Technical Report nr 16/INCID/04

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COPY nr. MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES GPIAA FINAL INCIDENT INVESTIGATION REPORT MONARCH AIRWAYS AIRBUS A321-231 G-OZBE FARO AIRPORT 14TH JUNE 2004 REPORT NR 16/INCID/2004 Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 2 of 23 FOREWORD This report expresses the technical conclusions determined by G.P.I.A.A. Investigation Commission about facts and causes involved in this occurrence. According to Annex 13 to the International Civil Aviation Organization Convention (Chicago 1944), to the Council Directive nr. 94/56/EC (21st November 1994) and to nr. 3, 11th article of Decree-Law 318/99 (11th August), it is not the object of this report to determine blame or liability but solely to identify causes and deficiencies capable of undermining flight safety and to gather information for preventing further occurrences of similar circumstances. Following ICAO Recommendation, Chapter 6 §6.7 (Note), this report has been prepared in English. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 3 of 23 SYNOPSIS On 14th June 2004 at 16:08 UTC, the Airbus A321-231, marks G-OZBE, departed London (Gatwick), with 2/7 crew and 33 passengers on board and made an uneventful transit to Faro Airport. The first officer was the pilot flying (PF) throughout the flight. Flight conditions were VMC, wind surface 280º at 10 kt. When the aircraft was fully stabilized with fully flaps for landing, the autopilot was disconnected. The autothrust was left engaged. The touchdown was smooth, the spoilers deployed and the pitch attitude started to reduce but then the nose reared up quickly upon sidestick nose-up demand. In spite the commander took over the aircraft control and put the stick forward to reduce the pitch attitude, the aircraft tail struck the runway. The landing time was 18:18 hours UTC. The aircraft had suffered tail structural damage. There were no personal injuries. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 4 of 23 1. FACTUAL INFORMATION 1.1 History of the flight The Airbus A321-231, marks G-OZBE, departed London (Gatwick), on 14th June 2004 at 16:081, with 2/7 crew and 33 passengers on board and made an uneventful transit to Faro Airport. This was a line training flight, being the 27th sector for a new first officer. The first officer was the pilot flying (PF) throughout the flight. i. Initial Approach The crew carried out a briefing, before the top of descent point, for an ILS R28 approach and manual landing at Faro. Autobrake medium was selected. Prior to descent ATC requested that the aircraft reduce to minimum speed for traffic spacing. Accordingly, Mach 0.74/250 kt was entered for the descent speed in the FMGC. The aircraft was initially given clearance to position to 20 nm final approach Runway 28 and then re-cleared to 7 nm final. ii. Final Approach Flaps 1 was selected prior to intercepting the localiser course and, when established inbound, flaps 2 was selected. Flight conditions were VMC with the sun low on the horizon beyond the runway. The approach continued and when the aircraft was fully stabilised with full flaps the autopilot was disconnected. Autothrust remained engaged and flight directors were on. The aircraft was slightly high on the glide slope at some point but, by 200 feet AGL, the PAPIS indicated on the correct approach path. iii. Touchdown (at 18:18 hours) At 50 feet AGL the descent rate was checked, (reduced) at 30 feet the thrust levers were closed and a landing flare carried out. A 5 feet RA callout was heard followed by a smooth touchdown. The spoilers deployed and the pitch attitude started to reduce but then the nose reared up quickly. The commander called out 1 All times referred in this report are UTC hours. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 5 of 23 "I HAVE CONTROL" (he cannot recollect whether he used the side-stick takeover push button) and put the stick forward to reduce the pitch attitude. He lowered the nose to the runway and completed the landing roll vacating the runway at the second to last turnoff. iv. Post Landing During the taxi to stand the crew was alerted to the possibility of a tailstrike having occurred by ATC. Neither the pilots or the cabin crew had heard any significant noise on touchdown although one passenger made a comment "WHAT WAS THAT?" and one of the rear crew members had felt a movement of the floor beneath her feet. Following shutdown and disembarkation of the passengers the commander inspected the aircraft and discovered the damage. 