MD82 crash in Venezuela (Reopening ... )

[jcjeant]

The original message is now closed.
http://www.pprune.org/rumours-news/1...venezuela.html

But a few days ago Venezuela accidents investigators released a new intermediate report and it sheds new light on this accident.
Unfortunately I did not manage to find a link to download this interim report ....
According to the report .. foreign regulatory bodies and even the manufacturer of the aircraft would be involved as responsible for the accident due to negligence .. etc ..
If someone can post a link it would be nice

[PLovett]

Thank you for reopening this thread as I hadn't read the previous one before. It, and the links contained in it, make interesting reading.

If now, as you state, the Venezuelan authorities have issued another report and it is putting the blame on to the manufacturer and other regulatory authorities, I can only assume that it is heavily influenced by the Venezuelan government with its agenda against all things American.

The thread seemed to make it clear that the crash was most likely due to engine icing followed by very poor flying skills but perhaps this is unacceptable to Venezuela.

[jcjeant]

Seem's that not the US who are taking the big slap but instead some french aviation authorities ...
The involve of the manufacturer is about a stall detection too much delayed ...
But I can't comment more as it's only some words from press release and not from the original report I had not yet found anywhere ...

And more from a french blog:

On August 16, 2005, the company Flight 708 took off from the West Caribbean International Airport of Tocumen, Panama. En route to Fort de France, he crashed in a mountainous area in Venezuela, killing all 152 passengers and 8 crew members on board.
After 5 years of waiting, Venezuela has just its report. He confirmed in 2.3 that this company was a regular on offense and 3.2.1 asserts that the state of financial crisis in the airline West Caribbean had created an unfavorable environment for air operations "
So the Flight 708 would never have taken place if the Colombian government was not complacent in allowing the activity of this company and if our trash DGCA had sought to know if the safety of passengers was guaranteed.
The responsibility of these two bodies is complete!
PS. One would think that after the drama of Sharm el-Sheikh in January 2004, lessons were learned from this tragedy. "I asked my staff to examine the conditions under which the French tour operators could better ensure the level of airline safety that they use" stated Gilles De Robien after the accident. Bussereau was already Secretary of State for Transport ...

And more .....

5 years ago to the day, a charter flight company West Caribbean crashed in the mountains of Maracaibo in Venezuela, killing 152 French returning to Martinique and eight crew members. Until now, investigators had found the fault of drivers. But a report by the Venezuelan Commission of Inquiry, which has been communicated, could revive the investigation.
The authors of the survey, responsibilities go far beyond the case of the only drivers. They said there would be a whole chain of responsibility leading to the accident including the company's West Caribbean Newvac charterer, and even the manufacturer McDonnell Douglas, now absorbed by Boeing.
The first report highlights the unreliability of the airline West Caribbean Colombian airline that went bankrupt shortly after the crash. The charterer in turn would be guilty of trusting the company in poor financial condition.
Then the aviation authorities, namely the Directorate General of Civil Aviation, have too readily permitted the aircraft to land on French soil.
Finally and this is the real surprise: the report recommends Boeing to review its alarm system on the MD 82 aircraft. Before the accident pilots were engaged in a dangerous area, they would be wrong maneuver causing fatal stall the aircraft. The report estimates that if the alarm had sounded earlier, the pilots could react and recover the aircraft.
So many tracks that will be reviving the inquiry is what hope in all cases the families of victims.

[IGh]

Suspect final rpt released ?

From top slot:

"... a few days ago Venezuela accidents investigators released a new intermediate report ..."

The BEA's web-site still shows NOTHING new in this investigation.

This case is about an MD8 CRZ spd-pitch upset. Due to the wreckage location, manufacturer's investigators had difficulty gaining entry (aircraft impacted in Venezuela). For the past few years BEA-guys have been the best source of information on the case; the lengthy investigation, and REPORT revision-circulation have been proceeding over years -- BEA-guys expected a FINAL AAR.

