PO Box 213, N-2001 LILLESTRØM Telephone: REP: Telefax: Date: 21 March PDF


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PO Box 213, N-2001 LILLESTRØM Telephone: REP: Telefax: Date: 21 March 2002 PRELIMINARY REPORT ON A SERIOUS INCIDENT WITH TF-FIO, ICELANDAIR FI JANUARY 2002 AT OSLO AIRPORT GARDERMOEN All information in this report is incomplete and subject to change as the investigation continuous. Only the final report will represent the complete investigation and be the official document All times given in this report is local time (UTC + 1), if not otherwise stated. Aircraft -type & reg.: Boeing , TF-FIO -year of man.: engines: RR RB E4 Radio call sign: FI-315 Date and time: January at 0949 hrs UTC Location: RWY 01L at Oslo airport Gardermoen Type of occurrence: Serious aircraft incident Type of flight: Scheduled commercial flight operation Weather cond.: METAR 0950Z: KT FZDZ BR FEW 001 SCT 002 BKN 003 M04/M04 Q0985 TEMPO FZDZ BR VV002= Light cond.: Daylight Flight cond.: IMC Flight plan: IFR No. of persons onb. : 75 passengers and a crew of 7 Injuries: None Aircraft damage: None Other damage: None Commander -sex/age: Male, age 43 years -licence: ATPL -fl. experience: Total flight time hrs, hrs on B757 Information sources: Commanders Voyage Report, First Officers Flight Occurrence Report, the company s Standard Operating Procedure (SOP), Flight Recorder Data (FDR), Senior Cabin Attendants report, taped communication between the aircraft and Gardermoen TWR, radar readout and several passenger reports. The Aircraft Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board s task to apportion blame or liability. Use of this report for any other purpose than for flight safety should be avoided. Aircraft Accident Investigation Board, Norway 2 FACTUAL INFORMATION A scheduled flight, a Boeing B757 with the registration TF-FIO from Icelandair with flight number FI-315, departed Keflavik (BIKF) airport at 0735 UTC for Oslo airport Gardermoen (ENGM) on 22 January The flight was dispatched from BIKF with the following equipment inoperative: Right ILS, right GPS and center autopilot. The flight was uneventful until the approach to ENGM. Take-off weight from BIKF was kg, and the landing weight at ENGM was kg. Both weights are within the normal limitations. The Commander was the flying pilot (PF) and the First Officer performed the duties of non-flying pilot (NFP). At about 200 NM from ENGM the First Officer noted down the ATIS for ENGM from 0920 UTC which stated that RWY 01R was in use. The Commander planned for a practice CAT II approach. Instruments were set and the approach was briefed according to Icelandair Standard Operating Procedure (SOP). The crew received later clearance for descent and SIG 2E arrival. (See Appendix no. 1 = AIP NORGE/NORWAY AD 2 ENGM 4 16 and 4 15.) During the descent FI-315 was cleared direct to SONER with free speed below FL 100. The commander slowed the aircraft speed down to approx. 240 kt. During the descent the crew was informed from ATC that RWY in use at ENGM was changed to RWY 01L. This is not a CAT II APP. The crew did a new approach briefing for this RWY. The aircraft was high on the approach profile and the Commander used speed brakes. The ATC cleared FI- 315 direct to NDB Solberg (SLB). (See Appendix no. 2: AIP NORGE/NORWAY AD 2 ENGM 5 1.) During the descent the First Officer as NFP identified left and center ILS and the NDB SLB. Approach Control cleared FI-315 to ft and informed the crew they could expect inbound turn on the localizer (LLZ) in 8 NM. At that point FI-315 was 10 NM from NDB SLB. The aircraft was slowed down to 220 KT, flaps were extended and landing gear was selected down. Almost overhead NDB SLB the crew received clearance to intercept the LLZ. The intercept angle was approx. 90 o. Approach mode was selected on the Mode Control Panel (MCP). This late inbound turn caused a marked overshoot of the LLZ due to the limitations of the Autopilot (AP). The AP corrected to the left to intercept again. At this time FI-315 was cleared down to ft and this altitude was set on the MCP. When the aircraft finally was established on the LLZ it was at least 1 dot high on the Glide Path (G/P). Flaps 20 o was set with appropriate speed selection. The descent and initial approach was made in strong tailwind. When established on the LLZ at ft, the tailwind velocity was approx. 