[PDF] Rapport final - version anglais

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MI

DES TRA

COM A

NISTERE D

RANSPORTS

-------MMISSION D'

ACCIDENTS

D'AVIATI

to

DE L'EQUIP

S ET DU DES----------

'ENQUETE S

S ET INCIDE

ON CIVILE

F o the Mc P

EMENT,SENCLAVEM

SUR LES

NTS FINAL A on 2 near cDonnell regi s operated MENT L REP

Acciden

24 July 2

r Gossi (

Dougla

s stered EC d by Swi UN PORT t 2014
Mali) s DC-9-8 C-LTV ftair S.A

Approved

N'F a REPUB

N PEUPLE -

T

3 (MD-83

d on 22 Apr aly CISSE LIQUE DU - UN BUT - 3) ril 2016 MALI

UNE FOI

2/170

Foreword

The aim of the safety investigation into civil aviation accidents and incidents is to establish the facts, the conditions and the circumstances of the accident or incident to determine the probable causes and the factors that caused it in order to be able to take the appropriate steps to prevent another accident or incident from occurring. In accordance with Annex 13 to the Convention on International Civil Aviation, the safety investigation is intended neither to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents.

SPECIAL FOREWORD TO ENGLISH EDITION

This report has been translated and published to make its reading easier for English- speaking people. As accurate as the translation may be, the original text in French is the work of reference. 3/170

TABLE OF CONTENTS

TABLE OF CONTENTS ........................................................................ ................................... 3 GLOSSARY ............................................................... .............................................................. 6 SYNOPSIS ............................................................... ................................................................ 8

ORGANISATION OF THE INVESTIGATION ........................................................................

10

1 - FACTUAL INFORMATION ........................................................................

....................... 12

1.1History of Flight.......................................................

................................................................ 12

1.2 Injuries to Persons ........................................................................

................................................. 15

1.3 Damage to Aircraft ........................................................................

................................................ 15

1.4 Other Damage ........................................................................

........................................................ 15

1.5 Personnel Information ........................................................................

.......................................... 16

1.5.1 Flight Crew ........................................................................

....................................................... 16

1.5.2 Cabin Crew ........................................................................

....................................................... 17

1.6 Aircraft Information ........................................................................

............................................. 18

1.6.1 Airframe ........................................................................

........................................................... 18

1.6.2 Engines ........................................................................

............................................................. 20

1.6.3 Monitoring of Maintenance Operations ........................................................................

........... 20

1.6.4 Weight and Balance ........................................................................

.......................................... 21

1.6.5 Systems Description ............................................................

..................................................... 22

1.6.6 Airborne Weather Radar ........................................................................

.................................. 37

1.7 Meteorological Information ........................................................................

.................................. 38

1.7.1 General Situation ........................................................................

.............................................. 38

1.7.2 Situation on the Day of the Accident ........................................................................

............... 38

1.7.3 Items Brought to the Crew's Attention ........................................................................

............ 39

1.7.4 Meteorological Conditions in the Aeroplane's Flight Sector.................................................... 40

1.7.5 Different Types of Icing ........................................................................

................................... 41

1.7.6 Situation Likely Encountered by the Aeroplane.............................................................

.......... 42

1.8 Aids to Navigation ........................................................................

................................................. 43

1.9 Telecommunications ........................................................................

.............................................. 43

1.10 Aerodrome Information ........................................................................

...................................... 43

1.10.1 Characteristics of Ouagadougou Aerodrome ..............................................................

........... 43

1.10.2 Ouagadougou Aerodrome Departure Procedures ................................................................... 44

1.11 Flight Recorders ........................................................................

.................................................. 45

1.11.1 Flight Recorder Opening and Readout Operations ................................................................. 45

1.11.

