Country
Crash of an Airbus A300-622R in Taipei: 203 killed
Date & Time:
Feb 16, 1998 at 2006 LT
Registration:
B-1814
Survivors:
No
Schedule:
Denpasar - Taipei
MSN:
578
YOM:
1990
Flight number:
CI676
Crew on board:
14
Crew fatalities:
Pax on board:
182
Pax fatalities:
Other fatalities:
Total fatalities:
203
Aircraft flight hours:
20193
Aircraft flight cycles:
8800
Circumstances:
Following an uneventful flight from Denpasar-Ngurah Rai Airport, the aircraft was approaching Taipei-Taoyuan Airport by night and marginal weather conditions with a limited visibility of 2,400 feet, an RVR of 3,900 feet and 300 feet broken ceiling, 3,000 feet overcast. On final approach to runway 05L in light rain and fog, at the altitude of 1,515 feet, the aircraft was 1,000 feet too high on the glide so the captain decided to initiate a go-around procedure. The automatic pilot system was disconnected but for unknown reasons, the crew failed to correct the pitch up attitude. The aircraft passed the runway threshold at an altitude of 1,475 feet, pitched up go around thrust was applied. The aircraft rapidly pitched up, reaching +35° and climbed through 1,723 feet at an airspeed of 134 knots. The gear had just been raised and the flaps set to 20°. The aircraft continued to climb to 2,751 feet when the speed dropped to 43 knots. At this point, the aircraft stalled, entered an uncontrolled descent (pitched down to 44,65°). The crew was apparently able to regain control when the aircraft rolled to the right at an angle of 20° 2-3 seconds prior to final impact. The aircraft struck the ground 200 feet to the right of the runway 05L centerline and 3,7 km from its threshold and eventually crashed on 12 houses. The aircraft disintegrated on impact and all 196 occupants were killed, among them five US citizens, one Indonesian and one French. On the ground, seven people were killed.
Probable cause:
The following factors were identified:
- Wrong approach configuration as the aircraft was too high on the glide,
- Poor crew coordination,
- The crew failed to comply with published procedures,
- Poor crew training,
- The crew failed to correct the pitch up attitude during the go-around procedure,
- Lack of visibility due to night, rain and fog.
- Wrong approach configuration as the aircraft was too high on the glide,
- Poor crew coordination,
- The crew failed to comply with published procedures,
- Poor crew training,
- The crew failed to correct the pitch up attitude during the go-around procedure,
- Lack of visibility due to night, rain and fog.
![](/sites/default/files/crash/images/B-1814.jpg)
![](/sites/default/files/crash/images/B-1814-3.jpg)
![](/sites/default/files/crash/images/B-1814-1.jpg)
![](/sites/default/files/crash/images/B-1814-2.jpg)
Crash of an Airbus A300B4-600 in Medan: 234 killed
Date & Time:
Sep 26, 1997 at 1334 LT
Registration:
PK-GAI
Survivors:
No
Schedule:
Jakarta - Medan
MSN:
214
YOM:
1982
Flight number:
GA152
Crew on board:
12
Crew fatalities:
Pax on board:
222
Pax fatalities:
Other fatalities:
Total fatalities:
234
Captain / Total hours on type:
782.00
Copilot / Total hours on type:
709
Aircraft flight hours:
27095
Aircraft flight cycles:
16593
Circumstances:
On 26 September 1997 the Garuda Indonesia Flight GA 152, PK-GAI Airbus A300-B4 departed from the Jakarta Soekarno-Hatta International Airport at 04:41 UTC. The aircraft was on a regular scheduled passengers flight to Polonia International Airport of Medan, North Sumatera with estimated time of arrival 06:41 UTC. Flight GA 152 was flying under Instrument Flight Rules during daylight. Before the flight, the flight crew reported to Garuda Indonesia Flight Operations office to receive flight briefings, including Notice to Airmen (NOTAM), weather conditions and forecast en-route, at destination and alternate airports, as well as the flight plan. The NOTAM stated that the MDN VOR was overdue for maintenance and advised to use the facility ‘with caution', although the Medan VOR has been calibrated with both ground and flight calibration on 14 June 1997 and valid until 14 December 1997, the use of Medan VOR was classified as “restricted due to radial course alignment at 270 degrees