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13:03:00 CAS had increased from 117kt to 128kt and fuel flow had reached around 5,500
lb/hr, the aircraft continued to descend and it is estimated that the lower surface of the
aircraft’s aft fuselage struck the ground at 13:03:01. Given that the minimum value of
approach speed during this period was 117kt and that according to simulator test results
described in section 2.12.9.2 a fuel flow of around 5,000 lb/hr was required to simply
maintain level flight, it is considered that at the time of the accident, nearly maximum
take off thrust would have been required to make the aircraft, descending with high
inertia, promptly transition to a climb. However, it is estimated that it the engines
reached maximum take off thrust at around 13:03:04.
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Further, based on the results of simulator tests on engine responsiveness described in
section 2.12.9.1, it is estimated that there is a time lag of several seconds between
manipulation of the thrust levers and a corresponding change in thrust.
(3) Thrust Lever Operation to enable Recovery from the Encountered Wind Shear
Based on the results of simulator tests as described in section 2.12.9.4, if the First
Officer had not reduced thrust in order to maintain the CAS at the target value when it
had increased following a sudden increase in wind speed, or if he had moderated the
reduction in thrust to maintain the increased CAS at above 144kt until the wind shear
warning sounded, it is considered that wind shear recovery may have been possible.
In this regard, although the flight crew had not recognized the possibility of a wind
shear encounter, it is considered they should have been cautious of the fact that when
making an approach in strong winds with gusts, in the event that thrust is reduced in
response to an increase in CAS and immediately afterwards the head wind decreases
resulting in a reduction in CAS and lift, and consequently an increased rate of descent,
even if the thrust levers are advanced promptly it may not be in time to prevent a descent
due to a time lag of several seconds before a corresponding increase in thrust.
3.1.8 Flight Crew Coordination
The aircraft was being operated by two flight crewmembers; the Captain and the First
Officer, who was training for upgrade to Captain. The Captain performed the duties of PNF
from the left commander’s seat, and the First Officer performed the duties of PF from the
right co-pilot’s seat. The following are considered regarding the coordination between the
flight crewmembers related to the accident:
(1) The Decision on Final Approach Speed
As described in section 3.1.6, the First Officer, acting as PF, calculated the final
approach speed using a simple method thought to be used by some ANA A321 flight
crews based on experience, but which differs from the procedure specified in the AOM. As
a result, he decided on a final approach speed of 143kt in consideration of gusts.
In interview statements made immediately after the accident, the Captain stated that
although the computer was indicating a VAPP value of 140kt as VLS + 8kt, because there is
a tendency to land nose-first if final approach speed is too high a further three knots were
added in consideration of gusts to give a final increment of 11kt and a final approach
speed of 143kt. Further, as described in section 3.1.6 (4), it is considered that the final
approach speed was set to 143kt based on the recording of the value set in the
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SPD/MACH window.
However, based on the CVR recording, although the Captain and the First Officer
discussed setting the final approach speed as plus 10kt at around 12:33:17, there was no
clear verbal confirmation regarding a change of final approach speed. Given that there
were strong winds with large wind speed variations at the time of the accident, it is
considered desirable that crews should mutually confirm their intent clearly regarding
the decision on final approach speed, which is a large factor for ensuring flight safety.
(2) Possibility of Go Around
At around 13:00:03, while the aircraft was on final approach and just after Hakodate
Tower had reported strong winds accompanied by gusts, the First Officer as a PF, carried
out a confirmation briefing on the go-around procedure with the Captain. It is considered
that this briefing was performed during final approach because it was thought that the
wind and any other conditions at that time would make the landing difficult and that it
was possible that there would be a go-around.
(3) Simultaneous Side Stick Operation
During the time from the wind shear recovery operations until the aircraft began to
climb, there were simultaneous control inputs made to the Captain’s and First Officer’s
　
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