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CA 12-14b 10 October 2018 Page 1 of 12
Section/division Accident and Incident Investigations Division Form Number: CA 12-14b
PRELIMINARY SERIOUS INCIDENT REPORT
Accident and Incident Investigations Division
Serious Incident - Preliminary Report -
AIID Ref No: CA18/3/2/1301
Aircraft Type
Figure 1: Aircraft TC-JNI (Source: Planespotter.net)
Description:
Failure of the left landing gear as reported by the crew following a fault in the Electronic
Centralized Aircraft Monitoring System (ECAM). The aircraft diverted to OR Tambo
international (FAOR) where it made a safe landing.
CA 12-14b 10 October 2018 Page 2 of 12
DESCRIPTION OF INCIDENT Reference Number : CA18/3/2/1301 Name of Owner/Operator : Turkish Airlines Manufacturer : Airbus Model : A330-343 Nationality : Turkey Registration Marks : TC-JNI Place : Cape Town International (FACT) Western Cape Province Date : 2 January 2020 Time : 1600Z All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011 this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to apportion blame or liability. Any person who has information concerning this incident should contact the AIID on [email protected] Investigations process: The Accident and Incident Investigations Division (AIID) of the SACAA was informed about an Aircraft incident, involving an A330-343, which occurred after departure from Cape Town International Airport (FACT) en-route to Istanbul International Airport (LTFM) on 2 January 2020. The incident was notified to the AIID Investigator on call on 3 January 2020 at 0418Z. The AIID appointed an Investigator-in-charge. Notifications were sent to the Sate of Registry, State of Operator, State of Manufacture and Design, BEA, the State did not assign an Accredited Representative to this Investigation however, assistance will be provided to the IIC should it be required. The AIID will lead the investigation and issue the Final Report. The information contained in this Preliminary Report is derived from the factual information gathered during the ongoing investigation into the Occurrence. Later Interim reports or the Final Report may contain altered information in case new evidence appears during the ongoing investigation that requires changes to the information depicted in this Report. The AIID Reports are made publicly available at: http://www.caa.co.za/Pages/Accidents%20and%20Incidents/Aircraft-accident-reports.aspx Notes: 1. Whenever the following words are mentioned in this Report, they shall mean the following:
• Incident - this investigated incident;
• Aircraft - the Airbus A330-343 involved in this incident;
• Investigation - the investigation into the circumstances of this incident;
• Pilot – the pilot involved in this incident;
• Report- this Incident report.
2. Photos and figures used in this Report were obtained from different sources and may be adjusted from the original for the sole purpose of improving the clarity of the Report. Modifications to images used in this Report are limited to cropping, magnification, file compression, or enhancement of colour, brightness, contrast, or the addition of text boxes, arrows or lines. Disclaimer: This report is produced without prejudice to the rights of the CAA, which are reserved.
CA 12-14b 10 October 2018 Page 3 of 12
TABLE OF CONTENTS PAGE NO
Cover Page 1
Purpose 2
Investigation Process 2
Disclaimer 2
Table of Contents 3
List of Abbreviations 5-
1. FACTUAL INFORMATION 6
1.1 History of Flight 6, 7
1.2 Injuries to Persons 7
1.3 Damage to Aircraft 7
1.4 Other Damage 7
1.5 Personnel Information 7
1.6 Aircraft Information 8
1.7 Meteorological Information 8
1.8 Aids to Navigation 9
1.9 Communication 9
1.10 Aerodrome Information 9
1.11 Flight Recorders 10
1.12 Wreckage and Impact 10
1.13 Medical and Pathological Information 10
1.14 Fire 10
1.15 Survival Aspects 11
1.16 Test and Research 11
1.17 Organisational Management Information 11
1.18 Additional Information 11
1.19 Useful and Effective Investigation Technique 12
2. Findings 12
2.1 General 12
2.2 Preliminary Findings 13
3. Ongoing Investigation 13
CA 12-14b 10 October 2018 Page 4 of 12
ABBREVIATION DEFINITION
AMSL Above Mean Sea Level
AMO Aircraft Maintenance Organisation
ATC Air Traffic Controller
ATPL Airline Transport Pilot Licence
BEA Bureau d'Enquêtes et d'Analyses
CAR Civil Aviation Regulation
C of A Certificate of Airworthiness
C of R Certificate of Registration
DME Distance Measuring Equipment
ECAM Electronic Centralised Aircraft Monitoring
FACT Cape Town International Airport
GPS Global Positioning System
FAOR OR Tambo International Airport
IFR Instrument Flight Rule
Ft Feet
IIC Investigator-in-charge
ILS Instrument Landing System
IOCC Integrated Operation Control Centre
K Kilometre
Kt Knots
LTFM Istanbul Airport
MOCC Mid-States Operation Control Centre
METAR Meteorological Terminal Aviation Routine
PAPI Precision Approach Path Indicator
QNH Query: Nautical Height
TBA To Be Announce
SACAA South African Civil Aviation Authority
SATCOM Satellite Communication
SAWS South African Weather Service
TSM Trouble Shooting Manual
VOR Omni-Directional Range
CA 12-14b 10 October 2018 Page 5 of 12
1. FACTUAL INFORMATION 1.1. History of Flight 1.1.1 On Thursday 2 January 2020 at 1755Z, an Airbus A330-343 aircraft took off from
Runway 19 at Cape Town International Airport (FACT) en-route to Istanbul
International Airport (LTFM) on a scheduled flight with flight number THY45T. On
board the aircraft were two pilots, 11 cabin crew members and 292 passengers.
