FINAL REPORT - Aviation Safety

[Pages:59]FINAL REPORT

Final report of the investigation into the probable causes of the accident with the KLM Cityhopper flight KL433, Saab 340B, PH-KSH at Schiphol, Amsterdam Airport on 4 April 1994, conducted by the Netherlands Aviatio n

Safety Board, composed of:

G.W.M . Bodewes, Chairman L.W . Snoek, Membe r J. Hofstra, Member C . Barendregt, Member H.P. Corssmit, Member

J . Smit, Deputy Member M.M . Boyer, Secretary

Hoofddorp, October 1995

CONTENTS

LIST OF ABBREVIATIONS

GENERAL INFORMATION OF THE ACCIDENT AND THE INVESTIGATION

THE INVESTIGATION

SYNOPSIS

1 FACTUAL INFORMATION

1 .1

History of the Flight

1 .2

Injuries to Person s

1 .3

Damage to Aircraft

1 .4

Other Damage

1 .5

Personnel Information

1 .5.1

Captai n

1 .5 .1 .1 General

1 .5 .1 .2 Duty and Rest Period s

1 .5 .1 .3 Medical History

1 .5 .2 First Officer

1.5 .2 .1 General

1.5 .2 .2 Duty and Rest Period s

1 .5 .2 .3 Medical History

1 .6

Aircraft Information

1 .6 .1

General

1 .6.2 Engines

1 .6.3 Propellers

1 .6.4 Engine and Propeller History

1 .6.5 Weight and Balance

1 .6.6 Flighthandling and Performance aspects

1 .7

Meteorological Information

1 .8

Aids to Navigation

1 .9

Communications and Recording s

1 .9 .1

Air Traffic Control

1 .9 .2 Ground Operations

1 .10

Airport Information

1 .11

Flight Recorders

1 .12

Wreckage and Impact Information

1 .12.1 Accident Site Description

1 .12.2 Aircraft Wreckage Description

1 .12.3 Technical Examination of the Wreckage

1 .12.3.1 Genera l 1 .12 .3 .2 Flight Controls

1 .12 .3 .3 Engines and Propellers

1 .12 .3 .4 Engine Instruments

1 .12.3 .5 Flight Instruments

i

1 .13

Medical and Pathological Information

1.13 .1 The Crew

1.13 .2 The Passengers

1 .14

Fire

1 .15

Survival Aspects

1.15 .1 Seating Plan

1.15.2 Interior Damage and Survivabilit y

1 .15.2 .1 General

1 .15.2.2 Cockpit

1 .15.2.3 Galley

1 .15.2.4 Cabin

1 .15 .2.5 Exits

1 .16

Tests and Research

1 .16.1 Procedures

1 .16.2 Pilot Selection and Trainin g

1 .16.2.1 Main requirements pursuant to Netherlands Aviation Law

1 .16.2 .2 KLC Initial Requirements

1 .16.2.3 KLC Selection

1 .16.2.4 KLC Type Qualificatio n

1 .16.2.5 KLC Captain's Training/Qualification

1 .16.2.6 RLD Inspection of KLC

1 .16.2.7 KLC's Assessment Procedure of Proficiency Check s

1 .16.2 .8 Training/Qualification Captain of Flight KL43 3

1 .17

Organizational and Management Informatio n

1 .18

Additional Information

1 .19

Useful or Effective Investigation Technique s

2 ANALYSIS

2 .1

Oil Pressure Warning

2.1 .1 Technical Aspects

2.1.2 Flightcrew Handling of Oil Pressure Warning

2 .2

Decision Making Process

2.2.1 General

2.2.2 Decision to Return to Amsterdam Airport

2.2.3 Decision to Maintain Flight Idle on the RH Engine

2.2.4 Choice of Runway 06

2 .3

Aircraft Handling

2.3.1 Descent

2.3.2 Final Approach

2.3.3 Go Around

2 .4

Crew Resource Management

2 .5

KLC Pilot Selection and Training

2 .6

Single Engine Performance SAAB 340B

2 .7

Procedures

2.7.1 Engine & Prop Oil Pressure Low Procedures

2.7.2 Ruddertrim Procedure

2.7.3 Approach Speeds

ll

2 .8

2.8 .1 2 .8 .2 2 .9 2 .10

Flight Safety Cabin/Passengers Preparation Survivability Air Traffic Control Fire Fighting & Rescue Services

