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Old 28th Feb 2013, 11:52
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1stspotter
 
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Final report on crash is available for download

Today the Libyan authorities published the final report on the Airbus A330 crash. It can be downloaded here
مصلØ*Ø© الطيران المدني - Home

Big human errors are the main cause.

The aircraft's approach was too low without proper sight of the ground. Pilots did not work together properly, were tired and distracted by busy radio communications. Also the weather forecast was not correct.
Also the co-pilot pulled nose up while the captain pulled nose down!

Below is a small part of the complete report which has 4 PDF files.

Probable Cause
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan.
The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches.
The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraft’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs,
applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.

Based on elements from the investigation, the accident resulted from:
-The lack of common action plan during the approach and a final approach
continued below the MDA, without ground visual reference acquired.
-The inappropriate application of flight control inputs during a go- around and on the
activation of TAWS warnings,
- The lack of monitoring and controlling of the flight path.
These events can be explained by the following factors:
- Limited CRM on approach that degraded during the missed approach. This
degradation was probably amplified by numerous radio-communications during the final approach and the crew’s state of fatigue,
-Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,
- Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.
- Non adherence to the company operation manual, SOP and standard terminology.
In addition, the investigation committee found the following as contributing factors to the accident:
-Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.
-In adequacy of training received by the crew.
-Occupancy of tower frequency by both air and ground movements control.

Last edited by 1stspotter; 28th Feb 2013 at 12:21.
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