The flight was conducted using instrument flight rules (IFR) and fine weather
conditions prevailed.
1.1.2 According to available information, during rotation when the landing gear lever was
selected up, the crew noted an error message on the Electric Centralised Aircraft
Monitoring (ECAM) indicating a left-gear fault message. The crew then opted to fly
overhead Robin Island with the landing gear still in the down position and mitigate
the error message on the ECAM. After completion of ECAM procedure, the crew
alerted the tower that they have a technical problem with the landing gear system
and requested a hold to trouble shoot and reduce fuel. During holding the crew
contacted the mid-state operations control centre (MOCC) and integrated
operations control centre (IOCC) through a satellite communication system
(SATCOM) for assistance with the landing gear fault. After 2 hours holding the
MOCC advised the crew that FAOR will be a better option as the resources needed
to correct the fault are available there and that led to the crew decision to divert to
FAOR.
1.1.3 The aircraft was cruising at 20 000 feet above mean sea level (AMSL) en route to
FAOR and it landed safely at 2018Z.
1.1.4 Following the incident, the crew tasked an Aircraft Maintenance Organisation
(AMO) at FAOR to conduct fault finding regarding the ECAM message and landing
gear problem. The AMO found that the pitch trimmer proximity sensor was out of
adjustment limits and was adjusted before the aircraft was returned to service.
1.1.5 The incident occurred at FACT airspace on the GPS location determined to be
33°58’08.58” South 018°36.06’00” East with elevation of 203 feet.
CA 12-14b 10 October 2018 Page 6 of 12
1.2. Injuries to Persons
Injuries Pilot Crew Pass. Other
Fatal - - - -
Serious - - - -
Minor - - - -
None 2 11 292 -
1.3. Damage to Aircraft 1.3.1 None.
1.4. Other Damage 1.4.1 None 1.5. Personnel Information
1.5.1 Captain
Nationality Turkish Gender Male Age 64
Licence Number ************** Licence Type Airline Transport Pilot
Licence valid Yes Type Endorsed Yes
Ratings To be added in the final report
Medical Expiry Date 26 January 2021
Restrictions None
Previous Accidents To be added in the final report
Flying Experience:
Total Hours 27000
Total Past 90 Days 180
Total on Type Past 90 Days 180
Total on Type 6000
1.5.2 First Officer 1.5.2.1 The details of the First Officer were still outstanding from the operator at
publication of this preliminary report and they will be discussed in the final report. Also, the State of Registry is yet to respond to our request on the aircraft and crew details.
CA 12-14b 10 October 2018 Page 7 of 12
1.6. Aircraft Information
Airframe:
Type A330-343
Serial Number 1160
Manufacturer Airbus
Date of Manufacture 2010
Total Airframe Hours (At time of Accident)
42921.43
Last MPI (Date & Hours) 24 December 2019 42901.28
Hours since Last MPI 20.15
C of A (Issue Date) 29 March 2019
C of R (Issue Date) (Present owner) 19 October 2019
Operating Categories Standard Part 121
Engine 1:
Type RB211T772B-6016
Serial Number 42443
Hours since New 18468
Cycles since New 4430
Hours since Overhaul 889
Engine 2:
Type RB211T772B-6016
Serial Number 41830
Hours since New 36708
Cycles since New 7606
Hours since Overhaul 14541
RH Main Landing Gear
Part Number 10-210201-004
Serial Number MDL1109
Hours Since New 43259 FH
Cycles Since New 8873 FC
Hours Since Overhaul
TBA
Last Maintenance Repair
23-SEP-19
LH Main Landing Gear
Part Number 10-210101-004
Serial Number MDL1109
Hours Since New 43259 FH
Cycles Since New 8873 FC
Hours Since Overhaul
TBA
Last Maintenance 23-SEP-19
CA 12-14b 10 October 2018 Page 8 of 12
Repair
Nose Landing Gear
Part Number D23581100-20
Serial Number B1081
Hours Since New 43259 FH
Cycles Since New 8873 FC
Hours Since Overhaul
TBA
Last Maintenance Repair
23-SEP-19
1.7. Meteorological Information 1.7.1 A weather report was obtained from the South African Weather Service (SAWS) for
FACT. The meteorological aeronautical reports (METARs) were made available for FACT taken on 2 January 2020 at 1600Z.