For those folks following the history of mysterious airliner inflight upsets, this report on the West Carib' MD8 is anxiously awaited -- hope we get an English version of the AAR.

[jcjeant]

The BEA's web-site still shows NOTHING new in this investigation.

Indeed .. nothing more from 2005 on the BEA site !!
5 years of silence !
Amazing BEA .......

[PBL]

5 years of silence !
Amazing BEA .......

Inappropriate comment, I think. Venezuela is an ICAO contracting state, and that is where the airplane crashed. It is therefore up to Venezuela to investigate and issue an Annex 13 report. Even if Venezuela has asked a non-Venezuelan organisation to lead the investigation and report, the timing and release of the resulting documents is solely up to Venezuela. If there is no public report, it may well be because Venezuela has not authorised public release. Most states don't.

[jcjeant]

Inappropriate comment, I think.

Seem's it's public !!
Rapport Crash West Caribbean (espagnol)

So I continue to tell ...
Amazing BEA .... !!!

[lomapaseo]

jcjeant

Seem's it's public !!
Rapport Crash West Caribbean (espagnol)

So I continue to tell ...
Amazing BEA .... !!!

I don't take your point on this from this post

[jcjeant]

I don't take your point on this from this post

Seem's to me the BEA is formaly linked in this investigation (and all the passangers are frenchs nationals)
Good sens can't understand why the BEA (who already published one report) don't publish on his site (and translated in french language) this venezuelian report ....
Of course if you compare the two reports it's a lot of divergences in the analyse but this can't (I hope) be the reason of the BEA silence about the venezuelian report.
So for my point of view it's amazing this report not be on the BEA site.

[lomapaseo]

jcjeant

So for my point of view it's amazing this report not be on the BEA site.

Thanks for the clarification.

I now see what you are getting at.

However, I am not surprised nor disapointed that the BEA has not posted another States, Investigation report.

My sense is that the french are only parties (assisted) to the investigation on behalf of their citizens and are welcome to hold separate views from those published in the state of occurence report. Since, I bellieve, no airworthiness actions are expected to be issued by the french this leaves the reponsibility for such with the states of manufacture and the state of the operator.

Thus it would probably serve no useful purpose for the BEA to either support by publication or publicly refute the report that you linked. Behind the scene I suspect that the BEA is supporting the factual findings in conjunction with the NTSB and Boeing.

If there are any disagreements or concerns then I'm sure they have already been expressed to the state responsible for the final report

[ATC Watcher]

Before firing on the BEA I do not think the BEA has the ressources to translate in a legal form the Venezuelian ( Spanish) report. They also do not have to do this as they were only part and not heading the investigation.
But I'll check if they plan something.

[Escape Path]

Final report released

Here it is guys, the final report on the crash released by Venezuela's Junta Investigadora de Accidentes de Aviacion Civil (Civil Aviation Accident Investigation Board). The report is 276 pages long (in Spanish) and cites the cause of the accident as "Human Error" due to, amongst others, apparent improper stall recovery procedures at high altitudes.

Rapport Crash West Caribbean (espagnol) - page 1

I would translate the 276 pages, but I have to go play with my cat

EDIT: Long story short:

Aircraft flying at FL310, too heavy to climb to FL330 but crew still do it. Aircraft cannot sustain itself at 330 thus losing speed, and in attempt to maintain altitude starts pitching up. Crew starts to descend back to FL310 and when leveling off the mix of low speed and high AOA creates a stall scenario (or something like a flat spin, since the aircraft goes down tail first). Crew attempts to recover the airplane but not from the stall condition by pitching up. Aircraft, uncontrollable, hits the ground.

[jcjeant]

And this is the answer of the family association (152 questions)

It's only available in french (PDF)
http://henrimarnetcornus.20minutes-b...1717272828.pdf

[DozyWannabe]

Originally Posted by lomapaseo

My sense is that the french are only parties (assisted) to the investigation on behalf of their citizens and are welcome to hold separate views from those published in the state of occurence report. Since, I bellieve, no airworthiness actions are expected to be issued by the french this leaves the reponsibility for such with the states of manufacture and the state of the operator.

