Yemenia A313 near Moroni on Jun 30th 2009, impacted ocean
Last Update: July 1, 2013 / 15:47:22 GMT/Zulu time
Incident Facts
Date of incident
Jun 30, 2009
Classification
Crash
Airline
Yemenia
Aircraft Type
Airbus A310-300
ICAO Type Designator
A313
The accident was caused by inappropriate flight control inputs by the crew which resulted in the aircraft entering stall, that was not recovered.
These flight control inputs followed a non-stabilized circling approach, during which many different alarms related to the proximity of ground, the aircraft configuration and approach to stall activated. The crew's attention was focussed on managing the flight's trajectory and the position of the runway, the crew probably did not have sufficient mental capacity available in this stressful scenario to react properly to these alerts.
Contributing factors:
- The weather conditions at the airport (in gusts around 30 kts).
- Lack of training or briefing of the crew before conducting the flight to Moroni in accordance with the Operations Manual of Yemenia, resulting in reluctance by the pilot to conduct the visual maneouvering MVI to Moroni's runway 20 (none of the documents submitted to the investigation show these briefings were conducted)
- The crew did not properly apply procedures to a Pull-Up GPWS Alarm (at the locator 5.2 NM before threshold runway 02), causing that the crew was slow to the right downwind.
- Non-adherence to the MVI procedure by the crew (the plane left the axis of LOC)
The captain (45, ATPL, 7,936 hours total, 5,314 hours on type) was assisted by a first officer (50, CPL, 3,641 hours total, 3,076 hours on type).
Following an uneventful flight the aircraft left FL350 on the descent towards Moroni, the crew received weather information indicating winds from 190 degrees at 15 knots, visibility 10km, clouds at 2000 feet, temperature 24 degrees C, dew point 17 degrees C, QNH 1018 hPa. Following the standard instrument arrival route the aircraft was cleared for a VOR DME ILS runway 02.
The aircraft intercepted the localizer with autothrust engaged maintaining 190 KIAS, at that point the flaps were selected to 15 degrees, the landing gear was still retracted, the autopilot was engaged in heading 060 selected and altitude hold at 3000 feet, autopilot 1 was flying the aircraft (editorial note: suggesting the captain was pilot flying though the report never identifies who was pilot flying).
Following the intercept of the localizer the speed was reduced to 170 knots, the aircraft encountered tail wind of 30 knots at that point. Tower reminded the crew that they were cleared for an VOR DME ILS approach to runway 02 circling MVI runway 20. The captain queried whether the flashing lights runway 20 would be available, the controller responded in the negative. The aircraft subsequenty intecepted the glideslope, the autopilot vertical mode was changed to V/S at 1300 fpm and the landing gear was selected down. At that point the aircraft was tracking 015 degrees on a heading of 018 degrees.
Descending through 2000 feet the autopilot shows vertical mode G/S* and lateral mode LOC* (capturing glideslope and localizer) for about 9 seconds, then changed to HDG and ALT, the aircraft maintains 1500 feet, target speed is selected to 160 knots.
Tower reported the threshold wind runway 20 at 200 degrees at 12 gusting 25 knots.
The target altitude is selected to 1000 feet, V/S mode engaged at 500 feet per minute rate of descent, then 800 feet per minute and another 4 seconds later 1100 fpm. The target altitude is changed to 0 feet, 5 seconds later selected to 3000 feet. The target heading is selected to the left to 314 degrees, descending through 1390 feet the aircraft turned left to join a right hand downwind.
At 1190 feet the target altitude is briefly changed to 1000 feet, the autopilot switched to ALT* (altitude capture), the target altitude was selected to 3000 feet, a vertical speed of -500 fpm selected. 20 seconds later the crew announced they were on the downwind, the autopilot was disconnected with autothrust still maintaining 160 KIAS, the aircraft began turning right through a heading of 320 degrees at 800 feet at that point, the pitch angle reduced. The controller instructed the crew to report turning final.
5 seconds later the GPWS alarm "Pull Up - Sink Rate" activated, the aircraft was descending through 500 feet at 2000 fpm and turning right through a heading of 027 degrees. The GPWS subsequently called out 400, 300 followed by a "TOO LOW TERRAIN" Alarm at 230 feet AGL, the aircraft was in right bank of 29 degrees. The crew rolled wings level and increased pitch to 17 degrees.
The radio altitude reduced to 161 feet before the aircraft started to climb again, autothrust increased engine thrust in order to maintain selected 160 KIAS, 11 seconds later the crew selected the gear up at 437 feet AGL. The autopilot is re-engaged, actual speed 158 KIAS, the flaps begin to retract, the target speed is select to 180 KIAS, the thrust levers approach TOGA position.