radial”. At the time of flight-planning, the visibility from Medan TAFOR (26 September 1997, 00.00 UTC – 24.00 UTC) was 1000 meters in smoke. The dispatcher stated that he received information through company channel that the actual visibility at Medan was 400 meters in smoke, which was below the minimum required visibility for runway 05 ILS of 800 meters. At 06:12:51 GA 152 requested a descend clearance to Medan Control. Medan Control cleared the aircraft to descend to FL 150. On passing FL 150, GA 152 was informed that the aircraft was in radar contact, at a distance of 43 nautical miles from MDN VOR/DME. The crew was then instructed to descend to 3000 ft for a landing on Runway 05 and to reduce the speed to 220 knots to allow Bouraq flight BO 683 to takeoff from Runway 23 at 06:20:47. GA152 requested a speed of 250 knots below 10000 feet which was approved. At 6:27:12, Medan Approach instructed GA 152 to maintain altitude on heading to Medan VOR/DME. GA 152 confirmed this instruction at 6:27:21. At 06:27:50 Medan Approach transmitted an instruction “Merpati one five two you er .. turn left heading two four zero vectoring for intercept ILS runway zero five from the right side traffic now er.. rolling”. There was no response by any aircraft to this transmission. At 06:28:06 Medan Approach enquired “Indonesia one five two do you read”. GA 152 asked the ATC to repeat the message. At 06:28:13 Medan Approach instructed GA 152 to “Turn left heading er.. two four zero two three five now vectoring for intercept ILS runway zero five”. This instruction was acknowledged by GA 152. At 06:28:52 the PIC asked the Medan Approach whether the aircraft was clear from the mountainous area northwest from Medan. This was confirmed by Medan Approach, and GA 152 was instructed to continue turning left on heading 215°M. At 06:29:41, GA 152 was instructed to descend to 2000 ft and the crew acknowledged it. Recorded FDR information indicates the aircraft is essentially wings level, heading approx 225M° and passing through 3000 feet on descent. Then at 06:30:04 GA 152 was instructed to turn right heading 046 degrees, and to report when established on the localizer. This was acknowledged by GA 152, but misread the heading “Turn right heading zero four zero Indonesia one five two check established”. Meanwhile recorded FDR information indicates the aircraft commences a roll to the left, heading reducing indicating a left turn and passing through 2600 feet on descent. At 6:30:33, while turning left, First Officer reminded the Captain to turn right. Two seconds later GA 152 queried Medan Approach whether the turn is to the left or to the right onto heading 046 degrees. At 6:30:39 Medan Approach replied “Turning right Sir”, which was acknowledged by GA 152. FDR data shows that the aircraft began to roll to wings level. At 06:30:51 Medan Approach asked whether GA 152 was making a left turn or a right turn. Recorded FDR information indicates the aircraft was wings level and rolling to the right, heading approximately 135°M and increasing, at 2035 feet pressure altitude on descent. GA 152 responded “We are turning right now”. At 06:31:05 Medan Approach instructed GA 152 to continue turning left. Recorded FDR information showed that at this point the aircraft had passed the assigned 2000 ft altitude and continued descending. GA 152 replied “Err...confirm turning left we are starting to turn right now”. During the interview, the controller stated that it was around this time that he recognized that the aircraft went below the required altitude (1800 ft and descending). Recorded FDR information indicates the aircraft reduced right roll from approx 24.3º to 10.2° and then rolled right again to approx 25°, while heading was increasing indicated a right turn was being maintained and the aircraft continued descending. At 06:31:32 the sound of tree impact is recorded. The elevation of the initial impact with the trees was at about 1550 ft above sea level. The final impact on the bottom of a ravine approximately 600 meters from the first tree impact destroyed the aircraft, and 234 people on board of the aircraft perished. There were no ground casualties.
