ASN Wikibase Occurrence # 199988
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| Date: | Wednesday 20 September 2017 |
| Time: | 21:02 |
| Type: |  Airbus A320-214 |
| Owner/operator: | Vueling |
| Registration: | EC-HTD |
| MSN: | 1550 |
| Year of manufacture: | 2001 |
| Engine model: | CFMI CFM56-5B4/P |
| Fatalities: | Fatalities: 0 / Occupants: 132 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Zürich-Kloten Airport (ZRH/LSZH) -
 Switzerland
|
| Phase: | Initial climb |
| Nature: | Passenger - Scheduled |
| Departure airport: | Zürich-Kloten Airport (ZRH/LSZH) |
| Barcelona-El Prat Josep Tarradellas Airport (BCN/LEBL) | |
| Investigating agency: | STSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
At 18:41:23 UTC on 20 September 2017, EC-HTD took off from Runway 28 in Zurich (LSZH) with the flight plan call sign VY6249 on a scheduled flight to Barcelona (LEBL). For the flight, the commander was pilot flying (PF) and the copilot was pilot monitoring (PM). Shortly after lift-off, the flight crew contacted Zurich Departure on the 125.950 MHz frequency and received clearance from the air traffic controller for a climb to Flight Level (FL) 120. At 18:44:56 UTC, the flight crew was instructed by the air traffic controller to switch to the 135.675 MHz frequency of Zurich Radar.
At 18:44:58 UTC, while the air traffic controller was still transmitting the new frequency, the autopilot and autothrust automatically disengaged. The master warning was activated and the beep known as the cavalry charge sounded to indicate that the autopilot was disengaged. This beep continued to sound for the next 21 seconds. The air traffic controller again transmitted his instruction to change frequency, to which the commander replied as follows: "we have a small issue, standby please". The copilot then expressed his uncertainty about task sharing.
The commander stated that he would continue to act as PF.
At 18:45:52 UTC the copilot mentioned a computer reset, which was acknowledged by the commander with "OK". The flight crew’s report stated, among other things, that a computer reset had been performed. The description of the steps performed corresponds to the procedure for resetting the Flight Management Guidance Computers (FMGC). The recordings show that the Circuit Breakers (CB) of both FMGCs were pulled practically simultaneously.
At 18:46:15 UTC the aircraft passed FL 118 and the commander asked the copilot to confirm the cleared flight level of FL 120. The copilot answered with "correctos" and reported "maintaining 120, Vueling 6249" to the air traffic controller, whereupon the air traffic controller issued clearance for FL 230. Shortly afterwards the aircraft continued its climb. At 18:46:32 UTC, the copilot said: "Autoflight, autothrust off" and just under a minute later he reported: "Both MCDU, flight directors off." At 18:47:27 UTC the commander requested a heading instruction from the air traffic controller.
At 18:47:45 UTC the air traffic controller instructed the flight crew to continue on a heading of 240°. The commander read the instruction back and added that they were busy with troubleshooting.
Recordings show that the autopilot and autothrust were engaged and disengaged several times shortly afterwards.
At 18:48:40 UTC the air traffic controller said: "You are well out of my airspace, are you able to switch over to next sector on the heading or do you need further assistance from me?" The commander replied, without this being broadcast by radio by saying "yes, we would like to come back to the airport, but we do not have navigation indication. So we like to vector to landing on Runway 14."
He immediately noticed that this message had not been transmitted on the radio, and transmitted "Vueling 6249?" again. This time the message was transmitted. The commander replied to the air traffic controller’ remark of "go ahead" by saying: "Yes, are you switched me on the next frequency, or we come back to your airfield?" The air traffic controller, still unaware of the commander’s intention to return to Zurich, asked: "Vueling 6249, do you wish to continue?" The commander answered: "Yes, if possible we would like to come back, but we have right now no navigation indication available." Shortly afterwards, at 18:50:59 UTC, the air traffic controller gave the instruction: "Left turn heading 050 degrees, radar vectors to Zurich."
Shortly afterwards the instruction followed to maintain the altitude that the aircraft had just attained.
At 18:51:50 UTC the air traffic controller asked whether the crew could fly an instrument approach or whether they wanted radar vectors for a visual approach. The captain answered: "Vectoring [...] long final for a visual", which was not transmitted, and shortly afterwards "Vectoring for a long approach to Runway 14", which was transmitted. The air traffic controller said: "ILS approach runway 14 or visual approach, if you prefer that later on" and gave clearance for a descent to FL 150. The commander read back this clearance twice. The communication was only transmitted the second time.
