Orange2fly A320 at Pristina on Dec 1st 2017, severe hard landing at 3.04G, aircraft flew 8 more sectors

Last Update: April 10, 2020 / 16:09:54 GMT/Zulu time

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Incident Facts

Date of incident
Dec 1, 2017

Classification
Report

Airline
Orange2Fly

Flight number
O4-3564

Destination
Pristina, Kosovo

Aircraft Registration
SX-ORG

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport ICAO Code
BKPR

An Orange2fly Airbus A320-200, registration SX-ORG performing flight O4-3564 from Basel/Mulhouse (Switzerland/France) to Pristina (Kosovo) with 178 passengers and 6 crew, had departed Basel with the left hand sliding window's heating inoperative under minimum equipment list requirements, the crew was aware that landing in Pristina was captains only. Following an uneventful flight the crew performed a VOR/DME approach to Pristina's runway 35 with the captain (ATPL, 10,078 hours total, 688 hours on type) flying the aircraft in night conditions, however, experiencing a foggy window having almost no peripheral view. The captain configured the aircraft for full flaps and maintained a Vapp 5 knots above landing speed. The autopilot was disengaged at 2000 feet, however, autothrust remained engaged. The crew acquired visual contact 3nm before the runway threshold, the first officer (ATPL, 7,356 hours total, 406 hours on type) called "stable approach" according to standard operating procedures. The crew had agreed in their briefing to perform a "positive arrival" (a rather firm touchdown to avoid hydroplaning) in snowy conditions with the runway being wet. The aircraft touched down firmly at 23:49L (22:49Z) and rolled out without further incident, the crew did not notice anything out of the ordinary. No printout (hard touchdown report) was created by the FMGS. The crew thus did not create a tech log entry.

Two days later the first officer had a private conversation with the training manager regarding that landing in Pristina because he was doubtful of that landing. As reaction to the conversation the aircraft was attended on Dec 5th 2017, paper was filled into the FMGS printer, which then printed a hard landing report indicating the aircraft had touched down in Pristina at +3.04G. The aircraft was grounded for further inspection, ferried to Craiova (Romania) for further inspection, where all four main landing wheels and the right hand shock absorber assembly was replaced. The aircraft was released to service on Dec 28th 2017.

Kosovo's Aeronautical Accident and Incident Investigations Commission (AAIIC) released their final report in multiple languages, English version starting on PDF page 56, concluding the probable causes of the serious incident were:

- The maneuvers of the PF on the stick seconds before touchdown. There were several nose up and nose down inputs at very low height.

- A late full back stick applied by the PF at 20ft/RA. This action was too late to change the vertical descent rate, so the hard landing was unavoidable at this point.

- The weather circumstances during that night were contributing factors to this occurrence, it was snowing and the runway was wet.

- Decision of the flight crew to have a Positive Landing resulted in an increased rate of descent

- Touchdown occurred with a high rate of descent (880 ft/min) as a result the Severe Hard Landing occurred.

- The left side window of the PF was foggy and was out of order because the heating was not working and the captain had reduced peripheral view. This malfunction was an MEL item, was inoperative and was out of order, the flight crew were in aware of it.

Findings as to risk

- The flight crew failed to obtain the task written in the AMM 05-51-11-200-004 regarding that the flight crew are responsible to make a report if they think that there was a hard/overweight landing.

- Missing printer paper in the DMU was an MEL item, but also crucial for printing the Load report and confirming the landing parameters.

- The aircraft continued to fly 8 more sectors without any inspection which might lead to compromising the safety of flight operations.

The AAIIC analysed:

The left side window of the PF was foggy and was out of order because the heating was not working and the captain had reduced peripheral view. This malfunction was an MEL item and did not had an impact on the perception of the PF and was not the cause of the incident.

...

The flight crew received the SNOTAM from the ATC 18 minutes before the event occurred. There was a briefing between the flight crew before the approach, and, because of weather conditions, they decided to aim for a positive landing due to snow and wet runway. The PM did callouts and declared a stabilized approach.