Probable cause:
There was confusion regarding turning direction of left turn instead of right turn at critical position during radar vectoring that reduced the flight crew’s vertical awareness while they were concentrating on the aircraft’s lateral changes. These caused the aircraft to continue descending below the assigned altitude of 2,000 feet and hit treetops at 1,550 feet above mean sea level.
Final Report:
![](/sites/default/files/crash/images/PK-GAI.jpg)
![](/sites/default/files/crash/images/PK-GAI-1.jpg)
![](/sites/default/files/crash/images/PK-GAI-2.jpg)
![](/sites/default/files/crash/images/PK-GAI-3.jpg)
![](/sites/default/files/crash/images/PK-GAI-4.jpg)
![](/sites/default/files/crash/images/PK-GAI-5.jpg)
![](/sites/default/files/crash/images/PK-GAI-6.jpg)
![](/sites/default/files/crash/images/PK-GAI-7.jpg)
![](/sites/default/files/crash/images/PK-GAI-8.jpg)
Crash of an Airbus A300B4-622R in Jeju
Date & Time:
Aug 10, 1994 at 1122 LT
Registration:
HL7296
Survivors:
Yes
Schedule:
Seoul - Jeju
MSN:
583
YOM:
1990
Flight number:
KE2033
Crew on board:
8
Crew fatalities:
Pax on board:
152
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The descent and approach to Jeju Airport was completed in poor weather conditions with turbulences and heavy rain falls as typhoon 'Doug' was passing over. On final approach, flaps were deployed at 15°/20° as the captain was suspecting windshear and microburst conditions. Twice, the copilot informed the captain about the approach speed of 147 knots which was acknowledged. The captain continued the approach but too high on the glide, the aircraft landed too far down the runway, about 1,773 metres past its threshold. On a wet runway surface, the aircraft was unable to stop within the remaining distance (1,227 metres remaining), overran at a speed of 104 knots and eventually collided with a concrete wall and military barracks, bursting into flames. All 160 occupants were quickly evacuated, among them seven were slightly injured.
Probable cause:
Wrong approach configuration on part of the crew who completed the approach at an excessive speed and too high on the glide. Investigations did not confirm any windshear or microburst conditions. The crew failed to initiate a go-around procedure.
![](/sites/default/files/import/uploads/1994/08/HL7296.jpg)
![](/sites/default/files/crash/images/HL7296-4.jpg)
![](/sites/default/files/crash/images/HL7296-2.jpg)
![](/sites/default/files/crash/images/HL7296-3.jpg)
![](/sites/default/files/crash/images/HL7296-1.jpg)
Crash of an Airbus A300-622R in Nagoya: 264 killed
Date & Time:
Apr 26, 1994 at 2015 LT
Registration:
B-1816
Survivors:
Yes
Schedule:
Taipei - Nagoya
MSN:
580
YOM:
1990
Flight number:
CI140
Crew on board:
15
Crew fatalities:
Pax on board:
256
Pax fatalities:
Other fatalities:
Total fatalities:
264
Captain / Total hours on type:
1350.00
Copilot / Total hours on type:
1033
Aircraft flight hours:
8550
Aircraft flight cycles:
3910
Circumstances:
China Airlines' Flight 140 (from Taipei International Airport to Nagoya Airport), B-1816, took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 (hereinafter all times shown are Coordinated Universal Time, unless otherwise specified), canying a total of 271 persons consisting of 2 flight crew members, 13 cabin crew members and 256 passengers (including 2 infants). The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:
Flight rule: IFR, Aerodrome of departure: Taipei International Airport, Destination Aerodrome: Nagoya Airport, Cruising speed: 465 knots, Level: FL330, Route: A1 SUCJAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodrome: Tokyo International Airport.
DFDR shows that the aircraft reached FL330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.
DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:
The aircraft which was controlled by the FIO, while cruising at FL330 was cleared at 1047:35 to descend to FL210 by the Tokyo Area Control Center and commenced descent. For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the F/O on approach and landing.
At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.
At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 010". Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower. After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 feet pressure altitude, AP No.2 was engaged during climb, cruise and descent.
At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No. 1 was also engaged. Later, at 1111:36, both AP No. 1 and 2 were disengaged by the FIO. The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots. Under manual control, the aircraft continued normal LS approach.