During the ongoing discussion with the copilot, the commander said the following at 18:52:59 UTC: "[…] double FMGC failure." At 18:53:50 UTC the air traffic controller gave the instruction to turn onto a heading of 020°. Clearance for FL 130 followed just over a minute later. At 18:56:03 UTC the air traffic controller said: "Just for my confirmation, you have got no primary and secondary flight display, or just no navigational system behind?", to which the commander answered "No navigation system, as I told you before, both navigation systems."
The air traffic controller thanked him and gave clearance for FL 110. The commander read back "one", which was not transmitted, followed by the transmission "one zero, six two fo...".
At 18:57:08 UTC, the air traffic controller stated that he estimated there were another 47 miles before the aircraft would land on Runway 14 and repeated his offer of an instrument approach or visual approach. The captain said: "We cannot follow any instrument approach, so we prefer visual", after which a visual approach was agreed upon.
During the discussion with the copilot, the commander repeated the following at 18:57:37 UTC: "Nada, nada, dual FMGC, dual MCDU […]."
The air traffic controller gave clearance for FL 70 at 18:58:27 UTC. The commander read back the clearance and asked the air traffic controller to report to the maintenance company. At 19:01:16 UTC clearance was given to descend to 6000 ft at a QNH of 1022 hPa. The flight crew worked through the approach checklist. The commander requested a level off at 4000 ft to configure the aircraft. Again, this was only transmitted on the second attempt. The air traffic controller confirmed this, saying: "You will get now minimum 10 nautical miles final, and I will vector you with a heading onto the extended centreline of Runway 14, that you can continue the last portion in VMC and visual conditions."
At 19:03:40 UTC clearance was given for 4000 ft. The flight crew’s discussion continued and the computer reset was discussed. At 19:05:04 UTC an instruction was given for a heading of 090°, together with the information: "I take you slightly through the extended centreline, in order for you to maintain 4000 ft for some time to configure."
At 19:06:10 UTC the air traffic controller gave the instruction for a heading of 180°, followed by an instruction for a heading of 200° some 30 seconds later. The landing flaps were extended to Setting 2. This was followed by an instruction to turn onto a heading of 230°.
At 19:07:36 UTC, the air traffic controller gave the flight crew the following information: "The runway is now at your about 9 to 10 o'clock position, and intensity is now on 100 % of the lighting, report the runway in sight." The copilot reported "runway in sight". The air traffic controller cleared a "visual straight-in approach to Runway 14".
At 19:08:20 UTC, the landing gear was extended. The landing flaps were extended to setting 3.
The air traffic controller informed the flight crew: "You are now 10 miles from touchdown, showing 3900 ft and mode Sierra shows indicated speed of 160 knots." The copilot replied, "fully established", after which the air traffic controller issued landing clearance and provided information that the wind was at 2 knots from 260 degrees.
At 19:13:11 UTC the automatic callout "fifty - forty - thirty - twenty - retard, retard - ten" was recorded. Touchdown took place at 19:13:23 UTC. During the landing roll, the Enhanced Ground Proximity Warning System (EGPWS) gave the warning "terrain ahead, pull up!" eight times. After the flight crew had established visual contact with the marshaller, they contacted Zurich Apron on the frequency 121.850 MHz and taxied to the stand. The passengers disembarked the aircraft as normal.
STSB Conclusions
The procedures specified by the aviation operator are in accordance with the aircraft manufacturer’s specifications. The recordings indicate that the flight crew did not consistently adhere to these requirements. This is most evident in the fact that the circuit breakers of both FMGCs were pulled virtually simultaneously, even though the relevant procedure explicitly prohibits this.
The task sharing between the two pilots for abnormal and emergency situations did not comply with the procedures. The principles of CRM and the standard phraseology were also followed inadequately. The commander’s decision to return to Zurich, for example, and his announcement to air traffic control was made without the involvement of the copilot.
Accident investigation:
 |
|
Sources:
https://www.sust.admin.ch/inhalte/AV-berichte/EC-HTD.pdf
https://www.flightradar24.com/data/aircraft/ec-htd#eee9bdf
History of this aircraft
Other occurrences involving this aircraft
| 11 May 2004 | EC-HTD | Iberia | 0 | Madrid-Barajas Airport (MAD/LEMD) |  |
min |
| Cowling loss | ||||||
| 21 February 2017 | EC-HTD | Vueling | 0 | near Málaga | |
non |
| Loss of pressurization | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-Sep-2017 07:44 | harro | Added |
| 28-Jul-2021 09:06 | harro | Updated [Destination airport, Narrative, Accident report] |
Corrections or additions? ... Edit this accident description
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