2 FDR data readout ........................................................................

............................................ 50

1.11.3 CVR data readout ........................................................................

............ 54 4/170

1.11.4 Regulations Relating to Magnetic Tape CVRs..............................................................

......... 57

1.12 Wreckage and Impact Information ........................................................................

................... 57

1.12.1 Description of Crash Site ........................................................................

............................... 57

1.12.2 Distribution of Wreckage ........................................................................

............................... 58

1.12.3 Controls and Control Surfaces.................................................

............................................... 62

1.12.4 Engines ........................................................................

........................................................... 64

1.12.5 Landing Gear ........................................................................

.................................................. 64

1.12.6 Emergency Locator Beacon ........................................................................

.... 65

1.12.7 Summary ........................................................................

........................................................ 65

1.13 Medical and Pathological Information ........................................................................

.............. 66

1.14 Fire ........................................................................

........................................................................ 66

1.15 Survival Aspects ........................................................................

.................................................. 66

1.16 Tests and Research ........................................................................

.............................................. 66

1.16.1 Questions Relating to Flight Crew Flight Time Limitations .................................................. 66

1.16.2 Erroneous EPR Measurement........................................................................

......................... 68

1.16.3 Evolution in Engine Parameters during Event .......................................................................

70

1.16.4 Flying behind the power curve ........................................................................

....................... 74

1.16.5 Determination of Activation of Anti-icing Devices ............................................................... 75

1.16.6 Stall ........................................................................

................................................................. 77

1.16.7 Disengagement of Automated Systems ........................................................................

.......... 84

1.16.8 Operational Ceiling ........................................................................

........................................ 84

1.16.9 Visual and Aural Warnings ........................................................................

............................ 85

1.16.10 Study of Events Involving Speed Decreases and Approach to Stall on MD80 .................... 86

1.17 Information on Organisations and Management ..................................................................... 90

1.17.1. Operator ........................................................................

......................................................... 90

1.17.1.6 Stationing of Swiftair SA crews for charter purposes ......................................................... 96

1.17.1.7 Flight crew employment framework ........................................................................

........... 96

1.17.1.8 Operator's conversion course (OCC) ........................................................................

.......... 97

1.17.1.9 Recurrent training and checking ........................................................................

.................. 98

1.17.1.10 Flight preparation in Ouagadougou ........................................................................

......... 100

1.17.1.11 Charter terms ........................................................................

........................................... 100

1.17.2 Oversight of the Operator by the Authority ........................................................................

. 101

1.17.3 Air Traffic Control Organisations ........................................................................

................ 102

1.17.4 Organisations responsible for Search and Rescue (SAR) .................................................... 104

1.18 Additional Information ........................................................................

.......... 109 1.18.

1 Testimony ........................................................................

..................................................... 109

1.18.2 Type Certification and Continuing Airworthiness ............................................................... 112

1.18.3 Previous Accidents and Recommendations ........................................................................

.. 113

2. ANALYSIS ........................................................................

............................................... 116

2.1 Scenario ........................................................................

...................... 116

2.2 Procedures for Activation of Anti-icing Systems ...................................................................... 120

2.3 Approach to Stall and Recovery ........................................................................

........................ 121

2.4 SAR ........................................................................

....................................................................... 122 5/170

2.5 Feedback ........................................................................

.............................................................. 123

3. CONCLUSION ........................................................................

......................................... 124

3.1 Findings ........................................................................

................................................................ 124

3.2 Causes ........................................................................

................................................................... 125

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

............. 127

4.1 Recommendations issued during previous investigations and relevant to the analysis of the

accident to flight AH5017 ........................................................................ ......................................... 127

4.1.1 Accident on 16 August 2005 to the DC-9-82 (MD-82) operated by West Caribbean

Airways ....................................................................... .................................................................... 127

