ISSN no 1148 - 4292 MINISTRY OF TRANSPORT AND TOURISM Official Report OF THE COMMISSION OF INVESTIGATION INTO THE ACCIDENT ON 20 JANUARY 1992 NEAR MONT SAINTE ODILE (BAS-RHIN) OF THE AIRBUS A.320 REGISTERED F-GGED OPERATED BY AIR INTER FRANCE MINISTRY OF TRANSPORT AND TOURISM __________ Commission of Investigation into the accident on 20 January 1992 of Airbus A320 F-GGED near Mont Sainte-Odile (Bas-Rhin) O F F I C I A L R E P O R T into the accident on 20 January 1992 near Mont Sainte-Odile (Bas-Rhin) of the AIRBUS A320 registered F-GGED operated by Air Inter -:-:-:­ 26 November 1993 - CONTENTS - Notice Organisation of work Synopsis SECTION 1. - FACTUAL INFORMATION. 1.1 - Flight progress. 1.2 - Killed and injured. 1.3 - Damage to the aircraft. 1.4 - Other damage. 1.5 - Personnel information. 1.6 - Aircraft information. 1.7 - Information relating to the Operator and the Civil Aviation authorities. 1.8 - Weather information. 1.9 - Navigational aids. 1.10 - Telecommunications. 1.11 - Airport information. 1.12 - Recording equipment. 1.13 - Details of wreckage and impact. 1.14 - Medical and pathological information. 1.15 - Fire. 1.16 - Questions relative to the survival of occupants. 116.1 - Aspects relative to the cabin. 116.2 - Organisation of searches. 116.3 - Organisation of rescue services. 1.17 - Testing and research. 117.1 - Evaluation of propulsion systems, Auxilliary Power Unit (APU) and fuel. 117.2 - Examination of the chain of pitch control. 117.3 - Examination of on-board navigation systems. 117.4 - Evaluation of ground-based radio navigation installations. 117.5 - Examination of Autopilot vertical mode on final approach. 117.6 - Examination of events linked to abnormal rate of descent. 117.7 - Synthesis of flight simulator research. 117.8 - Research relating to flight path. 117.9 - Testing and research relating to Ground Proximity Warning System (GPWS). 1.18 - Supplementary information. 118.1 - Certification of the ergonomics of the A320 flight deck. 118.2 - Controlled flights into terrain and avoidance systems. 118.3 - Emergency Locator Transmitter. 118.4 - Developments in the regulations concerning Digital Flight Data Recorders (DFDR) and Cockpit Voice Recorders (CVR). 118.5 - Co-ordination of the technical investigation and the judicial inquiry. 118.6 - The feed-back loop. 1.19 - Specific methods of investigation. 119.1 - Optical reading by garnet of the recorders' tapes. 119.2 - Victim identification techniques. 1.20 - Witness evidence. SECTION 2. - ANALYSIS. 2.1 - Analysis of the accident scenario. 21.1 - Principles and elements of analysis. 21.2 - Hypothetical flight path controlled by the crew. 21.3 - Hypothetical flight path not controlled by the crew. 21.4 - Conclusion on the hypotheses retained. 21.5 - Reconstruction of the most probable scenario. 2.2 - Analysis of the immediate causes of the accident. 22.1 - Technical malfunctions. 22.2 - Professional competence of the crew. 22.3 - Aircraft/crew interface. 22.4 - Internal relations among the crew. 22.5 - Relationships between crew and procedures. 22.6 - Relationships between crew and Control. 22.7 - Relationships between crew and environment. 2.3 - Analysis of related factors - regulatory, organisational, structural. 23.1 - Relevant factors associated with Air Inter. 23.2 - The exercising of supervision over Air Inter by the DGAC. 23.3 - Certification of the aircraft. 23.4 - The feed-back loop. 2.4 - Survival, search and rescue. 2.5 - Recording equipment. SECTION 3. - CONCLUSION. 3.1 - Facts established by the Investigation. 3.2 - Conclusions relative to the immediate causes of the accident. 3.3 - Conclusions relative to operational background. 3.4 - Conclusions relative to search and rescue operations. SECTION 4. - RECOMMENDATIONS. 4.1 - Recommendations relative to the crew. 4.2 - Recommendations relative to Ground Proximity Warning Systems. 4.3 - Recommendations relative to recording equipment. 4.4 - Recommendations relative to the ergonomics of the aircraft/crew interface and to its certification. 4.5 - Recommendations relative to survival. 4.6 - Recommendations relative to air traffic procedures. 4.7 - Recommendations relative to State supervision. 