FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT A310-324 F-OGYP

航空发表于 2010-10-3 08:48:07

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航空发表于 2010-10-3 08:48:47

"Approved" Deputy Chairperson of the Interstate Aviation Committee O. K. Ermolov 2007 INTERSTATE AVIATION COMMITTEE FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT Type of aircraft A-310-324 State of Registry France Registration F-OGYP Owner Wilminton Trust Company acting as the holder of fiduciary rights Lessor Airbus leasing II.Inc Operator ОАО Aviakompania Sibir Date and time of accident 8 July 2006, 10:44 pm UTC (07.09.06, 7:44 am local time) Place of accident At a distance of 2140 m and on a magnetic azimuth of 296° from Irkutsk ARP In accordance with the standards and recommendations of the Intergovernmental Civil Aviation Organization, this report was issued with the sole purpose of preventing accidents. The investigation conducted for this report does not presume to establish the share of any party's guilt or liability. Any criminal aspects of this accident are treated in separate criminal proceedings. Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 2 Table of Contents Glossary.................................................................................................................... 3 Background Information........................................................................................ 8 1. Factual Information ....................................................................................... 10 1.1. History of Flight ......................................................................................................10 1.2. Injuries to Persons ..................................................................................................11 1.3. Damage to Airplane ................................................................................................11 1.4. Other Damage .........................................................................................................11 1.5. Personnel information ............................................................................................11 1.5.1. Flight Crew .......................................................................................................11 1.5.2. Cabin Crew .......................................................................................................20 1.6. Aircraft Information...............................................................................................26 1.7. Meteorological Information...................................................................................32 1.8. Air Traffic Control .................................................................................................36 1.9. Aids to Navigation...................................................................................................39 1.10. Aerodrome Information.....................................................................................39 1.11. Flight Recorders..................................................................................................44 1.12. Wreckage and Impact Information...................................................................44 1.13. Medical and Pathological Information .............................................................47 1.13.1. Medical information .........................................................................................47 1.13.2. Results of pathological and anatomical examinations......................................49 1.14. Survival Aspects..................................................................................................49 1.15. Fire .......................................................................................................................50 1.16. Tests and Research .............................................................................................54 1.16.1. Full-scale experiment........................................................................................54 1.16.2. Mathematical simulation...................................................................................54 1.16.3. Analysis of materials from previous research work to determine the friction coefficient of a runway with various surface conditions ..................................................57 1.16.4. Assessment of forces needed to move the throttle control lever ......................57 1.16.5. Results of investigations made on engine control computers (FADEC)..........59 1.16.6. Results of examining the engine control console .............................................59 1.17. Information on Organizations and Management ............................................60 1.18. Additional information.......................................................................................62 1.18.1. Characteristics of the operation of A-310 airplane by Sibir .............................62 1.18.2. Flight assessment based on the results of studies conducted during the investigation.....................................................................................................................67 1.18.3. Information about previous incidents ...............................................................72 1.18.4. Expert conclusion reached by clinical psychologists based on records of the psychological examinations of the airplane captain of the A-310 F-OGYP that was involved in the accident on July 9, 2006 at Irkutsk airport...............................................77 1.18.5. Expert conclusion reached by aviation doctors based on records of the medical examinations of the airplane captain of the A-310 F-OGYP that was involved in the accident on July 9, 2006 at Irkutsk airport........................................................................80 2. Analysis............................................................................................................ 87 3. Findings and Conclusion ............................................................................. 109 4 Shortcomings Identified in the Course of the Investigation..................... 116 5 Safety Recommendations............................................................................. 