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Fokker 100 RVDL 93-01 -RAAD VOOR DE LUCHTVAART Netherlands Aviation Safety Board CRAFT ACCIDENT REPORT 93-01 THIS REPORT CONTAINS THE VIEWS OF THE NETHERLANDS AVIATION SAFETY BOARD ON THE ACCIDENT TO: PALAIR FLIGHT PMg301 , FOKKER 100, PH-KXL, SKOPJE, REPUBLIC OF MACEDONIA MARCH 5, '1993 Reference: Final Report dated May 1993 published January 1996, of the Aircraf t Accident Investigation Commission of the former Federal Republic of Yugoslavia . - CONTENTS - SYNOPSIS PREAMBLE 1 FACTUAL INFORMATION 1 .1 History of the Flight 1 .2 Injuries to Persons 1 .3 Damage to Aircraft 1 .4 Other Damage 1 .5 Personnel Information 1 .5 .1 General 1 .5 .2 Flight Crew Information 1 .5 .3 Cabin Crew Information 1 .5 .4 Ground Handling Crew Information 1 .6 Aircraft Information 1 .6 .1 General 1 .6 .2 Fokker 100 Fuel Storage Syste m 1 .6 .3 Fuel Circulation 1 .6 .4 Refuelling 1 .6.5 Take Off Flight Director Pitch Commands 1 .6.6 Roll control 1 .7 Meteorological Informatio n 1 .8 Aids to Navigation 1 .9 Communications 1 .10 Airport Information 1 .10.1 General 1 .10.2 Applicable Snowtam 1 .10.3 Airport De-/Anti-icing Equipment 1 .11 Flight Recorders 1 .11 .1 Cockpit Voice Recorde r 1 .11 .2 Digital Flight Data Recorder 1 .12 Wreckage and Impact Information 1 .12.1 Airframe Damage 1 .12.2 Engine Damage 1 .12 .3 Systems Damage 1 .13 Medical and Pathological Information 1 .14 Fire 1 .15 Survival Aspects 1 .15.1 Search and Rescue 1 .15.2 Survivability 1 .16 Tests and Research 1 .16.1 Calculations on the Fuel Temperature 1 .16.2 Fuel and Fuel Temperature Distribution 1 .16.3 Fuel Temperature Test I 1 .16.4 Aerodynamic Studies and Simulation 1 .17 Additional Information 1 .17 .1 Applicable Manuals and Procedure s 1 .17 .2 AFT Adverse or Cold Weather Operations 1 .17 .3 Post-accident Publications from Fokker and the RLD with regard to Win g Ice Contamination 1 .17 .4 Training of Palair Flight Crew 2 ANALYSIS 2 .1 General 2 .2 Prevailing Weather Conditions 2.3 The Flight of Palair 301 and the Loss of Lateral Contro l 2 .3 .1 Reconstruction of the Flight 2 .3 .2 Impaired Lifting Capability 2.3.3 Further Aerodynamic Analysis 2 .3 .4 Results of the Simulation 2 .4 Contamination of the Wing 2.4.1 External Inspection of the Wing 2 .4.2 Wing Contamination prior to Take Off 2 .5 Crew Performance 2.5.1 Crew Responsibilitie s 2.5.2 Flight Crew Actions 2 .6 Ar'1'/Palair Procedures/Guidance 2.6.1 AFT Deicing Procedure s 2 .6 .2 Palair Operating Environment 2 .7 Further Preventive Measures Considered 2.7 .1 General 2 .7 .2 Usage of Wing Leading Edge Heating on the Ground 2 .7 .3 Ice Detectors 2 .8 Epilogue 3 CONCLUSIONS 3 .1 Findings 3 .2 Cause 4 RECOMMENDATIONS 5 APPENDIXES II UST OF APPENDIXE S 1. PHOTOGRAPHS 2. TRANSCRIPT COCKPIT VOICE RECORDER 3. READ OUT DIGITAL FLIGHT DATA RECORDER 4. AIRFRAME DAMAGE 5. COLLECTED DATA FOR FUEL CALCULATION S 6. FOKKER 100 FUEL TANK TEMPERATURE CALCULATION S FOKKER 100 FUEL TEMPERATURE TES T 8. SECTION ADVERSE WEATHER OPERATION OF THE FOKKER 100 AOM 9. SWISSAIR V-CHECK (VORFLUG CONTROLLE) 10. RLD AIRWORTHINESS DIRECTIVE NO . 93-167/3(A) III - LIST OF ABBREVIATIONS - AD Airworthiness Directive AFCAS Automatic Flight Control and Augmentation Syste m (NAV and PROF modes = Navigation and Profile modes) AFM Airplane Flight Manual AFT Aircraft Financing and Trading B.V. AFTAS AFT Aviation Services AIIB Accident and Incident Investigation Bureau of the NASB AND Aircraft Nose Down ANU Aircraft Nose Up AOA Angle Of Attack AOC Air Operator Certificate AOM Aircraft Operating Manual APU Auxiliary Power Unit ATC Air Traffic Control BOM Basic Operating Manual C Celsius CT Collector Tank CVR Cockpit Voice Recorde r DDG Dispatch Deficiency Guide DFDR Digital Flight Data Recorder EFIS Electronic Flight Instrument Syste m F Fahrenheit FCC Flight Control Computer FD Flight Director FMS Flight Management System FOCA Federal Office for Civil Aviation of Switzerland FSE (Swissair) Flying Station Engineer GPWS Ground Proximity Warning System ICAO International Civil Aviation Organizatio n IRS Inertial Reference System LH Left Hand LT Local Time M Magnetic MEL Minimum Equipment Lis t METAR Meteorological Aviation Routine Weather Report MLG Main Landing Gear MPC Maintenance Preflight Check MT Main Tank Compartment Ni Low Pressure Rotor RPM NASB Netherlands Aviation Safety Board NLG Nose Landing Gear NOTAM Notice to Airmen OAT Outside Air Temperature PF Pilot Flying PFD Primary Flight Display PNF Pilot Not Flying IV QNH Sea Level Atmosphere Pressure RH Right Hand RLD Rijksluchtvaartdienst (= Civil Aviation Authority of the Netherlands) SAIC State Accident Investigation Commissio n SAT Static Air Temperature SNOWTAM Snow NOTAM SOP Standard Operating Procedures SPC Special Check TAF Terminal Aerodrome Forecast TAT Total Air Temperature TOW Take Off Weight UTC Coordinated Universal Time VOR VHF Omnidirectional Radio Rang e WS Wing Station a Angle of Attac k CL