1.2 Injuries to persons 1.3 Damage to the aircraft Engineering Report Examination of the aircraft at Faro Airport showed damage to the lower fuselage. The visual inspection carried out by maintenance revealed an extension of 2 meters, approximately, of exterior skin paint abrasion under the tail section. INJURIES CREW PASSENGERS OTHERS FATAL - - - SERIOUS - - - MINOR - - - NONE 2+7 333 Figure 1 – Tail strike area. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 6 of 23 The lower skin was abraded from Frame 63 to around Frame 67 between Stringer 42 L/H and Stringer 42 R/H. Within this area of abrasion, it seems there were no structural damages from the vertical loads applied in the contact with the runway. Nevertheless, this area was to be, latter on, the object of an accurate inspection to determine any sustaining structural damage as the result of the tail scrap during landing. The Engineering Report still informs that also the Galley/Lavatory drain mast sustained minor damage burns during fuse contact. Temporary repair has been carried out accordingly with IAW Airbus Technical Disposition 942-031144/012/2004 issue with minor deviations regarding alternative fasteners IAW SRM guidelines, so the aircraft could be approved for a single unpressurised ferry flight from Faro to Luton. 1.4 Damage to third parties There was no damage to third parties. Figures 2 & 3 – Location of frames and sections damaged. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 7 of 23 1.5 Pilots information INFORMATION COMMANDER COPILOT Identification Sex: Age: Nationality: Licence Details License held: Nr.: First issued: Expire date: Ratings: Instrument rating renewal date: Currency Proficiency check (date): Safety/Emergency check (date): Medical Certificate Class: Date issued: Limitations: Experience Total flying hours: Total hours on type: Hours in last 90 days: Hours in last 28 days: Hours in last 24 hours: Duty Times Start of duty: Planned end of duty: Length of preceding rest period: Male 43 years British ATPL AT/221231E/A 08 NOV 1999 07 NOV 2009 A318/319/320/321 - IR A330 IR (Val. 04/06/05) 17 FEB 2005 12 DEC 2003 30 NOV 2003 1 24 FEB 2004 None 10.700:00 6.171:00 134:20 60:15 5:18 15:00 hours 23:10 hours 17:55 hours Male 26 years British CPL CP/347628F/A 12 MAI 2003 11 MAI 2003 A320 - IR 16 MAI 2004 11 MAR 2004 1 04 FEB 2004 None 287:00 68:20 68:20 67:47 5:15 15:00 hours 23:10 hours 17:55 hours Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 8 of 23 1.6 Aircraft Information Aircraft Designation of aircraft: Serial nr.: Date of Manufacture: Nationality and Registration marks: Registered Owner: Operator: Certificate of Airworthiness: Total Time: Total Cycles: Previous Inspection: Next Inspection Due: Total Time: Total Cycles: M.T.O.W.: A.T.O.W.: C. of G. at Take-off: Landing Weight: C. of G. at Landing: AIRBUS A321-321 1707 01 FEB 2002 G-OZBE Monarch Airlines, Ltd Monarch Airlines, Ltd Issued on 27th MAR 2002, valid until 26th MAR 2005 7.722:25 hours 2.952 A7 on 18th MAY 2004 A8 due by 02nd JUL 2004 N/A N/A 89.000 kg (196 210 lb) 71.430 kg 21,2% 65,697 kg (estimated) 17,7% (estimated) Engines Constructor: Type: Date of Manufacture (Both): Engine # 1 S/N: Total Time: Time Since Last Inspection: Time Since Overhaul: Engine # 2 S/N: Total Time: Time Since Last Inspection: Time Since Overhaul: IAE – International Aero Engines 2 x V2533 – A5 23 JAN 02 V11214 7.726:00 hours 329:40 hours 7.726:00 hours V11207 7.724:00 hours 329:40 hours 7.724:00 hours Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 9 of 23 1.7 Meteorological information METAR for Faro airport, at 16:00 hours was surface wind 180° at 05 kts, the direction varying from 130° to 230°, visibility 10 km, cloud FEW at 2,500 feet with OAT 27°C and Dew Point 17°C. Aerodrome QNH was 1015 mb. At the time of the incident surface wind was 280 at 10kt, OAT 26ºC. 1.8 Aids to navigation Runway 28, equipped with an ILS and a PAPI, was used for landing. 1.9 Communications There was a standard and indubitable communication between aircraft and tower. 1.10 Airport Information Faro International Airport Faro Airport is located on the south side of Algarve, in a predominantly flat area. The airstrip is aligned East-West (QFUs 28/10), and it is 2.490 meters long, 45 meters wide and has no slope. Figure 3 – FARO International Airport Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 10 of 23 Figure 4 – Airport Chart Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 11 of 23 Figure 5 – Rwy 28 ILS approach chart Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 12 of 23 1.11 Flight recorders The aircraft was equipped with a CVR and a DFDR. A copy of the DFDR has been provided to Airbus for analysis. 