Aircraft Serious Incident Investigation Report AIRBUS A321 PK–YVE

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航空发表于 2010-10-2 09:01:02

TRANSPORTATION SAFETY COMMITTEE Aircraft Serious Incident Investigation Report
ISBN: When the NTSC makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the NTSC fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in NTSC reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability. This report was produced by the National Transportation Safety Committee (NTSC), Karya Building 7th Floor Ministry of Transportation, Jalan Medan Merdeka Barat No. 8 JKT 10110, Indonesia. The report is based upon the investigation carried out by the NTSC in accordance with Annex 13 to the Convention on International Civil Aviation, Aviation Act (UU No.1/2009), and Government Regulation (PP No. 3/2001). Readers are advised that the NTSC investigates for the sole purpose of enhancing aviation safety. Consequently, NTSC reports are confined to matters of safety significance and may be misleading if used for any other purpose. As NTSC believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging NTSC as the source.
i TABLE OF CONTENTS TABLE OF CONTENTS....................................................................................................... i TABLE OF FIGURES ......................................................................................................... iii GLOSSARY OF ABBREVIATIONS.................................................................................. iv SYNOPSIS ............................................................................................................................. 1 1. FACTUAL INFORMATION................................................................................... 2 1.1 History of the Flight ......................................................................................................2 1.2 Injuries to Persons..........................................................................................................5 1.3 Damage to aircraft .........................................................................................................5 1.4 Other damage.................................................................................................................5 1.5 Personnel information ...................................................................................................5 1.5.1 Pilot in command ...................................................................................................5 1.5.2 Copilot ...................................................................................................................6 1.6 Aircraft Information ......................................................................................................7 1.6.1 Aircraft Data ..........................................................................................................7 1.6.2 Engine Data ...........................................................................................................7 1.6.3 Weight and Balance...............................................................................................8 1.6.4 Maintenance...........................................................................................................8 1.7 Meteorological Information...........................................................................................8 1.8 Aids to Navigation .........................................................................................................8 1.9 Communications ............................................................................................................8 1.10 Aerodrome Information .................................................................................................9 1.10.1 General...................................................................................................................9 1.11 Flight Recorders.............................................................................................................9 1.11.1 Digital Flight Data Recorder (DFDR) ...................................................................9 1.11.2 Cockpit Voice Recorder (CVR) ............................................................................9 1.11.3 Notable facts from the CVR..................................................................................9 1.11.4 FDR Readout.......................................................................................................10 1.12 Wreckage and impact information...............................................................................10 1.13 Medical and Pathological Information .........................................................................11 1.14 Fire..............................................................................................................................11 1.15 Search and survival aspects..........................................................................................11 1.16 Test and Research ........................................................................................................11 1.17 Organizational and Management Information..............................................................12 ii 1.17.1 Batavia Air ..........................................................................................................12 1.18 Additional Information ................................................................................................12 No additional information relevant to the occurrence. .....................................................12 2. ANALYSIS............................................................................................................... 13 3. CONCLUSION........................................................................................................ 15 3.1 Findings .......................................................................................................................15 4. SAFETY RECOMMENDATIONS ....................................................................... 