As far as I know, the AP was part of the problem. I could not find any official report on the accident (this is Eastern Europe, you know?) but the bits and pieces I got access to claim that:
- The captain had a heart attack just after take off.
- The co-pilot tried to help the pilot.
- He tried to engage the AP, but the A310 AP would not activate if plane banking is higher than 20 degrees (and it was, at that time).
Low altitude, low speed, high banking degree, the captain dying on the seat nearby, no AP. That's what happened, it a nutshell.
This is a piece from some report I've found. It's in Romanian only, so you'll need to use an on line translation service.
There's also the flight data listing for that flight and the pilot communication. As you will notice, the captain becomes unavailable shortly after take off.
The report mentions that the captain was "incapacitated".
Azi, 31 martie 2001, se implinesc exact 6 ani de la tragicul accident al aeronavei Tarom YR-LCC de la Balotesti. Cursa ROT 371 a decolat de pe aeroportul Bucuresti-Otopeni, pista 08R, cu destinatia Bruxelles. La ora 09:11 AM ora Bucurestiului, in timp ce se afla in faza de urcare catre nivelul de 1500 metri, aeronava Airbus 310-325 a intrat intr-o evolutie descendenta necomandata finalizata printr-un picaj abrupt (cu un unghi de tangaj - in engl. "pitch" - de 80 de grade), prabusindu-se in apropierea garii Balotesti, pe un teren agricol. Pe durata evolutiei in urcare, la altitudinea de 670 de metri si la o viteza de 350 Km/h, echipajul a escamotat flapsurile. In acelasi moment, sistemul de reglare automata al tractiunii (setat pe modul de zbor "urcare" - in engl. "climb") ar fi trebuit sa reduca puterea la ambele motoare, dar maneta de reglare a tractiunii pentru motorul din dreapta (nr. 2) a ramas setata in modul de decolare. In 42 de secunde, motorul nr. 1 (din stanga) s-a redus la relanti. Pe durata acestor 42 de secunde s-a dezvoltat o situatie periculoasa de zbor cu tractiune asimetrica.
Aeronava Airbus trecuse in acel moment de radiofarul OTR si echipajul, in conformitate cu proceduile SID, a initiat un viraj de 25 de grade la stanga, pentru a se alinia cu un cap magnetic de 327 de grade pentru radiofarul STJ VOR/DME de la Strejnic. Ca urmare a situatiei de tractiune asimetrica, unghiul de tangaj (in engl. "pitch") s-a redus de la 18 grade la 0 grade. Aeronava a intrat intr-o inclinare laterala finalizata cu un unghi de ruliu (in engl. "roll") de 170 de grade si cateva secunde mai tarziu s-a prabusit si a explodat la impactul cu solul.
CAUZA PROBABILA: Lipsa de reactie a echipajului la o situatie de picaj extrem a aeronavei. Echipa de investigare a ajuns la concluzia ca pilotul in comanda a fost fie incapacitat sau absent din cabina de pilotaj, deoarece nu a comentat nimic in timp ce situatia critica se dezvolta. Cu putin inainte de impactul cu solul, copilotul si-a exprimat ingrijorarea cu privire la situatie, referindu-se fie la starea pilotulului in comanda, fie la pozitia critica a aeronavei ( inclinare verticala de 80 de grade si laterala de 170 de grade) si a incercat fara succes sa aduca aeronava la pozitia normala de zbor.
Datele aeronavei:
================= Model: Airbus 310-325 | Operator: Tarom | Inregistrarea: YR-LCC | Nr. de Serie: 450 | Anul Constructiei: 1987 | Echipaj: 10 | Pasageri: 50 Victime: 10 + 50 = 60 | Faza zborului: urcare | Cursa: Bucuresti - Bruxelles Nr. 371
TURN: Tarom 371, cleared to take off to maintain runway heading. COMANDANT: Packurile nu le scoatem? COPILOT: Nu. COPILOT: Binenteles ca nu i-am dat drumul la ceas.. COMANDANT: (ironic) Grav. COPILOT: Deci "take off"..Da? COPILOT: Checked COMANDANT: Thrust, SRS, heading..V one! COPILOT: Rotate COMANDANT: Pune mana pe mansa, tin eu motoarele. COMANDANT: Positive! COPILOT: Gear up! COPILOT: Tarom 371 after take off.
