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Final Report State Commission on Aircraft Accidents Investigation Boeing 767-300ER; SP-LPC; November 1, 2011; Warsaw, (EPWA) FINAL REPORT ACCIDENT Occurrence No.: 1400/11 Aircraft: B767-300ER, SP-LPC November 1, 2011 Warsaw Chopin Airport (EPWA), RWY 33 This Report is a document presenting the position of the State Commission on Aircraft Accidents Investigation concerning circumstances of the air occurrence, its causes and safety recommendations. The Report was drawn up on the basis of information available on the date of its completion. The investigation process can not be considered as finally closed. The investigation may be reopened if new information becomes available or new investigation techniques are applied, which may affect the wording related to the causes, circumstances and safety recommendations contained in the Report. Investigations into air occurrences are carried out in accordance with the applicable international, European Union and domestic legal provisions for prevention purposes only. The investigation was carried out without the need of application of the legal evidential procedures, applicable for proceedings of other authorities required to take action in connection with an air occurrence. The Commission does not apportion blame or liability. In accordance with Article 5 paragraph 5 of the Regulation (EU) No 996/2010 of the European Parliament and of the Council on the investigation and prevention of accidents and incidents in civil aviation […] and Article 134 of the Act – Aviation Law, the wording used in this Report may not be considered as an indication of the guilty or responsible for the occurrence. For the above reasons, any use of this Report for any purpose other than air accidents and incidents prevention, can lead to wrong conclusions and interpretations. This Report was drawn up in the Polish language. Other language versions may be drawn up for information purposes only. WARSAW 2017 State Commission on Aircraft Accidents Investigation Boeing 767-300ER; SP-LPC; November 1, 2011; Warsaw, (EPWA) TABLE OF CONTENTS ABBREVIATIONS ................................................................................................................... 4 GENERAL INFORMATION .................................................................................................... 7 SYNOPSIS ................................................................................................................................ 8 1. FACTUAL INFORMATION .............................................................................................. 10 1.1. History of the flight. ................................................................................................... 10 1.2. Injuries to persons ...................................................................................................... 12 1.3. Damage to aircraft ...................................................................................................... 12 1.3.1. Damage to engines ............................................................................................ 12 1.3.2. Damage to airframe .......................................................................................... 12 1.3.3. Damage to engines nacelles .............................................................................. 13 1.3.4. Damage to on-board systems ............................................................................ 14 1.4. Other damage. ............................................................................................................ 14 1.5. Personnel information (crew data). ............................................................................ 15 1.6. Aircraft information. .................................................................................................. 17 1.6.1. General information .......................................................................................... 17 1.6.2. Airplane hydraulic systems – operation and signaling ..................................... 18 1.6.3. Landing gear control systems - operation and signaling................................... 19 1.6.4. Circuit breakers ................................................................................................. 21 1.6.5. ETOPS .............................................................................................................. 24 1.7. Meteorological information ........................................................................................ 24 1.8. Aids to navigation ...................................................................................................... 24 1.9. Communications ......................................................................................................... 24 1.10. Aerodrome information. ........................................................................................... 25 1.11. Flight recorders ........................................................................................................ 27 1.12. Wreckage and impact information ........................................................................... 33 1.13. Medical and pathological information ..................................................................... 33 1.14. Fire ........................................................................................................................... 33 1.15. Survival aspects ........................................................................................................ 34 1.15.1. Cabin crew actions .......................................................................................... 34 1.15.2. Rescue and firefighting action ........................................................................ 38 1.15.3. Removal of the disabled airplane .................................................................... 40 1.16. Tests and research .................................................................................................... 41 1.16.1. Airplane documentation .................................................................................. 41 1.16.2. Technical issues .............................................................................................. 42 1.17. Organizational and management information .......................................................... 50 1.17.1. State Commission on Aircraft Accidents Investigation .................................. 50 1.17.2. Foreign Authorities ......................................................................................... 50 FINAL REPORT Page 2 of 87 State Commission on Aircraft Accidents Investigation Boeing 767-300ER; SP-LPC; November 1, 2011; Warsaw, (EPWA) 1.17.3. Operator’s Operations Centre and MCC......................................................... 50 1.18. Additional information. ............................................................................................ 51 1.18.1. Crew characteristics ........................................................................................ 52 1.18.2.Course of occurrences during flight LO 16 ..................................................... 52 1.19. Useful or effective investigation techniques ............................................................ 53 2. ANALYSIS .......................................................................................................................... 53 2.1. Hypotheses ................................................................................................................. 54 2.2. Analysis of the circuits powered via C829 - technical factors ................................... 55 2.2.1. Circuit 1 – CHILLER SHUTDOWN CONT .................................................... 55 2.2.2. Circuits 2, 3, 4. – L, R, APU GENERATOR CONTROL UNIT ................... 56 2.2.3. Circuits 5, 6 – L/R DRIVE DISC ..................................................................... 56 2.2.4. Circuit 7 – BUS POWER CONT UNIT (BPCU) ............................................. 57 2.2.5. Circuit 8 – STBY PWR CONT ........................................................................ 58 2.2.6. Circuit 9 – DC BUS TIE CONT ....................................................................... 58 2.2.7. Circuit 10 – HYD GEN CONT PWR ............................................................... 59 2.2.8. Circuit 11 – RAM AIR TURB-AUTO ............................................................. 59 2.2.9. Circuit 12 - BAT CUR MONITOR PWR ......................................................... 60 2.2.10. Circuit 13 – LANDING GEAR-ALT EXT MOTOR ..................................... 61 2.3. Analysis of the crew operation – human factors ........................................................ 62 2.3.1. Attempt to determine the time when C829 was set OFF .................................. 62 2.3.2. Analysis of the approach to landing.................................................................. 66 2.4. Summary of LO 16 flight analysis; technical and human factors .............................. 70 2.5. Analysis of SP-LPC airplane evacuation ................................................................... 71 2.6. Analysis of the operation of Operator’s Operations Centre ....................................... 72 2.7. ETOPS analysis .......................................................................................................... 72 3. CONCLUSIONS ................................................................................................................. 73 3.1. Commission
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