Incident description
Last updated: 24 April 2014
Status:Final
Date:Saturday 24 September 1994
Time:12:45
Type:Silhouette image of generic A310 model; specific model in this crash may look slightly different
Airbus A310-325
Operator:Tarom
Registration: YR-LCA
C/n / msn: 636
First flight: 1992-01-13 (2 years 9 months)
Engines: 2 Pratt & Whitney PW4158A
Crew:Fatalities: 0 / Occupants: 11
Passengers:Fatalities: 0 / Occupants: 175
Total:Fatalities: 0 / Occupants: 186
Airplane damage: None
Location:Paris-Orly Airport (ORY) (   France) show on map
Phase: Landing (LDG)
Nature:International Scheduled Passenger
Departure airport:Bucharest-Baneasa Airport (BBU/LRBS), Romania
Destination airport:Paris-Orly Airport (ORY/LFPO), France
Flightnumber: 381
Narrative:
Tarom Flight 381 approach to Paris-Orly runway 26 and the captain was at the controls. He decided to perform an automatic approach and landing. The flight crew started to put the aircraft into the approach configuration, with slats and flaps at 15/0 at 10:42:05, then at 15/15 at 10:42:53. The landing gear was
extended at 10:42:57. Approaching the OYE beacon at indicated speed 250 kt and heading 325, before lining up with the runway, the Captain noted that the aircraft was not capturing the ILS glide slope automatically. He disconnected the AP and continued the approach on manual control, keeping the Autothrottle in operation. As the aircraft descended through 1,700 feet, at 10:43:22, with a speed of about 195 knots, the Captain asked for flap extension to 20°. The VFE, the speed limit authorized for this new configuration, is 195 knots. When the flap control was set to 20°, the thrust levers advanced and engine thrust increased.
The flight crew countered the nose-up effect resulting from the increase in thrust by using the pitch controls, with the auto-throttle (ATHR) remaining in automatic mode. The throttle levers were then quickly brought back to the idle position. At the same time, the trimmable horizontal stabilizer started to move in a nose-up direction. The nose up effect that resulted was countered by the flight crew through gradual nose-down action on the elevators. When the trimmable horizontal stabilizer reached its maximum nose-up value and the elevators also reached their maximum nose down value, the throttle levers, according to the FDR readout, moved rapidly to their stops. In a few seconds, the flight path started to rise and the pitch attitude went to 60°. Witnesses saw the aircraft climb. It banked sharply to the left and the right and stalled before adopting a strongly negative pitch attitude (-33 degrees) towards the ground. The maximum altitude reached was 4,100 feet, while a minimum indicated speed of 35 knots was recorded. The stall and ground proximity warnings sounded during the descent. The flight crew managed to regain control of the aircraft, with the lowest point being around a height of 800 feet, that is 240 meters from the ground. The flight crew then performed a visual circuit, followed from the tower by the controller. The second approach was made with a configuration with slats and flaps at 20/20. Landing took place at 10:52:25.


PROBABLE CAUSE: "The direct causes of the unusual attitudes and the stall to which the aircraft was subjected were a movement of the THS towards the full pitch-up position and a rapid increase in thrust, both of which maneuvers were the due to the Captain, following an AFS mode reversion which was not understood. The pitch-up force caused a sudden change in attitude that the flight crew was unable to contain with the elevators.
The following elements contributed to the incident:
- Too rapid an approach, due to a late start in the descent, followed by a reduction of the standard procedure.
- Inadequate crew resource management.
- Premature selection of the go around altitude and precipitous setting of the configuration with slats and flaps at 20-20, which led to activation of the speed protection.
- Difficulty in understanding the action of the auto-throttle increasing thrust in its overspeed protection function."

Sources:
» Air Safety Week 17.10.1994 (p. 6)
» Air Safety Week 24.10.1994 (p. 3)
» Air Safety Week 03.10.1994 (p. 6)
» Aviation Week & Space Technology 03.10.94(37)
» Bureau Enquêtes-Accidents Report on the incident on 24 September 1994 during approach to Orly (94) to the Airbus A 310 registered YR-LCA operated by TAROM (YR-A940924A)
» Flight International 23-29.11.94(6)
» Flight International 5-11.10-94(4)
» Scramble 185

Official accident investigation report
investigating agency: Bureau d'Enquêtes et d'Analyses (BEA) - France
report status: Final
report number: Report yr-a940924a
download report: Report on the incident on 24 September 1994 during approach to Orly (94) to the Airbus A 310 registered YR-LCA operated by TAROM (BEA Report yr-a940924a)
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Bucharest-Baneasa Airport to Paris-Orly Airport as the crow flies is 1852 km (1157 miles).

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