(gear retraction noise) COPILOT: 371 cleared directly to Sierra Tango Juliet.. Da-mi un direct to Sierra Tango Juliet! COMANDANT: Mansa putin.. COMANDANT: Viteza.. COPILOT: Two-fifty in sight..flaps up! COPILOT: Slats in! COPILOT: Ce-ai ma?! COMANDANT: (inaudibil) COPILOT: Arm command one! bip! bip! bip!
(pilotul automat refuza sa se cupleze) COPILOT: Ba, s-a stricat ala... COPILOT: Aaaaaaaaaahhhhhhhhhh!!!!!!
(zgomotul impactului)
Flight ROT 371 took off from Bucharest-Otopeni runway 08R for a flight to Brussels. At 09:11 LT, climbing through 4500 feet, the Airbus began to descend again and finally entered a steep dive (80° nose-down) before crashing into a field. While climbing through 2000 feet at 350km/h the crew retracted flaps. At that time the auto throttles (on 'climb' mode) should have reduced power on both engines. But the right power lever (no. 2 engine) remained in take-off power setting. It took no. 1 power lever 42sec to move to idle power. During these 42 seconds an asymmetric thrust situation developed. The aircraft by then had past the 'OTR'-beacon and the crew had, according to SID procedures, begun a 25° left turn onto a 327° heading for the Strejnic 'STJ' VOR/DME beacon. Due to the thrust asymmetry the nose-up pitch of 18° decreased to 0°. The aircraft rolled through 170° laterally and finally crashed into an open field and exploded on impact.
PROBABLE CAUSE: Lack of crew response to an extreme nose-down attitude. The investigation committee concluded that the captain was either incapacitated or absent from his seat, because he had not said anything while the critical situation was developing. Just before impact the first officer expressed his concern about the situation (either the captain's condition or the aircraft's attitude) and attempted a recovery.
Quoted from AAR- translation, just above, characterizing an upset of Tarom A310:
"... Due to the ... asymmetry the nose-up pitch of 18° decreased to 0°. The aircraft rolled through 170° laterally and finally crashed into an open field and exploded on impact...."
That statement reads like phrases in the CAB's AAR describing the AA Flt One /1Mar62 B707 upset- impact [discrepant Rudder]. Climbing left turn departing NY's Idlewild AP. Investigators alluded to the aircraft's nose-high pitch attitude as one factor inhibiting the pilots' ability to detect the initial Yaw x Roll upset.
But the right power lever (no. 2 engine) remained in take-off power setting. It took no. 1 power lever 42sec to move to idle power. During these 42 seconds an asymmetric thrust situation developed. The aircraft by then had past the 'OTR'-beacon and the crew had, according to SID procedures, begun a 25° left turn onto a 327° heading for the Strejnic 'STJ' VOR/DME beacon. Due to the thrust asymmetry the nose-up pitch of 18° decreased to 0°. The aircraft rolled through 170° laterally and finally crashed into an open field and exploded on impact.
For some reason the pilots did nothing to correct the asymmetric thrust situation that occurred to the autothrottle system where one throttle came back to idle while the other remained at high power. A similar accident happened to a Chinese operator in a Boeing 737-300 a few years ago. In that accident the crew seems dumbfounded at why the huge split in the throttles and did nothing to fix the problem by switching off the autothrottles and controlling them manually.
