FINAL REPORT - aias.gov.ro · Serious incident – ATR 42-500, YR-ATF – Bucharest-Otopeni Airport...

For notifications regarding civil aviation accidents and serious incidents: Phone: +40 751 192088 (24/7) E-mail: [email protected]

1-3 Walter Maracineanu Square, 6th floor, District 1, Bucharest – postal code 010155, Romania

Phone: +40 21 2220535, Fax: +40 378 107106 E-mail: [email protected]

Website: www.aias.gov.ro

FINAL REPORT

of civil aviation safety investigation

CLASSIFICATION Serious Incident

Operator TAROM

Manufacturer Avions de Transport Regional ATR

Aircraft ATR 42 - 500

Registration country ROMANIA

Registration YR - ATF

Location Otopeni Airport

Date and time 09.07.2019 / 19:43 LT (16:43 UTC)

Nr. : I 20 - 08 Data: 15.06.2020

For notifications regarding civil aviation accidents and serious incidents: Phone: +40 751 192088 (24/7) E-mail: [email protected]

1-3 Walter Maracineanu Square, 6th floor, District 1, Bucharest – postal code 010155, Romania

Phone: +40 21 2220535, Fax: +40 378 107106 E-mail: [email protected]

Website: www.aias.gov.ro

ADVERTISMENT

This RAPORT presents data, analyses, conclusions and safety

recommendations of the civil aviation safety investigation Commission appointed by

the Director General of SIAA.

The civil aviation safety investigation was conducted in accordance with the

provisions of Regulation (EU) no. 996/2010 of the European Parliament and of the

Council of 20 October 2010 on the investigation and prevention of accidents and

incidents in civil aviation and repealing Directive 94/56/EC, of the provisions of the

Annex 13 to the Convention on International Civil Aviation signed in Chicago on 7

December 1944, as well as with the Romanian Government Ordinance no. 26/2009,

approved and completed by Law no. 55/2010, amended and supplemented by the

Romanian Government Ordinance no. 17/2018.

The objective of the civil aviation safety investigation is to prevent the

occurrence of accidents and incidents, by the actual determination of the causes and

circumstances that led to the occurrence of such events, to establish the necessary

recommendations for the civil aviation safety, and DOES NOT HAVE THE

PURPOSE of apportioning blame, individual or collective liability.

Consequently, the use of this REPORT for other purposes than those regarding

the prevention of accidents and incidents, may lead to misinterpretations.

Serious incident – ATR 42-500, YR-ATF – Bucharest-Otopeni Airport – 09.07.2019 – SIAA

Page 2 of 42

TABLE OF CONTENTS

1. GENERAL INFORMATION .................................................................................3

1.1 History of the incident .................................................................................3

1.2 Victims ........................................................................................................4

1.3 Damage to the aircraft ................................................................................4

1.4 Other damages ...........................................................................................5

1.5 Aircraft crew information .............................................................................5

1.6 Aircraft information ......................................................................................6

1.7 Meteorological information ........................................................................ 11

1.8 Navigation means ..................................................................................... 12

1.9 Communications ....................................................................................... 12

1.10 Airport data ............................................................................................... 14

1.11 Flight recorders ......................................................................................... 15

1.13 Medical and pathological information ........................................................ 17

1.14 Fire ........................................................................................................... 17

1.15 Survival aspects ........................................................................................ 17

1.16 Tests and checks ...................................................................................... 17

1.17 Management and organization information ............................................... 20

1.18 Additional information ............................................................................... 20

2. ANALYSIS ........................................................................................................ 20

2.1 Flight analysis ................................................................................................. 20

2.2 Operational and human factor aspects ........................................................... 23

3. CONCLUZII ....................................................................................................... 26

3.1 Findings .......................................................................................................... 26

3.2 Causes of the incident .................................................................................... 27

4. SAFETY RECOMMENDATIONS ...................................................................... 27

ANNEX 1 ................................................................................................................. 30

ANNEX 2 ................................................................................................................. 32

ANNEX 3 ................................................................................................................. 37

ANNEX 4 (CRM) ...................................................................................................... 38


Page 3 of 42

1. GENERAL INFORMATION

1.1 History of the incident

On 09.07.2019, the ATR 42-500 aircraft, registered YR-ATF, was planned to

perform two commercial transport flights: Bucharest Otopeni - Chișinău- Bucharest

Otopeni and Bucharest Otopeni -Satu Mare- Bucharest Otopeni, totaling 4 flight

segments. Both flights were performed by the same crew.

The last flight segment of the day was on the route Satu Mare International

Airport (LRSM/SUJ) – Bucharest Otopeni International Airport (LROP/OTP).

There were 26 people on board the aircraft: the pilot in command, the co-pilot,

two flight attendants and 22 passengers.

Take-off from Satu Mare went normally. The co-pilot was the “pilot flying” (PF),

and the pilot in command was the „pilot non flying” (PNF- terminology according to

operator’s Operations Manual)

The flight on the route to Bucharest Otopeni was normal. The approach and

landing procedure were performed for runway 08L of Bucharest Otopeni Airport.

