Would appear no one on the flight deck was qualified to be on the flight deck.
Question from SLF
Are engineers not qualified to be on the flight deck? When testing shall always a qualified person be present? Can you define a qualified person? I am intrigued because of the last posts I cannot understand what is the difference between qualified to fly and qualified to be on the flight deck? Thanks
I have an engineer instructor friend who used to make a living training engineers in simulators to qualify them to do this sort of thing. I think they used the same full-flight sims as the aircrew but perhaps they used fixed-base training devices; I never asked closely but I know that it certainly isn't just a matter of "Hop in there and give that thing a full-power run-up, would you?"
Perhaps it was the first time he had done this without other, more senior, Airbus people there to keep an eye on things. Probably the last time, too!
Typically a licenced engineer will have had a level 3 course on the aircraft/engine and then a run up and taxi course for that specific aircraft. More often than not run up training is conducted in the same simulators used for the pilots because of the high cost of running live aircraft. All personnel operating the aircraft panels will be qualified. This is a necessity from the stand point of insurance purposes.
While you are doing the engineers licence course on the particular type of aircraft you will have several sessions in the simulator. If you are very luck you get the full motion one but normally it is the fixed base type.
During the sessions all the procedures are gone through, including problems, with the instructor putting faults in to the system to get you to trouble shoot. At the end of the course you are licenced to carry out all the relevent tasks on the aircraft, including engine runs at what ever power is necessary.
All the info is in the AMM together with safety items, such as only running two engines (on a 4 engine A/C) at a high power one on either wing with the opposite one to the problem at a mid power range for balance reasons.
You have to realise that when running at significant power the aircraft is jumping about quite a bit and it may not be obvious that you are moving initally.
I've been on several engine runs and taxying with Engineers at the controls. Although a pilot I was certainly not qualified to fly or taxi that particular four engined turboprop. I handled the radio and touched nothing else. The Engineers were in charge and fully experienced. It was quite routine.
This was not translated by the BEA. Although efforts were made to translate as accurately as possible, only the French version is authentic. If there is a difference in meaning of texts between this english version and the French version, text in the french version is correct.
Accident on November 15, 2007 at Toulouse Blagnac Airport to Airbus A340-600 serial number 856
This report presents the technical conclusions reached by the BEA on the circumstances and causes of this accident. In judicial terms, this occurrence does not constitute an aviation accident or incident, since none of the people on board intended to perform a flight. Nevertheless, the term 'accident' will be used in this report, as commonly understood and accepted. In accordance with Annex 13 of the Convention on International Civil Aviation, with EC directive 94/56/CE and with Law N°99-243 of 29 March 1999, the investigation of the accident 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. Consequently, the use of this report for any purpose other than for the prevention of future accidents could lead to erroneous interpretations.
Table of Contents
Organization of the investigation
1 – FACTUAL INFORMATION 1.1 Summary of the event 1.2 Injuries and fatalities 1.3 Aircraft damage 1.4 Other damage 1.5 Personnel information 1.5.1 Persons on the flight deck 1.6 Aircraft information 1.7 Meteorological conditions 1.8 Communications 1.9 Airfield information 1.10 Flight recorders 1.10.1 CVR 1.10.2 FDR 1.10.3 Readout of the flight recorders 1.11 Information on the site and the wreckage 1.12 Medical and pathological Information 1.13 Tests and research 1.14 Information on the organizations and management 1.15 Additional information 1.15.1 Testimonies
2 – ANALYSIS 2.1 Test procedure 2.2 Reactions in the cockpit 2.3 Oversight of these activities
3 - CONCLUSIONS 3.1 Findings of the investigation 3.2 Causes of the accident 3.3 Measures taken following the accident
4 – SAFETY RECOMMENDATIONS
AESA Agence Européenne de la Sécurité Aérienne AMM Aircraft Maintenance Manual BEA Bureau d'Enquêtes et d'Analyses
(BEAD-Air) Bureau Enquête Accidents Défense Air CAM Customer Acceptance Manual CEV Centre d’Essais en Vol CVR Cockpit Voice Recorder EPR Engine Pressure Ratio FDR Flight Data Recorder GSAC Groupement pour la Sécurité de l’Aviation Civile JAR Joint Aviation Rules UTC Coordinated Universal Time
Date of accident Thursday November 15, 2007 at 1610 hrs (1)
Aircraft Airbus A-340-600 Registered as F-WWCJ
Location of accident Toulouse Blagnac Airport
Purpose of flight Engine ground run test
Persons on board 9
Note (1): Unless stated otherwise, the times quoted in this report refer to Coordinated Universal Time (UTC). One hour should be added to obtain the local time in France at the time of the event.
