HF A310 accident report @ Vienna out now

[readywhenreaching]

a looong wait of 7 years is over...

http://versa.bmvit.gv.at/uploads/media/A310_GZ._85007_vom_12._Juli_2000_01.pdf

unfortunately time was not long enough for a translation into english

[hetfield]

It's dated 08 Dec 2004......

[readywhenreaching]

today I called the head of the austrian accident investigation. Shortly before we´re finished he told me the report ist "just out in this moment"... what a coincidence !

He also stated most of the delays were due to gave other parties time to comment and 2ndly labs in other nations consumed "more time than planned" finding out about specific technical aspects.

However, it is exciting to read.

[mumbo jumbo]

My German language skills are zero and therefore the main contents of the report are lost on me and no doubt the vast majority of pilots worldwide. However, reading the comments from Airbus, it seems that the crew were trying to wriggle out of their incompetence by blaming some of the technology and wording in some of the FCOM's and manuals.

Whilst Airbus have covered their backsides (rightfully so) by pointing out that the FMC does not give an accurate fuel prediction when flying with landing gear extended, even though the bit about not being accurate for vertical profiles is a bit confusing, how come the most basic aspects of airmanship were disregarded by this crew? Apparently they were even discussing "phantom fuel" at a stage of the flight when they still had plenty of en-route alternates they could have diverted into!

I don't think there is one experienced Airbus or Boeing pilot out there that doesn't understand the fact that flying with an appendage extended into the breeze will cause increased drag and the associated increase in fuel consumption. Then again, I'm wrong as the crew of the accident flight have proved! As far as I'm aware, we are all taught to ignore the fuel predictions on the FMC for abnormal flight conditions, particularly so when landing gear or flaps are not fully retracted. It is usually drummed home at an early stage of training is it not?

I will wait another seven years for the translation to prove to me that the investigators have tried to pass some of the blame for the gross incompetence of this crew onto the equipment manufacturers and the fact that, despite the bleedin' obvious, they couldn't figure out that they were not going to make it to their destination with their company minimum reserves of fuel. To ignore basic cues such as almost twice the normal fuel consumption and fuel remaining over waypoints shows that you aren't going to make it to your planned destination, never mind the basic airmanship of "we only loaded enough fuel assuming normal flight parameters but now we have the landing gear extended but we'll carry on anyway... duh!", shows gross incompetence.

How can anone justify seven years to release a report where the crew are alive, uninjured and the aircraft and all its monitoring and recording systems survived intact? At least we can take some comfort that there is probaby very little to be learnt from this accident apart from the fact that anyone can screw up big time if they are poorly trained, lazy in thinking and have an arrogance that defies logic!

[Dream Land]

mumbo jumbo, after reading your post, I have no need to read the translation. Thank you. :ok:

[BOAC]

Has the art of a 'how-goze-it' chart been lost for ever?:ugh:

[old,not bold]

Oh dear, now you'll get all the hotshots telling you that a computer is the modern way, works wonderfully and never, ever fails, so back to the slippers, grandpa.

We wrinklies (well me, anyway) must realise that the fact that the chart wins on every operational and HF criterion, ie access speed, simplicity, ease of use, accuracy and so on does not overcome its fatal flaw.

It's a piece of paper and not a screen.

[HotDog]

Yes there is a hint of blame assigned to the the function of the FMS in the Austrian accident report. However, the last paragraph states:

" As audio and visual warnings on the flight deck indicated the low fuel status to the crew, the aircraft was abeam Zagreb where a safe diversion landing was available. In spite of all indications, the captain made a decision to fly for a further 30 minutes to Vienna instead.":sad:

[GlueBall]

The Austrian Accident Investigation Board assigns the probable cause as:
Continuation of flight with landing gear extended until engine failure due to fuel exhaustion.
- Non compliance of maintaining regulatory fuel reserves; contributing are human factors due to extreme workload and stress, resulting in loss of situational awareness.
- Over reliance on FMS fuel predictions which precluded data of flight with gear down.
- Failure to entertain alternative strategies in low fuel state.
- Ignoring "Fuel Low Level" warning and bypassing Zagreb Airport

[Basil Smallpiece]

Question from a PPL holder and flightsimmer for an FMS expert:

I understand that the FMS assumes a clean aircraft, however if on the fuel progress page the calculation was based on 'FF+FQ' ie fuel flow and fuel quantity, and the fuel flow was double its normal value because of the extended gear, why did the FMS not calculate the remaining fuel correctly?