Exactly - if you think about it the NTSB and Dutch accident investigators were in exactly the same position with the 1977 Tenerife disaster. While they were allowed to assist, the final report had to come from the Spanish, even though most of the fatalities were Dutch or US nationals.

[jcjeant]

Some news from the law front ...

Crash West Caribbean: "indisponibilité" des juridictions civiles françaises (cour cassation) - 08/12/2011 - leParisien.fr

Google Traduction

The Supreme Court said Wednesday the "unavailability" of the French civil courts to judge the crash occurred in air in Venezuela 2005 (160 dead, including 152 French), paving the way for the seizure of Justice U.S. officials said Thursday from corroborating sources.
Parallel to the criminal investigation, still ongoing in Fort-de-France, many relatives of victims had attempted to civil liability of the airline West Caribbean and the charterer Newvac before a judge in Miami, where the seat of Newvac to claim benefits both companies, told AFP Bellecave Jean-Pierre, a lawyer from Bordeaux to 669 relatives of victims

[punkalouver]

Originally Posted by jcjeant

Seem's to me the BEA is formaly linked in this investigation (and all the passangers are frenchs nationals)
Good sens can't understand why the BEA (who already published one report) don't publish on his site (and translated in french language) this venezuelian report ....
Of course if you compare the two reports it's a lot of divergences in the analyse but this can't (I hope) be the reason of the BEA silence about the venezuelian report.
So for my point of view it's amazing this report not be on the BEA site.

I don't understand....is there a second report somewhere?

[IGh]

Summary posted

Question posed just above: "....is there a second report somewhere?..."

Since that earlier thread had been "closed", I added a summary of the AAR in message #151 of this old thread:
http://www.pprune.org/tech-log/41797...titudes-8.html

Some of the Appendices are in English, and can be useful.

[punkalouver]

Here is the overview...

