Beschrijving:
A SmartLynx Estonia Airbus A320-214 suffered a loss off control during a training flight at Tallinn Airport, Estonia.
At 12:03 hours local time the aircraft departed Tallinn as crew training flight MYX9001. Onboard were a captain-instructor as well as a second pilot, four students and a Civil Aviation Administration inspector.
Numerous circuits and touch-and-goes were performed, including two full stop landings.
During final approach to runway 08 at 17:04, the aircraft stopped responding to flight control inputs. Altitude was lost and the aircraft hit the runway. The engines touched the runway and the main landing gear doors broke.
The aircraft then managed to gain altitude and the pilots were able to stabilize the aircraft and turn back. Both engines, however, lost power after the turn back to the airport.
An emergency landing was carried out at 17:11, about 150 meters from the runway. The aircraft came to a halt in the snow 15 meters south of the runway.
The flight crew members evacuated the aircraft via the L1 door emergency escape slides.
A video of the incident shows what appears to be a tire rolling away from the aircraft as it came to a stop. Photos from the scene seem to show that one of the nose landing gear tires is missing. Photos also indicate that the ram air turbine (RAT) had been deployed.
Causal factors:
This accident results from the combination of the following factors:
- The intermittent THSA override mechanism malfunction allowing to cause the loss of pitch control by both ELACs.
The repetitive triggering of the ELAC PITCH faults was caused by the non or late activations of the PTA micro-switches, which were due to the OVM piston insufficient stroke. The insufficient OVM stroke was caused by the THSA OVM clutch unit non-standard friction. The oil in the THSA OVM casing appeared to be with a higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit, causing the THSA OVM nonstandard friction.
- SEC design flaw allowing for a single event, the left landing gear temporary dedecompression, to cause the loss of pitch control by both SECs.
The absence of ground spoilers arming for landing in the context of touch and go's training may have contributed to the temporary decompression of the left main landing gear.
- The training instructor`s decision for continuation of the flight despite repetitive ELAC PITCH FAULT ECAM caution messages.
The lack of clear framework of operational rules for training flights, especially concerning the application of the MEL, and the specific nature of operations that caused pressure to complete the training program may have impacted the crew decision-making process.
Contributory factors
- Smartlynx Estonia ATO TM does not clearly define the need for arming spoilers when performing touch-and-go training (ATO procedures not in accordance with Airbus SOP). The fact that there is no clear reference in the Smartlynx Estonia ATO TM Touch-And-Go air exercise section to additional procedures that should be used, in combination with lack of understanding of the importance for arming the spoilers during this type of flights contributed to TRI making a decision to disarm the spoilers during touch and go training enabling landing gear bounce on touch down.
- At the time of the event Airbus QRH did not define the maximum allowed number of resets for the flight control computers.
- At the time of the event Airbus FCTM did not require to consider MEL on touch-and-go and stop-and-go training.
- The oil in the THS OVM casing was with higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit.
- The aircraft maintenance documentation does not require any test of the OVM during aircraft regular maintenance checks.
- Smartlynx Estonia ATO OM does not clearly specify the role in the cockpit for the Safety Pilot. The lack of task sharing during the event caused the ECAM warnings to be left unnoticed and
unannounced for a long period.
- The crew not resetting the ELAC 1. The fact that ELAC 1 PITCH FAULT was left unreset lead to the degradation of the redundancy of the system.
Considering the remoteness of the loss control of both elevators, there is no specific crew training for MECHANICAL BACKUP in pitch during approach, landing and take-off. This condition of the aircraft occurred for the crew in a sudden manner on rotation and during training flight, where the experienced TRI is not in PF role and cannot get immediate feedback of the aircraft behaviour and condition. Despite these difficult conditions the crew managed to stabilize and land the aircraft with no major damage to the persons on board. The crew performance factors that contributed to the safe landing of the aircraft are the following:
- The TRI followed the golden rule of airmanship (fly, navigate, communicate), by stabilizing the aircraft pitch by using the trim wheel and by keeping the aircraft engine power as long as possible;
- The Safety Pilot started to play a role in the cockpit by assisting the TRI and student by informing them about the status of the aircraft and later on taking the role of the PM.