From the moment the AP was disengaged at around 2000 ft the aircraft was in landing configuration and was handled by PF. Both FD’s and Final app mode were disengaged as a consequence of VOR DME 35 Missed Approach Point.

At 500 ft the right turn started so the aircraft to be aligned with the runway. The PF aligned the aircraft with runway axis, consequently the roll angle was increased up to +10 0, before being reduced.

The Digital Flight Data Recorder (DFDR) showed that seconds after crossing 500 ft the aircraft made unusual nose up and nose down orders. The pitch angle increased from +2° to +6° (nose up) and the rate of descent decreased from 770 ft/min to 200 ft/min.

Three significant forward stick inputs applied by PF in the continuation, these orders decreased the pitch angle from +6 0 to +2 0 and the rate of descent increased from 200 ft/min to 880 ft/min.

At 20 ft RA the PF applied a full back stick input which lead to increasing the pitch angle from +2 0 to +3.5 0 and increase of vertical load factor from + 0.96 G to +1.05 G.

This pitch-control input was applied at very low altitude and the vertical speed did not decrease sufficiently, remaining at 880 ft/min. The aircraft touched down at 3.04 G which is considered to be a “Severe Hard Landing.

The aircraft continued to fly on 8 more sectors after the hard landing occurred, on 6th of December the aircraft was declared AOG (Aircraft on the Ground). The heavy landing reporting is crucial for taking actions to ensure that the aircraft remains functional and in airworthiness condition. According to manufacturer manual where it states that reporting of high load events must come from the pilot’s experience and awareness as first detection. It is the responsibility of every pilot to report high load occurrence by entering it the logbook. This will initiate further actions for maintenance checks and inspections. If the pilots are doubtful about the landing, they can request a print of Load . The Load report is generated automatically or manually by request of the pilots.

In our case there was no automatically print out of Load report due to missing paper in the DMU printer.

Metars:
BKPR 020130Z 34006KT 8000 -SG SCT012 BKN030 01/M01 Q1011 NOSIG RMK 17290095=
BKPR 020110Z 34005KT 5000 -SN BR SCT009 OVC025 00/M01 Q1011 RMK 17290095=
BKPR 020101Z VRB03KT 3000 SN SCT009 OVC025 00/M01 Q1011 RMK 17290095=
BKPR 020100Z VRB03KT 5000 -SN BR SCT010 OVC030 01/M01 Q1011 NOSIG RMK 17290095=
BKPR 020030Z VRB02KT 6000 -SN SCT010 OVC030 00/M01 Q1011 NOSIG RMK 17290095=
BKPR 020000Z VRB03KT 4000 -SN BR SCT009 OVC025 00/M01 Q1011 NOSIG RMK 17290095=
BKPR 012330Z 34006KT 4000 -SHSN BR SCT010 OVC025 01/M01 Q1011 NOSIG RMK 17290095=
BKPR 012300Z 32006KT 5000 -SN BR SCT010 OVC025 01/M01 Q1011 NOSIG RMK 17290095=
BKPR 012230Z 33007KT 8000 -RASN SCT014 BKN040 02/M00 Q1011 NOSIG RMK 17290095=
BKPR 012200Z 32006KT 8000 -RASN SCT012 OVC030 02/M00 Q1011 NOSIG RMK 17290095=
BKPR 012130Z 34004KT 8000 -RA SCT012 OVC030 02/M00 Q1010 NOSIG RMK 17290095=
BKPR 012100Z 36006KT 9999 -RA SCT014 BKN030 02/M00 Q1010 NOSIG RMK 17290095=
BKPR 012030Z 35007KT 9999 -RA SCT015 BKN030 02/M00 Q1011 NOSIG RMK 17290095=
BKPR 012000Z 34007KT 8000 -RA SCT015 BKN030 02/M00 Q1011 NOSIG RMK 17290095=
Incident Facts

Date of incident
Dec 1, 2017

Classification
Report

Airline
Orange2Fly

Flight number
O4-3564

Destination
Pristina, Kosovo

Aircraft Registration
SX-ORG

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport ICAO Code
BKPR

This article is published under license from Avherald.com. © of text by Avherald.com.
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