1- FACTUAL INFORMATION
1.1 Summary of the event
On 15 November 2007, the Airbus A-340-600 F-WWCJ was undergoing static engine ground runs on the Toulouse-Blagnac airfield. The purpose was to test various systems with technicians of the airline that had ordered the aircraft. No wheel chocks were used. On completion of these tests, after having stopped and inspected the engines, the technicians started the engines again for another engine run at high power to find the origin of oil leaks.
Approximately three minutes after power up, the aircraft began to move forward. The technician in the left seat perceived the motion and informed the Airbus technician in the right seat. The latter acted on the brake pedals and then released the parking brake. The DFDR (digital flight data recorder) then indicates a partial release of the brake pedal command. Since the aircraft continued to move forward, he tried to modify its trajectory by using the nose wheel steering. The nose wheel gear quickly skidded sideways as the aircraft accelerated. The aircraft struck the slope of the anti-blast wall. The forward fuselage broke and fell down on the other side of the wall.
There were thirteen seconds between the start of aircraft movement and the collision with the wall.
1.2 Injuries and fatalities
Fatal - 0 Serious - 4 Slight/None – 5
1.3 Aircraft damage
The aircraft was destroyed.
1.4 Other damage
The anti-blast wall was damaged.
1.5 Personnel information
The ground tests during the customer delivery phase are performed under the responsibility of only one ground test technician, an Airbus employee. He was usually accompanied by one or more persons representing the customer, and sometimes by other Airbus employees. Airbus had no special qualification requirement toward the customer representatives attending testing. The representatives of the customer sitting in the cockpit normally had observer roles, but it could happen that the ground test technician allowed the representative of the customer to participate, for example by allowing him to taxi.
During this test, the technician in charge of ground testing was in the right seat, an aeronautical technician representing the customer was in the left seat and a flight test engineer was on the jump seat. The customer representative and the flight test engineer had no specific function in the aircraft handling. The role of the customer representative was to observe the parameters during testing to ensure compliance with the requirements of the customer.
1.5.1 Persons on the flight deck
188.8.131.52 Ground test technician in the right seat:
Male, 41 years old, Airbus employee, responsible for the test
• Line maintenance technician since 1992
• Ground test technician since 1998
• Course for engine tests and ground runs on A330 - A340 in 1998.
• RR Trent 500 familiarization course in May 2000
• Attached to the Flight Test / Aircraft Delivery Department since 2004
• Flight test engineer since 2004
• Recurrent training for A-330/340 engine test in October 2006
184.108.40.206 Aeronautical technician in the left seat:
Male, 36 years old, employee of a maintenance company (GAMCO), which maintains the Etihad Airlines aircraft and carries out their acceptance tests.
• Technician for the GAMCO company since 1997
• Courses at Lufthansa Technik and Airbus in 2002
• A-340-600 engine ground run training in 2006
220.127.116.11 Flight test engineer on the jump seat:
Male, 42 years old, Airbus employee
• Flight test engineer in 2000
• Attached to the Flight Test / Delivery Department since 2000
• Authorized to perform engine tests on Airbus family aircraft
• Commercial airplane pilot since 1998
• A-320 type rating in 2004
• ATR-42 type rating in 2006 1.6 Aircraft Information Airframe:
• Manufacturer: Airbus
• Type: A340-600
• Serial Number: 856
• Provisional Registration: F-WWCJ Engines:
Engine #1 Engine #2 Engine # 3 Engine #4 Manufacturer Rolls-Royce Rolls-Royce Rolls-Royce Rolls-Royce
Type Trent Trent Trent Trent
556A2-61 556A2-61 556A2-61 556A2-61
Serial Number 71492 71490 71491 71493 Total Time 24 h 26 h 24 h 23 h
Engine control parameter
The thrust of the A-340-600 engines is expressed in terms of the EPR (Engine Pressure Ratio) which represents the ratio of total pressure between the turbine outlet and compressor inlet. This ratio varies approximately between 1 (ground idle) and 1.41 (full thrust, or around 28000 daN).