[Dream Land]

I see your your point, a simple whiz wheel could have performed the computation, more factors must be involved, could it be due to the incorrect performance factor associated with the configuration, not sure myself.

[arem]

<<why did the FMS not calculate the remaining fuel correctly?>>

Although the FMS will not have the correct performance figures, it will always give a reliable indication of fuel at destination based on what it was told was there at the beginning of the flight and how much has been going through the fuel flowmeters during the flight - which I guess must have been 0 or less ( does it do minus figures?) for quite some time

[Basil Smallpiece]

So if I understand it correctly, they took off in Khania with 17t of fuel, couldn't retract the gear but continued anyway, the FMS showed not enough fuel to reach Hannover so they replanned Munich which was ok with a reserve of 3t, the FMS knew about the increased fuel flow but mislead the crew about remaining fuel at destination? Strange system!

[BOAC]

What would have happened is that on re-planning MUC it might well show 3T. That figure would then reduce as the fuel was burnt above expected. As I said, the back of a gas bill envelope would have shown them they would run out:ugh:

[Green Guard]

So if I understand it correctly, they took off in Khania with 17t of fuel, couldn't retract the gear but continued anyway, the FMS showed not enough fuel to reach Hannover so they replanned Munich which was ok with a reserve of 3t, the FMS knew about the increased fuel flow but mislead the crew about remaining fuel at destination? Strange system!

What would have happened is that on re-planning MUC it might well show 3T. That figure would then reduce as the fuel was burnt above expected. As I said, the back of a gas bill envelope would have shown them they would run out

The ONLY strange thing here is when we do not want to understand the system.

Ofcourse it might have showed CORRECTLY 3 tons or whatever at early stage of flight, BUT for that part of the flight WIND dir/speed.
that must have changed after passing Zagreb. Especially if the crew did not enter every stage of the flight wind dir/speed, in the FMS, given the situation.

[balsa model]

I'm just speculating here on why FMS didn't use fuel flow data:
Just suppose that it always use such instantaneous data. Then during takeoff, climb-out, acceleration, and level change climbs, it would show that you can't make it to your destination. Somewhat distracting.
Instead it probably assumes that any abnormalities are temporary, that the gear will be retracted any time now, the climb will stop as per entered profile, etc.
It's not strange, rather logical.
Am I far off? We need a real expert.

[ChristiaanJ]

I'm somewhat amazed.... having read the report.

I know reasonably well what mileage my car does in town and on the motorway. Never mind the exact figures.

At 10 ltrs/100km a 50 litre tank will take me about 500 km before running dry.
The "fuel remaining" indicator on a car is never all that accurate, but when it says 1/2 it means I roughly have 25 ltr= 250 km left.
I tend to look at the odometer. When that goes much over 300km I pull in and fill up.

Now for the first time I'm towing a caravan (the equivalent of flying gear down). Suddenly, at about 300km, the "fuel remaining" indication is much less than the just under 1/2 I'd expect.

"Motorway service area ahead" (ZGR). "Next service area at 80 km".
Do I sit fiddling with a calculator (FMS) to figure if I can make it to the next service area? Hell no.
Do I pull in to the service area coming up and fill up and have a think? Hell yes.

Situational awareness is not only 3D. It's also 4D.... knowing where you are going... in this case into the service area rather than onto the hard shoulder with an empty tank.

