Turkish Airlines
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Crashed during approaCh, Boeing 737-800, near amsterdam sChiphol airport, 25 February 2009 The Hague, May 2010 (project number M2009LV0225_01) The reports of the Dutch Safety Board are available to the public. All reports are also available on the website of the Dutch Safety Board www.safetyboard.nl the dutCh saFetY Board The Dutch Safety Board was established to investigate and determine the causes or probable causes of individual incidents or categories of incidents in all sectors. The sole purpose of a Dutch Safety Board investigation is to prevent future accidents or incidents and, if outcomes give cause to do so, issue associated recommendations. The organisation consists of a board with five perma- nent members, a professional Bureau manned by investigators and support staff and a number of permanent committees. Guidance committees are set up to oversee specific investigations. Board advisory Committee Chairman: Prof. Pieter van Vollenhoven Chairman: J.A. Hulsenbek Vice chairman J.A. Hulsenbek Prof. F.J.H. Mertens Annie Brouwer-Korf E.J. Burmeister Prof. F.J.H. Mertens J. Marijnen J.P. Visser Prof. J.A. Mulder H. Munniks de Jongh Luchsinger J.G.W. van Ruitenbeek General M. Visser Secretary: Project leader: J.W. Selles Visitors Anna van Saksenlaan 50 Correspondence P.O. Box 95404 address: 2593 HT Den Haag address: 2509 CK Den Haag Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl This report is published in the Dutch and English languages. In the event of conflict in interpretation, the Dutch text will be deemed binding. Contents Consideration ................................................................................................................... 5 list of abbreviations ....................................................................................................... 14 1 introduction .......................................................................................................... 17 1.1 Immediate cause..................................................................................................... 17 1.2 The investigation ..................................................................................................... 17 1.3 Reader’s guide ........................................................................................................ 19 2 Factual information ............................................................................................... 21 2.1 Introduction ........................................................................................................... 21 2.2 Boeing 737-800 relevant systems .............................................................................. 21 2.3 Other terms and concepts that are important .............................................................. 24 2.4 History of the flight .................................................................................................. 25 2.5 Injuries to persons .................................................................................................. 29 2.6 Damage to aircraft .................................................................................................. 29 2.7 Other damage ......................................................................................................... 29 2.8 Personnel information .............................................................................................. 29 2.9 Aircraft information ................................................................................................. 30 2.10 Meteorological information ........................................................................................ 30 2.11 Aids to navigation.................................................................................................... 30 2.12 Communications ..................................................................................................... 30 2.13 Aerodrome information ............................................................................................ 31 2.14 Flight recorders ....................................................................................................... 31 2.15 Wreckage and impact information .............................................................................. 31 2.16 Medical and pathologic information ............................................................................ 32 2.17 Fire ....................................................................................................................... 32 2.18 Survival aspects ...................................................................................................... 32 2.19 Tests and research .................................................................................................. 33 2.20 Organisational and management information .............................................................. 33 2.21 Additional information .............................................................................................. 33 3 assessment framework ......................................................................................... 35 3.1 General .................................................................................................................. 35 3.2 Legislation and regulations ....................................................................................... 35 3.3 Guidelines .............................................................................................................. 37 3.4 Assessment framework for safety management ........................................................... 38 4 involved parties and their responsibilities ............................................................ 41 4.1 Crew flight TK1951 .................................................................................................. 41 4.2 Turkish Airlines ....................................................................................................... 41 4.3 Turkish Technic Inc. ................................................................................................. 42 4.4 Ministry of Transport (Turkey) ................................................................................... 42 4.5 Boeing ................................................................................................................... 42 4.6 Federal Aviation Administration (United States of America) ........................................... 42 4.7 European Aviation Safety Agency .............................................................................. 42 4.8 Dutch Ministry of Transport, Public Works and Water Management ................................. 43 4.9 Air Traffic Control the Netherlands ............................................................................. 43 5 analysis ................................................................................................................ 45 5.1 Introduction ........................................................................................................... 45 5.2 Technology ............................................................................................................. 45 5.3 Air traffic control ..................................................................................................... 52 5.4 Available information with regard to the automatic flight system .................................... 57 5.5 Interception of the localizer signal and glide slope signal .............................................. 61 5.6 Completion of the landing checklist ............................................................................ 63 3 5.7 Speed reduction during the ILS approach ................................................................... 63 5.8 Stabilised approach versus aborting the approach ........................................................ 65 5.9 Line flying under supervision ..................................................................................... 66 5.10 Calling out flight mode annunciations ......................................................................... 67 5.11 Recovery procedure ................................................................................................. 68 5.12 Crew resource management ..................................................................................... 70 5.13 Training ................................................................................................................. 72 5.14 Guaranteeing Safety at Turkish Airlines ...................................................................... 73 5.15 Certification and oversight ........................................................................................ 74 5.16 Survival factors ....................................................................................................... 77 5.17 Measures taken after the accident ............................................................................. 78 6 Conclusions ........................................................................................................... 81 7 recommendations ................................................................................................. 85 glossary ....................................................................................................................... 87 APPENDIX A: Justification of Investigation ..........................................................................93 APPENDIX B: Comments