The aircraft contact with the runway was within “touch down” zone, in the

runway axis. After the runway contact, the pilot positioned the engines power levers

in the "ground idle" position, at which point the aircraft began a strong deceleration,

accompanied by unusual noises and vibrations.

Another aircraft, which was on the "O" taxiway, parallel to runway 08L,

reported that a dense smoke is visible in the area of the right main landing gear of

the YR-ATF aircraft.

After a run of approximately 560 m, at 19:43 LT, the YR-ATF aircraft stopped

on runway 08L, at the coordinates point N 44°34'39", E 026°05'57", near the

intersection with the "W" taxiway.

The emergency response teams of the airport, immediately arriving at the

aircraft, noticed the destruction of all main landing gears’ tires and wheels’ rims.

The aircraft was immobilized in the stopping position. The runway 08L/26R

was temporarily closed.

The passengers were disembarked in the position where the aircraft stopped,

using the normal procedure.

There were no injured persons.


Page 4 of 42

Fig.1 Aircraft after final stop on the runway

1.2 Victims

There were no victims.

1.3 Damage to the aircraft

All the tires of the main landing gears wheels were destroyed.

All the rims of the main landing gears wheels were destroyed.

Traces of blows with tire fragments on the left and right main landing gear

doors and on the middle right of the aircraft fuselage have been found.

Fig. 2 Damaged wheels of the main landing gear


Page 5 of 42

Fig. 3 Traces of blows with tire debris on the fuselage

1.4 Other damages

There were no other damages.

1.5 Aircraft crew information

Pilot in command Male, 29 years

License FCL/ATPL/RO/xxxxxxxA, valid

Medical certificate Class 1, valid, with no restrictions

Flight experience 2100 flight hours / 1930 on this aircraft type

Total working time 8 h 15 min

Total flight time 4h 45 min

Co-pilot Male, 30 years

License FCL/CPL/RO/xxxxxxxA, valid

Medical certificate Class 1, valid, with no restrictions

Flight experience 1400 flight hours / 1220 on this aircraft type

Total working time 8 h 15 min

Total flight time 4 h 45 min


Page 6 of 42

1.6 Aircraft information

1.6.1 Overview

The aircraft involved in the incident is of ATR 42-500 type, designed for

regional/short-haul flights.

It is an aircraft of classic construction with a ("parasol") upper wing. The

passenger cabin offers 48 seats for passengers, in a 2 + 2 setting.

Manufacturer and aircraft type Avions de Transport Regional – ATR 42-500

Serial number and year of manufacture 599 - 1999

State and registration mark Romania – YR-ATF

Owner TAROM

Operator TAROM

Airworthiness Certificate Valid

Total number of hours / cycles 37 142 / 33 071

Engines 2 x PWC PW127E, turbo-propeller

Maximum engine power 2516 hp (1876 KW)

The engines of the aircraft are turboprops with constant rpm (rotation speed).

Each engine drives a 6-blade propeller with variable pitch automatically controlled.

Fig.4 ATR 42-500 aircraft

The technical maintenance of the aircraft was performed in accordance with the

approved Maintenance Program.


Page 7 of 42

At the time of the incident occurrence, in the list of deferred defects – HIL

("Hold Item List") – two defects were registered, whose correction was postponed

according to the approved MEL: NL ("Low Pressure Spool Rotation Speed") and "RH

Strobe Light". These defects did not affect the flight safety and were not likely to

cause or influence this occurrence.

1.6.2 Landing gear and hydraulic system

The landing gear is of tricycle type, retractable in the fuselage.

Extending and retracting the 3 landing gear legs, as well as braking, are

performed hydraulically.

Each main gear leg is equipped with two wheels, which can be hydraulically

braked by the pilots, by pressing the brake pedals on the rudder pedals. Also, in case

of loss of hydraulic pressure in the main braking system, there is the possibility of

emergency braking by actuating a handle on the horizontal central pedestal. The

same handle also ensures the operation of the parking brake.

The ATR 42-500 aircraft is equipped with two independent hydraulic circuits,

the "green" circuit and the "blue" circuit – fig. 5.

The "green" circuit provides landing gear operation (extension and retraction)

and also ensures the (usual) normal braking of the four wheels of the main landing

gear. The "blue" circuit provides emergency braking and parking braking through a

specific hydraulic accumulator (fig. 5).

Fig. 5 The hydraulic brake system- schematic

Antiskid valves

Shuttle valves

Emergency / parking

brake handle


Page 8 of 42

The pressures in the green circuit, the blue circuit and the parking/emergency

braking accumulator have a separate indication in a combined triple indicator (fig. 6).

Fig. 6 Triple indicator of pressures in the braking system

The four wheels of the main landing gear are each equipped with their own

braking system.

The braking assembly of each main landing gear’s wheel has the capacity to

automatically adjust the position of the brake discs, has a mechanical indicator for

the visual inspection of the wear status of the brake discs and a system for detecting

and warning the overheating of the brake discs.

