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􀀴 For “funereal” purposes
􀂃 To put losses behind
􀂃 To reassert trust and faith in the system
􀂃 To resume normal activities
􀂃 To fulfil political purposes
􀀴 For improved system reliability
􀂃 To learn about system vulnerability
􀂃 To develop strategies for change
􀂃 To prioritize investment of resources
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Investigation
􀀴 The facts
􀂃 An old generation four engine turboprop freighter flies
into severe icing conditions.
􀂃 Engines 2 and 3 flameout as consequence of ice
accretion, and seven minutes later engine 4 fails.
􀂃 The flight crew manages to re-start engine number 2.
􀂃 Electrical load shedding is not possible, and the
electrical system reverts to battery power.
􀂃 ...
A project supported by AIRBUS and the CAAC
June 2007
􀀴 ... The facts
􀂃 While attempting to conduct an emergency landing, all
electrical power is lost.
􀂃 All that is left to the flight crew is the self-powered
standby gyro, a flashlight and the self-powered engine
instruments.
􀂃 The flight crew is unable to maintain controlled flight,
and the aircraft crashes out of control.
Investigation
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
􀀴 Findings
􀂃 Crew did not use the weather radar.
􀂃 Crew did not consult the emergency check-list.
􀂃 Demanding situation requiring decisive thinking and
clear action.
􀂃 Conditions exceeded certification condition for the
engines.
􀂃 Did not request diversion to a closer aerodrome.
􀂃 ...
Investigation
A project supported by AIRBUS and the CAAC
June 2007
􀀴 ... Findings
􀂃 Crew did not use correct phraseology to declare
emergency.
􀂃 Poor crew resource management (CRM).
􀂃 Mismanagement of aircraft systems.
􀂃 Emergency checklist – presentation and visual
information.
􀂃 Flight operations internal quality assurance
procedures.
Investigation
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
􀀴 Causes
􀂃 Multiple engine failures
􀂃 Incomplete performance of emergency drills
􀂃 Crew actions in securing and re-starting engines
􀂃 Drag from unfeathered propellers
􀂃 Weight of ice
􀂃 Poor CRM
􀂃 Lack of contingency plans
􀂃 Loss of situational awareness
Investigation
A project supported by AIRBUS and the CAAC
June 2007
􀀴 Safety recommendations
􀂃 Authority should remind pilots to use correct
phraseology.
􀂃 Authority should research into most effective form of
presentation of emergency reference material.
Investigation
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Investigation
􀀴 The facts
􀂃 An old generation two engine turboprop commuter
aircraft engaged in a regular passenger transport
operation is conducting a non-precision approach in
marginal weather conditions in an uncontrolled, nonradar,
remote airfield.
􀂃 The flight crew conducts a straight-in approach, not
following the published approach procedure.
􀂃 …
A project supported by AIRBUS and the CAAC
June 2007
􀀴 ... The facts
􀂃 Upon reaching MDA, the flight crew does not acquire
visual references.
􀂃 The flight crew abandons MDA without having
acquired visual references to pursue the landing.
􀂃 The aircraft crashes into terrain short of the runway.
Investigation
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
􀀴 Findings
􀂃 The crew made numerous mistakes.
But
􀂃 Crew composition legal but unfavourable in view of
demanding flight conditions.
􀂃 According to company practice, pilot made a direct
approach, which was against regulations.
􀂃 …
Investigation
A project supported by AIRBUS and the CAAC
June 2007
􀀴… But
􀂃 The company had consistently misinterpreted
regulations.
　
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