» delfi.lv
» Plane to make emergency landing in Tallinn landed with stopped engines (news.err.ee, 14 March 2018)
EETN 281420Z 07011KT 3700 SHSN DRSN SCT009 SCT013CB M12/M15 Q1043 R08/810295 NOSIG
14:50 UTC / 16:50 local time:
EETN 281450Z 07013KT 9000 -SHSN DRSN FEW008 BKN013 FEW015CB M13/M15 Q1043 R08/810295 NOSIG
15:20 UTC / 17:20 local time:
EETN 281520Z 07012KT 9999 -SHSN DRSN FEW008 BKN013 FEW015CB M13/M15 Q1043 R08/490195 NOSIG
15:50 UTC / 17:50 local time:
EETN 281550Z 09011KT 9999 -SN DRSN OVC013 M13/M15 Q1042 R08/490195 NOSIG
16:20 UTC / 18:20 local time:
EETN 281620Z 09010KT 9999 -SN OVC014 M14/M16 Q1042 R08/490195 NOSIG
| Status: | Accident investigation report completed and information captured |
| Datum: | woensdag 28 februari 2018 |
| Tijd: | 17:11 |
| Type: |  Airbus A320-214 |
| Luchtvaartmaatschappij: | SmartLynx Airlines Estonia |
| Registratie: | ES-SAN |
| Constructienummer: | 1213 |
| Bouwjaar: | 2000-04-12 (17 years 11 months) |
| Aantal vlieguren: | 44997 |
| Aantal vluchten: | 21839 |
| Motoren: | 2 CFMI CFM56-5B4/P |
| Bemanning: | slachtoffers: 0 / inzittenden: 7 |
| Passagiers: | slachtoffers: 0 / inzittenden: 0 |
| Totaal: | slachtoffers: 0 / inzittenden: 7 |
| Schade: | Groot |
| Gevolgen: | Written off (damaged beyond repair) |
| Plaats: | Tallinn-Lennart Meri Airport (TLL) ( Estland)
|
| Fase: | Landing (LDG) |
| Soort vlucht: | Training |
| Vliegveld van vertrek: | Tallinn-Lennart Meri Airport (TLL/EETN), Estland |
| Tallinn-Lennart Meri Airport (TLL/EETN), Estland | |
| Vluchtnummer: | MYX9001 |
A SmartLynx Estonia Airbus A320-214 suffered a loss off control during a training flight at Tallinn Airport, Estonia.
At 12:03 hours local time the aircraft departed Tallinn as crew training flight MYX9001. Onboard were a captain-instructor as well as a second pilot, four students and a Civil Aviation Administration inspector.
Numerous circuits and touch-and-goes were performed, including two full stop landings.
During final approach to runway 08 at 17:04, the aircraft stopped responding to flight control inputs. Altitude was lost and the aircraft hit the runway. The engines touched the runway and the main landing gear doors broke.
The aircraft then managed to gain altitude and the pilots were able to stabilize the aircraft and turn back. Both engines, however, lost power after the turn back to the airport.
An emergency landing was carried out at 17:11, about 150 meters from the runway. The aircraft came to a halt in the snow 15 meters south of the runway.
The flight crew members evacuated the aircraft via the L1 door emergency escape slides.
A video of the incident shows what appears to be a tire rolling away from the aircraft as it came to a stop. Photos from the scene seem to show that one of the nose landing gear tires is missing. Photos also indicate that the ram air turbine (RAT) had been deployed.
Probable Cause:
Causal factors:
This accident results from the combination of the following factors:
- The intermittent THSA override mechanism malfunction allowing to cause the loss of pitch control by both ELACs.
The repetitive triggering of the ELAC PITCH faults was caused by the non or late activations of the PTA micro-switches, which were due to the OVM piston insufficient stroke. The insufficient OVM stroke was caused by the THSA OVM clutch unit non-standard friction. The oil in the THSA OVM casing appeared to be with a higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit, causing the THSA OVM nonstandard friction.