Sorry to present a simple analogy, rather than a 60 page translation.
Oh, and to take that one step further, they could still have taken a motorway exit (GRZ) and found a local garage.

[llondel]

I thought that Airbus tweaked the software after the Air Transat glider incident to flag warnings if consumption was more than it could explain? Or was that just for leaks, and engines working harder than expected take an amount of fuel that is considered acceptable based on control settings?

It sounds like they could do with another tweak to at least display that at current fuel consumption rate (averaged over five minutes, perhaps), the target number of miles won't be reached. It shouldn't actually be that hard for it to flag standard reasons why, such as climb, headwind, excess bits hanging out causing drag, etc, as I'm sure the FMC normally knows all this.

[blue up]

Can anyone at T-Fly copy Colin Budenburgs' "I fly Purple Lines to Blue circles" letter onto here? Would make a useful addition to the thread.

I was in the Sim with a certain Eastender who was saying that he was gonna fail some random bloody FO on a line check one day if he couldn't tell him which country they were flying over!:E

[Avman]

I was in the Sim with a certain Eastender who was saying that he was gonna fail some random bloody FO on a line check one day if he couldn't tell him which country they were flying over!

Most Yanks would fail that one :E Running for cover ;)

[flyburg]

I usually hesitate to respond to topics like these because, there for the love of god, go I, but...

Come on, basic airmanship!!! The wheels hang out, sure, I admit, I would try and see if I could make it too. As a matter of fact, I have been in a similar situation once ( granted in a turboprop) and I did continue to the destination.

However, FMS aside, and knowledge about fuel predictions, etc, etc, you have an operational flightplan. In a situation like that you compare the OFP remaining fuel against the actual fuel on board. You get the picture, at each waypoint the actual remaining fuel on board falls more and more below the required fuel on board as per OFP.

Personally, I tend to trust the OFP ( we use LIDO) more than the FMS as the FMS uses average inputs while LIDO looks ahead. In any case a combination of the two would yield the best info to decide to continue or not.

In this case, I feel the guys really f%&*k up.

[ettore]

I'm not a pilot, and have no idea of the burden of such a situation. But reading the report in full, German included, my impression is that the Capt have been overconfident, hoping to please both the company and the pax despite the gear retraction failure. How much weight has a company-ACAR such as the one quoted on page 7, telling him to reach STR, whenever possible (since another A/C would have been available), when you're flying into troubles?

[what next]

Hello!
> In this case, I feel the guys really f%&*k up.
This is what the German court also thought when it convicted the captain to 6 months prison sentence (suspended) for endangering lives. Three years ago.
But I still don't know if it really was a criminal offence.

We all make mistakes of judgement all the time, and in this case, the pilot has trusted an instrument (that he had learned to trust over the years!) more than his common sense and the common sense of his colleague. Add commercial pressures and high workload to that. His decision was certainly a big mistake. But criminal?

Greetings, Max

[jettison valve]

llondel,

The warning on the A330/A340 classics that came out after the Air Transat incident, compares initial FOB with actual FOB plus FU; if that equation does not add up by 3.5t (if my memory serves me right here), then you´ll get a warning. It is therefore only useful if you have an external leak, and wouldn´t have helped Happy :D Lloyd.:cool:

Btw: The list of inhibitions for this warning is incredibly loooong. So, don´t trust the machine too much. Better check yourself every once in a while. :ok:

Cheers,
J.V.

[Green Guard]

And if you have time please check on that report why the same Capt, when both engines failed a minute or so before VIE runway, elected to land beside the runway, on the GRASS :bored::\

[411A]

It all comes down to looking at the FMS as though is 'knows all/tells all' but clearly we have not come far enough yet to realise the consequenses of a low fuel state.

PanAmerican, in all their jet aircraft, had a laminated flight conduct chart many times in two pages with detailed data on normal and abnormal flight planning...and yes, flying with the landing gear extended was well presented.

PanAm simply did it better, in my opinion....including a final configuration check as the very last item before brakes release, prior to takeoff.