A West Caribbean Airways McDonnell Douglas MD-82, registration HK-4374X performing flight WCW-708 from Panama City (Panama) to Fort de France (Martinique) with 152 passengers and 8 crew, was enroute at FL310 at a speed of 0.75 Mach in contact with Barranquilla (Colombia) when the crew requested to climb to FL330. Following the clearance the crew initiated the climb putting autothrust and autopilot into an EPR Climb (thrust channel controlling EPR, vertical channel maintaining Mach speed), the airplane climbed to FL314 and remained level for about 20 seconds before continuing to climb to FL323 where the airplane was level again for about 20 seconds. In each of these level periods the Mach speed remained stable, but reduces as soon as the climb resumed. About 3 minutes after the climb was initiated and 20 seconds after the airplane levelled off at FL323 the autopilot was switched into "Vertical Speed" commanding a fixed climb rate. 10 seconds later the EPR LIM mode is again selected on the master control panel (again having the autothrust control EPR and the vertical channel control Mach speed), the captain asks the first officer to deactive engine anti-ice. 10 seconds later the engine EPR increases above 2.0, one minute later the airplane reaches FL330 at a speed of 0.70 Mach. 90 seconds later the captain remarks they could not accelerate, the engines continue to produce 2.02 EPR. 150 seconds after reaching FL330 the speed begins to rise and the angle of attack reduces, 5 minutes after reaching FL330 the speed had reached 0.75 Mach and the autothrust system changed from EPR LIM to Mach mode (adjust thrust to maintain Mach speed while vertical channel now adjusts pitch to maintain altitude). About one minute later the EPR values drop probably because of selection of Max Cruise EPR limits instead of Max Climb limits, the Mach speed begins to reduce again. The autothrust system indicates "Mach ATL" indicating the system is commanding maximum selected thrust which however is insufficient to maintain the selected mach number, the speed continues to decrease indicating it was impossible to maintain FL330. At that time the airplane is handed off to Maiquetta (Venezuela) and cabin crew arrives in the cockpit with food service for the crew. One minute later the crew requested a route direct to Ongala, while the autopilot is permanently re-trimming the aircraft to compensate for the reducing speed. One minute later the EPR increases again probably because engine anti-ice was de-activated again, the speed was now 0.69 Mach. The captain asks whether they have engine anti-ice on, the first officer responds no, the engine thrust (maximum climb thrust) reduces corresponding to activation of engine anti-ice. Two minutes later the speed reduces through 0.65 Mach, angle of attack (AoA) had increased to 5.8 degrees, 45 seconds later the speed went through 0.63 Mach and the AoA went through 6.5 degrees. Another minute later, speed was 0.62 Mach and AoA was 7.2 degrees, the first officer radioed ATC to request a descent to FL310. 10 seconds later the captain switched the autopilot off, speed was 0.60 Mach and angle of attack 7.7 degrees, no alarm (stick shaker, stall warning, ...) was audible in the cockpit. 5 seconds later the airplane began to descend, the captain asked the first officer to "give me 310". 40 seconds after beginning the descent the airplane descends through FL317 at 2500 fpm sink rate, when the engines suddenly reduce to 1.8 EPR, the stick shaker activates, the "Stall!" aural alert and the horn activates. These alerts (stick shaker and stall aural alert and stall horn) continue until impact. In the next 10 seconds following the activation of the stall alert the engine EPR reduces from 1.8 to 1.16 while the stabilizer trim moves through -5 towards nose up. Due to the high angle of attack the engine inflow gets disturbed causing the engine EPR to reduce further. 15 seconds after the activation of the stick shaker the first officer advises "Captain, this is full stall, full stall", another 15 seconds upon request by the captain the first officer radioes ATC to advice they were descending to FL290. Speed was 0.50 Mach, the sink rate had increased to 5000 fpm, the elevator trim is further moving to nose up. 2 seconds later the EPR drops sharply below 1.06, 30 seconds later the first officer radioes ATC to advice they were continuing down to FL240 without declaring emergency. No checklists were executed. ATC asked whether they had any problem, the first officer upon advice by the captain told ATC they had a double engine flameout. Sink rate had increased to 7000 fpm. The first officer now requested minimum enroute altitude, sink rate increased to above 12000 fpm. The autothrottle gets disconnected, the engines suddenly spool up to EPR 1.80, 4 seconds later the first officer radioes upon advice from the captain that the airplane is uncontrollabe, the airplane descends through 12400 feet at that point. 5 seconds later the airplane descends through 10950 feet (editorial note: suggesting a sink rate of 17400 fpm), speed reduces through 0.38 Mach at engine EPR 1.88, elevator trim is 10.8 nose up, another 15 seconds later the Ground Proximity Warning System activates while the airplane descended through 3105 feet. Another 9 seconds later the recordings of both cockpit voice and flight data recorder end, the airplane impacted ground at Machiquez in Venezuela. All occupants perished.

The Venezuelean Ministry of Communication and Transport's Air Accident Invesitgation Commission (JIAAC) released their final report in Spanish concluding the probable cause of the accident was:

- operation of the aircraft outside the limits and parameters set by the aircraft manufacturer together with inappropriate flight planning failing to take climate conditions into account

- the absence of appropriate actions to correct the stall of the aircraft

- misguided ranking of priorities during the emergency

Given the aerodynamic and performance conditions the aircraft was taken to a critical state which led to loss of lift. Subsequently the cockpit resource management and decision making during the development of the emergency were misguided, probably caused by the following factors:

- situation awareness was insufficient or inappropriate disabling the crew to become aware of what was happening regarding the performance and behaviour of the aircraft

- lack of effective communication between the cockpit crew which limited the decision making processes, the ability to choose appropriate alternatives and establish priorities in the actions to counter the critical/emergency situation (stall at high altitude)

The captain (male, 40 years) had accumulated 5942 hours of professional flying experience over a period of 14 years, thereof 422 hours in command on the MD-82 and 2530 hours as a first officer and 706 hours as pilot in command on Douglas DC-9-15s. His last simulator check had taken place on Jun 24th 2005 with satisfactory results.