Weight and balance
The aircraft weight was 223 tons including 40 tons of fuel, and the CG was at 25.8%. Ground tests are usually performed with 80 tons of fuel. The maximum certified take-off weight is 380 tons.
Description of the system
The A-340-600 has two Main LG, one on the right side and one on the left, one Central LG and one Nose LG. Each MLG and the CLG have 4 wheels each. The CLG is slightly aft of both MLG. Each MLG wheel and CLG wheel is equipped with a braking system, and each brake is powered by two independent hydraulic systems. The NORMAL braking pressure is controlled through the green system. The blue system powers the ALTERNATE braking.
When the parking brake is set, the blue system applies 2500 psi to both MLG. The CLG brakes are not operated by the parking brake.
When the brake pedals are pressed, the green system operates both MLG and the CLG, with the amount of pressure applied depending of the position of the brake pedals. The green system pressure is inhibited as long as the parking brake is activated.
If the parking brake is released while simultaneously pressing on the brake pedals, the system allows both circuits to be pressurized together, while the ALTERNATE circuit depressurizes. This applies only to both MLG and the total amount of pressure from both circuits is limited to 2770 psi.
In addition, the braking of the CLG wheels is automatically reduced when the nose wheels are steered. When the nosewheel steering command is greater than 20 degrees, the CLG braking is completely inhibited.
The JAR25.735d regulation for certification indicates that the parking brake must be designed to prevent the aircraft from moving on a dry paved runway with one engine at maximum thrust, the others being at ground idle. In these circumstances, the A-340-600 parking brake must develop a minimal braking force of 28000 daN or 3500 daN per braked wheel. The system was designed to develop a braking force of 8500 daN per braked wheel with a brake pressure of 2500 psi.
1.7 Meteorological conditions
At 1600 hrs, the meteorological conditions measured at the Toulouse Blagnac airfield were:
-Wind 330°/16 knots, visibility greater than 10 km, cloud cover few at 4100 feet, temperature 5°C, dewpoint -5°C, QNH 1019 hPa.
The ground test technician, who taxied the aircraft, was in contact with the ground controller of the St-Martin watchtower. This frequency, specific to Airbus, makes it possible to control the traffic during the taxiing of aircraft on the Airbus site of the Toulouse Blagnac airfield.
1.9 Airfield information
The accident occurred on the BIKINI ramp. This area is dedicated to testing and is part of the manufacturer's facilities.
No grip data for the surface of the test area were available before the accident. To enable a quantitative analysis of the braking performance, it was necessary to undertake measurements of slipperiness. These measurements were carried out in conditions close to those on the day of the accident. The measured friction coefficients were between 0.65 and 0.68. These values correspond to the coefficient of a dry runway in good condition.
1.10 Flight recorders
In accordance with the applicable regulations, the aircraft was equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR).
The CVR is a recorder with static storage capable of storing the last two hours of recording.
• Manufacturer: L-3 Communications
• Model: FA 2100
• Type Number: 2100-1020-02
• Serial Number: 455462
The following tracks are recorded:
1. VHF and mouth microphone from the third seat (rear location) 2. VHF and mouth microphone from the captain’s seat (left side) 3. VHF and mouth microphone from the first officer's seat (right side) and FSK signal 4. Area microphone
The recording quality was good and lasts a little more than two hours. The event has been recorded in its entirety.
The FDR is a recorder with static storage capable of reproducing at least the last twenty five hours of recording.
• Manufacturer: L-3 Communications
• Model: FA 2100
• Type Number: 2100-4043-02
• Serial Number: 440952
The data are of good quality and the event could be identified at the end of the recording. The graphs of the recorded significant parameters appear in the annex.
1.10.3 Readout of the flight recorders
The CVR and FDR have been synchronized using the UTC time recorded in the FDR and the “Master Caution” “Single Chime” identified on the CVR.
The aircraft arrives at the BIKINI area approximately 14:19 It is at a magnetic heading of 312 degrees. The parking brake is set and active.
During the tests between 14:19 and 14:58 the maximum EPR values are between 1.04 and 1.22
The last engine ground run is started at 15:58. The aircraft is still not moving.
Between 15:58:10 and 15:59:03 the thrust is increased gradually from idle to a steady value of 1.25 EPR. This engine thrust setting corresponds to a position of the thrust levers between MCT (Max Continuous Thrust) and MTO (Max Take Off Thrust).
