ASN Wikibase Occurrence # 218814
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| Date: | Tuesday 6 November 2018 |
| Time: | 06:35 LT |
| Type: |  Airbus A340-642 |
| Owner/operator: | South African Airways - SAA |
| Registration: | ZS-SNF |
| MSN: | 547 |
| Year of manufacture: | 2003 |
| Engine model: | Rolls-Royce Trent 556-61 |
| Fatalities: | Fatalities: 0 / Occupants: 259 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | over Clariden -
 Switzerland
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Johannesburg-O.R. Tambo International Airport (JNB/FAOR) |
| Frankfurt International Airport (FRA/EDDF) | |
| Investigating agency: | BFU |
| Confidence Rating: |  Accident investigation report completed and information captured |
South African Airways flight SA260 was in cruise flight at flight level (FL) 380 in Swiss airspace when a change in the wind caused it to exceed its maximum operating power.
The autopilot was switched off and the aircraft was steered manually into climb. While reaching FL 400, the maximum angle of attack was reached several times and the stall warning activated. The PIC initiated the descent stabilizing the flight path again at FL 340.
The investigation determined:
• A rapidly turning wind direction during cruise flight, unpredictable for the flight crew. This caused an overspeed condition.
• The flight crew did not respond to this overspeed condition with the procedure Abnormal and Emergency Procedures / Misc / Overspeed Recovery.
• The PIC had deactivated the autopilot and in the course of the incorrect application of the OEB No. 49, he had two Air Data Reference (ADR) of the three Air Data Inertial Reference Units (ADIRU) switched off. Subsequently, the Autothrust (A/THR) was deactivated and flight idle thrust initially maintained.
• Temporarily, the aircraft was controlled in Alternate Law.
• Due to the dynamic pitch-up control inputs of the PIC, the subsequent climb and the low engine thrust in flight idle, rapid deceleration of airspeed and triggering of the stall warning occurred.
• Due to the erroneous application of the OEB No. 49, the aircraft was close to a stall at high altitude.
• The PIC’s control inputs during the active stall warning were insufficient and not energetic enough to stabilise the flight attitude in time.
• Crew cooperation during the overspeed condition and the stall recovery was erroneous in regard to the analysis of the situation and the implementation of procedures
Accident investigation:
 |
|
Sources:
https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-de-lairbus-a340-immatricule-zs-snf-et-exploite-par-saa-survenu-le-06112018-en-croi/
BF
Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 30-Nov-2018 17:12 | harro | Added |
| 14-Mar-2019 11:49 | harro | Updated [Time, Source, Narrative] |
| 16-Jul-2023 09:16 | harro | Updated [[Time, Source, Narrative]] |
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