4.8 - Recommendations relative to the feed-back loop. APPENDICES Appendix 0 : Glossary. Appendix 1 : Location of accident site. Appendix 2 : Topographical plan of accident site. Appendix 3 : Sketch showing distribution of wreckage. Appendix 4 : Sketch showing distribution of sources of fire. Appendix 5 : Drawing showing distribution of survivors on board. Appendix 6 : Arrival and approach procedure charts: - issued by the SIA - available to the crew. Appendix 7 : Graphs showing Quick Access Recorder (QAR) parameter extracts. Appendix 8 : Extracts from Cockpit Voice Recorder (CVR) transcription. Appendix 9 : Transcription of Air Traffic Control (ATC) radio communications. Appendix 10: Transcription of the telephonic communication between the Centre Régionale de la Navigation Aérienne Est (Eastern Regional Centre for Air Navigation), and Strasbourg Approach. Appendix 11: Radar flight path analysis and associated technical note. Appendix 12: Flight Management Guidance Computer 1 (FMGC1) flight path analysis and synthesised flight path analysis. Appendix 13: Meteorological records. Appendix 14: Tree of potential causes of the accident. Appendix 15: Description of aircraft control and navigation systems. Appendix 16: Photographs. NOTICE This report sets out the technical conclusions reached by the Commission of Investigation concerning the circumstances and causes of this accident. In accordance with Annex 13 of the Convention relating to international civil aviation, the analysis and safety recommendations drawn up in this report do not aim to apportion blame or to assess individual or collective responsibility. Their sole objective is to derive from this occurrence the lessons necessary to prevent future accidents. With this in mind, and because doubt must be of ultimate benefit to safety, some of the recommendations proposed concern points which it has so far not been possible to validate categorically or which occasionally have no direct relationship to the causes of the accident. Moreover, the analysis and recommendations have been drawn up following exhaustive investigation and are therefore based on an experience and understanding of events which may differ substantially from those prevailing at the precise time of the accident. Finally, although the people and organisations whose opinions were deemed to be relevant were invited to present their observations at the appropriate time, the Investigation was not conducted in an adversarial manner. As a consequence, the use of this report for any purposes other than for the prevention of accidents could lead to erroneous interpretations. - SYNOPSIS - Date of the accident Aircraft: Monday 20 January 1992 AIRBUS A320 at 18.20 UTC (*) Registration F-GGED Site of accident Owner: Place known as "La Bloss" DIA A.I. France LTD Barr Commune (Bas-Rhin) 7-2, YAESU 2-CHOME, CHUO-KU (near Mont Sainte-Odile) TOKYO 104 JAPAN Type of flight Operator Scheduled flight The company AIR INTER Public transport (passengers) Persons on board 2 Flight crew 4 Cabin crew 90 passengers Summary During a VORTAC approach, carried out at night and in IMC conditions towards runway 05 at Strasbourg-Entzheim, the aircraft crashed into the mountain known as "La Bloss" during its descent towards the runway, at an altitude of approximately 800 metres and a distance of approximately 10.5 nautical miles from the runway threshold. Consequences Injuries Equipment Cargo Third party Fatal Serious Slight Crew 5 1 100% 100% Approx. 1 destroyed destroyed hectare of forest Passengers 82 4 4 destroyed (*) Times referred to in this report are expressed in Universal Time Co-ordinated (UTC). One hour should be added to give French time on the day of the accident. ORGANISATION OF WORK 1 - COMPOSITION OF THE COMMISSION OF INVESTIGATION By Arrêtés (Orders) dated 21 and 27 January 1992, the Ministry of Transport and Tourism established a Commission of Investigation to investigate the circumstances, research the causes and determine the lessons to be drawn from the accident of an aircraft of the type Airbus A320 operated by the company Air Inter which occurred on 20 January 1992 within the territory of the Barr Commune (Bas-Rhin). The Commission comprised the following members: M. Alain Monnier, ingénieur général de l'aviation civile, Chairman M. Paul Arslanian, Head, Bureau Enquêtes-Accidents, Vice Chairman M. Pierre Bernard, technical investigator, Bureau Enquêtes-Accidents M. Jean-Louis Chatelain, airline pilot, captain M. Philippe Gourguechon, Pilot Inspector, Organisme du Contrôle en Vol (Flight Inspection Organisation) M. Michel Guillaume, conseiller d'Etat Colonel Guy Lagrange, Chief of Staff of the Direction de la circulation aérienne militaire (Military Air Traffic Directorate) M. Dominique Marbouty, ingénieur général de la météorologie Professor Henri Marotte, médecin-chef, centre d'essais en vol (Flight Test Centre) M. Jean Pariès, Deputy, Bureau Enquêtes-Accidents M. Frédéric Rico, Deputy, navigation aérienne (Air Navigation Department) M. Alain Tert, Deputy for Technical Affairs, centre d'essais en vol (Flight Test Centre) Monsieur Jean Pariès, a member of the Commission, acted as Investigator-In-Charge. In order to apply the provisions of Annex 13 of the convention relating to international civil aviation, Mr. Robert M. MacIntosh, accredited United States representative in the capacity of State