At 1114:05, however, while crossing approximately 1,070 feet pressure altitude, the F/O inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust. The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 feet pressure altitude (at a point some 5.5 km from the Runway). The CAP instructed the F/O to correct the descent path which had become too high. The F/O acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path. During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
At 1114: 18, both AP No.2 and No. 1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 feet pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from -5.3" to -12.3", which is close to the maximum nose-up limit. The THS remained at -12.3" until 1115: 1 1. During this period, the elevator was continually moved in the nose-down direction. In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 feet pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the FIO that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.
At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The F/O reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the TI-IS decreased from -12.3" to -7.4", and SLATS/FLAPS were retracted from 30/40 to 15/15 after the F/O reported "Go Around to Nagoya Tower.
At 1115:17, the GPWS activated Mode 5 warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.
At 1115:31, after reaching about 1,730 feet pressure altitude (about 1,790 feet radio altitude), the aircraft lowered its nose and began to dive.
At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall warning sounded from 1115:40 to the time of crash.
At about 1115:45, the aircraft crashed into the landing zone close to the El taxiway. The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45. Seven passengers were seriously injured and all 264 other occupants were killed.
Flight rule: IFR, Aerodrome of departure: Taipei International Airport, Destination Aerodrome: Nagoya Airport, Cruising speed: 465 knots, Level: FL330, Route: A1 SUCJAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodrome: Tokyo International Airport.
DFDR shows that the aircraft reached FL330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.
DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:
The aircraft which was controlled by the FIO, while cruising at FL330 was cleared at 1047:35 to descend to FL210 by the Tokyo Area Control Center and commenced descent. For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the F/O on approach and landing.
At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.
At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 010". Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower. After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 feet pressure altitude, AP No.2 was engaged during climb, cruise and descent.
At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No. 1 was also engaged. Later, at 1111:36, both AP No. 1 and 2 were disengaged by the FIO. The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots. Under manual control, the aircraft continued normal LS approach.
At 1114:05, however, while crossing approximately 1,070 feet pressure altitude, the F/O inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust. The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 feet pressure altitude (at a point some 5.5 km from the Runway). The CAP instructed the F/O to correct the descent path which had become too high. The F/O acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path. During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
At 1114: 18, both AP No.2 and No. 1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 feet pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from -5.3" to -12.3", which is close to the maximum nose-up limit. The THS remained at -12.3" until 1115: 1 1. During this period, the elevator was continually moved in the nose-down direction. In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 feet pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the FIO that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.
At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The F/O reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the TI-IS decreased from -12.3" to -7.4", and SLATS/FLAPS were retracted from 30/40 to 15/15 after the F/O reported "Go Around to Nagoya Tower.
At 1115:17, the GPWS activated Mode 5 warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.
At 1115:31, after reaching about 1,730 feet pressure altitude (about 1,790 feet radio altitude), the aircraft lowered its nose and began to dive.
At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall warning sounded from 1115:40 to the time of crash.
At about 1115:45, the aircraft crashed into the landing zone close to the El taxiway. The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45. Seven passengers were seriously injured and all 264 other occupants were killed.
Probable cause:
While the aircraft was making an ILS approach to Runway 34 of Nagoya Airport, under manual control by the F/O, the F/O inadvertently activated the GO lever, which changed the FD (Flight Director) to GO AROUND mode and caused a thrust increase. This made the aircraft deviate above its normal glide path. The APs were subsequently engaged, with GO AROUND mode still engaged. Under these conditions the FIO continued pushing the control wheel in accordance with the CAP'S instructions. As a result of this, the THS (Horizontal Stabilizer) moved to its full nose-up position and caused an abnormal out-of-trim situation. The crew continued approach, unaware of the abnormal situation. The AOA increased. The Alpha Floor function was activated and the pitch angle increased. It is considered that, at this time, the CAP (who had now taken the controls), judged that landing would be difficult and opted for go-around. The aircraft began to climb steeply with a high pitch angle attitude. The CAP and the FIO did not carry out an effective recovery operation, and the aircraft stalled and crashed.
