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• Although a flight attendant had been in the cockpit previously, after the last meal
service and until the stoppage of the CVR there was no indication that anyone else
was in the cockpit other than the two pilots.
• In the final seconds of the CVR recording the PIC voiced his intention to leave the
flight deck, however there were no indications or evidence that he had left.
• Interviews and records showed that in 1997 the PIC had experienced a number of
flight operations related events, one of which resulted in his being relieved of his LIP
position.
• The PIC was involved in stock-trading activities, but no conclusions could be made
indicating that these activities had influenced his performance as a pilot.
• From the data available to the NTSC there was no evidence found to indicate if the
mortgage policy taken out by the PIC in connection with his housing loan has any
relevance to the accident.
3.2 Final Remarks
• The NTSC investigation into the MI 185 accident was a very extensive, exhaustive
and complex investigation to find out what happened, how it happened, and why it
happened. It was an extremely difficult investigation due to the degree of destruction
of the aircraft resulting in highly fragmented wreckage, the difficulties presented by
the accident site and the lack of information from the flight recorders during the final
moments of the accident sequence.
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• The NTSC accident investigation team members and participating organizations have
done the investigation in a thorough manner and to the best of their conscience,
knowledge and professional expertise, taking into consideration all available data and
information recovered and gathered during the investigation.
• Given the limited data and information from the wreckage and flight recorders, the
NTSC is unable to find the reasons for the departure of the aircraft from its cruising
level of FL350 and the reasons for the stoppage of the flight recorders.
• The NTSC has to conclude that the technical investigation has yielded no evidence to
explain the cause of the accident.
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4 RECOMMENDATION
Recommendations to manufacturers
• It is recommended that the ICAO FLIREC Panel undertake a comprehensive review
and analysis of flight data recorders and cockpit voice recorders systems design
philosophy be undertaken by aircraft and equipment manufacturers. The purpose of
the review and analysis would be to identify and rectify latent factors associated with
stoppage of the recorders in flight, and if needed, to propose improvements to ensure
recording until time of occurrence.
• It is recommended that, to facilitate the recovery of flight recorders after impact into
water, a review of the flight recorders design philosophy be undertaken by the
equipment manufacturers to ensure that the underwater locator beacons (ULB) are
fitted to the flight recorders in such a manner that the ULB would not be separated
from the recorders in an accident.
• It is recommended that the ICAO FLIREC Panel recommend aircraft and equipment
manufacturers to include recording of actual displays as observed by pilots in
particular for CRT type of display panels.
• It is recommended that a review of the flight crew training syllabi be undertaken by
aircraft manufacturers to include recovery from high speed flight upsets beyond the
normal flight envelope. The purpose of developing the additional training is to
enhance pilot awareness on the possibility of unexpected hazardous flight situations.
• It is recommended that a review of aircraft auto-flight systems be undertaken by
aircraft and equipment manufacturers to provide all passenger aircraft with auto flight
systems that could prevent an aircraft from flying beyond the high speed limit of its
flight envelope. It is also recommended that such auto flight systems limit the rate of
descent of the aircraft to a certain value that operationally safe.
General recommendation
• It is recommended that a regional investigation framework for co-operation in aircraft
accident investigations be established to enable fast mobilization of resources and
coordination of activities to support those states that do not have the resources and
facilities to do investigations on their own.
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REFERENCES
1. Air Traffic Services (ATS) Report
2. Flight Data Recorder, NTSB Report DCA98RA013, 21 June 1999
3. FDR BEA Garnet Microscope
4. Cockpit Voice Recorder, NTSB Report DCA98RA013, 21 June 1999
5. Structures Group Notes – Phase Two, 18 March 1998
6. Aircraft Technical Log
7. Summary of Records of Fuselage Skin Repair
　
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本文鏈接地址：NTSC Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B(32)