After take-off, when the landing gear control lever is set to the "UP" position

(retracted), the wheels of the main landing gear are automatically braked, and after

the landing gear is locked in the "UP" position, the brake pressure is also released

automatically, so that there is no hydraulic pressure in the braking system during the

flight.

The wheels of the main landing gear are provided with an anti-lock system

("antiskid system") that prevents them from locking during braking (fig. 5). The

system is functional only when the "green" circuit of the hydraulic system is used,

respectively when the braking is normally performed. The purpose of the system is to

ensure maximum braking performance by removing the locking phenomenon, for

each wheel. To this purpose, the system modulates the braking pressure of each

wheel, depending on the commanded braking pressure, the wheel load and the

friction coefficient (degree of contamination of the runway surface).

The system monitors each wheel of the main landing gear, as well as

crosswise. This is done by comparing the rotation speed of the two inner wheels with

the two outer ones of the main landing gear. If the aircraft speed is greater than 23

Kts and the speed difference between the two inner wheels and the two outer ones is


Page 9 of 42

more than 50%, then the braking pressure is automatically released on the relevant

wheels.

The antiskid system is operational when the landing gear lever is in “DOWN-

IN” position and the aircraft speed is greater than 10 Kt. This system also reduces

the possibility of wheels’ tire burst.

The system also has a protection that prevents brakes pressurization at

runway contact (TOUCHDOWN PROTECTION).This TOUCHDOWN PROTECTION

is active for the first 3 seconds after the aircraft weight-on-wheel signal indicates ON-

GROUND mode, or until the main landing gear's wheel speed exceeds 35 Kt. This

prevents inadequate (premature) actuation of the brakes, as long as the braking

coefficient is low or the landing gear vertical compression is not complete.

Emergency braking and parking braking are performed by actuating the

EMERGENCY-PARKING BRAKE handle (fig. 5 and fig. 7). In this case, the

ANTISKID system becomes inoperative with all its protection channels. In fig. 5 it can

be seen that when operating the emergency/parking brake handle, the hydraulic

pressure in the blue circuit goes directly to the four wheels of the main landing gear,

through the shuttle valves, bypassing the antiskid valves.

When operating the EMERGENCY-PARKING BRAKE handle, the braking

pressure is controlled by its positioning, so that when positioning it up, to half of the

available movement, the braking pressure will be gradually applied up to 500 psi

(36 bar).

According to the Aircraft Operations Manual, moving the handle further by

approximately another half inch (1.25 cm) beyond this point, is authorized only if the

aircraft speed is less than 60 Kt. Further moving the brake handle will increase the

pressure to 2030 psi (140 bar) suddenly. Therefore, for emergency braking it is

advisable to operate the brake handle up to half movement and maintain its position.

In case of using emergency braking at speeds of over 20 Kt, it is requested to

perform a visual inspection of the tires condition, before the next take off.

Operating the emergency/parking brake handle (removal from the "OFF"

position) on the ground or in flight causes the "PRKG BRAKE" "amber" indicator to

light up on the "Crew Alerting Panel" (fig. 7 and fig. 8) and is taken into account by

the “Takeoff Config. Warning System”.


Page 10 of 42

Fig. 7 Emergency/parking brake handle in the parking position (left) and OFF position (right)

CAP (Crew Alerting Panel)

Emergency /

parking brake

handle

Emergency / parking brake indication


Page 11 of 42

Fig. 8 Crew Alerting Panel

1.7 Meteorological information

Meteorological report for landing time:

METAR LROP 091630Z 03006 KT 9999 FEW 042CB BKN045 23/14 Q1011

R88/09//95 NOSIG.

Decoding: date 09, time 16:30 UTC, wind from 030° direction with a 6 Kt

speed, visibility of 10 Km or more, ceiling 1-2/8 CB at 4200 ft height, 5-7/8 at 4500 ft

height, temperature 23°C, dewpoint 14°C, QNH atmospheric pressure 1011 mb,

runways condition (R88), deposit type: unreported (/), dry and clean runways (0), in a

proportion of 100% (9), thickness insignificant/non-existent (//), “good” braking

coefficient (95), with no significant changes (NOSIG).

The relevant meteorological conditions for the landing at LROP on the 08L

runway, respectively the wind direction and speed, the visibility, were not contributing

to the incident occurrence.


Page 12 of 42

1.8 Navigation aids

Not applicable.

1.9 Communications

According to the co-pilot’s statement, during the analyzed flight segment (but

also during the previous two flight segments) radio calls were performed by pilots

without using the headsets, due to the failure of the headset of the pilot in command

during the flight on the first segment of the day.

According to the statements, the pilots were provided by the company with

individual headsets.

The procedure of the preliminary examination of the cockpit (Preliminary

Cockpit Preparation) does not require the verification of the existence of the back-up

headsets on board.

The absence of communication headphones on board the aircraft is not

recorded in the Aircraft technical logbook.

Fig. 9 presents the provision regarding the minimum requirement for the

functional communication headsets on board, according to the TAROM Minimum

Equipment List (MEL).