In the simulator we have seen the same thing happen when one autothrottle clutch motor was failed by the instructor during flap and gear extension on an ILS with a 737-300. As the drag cut in intercepting the glide slope and the thrust increased to mainatin vref + five, the left throttle remained at idle (which was the throttle setting when the instructor failed its clutch motor) while the No 2 throttle increased to 75%N1 to maintain the selected speed. The autopilot was engaged at the time and the control wheel was well over to one side trying to maintain the localiser. NEITHER PILOT TOOK ANY CORRECTIVE ACTION despite both being aware of the unusual throttle split and control wheel position.
Eventually the autopilot disengaged itself and the 737 rolled to the left beyond the vertical and the nose dropped. The captain called for the engine failure checklist when there was nothing wrong with the engine. The aircraft crashed in a spiral while the first officer was still trying to find the engine failure page in his QRH. NEITHER PILOT HAD A CLUE WHAT TO DO. I suggest a similar defect happened to TAROM and from the tragic result the crew also didn't have a clue what to do for something as simple as an AT defect. It's the old story of simulator training. For some airlines if it is not in the syllabus of training, then a head in the sand approach is adopted and lessons from past accidents are disregarded.
It's been a really long time since the accident, and I can't seem to find the final report anywhere on the net anymore (it was available, I have read it entirely a few years ago).
I distinctly remember this pre-existing condition with the async thrust levers, and how Airbus had issued a memo about this just shortly before the accident. All I can seem to find right now is a quote from the lead investigator in this article:
Maneta din dreapta a intarziat din cauza ca avea o frecare in lagar (n.r. - cutia de viteze a avionului), iar cea din stanga a continuat in mod liber sa se retraga. Pilotii stiau ca manetele de control aveau o problema, o rezolvau de fiecare data, asa ca nu aceasta a fost cauza accidentului
Which roughly translated says:
Quote:
The right thurst lever lagged behind because of a friction problem(on the clutch), while the left thrust lever continued to move backwards. The pilots were aware that the thrust levers had a problem, they were fixing it every time, so this was not the cause of the accident.
The final report had some more info on this, including the "fixing method" of moving the damaged thrust lever nr.2 by hand to match the nr.1
Gosh, I wish I could find that final report again!
I have a note that says 'On April 10th., 1995, Airbus Industrie apparently issued a statement, which, as reported, said that the 'improper response by the right-hand throttle lever was most probably due to abnormal stiffness of a related mechanical component'. It is understood that 'similar behaviour' first occurred on March 24th., 1992, when the aircraft was being operated by Delta and continued subsequent to that date.'
This incident was used as an illustration of increasing UNMONITORED A/P use, in a series of lectures on Performance and unusual attitude recovery. Excellent material, superbly presented and inarguably pointed out that the failure of the handling pilot to KEEP HIS HANDS ON THE THROTTLES was a primary cause. Had he kept his hands on, he could not have failed to notice the asymmetric movement and (one hopes) taken the necessary remedial action. This lecture lead on to the equally excellent 'Children of the Magenta'. The full series ought to be mandatory viewing for anyone operating in public transport aviation.
This lecture lead on to the equally excellent 'Children of the Magenta'. The full series ought to be mandatory viewing for anyone operating in public transport aviation.
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Never a truer word. But I doubt it wll happen primarily because managements are not really interested enough in other people's incidents and accidents enough to do something about education of their own pilots. They may pay lip service but that's as far as they are prepared to go. Secondly, the majority of airline pilots seem not to be interested reading overseas accident reports. To these people, crashes always happen to the other fellow - not my company.
In my view, Ppprune is by far the most immediate and effective flight safety education medium with its wealth of linked information if only pilots could be bothered to seriously research its pages.
In my view they didn't need to keep hands on the throttles as much as they needed to monitor the aircraft roll while in AP.
Of course it helps to recognize the importance of uncommanded thrust changes before you roll over and dive. Several lessons learned in this regard on other than AB aircraft. This accident pushed the learning out in the open very hard. From memory I can think of five or six
I would be very unhappy if the typical airlines flight safety officer doesn't know this today. How it gets to the average pilot is another question (only for me)
