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Technical Report A-002/2003

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Technical Report A-002/2003 TECHNICAL REPORT A-002/2003 Accident of aircraft FOKKER 50, registration PH-FZE, at Melilla Airport (Spain), on 17 January 2003 Technical report A-003/2003 Accident of aircraft FOKKER 50, registration PH-FZE, at Melilla Airport (Spain), on 17 January 2003 SECRETARÍA GENERAL DE TRANSPORTES MINISTERIO DE FOMENTO COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-03-011-0 Depósito legal: M. 23.129-2003 Imprime: Centro de Publicaciones Diseño cubierta: Carmen G. Ayala COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 63 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.fomento.es/ciaiac 28011 Madrid (España) Foreword This report is a technical document that reflects the point of view of the Civil Aviation Accident and Incident Investigation Commission (CIAIAC) regarding the circumstances of the accident and its causes and consequences. In accordance with the provisions of Law 21/2003 and Annex 13 to the Con- vention on International Civil Aviation, the investigation has exclusively a technical nature, without having been targeted at the declaration or assign- ment of blame or liability. The investigation has been carried out without having necessarily used legal evidence procedures and with no other basic aim than preventing future accidents. Consequently, any use of this report for purposes other than that of preven- ting future accidents may lead to erroneous conclusions or interpretations. This report has originally been issued in Spanish language. This English trans- lation is provided for information purposes only. Technical report A-002/2003 Table of contents Abbreviations ................................................................................................................................ vii Synopsis ......................................................................................................................................... ix 1. Factual information ............................................................................................................... 1 1.1. History of the flight ........................................................................................................ 1 1.1.1. Takeoff from Malaga, cruise and approach to Melilla ....................................... 1 1.1.2. Landing at Melilla Airport ................................................................................. 2 1.1.3. Actions taken after the crash of the aircraft ..................................................... 3 1.2. Injuries to persons .......................................................................................................... 4 1.3. Damage to aircraft ......................................................................................................... 4 1.4. Other damage ................................................................................................................4 1.5. Personnel information .................................................................................................... 5 1.5.1. Pilot in command .............................................................................................. 5 1.5.2. Copilot .............................................................................................................. 5 1.5.3. Flight observer ................................................................................................... 6 1.6. Aircraft information ........................................................................................................7 1.6.1. Airframe ............................................................................................................ 7 1.6.2. Description of the brake system ........................................................................ 7 1.6.3. Description of the power plant ......................................................................... 9 1.6.4. Normal, abnormal and emergency procedures related to the brake system ..... 17 1.6.5. Previous maintenance on the aircraft ................................................................ 19 1.6.6. Loadsheet of the aircraft ................................................................................... 22 1.7. Meteorological information ............................................................................................ 23 1.8. Aids to navigation ..........................................................................................................24 1.9. Communications ............................................................................................................ 24 1.10. Aerodrome information .................................................................................................. 24 1.11. Flight recorders .............................................................................................................. 27 1.11.1. Cockpit voice recorder .................................................................................... 27 1.11.2. Flight data recorder ......................................................................................... 32 1.12. Wreckage and impact information ................................................................................. 39 1.12.1. Runway tracks and marks in the terrain ......................................................... 39 1.12.2. Wreckage layout ............................................................................................. 40 1.12.3. Status of the controls and indicators of the aircraft ....................................... 42 1.13. Medical and pathological information ............................................................................ 42 1.14. Fire ................................................................................................................................. 43 1.15. Survival aspects .............................................................................................................. 43 1.15.1. Cabin damage ................................................................................................ 43 1.15.2. Evacuation of the aircraft ................................................................................ 45 1.16. Tests and research .........................................................................................................46 1.16.1. Testing of the flight idle solenoids on the field .............................................. 46 1.16.2. Bench testing of components of the propeller, landing gear and brake sys- tems ................................................................................................................ 47 1.16.3. Estimate of the performances of the aircraft .................................................. 52 1.17. Organizational and management information ................................................................ 53 v Technical report A-002/2003 1.17.1. Organization of Air Nostrum ........................................................................... 53 1.17.2. Organization of Denim Air .............................................................................. 53 1.18. Additional information ................................................................................................... 57 1.18.1. Stabilized approach concept ........................................................................... 57 1.18.2. Landing distance requirements ........................................................................ 58 1.18.3. Instructions provided by the operator for landings at Melilla .......................... 59 1.18.4. Maintenance safety actions carried out by the operator of the aircraft .......... 59 1.18.5. Operational safety actions carried out by the operator of the aircraft ............ 60 1.19. Useful or effective investigation techniques ................................................................... 61 2. Analysis .................................................................................................................................. 63 2.1. General .......................................................................................................................... 63 2.2. Aircraft systems malfunctions during the landing roll .................................................... 65 2.2.1. Malfunctions in the braking system .................................................................. 66 2.2.2. Impossibility to select propeller reverse after touchdown .................................. 68 2.3. Operational aspects ........................................................................................................ 70 2.3.1. Decision to change the landing runway ............................................................ 70 2.3.2. Final approach and touchdown ........................................................................ 71 2.3.3. Braking and propeller reverse application ......................................................... 73 2.3.4. Landing distance ............................................................................................... 75 2.4. Crashworthiness and survival aspects ............................................................................. 76 3. Conclusions ............................................................................................................................ 79 3.1. Findings .........................................................................................................................
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