119 Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 3 Glossary ACAFA - Aktyubinsk Civil Aviation Flight Academy ACT - airport control tower AeMS - aeronautical meteorological station (civilian) AMS - aviation meteorological station ANO - autonomous noncommercial organization A & AE - aviation and avionics equipment AS - airport service CRT - crash and rescue team CRTr - crash and rescue training CRW - crash and rescue work CRS - crash and rescue station AMC - aviation maintenance center АMB - aircraft maintenance base AS - air squadron FS - flight safety MM - middle marker SSN - spring-summer navigation SSP - spring-summer period PEB - physical evaluation board AQC - advanced qualifications commission DFB - departmental fire brigade ASCC - auxiliary start control center APU - auxiliary power unit AT - air transport CA - civil aviation HV - horizontal visibility PAS - public address system SSRICA - State Scientific and Research Institute of Civil Aviation GPT - glide-path transmitter ArCC - area control center AppCC - approach control center TCC - taxi control center OM - outer marker US - unified system ZAO - closed joint-stock company ASDC - air squadron deputy commander AES - aviation engineering service ICAO - International Civil Aviation Organization ILS - instrument landing system MP - maintenance personnel ASC - air squadron commander ATC - air traffic control Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 4 PIC - pilot in command SW - short waves KCAFA - Kirovograd Civil Aviation Flight Academy ADD - aircraft division director PRC - People's Republic of China LB - localizer beacon ARP - airport reference point FRI - flight research institute FS - flight section IAC - Interstate Aviation Committee MH - magnetic heading МLH - magnetic landing heading MT - main taxiway PA - parking area MU - medical unit MES - Ministry for Emergency Situations AAERC IAC - Air Accident Engineering and Research Commission of the International Aviation Committee AOS - Airport Operating Standards AAS - Aircraft Airworthiness Standards CAMM - civil aviation meteorological manual NOTAM - notes to airmen (changes in aeronautical information) CAFOM - civil aviation flight operations manual CAMRM - 93 - Civilian Aircraft Maintenance and Repair Manual – 1993 NSM - navigation service manual ОАО - open joint-stock company UAE - United Arab Emirates TOC - departure control ATS - air traffic service HIL - high-intensity lights VHF - very high frequency ООО - limited-liability company MOP - main observation point SLB - separate locator beacon ATM - air traffic management LSE - landing system equipment OCS - operations control service ACS - approach controller station CRP - compulsory reporting point FPTC - flight personnel training course RIAAI-98 - 1998 Rules for Investigating Air Accidents and Incidents PM - periodic maintenance TORA - takeoff run available ASDA - accelerate-stop distance available Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 5 RF - radar facility FM - flight manual FOM - flight organization manual FOO - flight operations officer AFOD - airport flight operations director CAFSRM - civil aviation flight search and rescue manual LDA - landing distance available FOM - flight operations manual RSRB - regional search-and-rescue base PMP - periodic maintenance procedure AMG - airplane maintenance guide TCL - throttle control lever RTL - reverse thrust lever RF - Russian Federation RC - regional center RF CAOG - RF Civilian Airport Operations Guideline ICC - integrated control center FME - forensic medical examination TTSN - total time since new TMS - transport management service FSRS - flight search and rescue service USA - United States of America CMEA - Council for Mutual Economic Assistance M&R - maintenance and repair ATC - air traffic control USW - ultra short waves FIA - flight inspection authority RFPL - required fire protection level TC - training center FAR - federal aviation rules FCAMCR - federal civil aviation medical certification regulations FSUE - federal state unitary enterprise FTOA - Federal Transportation Oversight Authority CPEB - Central Physical Evaluation Board CIL - central indicator light EIF - electrical illumination for flights A/C - aircraft AFS - automatic flight system ATIS - automatic terminal information system BEA - Bureau d'Enquêtes et d'Analyses (French accident investigation authority) BFU - Bundesstelle für Flugunfalluntersuchung (German accident investigation authority) Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 6 CBT - computer-based training CRM - crew resources management CVR - cockpit voice recorder DFDR - digital flight data recorder DGAC - Direction Générale de l'Aviation Civile (French civil aviation authority) EASA - European Aviation Safety Agency ECAM - electronic centralized aircraft monitoring EGT - exhaust gas temperature EPR - engine pressure ratio (determines thrust) FADEC - full authority digital electronics control FC - flight cycles FCOM - flight crew operating manual FCU - flight control unit FDR - flight data recorder FFS - full flight simulator FH - flight hours Flare - (caption on flight mode annunciator) FMA - flight mode annunciator (on primary flight display) FWC - flight warning computer GE - General Electric GLB - ground log book IATA - International Air Transport Association Reverse Idle - reverse idle mode ILS - instrument landing system IOSA - IATA operational safety audit LOW - automatic braking mode Max Rev - maximum reverse thrust MEL - minimum equipment list MMEL - master minimum equipment list N1 - low rotor rotation speed N2 - high rotor rotation speed NOTAM - notices to airmen NTSB - US National Transportation Safety Board PFD - primary flight display P&W - Pratt & Whitney Retard - engine shift to idle (caption on flight mode annunciator) Rollout - (caption on flight mode annunciator) SIGMET - significant meteorological information SOP - standard operating procedure STC - supplement type certificate TLB - technical log book Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 7 UTC - coordinated universal time VOR-DME - VHF omni-directional radio range/distance-measuring equipment Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 8 Background Information On July 8, 2006 at 22:44 UTC1 (7:44 local time on July 9, 2006), as it was landing at Irkutsk airport, an А-310 airplane, registration F-OGYP, operated by ОАО Aviakompania Sibir , ran down the runway, overran the runway threshold and, at a distance of 2140 m and on a magnetic azimuth of 296° from the aerodrome reference point, collided with barriers, broke apart and burst into flames. As a result of the accident 125 individuals died, including both pilots and 3 of the cabin crew; 60 passengers and 3 cabin crew suffered