The ALTERNATE pressure values are close to 2600 psi for the wheels 1,2,5,6 (left gear) and 3,4,7,8 (right gear). They are at 64 psi for the wheels 9,10,11,12 (central gear) (2).
Note (2): Brake pressure values are recorded in increments of 64 psi
At 16:02:06 the person in the right seat starts talking but is interrupted at 16:02:08 by the person in the left seat who announces :
“Euh ... cabin is ... aircraft is moving forward”
The first significant LONGITUDINAL ACCELERATION parameter values showing a forward acceleration of the aircraft are observed around 16:02:07. The recorded ground speed starts to increase at 16:02:09 (3)
Note (3): Ground Speed values are recorded in increments of 1 kt.
Between 16:02:08 and 16:02:13 the ground speed increases from 0 to 4 kt.
At 16:02:11 the person on the left seat again says :
“Aircraft is moving forward”
An action on the brake pedals is recorded from around 16:02:11
The parking brake is deactivated around 16:02:13 The person on the right seat announces :
“Parking brake off”
From the moment the park brake is released:
• the brake pedals are briefly released on two occasions
• the ALTERNATE circuit braking pressures drop below 192 psi
• the NORMAL circuit braking pressures on the MLG are consistent with the brake pedals position on both right and left sides, and increase from 300 to 2500 psi in one second
• the NORMAL circuit braking pressures for the CLG reach a maximum of 192 psi at 16:02:14 and then decrease to 64 psi and stabilize at that value
• the wheel speed values which were still recorded as zero (the sensors do not work until a wheel speed of 3 to 5 kt) become positive and are consistent with recorded ground speed and aircraft movement
• the recorded ground speed increases rapidly from 4 to 31 kt in seven seconds Between 16:02:13 and 16:02:15 the command given from the right-hand side to the NWS (Nose Wheel Steering) goes from 0 to -75 degrees (full right command against the stops). The evolution of the nose wheel angle until impact is consistent with that command. From 16:02:15 the magnetic heading of the aircraft begins to increase; it goes from 312 to 349 degrees in seven seconds.
The angle of the nose gear reaches 77 degrees right at 16:02:19 and remains at that value until the end of the recording. From 16:02:18 we can hear on the CVR severe vibration noises followed by impact noises.
The thrust levers did not move until 16:02:20 when they are retarded to the IDLE detent. The EPR values of the 4 engines start to decrease immediately afterward.
The longitudinal acceleration becomes significantly positive, indicating an aircraft deceleration, around 16:02:20.5
FDR recording ends between 16:02:21 and 16:02:22 CVR recording ends at 16:02:23
1.11 Information on the site and the wreckage
The aircraft was involved in a collision with the anti-blast wall located at the north side of the BIKINI ramp. It came to rest leaning on the wall, pointing to the north. The tail cone and the tip of the right wing were in contact with the ground. Only the right MLG was touching the ground.
The aircraft had struck the anti-blast wall at an angle of about 30 degrees. The underside of the forward cabin was torn over about fifteen meters and folded to the ground when passing the anti-blast wall.
The cockpit crashed to the ground north of the wall. The avionics bay containing most of the flight control computers, located under the cockpit, was completely destroyed.
Engine #1 and #2 hit the wall and were severely damaged. The #2 pylon was twisted. Engine #3 and #4 kept running after impact and did not stop immediately. It was not possible to shut them down, neither by activating the fire extinguisher handles nor by positioning the thrust levers on OFF. Water and foam spray on engine #4 managed to extinguish it at 18:48.
Due to the proximity of the wall this was not was not possible with engine #3 in a similar manner to engine #4. It shut down by itself only on November 16 at 01:25 after it had consumed all the fuel from its collector tank.
The NWG was broken and separated from the fuselage. The wheels were oriented to the right and had a steering angle close to the maximum value. The nosewheel tires had cuts in them, and showed marks of rubbing at right angles to the tread.
Ground tire traces
For the following descriptions, the distance reference is taken from the point of impact on the wall, and back along the aircraft trajectory.
A first tire trace, corresponding to one of the internal wheels of the right MLG, is visible starting at 120 meters over a length of approximately 10 meters. The trace of the external tires is present but less marked. Those traces are oriented along an axis with a magnetic heading of 330 degrees. No trace of the left MLG tires was observed.