Fig. 9 Extract from TAROM - M.E.L., regarding the minimum requirement for communication headset


Page 13 of 42

However, the CS-MMEL BOOK2/23-10-1 (Master Minimum Equipment List) provided by EASA is more restrictive than the Operator’s MEL (Fig.10-red square). It requests as for minimum functional headsets onboard for dispatch, one set for each pilot (each required crew member on flight crew compartment).

Fig.10 Extract of CS-MMEL BOOK2

Also, the Operations Manual (OM) of the operator presents the requirement for both pilots to perform communications using headsets under specific circumstances.

Fig. 11 presents the provision in the TAROM Operations Manual (OM) regarding the use of communications headsets by pilots.

Fig. 11 Provision from TAROM- O.M. regarding the use of communications headsets by the crew


Page 14 of 42

1.10 Airport data

“Henri Coandă” Otopeni International Airport (IATA:OTP, ICAO:LROP) is the

largest airport in Romania and is located outside the urban area of Bucharest, in the

city of Otopeni, Ilfov county.

It is authorized for IFR and VFR air traffic, both day and night.

LROP has two parallel runways, each 3500 m in length, 08L/26R and 08R/26L

and several taxiways which are shown schematically below:

Fig. 12 Map of Henri Coandă / Bucharest Otopeni Airport (LROP)


Page 15 of 42

Fig.13 Final position of the aircraft on runway 08L

The surface of runway 08L was dry and the reported braking coefficient was

95 (GOOD).

The runway condition did not influence the occurrence.

1.11 Flight recorders

The ATR 42-500, YR-ATF aircraft is equipped with a Digital Flight Data

Recorder (DFDR) and a Cockpit Voice Recorder (CVR).

Both recorders have been taken over by the SIAA’s investigation commission

to download and analyze the recorded data.

After downloading and decoding the data files from the DFDR, the following

aspects were noted:

- The capability to record the position of the emergency/parking brake handle

is not constructively provided;

- The capability to record the hydraulic pressure of the normal braking system

and of the emergency braking system is not constructively provided.

To be noted that this is not a non-conformity. The ATR MSN 599 - YR-ATF was

delivered in March 1999 and then as per the Ops rule (CAT.IDE.A.190) recording of

the brake and hydraulic parameters was not required. Aircraft who’s first Certificate of

Airworthiness was issued after 1st of January 2016, have to record the brake

pressure/the pedal position/hydraulic circuits pressures (refer to CAT.IDE.A.190 and

associated AMC). On ATR, compliance to this new requirement is done through the

installation of a specific FDAU and associated sensors through the modifications

5044 or 5876. In addition, a retrofit solution is available for legacy aircraft (optional

SB ATR42-31-0082). The Operator (TAROM) did not provide the modifications of this

optional Service Bulletin to its fleet of ATR-42s.

YR-ATF

08 L


Page 16 of 42

Significant parameters for the last two minutes of the analyzed flight were

synthesized in graphical form and are shown in fig.14.

Fig.14 The significant parameters for the last two minutes of the flight

Moment for both main

gears compression


Page 17 of 42

In this context, the CVR recordings were also analyzed. The recordings

provided confirmations for the data extracted from de DFDR.

1.12 Wreckage and impact information

Not applicable.

1.12 Medical and pathological information

After the incident occurrence, the crew did not undergo any medical

investigations.

Medical status of the crew members was not checked neither before the

beginning of the flight, because of the inexistence of a legal procedure.

No passengers needed medical care.

1.14 Fire

There was no fire.

1.15 Survival aspects

N/A

1.16 Tests and checks

The investigation commission arrived at the accident site found the destruction

of the four tires of the main landing gear, as well as of the rims, due to their friction

with the runway surface after the destruction of the tires.

In the presence of the investigation commission, the TAROM technical team

proceeded to remove and check the wheel assemblies of the main landing gear, in

order to replace them with functional ones, so as to be possible to tow the aircraft

and clear the runway 08L.

Upon removing the assemblies, following the visual inspection, the following

were found:

- Brake disc assemblies of all the wheels were in proper technical condition

(fig.14);

- Self-positioning mechanisms of the brake discs of all four wheels were in a

proper technical condition (fig.15);

- Mechanical wear indicators of the brake discs showed a normal use (brake

discs with allowable use for proper operation) on all four wheels (fig.14);

- Inner and outer bearings of the main landing gear wheel axles were in a

proper technical condition, without any tear (scratches or deterioration of the rollers

and/or rolling surfaces) (fig. 16).


Page 18 of 42

Fig.15 Wheel brake assembly

Fig.16 Bearings and wheel axle without non-conformities

After replacing the wheels of the main landing gear, the braking system was

checked, by operating the emergency/parking brake handle and the normal operation

of the brake was found:


Page 19 of 42

- When moving the handle from the "OFF" position, the indication "PRKG BRK"

lights up on the CAP (CREW ALERTING PANEL) and the aircraft main wheels are

braking (fig.17).

