Unntatt Offentlighet, Jf
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Issued March 2010 REPORT SL 2010/05 REPORT ON SERIOUS AVIATION INCIDENT AT SANDEFJORD AIRPORT TORP 26 MARCH 2006 INVOLVING AIRBUS A321 OY-VKA OPERATED BY MY TRAVEL AIRWAYS SCANDINAVIA Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01 www.aibn.no • [email protected] This report has been translated into English and published by the AIBN to facilitate access by international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference. The Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board’s task to apportion blame or liability. Use of this report for any other purpose than for flight safety should be avoided. Photos: AIBN and Trond Isaksen/OSL Accident Investigation Board of Norway CONTENTS INCIDENT NOTIFICATION..............................................................................................................4 SUMMARY.........................................................................................................................................4 1. FACTUAL INFORMATION..............................................................................................5 1.1 Course of events...................................................................................................................5 1.2 Personal injuries...................................................................................................................9 1.3 Damage to the aircraft..........................................................................................................9 1.4 Other damage.......................................................................................................................9 1.5 Personnel information........................................................................................................10 1.6 The aircraft.........................................................................................................................11 1.7 The weather........................................................................................................................12 1.8 Navigational aids...............................................................................................................14 1.9 Communication network....................................................................................................15 1.10 Airport and aids..................................................................................................................15 1.11 Flight recorders..................................................................................................................16 1.12 The aircraft and scene of the incident................................................................................18 1.13 Medical matters..................................................................................................................21 1.14 Fire .....................................................................................................................................21 1.15 Survival aspects.................................................................................................................21 1.16 Special investigations.........................................................................................................22 1.17 Organisation and management...........................................................................................22 1.18 Other information...............................................................................................................25 1.19 Useful or efficient methods of investigation......................................................................30 2. ANALYSIS........................................................................................................................30 2.1 AIBN’s investigations........................................................................................................30 2.2 Constraints of the analysis .................................................................................................31 2.3 Weather conditions and weather information received .....................................................31 2.4 Planning .............................................................................................................................32 2.5 Assessment of the course of events prior to landing..........................................................33 2.6 Assessment of the course of events after landing ..............................................................34 2.7 Survival aspects.................................................................................................................38 2.8 MyTravel Airways Scandinavia’s procedures for operations on slippery runways ..........39 2.9 The crew’s practice of MyTravel’s procedures for winter operations...............................41 2.10 Sandefjord Airport’s procedures and application for winter maintenance ........................43 2.11 EASA certification of contaminated runways ...................................................................46 2.12 Calculation of landing data ................................................................................................47 2.13 Winter operations and friction measurements ...................................................................48 2.14 Human factors....................................................................................................................48 3. CONCLUSION..................................................................................................................49 3.1 Investigation results...........................................................................................................49 3.2 Significant investigation results.........................................................................................52 4. SAFETY RECOMMENDATIONS...................................................................................52 2 Accident Investigation Board of Norway REFERENCES...................................................................................................................................54 APPENDICES ...................................................................................................................................54 3 Accident Investigation Board of Norway SERIOUS AVIATION INCIDENT REPORT Aircraft: Airbus A321-211 Nationality and registration: Danish, OY-VKA Owner: Sunshine Leasing Ltd, Cayman Islands User: My Travel Airways Scandinavia1, Denmark Crew: 2 pilots and 5 cabin crew Passengers: 210 adults and 6 children Place of incident: Sandefjord Airport Torp (ENTO), runway 18 Time and date of incident: Sunday 26 March 2006 at 19:58 hrs. All times and dates referred to in this report are stated in local time (UTC + 2 hours) unless otherwise specified. INCIDENT NOTIFICATION The Aviation Section on-call service (currently the aviation department) of the Accident Investigation Board of Norway (AIBN) was notified of the accident by the air traffic controller on duty at ENTO. An accident investigation inspector arrived on the scene the same night, while a second accident investigation inspector arrived at Torp the following morning. SUMMARY An Airbus A321, with registration OY-VKA and flight number VKG866, flew from Tenerife Airport (GCTS) to Sandefjord Airport Torp (ENTO) on 26th of March 2006. The first officer was Pilot Flying (PF) and the commander was Pilot Not Flying (PNF). The crew reviewed updated weather and runway status before commencing the approach to ENTO. Air Traffic Information Services (ATIS) indicated dry runway and Braking Action (BA) GOOD. When checking in on TWR frequency, the crew was informed that the runway was contaminated by 8 mm wet snow with a measured (Friction Coefficient, FC) of 32-33-31. These numbers indicated a MEDIUM BA. The crew requested wind information in order to check for any crosswind or tailwind limitations. They made a mental consideration regarding the landing conditions and decided that it was acceptable to perform the landing. The airplane got high on the glide slope after passing 250 ft Radio Height. This resulted in a touch down approximately 780 metres from the threshold. After landing the crew experienced POOR braking action and suspected auto brake failure. The first officer performed maximum manual braking without noticing any BA. After landing the crew 1 MyTravel Airways Scandinavia AS changed its name to Thomas Cook Airlines Scandinavia AS effective from 9 May 2008 4 Accident Investigation Board of Norway experienced POOR BA and suspected a brake failure. The commander took control, pulled the Park Brake (PB) and steered the aircraft with Nose Wheel Steering (NWS) towards the left side of the runway with guidance from the first officer. The effect of the PB and NWS was that the aircraft skidded sideways towards the end of the runway 18. This resulted in increased deceleration and the aircraft stopped at the very end of the hard surfaced runway, with the nose wheel against a concrete antennae base. The crew advised the TWR about the anticipated runway excursion while the aircraft skidded towards