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

航空

游客，如果您要查看本帖隐藏内容请回复

航空

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

好东西，支持一下

f214216709

什么内容的呀 看看哦