Air Accident Investigation Sector Failure of the Integrated Primary

Air Accident Investigation Sector Incident - Summary Report - o AAIS Case N AIFN/0010/2015 Failure of the Integrated Primary Computer Operator: Rotana Jet Make and Model: Embraer EMB-145MP Nationality and Registration: The United Arab Emirates, A6-RRA Place of Occurrence: Inflight State of Occurrence: Oman Date of Occurrence: 12 September 2015 Investigation Objective This Investigation is performed pursuant to the - (Aircraft) - the aircraft involved in this United Arab Emirates (UAE) Federal Act 20 of 1991, incident promulgating the Civil Aviation Law, Chapter VII- - (Investigation) - the investigation into Aircraft Accidents, Article 48. It is in compliance with this incident Part VI, Chapter 3 of the UAE Civil Aviation Regulations, in conformity with Annex 13 to the - (Incident) - this investigated incident Convention on International Civil Aviation, and in - (Report) - this incident investigation adherence to the Air Accidents and Incidents Final Report. Investigation Manual. 2 Unless otherwise mentioned, all times in this The sole objective of this Investigation is to Report are Coordinated Universal Time prevent aircraft accidents and incidents. It is not the (UTC), (UAE Local Time minus 4). purpose of this activity to apportion blame or liability. 3 Photos used in this Report are taken from different sources and are adjusted from the Investigation Process original for the sole purpose of improving the clarity of the Report. Modifications to images The occurrence, involving Embraer EMB-145MP used in this Report are limited to cropping, passenger Aircraft, registration A6-RRA, came to the magnification, file compression, or attention of the AAIS through routine review of the enhancement of color, brightness, contrast General Civil Aviation Authority (GCAA) mandatory or insertion of text boxes, arrows or lines. reporting system; Reporting of Safety Incidents (ROSI). After the initial investigation, the occurrence was Factual Information classified as ‘incident’. Accordingly, the AAIS notified History of the Flight the Brazilian Centro de Investigaçáo e Prevençáo de Acidentes Aeronauticos (CENIPA), as Brazil is the On 12 September 2015, at approximately 1500 State of Manufacture, and also notified the UTC, an Embraer EMB-145MP, operating scheduled International Civil Aviation Organization (ICAO). flight number RJD123, took off from Abu Dhabi International Airport, UAE, at 1505UTC bound for This Investigation was limited to the events Salalah International Airport, Oman, with two flight leading up to the occurrence and no in-depth crewmembers, one cabin crewmember, and 11 analysis of non-contributing factors was undertaken. passengers onboard. This Summary Report does not resort to any The flight continued normally until the top of proof production procedure for the determination of climb at flight level (FL)360 when the primary flight civil or criminal liability, and is issued in accordance display (PFD)1, the multi-function flight display with paragraph 3.1, Annex 13 to the Convention on (MFD)1 and the engine indicating and crew alerting International Civil Aviation, which was incorporated system (EICAS), went blank and displayed a red in the UAE legal system. cross (X) along the diagonal. The use of this Summary Report for any purpose The flight crew stated that from their experience other than that of preventing future accidents, may and initial training, they believed that the cause of lead to erroneous interpretations and conclusions. the blackout of the screens was the failure of No.1 All AAIS reports are publicly available at: integrated computer (IC-600). http://www.gcaa.gov.ae/en/epublication/pages/invest The Commander, who was the pilot monitoring (PM), igationreport.aspx pushed the symbol generation (SG) button located on the No.1 reversionary panel which then resulted Notes: in the other IC-600 (No.2 IC-600) generating the 1 indications for the PFD1, MFD1 and EICAS. In Whenever the following words are addition, IC BUS FAIL message was displayed on mentioned in this Report with the first letter the EICAS. Capitalized, it shall mean: Incident Investigation Summary Report №. AIFN/0010/2015, issued on 8 November 2016 1 The display failures were accompanied by a technical fault, and he would give her a NITS2 autopilot disengagement, accordingly the pilot flying briefing shortly. Upon establishing the Aircraft on a (PF), who was the copilot at the time of the event, track to Al Ain, and completing various other flew the Aircraft manually until landing. procedures, the Commander contacted the cabin crewmember and requested her to open the cockpit Soon after, the crew sensed, with no door for a NITS briefing. The Commander asked the accompanying sign of smoke, an electrical odor cabin crewmember if she could smell any burning, or which they suspected to be coming from the IC-600. see any smoke, and she responded that there was Because of the increasing odor, the unidentified no smell or