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Airbus Safety First Magazine 01 PDF
Airbus Safety First Magazine 01 PDF
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# 01 January 2005
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© Airbus S.A.S. 2005 – All rights reserved. Confidential and proprietary documents.
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sharing. We will de-identify the information
Contacts/Organisation
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..................... 26 Editors:
By taking delivery of this Brochure (hereafter “Brochure”), you accept on behalf of your
if requested. 90°
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Christopher Courtenay, the right to read it, for the sole purpose of information.
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this first issue but we rely on your feedback Director of Flight Safety
This Brochure and its content shall not be modified and its illustrations and photos shall
to tell us what you think and what you Concept Design by HCSM not be reproduced without prior written consent of Airbus.
would like to see included. Production by CITYCompo
This Brochure and the materials it contains shall not, in whole or in part, be sold,
Copyright: EI rented, or licensed to any third party subject to payment.
Yours sincerely,
Photos copyright Airbus This Brochure contains sensitive information that is correct at the time of going to press.
Photos by ExM: This information involves a number of factors that could change over time, effecting the
Hervé Berenger true public representation. Airbus assumes no obligation to update any information
Yannick MALINGE Philippe Masclet contained in this document or with respect to the information described herein.
Hervé Goussé
Vice President Flight Safety Airbus SAS shall assume no liability for any damage in connection with the use of this
Brochure and of the materials it contains, even if Airbus SAS has been advised of the
Printed in France
likelihood of such damages.
44 5
NEWS
Are you on
Go-Arounds at
the distribution list? Flight Safety Addis Ababa due VOR
If you are reading this you obviously have a copy Conference
of the magazine either in paper format or
electronically. We need to make sure that our Airbus’ annual flight safety conference was held in
Reception Problems
distribution list is up to date so please contact us Toulouse from 11th to 14th October 2004, bringing
to give us your details. Do not assume that you the aircraft manufacturer and its customers together By: Jean Daney
received it this once so you will get it next time! in a confidential forum that allows them to share Director of Flight Safety
If you are an Airbus customer then contact us experiences learned through in-service events. As reported by an Airbus Operator
giving your name, title, company, address, phone
and e-mail information and we will ensure that you Now in its eleventh year, the conference was also and reproduced with their permission
regularly receive a paper and/or electronic copy of an opportunity for Airbus to raise awareness of
the safety magazine. general issues relating to the safe operation of its
aircraft. This year’s conference is the largest to
The plan is to issue a magazine on a regular date with 135 representatives from 83 airlines. The following article was provided by the started fluctuating during the descent and
basis but for those who have e-mail contacts Alain Garcia, executive vice-president, Airbus
involved Airbus operator and has been eventually the indications disappeared. With no
some articles could be sent out in between the engineering, opened the three-day safety
reproduced with their agreement but has been adequate visual reference, a standard missed
full magazine issues. conference for operators of all aircraft types.
de-identified. At the end of the article there is approach was flown from a minimum altitude of
Contact: Mrs Nuria Soler As in previous years, a spirit of trust and openness information on the Airbus policy concerning the 8922’ amsl and the aircraft entered the hold over
nuria.soler@airbus.com prevailed throughout the conference, despite the use of GPS position for Terrain Awareness and the ADS. Once in the hold and after confirming
fax: +33 (0) 561934429 sensitive nature of some of the topics being Warning System (TAWS). This policy was issued with Bole ATC that the VOR/DME was serviceable
discussed. The open exchange of information by in an OIT/FOT (ref: SE 999.0015/04/VHR dated the crew carried out a navigation accuracy check
Let us know what you think and do you both airlines and Airbus has proved to be a 05 February 2004). that appeared normal and elected to carry out a
have inputs? significant contributor to safety enhancement. further approach. Once again, the VOR indication
fluctuated during the inbound leg and another
As already said this magazine is a tool to help Safety representatives from airlines who will be
The same crew and aircraft had been scheduled missed approach was flown from a minimum
share information. Therefore we rely on your operating the A380 when it enters service in 2006
to operate the flight from **** to Addis Ababa altitude of 8866’ amsl after which the aircraft
inputs. If you have ideas or desires for what is in also received a special briefing related to the aircraft.
Bole Airport (HAAB) with a single en-route stop diverted to Djibouti. A brief EGPWS “Terrain Ahead”
the magazine please tell us. If you have at****. warning occurred as the go-around was initiated.
