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ASN Wikibase Occurrence # 147069
Last updated: 17 July 2019
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Date:24-SEP-1994
Time:12:45
Type:Silhouette image of generic A310 model; specific model in this crash may look slightly different
Airbus A310-325
Owner/operator:Tarom
Registration: YR-LCA
C/n / msn: 636
Fatalities:Fatalities: 0 / Occupants: 186
Other fatalities:0
Aircraft damage: None
Category:Accident
Location:Paris-Orly Airport (ORY) -   France
Phase: Landing
Nature:International Scheduled Passenger
Departure airport:Bucharest-Baneasa Airport (BBU)
Destination airport:Paris-Orly Airport (ORY)
Investigating agency: BEA
Narrative:
Tarom flight 381 was making an 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:

Scramble 185 ; Flight International 5-11.10-94(4) + Flight International 23-29.11.94(6); Aviation Week & Space Technology 03.10.94(37) ; Air Safety Week03.10.94(6) + 17.10.94(6) + 24.10.94(3); 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)

Accident investigation:
cover
  
Investigating agency: BEA
Status: Investigation completed
Duration:
Download report: Final report


Images:

Photo of YR-LCA courtesy AirHistory.net


Amsterdam - Schiphol (EHAM / AMS)
14 August 2015; (c) Gerard Helmer

Revision history:

Date/timeContributorUpdates
26-Jul-2012 07:20 harro Added
27-Mar-2015 19:04 Anon. Updated [Narrative]
28-Mar-2015 08:38 Anon. Updated [Narrative]
13-Mar-2016 17:52 hexatus Updated [Embed code]

Corrections or additions? ... Edit this accident description