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The crew of G-UKLL had not been trained on the emergency use
of the Parking Brake switch as an alternative method of stopping the
aircraft and as last resort after loss of both the Normal and Alternative
systems nor has this use been explained to them during their training
courses. As the information gathered reveals, the standard training
courses given before the event for training of pilots of the Airbus-A320
family apparently did not mention or include training on the use of the
Parking Brake as a last-resort Emergency brake, although some other
A320 pilots did have knowledge of it.
Regarding the use of the parking brake, to use it with the aircraft in
motion is not intuitive and crews know that its use causes a highly
intense braking that can only be modulated by rapidly and successively
switching the lever from ON to OFF. Brief and successive applications
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of the Parking Brake is now the recommended procedure and it has been
published in the Abnormal & Emergency Procedures section of the
Flight Crew Operating Manual Vol. 3.
2.2.2. Evacuation of the aircraft.
The passengers seemed reluctant to open the over-wing exit
hatches, preferring to use the main cabin doors and slides. The
congestion in the aisle precluded the rear cabin crew member reaching
these exits to direct their opening. This could have lost valuable time
had any fire been present after the aircraft stopped.
The evacuation was delayed somewhat by the passengers attempting
to collect hand luggage and by not using the over-wing exits, but was
achieved apparently around the specified maximum time of 90 seconds.
The post-evacuation handling of the passengers did not appear to have
proceeded smoothly and there was a significant delay in the arrival of
medical assistance for the one passenger suffering an asthma attack.
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3. CONCLUSIONS.
3.1. Findings.
1. The crew was qualified for the flight and had valid licences.
2. The aircraft had been maintained in accordance with the established
Maintenance Schedule and had a Certificate of Airworthiness in force.
3. When the handling pilot selected Autobrake LO an internal fault
occurred within both BSCU channels. This fault left the system
inoperative for the brake function through the Normal Braking system.
4. The crew was aware of a BSCU internal fault. The information
contained in the FCOM-Abnormal and Emergency procedures, did not
require any further action by the crew or provide any additional
information. However in FCOM-Supplementary Techniques, there was
a procedure to reset the BSCU computer.
5. In spite of the presence of an internal fault in both BSCU channels, the
aircraft still should have had braking capability through the Alternate
Brake System.
6. When the crew operated the brake pedals, the Alternate Braking system
did not function. This was due to a dormant condition within the BDDV
which had been present for an unidentified period.
7. The malfunction of the BDDV occurred as a result of the presence of
water and detergent mixture which had frozen due to the low external
temperature during the cruise and had not melted in the relatively short
descent period. This prevented the movement of the rocker assembly in
the lower part of the valve.
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8. The commander, faced with the impossibility of stopping the aircraft
within the stop-way, sensibly chose to swerve the aircraft from side to
side and, above all, to turn to the right hand side of the runway in order
to prevent the aircraft from running into the Mediterranean sea.
9. The crew had not been trained on the use of the Parking Brake as a last
resort in the event of an emergency when the Normal and Alternate
Braking systems were lost. This training deficiency was widespread in
the standard training courses for the pilots of these aircraft.
3.2. Causes.
The accident was caused by the lack of availability of both the Normal
and the Alternate Brake systems during the landing roll.
The loss of the Normal Braking system occurred as a result of a logic
disagreement in both channels of BSCU caused by the acquisition of the
AUTO/BRK LO input.
The automatic transfer to the Alternate Braking system did not occur
as a result of the BDDV failed to function because of the presence of a
frozen aqueous solution in its lower cover.
The deficiencies of the FCOM concerning the emergency procedures
to be followed in these two failures, and the deficiencies of the flight crew
training, contributed to the aircraft running out of the runway.
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4. SAFETY RECOMMENDATIONS.
I. The initial event was the disagree condition experienced on both channels
　
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