final aircraft accident report presentation

7/27/2019 Final Aircraft Accident Report Presentation

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Final Aircraft Accident Report

Regarding The Airbus 310-324

Accident on 10/06/2008Registration ST-ATN


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Presented by

The Investigation Board which was formed by

The Minister,

and being nominated by the Deputy

DGCA at the time of the accident


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The Board Comprises :

Eng. Sirelkhatim Kambal Head of BoardMr. Kamil Ahmed Member

Mr. Abdelkariem A/Lateef Member

Mr. Mohmed Elhassan MemberCap. Osman Alsaied Member

Cap. Abdelfatah Satti Member

Eng. Abdelgadir Sirelkhatim MemberMr. Abdelmuniem Tyfor Member

mr. Abdelsamie Adam Member


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BEA (Accident Investigation Bureau) of France

appointed

Mr. Francois Hochart Accredited representative

Assisted by

Mr. Vincent Ecalle

Airbus Industry investigators teamMr. Albert Urdiroz Flt. Safety director

Mr. Xavier Barriola Flt. Safety

Mr. Jean Philippe Propulsion systemMr. Jean Paul Structure

Mr. Christophe Duphil Systems


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International Statistic about the Airbus 310 SerialNumber 548 (current ST-ATN)

The First Flight was On 23/08/1990

Delivered to Singapore On 22/10/1990

Registered as 9V-STU

Leased to Air India by Owner (Osprey AircraftLeasing Limited of Cayman Islands)Registered as VT-EVF and

issued Indian Airworthiness Certification On

7/2/2001Delivered to Sudan On 14/09/2007

Registered as ST- ATN


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Ref Airliners.net

The accident was

9th

loss of Airbus 310 at that date

7th worst accident involving A310 at that time

6th worst accident in Sudan


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From general history

The A310 serial number 548 accomplished the

C1 + C2 in the period

06 March 2007 26 August 2007 at

Jordan Aircraft Maintenance Limited

Which covered

Routine, zonal, structural task, ADs, SBsprovided by Air India i.a.w the Approved Main.

Program.


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During the check 41 Discrepancies were found andbeing repaired. This includes

Fuel leakage at

(L/H wing)

Aft pylon fitting, lower surface, wing inner tank wing

jacking fitting through access panel 575DB, etc(R/H wing)

Lower surface, aft pylon fitting, drain hole at slat 2screw jack alignment, at lower I/B area I/B of pylon

In addition to corrosion areas and spots andreinforcement panels cracks


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Objective of the Investigation

In accordance to Annex 13 Para

The sole objective of the investigation is

to draw lessons from the occurrences that mayhelp to prevent future accidents and incidents

and

NOT. NOTTo apportion blame or to assess individual or

collective responsibility


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Number of witnesses being interviewed by theInvestigation Board were as follows :-

Sudan Airways personnelThe Flying Captain

The First Officer

7 Cabin Crew membersThe Flying Security Officer

Others

3 Police officers different ranks9 Citizens ( passengers)


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Brief description of the accident flight

On 10th of June 2008 A310 serial number 548

Arrived Khartoum Airport from Cairo With a

deactivated No. 1 engine Thrust reverser.

As it was previously scheduled for a flight to

Oman

The designated Captain for that flight accepted

to fly the aircraft as being labelled according the

MEL requirement.


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Flight to Amman via Damascus was uneventful.

On the return flight there were 203 passengersand eleven crew members on board.

On Approaching Khartoum that day in theafternoon and due to bad weather conditions

The Captain of the flight decided to divert to PortSudan and landed safely.

20 tons of fuel topped up at Port Sudan


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The captain said he was on contact with Khartoum

enquiring about the weather.

After staying at Port Sudan for 1:15 hrs he was

informed that the weather is getting better.

