Report on the accident to Airbus A330-342 B-HYA

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AIRCRAFT ACCIDENT REPORT 1/2005 ACCIDENT INVESTIGATION DIVISION Civil Aviation Department Hong Kong Report on the accident to Airbus A330-342 B-HYA Within the Manila Flight Information Region on 18 July 2003 Hong Kong May 2005
I Contents Page GLOSSARY ..……………………...…………………………………………………………i SYNOPSIS …………………………………………………………………………………1 1. FACTUAL INFORMATION ………………………………………………………..3 1.1. History of the Flight ………………………………………………………….3 1.2. Injuries to Persons ……………………………………………………………5 1.3. Damage to Aircraft…………………………………………………………...5 1.4. Other Damage ………………………………………………………………...7 1.5. Personnel Information ……………………………………………………..7 1.5.1. Flight Crew …………………………………………………………………...7 1.5.2. Cabin Crew ………………………………………………………………...10 1.6. Aircraft Information ………………………………………………………11 1.6.1. Aircraft Particulars …………………………………………………………11 1.6.2. Maintenance History ……………………………………………………….11 1.6.3. Aircraft Weight and Centre of Gravity …………………………………….12 1.6.4. Weather Radar ……………………………………………………………..12 1.6.5. Automatic Pilot System ……………………………………………………14 1.7. Meteorological Information …………………………….…………………14 1.7.1. Meteorological Information at Departure and Destination Aerodromes …...14 1.7.2. Meteorological Information Enroute ….……………………………………14 1.7.3. Meteorological Information Provided to the Flight Crew ….………………16 1.8. Aids to Navigation …………………………………………………………..17 1.9. ATC and Communications …………………………………………………18 1.10. Aerodrome Information ……………………………………………………19 1.11. Flight Recorders …………………………………………………………….19 1.11.1. Digital Flight Data Recorder (DFDR) ………………………………………19 1.11.2. Cockpit Voice Recorder (CVR) …………………………………………….20 1.11.3. Quick Access Recorder (QAR) ……………………………………………..20 II 1.12. Wreckage and Impact Information ………………………………………..21 1.13. Medical and Pathological Information…………………………………….21 1.14. Fire …………………………………………………………………………...22 1.15. Survival Aspects …………………………………………………………….22 1.16. Test and Research …………………………………………………………..23 1.17. Organizational and Management Information …………………………...23 1.17.1. Crew Resources Management (CRM) ………………………………………23 1.17.2. Training Records and Training Material ……………………………………24 1.18. Additional Information ……………………………………………………..25 2. ANALYSIS …………………………………………………………………………..26 2.1. Weather Conditions ………………………………………………………...26 2.2. Operation of the Weather Radar …………………………………………..26 2.3. Weather Avoidance …………………………………………………………30 2.4. Standard Operating Procedures (SOP) for Turbulence Penetration ……33 2.5. Decision to Continue the Flight to Hong Kong ……………………………36 2.6. Crew Training and Documentation ………………………………………..36 2.6.1. Use of Weather Radar ……………………………………………………….36 2.6.2. Weather Briefing to Cabin Crew ……………………………………………39 2.7. Handling of the Injured and Cabin Management ………………………...41 2.8. Crew Communication and CRM Training ………………………………..42 2.9. Fasten Seat Belt Signs (FSBS) ……………………………………………...44 2.10. ATC and Emergency Services ……………………………………………...45 2.11. Quick Access Recorder ……………………………………………………..46 2.12. Cockpit Voice Recorder …………………………………………………….47 2.13. Analysis of the DFDR Data ………………………………………………...49 III 3. CONCLUSIONS…………………………………………………………………….49 3.1. Findings ……………………………………………………………………...49 3.2. Cause ………………………………………………………………………...52 3.3. Contributing Factors ……………………………………………………….52 4. SAFETY RECOMMENDATIONS ………………………………………………..53 5. APPENDICES Appendix 1 - Area Route Chart Appendix 2 - Plot of Aircraft Track Appendix 3 - Plot of DFDR Data Appendix 4 - Track of Tropical Depression/Storm ‘Koni’ Appendix 5 - GOES-9 Infra-red Satellite Picture Appendix 6 - WAFC Significant Weather Forecast Chart Appendix 7 - Record of Traffic Operated in the Vicinity of NOBEN Appendix 8 - Dragonair A330 Operational Notice 75/02 – Turbulent Air Appendix 9 - Dragonair A330 Operational Notice 59/03 – Turbulent Air Appendix 10 - Extract from FCOM 3.04.34 Page 3 – 5 Appendix 11 - Extract from FCOM 3.03.15 Page 2 Appendix 12 - Extract from A320/A321/A330 Operations Manual, Volume 8 – Company Instruction on Weather Radar Appendix 13 - Extract from A320/A321/A330 Operations Manual, Volume 12 – Crew Instruction on DFDR/CVR/QAR Recordings i GLOSSARY α Angle of attack αprot Angle of attack protection flight control law ° Degree(s) °M Degree(s) Magnetic AP Autopilot ATC Air Traffic Control ATPL Airline Transport Pilot Licence CAD Civil Aviation Department CB Cumulonimbus Cloud cm Centimetres CP Chief Purser CPL Commercial Pilot Licence CRM Crew Resource Management CVR Cockpit Voice Recorder DFDR Digital Flight Data Recorder ECAM Electronic Centralized Aircraft Monitoring FCOM Flight Crew Operating Manual FIR Flight