- After positioning the brake handle in the "OFF" position, the indication "PRKG

BRK" went off and the wheels of the aircraft were unlocked. The towing roll went

normally, without any noise, jamming or other non-conformities of the main landing

gear’s wheels.

Fig. 17 Checking the functioning of the parking brake/emergency handle position warning

The operator informed the aircraft manufacturer about this occurrence. The

Manufacturer recommended inspections, functional and operational tests of the

equipment and subassemblies of the braking system (normal and emergency).

After performing them by the operator's technical service, it was concluded that there

was no technical failure or non-conformity with the braking system.

Parking brake handle

removed from the OFF

position

Functional Parking Brake indicator


Page 20 of 42

1.17 Management and organization information

TAROM company operates a total of seven nine ATR aircraft in the ATR

detachment (seven ATR 42-500 and two ATR 42-700).

The training of the pilots in the ATR detachment is performed according to the

approved Training Program, being led by the detachment commander in the

coordination of the chief pilot and the manager responsible for the training ("crew

training post holder").

Reference to Operator’s Operations Manual, the investigation commission

noted that the Operator is still using the concept of PF/PNF (Pilot Flying/Pilot Non

Flying) and not the new concept of PF/PM (Pilot Flying/Pilot Monitoring) as largely

used by the industry.

From the analysis of the individual training files of the two pilots, the

investigation commission found that they received only positive evaluations, having a

normal training path.

1.18 Additional information

After disembarking the passengers and taking over of the aircraft by the

operator's technical team, the crew went to the Bucharest Otopeni airport terminal,

where responsible staff of the operator organized a “debriefing” with them.

As part of the on-site investigation, the SIAA’s investigation commission was

not informed about the presence of the crew in the Otopeni airport area, finding out

about this later on, when interviewing the crew members.

2. ANALYSIS

2.1 Flight analysis

The investigated flight (Satu Mare-Bucharest Otopeni) was the fourth flight

segment on that day for the crew.

Take-off from Satu Mare went normally. The co-pilot acted as a “pilot flying”

(PF), and the pilot in command acted as a „pilot monitoring” (PNF).

Because the pilot in command had an U/S radio communications headset, the

crew used the cabin speakers and handheld microphones to make the radio calls.

Moreover, for this reason, the crew did not use communications headsets on the last

three flight segments.

TAROM Operations Manual provides in Part B Airplane Operating Matters,

ATR42/72-500 Cap.2 Normal Procedures Para.2.0.5.1 Communication in the Cockpit

- Standard Calls – that the crew has to use headsets in the following flight phases:

- Before starting the engines, up to FL 100;

- In the descent phase, from FL 100, until stopping the engines after landing;


Page 21 of 42

- Whenever the crew commander decides.

Analyzing the recordings of the conversations in the cockpit, the investigation

commission considers that the flight on the route went without problems.

Following the analysis of the CVR recordings, the investigation commission

found that in the cockpit, during the flight in descent below FL100 and the approach

for landing ILS 08L to LROP, there were some irrelevant discussions for executing

the critical phases of the flight, so the requirements of the concept "sterile cockpit"

not being applied (detailed information on this concept in annex 1).

Also, the investigation commission considers that the fact that the crew did not

use the headsets during the flight under FL100, was an impediment for the quality of

performing the radio communications and crew cross-checks.

The landing was performed on the 08L runway of Bucharest-Otopeni airport.

After the runway contact, when positioning the power levers in the "Ground

idle", the aircraft started a strong deceleration, accompanied by unusual noises and

vibrations, due to the locking of all the wheels of the main landing gear.

Considering that something abnormal was happening to the aircraft, the pilot

in command switched the engine's power levers to the "Flight idle" position. This

resulted in a reduction of the deceleration, but without eliminating the abnormal

vibrations and noises, which were caused by the main landing gears tires and wheels

damage whose rotation was almost completely blocked due to the deactivation of all

protection systems.

All the four wheels (tires and rims) of the main landing gear were destroyed.

The analysis of the decoded DFDR recordings highlighted the following

elements of the final evolution of the aircraft:

- Final approach was performed in a normal configuration and with a speed of

105 Kt, corresponding to the aircraft weight and the runway condition;

- Just before touch-down, the power levers of the engines were retracted to

"Ground idle" position (t.1 on the graph- fig.18); the aircraft starts to

decelerate (the green graph in fig 18 presents the deceleration factor- as

“longitudinal acceleration”).

