Country
Crash of an Airbus A310-324 in Bucharest: 60 killed
Date & Time:
Mar 31, 1995 at 0908 LT
Operator:
Registration:
YR-LCC
Survivors:
No
Schedule:
Bangkok - Abu Dhabi - Bucharest - Brussels
MSN:
450
YOM:
1987
Flight number:
RO371
Crew on board:
11
Crew fatalities:
Pax on board:
49
Pax fatalities:
Other fatalities:
Total fatalities:
60
Captain / Total hours on type:
1735.00
Copilot / Total hours on type:
650
Aircraft flight hours:
31092
Aircraft flight cycles:
6216
Circumstances:
Tarom flight 371 was a scheduled passenger service from Bucharest Otopeni Airport (OTP) in Romania to Brussel Airport (BRU), Belgium. On board were 49 passengers and eleven crew members. The first officer was pilot flying, the captain was pilot monitoring. Following de-icing, the Airbus A310 taxied to runway 08R for departure. The flight was cleared via the Strejnic 'STJ' VOR/DME beacon and an initial climb to flight level 260. Takeoff was initiated at 09:04 hours local time. When airborne, the captain announced positive climb and co-pilot requested to retract the landing gear. At 09:07:20 the captain called the Otopeni Approach controller and received a clearance to turn left and proceed direct to STJ. The co-pilot asked the captain to select direct STJ on FMS. The captain confirmed a direct STJ selection and requested the co-pilot to move the control wheel slightly. At an altitude of 1700 feet and speed a 187 knots, with flaps 15/slats 15 and pitch angle of 17.6 degrees, the aircraft was turning left, with a bank angle of 12 degrees, flying towards STJ. At 09:07:36, when the aircraft crossed 2000 feet at 188 knots, an engine thrust asymmetry started developing with continuous decrease of the left engine thrust, approximately 1 degree TRA (throttle resolver angle)/second. At 09:07:53, when the aircraft was crossing 3300 feet altitude at 195 kts turning with a decreasing bank angle of 20 degrees, the first officer called "250 in sight" and asked the captain to retract the flaps. This was carried out. At that moment, the engine thrust asymmetry reached 14.5 TRA degrees and 0.19 for EPRs. The first officer then requested slats retraction, but this action which was not carried out by the captain. At this moment the aircraft was passing through 013 degrees magnetic heading, at 3800 feet altitude and a decreasing speed of 185 kts. The aircraft pitch angle was 16,5 degrees, decreasing, and the left bank angle was 18 degrees, also decreasing. At that time the thrust asymmetry reached was 28 TRA degrees and 0.27 for EPRs. At 09:08:02, the first officer asked the captain: "Are you all right?" The aircraft was passing through 330 degrees magnetic heading, 4200 ft altitude, a decreasing speed of 181 kts, and an increasing 17 degrees left bank angle. At 09:08:08, a noise like an uttering of pain or a metallic noise was heard. The aircraft was crossing 4460 ft altitude, 179 kts speed and an increasing bank angle of 22 degrees. At that time the engines thrust asymmetry reached 0.36 for EPRs. The bank angle continued to increase to 28 degrees and the engine thrust asymmetry reached 0.41 for EPRs. At 09:08:15, the first officer, with a stressed and agitated voice, requested engagement of autopilot no. 1. The aircraft was crossing 4620-ft altitude, continuing its turn at an increasing bank angle of 43 degrees and a steadily decreasing pitch angle of 3.5 degrees. One of the pilots attempted to engage autopilot no. 1 The aircraft started a descent with 45 degrees bank angle and the engine thrust asymmetry had reached the maximum value of 0.42 for EPRs, followed by a continuous thrust reduction of engine n°2. One second later, there was recorded autopilot disengagement followed by the aural warning a level 3 "cavalry charge" lasting several moments. From that moment on, the aircraft started diving, the speed increased and the aircraft performed a complete rotation around its roll axis. At 09:08.28, first officer cried out "THAT ONE HAS FAILED!" without any other comments. The aircraft was descending through 3600 ft at 258 kts speed and an increasing nose down pitch angle at 61.5 degrees. The aircraft continued until it impacted the ground at a nose down attitude of approximately 50 degrees pitch angle with both engines at idle power. The airplane was destroyed and all 60 occupants were sustained fatal injuries.
Probable cause:
The following factors were reported:
- Thrust asymmetry,
- Possible incapacitation of the captain,
- Insufficient corrective action from the copilot in order to cover the consequences of the first factors.