smoke. source, and the accompanying No.1 IC-600 malfunction, the Commander assessed the situation The Commander stated that the NITS briefing for the potential development of an electrical system verified that the landing would be precautionary fire. unless smoke developed and if this happened, he required the cabin crewmember to inform him and The Commander decided to initiate the memory prepare for an evacuation. items1 for Electrical System Fire or Smoke (appendix 1) and both crewmembers donned their emergency After the NITS briefing had been completed, the oxygen masks. cabin crewmember secured the cabin and informed the passengers that the Aircraft was diverting to Al Flight crew communication was normal with their Ain due to technical issue. oxygen masks on and the copilot continued to fly the Aircraft manually, as the Commander broadcast a The flight continued with the copilot flying MAYDAY to Muscat Airport, Oman. manually and wearing his oxygen mask. The descent, descent transition, approach and landing The Commander then reviewed the Electrical checklists were completed and the Aircraft was System Fire or Smoke procedure from the Quick configured for landing. Reference Handbook (QRH). He confirmed that the memory items had been completed and that the The Aircraft landed uneventfully on runway 01 at Aircraft was being diverted to land at Muscat Al Ain International Airport at approximately International Airport, Oman, as this was the nearest 1613UTC. suitable airport. After landing, the airport rescue and firefighting Upon receiving air traffic control (ATC) staff attended the Aircraft and reported no smoke or clearance, the crew initiated a fast descent (3,000- fire. The Aircraft then taxied to the stand normally. 6,000 feet per minute) to the initially cleared altitude After parking, the engines were shutdown of 12,000 ft, turned to the north and set the normally and the passengers disembarked. transponder to ‘7700’. Further descent clearance was given to 10,000 ft during the descent. There were no injuries to the crew or passengers, and the Aircraft was undamaged. During descent, TERR INOP and GPWS INOP messages appeared on the EICAS. The Commander stated that he pressed the AC power button to Personnel Information isolate the affected systems and decided to divert to The 27-year Commander and 29-year copilot Al Ain Airport, UAE, due to high terrain in the vicinity held valid ATPL3 issued by the GCAA with an EMB of Muscat Airport. 135/145 type rating. Both pilots held valid class 1 The Electrical System Fire or Smoke, IC medical certificates. Failure/IC Bus Failure, and GPWS INOP checklists The most recent line and proficiency checks for were completed. the Commander were on 19 August and 8 August The cabin crewmember called the cockpit, using the interphone, reporting a burning odor in the cabin, and the Commander briefly explained that there was 2 A ‘NITS’ brief is given to the senior member of the cabin crew, by the operating crew, in the event of an incident or emergency. NITS stands for Nature [of emergency], Intentions, Time [available before landing] and Special instructions, e.g. whether there will be a need to evacuate 1 Memory items are Immediate Actions (IA) to be done from upon landing memory 3 ATPL: Airline Transport Pilot License Incident Investigation Summary Report №. AIFN/0010/2015, issued on 8 November 2016 2 2015, respectively, and for the copilot were on 12 two IC-600 computers interface with other systems June and 2 September 2015, respectively. and manage the information flow to the cockpit. The Commander’s flying experience was 3,743 The data acquisition units (DAU) are the central hours, and the copilot had flown a total of 3,630 data collection points for the EICAS. DAU1 collects hours. On-type experience was 2,443 for the data from the forward aircraft systems and left Commander and 370 for the copilot. engine, and DAU2 collects data from the aft aircraft systems and the right engine. Engine data is The Commander had rested for 24 hours prior to supplied to the DAUs through the full authority digital the Incident flight. The copilot’s flying time was about electronic control (FADEC), and directly from the 2:10 hours during the 24 hours prior to the Incident engine sensors. flight. The discrete signals collected by the DAUs are Aircraft Information converted into digital signals and sent to the IC-600 computers which contain a symbol generator (SG)4 General that provides images to the display units. Each DAU The Embraer EMB-145MP is a glass cockpit, is a dual (A and B) channel unit. Channel B on both narrow body, Rolls-Royce AE3007A1 twin-engine DAUs is a standby source, which must be manually powered, single-aisle aircraft. selected through the DAU reversionary button in case of a channel ‘A’ DAU failure. Both IC-600 use The Incident Aircraft, MSN 145398, was channel ‘A’ of DAU (1 or 2) as the primary source of manufactured in 2001, and registered in the United information.

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