1.12 Information on the local of the incident The examination of the runway showed a single mark from the contact with GOZBE, some 5 metres long, within the normal touchdown zone and close to the runway centre line. The abrasion marks were parallel with the fuselage axis, showing that there was negligible aircraft yaw at contact. Figure 6 – Tail strike mark on runway. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 13 of 23 1.13 Medical and pathological information Both pilots possessed valid medicals and indicated no restrictions on their capabilities. There were no personal injuries to all aircraft occupants. 1.14 Fire No fire broke out as a result of the incident. 1.15 Survival aspects No-one was injured. 1.16 Tests and research 1.16.1 FCOM The FCOM Bulletin from Airbus shows the corresponding tail contact angles, with oleos fully compressed, to be 9.7° for the A321. Figure 7 - FCOM Bulletin, from Airbus – A/C Geometry Limits Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 14 of 23 From the geometry of the impact damage, the aircraft pitch attitude would have been between 10° and 11° relative to the runway. Examination of the aircraft's technical records showed no previous entry which would have had a bearing on this incident. 1.16.2 Comments/observations regarding the F/O The F/O was recruited as a cadet having completed basic flying training but with no commercial experience. During his basic instrument flying training (before joining Monarch, Piper Seneca) the emphasis was on instrument flying and landings were rarely completed. The F/O had experienced earlier in his Airbus training a firm nose wheel derotation following a landing. Type conversion training, at Monarch’s, was completed in a simulator followed by circuit flying in the aircraft until the standard was reached. He completed 14 landings during circuit flying. Figure 8 – Idem, ibidem – Clearance at touchdown Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 15 of 23 The training records indicate that he was making good progress in all areas except that he needed to improve his landing technique. Monarch’s pilots have access to their training reports during training. The F/O was aware that while his progress was good in most areas he still needed to improve his landings. The minimum requirement for completion of training for a cadet is 30 sectors with the average being 36. This was his 27th sector on the A321 aircraft, the first sector was flown as PNF and all further sectors as PF. 1.16.3 F/O statement The PF stated Faro Control asked the aircraft to reduce speed for traffic separation. The aircraft slowed down and was cleared to a 20 nm final and then a 7 nm final. The aircraft flew to a 12 nm final to allow plenty of time for the approach to stabilize (training). Heading mode was used to turn the aircraft onto the final approach course for the localiser. The aircraft was established at 7 nm with flaps 2. The visibility ahead was restricted by haze so the runway was not in sight at this time. When established on the glide slope and the runway came in sight the visual aspect appeared to him that the descent was steep. At 200 to 100 feet the pitch was reduced slightly in response to being "HALF A TRIANGLE" high on the glide slope and just before landing the glide slope pointer was central and the vertical speed indicated 700 fpm down. At 50 feet AGL he gave a slight 'tweak' to slow the descent and at 30 feet started the flare. The aircraft came down to a good touchdown, he selected reverse and saw the nose pitch up. (He had planned to use full reverse). He was not conscious of having made any aft side-stick input but when he heard the commander say "I HAVE CONTROL" he took his hands off the controls. 1.16.4 Crew Resource Management The Flight Crew Operating Manual from Monarch Airlines, in the Standard Operating Procedures – General Information section, mentions the requirement to the PNF to call clearly “I HAVE CONTROL” if a take-over becomes necessary. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 16 of 23 1.17 Organizational and management information The operator had fully complied with crew training and the pilots were qualified to undertake the flight. 1.18 Additional information None. 1.19 Useful or effective investigation techniques None. Figure 9 – FCOM, Standard Operating Procedures, page 5. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 17 of 23 2. ANALYSIS 2.1 DFDR - The Copilot was the PF. 2.1.2 Approach from 1000 ft to flare a. The approach was carried out with: 􀂃 Autopilot off; 􀂃 Both flight directors engaged; 􀂃 Autothrotle engaged; 􀂃 Slats and flaps were full extended; 􀂃 Vapp was selected to 138 kt (which is Vref + 8). b. The average wind direction was 260º, with a wind speed rather constant (slight variations between 10 and 13 kt); c. The average aircraft heading was 283º; d. The runway 28 heading is 284º; e. Consistently with the wind speed and the wind direction recorded, the difference between the ground speed and the true air speed indicates that the approach was performed with 11 kt average headwind; f. The aircraft remained well aligned on the glide slope and localizer beam, with a slight correction of a "half a triangle" high on the glide slope when about 200 ft, and just before landing the glide slope pointer was central and the vertical speed indicated 700 fpm down). The DFDR analysis indicated that: - The aircraft had a mass weight of 65,5 tons registered for landing; Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 18 of 23 2.1.3 From flare to main landing gear touchdown Flare was initiated at 50 ft RA with a sharp half back stick input (7º nose up) maintained for 5 seconds. The pitch attitude was stabilized at about 5º then slightly released to be again applied half stick nose-up. The RH gear touched first the runway, followed 2 seconds later by the LH gear, in a smooth touchdown. Ground spoilers start deployed. In between the RH and the LH gears touchdown, ¼th of side-stick nose down (+ 4º) was applied, leading to a negative pitch rate. As this input occurred at the same time the ground spoiler extended, the result was an aircraft sinking. Just prior to the RH gear touchdown the PF applied full aft stick (-16º nose up). 2.1.4 From touchdown to tail strike The PF maintained full stick nose up for one second from RH gear touchdown, and then progressively reduced his input. Stick was however kept deflected nose up for an additional second. This large nose up demand went simultaneously with the ground spoilers extension which resulted in the pitch attitude building up from about 5º to 9.9º, with the aircraft nose rearing up quickly. The strike prevention requires flying the nose wheel into the ground without delay but the PF had the side-stick fully pulled after touchdown. At this point the Commander became conscious of the inconvenient aircraft nose up pitch attitude, called “I HAVE CONTROL” and took over the flight controls. However, the resulting pitch-up rate did not allow him to take over early enough to correct the attitude and the tail struck the runway because there was no clearance to the ground with such pitch when gear is compressed. 2.2 Flight Officer This was the F/O’s 27th sector (of 30 planned) on his line training Syllabus, being 36 sessions the cadets average to a trainee pilot be considered fitted for the airline flight. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 19 of 23 In spite of the fact he was making good progress in all areas, he showed some tendency for a nose wheel de-rotation following a landing, predisposition he already exhibited on Airbus training sessions. 2.3 Airbus Fly By Wire The side-stick controls very powerful control surfaces through only a small range stick of movement. It is impossible for one pilot to know what side-stick inputs the other pilot has made until he observes the response of the aircraft because their movement is not linked together. Each side-stick input is normally additive, (sum of the two inputs) although there is a pushbutton disconnect switch which allows one pilot to override the other. All these features mean that it can be difficult for the PNF to make corrections during the landing phase. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 20 of 23 3. CONCLUSIONS 3.1 Findings 􀂃 Both pilots possessed airline transport pilot’s licences and had valid medicals issued by the appropriate authorities; 􀂃 Limits concerning crew time, flying time and rest time were complied with; 􀂃 The operator had fully complied with crew training and the flight crew were properly qualified to undertake the flight; 􀂃 Aircraft's technical records showed no previous entry which would have had a bearing on this incident; 􀂃 The meteorological conditions were not factor to the incident. 􀂃 The manual approach was carried out correctly established; 􀂃 Full nose input has been applied at the moment of the touchdown; 􀂃 This large nose up demand in conjunction with the ground spoilers extension resulted in the aircraft nose to rise up quickly; 􀂃 The Commander took over the flight controls and applied a nose down input; 􀂃 The tail strike occurred with a pitch attitude of 9.9º. 3.2 Causes The investigation concluded that the F/O action of maintaining a full aft stick input after the landing leaded the aircraft to pitch up beyond its geometry limit causing the tail section to contact the runway. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 21 of 23 4. SAFETY RECOMMENDATIONS This Report does not sustain any Safety Recommendations. The Investigator-in-charge Artur A. Pereira Lisboa, 5th June 2006. Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 22 of 23 INDEX Page FOREWORD ...................................................................................... 2 SYNOPSIS .......................................................................................... 3 1. FACTUAL INFORMATION .......................................................... 4 1.1 History of the flight .................................................................. 4 1.2 Injuries to persons .................................................................... 5 1.3 Damage to the aircraft ........................................................... 5 1.4 Damage to third parties ............................................................ 6 1.5 Pilots Information .................................................................... 7 1.6 Aircraft information ................................................................. 8 1.7 Meteorological information ..................................................... 9 1.8 Aids to navigation .................................................................... 9 1.9 Communications ...................................................................... 9 1.10 Airport information .................................................................. 9 1.11 Flight recorders ........................................................................ 12 1.12 Information on local of the incident ........................................12 1.13 Medical and pathological information .....................................13 1.14 Fire ........................................................................................... 13 1.15 Survival aspects ....................................................................... 13 1.16 Tests and research ....................................................................13 1.16.1 FCOM ...................................................................................... 13 1.16.2 Comments/Observations regarding the F/O ............................. 14 1.16.3 F/O Statements ......................................................................... 15 1.16.4 Crew Resource Management ................................................... 15 1.17 Organizational and management .............................................. 16 1.18 Additional information ............................................................. 16 1.19 Useful or effective investigation techniques ............................ 16 2. ANALYSIS ........................................................................................ 17 2.1 DFDR ....................................................................................... 17 2.1.2 Approach from 1000 ft to flare ................................................. 17 2.1.3 From flare to main landing gear touchdown ............................ 18 2.1.4 From touchdown to tail strike ................................................... 18 2.2 Flight Officer ............................................................................ 18 2.3 Airbus Fly by Wire .................................................................... 19 3. CONCLUSIONS ............................................................................... 20 3.1 Findings ...................................................................................... 20 3.2 Causes ........................................................................................ 20 4. SAFETY RECOMMENDATIONS ................................................. 21 INDEX ................................................................................................ 22 ACRONYMS ...................................................................................... 23 Technical Report nr 16/INCID/04 DOWNLOAD COPY Page 23 of 23 ACRONYMS A Aeroplane Aft Aftward AGL Above Ground Level AT Airline Transport ATC Air Traffic Control ATPL Airline Transport Pilot Licence CPL Commercial Pilot Licence CVR Cockpit Voice Recorder FDR Flight Data Recorder FCOM Flight Crew Operating Manual F/O Flight Officer Ft/min Feet per minute GPIAA Gabinete de Prevenção e Investigação de Acidentes com Aeronaves (Portuguese Air Accident Investigation Branch) IAW Indications, Analysis & Warnings ILS Instrument Landing System IR Instrument Rating Kg Kilograms Kt Knot L/H Left Hand NM Nautical Miles OAT Outside Air Temperature PAPI Precision Approach Path Indicator PF Pilot Flying PNF Pilot Not Flying RA Radio Altimeter R/H Right Hand RWY Runway SRM Structural Repair Manual UTC Universal Time Coordinated Vapp Velocity approach Vref Velocity reference VMC Visual Meteorological Conditions

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Technical Report nr 16/INCID/04