At 83 meters, we can see the first NWG marks. They curve toward a northerly heading. They are initially parallel, then at 50 meters converge to leave only one single trace. By then, the NLG is no longer directional.
Symmetrical braking traces from both MLG are present from around 60 meters until the wall.
1.12 Medical and pathological information
The investigation did not highlight any medical anomalies likely to have deteriorated the capacities of the occupants.
1.13 Tests and research
The recording of a video camera permanently filming the BIKINI area was reviewed. It shows the aircraft during the last test. At first the aircraft moves slowly then suddenly accelerates. While the path begins to slowly turn to the right, the NLG starts skidding sideways. The plane continues on its path until it hits the wall. The forward section rises, falls back on the wall and the fuselage breaks. There are flames at engines #1 and #2 as well as on the aft section of the aircraft.
By looking at the recordings from several days before the accident, it can be seen that some tests are carried out with wheel chocks and some others without.
Analysis of braking force and surface grip
The braking system of the aircraft has been modelized, in order to better understand the cause of the aircraft having started to move. The modelling uses the theoretical system functioning as described in paragraph 1.6 and is based on the values of the brake pressure parameters recorded by the FDR. The values of the EPR parameters of the four engines have also been used to determine the total thrust.
For each of the braked wheels, the maximum braking force created by the brake pressure is determined based on the specification of the brakes, as a function of the recorded pressure. The overall braking force is obtained by summing the braking forces from the 12 wheels. When the parking brake alone is used, the brake pressure on the CLG wheels is zero and only the MLG wheels contribute to braking.
Slip resistance force
For each of the wheels, the value of the slip resistance is equal to the weight supported by the wheel multiplied by the friction coefficient μ between tire and tarmac. The simulation allows computation of the limit friction coefficient value below which the wheels would slip, under certain mass distribution assumptions. In the same way, the forces of slip resistance for each of the wheels are summed to obtain the overall slip resistance force.
The thrust of the engines was calculated from the recorded EPR parameters and from manufacturer data, based on the day conditions (320 ft, nil speed, ISA -9C, no bleed air from engines). It stabilized at approximately 83500 daN.
The model allows calculation of the theoretical changes in thrust and the maximum braking force developed by the braking system, and compare these to the slip limit force above which the wheels start to slip. For the aircraft to remain motionless, it is necessary that the thrust is less than both the maximum braking force developed by the system and the slip limit force.
Throughout the last test, the thrust of the engines and the maximum braking force on the parking brake are very close. To obtain under the same conditions a slip limit force equivalent to the thrust force, a friction coefficient μ of 0.687 is necessary. Given the measured friction coefficient values, it is reasonable to believe that the aircraft was quickly on the edge of slipping.
The fact that a balance, even fragile, has existed for about three minutes confirms that the brakes were functioning in accordance with their specifications.
Therefore, modeling has allowed to establish, with a reasonable confidence level, that during the last test the thrust and braking forces compensated each other, but that the balance of those forces was particularly precarious.
Thus, the aircraft remained motionless with 8 wheels braked through the parking brake, then started moving. Several factors may have contributed to the aircraft starting to move, notably :
• the vibrations created by the engines
• the reduction of weight due to fuel consumption (about 1270 kg)
• a slight local brake pressure reduction on one of the wheels
When the parking brake was released, the application of the brake pedals never allowed to attain the same level of braking action despite the fact that brakes were applied to 12 wheels. This is due to two factors: first, the actions on the brake pedals were not sustained at the maximum level, and, secondly, the action on the NWS very quickly led to inhibiting the CLG braking. The resulting braking during the motion varied between 65 and 95% of the braking level obtained before the aircraft movement.
Last edited by punkalouver; 24th Feb 2009 at 02:26.
The aircraft had completed the necessary tests for the certificate of airworthiness. It was in the phase of delivery to the customer.
The delivery of an aircraft to a customer is effected on the basis of the CAM 'Customer Acceptance Manual) drawn up by Airbus. This manual consists of three sections. The first section concerns the checks to be performed on the ground, without the engines running. The second concerns the engine ground runs. Finally, the third one deals with acceptance flight testing. The manual takes the form of a list of actions and checks that the manufacturer proposes to carry out in the presence of the customer. In practice, the customer can request additional checks.