physical injuries of varying degrees of severity. The investigation of the accident was conducted by a commission appointed by Order no. 13/379-R dated July 8, 2006 of the Deputy Chairman of the Interstate Aviation Committee (IAC), as amended by Order no. 33 dated July 18, 2006 of the IAC Chairman: Commission chairman A.N. Morozov, Chairman of the Accident Investigation Commission of the Interstate Aviation Committee Deputies of the commission chairman: V.V. Chernyaev, Deputy Chairman of the Accident Investigation Commission of the Interstate Aviation Committee Yu.V. Zhuravlyov, Director of the East Siberian Administration of Gosavianadzor (Federal Transport Oversight Authority) of the Ministry of Transportation of Russia Commission members: V.A. Trusov, Chairman of the Commission for the Scientific and Technical Support of Air Accident Investigation of the IAC; S.A. Maryshev, branch consultant of the Inspection board for flight safety and the investigation of accidents of the Federal Transport Oversight Authority (Rostransnadzor); V.I. Volobuyev, director of the Department of Aerodromes and Airports of the Airport Operations Administration of the Federal Air Transportation Agency (Rosaviatsia); 1 Hereinafter, unless otherwise specified, UTC is used. Sunrise at Irkutsk was at 20:50 UTC. Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 9 A.P. Dovzhik, chief maintenance engineer of the aviation maintenance center ОАО "Aeroflot - Rossiskiye avialinii"; R.A. Teimurazov, IAC technical director for safety issues; A.G. Kruglov, advisor to the Chairman of the IAC; V.V. Biriukov, class 1 test pilot of the federal state unitary enterprise "М.М. Gromov Flight Research Institute" Specialists from FTOA, Rosaviatsia, Rosaeronavigatsia, Irkutsk airport, the airlines Aeroflot - Rossiskiye avialinii and Sibir, as well as the accredited representative of BEA, who represented the State (France) of the airplane Design, Manufacture and Registry, and of NTSB, which represented the State (USA) of the engine developer and manufacturer, as well as their advisors from Airbus and P&W, participated in the investigation. During the course of the investigation the Commission requested information about the cabin reconfiguration carried out by Lufthansa Technik (Germany). In accordance with Annex 13 to the ICAO Convention, this information was provided via BFU, which also appointed an accredited representative. Start of investigation - July 9, 2006 End - 2007 Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 10 1. Factual Information 1.1. History of Flight On July 8, 2006 an А-310 airplane with state registration number FOGYP (France), leased by ОАО Aviakompania Sibir, and with a flight crew consisting of the Captain and the co-pilot, was flying scheduled passenger flight С7 778 from Domodedovo to Irkutsk. Apart from the two cockpit personnel, there were 6 flight attendants and 195 passengers on board (of these, 2 worked for the company), which included 181 nationals of Russia, 3 of Germany, 3 of the PRC, 2 of Poland, 3 of Belarus, 2 of Moldova and 1 of Azerbaijan. The airplane's payload according to the flight manifest was 19,800 kg (which included about 80 kg of hazardous freight - perfume), its take-off weight 140414 kg (maximum permissible – 150,000 kg), and center-of-gravity position 25.5% (the range of permissible center-of-gravity positions for take-off is 18% - 32%). Upon completion of the pre-flight preparation, the crew took off from Domodedovo airport at 17:17 (17:15 – as per schedule) and after climbing set a course for its destination airport of Irkutsk (alternate airport Bratsk). The flight proceeded without incident and at 22:17 the crew initiated descent for an approach and landing at Irkutsk airport. At 22:43:40 the airplane landed without misalignment on runway 30 at Irkutsk airport. Note: Before the flight, in accordance with Sibir’s MEL, the maintenance personnel deactivated the thrust reverser on the airplane's left engine after hearing the crew's observation about this thrust reverser's malfunction during a previous flight. After touchdown all spoiler sections prepared ("armed") by the crew for utilization were deployed and the autobrake in Low mode, previously selected by the crew, was activated. The pilot moved the right engine (no. 2) thrust reverser forward. However, simultaneously with the subsequent reduction of the reverse mode of engine no. 2, engine no. 1 started to speed up (forward thrust), which led to an increase in airplane speed and the onset of torque that pulled the airplane to the right. The crew failed to perceive the cause of what was happening. In spite of intense wheel-braking efforts, the airplane used up the entire length of the runway and overshot its end at a speed of about 180 kph. The airplane then continued to travel on wet soil. At a distance of about 300 m from the departure threshold of the runway, the airplane collided with a concrete barrier of the aerodrome and then with some garages located directly behind the barrier, after which the airplane, now seriously damaged, stopped. As a result of the Final Report INTERGOVERNMENTAL AVIATION COMMITTEE 11 destruction of the fuel tanks the fuel ignited and fire penetrated the airplane's interior. As a result of the accident, 125 individuals died, including the two pilots and three of the flight attendants. The airplane was practically completely destroyed by the fire. 1.2. Injuries to Persons fatal serious minor n/a passengers 120 38 22 15 crew 2/3 0/3 - - 1.3. Damage to Airplane As the airplane was overshooting the runway, it collided with a concrete barrier of the aerodrome and with some garages behind it. As a result of the break-up of the airplane's structure and the subsequent fire, the airplane was practically completely destroyed. 1.4. Other Damage As the airplane was overshooting the runway, its left engine cowling and air intake damaged six first-row elements and one second-row element of the localizer antenna array. The shock struts of the landing gear then broke the aerodrome's concrete barrier, after which the airplane collided with the garage structures behind the barrier, resulting in the destruction of 20 garages.

6626 发表于 2010-10-14 18:41:34

FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT A310-324 F-OGYP

f214216709 发表于 2010-12-7 09:36:59

看看的谢谢

kmlihe 发表于 2015-7-4 14:14:34

thank you very much

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FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT A310-324 F-OGYP