He decided to return to KhartoumHe initiated a night approach for R/W 36 after being

cleared to land

The Tower provided the flight with Windinformation as

{ 320/7 Kt} and R/W condition {Wet}


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At that moment the actual METAR was

10/1830 150/10 Kt 9/9 few CB 050 to E SCT 056SCT 056 Q 1010


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The Accident

Most important remarks obtained fromwitnesses interview were as follows :-

The Flying pilot stated

The weather was somehow bad and

the hold took a long time before being clearedto land and

he was always asking the First officer to monitor

himThe touchdown was very smooth and it waswithin the required distance


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He did not select autobrake for passenger comfort onlanding

Autobrake was not a must as it is a recommendation atthat time

After selected both engines reverse the aircraft slippedrightward

Due to that he deselect the reverse and managed toreturn the aircraft to R/W centreline by using differentialbrakes

Using brakes the deceleration was abnormal

Called the F/O to assist on brakes


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Approaching the end of the R/W he selected

reverse and aircraft did not decelerate

The aircraft overrun the R/W and burst on fire

Right hand slides could not be deployed

Passengers and crew vacated from the left front

slide

Two of the occupant stated that they saw fire on

the right wing during aircraft rolling on R/W


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FDR Information

The flying pilot was the captain

The aircraft was fully and properly configured forlanding

The AP was disconnected at 800 ft with Athrengaged till landing

Both thrust levers set to idle for touchdown

Touchdown at 132 kt IAS, 155Kt ground speedTouchdown was smooth at about 800 meters afterR/W threshold


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FDR event (UTC time )16 h 12 Takeoff

16 h 30 Level off at FL310

16 h 47 Top of descent

17 h 02 min 15 s Level off at 7000 ft

17 h 06 min 52 s Level off at 5000 ft

17 h 09 min 43 s Spoiler 5 FAULT/OFFparameter turns to

FAULT

17 h 13 min 48 s Master warning Capt (2 s)

VFE exceedance due to slatsDeployment

CAS 250 kt, VFE 245 kt


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17 h 14 min 58 s Level off at 4000 ft CAS 202 kt

17 h 17 min 18 s Level off at 3000 ft CAS 206 kt

17 h 22 min 57 s Top of final descent Zp 2800 ft

CAS 153 kt, GS 152 kt

A/THR engaged in SPEED mode

A/P 1 engaged in CMD

FLAPS 41, SLATS 25


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17 h 23 min 45 s Spoiler 5 FAULT/OFF parameter

turns to NO FAULT

17 h 23 min 52 s A/P disengaged CAS 142 kt,

GS 148 kt

17 h 25 min 06 s Thrust levers pulled to idleposition

Both EPR decrease to around 1



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17 h 25 min 10 s Touchdown (LH then RH main

landing gears compressed)

A/THR disengagedAll spoilers deploy except LH and

RH number 5 spoilers


17 h 25 min 12 s Thrust levers pulled to full reverseposition

Engine 2 thrust reversers deploy

and EPR of engine 2 start toincrease



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17 h 25 min 13 s Spoiler 5 FAULT/OFF parameter

turns to FAULT

CAS 131 kt, GS 148 kt17 h 25 min 15 s Nose gear compressed


17 h 25 min 20 s Max EPR of engine 2

reached at 1.2

Thrust levers pushed to idle

position

EPR of engine 2 start todecrease



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17 h 25 min 28 s GPWS Terrain warning (2 s)


17 h 25 min 30 s GPWS Whoop whoop pull

up warning (22 s)

CAS 90 kt, GS 106 kt17 h 25 min 38 s Thrust levers pulled to full

reverse position

CAS 79 kt, GS 93 kt


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17 h 25 min 46 s Runway excursion

CAS 54 kt, GS 76 kt17 h 25 min 54 s Spoilers retract CAS NCD

(


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CVR ReadoutThe readout was done at the BEA laboratory

The recording contains the following tracks:

3 tracks corresponding to the last 30 minutes of

recording containing VHF and crew communications(Captain, First Officer, CAM)

1 track corresponding to the 2 hours of recording

containing the Public Address signal

1 track corresponding to the 2 hours of recordingcontaining the signal of the first three channels mixed

together


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Note: this track allocation is not standard sincethe signal from the cockpit area microphoneshould always be recorded separately andduring two hours on this type of CVR.