The French Ministry of Transport commented on the Romanian investigation report, stating that the pilot flying's actions that led to the loss of control could have been caused by the fact that the artificial horizon between Eastern and Western built aircraft is inverted in roll and that the first officer spent the majority of his career on Eastern-built aircraft.
- Thrust asymmetry,
- Possible incapacitation of the captain,
- Insufficient corrective action from the copilot in order to cover the consequences of the first factors.
The French Ministry of Transport commented on the Romanian investigation report, stating that the pilot flying's actions that led to the loss of control could have been caused by the fact that the artificial horizon between Eastern and Western built aircraft is inverted in roll and that the first officer spent the majority of his career on Eastern-built aircraft.
Final Report:
Crash of an Airbus A310-308 near Mezhdurechensk: 75 killed
Date & Time:
Mar 23, 1994 at 0057 LT
Operator:
Registration:
F-OGQS
Survivors:
No
Schedule:
Moscow - Hong Kong
MSN:
596
YOM:
1991
Flight number:
SU593
Crew on board:
12
Crew fatalities:
Pax on board:
63
Pax fatalities:
Other fatalities:
Total fatalities:
75
Captain / Total hours on type:
38.00
Copilot / Total hours on type:
440
Aircraft flight hours:
5375
Aircraft flight cycles:
846
Circumstances:
While cruising by night at the assigned altitude of 10,100 metres, approaching the Novokuznetsk reporting point, the captain's daughter entered the cockpit. She was allowed to sit the left-hand seat while the captain demonstrated some autopilot features, using HDG/S and NAV submodes to alter the heading. The captain's son then took the left front seat. The captain intended to demonstrate the same manoeuvre when his son asked if he could turn the control wheel. He then turned the wheel slightly (applying a force of between 8-10 kg) and held it in that position for a few seconds before returning the wheel to the neutral position. The captain then demonstrated the same features as he did to his daughter and ended by using the NAV submode to bring the aircraft back on course. As the autopilot attempted to level the aircraft at its programmed heading, it came in conflict with the inputs from the control wheel which was blocked in a neutral position. Forces on the control wheel increased to 12-13 kg until the torque limiter activated by disconnecting the autopilot servo from the aileron control linkage. The autopilot remained engaged however. The aircraft then started to bank to the right at 2,5° per second, reaching 45° when the autopilot wasn't able to maintain altitude. The A310 started buffeting, which caught the attention of the captain who told the copilot to take control while he was trying to regain his seat. The seat of the copilot was fully aft, so it took him an additional 2-3 seconds to get to the control wheel. The bank continued to 90°, the aircraft pitched up steeply with +4,8g accelerations, stalled and entered a spin. Two minutes and six seconds later the aircraft struck the ground. The aircraft disintegrated on impact and all 75 occupants were killed, among them 25 foreigners.
Probable cause:
The accident was caused by a stall, spin and impact with the ground resulting from a combination of the following factors:
1. The decision by the PIC to allow an unqualified and unauthorized outsider (his son) to occupy his duty station and intervene in the flying of the aeroplane.
2. The execution of demonstration manoeuvres that were not anticipated in the flight plan or flight situation, with the PIC operating the autopilot while not at his duty station.
3. Application by the outsider and the co-pilot of control forces that interfered with the functioning of the roll channel of the autopilot (and are not recommended in the A310 flight manual), thus overriding the autopilot and disconnecting it from the aileron control linkage.
4. The copilot and PIC failed to detect the fact that the autopilot had become disconnected from the aileron control linkage, probably because:
- The A310 instrumentation has no declutch warning. The provision of signals in accordance with the requirements of Airworthiness Standard NLGS-3, para. 8.2.7.3., and international recommended practices, could have enabled the crew to detect the disengaged autopilot in a timely manner.
- The copilot and PIC may have been unaware of the peculiarities of the declutching function and the actions to be taken in such a situation because of a lack of appropriate information in the flight manual and crew training programme;
- It was difficult for the co-pilot to detect the disengagement of the autopilot by feel, either because of the small forces on his control column or because he took changing forces to be the result of Eldar's actions;
- The PIC was away from his position and distracted by the conversation with his daughter.
5. A slight, unintentional further turn of the control wheel(s) following disengagement of the autopilot caused a right roll to develop.