[Basil Smallpiece]

Seems to me that they didn't actually have a valid fuel 'plog' - they just changed the destination in the FMS and accepted its calculations.

Interesting items in the report are that the F/O tried to present the Capt with the gear down ferry tables early in the flight but was dismissed with the remark that they were for pre-flight planning only; the F/O effectively took the initiative when the 2nd engine flamed out and the reason the aircraft landed on the grass was that the 'Land Recovery' system was not activated so only partial flight controls were available?

[hetfield]

and the reason the aircraft landed on the grass was that the 'Land Recovery' system was not activated so only partial flight controls were available?"Land Recovery" has nothing to do with flight controls. It supplies

- Anti skid
- SFCC
- Spoilers

[ettore]

Report, page 11: das Schalten des "Land Recovery" -Schalter unterblieb,was dazu führte, dass die Steuerung auf die innen angeordneten Querruder beschränkt und die Manövrierbarkeit im unteren Geschwindigkeitsbereich eingeschränkt war (keine Spoiler, Klappen oder Vorflügel
Which means, according to the report, that the Land Recovery being OFF, the use of the roll aileron was limited, as well as the maneuverability at low speed.
Additionnal note: From flame-out to impact they glided 12 NM.

[nankanguy]

flyburg said it all. The guys botched it. Had it been an oriental ot third world guy, people would have made all kinds of disparaging remarks about airmanship and pilot skills! You guys are so kind to this crew.:{:ugh:

[prospector]

what next,
"Add commercial pressures and high workload to that. His decision was certainly a big mistake. But criminal?"
If the driver of a coach went over the centre line of a motorway, and because of that action people were killed or injured, would you say that action was a "big mistake" or criminal negligence?. If yes, for criminal negligence which would very likely be the end result, then why the difference? because one is driving an aeroplane and one a coach??

[hetfield]

dass die Steuerung auf die innen angeordneten Querruder beschränkt und die Manövrierbarkeit im unteren Geschwindigkeitsbereich eingeschränkt war (keine Spoiler, Klappen oder Vorflügel)It's a translation problem.
It doesn't mean "the use of the roll aileron was limited."

It means FLIGHT CONTROL WAS LIMITED TO INNER MOUNTED AILERONS.

And yes, with regards to the spoilers, flight controls were affected without Land Recovery provided windmilling or RAT pressure was sufficient to operate some of the spoilers. Same with slats/flaps. With Land Recovery on you still need HYD of windmilling eng and/or RAT. With 220 kt I'm not sure about windmilling HYD pressure, RAT should be fine but only YELLOW for primary FCTL/flaps and it takes veeeery long to extend them.

[Busbert]

The event has parallels with the Indian Airlines forced landing in a paddy field in Nov 1993. They had a missed approach due to weather and could not retract the flaps due to a flap jam. They ran out of fuel when diverting.
http://dgca.nic.in/accident/acc93.pdf see page 7.

At least the Indian authorities had the balls to lay the fault squarely at the pilot and not squirm for 7 years and then try to point fingers at the aircraft.

[John Boeman]

balsa wood, your description of the way the fms looks at fuel consumption, is pretty much spot on, on a Boeing anyway.

[BOAC]

Indeed, JB, but we do not even need to worry ourselves about how it does it. For those with FMS 'fixation', the 'predicted' arrival fuel would have been reducing all the time. This is not withstanding a fuel flow of xxxx and a fuel remaining of yyyy - pretty basic stuff. How anyone can sit and look at that and not do the obvious defeats me. :confused:

[Green Guard]

For those with FMS 'fixation', the 'predicted' arrival fuel would have been reducing all the time

Yes ---if you mean OFP.
No---if you mean FMS. *


* It should remain the same all the remaining flight
IF the changing wind conditions were input correctly in FMS,
or IF there was no wind change along the "all the time" part of the flight.


:=

[BOAC]

GG - I go with post #17.