In the customer delivery manual, the seat occupied by the representative of the customer during ground tests is not specified. In practice, the representative of the customer is generally in the left seat. He takes note with the Airbus technicians of the parameters to be monitored.
The Aircraft Maintenance Manual (AMM) and the CAM (Customer Acceptance Manual) state that the engines tests must be carried out with the use of wheel chocks for the MLG.
The CAM uses tasks listed in the AMM. Thus, there is in the AMM a procedure to search for oil leaks called “Fuel and Oil Leak Test”. This procedure calls for testing with two engines in operation. These engines must be the symmetrical engines of each wing. For the engine on which the oil leak is sought, the maximum thrust value of the day must be applied (1.25 EPR that day, corresponding to the maximum value for this type of test). For the opposite engine the EPR value to be applied is 1.145. These actions are carried out by memory.
Until 21 July 2008, on behalf of the DGAC (4), the "Groupement pour la Sécurité de l'Aviation Civile" (GSAC) provided oversight of Airbus production in France for the following phases:
• manufacture of aircraft components
• aircraft assembly
• ground testing and flight testing
• delivery to customers
Note (4): This oversight is today the responsibility of the European Aviation Safety Agency. Under the terms of an EASA contract, the GSAC will continue to act under the authority of the DGAC.
This oversight continues until the issuance of the certificate of airworthiness (aircraft to be registered in France), the certificate of airworthiness for export (aircraft exported outside the EU), or the certificate of conformity to type (aircraft exported to another EU country). The issuance of these documents takes place after ground and flight testing, the delivery flight to the customer and the transfer of ownership. The purpose of the GSAC oversight is to ensure that the aircraft is delivered in accordance to certified standards and in an airworthy state. It does not ensure the safety of ground and flight testing.
The GSAC has no personnel with specific skills for the supervision of ground and flight testing. In France, the Flight Test Center (CEV) is responsible for testing activities of civilian and military aircraft. A 1st of June 1999 regulation directs organizations engaged in testing and acceptance of aircraft to file with the director of CEV, an operations manual laying down rules and procedures to implement these activities so that air testing and acceptance tests are carried out under satisfactory conditions of safety. This regulation does not provide for oversight by the authority of the application of the procedures described in the manual. The manual filed by Airbus does not address the ground test procedures.
Training of ground test technicians
After a theoretical phase of familiarization with the aircraft systems, trouble-shooting and functional tests, ground test technicians take training courses for cabin crew, courses in radiotelephony and taxiing.
The next phase is practical during which the trainee works with an instructor. The following points are notably addressed:
• ground tests
• low speed taxi
• participation in accelerate-stops
• production flights
• carrying out tests in the Customer Acceptance Manual and associated tests
• use of technical documentation and software
• training in pressurization tests. Practical parts of this training are accomplished in the airplane and in the simulator.
A refresher session is performed in a simulator every two years for all ground test technicians.
1.15 Additional information
Ground test technician on the right seat After conducting the ground tests, the client company technicians noticed an oil seepage on the pipe of one engine. Hence, the ground test technician decided to carry out another test before leaving. He increased the thrust in order to heat up the engine oil. After approximately three minutes, as he was looking inside the cockpit, he heard the person sitting on the left seat announcing that the plane was moving. He then noticed the movement himself. He released the parking brake in order to use normal braking. When the aircraft continued to move forward he thought there was a brake problem. He then tried to change the trajectory of the aircraft using the NWS. He testified to have often carried out this kind of test, but at a higher aircraft weight.
Aeronautical technician on the left seat During the last test at high thrust, he perceived the motion of the aircraft by looking outside. He felt jolts that he believed were caused by the brakes. He noted the ineffectiveness of the NWS action. He did not touch any controls. He specifies the high thrust test was performed to thin the oil in order to detect any seepage.
Flight test engineer on the jump seat He attended as an observer for his first A-340-600 delivery. During the last high thrust test, he heard the person on the left seat announcing that the plane was moving. Given the vibration environment generated by the high thrust setting, he was unable to perceive the accelerations caused by the aircraft movement. He only remembers to have grabbed and retarded the thrust levers when seeing the wall very close.
The ground personnel They watched the end of the tests. Before leaving the testing area, the technician on the right seat told them to move further away from the aircraft as he was going to proceed to a last high thrust test. They positioned their vehicle in front of the aircraft then moved further away on the side when thrust was set. They then saw the plane moving, initially slowly then faster. They saw it hit the wall. They raised the alarm.