16 4.1 Recommendation to Batavia Air ...............................................................................16 4.2 Recommendation to Directorate General Civil Aviation.........................................16 iii TABLE OF FIGURES Figure 1: PK-YVE, Batavia Air Airbus A320 at Medan on 2 June 2008 ............................... 2 Figure 2: Touch down tire marks on touch down area............................................................ 4 Figure 3: Rolling tire marks on runway up to final stop at adjacent to taxi way D ................ 4 Figure 4: Wheel number 1....................................................................................................... 5 Figure 5: Broken left landing gear down lock cable ............................................................... 8 Figure 6: Tire mark on runway close to taxi way D.............................................................. 10 Figure 7: Tire number 1 and number 2 marks....................................................................... 11 Figure 8: Tire number 3 mark ............................................................................................... 11 Figure 9: Touch down number 1 and number 2 tire marks ................................................... 11 iv GLOSSARY OF ABBREVIATIONS AD Airworthiness Directive AFM Airplane Flight Manual AGL Above Ground Level ALAR Approach-and-landing Accident Reduction AMSL Above Mean Sea Level AOC Air Operator Certificate ATC Air Traffic Control ATPL Air Transport Pilot License ATS Air Traffic Service ATSB Australian Transport Safety Bureau Avsec Aviation Security BMG Badan Meterologi dan Geofisika BOM Basic Operation Manual CAMP Continuous Airworthiness Maintenance Program CASO Civil Aviation Safety Officer CASR Civil Aviation Safety Regulation CPL Commercial Pilot License COM Company Operation Manual CRM Cockpit Recourses Management CSN Cycles Since New CVR Cockpit Voice Recorder DFDAU Digital Flight Data Acquisition Unit DGCA Directorate General of Civil Aviation DME Distance Measuring Equipment EEPROM Electrically Erasable Programmable Read Only Memory EFIS Electronic Flight Instrument System EGT Exhaust Gas Temperature EIS Engine Indicating System FL Flight Level F/O First officer or Copilot FDR Flight Data Recorder FOQA Flight Operation Quality Assurance GPWS Ground Proximity Warning System Hrs Hours ICAO International Civil Aviation Organization IFR Instrument Flight Rules IIC Investigator in Charge 5 ILS Instrument Landing System Kg Kilogram(s) Km Kilometer(s) Kts Knots (NM/hour) Mm Millimeter(s) MTOW Maximum Take-off Weight NM Nautical mile(s) KNKT / NTSC Komite Nasional Keselamatan Transportasi / National Transportation Safety Committee °C Degrees Celsius PIC Pilot in Command QFE Height above aerodrome elevation (or runway threshold elevation) based on local station pressure QNH Altitude above mean sea level based on local station pressure RESA Runway End Safety Area RPM Revolution Per Minute SCT Scattered S/N Serial Number SSCVR Solid State Cockpit Voice Recorder SSFDR Solid State Flight Data Recorder TS/RA Thunderstorm and rain TAF Terminal Aerodrome Forecast TSN Time Since New TT/TD Ambient Temperature/Dew Point TTIS Total Time in Service UTC Coordinated Universal Time VFR Visual Flight Rules VMC Visual Meteorological Conditions
1 SYNOPSIS On 1 June 2008, an Airbus A320 aircraft, registration PK-YVE, was being operated by Metro Batavia Airlines (Batavia Air) flight number 7P-591, on a scheduled passenger flight from Jakarta to Medan. The flight departed at 00:10 UTC (07:10 local time) with an estimated arrival time at Medan of 02:25. There were 140 people on board; two pilots, five cabin crew, and 133 passengers. The aircraft touched down towards the departure end of the touch-down area of runway 05 at Polonia Airport, Medan at 03:04. After a landing run of 41 seconds, the aircraft stopped on the runway adjacent to taxiway ‘D’, approximately 1,200 meters from the estimated point of touch down. Three main-wheel tires and two main wheels were substantially damaged. The aircraft could not be taxied from the runway to the apron, nor could it be towed to the apron due to damage to the wheels. The passengers and crew disembarked normally at taxiway ‘D’; there were no injuries. Following an inspection of the landing gear and replacement of the damaged wheels, the aircraft was towed to the apron at 10:10. The runway was closed for about 7 hours. The investigation found that the left landing gear down-lock cable was broken. The aircraft touched down with the wheel brakes locked due to a hydraulic lock in the system, which was the result of an incorrect manual landing gear extension procedure being used by the pilots. The pilots’ actions indicated that they did not sufficiently understand the aircraft’s landing gear system, resulting in them using inappropriate trouble shooting and rectification procedures. The pilots were not sufficiently confident of the aircraft’s fuel state to conduct a go around and fly past as cleared by ATC. With the release of the final report, the National Transportation Safety Committee’s (NTSC) issued two recommendations to address the safety deficiencies identified in the report. These covered flight crew technical knowledge of aircraft systems, fuel planning and flight management, and the regulatory oversight of the airline’s training program. 2 1. FACTUAL INFORMATION 1.1 History of the Flight On 1 June 2008, an Airbus A320 aircraft, registration PK-YVE, operated by Metro Batavia Airlines (Batavia Air) as a flight number 7P-591, was being operated on a scheduled passenger flight from Jakarta to Medan. The aircraft departed from Soekarno – Hatta Airport, Jakarta at 00:10 Coordinated Universal Time1 (UTC) (07:10 local time), under the instrument flight rules (IFR). The estimated time of arrival (ETA) at Polonia Airport, Medan, North Sumatera was 02:25. The pilot in command (PIC) was the handling pilot and the copilot was the support/monitoring pilot.

6626 发表于 2010-10-14 18:42:02

Aircraft Serious Incident Investigation Report AIRBUS A321 PK–YVE

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Aircraft Serious Incident Investigation Report AIRBUS A321 PK–YVE