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A V E R T I S S E M E N FRANCE - Accident survenu le 20 janvier 1992 près du Mont Sainte-Odile (Bas Rhin) à l'Airbus A 320 immatriculé F-GGED INSPECTION GENERALE DE L'AVIATION CIVILE ET DE LA METEOROLOGIE METEOROLOGIE LA DE ET CIVILE L'AVIATION DE GENERALE INSPECTION - exploité par la compagnie Air Inter RAPPORT de la commission d'enquête f-ed920120 MINISTERE DE L'EQUIPEMENT DES TRANSPORTS ET DU LOGEMENT LOGEMENT DU ET TRANSPORTS DES L'EQUIPEMENT DE MINISTERE AVERTISSEMENT Ce rapport exprime les conclusions techniques auxquelles est parvenue la Commission d'Enquête sur les circonstances et les causes de cet accident. Conformément à l'Annexe 13 de la Convention relative à l'aviation civile internationale, l'analyse et les recommandations de sécurité formulées dans ce rapport ne visent pas à établir des fautes ou évaluer des responsabilités individuelles ou collectives. Leur unique objectif est de tirer de cet évé- nement les enseignements susceptibles de prévenir de futurs accidents. Dans cette démarche, parce que le doute doit profiter à la sécurité, certaines des recommanda- tions proposées concernent des points dont la démonstration rigoureuse n'a pas toujours pu être apportée, ou qui sont même parfois sans relation directe avec les causes de l'accident. De plus, cette analyse et ces recommandations sont formulées au terme d'investigations approfon- dies, et s'appuient donc sur une expérience et une compréhension des événements qui peuvent différer notablement de celles qui prévalaient au moment de l'accident. Enfin, bien que les personnes et organismes dont la consultation a été jugée opportune aient été invités à présenter leurs observations en temps utile, l'enquête n'a pas été menée de façon contra- dictoire. En conséquence, l'utilisation de ce rapport à d'autres fins que la prévention des accidents pourrait conduire à des interprétations erronées. immat - date - 2 - Table des matières immat - date - 3 - Glossaire ACARS Aircraft Communication Adressing and Reporting System ,Système permettant l'échange d'information sous forme digitale entre l'avion et le sol. ADIRS Air Data Inertial Reference System. AFS Auto Flight System. ALT Altitude AP Auto-pilot (Pilote Automatique) APU Auxilliary power unit ,Groupe auxiliaire de puissance ARPT Airport ATA Nomenclature ATIS Automatic terminal information service,Service automatique d'informa- tion de région terminale ATC Air Traffic Control A/THR Auto-thrust (auto poussée) AWY Airway BITE Built-In Test Equipment CFDIU Centralized Fault Data Interface Unit CLA Contrôle Local d'Aérodrome CMD Commande (N1 CMD : N1 Commandé) CORTE Company Route COST Le cost index est le ratio du coût de 1' heure de vol et du coût du carbu- INDEX rant, et c'est le paramètre essentiel du calcul par le FMGS de la vitesse qui sera adoptée par l'avion en mode managé. Un cost index plus élevé conduit à une vitesse managé plus élevée. La valeur du cost index est propre à chaque compagnie, et à chaque route. Elle est contenue dans la data-base avec la CO-ROUTE, elle est modifiable en vol. CPU Cabin Pressure Controller Unit CRNA/Est Centre Régionale de la Navigation Aérienne Est, situé à Reims. CRS Course CRT Cathode Ray Tube CVR Cockpit voice recorder, Enregistreur phonique DDRMI Digital Distance and Radio Magnetic Indicator DFDR Digital Flight Data Recorder , Enregistreur numérique des paramètres de vol immat - date - 4 - DIR TO Direct To DMC Display Management Computer DME Distance Measuring Equipement, Dipositif de mesure de distance ECAM Electronic Centralized Aircraft Monitoring (sur avion Airbus) EFIS Electronic Flight Instrument System ELAC Elevator Aileron Computer ENAC Ecole Nationale de l 'Aviation Civile, située à Toulouse E/WD Engine/Warning Display FAF Final Approach Fix FCU Flight Control Unit FD Flight Director FL Flight level, Niveau de vol FMA Flight Mode Annunciator FMGC Flight Management Guidance Computer FMGS Flight Management Guidance System F/PLN Flight Plan FPV Flight Path Vector FWC Flight Warning Computer GA Go Around GPWS Ground Proximity Warning System HDG Heading hPa Hectopascal (Unité de mesure de la pression atmosphérique) HUD Head Up Display IAF Initial Approach Fix IAS Indicated Airspeed IDLE Régime Ralenti IFR Instrument Flight Rules, Règles de vol aux instruments ILS Instrument Landing System, Système d'atterrissage aux instruments INIT Initialisation IRS Inertial Reference System KT Knot MCDU Multifunction Control and Display Unit MDA Minimum Descent Altitude NDH Minimum Descent Height METAR Message d'observation météorologique régulière pour l'aviation MSA Minimum Saft Altitude immat - date - 5 - NAV Navigation NAVAID Navigation Aid (VOR/DME) ND Navigation Display NM Nautical Mile N1 Pour le CMF56, ce paramètre est représentatif de la poussée du réac- teur dans toutes les phases du vol. PA Public Address P/B Push-Button PFD Primary Flight Display PHR Plan Horizontal réglable QAR Quick Access Recorder, Enregistreur de paramètres pour la mainte- nance QFE Pression atmosphérique à l'altitude de