This unusual track allocation could be relatedto the wiring of the CVR.

Samplitude audio editing software was used toperform the read out of the audio files.

It was confirmed that the event was recorded.The overall quality of the recording isacceptable


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Reading indicated that

* The captain got clearance to perform approach

R/W 36

* Aircraft configured for landing, checks completed

* Captain got clearance for landing

* Controller informed the flight wind 320/07kt and

R/W condition (rain, wet)


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* Co-pilot suggested the use of Auto-brake and

captain decided not to use it* Co-pilot announced centre line

* Co-pilot announced centre line left

* A single chime was recorded about 20 secondsafter touchdown

* GPWS warnings were triggered several times

prior to overrun TerrainPull up


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As the readout of FDR could not provide accurate

information about the low deceleration, the Board,

Airbus and BEA suggested to again to review

aircraft Maintenance documentation

To examine wreckage parts by appropriate

laboratories in France under supervision of the

board through BEA

Such parts are as

Parking brakes, the tyres, the brakes, remaining

computers, the anti-skid switch


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Unfortunately no remaining computers

were found


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Review of log books show

1- No braking issue was highlighted2- No report about the GPWS was highlighted

3- Engine No. 1 thrust reverser was found stuck

in open position after landing on 22/04/2008and was deactivated up to 10/05/2008 when

the RH master actuator was replaced

4- No tyre inflation information is recorded as theaircraft was not equipped with TPIS


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The aircraft was fitted an EGPWS P/N 965-0976-

003-206-206

The aural warning Terrain, Pull up were trigged

19 seconds after touchdown

Such warnings are Mode 2 which based on radio

altitude and closure rate associated

Below 30 ft no warnings should be triggered

The A310 MSN 548 was not covered by Airbus

Service BulletinA310-34-2163

That is its installation was not defined by Airbus


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Unfortunately no computers were found

The brake units were tested locally at Sudan

Airways facility attended by representatives

from :-

Sudan Investigation Board

The BEA

Sudan Airways

Airbus


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The aim of the test was to determine the status

of both normal and alternate braking systems

Visual inspection revelled that

* All brakes were in good shape within wear limit

* No hydraulic leak was evidenced

* There several impacts due to accident

* Pistons were covered with dirt from accident site

* Some pistons covered with melted aluminium


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On hydraulic Test

* All pistons were active under low pressurewith no leak

* At low pressure ( 200 psi)

pistons were observed moving,discs were not free to rotate,

pistons applied pressure on thrust plate

* At high pressure (2000 psi) no leak was seen* According to the test no failure was evident dueto brakes


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Also

According to FDR analysis

The left main gear braking system was working

about 10 seconds after touchdown when the

captain succeeded to bring the aircraft back on the

centre line by differential brakes as he stated.No failure of brakes was recorded on the FDR

and

According to the rubber marks at the end of theR/W due to wheel lock , braking system failure

appears to be unlikely


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Tyres Examination

The tyres were shipped to France and being examined in

a French Laboratory the

Centre dEssais Aeronautique de Toulouse

(CEAT)

Conclusion of examination 8 tyres show flat spot on the tread

The flat spot damage were due to locking of the wheels

7 tyres were burst except tyre No. 1 (LH/MLG)

No evidence of hydroplaning Wheels rim had no wear marks indicating the rim did

not touch R/W surface, no scraping


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Antiskid

The BRK A/SKID lever was found hanging from

the 401VU panel, in the position indicated in the

photo.

This position was consistent with the switch

being set to ALTN/OFF

Alternate braking/Antiskid off

The 3 push buttons of AUTO BRK selection were

severely damaged by fire.


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final aircraft accident report presentation

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