The first officer (male, 21) had accumulated 1341 hours flying experience thereof 862 hours as first officer on MD-82s. His last simulator check took place on July 22nd 2005 with satisfactory results.

The aircraft had accumulated 49494 hours in 24312 cycles. The (left/right) engines accumulated 43896.26/46457.08 hours in 22 977/23 606 cycles.

The airplane took off with takeoff weight of 149,023 lbs (67656 kg). Analysis showed, that the engine thrust with engine anti ice was insufficient to maintain FL330 even with a takeoff weight of 145,000 lbs, without engine anti-ice however the thrust would have been sufficient even for a takeoff weight of 155,000 lbs. Computations showed, that at 150,000 lbs takeoff weight the airplane would have been able to maintain FL316 with engine and wing anti-ice on, FL326 with engine anti-ice on and FL346 with all anti-ice off.

After the autothrust switched from EPR LIM to MACH observing the selected EPR limit with engine anti-ice on the resulting thrust (1.82) was insufficient to maintain FL330. After de-activation of engine anti-ice the EPR increased to 1.88 which was sufficient to maintain FL330.

Aerodynamic evaluation showed, that the minimum drag occurred at 0.73 Mach, below that speed the airplane would incur increasing drag with decreasing speed until a point where engine thrust was insufficient to accelerate the airplane again.

Flight data recorder data showed, that the EPR was about 1.95-2.00 when the airplane was established on FL330 and maintained 0.75 Mach, when engine anti-ice was activated the EPR fell to 1.90 and the Mach speed began to decline.

Studies provided by the NTSB in 2008 showed, the flight took place in a region of strong winds rising vertically with a speed of 69 meters/second (13660 feet per minute or 138 knots) which may have adversely affected the airplane performance. The airplane's stick shaker activated at a speed of 215 KCAS while the activation would normally be expected at 187 KCAS, the stall actually occurred at 9 degrees AoA, while the stick shaker would normally activate at 10.9 degrees AoA with retracted flaps and slats. The early stick shaker activation was the result of the strong vertical updraft, the study concluded.

A low pressure system was present with its center of 1008 millibar in Venezuela near the crash site. As result of the low pressure system cumulo nimbus clouds with scattered rainfalls had formed in Panama, Venezuela and along the Caribbean Coast. At the same time a tropical depression with a center pressure of 983 millibar was overhead Cuba. Weather services computed that there was strong convective activity overhead Colombia and Venezuela computing updrafts of 69 meters/second as result of the weather systems.

The Accident Investigators analysed, that when the airplane descended through FL317, the aural altitude alerter sounded indicating the airplane was about to reach the (newly selected) target level 310. At that point the AoA was 7.7 degrees, the captain probably pulled the elevator to arrest sink rate and level the airplane off. At this point the investigator determine the airplane actually entered stall, the stick shaker activated and the aural stall alert activates. At the same time the engine EPR suddenly falls to about 1.2 EPR consistent with airflow separation over the main wings resulting in turbulent airflow entering the engine inlets. According to the CVR the captain is now focussed with the engine indications. The continued nose-up trim reduced the airplane's speed that much that the drag exceeded the maximum engine thrust making a recovery impossible. The airplane subsequently entered deep stall caused by the turbulent airflow from the stalled main wings flowing over the tail plane making the horizontal stabilizers ineffective, at the same time the turbulent airflow no longer reached the engines, so that the engines were able to deliver 1.80 EPR again.

The Transport Ministry of Venezuela released a number of safety recommendations to improve flight crew training for high altitude stalls (simulator training usually has low altitude stalls which are significantly different due to energy status of the aircraft), improve flight crew training for cockpit resource management in abnormal flight conditions, introduce additional aural alerts for abnormal performance and introduce additional parameters on the flight data recorders.