4.1.2 Serious incident on 4 June 2002 to the DC-9-82 (MD-82) operated by Spirit Airlines .. 128

4.1.3 Accident on 1 June 2009 to the Airbus A330-203 operated by Air France ..................... 128

4.2 Interim Recommendations ..................................................................

....................................... 128

4.3 New Safety Recommendations ........................................................................

........................... 129

4.3.1 Anti-icing protection devices .......................................................................

........................ 129

4.3.2 Stall in cruise on MD80 type aeroplanes and associated training .................................... 130

4.3.3 CVR .......................................................................

................................................................ 131

4.3.4 SAR .......................................................................

................................................................. 131 LIST OF APPENDICES ........................................................................ ............................... 132 APPENDIX 1 FDR PARAMETERS ........................................................................ ............. 133 APPENDIX 2 TRANSCRIPT OF ATC COMMUNICATIONS FROM OUAGADOUGOU ATC SERVICES .................................................................... ....................................................... 141 APPENDIX 3: TRANSCRIPT OF ATC COMMUNICATIONS FROM NIAMEY CONTROL CENTRE ........................................................................ ....................................................... 151 APPENDIX 4 IR SATELLITE IMAGE OF METEOROLOGICAL SITUATION .................... 155 APPENDIX 5 SUMMARY OF TRAINING AND CHECKS UNDERTAKEN BY THE CREW ...................................................................... 156

APPENDIX 7 CHRONOLOGY OF EVEN

TS AT THE NIAMEY ACC .................................. 158 APPENDIX 8 FAA INFORMATION FOR OPERATORS ..................................................... 161 APPENDIX 9 EASA SIB ........................................................................ .............................. 163

APPENDIX 10 BOEING INFORMATION ........................................................................

.... 164 APPENDIX 11 FCOM PROCEDURES ........................................................................ ........ 165 6/170

GLOSSARY

AAIB Air Accident Investigation Board (United Kingdom)

ACC Area Control Centre

AOA Angle of Attack

AOC Air Operator Certificate

AP Autopilot

ATC Air Traffic Control

BEA Bureau d'Enquêtes et d'Analyse pour la sécurité de l'aviation civile (French Safety

Investigation Agency)

CIAIAC Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (Spanish civil aviation accident and incident investigation commission)333

CRM Crew Resource Management

CSMU Crash Survivable Memory Unit

CVR Cockpit Voice Recorder

DFGC Digital Flight Guidance Computer

DGAC Direction Générale de l'Aviation Civile (French Civil Aviation Administration)

EASA European Aviation Safety Agancy

EGT Exhaust Gas Temperature

EPR Engine Pressure Ratio

ETOPS Extended-range Twin-engine Operation Performance Standards

FAA Federal Aviation Administration (USA)

FAR Federal Aviation Regulation

FCL Flight Crew Licensing

FCOM Flight Crew Operations Manual

FD Flight Director

FDR Flight Data Recorder

FGCP Flight Guidance Control Panel

FIR Flight Information Region

FL Flight Level

FMA Flight Mode Annunciator

FMS Flight Management System

GPS Global Positioning System

ICAO International Civil Aviation Organisation

ITCZ Inter-Tropical Convergence Zone

LMC Last Minute Change

MEL Minimum Equipment List

METAR METeorological Aerodrome Report

MLW Maximum Landing Weight

MMO Mach Max Operating

NASA National Aviation and Space Administration

ND Navigation Display

NM Nautical Mile

NTSB National Transportation Safety Board (USA)

P/N Part Number

PFD Primary Flight Display

PNC Personnel Navigant Commercial

QNH Altimeter sub-scale setting to obtain elevation when on the ground,

RPM Revolution Per Minute

S/N Serial Number

SAFA Safety Assessment of Foreign Aircraft

SAR Search And Rescue

SAT Static Air Temperature

SIB Service Information Bulletin

7/170

SIGMET Significant Meteorological Information

STC Supplemental Type Certificate

TAF Terminal Area Forecast

TAT Total Air Temperature

THS Trimmable Horizontal Stabilizer

TRP Thrust Rating Panel

UTC Universal Time Coordinated

VMO Maximum Operating Limit Speed

8/170

SYNOPSIS

Aircraft MD-83

1 registered EC-LTV

Date and time 24 July 2014 at 1 h 47

2

Operator Swiftair S.A.

Place of accident 80 km south-east of Gossi, Mali

Type of flight International public transport

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