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recorder was removed from the aircraft and voice signal was
retrieved with good playback quality. However, an irregularity in
the CVR record was noted. A command input of “Push To Erase”
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was identified at 0658:13 (21 minutes after the aircraft landed) and
all voice recording prior to that point was erased. Thereafter, a
period of 18 minutes and 17 seconds was recorded, which included
the voices of the flight crew before they left the cockpit at around
0704.
2.12.2. Constrained by the CVR recording capacity, cockpit voice
recording during the period of the accident had already been overwritten
well before the aircraft landed. The erasure of the CVR
recording after landing therefore did not materially affect the
course of the investigation. However, considering that the “Push to
Erase” button can only be activated when the aircraft is on the
ground with parking brakes selected ON, it is clear that this was an
action on the part of a person who possessed sufficient knowledge
of the aircraft systems to be aware of the nature and consequence
of such an action. Although the investigation team was unable to
establish the precise reason of the “Push To Erase” input, it can be
inferred that it was an attempt to erase the CVR record. This action
was in contravention of the company’s instruction with regard to
the preservation of flight records. Volume 12 (Organization) of the
operator’s A320/A321/A330 Operations Manual states:
“Commanders and engineers are reminded that DFDR and CVR
recordings should not be erased” (Appendix 13 refers). However,
given that Volume 12 of the Operations Manual mainly contains
organizational and administrative information, it would be
appropriate for the operator to consider issuing additional
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instructions to flight crew and maintenance staff with regard to the
need for preserving the integrity of DFDR and CVR data, or
alternatively, to incorporate the instruction into FCOM 8.
2.13. Analysis of the DFDR Data
In response to the investigation team’s request for a review of the DFDR
data to verify the aircraft performance, the aircraft manufacturer conducted
an analysis of the data and subsequently submitted an Event Report and
Analysis. In the report, it was concluded that the aircraft behaved normally
during the period of severe turbulence encounter. No system anomaly was
found. No structural load limits were exceeded both in the longitudinal and
lateral axes. The maximum angle of attack (α) recorded was +6.7º, which
triggered the angle of attack protection flight control law ( α prot) and
disconnected the Autopilot. The PF subsequently disconnected the
Autothrust and reduced both engines to idle power. Both the α protection
and the pitch up compensation laws commanded a pitch down elevator input
of 7.4º, in accordance with design parameters.
3. CONCLUSIONS
3.1. Findings
3.1.1. The pilots were properly licensed and qualified to operate the flight.
There was no evidence suggesting any pre-existing medical or
behavioural conditions that might have adversely affected the flight
crew’s performance during the flight. (Ref. Para. 1.5.1.3)
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3.1.2. Loading for the flight was within authorized weight limits, and the
aircraft was operating within prescribed centre of gravity limits.
(Ref. Para. 1.6.3)
3.1.3. The weather in the vicinity of NOBEN where the severe turbulence
was encountered was affected by the presence of a tropical
depression situated at approximately 160 NM east-southeast of the
aircraft position, with isolated and embedded CB extending up to
FL 450. (Ref. Para. 1.7.2.1)
3.1.4. The meteorological information provided to the flight crew prior to
departure from Kota Kinabalu sufficiently covered the flight. (Ref.
Para. 1.7.3)
3.1.5. For the purpose of training, the company procedures in FCOM 3 on
the use of weather radar are not sufficiently clear in its description
of the recommended technique for operating the radar for weather
avoidance. (Ref. Para. 2.3.6)
3.1.6. The aircraft inadvertently flew into an area of turbulent weather
caused by strong convective activity associated with a tropical
depression. (Ref: Para. 2.3.7)
3.1.7. While deviating to the right of track, the aircraft encountered
severe turbulence at FL 410 at 14 NM north-northeast of NOBEN.
(Ref. Para. 2.3.8)
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3.1.8. It was highly probable that the way in which the weather radar was
operated precluded optimum detection and indication of the
position and intensity of the weather in the vicinity of the aircraft.
　
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本文鏈接地址：Report on the accident to Airbus A330-342 B-HYA(17)