l'aérodrome Atmospheric pres- sure at aerodrome elevation QFU Direction Magnétique de la Piste, Magnetic orientation of runway QNH Calage altimétrique requis pour lire une fois au sol l'altitude de l'aéro- drome, Altimeter Setting to obtain aerodrome elevation when on the ground RA Radio Altitude RBDA Radiobalise de détresse à déclenchement automatique , ELBA : emer- cencY location beacon aircraft RTE Route RWY Runway SC Single Chime SD System Display SEC Spoiler Elevator Computer Secondary SID Standard Instrument Departure SLT Slat SPAR Slight precision approach radar, Radar léqer d'approche de précision SPD Speed SPLR Spoiler STAR Standard Terminal Arrival Route SYS System TACAN Tactical air navigation aid, Système de navigation tactique (comprend une partie"mesure de distance " utilisée par l'Aviation Civile) TAF Prévision météorologique d'atterrissage TAS True Air Speed TAT Total Air Temperature immat - date - 6 - THR Thrust THS Trimmable Horizontal Stabilizer TLA Thrust Lever Angle TO Take off TOGA Take off go around TRK Track, Route UTC Universal Time Coordinated , Temps universel coordonné VBV Variable Bleed Valve , Vanne de décharge du compresseur basse pression(sur moteurs CFM 56) VFE Maxi Velocity Flaps extended VHF Very High Frequency VOR VHF omnidirectional range , Radiophare omnidirectionnel VHF VORTAC Combinaison VOR et TACAN VREF Landing Reference Speed V/S Vertical Speed VSV Variable Stator Vane , Aube de stator à calage variable (sur moteurs CFM 56) immat - date - 7 - SYNOPSIS Date de l' accident Aéronef Le lundi 20 janvier 1992 AIRBUS A320 immatriculé F-GGED à 18 h 20 UTC 1 Lieu de l'accident Propriétaire Lieu-dit "La Bloss" DIA A.I. France LTD Commune de Barr (Bas-Rhin) 7-2, YAESU 2-CHOME, CHUO-KU (près du Mont Sainte-Odile) TOKYO 104 JAPON Nature du vol Exploitant Vol régulier Compagnie AIR INTER Transport public de passagers Personnes à bord 2 PNT 4 PNC 90 passagers Résumé : Lors d'une approche VORTAC effectuée de nuit et en conditions IMC vers la piste 05 à Strasbourg-Entzheim, l'avion percute le mont "La Bloss" au cours de sa des- cente vers la piste, à environ 800 mètres d'altitude et 10,5 milles nautiques du seuil de piste. Conséquences : Personnes Matériel Chargement Tiers Tué(s) Blessé(s) Indemne(s) Détruit à environ Equipage 5 1 100% Détruit à 1 ha de 100% forêt dé- Passagers 82 4 4 truit 1 Les heures figurant dans ce rapport sont exprimées en temps universel coordonné (UTC), il con- vient d'y ajouter une heure pour obtenir l'heure en vigueur en france le jour de l'accident. immat - date dateimpression - 8 - ORGANISATION DES TRAVAUX 1 - CONSTITUTION DE LA COMMISSION D'ENQUETE Par arrêtés des 21 et 27 janvier 1992, le ministre de l'équipement, du logement, des transports et de l'espace a institué une commission d'enquête pour étudier les circonstances, rechercher les causes et dégager les enseignements de l'accident survenu le 20 janvier 1992, sur le territoire de la commune de Barr (Bas-Rhin) à un avion de type Airbus A320 de la compagnie Air Inter. La commission comprenait les membres suivants: M. Alain Monnier, ingénieur général de l'aviation civile,Président M. Paul Arslanian, chef du Bureau Enquêtes-Accidents,Vice-Président M. Pierre Bernard, enquêteur technique au bureau enquêtes-accidents M. Jean-Louis Chatelain, pilote de ligne, commandant de bord M. Philippe Gourguechon, pilote inspecteur à l'Organisme du Contrôle en Vol M. Michel Guillaume, conseiller d'Etat M. le colonel Guy Lagrange, Chef d'état-major de la Direction de la circula- tion aérienne militaire M. Dominique Marbouty, ingénieur général de la météorologie M. le professeur Henri Marotte, médecin-chef du centre d'essais en vol M. Jean Pariès, chef adjoint du Bureau Enquêtes-Accidents M. Frédéric Rico, adjoint au directeur de navigation aérienne M. Alain Tert, sous-directeur technique du cent d'essais en vol Monsieur Jean Pariès membre de la Commission a assuré les fonctions de rapporteur général. En application des dispositions de l'annexe 13 à la convention relative à l'aviation civile internationale, M. Robert M. MacIntosh, représentant accrédité des Etats- Unis au titre d'un Etat constructeur (moteurs), a été associé aux travaux de la commission d'enquête. 2 - METHODE DE TRAVAIL De sa première réunion tenue le 27 janvier 1992 à la remise de son rapport préli- minaire le 20 février 1992, la commission d'enquête a travaillé en son sein pour procéder aux premières investigations et arrêter les termes de trois premières re- commandations de sécurité présentées au Ministre avec le rapport préliminaire et reprises par la commission dans son rapport final (trois réunions tenues les 27 janvier, 10 février et 17 février 1992). La commission d'enquête a ensuite créé dix groupes de travail composés d'ex- perts de l'Administration, des contructeurs, de l'exploitant et des syndicats intéres- sés, pour préparer les éléments du chapitre I "Renseignements de base" de ce rapport et procéder aux analyses permettant notamment de décrire le scénario de l'accident.
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