- Runway contact was at 16:41:52 UTC and went normally, with a vertical

acceleration of 1.13 g; This is the moment when the first main gear contacts

with the runway (t.2 on the graph). The deceleration of the aircraft increases

rapidly;

- Then deceleration of the aircraft increases further and rapidly, after the

second main gear contact with the runway (t.3) which was followed almost

instantly, by the full compression of both legs (t.3-1);

- Approximately one second after the complete compression of both main

legs, the deceleration of the aircraft reached its maximum value: 0.45g;


Page 22 of 42

This strong deceleration is due to the fact that at the contact with the

runway, the brakes of all main landing gear’s wheels were actuated;

- After this peak, the deceleration factor started to decrease, due to main

wheels’ tires destruction- until t.4 on the graph;

- Between t.4 and t.5, graph shows a decrease of the deceleration, due to

placing the engine levers in Flight Idle again, and emergency brake

deactivation, by the captain, immediately when he noticed the brake lever’s

out of the OFF position. That explains also the tire debris marks on the

airframe - for few seconds, the destroyed tires did rotate, due to brakes

release;

- Between t.5 and t.6 the deceleration graph shows some new increases in

value, due to several intentional applications of the emergency braking by

the captain (as by his statement);

Fig. 18 Part of the graph of the parameters recorded by DFDR

The longitudinal deceleration (due to brakes

actuation) instantly increases at main landing

gear full contact with the runway

The moment of full

compression of both main

landing gear’s legs (t.3.1)

The moment when first

main gear touches the

runway (t.2)

The moment when the

second main gear

touches the runway

(t.3)

t.4

t.5

t.6 t.7

The moment of

retarding engines at

Ground Idle (t.1)


Page 23 of 42

- When the emergency brake lever was set in OFF position, due to the slight

traction provided by the engines at Flight Idle setting, the deceleration factor

decreases and even passes below “0”, thus showing a slight acceleration of

the aircraft (from t.6 to t.7 on the graph) ;

- Then, again the speed of the aircraft continued to decrease, due to

emergency (or normal) braking application by the captain;

- Aircraft was completely stopped, after approximately 60 seconds from the

initial runway contact, of the main gear wheels.

The investigation commission considers that, at the aircraft contact with the

runway, the emergency/parking brake handle was in the “EMER BRAKE” notch

allowing the hydraulic braking pressure to be sent to the wheel brakes so as to lock

the brakes of all four main wheels, as a result of the deactivation of all brake

protection systems (by removing the handle from the "OFF" position).

The analyze is confirmed by the CVR recordings.

2.2 Operational and human factor aspects

The pilot in command, at the time of the incident, held a total experience of

approximately 2100 flight hours, of which 1930 on ATR 42-500 type; pilot of TAROM

company since December 2015 with no experience in other companies. The pilot

holds the qualification of commander since November 2018, gathering 544 hours

flying experience as pilot in command.

The co-pilot, at the time of the incident, held a total experience of 1400 flight

hours, of which 1220 on the ATR 42-500 type; pilot of TAROM company since May

2017 with no experience in other companies.

On the day of the incident, the crew arrived to the briefing room for the "before

flight briefing" at 11.30 LT, in order to prepare the planned flight, which consisted of

four segments: OTP-KIV; KIV-OTP; OTP-SUJ; SUJ-OTP.

The planning complied with the regulations regarding the flight time allowed /

legal working time allowed.

The 4 segments were performed as follows:

OTP-KIV: The co-pilot as PF (Pilot Flying)

The pilot in command as PNF (Pilot Non-Flying)

KIV-OTP: The pilot in command as PF

The co-pilot as PNF

OTP-SUJ: The pilot in command as PF

The co-pilot as PNF


Page 24 of 42

SUJ-OTP: The co-pilot as PF

The pilot in command as PNF

The incident occurred at 19.43 LT during the landing roll, after landing in the

last segment, the crew accumulating in that working day approximately 4 hours and

45 minutes of flight time. The total time of work from that day was of about 8 hours

and 15 minutes.

During the interview of the crew members, the investigation commission

noted, according to the co-pilot's statement, that during that flight day, he noticed

several times the turning on and off the "PRKG BRK" light, without communicating

this to the pilot commander.

This signaling was determined by the random operation of the emergency/

parking brake handle by the pilot in command.

During the last segment (SUJ-OTP) the crew did not serve the meal, and the

pilot in command did not complete the ATL, but he admitted that he operated the

emergency/parking brake handle for no specific reason.

In this context, the investigation commission considers that the crew was aware of

the reason for the random "PRKG BRK" light signaling. The fact that the first officer

which was acting as PF, did not challenged the pilot in command on the events, is a

nonconformity, according to FCTM-42-72 PEC 2012, Edition - 4. CROSS CONTROL:

“Any pilot action which influences flight parameters -flight path, speed or a system

status- must be called out loud by any pilot and crosschecked by the other one."

It was noted from discussions with other ATR-42 pilots that, within the ATR

detachment, it is customary to use the emergency/parking brake handle in an

intermediate position to support the Aircraft Technical Log (ATL) during its

completion, or the food tray.

Also, it was considered as non-compliant (but already routine) practice to use

the movement of the emergency brake handle from the "Off" position in order to

switch “ON” its corresponding lamp as a "reminder" (warning) for some items in the

Checklists, which were left open or not completed.

For the last flight segment, the co-pilot had the PF quality and according to his

statement, during the intermediate and final approach, he only monitored the flight

control instruments on the right panel, respectively PFD (Primary Flight Display) and

ND (Navigation Display), without paying attention to the other warning

instruments/panels, considering that this is the PNF attribution.