[SailorOrion]

Interesting:

(personal translation)

For the item "LG unsafe indication", there is a noticable difference to the checklist of the manufacturer. The manufacturer's checklist contains, as last madatory item, "FUEL CONSUMPTION (FCOM 2.18.40) .... DETERMINE. This item misses completely in the operator's manual.

end quote.

A non-secured screw on the right MLG (actuator cylinder) went loose. Thus said cylinder had an increased "work length" and prevented full retraction of landing gear.

If anyone needs some translation of specific parts, I'll try to help out.

SailorOrion

[hetfield]

Yes ---if you mean OFP.
No---if you mean FMS. *

I don't think so, but I'm not sure, can't find any explaination in FCOM.

Guess the FMS is taking FF/FQ into acount for the next waypoint, thereafter its computations are considering a clean ship. Passing the next waypoint, same thing and so on... Therefore estimates of arrival fuel change every waypoint to a lower value.

[D O Guerrero]

I'm ready to be accused of being simplistic, although I am only training for my ATPL. However... isn't it all a bit obvious? Even I know that flight with large bits of metal and rubber extended aren't going to help your fuel consumption. I find it utterly amazing that the pilots concerned tried to blame the FMS! It sound like utter complacency to me.
Wouldn't a simple "gross error check" have identified the problem quite early on?

[hetfield]

I agree with you, a glance at the groundspeed and fuelflow would have given a clear answer how far they can go.

Pointing the finger on the FMS just belongs to the strategie of defence.

[fox niner]

Hello!
> In this case, I feel the guys really f%&*k up.
This is what the German court also thought when it convicted the captain to 6 months prison sentence (suspended) for endangering lives. Three years ago.
But I still don't know if it really was a criminal offence.

We all make mistakes of judgement all the time, and in this case, the pilot has trusted an instrument (that he had learned to trust over the years!) more than his common sense and the common sense of his colleague. Add commercial pressures and high workload to that. His decision was certainly a big mistake. But criminal?

Greetings, Max


Does anyone know how to find this court ruling online? These rulings are published on the internet, right? In my home country they are.
And before you all think I live in some sort of Banana Republic with no respect for civil rights: I live in the Netherlands....civil rights since 1648.

[threemiles]

http://www.oberlandesgericht-braunschweig.niedersachsen.de/master/C10300340_L20_D0_I4798307_h1.html

[JFA]

People are assuming too much things about the modus operandi of the FMS here. I would at this time advise that people check out an operating manual of the Airbus in question, before assuming it takes account for FF and the how's and do's, and even, accuracy of.

Pilots should know better to always check the performance tables. Always, no workaround here, always is the way to go. So, these men didn't do it, maybe the focus should be on the reasons why they didn't, because i am pretty sure that they we taught like that, some time or another along their training.

FMS is a tool that supports pilots in conducting flights, not a tool where pilots supports their flight planning altogether. Proeficient pilots crosscheck the FMS from performance charts, take conclusions about the results and act accordingly. No more to it. Pilots that trust whatever the FMS throws at them are in a collision course with a problem.

[jshg]

I last flew the 300-600/310 three years ago, but as I remember it the FMS assumes current wind unless manual winds are entered, in which case it uses them, whilst using current wind for the next 200 nm or so. So forecast wind is normally entered on the ground before flight, modified if required during flight, and on a shortish flight should not have a major effect.
It's hard to understand how mental alarm bells didn't ring as the fuel surplus column on the manual plog plummetted, and the FMS prediction dropped rapidly. It also seems strange to contemplate flight over high MSAs with the gear down (engine fail case).
A point about Land Recovery. With this 'off' for landing, whilst it is correct that they would still have had inboard ailerons, the lack of roll spoilers would have been felt because the 300/310 doesn't have outboard,'low speed' ailerons - it uses roll spoilers instead.
Having said that - there but for the grace of God go all of us to some extent. I think we often apply our own excessive commercial pressures to ourselves without the Company saying a word.