew to continue the flight with a plane of which they did not know the extent of damage. 11

12 Fatigued Crew Lands on Taxiway Three pilots were required for the scheduled flight from Rio-de- Janeiro, Brazil, to Atlanta Hartsfield International Airport the night of Oct. 19, the flight crew comprised a check airman, a captain and a first officer. During preflight preparations, the check airman experienced gastrointestinal distress. After a brief time away from the flight deck, the check airman returned to the flight deck and advised the other crewmembers he was fine. There was a 30-minute delay before the Boeing ER departed with 182 passengers and 12 crewmembers. The captain was on the left seat, the check airman was on the right seat, and the first officer was on the observer s seat. After establishing the airplane in cruise flight, the crew discussed rest breaks and decided that the check airman should take the first break, comprising 2 hours and 50 minutes. At the completion of his rest break, it was determined that the check airman was ill, and the crew enlisted the aid of a physician aboard the flight, so the flight crew elected to continue the flight to Atlanta and requested that dispatch arrange for emergency services to meet the airplane. The remaining two crewmembers conducted the entire night flight without the benefit of a customary break period. Throughout the flight, the crew made comments indicating that they were fatigued and identified fatigue as their highest threat for the approach, but they did not discuss strategies to mitigate the consequences of fatigue. Atlanta had clear skies and calm winds, and the crew briefed for a landing on Runway 27L. However, an approach controller later told the crew to expect to land on Runway 26R. Then shortly after they 12

13 briefed for the approach to Runway 26R, the pilots were reassigned to Runway 27L. At about the outer marker for that runway approach, the Atlanta tower controller offered Runway 27R, which the crew accepted. The first officer became preoccupied in trying to tune the ILS frequency. The crew had not briefed the approach to Runway 27R and were not aware that the ILS and the approach light system for Runway 27R were not available. The captain told investigators that as he maneuvered for the side-step to Runway 27R, he saw the PAPI and lined up on the brightest set of lights that he saw. He stated that he saw bright edge lights and centerline lights and thought he had the runway in sight. The 767 however, was landed on Taxiway M, which is north of and parallel to Runway 27R, and was unoccupied at that time. Flight tests conducted by investigators showed that, without the aid of the approach lights and the ILS, there are several misleading visual cues for an approach to Runway 27R, these cues included numerous taxiway signs along the side of Taxiway M, which from the air appeared to be white and could be perceived as runway edge lights. The alternating yellow and green lights in the ILS critical area provided the appearance of a runway centerline, these lights and the ILS, and the crew s decision to accept a late runway change were cited as factors that contributed to the taxiway landing. NTSB concluded that fatigue was the probable cause of the crew s misidentification of the correct landing surface. The incident occurred at 0605 local time more than 14.5 hours after the 767 left the gate at Rio and the captain had been awake for more than 22 hours. 13