Wheel chocks are not always used because their use is restrictive. Sometimes, it happens they stay trapped under the tires after the tests. This requires the plane to be pushed back to remove them.
Note: It is clear from discussions with other Airbus technicians that this kind of test, including with 4 engines at high thrust, are frequent. All confirm that the use of wheel chocks is not systematic. Finally many emphasize the pressure from the customers to go and check some details. This leads sometimes to conducting tests outside the scope of the Customer Acceptance Manual.
2.1 Test procedure
Although the reference documents require using wheel chocks during engine tests, the investigation showed they were not systematically used. Similarly, during the test for detecting oil leaks, it often seems that the procedure to apply thrust on 2 engines only is not respected.
The industrial and commercial issues that are associated with the delivery activities may lead to induce time pressure on testing technicians during this phase.
The presence of representatives of the customer on board during the delivery phases can create pressures inducing testing technicians to not respect their frame of reference.
2.2 Reactions in the cockpit
The ground test technician’s concentration was on the braking system for about ten seconds. He did not think to retard the thrust levers. This can be explained by his focusing on the braking problem, by the dynamics of the situation and by the lack of training for this kind of situation.
The persons in the left seat and jump seat were present only as observers. The aeronautical technician in the left seat did not intervene on the controls until impact. The flight test engineer intervened, but late, to retard the thrust levers. This can be explained by his statute, the fear of interfering with the actions of the technician and also by the dynamic of the situation.
2.3 Oversight of these activities
The regulations relating to the tests and acceptances does not envisage oversight by the regulating authority of the activities of tests and reception of aircraft. Thus the control of these activities is implicitly delegated to the manufacturer.
3.1 Findings of investigation
• The aircraft, including its braking system, operated in accordance with its specifications
• The accident occurred in the delivery phase of a unprogrammed test
• The procedure was not in conformity with the task “Fuel and Oil Leak Test” listed in the AMM. In particular, it was carried out at high thrust on all engines without the use of wheel chocks
• Testimonies and video recordings indicate that engine tests are regularly carried out without wheel chocks
• The thrust used on the engines was at the same level as the nominal braking capacity of the parking brake
• When the aircraft began to move, the ground testing technician pushed on the brake pedals and released the parking brake
• The ground testing technician turned the NWS to the right. This action, by inhibiting the CLG braking, limited the braking effectiveness
• The actions on the brake pedals were not sustained to the maximum level
• The flight testing engineer retarded the thrust levers when the plane hit the anti-blast wall
3.2 Causes of the accident
The accident is due to the run up on all 4 engines at the same time, without wheel chocks, and during which the total engine thrust was close to the parking brake capacity.
The lack of a detection process and deviation correction in the ground test procedure, in a context of industrial and commercial pressure, promoted the operation of a test outside of the established procedures.
The sudden onset of aircraft movement led the ground testing technician to focus on the braking system; therefore he did not think to reduce the thrust of the engines.
3.3 Measures taken following the accident
The Customer Acceptance Manual has been revised (May 2008) to strengthen the instructions to follow when conducting an engine ground run. This includes:
• installing wheel chocks on all MLG wheels (and all CLG wheels if applicable)
• mandatory presence of two qualified persons at the controls during run up and taxiing. In this same revision of the CAM, the conditions for performing engine runs at high power settings on four-engine aircraft have been modified. Such engine runs will, from now on, be performed only on two engines at a time, run symmetrically. An internal note (EVR 473.0025/08) has been distributed to all operators of the aircraft in January 2008. This note specifies that re-tests should no longer be carried out during the same customer engine ground run (for instance for the detection of oil seepage, as happened the day of the accident). Such additional tests should be the object of a new and separate engine ground run, and not until after the problem has been reviewed at the aircraft delivery centre. The radio communication phraseology with 'St-Martin Traffic' for the operations at Toulouse and 'Finki Tower' at Hamburg Finkenwerder has been improved, so as to assure that the engine runs will not be started until the chocks are in place: from now on, the aircraft operator will have to confirm that the chocks are in place before announcing the start of the engine runs. This modification has been introduced in June 2008 for Toulouse and in July 2008 for Hamburg Finkenwerder. It has been documented through internal notes (ME 0818073 and EVRG 473.4215/2008). Airbus has stated that they will be creating a new document dealing with ground tests. This document, titled "Ground Operations Manual", is currently being written. As far as training is concerned, the engine ground running "refresher course" performed on the simulator (once every two years) will be completed for each ground test technician by an internal audit carried out during a ground engine run by a "senior" technician, in order to improve the transfer of knowledge and experience. Also, the simulator session will be enhanced by the treatment and analysis of failure cases that may occur on "customer ground run" tests. 4. Safety Recommendations
The investigation highlighted repetitive deviations from the operational procedures for the conduct of ground tests, as drawn up by the direction of the ground and flight test department.
