Aviation Occurrence Report Crosswind Landing Event Melbourne Airport

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ATSB TRANSPORT SAFETY INVESTIGATION REPORT
Aviation Occurrence Report – 200505311 Final
Crosswind Landing Event Melbourne Airport, Vic. - 26 October 2005 HS-TNA Airbus A340-642

ATSB TRANSPORT SAFETY INVESTIGATION REPORT
Aviation Occurrence Report
200505311
Final
Crosswind Landing Event
Melbourne Airport, Vic. - 26 October 2005
HS-TNA, Airbus A340-642
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Published by:
Australian Transport Safety Bureau
Postal address:
PO Box 967, Civic Square ACT 2608
Office location:
15 Mort Street, Canberra City, Australian Capital Territory
Telephone:
1800 621 372; from overseas + 61 2 6274 6440
Accident and incident notification: 1800 011 034 (24 hours)
Facsimile:
02 6247 3117; from overseas + 61 2 6247 3117
E-mail:
atsbinfo@atsb.gov.au
Internet:
www.atsb.gov.au
© Commonwealth of Australia 2007.
This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this material in unaltered form (retaining this notice). However, copyright in the material obtained from non-Commonwealth agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly.
Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau.
Please direct requests for further information or authorisation to:
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ISBN and formal report title: see ‘Document retrieval information’ on page iii.
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DOCUMENT RETRIEVAL INFORMATION
Report No. Publication date No. of pages ISBN
200505311 29 June 2007 52 978-1-921165-04-7
Publication title
Crosswind Landing Event - Melbourne Airport, Vic. -26 October 2005 – HS-TNA, Airbus A340-642
Prepared by Reference No.
Australian Transport Safety Bureau Jun2007/DOTARS 50301 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au
Acknowledgements
Figure 3 – sourced from the Airbus A340 Aircraft Maintenance Manual
Figure 5 -© Airservices Australia 2006. Reproduced with the permission of Airservices Australia.
Appendix B – graphic reproduced with the permission of Australia Pacific Airports (Melbourne) Pty. Ltd
Appendix D – reproduced with the permission of Flight Safety Manager, Flight Safety – GSE, AIRBUS Central Entity
Abstract
At 1200 Eastern Standard Time on 26 October 2005, the outboard bead heel of the number-1 wheel tyre on the left main landing gear (MLG) of an Airbus A340-642 (A340) aircraft, registered HS-TNA, separated from the outboard rim of the wheel assembly during a landing on runway 16 at Melbourne Airport, Vic. The landing was conducted during gusting crosswind conditions.
The number-1 wheel tyre deflated immediately after the bead heel separated from the wheel rim. The tyre then partially disintegrated during the remainder of the landing roll, and the tyre tread detached from the tyre casing. Following the number-1 wheel tyre deflation, the crew maintained control of the aircraft and, apart from some minor deviations to the left and right of the runway centreline, tracked along the centreline.
The aircraft touched down with 15-degrees of yaw as a result of its handling by the flight crew. That yaw angle was greater than recommended by the aircraft manufacturer, and increased the risk of damage to the MLG at touchdown. It also increased the risk that the resultant groundslip angle of the MLG tyres would exceed the ‘saturation’ point at which they entered a fully-skidded state.
The pilot in command made dual side stick inputs during the latter stages of the approach intending to assist the copilot to maintain the attitude and trajectory of the aircraft. Those dual inputs compounded the handling difficulties being experienced by the copilot and increased the associated risks. Those risks could have been mitigated by the pilot in command taking control of the aircraft and pressing the side stick priority pushbutton at the point where he appeared to have become concerned about its attitude and trajectory, instead of making dual side stick inputs.
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THE AUSTRALIAN TRANSPORT SAFETY BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent multi-modal Bureau within the Australian Government Department of Transport and Regional Services. ATSB investigations are independent of regulatory, operator or other external bodies.
The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. Accordingly, the ATSB also conducts investigations and studies of the transport system to identify underlying factors and trends that have the potential to adversely affect safety.
The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and, where applicable, relevant international agreements. The object of a safety investigation is to determine the circumstances in order to prevent other similar events. The results of these determinations form the basis for safety action, including recommendations where necessary. As with equivalent overseas organisations, the ATSB has no power to implement its recommendations.
It is not the object of an investigation to determine blame or liability. However, it should be recognised that an investigation report must include factual material of sufficient weight to support the analysis and findings. That material will at times contain information reflecting on the performance of individuals and organisations, and how their actions may have contributed to the outcomes of the matter under investigation. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. While the Bureau issues recommendations to regulatory authorities, industry, or other agencies in order to address safety issues, its preference is for organisations to make safety enhancements during the course of an investigation. The Bureau prefers to report positive safety action in its final reports rather than make formal recommendations. Recommendations may be issued in conjunction with ATSB reports or independently. A safety issue may lead to a number of similar recommendations, each issued to a different agency.
The ATSB does not have the resources to carry out a full cost-benefit analysis of each safety recommendation. The cost of a recommendation must be balanced against its benefits to safety, and transport safety involves the whole community. Such analysis is a matter for the body to which the recommendation is addressed (for example, the relevant regulatory authority in aviation, marine or rail in consultation with the industry).