- SEC design flaw allowing for a single event, the left landing gear temporary dedecompression, to cause the loss of pitch control by both SECs.
The absence of ground spoilers arming for landing in the context of touch and go's training may have contributed to the temporary decompression of the left main landing gear.
- The training instructor`s decision for continuation of the flight despite repetitive ELAC PITCH FAULT ECAM caution messages.
The lack of clear framework of operational rules for training flights, especially concerning the application of the MEL, and the specific nature of operations that caused pressure to complete the training program may have impacted the crew decision-making process.
Contributory factors
- Smartlynx Estonia ATO TM does not clearly define the need for arming spoilers when performing touch-and-go training (ATO procedures not in accordance with Airbus SOP). The fact that there is no clear reference in the Smartlynx Estonia ATO TM Touch-And-Go air exercise section to additional procedures that should be used, in combination with lack of understanding of the importance for arming the spoilers during this type of flights contributed to TRI making a decision to disarm the spoilers during touch and go training enabling landing gear bounce on touch down.
- At the time of the event Airbus QRH did not define the maximum allowed number of resets for the flight control computers.
- At the time of the event Airbus FCTM did not require to consider MEL on touch-and-go and stop-and-go training.
- The oil in the THS OVM casing was with higher viscosity than defined in the CMM. The higher viscosity might have reduced the friction of the OVM clutch unit.
- The aircraft maintenance documentation does not require any test of the OVM during aircraft regular maintenance checks.
- Smartlynx Estonia ATO OM does not clearly specify the role in the cockpit for the Safety Pilot. The lack of task sharing during the event caused the ECAM warnings to be left unnoticed and
unannounced for a long period.
- The crew not resetting the ELAC 1. The fact that ELAC 1 PITCH FAULT was left unreset lead to the degradation of the redundancy of the system.
Considering the remoteness of the loss control of both elevators, there is no specific crew training for MECHANICAL BACKUP in pitch during approach, landing and take-off. This condition of the aircraft occurred for the crew in a sudden manner on rotation and during training flight, where the experienced TRI is not in PF role and cannot get immediate feedback of the aircraft behaviour and condition. Despite these difficult conditions the crew managed to stabilize and land the aircraft with no major damage to the persons on board. The crew performance factors that contributed to the safe landing of the aircraft are the following:
- The TRI followed the golden rule of airmanship (fly, navigate, communicate), by stabilizing the aircraft pitch by using the trim wheel and by keeping the aircraft engine power as long as possible;
- The Safety Pilot started to play a role in the cockpit by assisting the TRI and student by informing them about the status of the aircraft and later on taking the role of the PM.
Accident investigation:
 |
|
Bronnen:
» lentoposti.fi» delfi.lv
» Plane to make emergency landing in Tallinn landed with stopped engines (news.err.ee, 14 March 2018)
METAR Weather report:
14:20 UTC / 16:20 local time:EETN 281420Z 07011KT 3700 SHSN DRSN SCT009 SCT013CB M12/M15 Q1043 R08/810295 NOSIG
14:50 UTC / 16:50 local time:
EETN 281450Z 07013KT 9000 -SHSN DRSN FEW008 BKN013 FEW015CB M13/M15 Q1043 R08/810295 NOSIG
15:20 UTC / 17:20 local time:
EETN 281520Z 07012KT 9999 -SHSN DRSN FEW008 BKN013 FEW015CB M13/M15 Q1043 R08/490195 NOSIG
15:50 UTC / 17:50 local time:
EETN 281550Z 09011KT 9999 -SN DRSN OVC013 M13/M15 Q1042 R08/490195 NOSIG
16:20 UTC / 18:20 local time:
EETN 281620Z 09010KT 9999 -SN OVC014 M14/M16 Q1042 R08/490195 NOSIG
Foto's
Video, social media
Noseanas laika lidmainai ir noluzusi dala no asijas, zino Igaunijas mediji. Tallinas lidosta bus slegta lidz plkst. 22.00, liecina lidostas pazinojums. pic.twitter.com/wstLAFB2vp
LTV Zinu dienests (@ltvzinas) 28 februari 2018
Kaart
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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