Tarom 371 Crash '95

[speedrestriction]

Hi folks,

I'm looking for info on above crash, particularly whether the AP was engaged or not. Any ideas on where to find the official investigation report?

sr

[bradf]

AP engaged

Hi.

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.

[bradf]

A piece of the report

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

Listing date de zbor:
====================

Sec. X Y Alt. Viteza Cap Ruliu Tangaj

1 343 201 296 2 82 1 1
2 343 201 292 1 83 1 1
3 343 201 291 31 83 1 1
4 343 201 298 33 82 1 0
5 343 201 302 39 80 0 1
6 343 201 302 43 81 2 1
7 343 201 307 46 80 0 1
8 343 201 303 51 79 2 1
9 343 201 308 55 80 2 1
10 343 201 309 61 80 0 1
11 343 201 307 63 80 1 0
12 343 201 314 72 79 1 1
13 343 201 311 76 80 0 2
14 343 201 311 84 79 1 1
15 343 201 316 88 80 0 1
16 343 201 321 97 79 0 1
17 343 201 317 99 81 2 1
18 343 201 312 108 81 0 1
19 343 201 314 115 80 1 0
20 343 201 317 121 81 1 2
21 343 201 308 125 80 1 0
22 343 201 309 134 80 0 1
23 343 201 305 138 80 1 1
24 343 201 305 146 80 1 5
25 343 201 273 146 80 1 10
26 343 201 245 148 80 3 13
27 343 201 244 159 78 4 14
28 343 201 262 165 79 3 17
29 343 201 305 170 77 3 16
30 343 201 341 175 78 3 16
31 343 201 374 178 79 4 17
32 343 201 427 184 78 4 18
33 343 201 466 180 78 5 18
34 343 201 529 181 78 6 18
35 343 201 573 183 79 5 17
36 343 201 636 182 78 4 18
37 343 201 704 181 79 3 18
38 343 201 767 185 79 3 19
39 343 201 844 184 80 4 18
40 343 201 902 185 81 5 20
41 343 201 983 185 80 5 18
42 343 201 1066 186 80 0 18
43 343 201 1135 184 81 -1 18
44 343 201 1217 186 79 -5 18
45 343 201 1288 189 77 -6 19
46 343 201 1375 185 78 -9 18
47 343 201 1444 188 75 -9 19
48 343 201 1535 189 76 -9 19
49 343 201 1599 186 73 -9 19
50 343 201 1689 190 72 -10 19
51 343 201 1776 193 71 -12 19
52 343 201 1855 191 70 -12 20
53 343 201 1939 190 68 -12 20
54 343 201 2015 190 67 -14 20
55 343 201 2105 192 65 -16 19
56 343 201 2184 196 64 -18 19
57 343 201 2267 195 61 -21 18
58 343 201 2360 195 61 -22 16
59 343 201 2434 194 58 -25 18
60 343 201 2519 197 54 -26 18
61 343 201 2592 194 51 -29 18
62 343 201 2677 198 48 -30 19
63 343 201 2741 198 44 -33 19
64 343 201 2836 196 41 -33 17
65 343 201 2922 199 39 -27 17
66 343 201 2990 195 36 -25 19
67 343 201 3070 194 33 -23 19
68 343 201 3161 197 29 -23 19
69 343 201 3239 196 27 -21 19
70 343 201 3329 198 27 -19 20
71 343 201 3400 196 23 -19 20
72 343 201 3501 195 22 -19 20
73 343 201 3577 191 20 -17 19
74 343 201 3668 192 17 -17 19
75 343 201 3771 190 15 -18 17
76 343 201 3856 186 14 -16 18
77 343 201 3932 188 12 -18 18
78 343 201 3993 184 10 -16 17
79 343 201 4072 185 8 -16 17
80 343 201 4137 185 7 -15 15
81 343 201 4209 181 4 -18 14
82 343 201 4260 180 2 -19 14
83 343 201 4327 181 359 -20 12
84 343 201 4383 178 357 -19 13
85 343 201 4419 179 354 -21 13
86 343 201 4466 180 351 -20 12
87 343 201 4106 182 347 -23 10
88 343 201 4531 181 344 -28 10
89 343 201 4556 180 342 -28 9
90 343 201 4576 183 338 -28 10
91 343 201 4598 185 335 -29 9
92 343 201 4614 185 330 -35 6
93 343 201 4621 186 326 -43 5
94 343 201 4632 191 321 -41 4
95 343 201 4632 193 317 -40 2
96 343 201 4623 195 312 -43 1
97 343 201 4601 193 306 -50 0
98 343 201 4586 200 300 -57 -6
99 343 201 4563 203 296 -68 -10
100 343 201 4518 204 289 -87 -17
101 343 201 4450 210 283 -93 -23
102 343 201 4373 219 280 -94 -30
103 343 201 4232 224 275 -108 -40
104 343 201 4083 233 270 -129 -45
105 343 201 3869 246 270 -148 -53
106 343 201 3633 260 271 -162 -60
107 343 201 3361 280 272 180 -70
108 343 201 2920 296 278 155 -82
109 343 201 2523 311 306 41 -73
110 343 201 2037 326 60 12 -63
111 343 201 1460 339 61 10 -48
112 343 201 196 288 118 2 3


Listing convorbiri echipaj:
==========================

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)

[lomapaseo]

I'm looking for info on above crash, particularly whether the AP was engaged or not. Any ideas on where to find the official investigation report?

major issue was auto-thrust in a commanded turn in scud

[tubby linton]

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.

[speedrestriction]

Thank you for the info folks, much appreciated.

[Tee Emm]

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.

[Clandestino]

Originally Posted by bradf

As far as I know, the AP was part of the problem.

It wasn't. Stuck thrust lever number two was.

Originally Posted by bradf

The captain had a heart attack just after take off.

That was a hypothesis put forward by investigating authority. Apart of capt being totally silent, nothing on the CVR suggests it was really so.

Originally Posted by bradf

The co-pilot tried to help the pilot.

Nothing on CVR suggests it was so. It's usual "they-fought-bravely-till-the-end-and-missed-the-orphanage" kind of journo exaggeration.

Originally Posted by bradf

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)

Could be, so what? Nothing suggests that aeroplane couldn't be flown manually.

[Radu Poenaru]

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:

Remember Balotesti - Pe Dumnezeu a cazut toata vina | Jurnalul National

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:

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!

[MrNosy2]

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.'

[Cornish Jack]

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.

[A37575]

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.

]

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.

[lomapaseo]

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)

[Dreemsnake]

Report

I know this thread is old but if you still want the final report, you can find it here: http://www.thai-aviation.net/files/M...CC_31Mar95.pdf

[bandreoca]

Final Report

Here is the final report:
http://www.cias.gov.ro/images/rapoar...ti%20Ilfov.pdf

Many people does not belive in it. The CVR box was broken and many people suspect the conversations were "edited" before public presentation.
There are eye witnesses who says that the aircraft exploded in air.

[becauseiwasinverted]

Now everyone has seen the Air Crash Investigation episode with Tarom 371
so I guess the mistery is over and done with.

to recap:

1. aircraft has a built-in malfunctioning autothrottle on eng1 reducing
power to idle after takeoff
known procedure to overcome this is holding the thrust lever in position for a while and then all is well

2. PIC is incapacitated due to unknown and sudden critical condition

3. F/O surprised by incapacitated PIC and reduced thrust on eng 1 at the same time.
recovery impossible due to low altitude and aircraft upset condition.

[atakacs]

What are the chances for 1+2+3 ? That's not a Swiss cheese anymore...