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Nagoya Accident Report B1816

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AIRCRAFT ACCIDENT INVESTIGATION REPORT China Airlines Airbus Industrie A300B4-622R, B1816 Nagoya Airport April 26, 1994 July 19, 1996 Aircraft Accident Investigation Commission Ministry of Transport ATTENTION The English version report has been published and translated by ARAIC to make its reading easier for English speaking people those who are not familiar with Japanese. Although efforts are made to translate as accurate as possible, only the Japanese version is authentic. If there is difference in meaning of the texts between the Japanese version and the English version, text in the Japanese version are correct. This report on the accident of China Airlines B1816 has been prepared based upon the investigation carried out by the Aircraft Accident Investigation Commission, in accordance with Annex 13 to the Convention on International Civil Aviation and Article 20 of Aircraft Accident Investigation Commission Establishment Law of Japan. Kazuyuki Takeuchi Chairman, Aircraft Accident Investigation Commission Abbreviations used in this report are as follows: AD : Airworthiness Directive ADC : Air Data Computer AFS : Automatic Flight System ALT : Altitude ALT SEL : Altitude Selector AOA : Angle of Attack AP : Auto-Pilot mu : Auxiliary Power Unit AITHR : Automatic Thrust AT : AutoThrottle ATS : Auto-Throttle System ATT : Attitude BEA : Bureau Enquetes Accidents BKN : Broken CAP : Captain CAS : Computed Airspeed CGCC : Center of Gravity Control Computer CAT : Category CMD : Command CN : Consigne de Navigabilite CVR : Cockpit Voice Recorder CWS : Control Wheel Steering CFDR : Digital ~ii~htData Recorder DGAC : Direction Genrale de 1' Aviation Civile ECAM : Electronic Centralized Aircraft Monitoring EFCU : Electronic Flight Control Unit EFIS : Electronic Flight Instrument System ENG : Engine EPR : Engine Pressure Ratio FAA : Federal Aviation Administration FAC : Flight Augmentation Computer FADEC : Full Authority Digital Electronic Control FCC : Flight Control Computer FCOM : Flight Crew Operating Manual FCU : Flight Control Unit FD : Flight Director FIDC : Fault Isolation and Detection Computer FIDS : Fault Isolation and Detection System FL : Flight Level FMA : Flight Mode Announciator FMC : Flight Management Computer FMS : Flight Management System F/O : First Officer FMC : Flight Warning Computer GCU : Generator Control Unit GPWC : Ground Proximity Warning Computer GPWS : Ground Proximity Warning System GS : Glide Slope HDG : Heading HDGISEL : Heading Selector HPC : High Pressure Compressor HPT : High Pressure Turbine ICAO : International Civil Aviation Organization IGS : Instrument Guidance System IGV : Inlet Guide Vane IND : Indicator LS : Instrument Landing System IRS : Inertial Reference System IRU : Inertial Reference Unit LAND : Landing L/D : Landing LIG : Landing Gear LOC : Localizer LPC : Low Pressure Compressor LPT : Low Pressure Turbine . LVLICH : Level Change MAC : Mean Aerodynamic Chord MAN THR : Manual Thrust MIC : Microphone MTP : Maintenance and-~estPanel NAV : Navigation NTSB : National Transportation Safety Board OVC : Overcast PCM : Pulse Code Modulation PF : Pilot Flying PFD : Primary Flight Display PIC : Pilot in Command PNF : Pilot Not Flying QNH : Pressure Setting to Indicate Elevation above Mean Sea Level R. ALT. : Radio Altitude RET : Retract RMI : Radio Magnetic Indicator RWY : Runway SB : Service Bulletin SCT : Scattered SGU : Symbol Generator Unit SPD : Speed SPDMCH : SpeedlMach SRS : Speed Reference System SW : Switch TCC : Thrust Control Computer TCD : Ministry of Transport Civil Aviation Bureau Directive THR : Thrust THR L : Thrust Latch THS : Trimmable Horizontal Stabilizer TIPS : Technical Instruction Processing Sheet TRP : Thrust Rating Panel VAPP : Approach Target Speed VOR : VHF Omnidirectional Radio Range V/S : Vertical Speed Vs : Stall Speed VTG ' : Target Speed W.STA : Wing Station CONTENTS 1 PROGRESS AND PROCESS OF THE AIRCRAFT ACCIDENT INVESTIGATION ............ 1. 1 1.1 Summary of the Aircraft Accident .............................................................................................. 1-1 1.2 Outline of the Aircraft Accident Investigation .......................................................................... 1-1 1.2.1 Organization for Investigation ........................................................................................... 1. 1 1.2.2 Implementation of Investigation ....................................................................................... 1-2 1.2.3 Hearings from the Persons Relevant to the Cause of the Accident ................................... 1-2 1.2.4 Public Hearing ................................................................................................................... 1-2 1.2.5 Reporting and Publication ................................................................................................. 1-3 2 FACTUAL INFORMATION ............................................................................................................... 2-1 2.1 Flight. History ................................................................................................................................. 2-1 2.2 Injur~esto Persons ......................................................................................................................... 2-3 2.3 Damage to Aircraft ....................................................................................................................... 2-3 2.3.1 Extent of Damage .............................................................................................................. 2-3 2.3.2 Damage to Aircraft by Part ................................................................................................ 2-3 2.3.3 Distribution of Wreckage. etc............................................................................................ 2-12 2.4 Damage to Other than the Aircraft ............................................................................................. 2-13 2.5 Crew Information .......................................................................................................................... 2-13 2.5.1 Flight Crew ..................................................................................................................2-13 2.5.2 Cabin Attendants ............................................................................................................... 2-14 2.6 Aircraft Information ..................................................................................................................... 2-16 2.6.1 Aircraft ............................................................................................................................... 2-16 2.6.2 Engines .............................................................................................................................. 2-16 2.6.3 Weight and Center of Gravity ...........................................................................................2-16 . 2.6.4 Fuel and Lubricating Oil ................................................................................................... 2-16 2.7 Meteorological Information ........................................................................................................ 2-17 . 2.7.1 Synoptic Weather ............................................................................................................... 2-17 2.7.2 Aeronautical Meteorological Observation and Reports .................................................... 2-17 2.8 Navigational. .Aids ........................................................................................................................... 2-18 2.9 Commun~cat~ons............................................................................................................................ 2-18 2.10 Airport and Ground Facility Information ................................................................................. 2-18 2.1 1 Information on DFDR and CVR .................................................................................................2-19 2.1 2 Medical Information ................................................................................................................... 2-19 2.12.1 Autopsies of CAP, F/O and Purser ................................................................................... 2-19 . 2.12.2 Injuries to Survivors ........................................................................................................ 2-21 2.12.3 Damage to Bodies ............................................................................................................... 2-21 2.13 Fire and Fire Fighting ................................................................................................................. 2-21 2.13.1 Fire Fighting and Rescue System at Nagoya Airport ........................................................ 2-21 2.13.2 Fire Fighting Activities .................................................................................................... 2-22 2.14 Information on Search, Rescue and Evacuation relevant to Survival, Death or Injury ....... 2-24 2.14.1 Information on Search and Rescue Activities ................................................................... 2-24 2.15 Tests and Research to Find Facts ............................................................................................... 2-27 2.15.1 Investigation of Traces Left on the Ground ......................................................................2-27 2.15.2 Indication of Major
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