Final Report

MINISTERE DE L’EQUIPEMENT, REPUBLIQUE DU MALI DES TRRAANSPORTS ET DU DESENCLAVEMENT UN PEUPLE – UN BUT – UNE FOI ---------------- ----------------- COMMMISSION D’ENQUETE SUR LES ACCIDENTS ET INCIDENTS D’AVIATION CIVILE ---------------- FINAL REPORT Accident on 24 July 2014 near Gossi (Mali) to the McDonnell Douglas DC-9-83 (MD-83) registered EC-LTV operated by Swiftair S.A. Approved on 22 April 2016 N’Faly CISSE Foreword The aim of the safety investigation into civil aviation accidents and incidents is to establish the facts, the conditions and the circumstances of the accident or incident to determine the probable causes and the factors that caused it in order to be able to take the appropriate steps to prevent another accident or incident from occurring. In accordance with Annex 13 to the Convention on International Civil Aviation, the safety investigation is intended neither to apportion blame, nor to assess individual or collective responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. SPECIAL FOREWORD TO ENGLISH EDITION This report has been translated and published to make its reading easier for English- speaking people. As accurate as the translation may be, the original text in French is the work of reference. 2/170 TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................................... 3 GLOSSARY ............................................................................................................................. 6 SYNOPSIS ............................................................................................................................... 8 ORGANISATION OF THE INVESTIGATION ........................................................................ 10 1 - FACTUAL INFORMATION ............................................................................................... 12 1.1 History of Flight....................................................................................................................... 12 1.2 Injuries to Persons ......................................................................................................................... 15 1.3 Damage to Aircraft ........................................................................................................................ 15 1.4 Other Damage ................................................................................................................................ 15 1.5 Personnel Information .................................................................................................................. 16 1.5.1 Flight Crew ............................................................................................................................... 16 1.5.2 Cabin Crew ............................................................................................................................... 17 1.6 Aircraft Information ..................................................................................................................... 18 1.6.1 Airframe ................................................................................................................................... 18 1.6.2 Engines ..................................................................................................................................... 20 1.6.3 Monitoring of Maintenance Operations ................................................................................... 20 1.6.4 Weight and Balance .................................................................................................................. 21 1.6.5 Systems Description ................................................................................................................. 22 1.6.6 Airborne Weather Radar .......................................................................................................... 37 1.7 Meteorological Information .......................................................................................................... 38 1.7.1 General Situation ...................................................................................................................... 38 1.7.2 Situation on the Day of the Accident ....................................................................................... 38 1.7.3 Items Brought to the Crew’s Attention .................................................................................... 39 1.7.4 Meteorological Conditions in the Aeroplane's Flight Sector.................................................... 40 1.7.5 Different Types of Icing ........................................................................................................... 41 1.7.6 Situation Likely Encountered by the Aeroplane....................................................................... 42 1.8 Aids to Navigation ......................................................................................................................... 43 1.9 Telecommunications ...................................................................................................................... 43 1.10 Aerodrome Information .............................................................................................................. 43 1.10.1 Characteristics of Ouagadougou Aerodrome ......................................................................... 43 1.10.2 Ouagadougou Aerodrome Departure Procedures ................................................................... 44 1.11 Flight Recorders .......................................................................................................................... 45 1.11.1 Flight Recorder Opening and Readout Operations ................................................................. 45 1.11.2 FDR data readout .................................................................................................................... 50 1.11.3 CVR data readout ................................................................................................................... 54 3/170 1.11.4 Regulations Relating to Magnetic Tape CVRs....................................................................... 57 1.12 Wreckage and Impact Information ........................................................................................... 57 1.12.1 Description of Crash Site ....................................................................................................... 57 1.12.2 Distribution of Wreckage ....................................................................................................... 58 1.12.3 Controls and Control Surfaces................................................................................................ 62 1.12.4 Engines ................................................................................................................................... 64 1.12.5 Landing Gear .......................................................................................................................... 64 1.12.6 Emergency Locator Beacon ................................................................................................... 65 1.12.7 Summary ................................................................................................................................ 65 1.13 Medical and Pathological Information ...................................................................................... 66 1.14 Fire ................................................................................................................................................ 66 1.15 Survival Aspects .......................................................................................................................... 66 1.16 Tests and Research ...................................................................................................................... 66 1.16.1 Questions Relating to Flight Crew Flight Time Limitations .................................................. 66 1.16.2 Erroneous EPR Measurement................................................................................................. 68 1.16.3 Evolution in Engine Parameters during Event ....................................................................... 70 1.16.4 Flying behind the power curve ............................................................................................... 74 1.16.5 Determination of Activation of Anti-icing Devices ............................................................... 75 1.16.6 Stall ......................................................................................................................................... 77 1.16.7 Disengagement of Automated Systems .................................................................................. 84 1.16.8 Operational Ceiling ................................................................................................................ 84 1.16.9 Visual and Aural Warnings .................................................................................................... 85 1.16.10 Study of Events Involving Speed Decreases and Approach to Stall on MD80 .................... 86 1.17 Information on Organisations and Management ..................................................................... 90 1.17.1. Operator ................................................................................................................................. 90

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