40 kt. The crew was not informed by the ATC about the strong tailwind on final. The wind on the ground was light from the North. The Commander doubted that the AP in AUTO mode could capture the GP, he therefore disconnected both AP's and the Autothrottle (AT) with the thumb-switches in order to manually capture the GP from above. Shortly there after the Commander informed the first officer that raw data information on his ADI and HSI were lost. He therefore reduced the rate of descent. The raw data signals on his panel came in and disappeared again. At this Aircraft Accident Investigation Board, Norway 3 time the Commander considered the flight to be unstabilized and that a safe landing could not be made. He therefore announced and initiated Go-Around (GA). The GA was initiated with GA thrust and attitude by auto GA mode and flaps 20 o. When a positive rate of climb was reached, the landing gear was retracted. SOP calls for GA altitude to be set on MCP when stabilized on GP in the approach. As the aircraft was never stabilized on GP, ft was on MCP, altitude capture occurred almost immediately, causing throttles to retard to idle as existing speed was higher than the speed selected on MCP, and the flight Director (FD) commanded level off at ft. Flaps 20 o was maintained during the GA. The aircraft had in the meantime climbed to a higher altitude (FDR =3 735 ft). The FD pitch bar therefore commanded max pitch down to get the aircraft back to ft. The First Officer called for bug up (to set the flaps up manoeuvring speed) to set the airspeed on the air speed indicator, and the Commander pushed on the Flight Level Change Switch (FLCH) button to break the altitude lock on. At this time the speed was dropping and the Commander pushed the flight controls aggressively forward (FDR = -0,60 G ), which with the combined effect of idle thrust changed the aircraft attitude to a severe nose down attitude. (FDR max pitch angle = -49 o.) The aircraft started a rapid descent. The Commander pulled back at the controls, disengaged the A/T again with the thumbswitch and manually put the throttles full forward. The first officer, who at this time became concerned about the manoeuvring of the aircraft, simultaneously pulled hard back on the controls. The descent was arrested at an altitude above ground of 321 ft and with a positive maximum G of 3,58. The aircraft now entered a steep climb (FDR max pitch angle = +37 o ) with full engine thrust. Again abrupt flight control inputs was made when the aircraft was levelled off at ft. The speed limit for flaps 20 o was exceeded. The incident from the start of the GA until established at ft lasted approx. 3 minutes. When established at ft the appropriate selections were made on the MCP. The AP was engaged. The First officer reported the GA to the Approach Control, which gave FI-315 vectors for a new approach. When established on final the Commanders raw data disappeared again, and he handed over the control of the aircraft to the First Officer who landed the aircraft at 1002 UTZ. The Commander was not aware of the fact that the aircraft could have been overstressed. The flight continued to Stockholm airport Arlanda and later on to Iceland. The flights were uneventful and all systems worked normally. The aircraft, TF-FIO, continued operating until 25 th of January when a C-check was started on the aircraft. The aircraft was released on the 7 th of February, and was flying on scheduled flights until 13 th of March when the Boeing Company recommended further inspections after valuating the incident s data from the FDR. The morning after the incident, Icelandair informed AAIB Iceland, describing the occurrence as an upset after a GA at Gardermoen. AAIB Iceland informed AAIB/N the same morning that an occurrence had taken place at Gardermoen January 22. The seriousness of the incident was not evident, and AAIB/N did not start an investigation, at Aircraft Accident Investigation Board, Norway 4 that time. On the 31 st of January AAIB/N received information about the incident indicating the necessity to start an investigation. AAIB Iceland was informed and they appointed an accredited representative. Later AAIB/N received letters from concerned passengers requesting the incident to be investigated. AAIB/N will continue the investigation of this incident. SAFETY RECOMMENDATIONS AAIB/N recommend: The company should review the operational procedure for the Boeing B757 regarding aborted approaches. The company should also check if the flight crew training covers an unstabilized approach followed by a GA. The company should consider reviewing its procedures of informing the passengers after unwanted occurrences. 3 Appendixes: AIP NORGE Aircraft Accident Investigation Board, Norway 5 Aircraft Accident Investigation Board, Norway 6 Aircraft Accident Investigation Board, Norway 7
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