Technical Report nr 16/INCID/04

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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
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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
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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.
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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.
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"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.
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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.
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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
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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
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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
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Figure 4 – Airport Chart
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Figure 5 – Rwy 28 ILS approach chart
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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.
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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
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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
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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.
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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.
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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;
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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.
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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.
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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.
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4. SAFETY RECOMMENDATIONS
This Report does not sustain any Safety Recommendations.
The Investigator-in-charge
Artur A. Pereira
Lisboa, 5th June 2006.
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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
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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