Taking into account the risk that these deviations comprise, it is necessary to guarantee that the procedures are effective and are applied, including for the other stages of the delivery.
The delivery is part of the production process supervised by EASA (European Aviation Safety Agency), and the ground and flight tests of aircraft are placed, in France, under the supervision of the CEV (Centre d’Essais en Vol).
Consequently the BEA and the BEAD-Air recommend:
• that EASA and the CEV evaluate the procedures used at the time of ground tests and of customer delivery flights, and ensure they are properly applied.
Last edited by punkalouver; 24th Feb 2009 at 00:28.
I have tried to make a 100% translation of the report posted by CONF iture, with much help from the previous one posted. If someone else takes the time to compare this one to the actual report to find any mistakes, however minor and then post them or send them to me I would be grateful as I had to put some things into my own words to sound proper in english.
1. Cours essais et points fixes moteurs A 330 - A 340 réalisé en 1998
Courses in testing and ?specific procedures? in A 330 and A 340 engines taken in 1998.
2. 64 psi est la résolution d’enregistrement des paramètres de pression de freinage.
64 psi is the recording resolution in the brake pressure parameters
3. La résolution du paramètre GROUND SPEED (vitesse sol) est de 1 kt.
The resolution in the GROUND SPEED parameter is 1 kt.
4. Cette surveillance est aujourd’hui de la responsabilité de l’Agence Européenne de la Sécurité Aérienne, le GSAC continuant à intervenir sous contrat de l’AESA en tant que sous-traitant de la DGAC.
This surveillance | supervision | monitoring | oversight is the responsibility of the European Aviation Safety | Security Agency -- GSAC continuing to intervene under contract with EASA in what comes under DGAC's mandate.
5. la plupart des calculateurs de vol, située sous le poste de pilotage, a été totalement détruite.
Most of the speed computers [INS |GPS ?] situated below the flight deck were totally destroyed.
6.Les pneumatiques du train avant sont entaillés et présentent des marques de frottement perpendiculaires à la bande de roulement.
The nose gear tires lost pieces [ threw treads ?] and showed rubbing marks perpendicular to normal rotation.
Thanks I have used your inputs to complete the report. You can look at the time of the last edit at the bottom of each of the two posts to see when the latest update was as there have been several modifications since I posted it last night.
No doubt there will be some small errors in the english version but I have read many reports and changed some of the wording around to sound as if it was initially written in english.(perhaps a future career if I lose my medical).
Any suggestions for corrections are welcome and encouraged.
punkalouver, A small aside. Your item 5 is a classic example of how easy it is to mis-quote and then mis-translate when working out of context.
Page 16 from the BEA document, the complete sentence:
"La soute électronique contenant la plupart des calculateurs de vol, située sous le poste de pilotage, a été totalement détruite." That translates to:
"The electronics bay, which contains most of the flight control computers and is located underneath the cockpit, was totally destroyed."
That in turn translates to the bay itself being totally smashed up, but not necessarily to the computers themselves being totally destroyed (I've seen results of crashes...). So if e.g., somebody needed to access data inside those computers it might have been entirely feasible.
In this case it's not relevant to the report, but I expect you can see where it could have mattered elsewhere.
I've now printed the French report and saved your translation from the forum with cut-and-paste. But maybe you can mail me a cleaner version of your translation (formatting-wise) so I can add my corrections in there and bounce it back? PM ?
This is to update I believe for the last time the report that was translated and posted on here under my name a few posts back. It has been updated. There were some paragraphs missing and it is worded much better now. I would suggest that previous copies be deleted.
Special thanks to CONF iture for his initial translation and ChristiaanJ for helping me with further translation.
It is a bigger job than I thought. Maybe another one this spring. Unless the BEA decides to do it for me