Air France A332 at Caracas on Apr 13th 2011, hard landing
Last Update: September 25, 2013 / 14:28:11 GMT/Zulu time
the hard landing was caused by the continuation of the landing although deviations from the trajectory should have prompted a go-around.
The workload created by manual handling of the aircraft, without assistance by autothrust systems and in detereorating weather conditions, contributed to the accident.
The hard landing caused the implosion of the piston mounted on the right main gear oleo, which was undetectable on the ground but prevented the gear retraction on the return flight.
The use of inadequate technical notes by the operator as well as the lack of an automatic R15 report issued by the aircraft systems prevented detection of the damage caused by the hard landing. This resulted in the departure of the substantially damaged aircraft for a passenger flight.
The BEA reported that the captain (12,921 hours total, 1,122 hours on type) was pilot flying on approach to Caracas, the first officer (6,319 hours total, 922 hours on type) was pilot monitoring, a relief first officer was on board as well. There were several thunderstorms, rain and wind reported and subsequently discussed by the crew about 15 minutes prior to arrival in the approach briefing. The crew determined their Vapp was 136 KIAS at full flaps. The aircraft was cleared for an ILS approach to runway 10.
The aircraft intercepted the localizer 10nm before touchdown in instrument meteorologic conditions with autopilot and autothrust engaged and intercepted the glidepath 6nm before touchdown. The crew selected 136 KIAS into the speed window, disconnected autopilot and autothrust and applied full flaps.
After being handed off to tower tower reports winds from 060 degrees at 10 knots, windshear on one mile final.
The aircraft breaks clouds at 1000 feet AAL (above aerodrome level) and the crew established visual contact with the runway, at that point the attitude is 0.4 degrees nose down at 153 KIAS and a descent rate of 950 feet per minute, the aircraft banked about 3 degrees to the right, the speed is gradually reducing.
While descending through 500 feet AAL the pilot monitoring calls out deviations which are being corrected by the pilot flying. The bank angle reaches 9 degrees to the left countered by a full deflection of the captain's side stick to the right.
At 200 feet AAL the captain considers the aircraft to be above glidepath. The speed increases from 138 to 153 knots called out by the pilot monitoring, two control inputs to lower the nose occur, the attitude becomes nose down again and the aircraft begins to descend again.
At 50 feet AGL the captain applies nose up commands, the attitude increases, the speed reduces through 136 KIAS. At 35 feet AGL the ground proximity warning systm (GPWS) issues a "Sink Rate!" warning, a few seconds later the aircraft touched down at a sink rate of 1200 feet per minute and a vertical acceleration of +2.74G.
The BEA annotated that there was no windshear warning issued by the GPWS.
After landing the captain reported the hard landing in the tech log of the aircraft. The maintenance teams follows up on the recording stating that no R15 hard landing report had been generated by the aircraft systems and annotate that according to the technical documentation no hard landing check is necessary and release the aircraft to service again.
The pilot monitoring assigned to the return flight, assisted by a maintenance engineer, performed a walk around before the departure for the return flight. Both did not notice any anomaly, and the aircraft departed for the return flight, however, after departure the landing gear could not be retracted, a number of ECAM alarms related to cabin air conditioning and the landing gear were issued. The crew aborted the flight, burned off fuel and returned to Caracas for a landing at maximum landing weight.
After the aircraft reached the stand following the return substantial damage was seen at the right main gear and the fuselage structure.
The BEA analysed that the call outs by the pilot monitoring with respect to deviations from required flight trajectory and speeds would have required a go-around. Instead, the deviations were corrected, at all times in the correct direction. When the GPWS sounded "Sink Rate!" at 35 feet - and did not stop before touch down - a balked landing (rejected landing) should have occurred. However, the crew did not initiate a go-around or balked landing.
The aircraft encountered a tail wind of 10 knots throughout most of the approach, which changed to a head wind component of 7 knots and cross wind component of 10 knots from the left on short final, a downdraft of 7 knots occurred simultaneously. The wind change however did not satisfy the windshear criteria of the GPWS, hence no windshear warning was issued.
The BEA analysed that information about the vertical acceleration at touch down is always available however is NOT displayed to the flight crew. Flight crew have to solely rely on the generation of the R15 hard landing report by the aircraft systems.
After landing the captain met the station manager at Caracas and repeated that they had made a hard landing and an inspection was necessary. The station manager was already aware of passenger talks reporting the hard landing. A maintenance engineer was sent out to the aircraft in heavy rain and darkness, the engineer was subsequently informed that the commander had reported the hard landing and necessity of an inspection. The engineer looked up the aircraft systems, found two R15 reports that had been created earlier the year but no report of April 13th 2011. Applying the technical notes of the airline the engineer thus (incorrectly) concluded that a hard landing inspection was not required. As a precaution the engineer discussed the finding with the operator'S maintenance coordination center who upheld the finding.
The BEA analysed that the technical notes did not contain a flow chart - unlike the A320 maintenance manuals - showing the decision process to be made when a hard landing is reported, the flow chart identifying the need to conduct an inspection as soon as a hard landing is being reported, by an automatic R15 report or not. The BEA analysed that the A330 maintenance manual's verbal description applied only to the case that an R15 report had been issued, but did not apply to the case of no R15 report. The documentation was updated to require the local maintenance engineers to access the data management unit of the aircraft to verify the landing parameters and to require the maintenance coordination center to read out the quick access recorders in case of a hard landing reported but no R15 report being issued.
An examination of the right hand main gear's fixed piston revealed the absence of fluid in the oleo and fractures in the body of the fixed assembly at the upper piston. The fractures were identified as result of "brutal" overload. The cracking continued to propagate throughout the stop on the ground and subsequently prevented the gear retraction and could have caused a complete failure of the gear structure at any time.
The BEA analysed that it was likely that after the first hard landing there was still fluid in the oleo - the chrome portion of the oleo was still visible when the maintenance engineer and the walkaround by the pilot monitoring of the return flight occurred, making the aircraft appear normal.
One safety recommendation to ammend the maintenance procedures with respect to lack of R15 automatic reports as well as the inclusion of a flow chart of decision making has been released by the investigation.
This article is published under license from Avherald.com. © of text by Avherald.com.
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