Information Region FL Flight Level FLT Flight FMS Flight Management System FSBS Fasten Seat Belt Signs GOES-9 Geostationary Operational Environmental Satellite-9 HKIA Hong Kong International Airport IMC Instrument Meteorological Conditions JMA Japan Meteorological Agency M Mach Number MAC Mean Aerodynamic Chord MB Megabyte METAR Aviation Routine Weather Report MHz Megahertz Mmo Maximum Operating Mach Number ii MO Magneto-Optical MOD Moderate ND Navigation Display NEDIS National Environmental Satellite Data and Information Service NM Nautical Miles PA Public Address PF Pilot Flying PIC Pilot-in-Command PN Part Number PNF Pilot Not Flying QAR Quick Access Recorder QRH Quick Reference Handbook SEV Severe SIGMET Significant Meteorological Warning SOP Standard Operating Procedure SP Senior Purser TAF Aerodrome Forecast Turb Turbulence US NOAA United States National Oceanic and Atmospheric Administration UTC Universal Time Co-ordinated VHF Very High Frequency Vls Lowest Selectable Speed Vmo Maximum Operating Speed Wx Weather WAFC World Area Forecast Centre 1 ACCIDENT INVESTIGATION DIVISION CIVIL AVIATION DEPARTMENT Aircraft Accident Report Operator : Hong Kong Dragon Airlines Limited Aircraft Type : Airbus A330-342 Registration : B-HYA Flight Number : HDA060 Place of Accident : 14 NM north-northeast of Reporting Point NOBEN within Manila FIR Latitude: 13∘00’ N Longitude: 116∘51.3’ E Flight Level 410 Date and Time : 18 July 2003 at 0510 UTC (daylight) All times in this report are in UTC. SYNOPSIS On 18 July 2003, a passenger flight, HDA060, was enroute from Kota Kinabalu to Hong Kong along Route M754 within the Manila FIR cruising at Flight Level (FL) 410. Prompted by weather returns displayed on the weather radar, the flight crew requested permission from Air Traffic Control (ATC) in Manila to deviate right of track to avoid weather. Soon after commencement of the track deviation, the aircraft encountered severe turbulence1. At the time of the occurrence, the Fasten Seat Belt Signs (FSBS) were selected ON and all 1 Severe turbulence is described as conditions in which abrupt changes in aircraft attitude and/or altitude occur, aircraft may be out of control for short periods and usually with large variation in airspeed. Changes in accelerometer reading greater than 1.0 ‘G’ at the aircraft’s centre of gravity. Occupants are forced violently against seat belts. Loose objects are tossed about. (Ref. ICAO PANS-ATM Doc 4444) 2 passengers were seated with their seat belts fastened. However, as the cabin crew were serving meals along the aisles and galley areas they were not strapped in. Based on the Digital Flight Data Recorder (DFDR) data, during the turbulence encounter, the cruising level varied between FL 408 and FL 416. The aircraft experienced a rapid sequence of jolts that resulted in various degrees of injuries to all twelve cabin crew members. Of the 236 passengers on board, three sustained minor injuries. The accident occurred within the Manila Flight Information Region (FIR) where a tropical depression had just moved to an area over the sea to the west of the Philippines, moving on a track of west-northwest and was forecast to intensify over water. At the time of the accident, the aircraft was deviating 6 NM to the right of Route M754 northbound at a position approximately 160 NM to the west-northwest of the centre of the tropical depression. After the accident, the aircraft was promptly accorded priority landing at Hong Kong. It subsequently landed safely at Hong Kong International Airport (HKIA). As the occurrence resulted in serious injuries, in the form of bone fractures, to persons on board, it was classified as an aircraft accident. The Chief Inspector of Accidents therefore ordered an Inspector’s Investigation be carried out in accordance with the Hong Kong Civil Aviation (Investigation of Accidents) Regulations 1983. The investigation concluded that the aircraft inadvertently flew into an area of turbulent weather caused by strong convective activity associated with the tropical depression. Based on the evidence as to the way in which the weather radar was operated, it was highly probable that the flight crew were not presented with the optimum weather radar picture that would have enabled a full appreciation of the intensity and extent of the weather in the vicinity of 3 the aircraft. As a result, the deviation around weather was not initiated early enough, nor was the deviation large enough to avoid the weather.

6626 发表于 2010-10-14 18:40:55

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f214216709 发表于 2010-11-10 09:27:29

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Report on the accident to Airbus A330-342 B-HYA