3 CONCLUSIONS

4 PROBABLE CAUSES

5 RECOMMENDATIONS

APPENDIXES

1. Photograph s 2. UFDR Plots

AEO AMS AOM AP APR ATC ATIS ATPL

Bl B2 B3 BHX BRE BRU BVOI

C CA CHU CMC CPL CRM CTOT Cu CVR CWL CWP

ECL EGFF EGGD EGHI EGLL EHAM

FAR FDAU F0 FL FST BV ft fpm

GMT

- LIST OF ABBREVIATIONS -

All Engines Operative Amsterdam Schiphol Airport Aircraft Operations Manual Auto Pilot Automatic Power Reserve Air Traffic Control Automatic Terminal Information Service Airline Transport Pilot's Licence

ATPL (Netherlands Airline Transport Pilot's Licence ) SCPL (Netherlands Senior Commercial Pilot's Licence) CPL (Netherlands Commercial Pilot's Licence) Birmingham Airport Bremen Airport Brussel Airport Bureau Vooronderzoek Ongevallen en Incidenten (Accident en Incident Investigation Bureau)

Celcius Cabin Attendant Commuter Handling Unit Cockpit Management Course Commercial Pilot's Licence Cockpit Resource Managemen t Constant Torque On Take off Cumulu s Cockpit Voice Recorder Cardiff Airport Central Warning Panel

Emergency Checklist Cardiff Airport Bristol Airport Southampton Airport London Heathrow Airport Amsterdam Schiphol Airport

Federal Aviation Regulations (of the FAA) Flight Data Acquisition Unit First Officer Flight Level Flight Simulator Training B.V. Feet Feet per minute

Greenwich Mean Time

iv

HPa

IAS IATA ICAO IF IFR ILS IR

JAR

kg KLC KLM km kt

Lat lb LH Long LUX

m MHz MLH MMX MTOW

N NLRGC

NLM nm NOTAM NTSB NVLS

OEI OM

PAN-call PAS PF PIC PNF psi

Hectopascals

Indicated Airspeed International Air Transport Association International Civil Aviation Organizatio n Instrument Flying Instrument Flight Rules Instrument Landing System Instrument Rating

Joint Airworthiness Regulations

Kilogram(s) KLM Cityhopper Koninklijke Luchtvaart Maatschappij (Royal Dutch Airlines) Kilometer(s) Knot(s )

Latitude Pound(s) Left Han d Longitude Luxembourg Airport

Meter(s) Megahertz Basel Mulhouse Airport Malm? Airport Maximum Take Off Weigh t

North Stichting Nationaal Lucht- en Ruimtevaart Geneeskundig Centru m (Netherlands Aerospace Medical Centre ) Nederlandse Luchtvaart Maatschappij Nautical mile s Notice to Airmen National Transportation Safety Board (USA) NV Luchthaven Schiphol (Schiphol Airport)

One Engine Inoperative Outer Marker

Urgency call Public Address Syste m Pilot Flying Pilot in Command Pilot Not Flying Pounds per square inch

v

PSU

QNH

RA RD RLD

RH RIV RPM RT RTB RTL RV

Sc SCPL SOU SXB

UFDR UHF UTC

V VHF VMC VSI VT 1 VTH

W

Passenger Service Unit

Sea Level Atmosphere Pressure

Radio Altitude Route Day Rijksluchtvaartdiens t (Civil Aviation Authority of the Netherlands ) Right Hand Rapid Intervention Vehicle Revolutions per Minute Radio Telephony Reserve Thuis Beschikbaar (Reserve/available) Reserve Thuis [oproepbaar] (Reserve/on call) Reis Verlof (Off Duty)

Stratocumulus Senior Commercial Pilot's Licence Southampton Airport Strassbourg Airport

Universal Flight Data Recorder Ultra High Frequency Coordinated Universal Time

Airspeed Very High Frequency Visual Meteorological Condition s Vertical Speed Indicato r Summer Type Recurrent Threshold Speed

West

vi

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download