6. The PIC and copilot failed to detect the excessive right bank angle, which exceeded operating limits, and were late in re-entering the aircraft control loop because their attention was focussed on determining why the aircraft had banked to the right, a manoeuvre they interpreted as entry into a holding area with either no course line or with a new (false) course line generated on the navigational display.
A strong signal indicating that the aeroplane had exceeded the allowable operating bank angle, taking account of the delay in recognizing and assessing the situation and making a decision, could in this situation have attracted the crew's attention and enabled them to detect the bank at an earlier stage.
7. The aeroplane was subjected to buffeting and high angles of attack because the autopilot continued to perform its height-keeping function even after the actuator declutched and as the right roll developed, until the pilot disconnected it by overriding its longitudinal channel.
8. Inappropriate and ineffective action on the part of the copilot, who failed to disconnect the autopilot and to push the control column forward when the buffeting occurred and the aeroplane entered an unusual attitude (high angles of attack and pitch). These actions, which caused the aeroplane to stall and spin, could have resulted from:
- the presence of an outsider in the left-hand pilot's seat and the resulting delay before the PIC re-entered the aeroplane control loop;
- the less-than-optimum working posture of the copilot, whose seat was pushed back to its rearmost position;
- the occurrence, 2 seconds following the onset of buffeting, of an unintentional pitching up of the aeroplane, which sharply increased the angle of attack and reduced lateral controllability;
- unpreparedness of the crew to act in this situation because of lack of appropriate drills in the training programme;
- temporary loss of spatial orientation in night conditions.
1. The decision by the PIC to allow an unqualified and unauthorized outsider (his son) to occupy his duty station and intervene in the flying of the aeroplane.
2. The execution of demonstration manoeuvres that were not anticipated in the flight plan or flight situation, with the PIC operating the autopilot while not at his duty station.
3. Application by the outsider and the co-pilot of control forces that interfered with the functioning of the roll channel of the autopilot (and are not recommended in the A310 flight manual), thus overriding the autopilot and disconnecting it from the aileron control linkage.
4. The copilot and PIC failed to detect the fact that the autopilot had become disconnected from the aileron control linkage, probably because:
- The A310 instrumentation has no declutch warning. The provision of signals in accordance with the requirements of Airworthiness Standard NLGS-3, para. 8.2.7.3., and international recommended practices, could have enabled the crew to detect the disengaged autopilot in a timely manner.
- The copilot and PIC may have been unaware of the peculiarities of the declutching function and the actions to be taken in such a situation because of a lack of appropriate information in the flight manual and crew training programme;
- It was difficult for the co-pilot to detect the disengagement of the autopilot by feel, either because of the small forces on his control column or because he took changing forces to be the result of Eldar's actions;
- The PIC was away from his position and distracted by the conversation with his daughter.
5. A slight, unintentional further turn of the control wheel(s) following disengagement of the autopilot caused a right roll to develop.
6. The PIC and copilot failed to detect the excessive right bank angle, which exceeded operating limits, and were late in re-entering the aircraft control loop because their attention was focussed on determining why the aircraft had banked to the right, a manoeuvre they interpreted as entry into a holding area with either no course line or with a new (false) course line generated on the navigational display.
A strong signal indicating that the aeroplane had exceeded the allowable operating bank angle, taking account of the delay in recognizing and assessing the situation and making a decision, could in this situation have attracted the crew's attention and enabled them to detect the bank at an earlier stage.
7. The aeroplane was subjected to buffeting and high angles of attack because the autopilot continued to perform its height-keeping function even after the actuator declutched and as the right roll developed, until the pilot disconnected it by overriding its longitudinal channel.
8. Inappropriate and ineffective action on the part of the copilot, who failed to disconnect the autopilot and to push the control column forward when the buffeting occurred and the aeroplane entered an unusual attitude (high angles of attack and pitch). These actions, which caused the aeroplane to stall and spin, could have resulted from:
- the presence of an outsider in the left-hand pilot's seat and the resulting delay before the PIC re-entered the aeroplane control loop;
- the less-than-optimum working posture of the copilot, whose seat was pushed back to its rearmost position;
- the occurrence, 2 seconds following the onset of buffeting, of an unintentional pitching up of the aeroplane, which sharply increased the angle of attack and reduced lateral controllability;
- unpreparedness of the crew to act in this situation because of lack of appropriate drills in the training programme;
- temporary loss of spatial orientation in night conditions.
Final Report:
