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REPORT on the Accident on 6 March 2003 at Tamanrasset to the Boeing 737-200 Registered 7T-VEZ Operated by Air Algérie

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REPORT on the Accident on 6 March 2003 at Tamanrasset to the Boeing 737-200 Registered 7T-VEZ Operated by Air Algérie DEMOCRATIC PEOPLE’S REPUBLIC OF ALGERIA MINISTRY OF TRANSPORT NATIONAL COMMISSION OF INQUIRY REPORT on the accident on 6 March 2003 at Tamanrasset to the Boeing 737-200 registered 7T-VEZ operated by Air Algérie 7t-z030306a FOREWORD This report presents the technical conclusions reached by the national Commission of Inquiry on the circumstances and causes of the accident on 6 March 2003 at Tamanrasset. The investigation was conducted in accordance with: • law No 98-06 of 03 Rabie el-Aouel 1419, corresponding to 27 June 1998, which sets the general rules concerning civil aviation, in particular Article 24; • order No 63-84 of 5 March 1963, relating to the Democratic Republic of Algeria’s adherence to the Convention on International Civil Aviation; • law No 89-165 of 29 August 1989 relating to the administrative powers of the Ministry of Transport; and to the provisions of Annex 13 of the Convention on International Civil Aviation, with the aim of gathering all information from this accident that may help prevent future accidents. The sole objective of the investigation into an accident or incident is to draw lessons from this occurrence which may help to prevent future accidents or incidents. It is intended neither to apportion blame, nor to assess individual or collective responsibility (ICAO - Annex 13 - § 3.1). SPECIAL FOREWORD TO ENGLISH EDITION This report has been translated to make its reading easier for English-speaking people. As accurate as the translation may be, the original text should be considered as the work of reference. 7T-VEZ – 6 March 2003 - 2 - Table of Contents GLOSSARY ........................................................................................................... 6 SYNOPSIS............................................................................................................. 8 ORGANISATION OF THE INVESTIGATION......................................................... 9 1 - FACTUAL INFORMATION............................................................................. 11 1.1 History of the Flight ..................................................................................... 11 1.2 Injuries to persons ....................................................................................... 12 1.3 Damage to Aircraft ....................................................................................... 12 1.4 Other Damage............................................................................................... 12 1.5 Personnel Information ................................................................................. 12 1.5.1 Flight Crew............................................................................................... 12 1.5.1.1 Captain.............................................................................................. 12 1.5.1.2 Co-pilot.............................................................................................. 13 1.5.2 Cabin crew............................................................................................... 14 1.5.2.1 Chief Flight Attendant........................................................................ 14 1.5.2.2 Flight Attendants ............................................................................... 14 1.6 Aircraft Information...................................................................................... 14 1.6.1 Airframe ................................................................................................... 14 1.6.1.1 General ............................................................................................. 14 1.6.1.2 Maintenance...................................................................................... 15 1.6.2 Engines.................................................................................................... 15 1.6.3 Fuel.......................................................................................................... 16 1.6.4 Weight and Balance................................................................................. 16 1.6.4.1 Weight ............................................................................................... 16 1.6.4.2 Balance ............................................................................................. 16 1.7 Meteorological Information ......................................................................... 16 1.8 Aids to Navigation........................................................................................ 16 1.9 Communications .......................................................................................... 17 1.10 Aerodrome Information.............................................................................. 17 7T-VEZ – 6 March 2003 - 3 - 1.11 Flight Recorders......................................................................................... 19 1.11.1 Types and readout operations ............................................................... 19 1.11.2 CVR readout .......................................................................................... 19 1.11.3 FDR readout .......................................................................................... 19 1.11.4 Summary ............................................................................................... 20 1.12 Wreckage and Impact Information............................................................ 21 1.12.1 Examination of the site........................................................................... 21 1.12.2 Visual examination of the wreckage....................................................... 22 1.12.3 Observations in the cockpit.................................................................... 22 1.12.3.1 Instruments on Captain’s side ......................................................... 23 1.12.3.2 Instruments on co-pilot’s side.......................................................... 23 1.12.3.3 Center panel instruments ................................................................ 23 1.12.3.4 Overhead Panels............................................................................. 23 1.13 Medical and Pathological Information...................................................... 23 1.14 The fire ........................................................................................................ 24 1.15 Survival Aspects ........................................................................................ 24 1.16 Tests and Research.................................................................................... 24 1.16.1 Summary of witness statements ............................................................ 24 1.16.2 Preliminary examination of the engines ................................................. 25 1.16.3 Additional examinations of the engines.................................................. 25 1.16.3.1 Left engine ...................................................................................... 26 1.16.3.2 Right engine .................................................................................... 27 1.16.3.3 Metallurgical analyses ..................................................................... 28 1.16.3.4 Debris recovered from the left engine LP casing and the runway ... 28 1.16.3.5 Summary of results ......................................................................... 29 1.16.4 Examination of the equipment, flight instruments and warning lights..... 29 1.16.4.1 Electrical power system................................................................... 29 1.16.4.2 Warning lights.................................................................................. 30 1.16.4.3 Flight Instruments and equipment ................................................... 30 1.16.5 Airplane performance on take-off........................................................... 31 1.16.5.1 Performance calculations ................................................................ 31 1.16.5.2 Flight simulator session................................................................... 31 1.17 Organizations and Management ............................................................... 32 1.17.1 Crew on Boeing 737-200 by Air Algérie................................................. 32 1.17.1.1 Typical type rating training course................................................... 32 1.17.1.2 Recurrent training and checks......................................................... 33 1.17.1.3 Crew training ................................................................................... 34 1.17.2 Feedback system................................................................................... 34 2 - ANALYSIS...................................................................................................... 35 2.1 Accident Scenario ........................................................................................ 35 2.1.1 Flight preparation and takeoff roll ............................................................ 35 2.1.2 Failure of left engine during takeoff.......................................................... 35 7T-VEZ – 6 March 2003 - 4 - 2.1.3 Management of the engine burst during initial climb................................ 36 2.1.3.1 Crew coordination ............................................................................. 36 2.1.3.2 Maintaining climb rate ....................................................................... 37 2.1.4 Loss of control of the airplane.................................................................
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