Based on the general recommendations regarding the principles of monitoring

in the cockpit (additional information in Annex 2), the commission considers this

attitude as being non-compliant.

The crew did not apply the principles of the "Sterile cockpit" concept according

to Operations Manual-Part B Airplanes Operating Matters ATR42 / 72-500 Cap.2


Page 25 of 42

Normal Procedures Para.2.0.10 "Admission to Flight Deck / Sterile cockpit concept"

(details in annex 1) by conducting some dialogs and activities not related to the flight.

Due to these activities, the crew was distracted from the proper performance

of the tasks and as a result, the Crew Alert Panel (CAP) signals were not effectively

monitored.

The commission considers that the failure to observe the warning light for the

improper position of the emergency/parking brake handle ("PRKG BRK") prior to

landing was determined by:

- routine of using the parking brake handle as a "reminder" and/or support;

- failure to comply with the requirements of the "sterile cockpit" concept.

According to the DFDR and CVR recordings and the pilots’ statements, before

starting the descent for approach and landing, when performing the "Descent

Checklist" and, respectively, checking the emergency/warning signals "CCAS -

RECALL", all indications were normal, without the presence of "PRKG-BRK" warning

on CAP.

Under these conditions, it can be concluded that the last actuation of the

emergency/parking brake handle, respectively its removal from the "OFF" position,

was carried out during the descent phase for approaching and landing.

As a summary of the analysis of the available elements, the investigation

commission considers that in terms of operational/human factor, the following risk

factors have been met:

Management and supervision:

- The training management system, together with the flight safety system

within the ATR detachment did not identify the most efficient methods in

order to correct the inappropriate behavior and elements of overconfident

behavior, mainly for the less experienced pilots. Informal talks with some

ATR pilots, revealed that there are noncompliant habits which became

routines among part of the pilots.

- Referencing the notes on flight crew task allocation from the Flight Safety

Foundation (2014) A Practical Guide for Improving Flight Path

Monitoring – Recommendations: "Promoting an atmosphere in which

either pilot can challenge the other in spite of his position is essential, as

monitoring becomes ineffective when the identified deviations are not

pointed out or acted upon. Pilot task allocation can integrate this notion,

ensuring that each pilot understands his/ her responsibility for monitoring

and the importance of the monitoring task.".

This can further enhance training and the investigation commission

considers that the ideas can be enclosed by the company Operations

Manual accordingly.


Page 26 of 42

Precondition for unsafe actions (crew):

- Defective CRM (Crew Resource Management), superficially executed

checklists, out of routine. Essentially, the CRM concept refers to the efficient

use of all available crew resources, aircraft systems, auxiliary facilities and

aims at improving communication and management skills of crew members

in order to increase the efficiency of their overall activity - details in Annex 4;

- Inefficient monitoring of the indications and signals in the cockpit.

Unsafe actions (crew):

- Failure to fully comply with the provisions of the Company Operations

Manual and Standard Operational Procedures (SOPs).

The investigation commission considers the behavior of the pilots as one that

can fall into the category "overconfident" (too confident).

3. CONCLUSIONS

3.1 Findings

3.1.1 Technical aspects

From the technical point of view, the aircraft was appropriate/airworthy for

performing the planned flights;

The aircraft did not have any records in the technical logbook regarding the

malfunctions/non-conformities of the hydraulic system nor of the braking

system of the main landing gear wheels;

There were no spare headsets for the crew in the aircraft;

When the damaged wheels were removed by the TAROM technical team, no

malfunctions or non-conformities of the braking system subassemblies were

found;

Operational and functional tests carried out did not reveal any malfunction of

the braking system nor of other subassemblies in the landing gear area.

After replacing the damaged wheel assemblies (rims and tires), the operation

of the aircraft's braking system was normal;

Visual signaling related to the position of the emergency/parking brake handle

in the crew cabin was functioning normally;

For all landings performed on the day of the incident, the load factor on the

vertical axis was within the normal operating limits of the aircraft (respectively

1.05 g, 1.08 g, 1.34 g, 1.13 g for the last landing);


Page 27 of 42

At landing, all the main landing gear’s wheels were locked, resulting in a

strong deceleration (maximum peak of 0,45g), immediately at the moment

when the first main landing gear touched the runway.

Upon landing, the emergency/parking brake handle was incorrectly positioned.

3.1.2 Crew aspects

The pilots held qualifying documents and medical certificates, all valid;

The pilots’ flight schedule was performed in compliance with the instructions

provided in the RACR - LTMO (Romanian Civil Aeronautical Regulations -

"Limitations on Working Time and Rest Requirements for Navigating Civil

Aeronautical Personnel");

During the flight under FL100 the crew did not fully comply with the

requirements of the "sterile cockpit" concept as provided in the Company

Operations Manual;

The on-board equipment was monitored inefficiently, and the checklists for

critical phases of the flight were superficially performed.