The questionnaires returned from the participants
information that we can share between us then
were very positive with 100% of the returns
please contact us. We are ready to discuss The first sector was operated without incident After refuelling at Djibouti, the commander
believing the conference objectives were achieved.
directly with you.
There were comments on some points and these and, after disembarking passengers and refuelling, elected to use his discretion to extend the flying
Contact: Chris Courtenay are being reviewed for next year’s conference. continued to HAAB. On arrival overhead the Addis duty period and return to HAAB. On arrival at
One of the main concerns was the conference Ababa VOR/DME (ADS 112.90 MHz), the flight Bole, a daylight visual approach was flown to
christopher.courtenay@airbus.com
facilities. This point has been taken and as a result was cleared to carry out a standard VOR/DME runway 25L and a successful landing made. It
Phone: +33 (0) 562110284
the date and venue for the next conference are approach to runway 25L at Bole. Touchdown was noted during this approach that the VOR
Mobile: +33 (0) 671631903 confirmed: elevation at Bole was 7593’ amsl and the MDA bearing information was in error up to 30° and
for the procedure 8020’ amsl. There were no that any attempt to fly the procedural inbound
LISBON, Portugal
civilian radar facilities. QDM would have displaced the aircraft to the
17th to 20th October 2005
North of the required track.
There will be more news on the conference in the The VOR/DME indications had appeared normal
next issue of the magazine. up to the start of the procedure, but during the The commander filed an Air Safety Report (ASR)
outbound leg, ADS 092° radial, an unexpected as required by the company in the event of any
large correction left was required to acquire the go-around. Normal company procedures also
radial. After flying the ADS DME 13nm arc, a left required an inspection of flight data from the
turn was made to intercept the 249° inbound Quick Access Recorder (QAR) as part of the
QDM and descent from 11200’ amsl commenced follow up to any ASR and the company Flight
in accordance with the procedure. The VOR radial Safety Manager carried this out.
66 7
DVORDME facility in the area since this incident Bole Airport is located on the south western
took place. The incident was discussed with the Director of outskirts of the city of Addis Ababa, Ethiopia.
the Air Operations and Navigational Aids The airport reference co-ordinates shown on the
The incident aircraft has also been fitted with a Department (DONAD) and the Head of Safety EAG Aerad chart are: N08 58.7 E038 47.9
GPS engine in the EGPWS computer as an interim Investigations of the Ethiopian CAA. The former
measure, with a full GPS MMR upgrade scheduled stated that he was not aware of any other Addis Ababa is situated on the Ethiopian plateau
for early 2005. reports of problems with the ADS VOR but that at an elevation of 7600’ amsl and is surrounded
an investigation would be carried out in response by areas of high ground rising to approximately
to this particular report. On the following day a 11000’ amsl.
verbal report was received that an examination
88 9
11000
9000
derived using the data from the QAR. The pressure 8000
The airport is situated on a relatively flat plain at The involved aircraft is fitted with a Honeywell altitudes recorded have been corrected for a 7000
7600’ amsl. The level of the plain rises gradually Enhanced Ground Proximity Warning System QNH of 1027 HPa for Figure 1 and 1029 HPa for 6000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
to the east attaining an elevation of approximately (EGPWS) with software to standard 428. The Figures 2 & 3.
8500’amsl 15nm from the airport. There are EGPWS computer has been removed from the Figure 3
12000
significant high peaks around the airport as aircraft and an attempt made to download event 11000
follows: Figure 3 shows the profiles for the second
data from it. This was initially unsuccessful due 10000
approach at HAAB. Here, the notable points are
to a fault condition at the time of removal. The 9000
• 10535’ amsl 010°T / 8nm 8000 again the flat terrain between 15nm and 7.5nm
unit was returned to the OEM who achieved a
Bearings and distances are approximate 7000 and the high point at just over 5nm. The river valley
download in his workshop. During the subject 6000
• 9646’amsl 025°T / 11nm is still apparent at 9nm, but has split into two.
approaches and go-arounds the crew heard only 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Take-off was performed with the shift first The functional check required after performing
compensated by inputs on the pedals and then AMM tasks had partially been performed on the
by the autopilot yaw actuator once autopilot was F/O side only, and thus the anomaly was no
engaged. But the rudder moved sharply to the detected by mechanics. Crew missed the last
rudder trim position once the autopilot opportunity to detect it by not carefully performing
declutched and the aircraft experienced an the existing SOP F/CTL Check.
unexpected and sudden bank.