The target altitude is selected to 0 feet at 802 feet AGL, the autothrust system indicates "DELAY" indicating the engines were slowing to idle, the thrust levers retard towards idle. The autopilot, in order to maintain commanded 180 knots, reduced the pitch angle, the target speed is increased to 210 knots, the flaps reach 0 degrees. The aircraft peaked at 872 feet AGL and began to descend again. The engines reach idle thrust.
The autopilot changed to open climb (level change in a climb) indicating that the target altitude selected was now greater than the current altitude, autothrust began to move the thrust levers forward. With the engines however still at idle the aircraft reached 690 feet, the alarm for "landing gear not down" sounded. The autopilot was disconnected, the cavalry sound silenced the landing gear not down alarm due to the higher priority.
At 653 feet AGL the pitch angle begins to increase and reaches 12.1 degrees nose up at 190 knots, the Alpha Floor protection activates increasing the speed of thrust lever movement commanded by the autothrust system from 1 to 8 degrees/second and causing the engines to spool up to takeoff/go-around thrust, which is maintained until impact.
The pitch angle increases through 13 degrees, the speed reduces further through 185 knots at the aircraft climbs. Climbing through 698 feet AGL the speed decayed to 170 knots, the pitch angle was 17.1 degrees. The aircraft climbs through 731 feet. The target altitude is selected to 0 feet, the flight director changes to open descent (level change descend), the stall warning activated and continued for 40 seconds until impact. The aircraft reached 943 feet at 26 degrees nose up, the aircraft reaches a maximum of 1034 feet AGL which remained nearly constant over 27 seconds. The aircraft rolls left and right between 37.6 degrees left and 39.7 degrees right, the pitch angle oscillates between 14.6 degrees and 23.7 degrees, 14 seconds prior to impact the aircraft descends through 972 feet, the aircraft pitches rapidly down reaching 4 degrees nose down, the speed increases to 182 knots, the pitch increases, but the aircraft impacted the waters 10nm north of Moroni Airport, about 3nm north of the north coast.
141 passengers and all 11 crew died, one passenger survived with serious injuries.
The survivor, a 13 year old girl, later reported that she had not noticed any anomaly throughout the flight, however, after the announcement of landing she felt the aircraft was shaking heavily. Following impact she had no time to look for a life vest and clinged onto a floating aircraft part. She was discovered by a rescue boat and taken on board about 12 hours after the crash.
ANACM identified three stages of the approach, stage 1 being the ILS approach to runway 02, stage 2 the visual maneouvering onto downwind and stage 3 the loss of control.
ANACM analysed that the lead in lights were operative, the NOTAMs however had identified the flashing runway threshold edge lights inoperative. While the pilot meant the lead in lights, the tower referred to the threshold edge lights. Following the exchange with the controller the crew assumed the lead in lights were inoperative and due to the lack of preparation for this scenario by NOTAM did not know how to proceed. The approach chart used by the operator required the lead in lights operative to conduct the approach, however did not require the approach to be abandoned in case of failure of the lights. ANACM stated: "Thus, the discovery of the inoperative lights provided an additional difficulty to the crew to fly the turn onto final in a moonless night environment with little visual cues available and close to the terrain of the island."
ANACM analysed that the frequent target altitude changes including the display of 0 were inadvertent inputs while the heading bug was intended to be operated. The target altitude of 3000 feet, selected repeatedly, had no operational justification, the go-around altitude was 8000 feet.
Due to the thus delayed turn off the localizer onto downwind and the tail wind the aircraft was thus bound to veer north much farther than anticipated. It is likely, that the captain could not see the runway from his left hand seat. It is likely that the crew intended to descent to MDA for the visual maneouver. Instead of rotating the heading bug to turn onto final the target altitude selector was rotated. It is likely that the crew became occupied with establishing the correct path and did not notice that they had descended below MDA, with their focus towards the lateral management of the track the crew did not monitor the altitude.
The GPWS alerts permitted the crew to recognize their altitude, the crew responded by increasing the pitch, however, did not initiate the proper go around procedures, which would have aborted the approach but permitted to climb out to safety.
When the crew selected the gear up this was not the initiation of a go around, but rather the recognition that they could not turn final right away and needed a long final, also evidenced by the transmission indicating they would make a long final. The captain had no plan to abandon the approach.
Again the crew manipulates the altitude rotating knob while probably intending to operate the heading select button.
Incident Facts
Date of incident
Jun 30, 2009
Classification
Crash
Airline
Yemenia
Aircraft Type
Airbus A310-300
ICAO Type Designator
A313
This article is published under license from Avherald.com. © of text by Avherald.com.
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