Medical status of the crew members was not checked neither before the

beginning of the flight mission nor at the end of it, because of the inexistence

of a legal procedure.

3.2 Causes of the incident

3.2.1 Determining cause

Incorrect position of the emergency/parking brake handle, moved from the

"OFF" position, upon aircraft runway contact during landing.

3.2.2 Favoring causes

In-flight use of the emergency/parking brake handle, for non-compliant

purposes/maneuvers;

Defective/inefficient CRM by superficial execution of Checks and Cross

checks for landing;

Crew failure to fully comply with the standard operating requirements

according to the Company Operations Manual, by ignoring in some cases the

"sterile cockpit" concept under FL100.

4. SAFETY RECOMMENDATIONS

The investigation commission makes the following safety recommendations:


Page 28 of 42

1. It is recommended to TAROM S.A. to introduce in the Normal Checklist

Operation / Before Landing Checklist, an additional check of the position of

the emergency/parking brake handle;

2. It is recommended to TAROM S.A. to elaborate and implement procedures to

eliminate the risk of superficial execution of the SOPs (Standard Operating

Procedures);

3. It is recommended to TAROM S.A. to update the MEL for its ATR fleet,

according to the requirements of the EASA CS-MMEL BOOK2.

4. It is recommended to TAROM S.A. to ensure the existence on board the

aircraft of a functional (spare) set of radio communication headset for the

command crew, besides the individual serviceable headsets of each pilot.

5. It is recommended to TAROM S.A. to introduce a procedure for checking the

existence of the back-up headset on board the ATR 42 aircraft.

6. It is recommended to TAROM S.A. to align the provisions of the Company

Operational Manual (OM) with those of the MEL (Minimum Equipment List on

board) regarding the use of communication headsets by the crew.

7. It is recommended to TAROM S.A to update “pilot task allocation” in the

Company Operations Manual according to the new concepts of flight,

promoted by the Flight Safety Foundation Org.(including the recommendations

regarding the Flight path monitoring). See please: “Flight Safety Foundation

(2014) A Practical Guide for Improving Flight Path Monitoring”

8. It is recommended to TAROM S.A. to supplement the individual assessment

measures in the process of training the crews of the ATR Detachment,

regarding their attributions related to "Functional tasks on board" according to

the provisions of the “Flight Safety Foundation (2014) A Practical Guide for

Improving Flight Path Monitoring”. The evaluation of the pilots should

check their ability to notice, acknowledge and report – regardless of the

position/rank onboard - of any modification of the flight path, essential

parameters or systems status, which must be called out loud by any pilot and

crosschecked by the other one;

9. It is recommended to TAROM S.A. to introduce a procedure which will identify

all the noncompliant habits which became routines among part of the pilots,

and promote effective actions to stop them.

10. It is recommended to TAROM to perform a safety assessment (safety

improvement against operational costs), in order to provide for its ATR42s in

operation (and manufactured before 1st of January 2016), the application of

the ATR optional SB ATR42-31-0082 - modifications 5044 or 5876, so to


Page 29 of 42

introduce the pressure values in the main and emergency braking systems,

and the brake pedals position, among the parameters recorded by the DFDR.

11. It is recommended to the Ministry of Transport, Infrastructure and

Communications (as a Regulatory Authority for civil aeronautics activities in

Romania) to elaborate and promote a legislative initiative in order to produce a

regulation which will ensure as compulsory and regulate the performing of

toxicological analysis (alcohol and prohibited substances) for the aircraft crew

involved in an aviation serious incident or accident, and also for random

checks, before boarding the aircraft.

12. It is recommended to the Ministry of Transport, Infrastructure and

Communications (as a Regulatory Authority for civil aeronautics activities in

Romania) to elaborate and promote a legislative initiative in order to produce a

regulation which will ensure performing random medical checks for the flight

crews before flight.

Note: The documents and analysis objects used for the issuance of the flight safety

investigation Report are confidential and are archived at the Civil Aviation Safety Investigation

and Analysis Authority, according to legal provisions.


Page 30 of 42

ANNEX 1

References to the “Sterile Cockpit” concept in EASA recommendations: AMC/GM TO ANNEX III (PART-ORO)


Page 31 of 42

References to the “Sterile Cockpit” concept in the Operations Manual of TAROM S.A

.


Page 32 of 42

ANNEX 2

IATA recommendations on cabin crew monitoring


Page 33 of 42


Page 34 of 42


Page 35 of 42


Page 36 of 42


Page 37 of 42

ANNEX 3

Reference in the Operations Manual of TAROM S.A., on the use of radio communication headsets by the pilots.


Page 38 of 42

ANNEX 4 (CRM)

EASA references regarding the CRM concept


Page 39 of 42


Page 40 of 42

Extracts regarding the CRM training from the Flight Crew Human Factors Handbook published by the UK CAA.


Page 41 of 42


Page 42 of 42

Date post:	17-Oct-2020
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times

FINAL REPORT - aias.gov.ro · Serious incident – ATR 42-500, YR-ATF – Bucharest-Otopeni Airport...

Documents