The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident:
1. The F/O inadvertently triggered the Go lever. It is considered that the design of the GO lever contributed to it: normal operation of the thrust lever allows the possibility of an inadvertent triggering of the GO lever.
2. The crew engaged the APs while GO AROUND mode was still engaged, and continued approach.
3. The F/O continued pushing the control wheel in accordance with the CAP'S instructions, despite its strong resistive force, in order to continue the approach.
4. The movement of the THS conflicted with that of the elevators, causing an abnormal out-of-trim situation.
5. There was no warning and recognition function to alert the crew directly and actively to the onset of the abnormal out-of-trim condition.
6. The CAP and FIO did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM (Flight Crew Operating Manual) prepared by the aircraft manufacturer contributed to this.
7. The CAP'S judgment of the flight situation while continuing approach was inadequate, control take-over was delayed, and appropriate actions were not taken.
8. The Alpha-Floor function was activated; this was incompatible with the abnormal out-of-trim situation, and generated a large pitch-up moment. This narrowed the range of selection for recovery operations and reduced the time allowance for such operations.
9. The CAP'S and F/O's awareness of the flight conditions, after the PIC took over the controls and during their recovery operation, was inadequate respectively.
10. Crew coordination between the CAP and the FiO was inadequate.
11. The modification prescribed in Service Bulletin SB A300-22-6021 had not been incorporated into the aircraft.
12. The aircraft manufacturer did not categorise the SB A300-22-602 1 as "Mandatory", which would have given it the highest priority. The airworthiness authority of the nation of design and manufacture did not issue promptly an airworthiness directive pertaining to implementation of the above SB.
The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident:
1. The F/O inadvertently triggered the Go lever. It is considered that the design of the GO lever contributed to it: normal operation of the thrust lever allows the possibility of an inadvertent triggering of the GO lever.
2. The crew engaged the APs while GO AROUND mode was still engaged, and continued approach.
3. The F/O continued pushing the control wheel in accordance with the CAP'S instructions, despite its strong resistive force, in order to continue the approach.
4. The movement of the THS conflicted with that of the elevators, causing an abnormal out-of-trim situation.
5. There was no warning and recognition function to alert the crew directly and actively to the onset of the abnormal out-of-trim condition.
6. The CAP and FIO did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM (Flight Crew Operating Manual) prepared by the aircraft manufacturer contributed to this.
7. The CAP'S judgment of the flight situation while continuing approach was inadequate, control take-over was delayed, and appropriate actions were not taken.
8. The Alpha-Floor function was activated; this was incompatible with the abnormal out-of-trim situation, and generated a large pitch-up moment. This narrowed the range of selection for recovery operations and reduced the time allowance for such operations.
9. The CAP'S and F/O's awareness of the flight conditions, after the PIC took over the controls and during their recovery operation, was inadequate respectively.
10. Crew coordination between the CAP and the FiO was inadequate.
11. The modification prescribed in Service Bulletin SB A300-22-6021 had not been incorporated into the aircraft.
12. The aircraft manufacturer did not categorise the SB A300-22-602 1 as "Mandatory", which would have given it the highest priority. The airworthiness authority of the nation of design and manufacture did not issue promptly an airworthiness directive pertaining to implementation of the above SB.
Final Report:
![](/sites/default/files/crash/images/B-1816.jpg)
![](/sites/default/files/crash/images/B-1816-1.jpg)
![](/sites/default/files/crash/images/B-1816-2.jpg)
![](/sites/default/files/crash/images/B-1816-3.jpg)
![](/sites/default/files/crash/images/B-1816-4.jpg)
![](/sites/default/files/crash/images/B-1816-5.jpg)
![](/sites/default/files/crash/images/B-1816-6.jpg)
![](/sites/default/files/crash/images/B-1816-7.jpg)
![](/sites/default/files/crash/images/B-1816-8.jpg)
![](/sites/default/files/crash/images/B-1816-9.jpg)
![](/sites/default/files/crash/images/B-1816-10.jpg)
![](/sites/default/files/crash/images/B-1816-11.jpg)