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時間:2010-08-14 20:48來源:藍天飛行翻譯 作者:admin
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unsuccessful due to unidentifiable reasons.
1.12. Wreckage and Impact Information
Not applicable.
1.13. Medical and Pathological Information
1.13.1. The PIC, Co-pilot and the riding engineer were not injured in the
accident.
1.13.2. The entire cabin crew, comprising twelve female flight attendants,
sustained various degrees of injuries and were sent to hospital after
landing. Two flight attendants sustained serious injuries involving
bone fracture and joint dislocation. They were hospitalized for six
and seven weeks respectively. Ten flight attendants received
treatment for minor injuries, eight of whom were released from
hospital on the same day, while the other two were discharged after
treatment over the following two days.
1.13.3. Three of the 236 passengers were sent to hospital for examination.
Only one of them required treatment. They were all discharged
from hospital on the same day.
22
1.14. Fire
There was no fire.
1.15. Survival Aspects
1.15.1. All crew and passengers survived the accident.
1.15.2. Upon the FSBS being selected ON shortly before the turbulence
encounter, the cabin crew had checked to ensure that the
passengers had fastened their seat belts and, as a result, the
majority of the passengers sustained no injury. All twelve cabin
attendants were serving meals and were not seated at the time of
the accident. During the period of the severe turbulence encounter,
the aircraft experienced a series of rapid changes in positive and
negative ‘G’ forces. The cabin attendants tried to secure
themselves by holding onto fixtures inside the cabin. Those who
did not manage to do so were thrown into the air, some hitting their
heads against the ceiling panels, then crashing to the floor. The
two cabin attendants who sustained the most serious injuries were
working at the rear galley at the time.
1.15.3. On being notified of the accident, ground emergency units
proceeded to the airport, standing-by to meet the aircraft on arrival.
The company arranged extra ground staff at the airport to assist the
injured crew after landing. Five ambulances and three helicopters
were deployed to transport casualties to the hospitals.
23
1.16. Test and Research
The DFDR data was sent to the aircraft manufacturer for analysis in order to
determine if the aircraft performed normally as per design. It was also noted
that during the initial period of the turbulence encounter, when the Autopilot
was disconnected, the elevator angle changed momentarily from 0º to 7.4º
without any input from the pilots. The aircraft manufacturer was requested
to verify that this change in elevator angle was normal.
1.17. Organizational and Management Information
1.17.1. Crew Resources Management (CRM)
The operator conducts separate CRM courses for flight crew and
cabin crew. While the theme of these two CRM courses such as
teamwork, crew behaviour, communication and co-ordination are
similar, their contents and formats are quite different. The CRM
course for the flight crew is a two-day course that mainly features
the review of aircraft accidents/incidents, their causal factors and
the lessons learnt. The one-day CRM course for the cabin crew
mainly focuses on the practical aspects of in-flight handling of
critical situations e.g. seeking assistance from passengers, conflict
management and communications with flight crew.
24
1.17.2. Training Records and Training Material
1.17.2.1. According to the flight crew training records, the PIC
last completed his CRM training on 27 July 1998.
There was no record of recurrent CRM training having
been conducted since then.
1.17.2.2. The Co-pilot was recruited as a Second Officer in
November 2002. He had not attended any local CRM
training course prior to the day of the accident. This is
acceptable under the Air Operator’s Certificate
Requirements Document (CAD 360), which only
requires flight crew to complete CRM training within
12 months of commencing airline operations.
1.17.2.3. Before conversion to Airbus A330, the PIC had been
flying as a Commander of the Lockheed L1011 aircraft.
Training records revealed that the PIC completed his
A330 Line Training in September 1995 and was
provided with supplementary Line Training in
December 1998. On neither occasion was there any
record that ‘Use of Radar and Weather Avoidance’ had
been discussed.
1.17.2.4. The training records of the Co-pilot indicated that ‘Use
of Radar and Weather Avoidance’ had been discussed
25
twice during his Line Training that was completed in
 
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