Wind direction 190 Wind speed 22 Visibility 9999km
Temperature 22 Cloud cover Nil Cloud base Nil
Dew point 16 QNH 1015
1.8. Aids to Navigation 1.8.1 The aircraft was equipped with standard navigational equipment as approved by the
Regulator for the aircraft type. There were no recorded defects prior to the accident.
Figure 2: Shows an orbit overhead Robben Island and routing to FAOR. (Source: Flight
Aware and Google Earth)
CA 12-14b 10 October 2018 Page 9 of 12
1.9. Communications. 1.9.1 The aircraft was equipped with standard communication equipment as approved by
the Regulator. There were no recorded defects prior to the accident.
1.10. Aerodrome Information
Aerodrome Location Cape Town, South Africa
Aerodrome Co-ordinates South 33°58’16.93” East 028°36’15.45”
Aerodrome Elevation 151ft AMSL
Runway Designations 01/19 16/34
Runway Dimensions 10501ft 5580ft
Runway Used 19
Runway Surface Asphalt
Approach Facilities PAPI, VOR, ILS, DME, Runway lights
Aerodrome Status Licensed
Figure 3: FACT Aerodrome chart.
1.11. Flight Recorders
CA 12-14b 10 October 2018 Page 10 of 12
1.11.1 The aircraft was equipped with flight data recorder and a cockpit voice recorder as approved by the Regulator. There were no recorded defects with either equipment prior to the incident.
1.12. Wreckage and Impact Information 1.12.1 Not Applicable 1.13. Medical and Pathological Information 1.13.1 None 1.14. Fire 1.14.1 There was no evidence of pre or post impact fire. 1.15. Survival Aspects 1.15.1 The incident was considered to be survivable as there was no damage to the
aircraft which could have caused injuries to persons on board. 1.16. Tests and Research
1.16.1 Following the incident the operator requested the AMO to conduct a fault finding.
The engineers used the trouble shooting manual (TSM) ref 32-30-00-810-815-A
which talks to main landing gear (L/G) left/right Pitch Trimmer Fault. According to
the TSM the fault symptoms associated with L/G Retraction Fault warning were
listed. The engineers put the aircraft on jacks and bleed the pitch trimer system.
The extension and retraction tests were performed. Following the tests, it was
discovered that the pitch trimmers 31GA1 and 32GA2 were out of limits. The
engineers then adjusted the proximity sensor of pitch trimmer on the right-hand
main landing gear even though the ECAM fault was on the left gear. Extension and
retraction tests were performed and the landing gear system operated within
acceptable limits and was signed out.
CA 12-14b 10 October 2018 Page 11 of 12
Figure 4: Shows schematic diagram of location of the main landing gear pitch trimmer proximity sensors (31GA1 and
31GA2) Source: Airbus AMM 32-31-73-820-804-A.
1.17. Organizational and Management Information 1.17.1 To be discussed in the final report. 1.18. Additional Information 1.18.1 To be discussed on final report
1.19. Useful or Effective Investigation Techniques 1.19.1 None 2. Findings 2.1. General
From the evidence available, the following preliminary findings were made with respect to this Incident. These shall not be read as apportioning blame or liability to any particular organisation or individual. To serve the objective of this Investigation, the following sections are included in the conclusions heading:
• Findings- are statements of all significant conditions, events or circumstances in this Incident. The findings are significant steps in this Incident sequence but they are not always causal or indicate deficiencies.
CA 12-14b 10 October 2018 Page 12 of 12
2.2. Preliminary findings 2.2.1 The PIC had been initially issued with an Airline Transport Pilot Licence (ATPL) on
8 May 1991, his last skills test was carried out on 20 July 2019 and his ATPL will
expire on 31 August 2020. He also had been issued with a class 1 aviation medical
certificate in January 2019 with an expiry date of 26 January 2020.
2.2.2 The FO details and experience were still to be submitted by the operator and the
State of Registry is yet to respond to our request on the aircraft and crew.
2.2.3 The aircraft had been issued with a certificate of airworthiness (C o A) on 29 March
2019 with an expiry date of 29 March 2020.
2.2.4 The last maintenance inspection on the aircraft was an “A check” which had been
carried out on 4 December 2019 at 42901.28 airframe hours. The aircraft had
accumulated a further 20.15 airframe hours since the last inspection.
2.2.5 The flight was conducted under Instrument Flying Rules (IFR) by day and the
weather was not a factor in this incident.
2.2.6 The aircraft sustained no damage and none of the occupants sustained any injuries.
2.2.7 After the serious incident, the operator requested an AMO to conduct fault finding to
determine the fault message that registered on ECAM. During fault finding, it was
noted that the pitch trimmers (31GA1 and (31GA2) were out of limits. The engineers
adjusted the proximity switch sensors of the pitch trimmers on the right-hand side.
Extension and retraction system tests were carried out, all tests were satisfactory
and the aircraft was returned to service.
3. On-going Investigation
3.1. The SACAA investigation is on-going and the cause of the pitch trimmers being out
of limits will be discussed in the final report which may or may not have safety implications.
This Report is issued by: Accident and Incident Investigation Division South African Civil Aviation Authority Republic of South Africa