Liftcoefficient t C Lma x Maximum Liftcoefficien V1 Take off Decision Speed V2 Safety Speed VFR Minimum Flap Retraction Spee d VR Rotation Speed Vs,aii Stall Speed 31 SYNOPSIS On March 5, 1993, Palair Flight PMK301, a Fokker 100 with registration PH-KXL , crashed shortly after taking-off from Skopje Airport, Republic of Macedonia, for a scheduled passenger flight to Zürich, Switzerland . Seventy-nine passengers and four crewmembers were fatally injured and thirteen passengers and one cabin crew membe r survived. The aircraft was destroyed by impact and fire . The weather conditions at the time of the accident were: visibility 1,000 meters in snow, temperature 0°C , dewpoint -1°C. The accident was caused by loss of roll controllability due to contamination of the wing s with ice. This situation resulted from an omission to carry out spraying of the aircraft with deicing or anti-icing fluid in meteorological conditions conducive to icing, due to a lack of ice-awareness of the flight crew and the Flying Station Engineer . Contributing factors were a lack of common background and procedures in a difficult multi-source s operational environment . Safety issues addressed in the report include : n Airline operating instructions as regards criteria for anti-icing as well as de-icing , taking into account variability of contamination conditions at temperatures around th e freezing level, the presence of cold-soaked fuel and local effects of warmer fres h fuel depending on the aircraft fuel systems ; n flight simulator training to increase pilot awareness of how aircraft behaviour coul d be affected by wing contamination, with a view to early recognition and prevention ; n special attention for procedural consistency with start-up or lease operations tha t involve contracting of airline functions from multiple external sources . Six safety recommendations are presented . 1 PREAMBLE Immediately after the accident the Macedonian Government appointed a State Accident Investigation Commission (SAIC), chaired by the head of the Accident Investigatio n Department of the Ministry of Transport and Communications of the Federal Republic o f Yugoslavia from Belgrade. The Kingdom of the Netherlands, being State of Registry an d State of Manufacture, appointed an Accredited Representative who travelled to Skopj e accompanied by a team of experts and advisors and participated in the investigation according to ICAO Annex 13. Representatives from the engine manufacturer Rolls Royce and from Swissair also assisted in the investigation . The aircraft recorders DFDR and CVR were processed by the Bureau Enquêtes Accidents in Paris, France . At the closing of a collaborative on site investigation phase it was agreed that the DFDR and CVR data would be available to Fokker Aircraft B .V. (Fokker), to analyse the take off and to investigate the possible effects of wing contamina- tion on the flight and handling characteristics . It was also agreed that Fokker would , ~ based on previous research, present the results in the form of a flight simulator dat a model and demonstrate it to the SAIC in Fokkers engineering flight simulator. It was anticipated that this work would take some months to complete . During this investigation phase it appeared that fuel temperature distribution effect s associated with the particular way of flight preparation in this case could play a n important role in the distribution of frozen contamination. On-aircraft testing was considered necessary to quantify the fuel temperature distribution resulting from adding small quantities of relatively warm fuel to a large amount of cold soaked fuel remainin g from the previous flight . Also additional windtunnel model testing was done to investigat e the aerodynamic effects of particular types of frozen contamination accumulated on col d fuel tanks and adjacent wing structure . Furthermore, as the flight analysis showed the primary reason for the accident to be los s of roll controllability, it was considered necessary to develop an addition to the fligh t simulation software to represent the drastical changes to roll damping resulting fro m airflow separation ahead of the ailerons . Whilst this took considerably more effort than initially anticipated, most of it was ready for review by October 1993, it appeare d extremely difficult to communicate with either Skopje or Belgrade on the progress an d results. Meanwhile the Accident and Incident Investigation Bureau (AIIB) of the Netherland s Aviation Safety Board (NASB) had conducted an inquiry among RLD, Fokker and AFT , addressing important aspects of the organization of the operation at Palair, supervision b y the RLD and aircraft technical and operational characteristics, particularly in relation t o operation in ground icing conditions . The results of this contribution to the investigation were made available to the SAIC in Skopje in September 1993 .
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