This event was presented during the 8th flight
Such an event is covered with criteria 3, rudder safety conference held in October 2001 (Item 15
at neutral with controls (what includes rudder entitled “A320 crossed roll controls”). It was also
trim) at neutral. There was no warning triggered covered with an OIT/FOT entitled “ATA 27 – In-
to the crew, but it could have been detected by flight turn back due to inverted aileron deflection
carefully performing the existing Standard after take-off”, Ref. AI/SE 999.0069/01/CL REV
Operating Procedures (SOP) F/CTL Check. 01 dated 15 June 2001.
Flight data analysis: Maintenance actions Operational aspect However, the aircraft was dispatched with the
thrust reverser unlocked and free to move under
GMT:14.16.30 A/C takes off TLA are set to analysis: analysis: aerodynamic forces.
TOGA position - EPR reach 1.4 A/THR engages
- The HCU deactivation was done properly Prior to engine start, the ECAM warning “ ENGX Less than 4 minutes after take-off, the engine
GMT: 14.17.30 A/P 1 is engaged Altitude is following the AMM procedure: REVERSE UNLOCKED” was annunciated. N°1 auto-idle was activated. It activates once
1,700 ft AGL, TLA are set to CLB • “A. Deactivation of the Thrust Reverser HCU” there is more than 10% opening of the reverser,
GMT: 14.18.30 SLAT/FLAP conf clean is procedure. and brings down the TRA to idle based on the
selected - The following AMM procedure steps were not initial TRA position. This reverser opening detection
performed , because it was not possible to do also triggered the Auto thrust disconnection. The
GMT: 14.20.22 ENG 1 thrust suddenly drops
so while the thrust reverser actuators were lock Auto re-stow which is also normally triggered
down
wired in the unlocked position: was not effective since there was no hydraulic
ALT is about 6500 ft AGL – CAS = 250kts •“B. Manually move the translating sleeves to power due to the proper de-activation of the
The a/c was in a left commanded turn. The roll the fully retracted position” HCU.
angle was decreasing from around 10° with a •“C. Lock the Left and the Right Translating
rate of 2°/sec. sleeves” As described in the Flight data analysis, there
EPR actual, EPR command and EPR target - Finally the last AMM procedure step was not was very little changes on aircraft flight
decrease from 1.24 to 1.0 in 10 seconds (auto- done. Figure 2 characteristics. Based on the flight parameters
idle logic activated due to a reverse deployment • “D. Put the locking actuators in the locked evolution it is assumed that the thrust reverser
beyond 10%) position” According to information received, maintenance deployed slowly due to the aerodynamic forces
A/THR disengages personnel cancelled the “ENGX REVERSE (there was no hydraulic power due to HCU
Concurrently, VRTG decreases to 0.99g. Roll UNLOCKED” message through the “EMER/CAN” de-activation).
rate which was about 2°/sec (aircraft was in left button.
turn) reduces to 0.4°/sec ; LATG increases to Lock pins Upon engine start, the “ENGX REVERSE The aircraft maintained control with no upset
0.05g. Rudder moves from 0 to -3DA (right missing UNLOCKED” warning was then displayed under throughout the event.
input) cancelled cautions, while the ECAM showed
GMT: 14.20.32 ENG 1 TLA increases “REV” Amber in EPR gauge and “STS” indication. The engine was shut-down, then the Auto thrust
When Engine 1 reaches Idle, crew moves TLA1 was re-engage, and an IFTB was made followed
up to 31DA, ENG1 intends to follow TLA1 position by an uneventful single engine landing.
(short thrust increase) but continues to decrease
down to Idle (auto-idle logic)
GMT: 14.20.45 ENG 1 TLA decreases Actuator unlocked
Crew elects to retard TLA1 to Idle and increases
TLA2 to 35DA (MCT)
GMT: 14.21.25 Aircraft levels off Altitude is Due to the combination of having:
8000ft ; CAS increases to 262kts (maximum
reached during this flight) - The HCU deactivated (leading to no hydraulic
power to the actuators) Figure 3
GMT: 14.21.59 ENG1 shut down Main ENG1 - And the actuators not locked
parameters start to toggle, NCD parameters Per FCOM Standard Operating Procedure
- And the lock-out bolts not properly installed on
“cockpit preparation”, the ECAM control
GMT: 14.22.27 Auto thrust is reactivated the translating sleeves,
panel STS page must be checked to ensure
GMT: 14.42.25 Crew performs a manual the translating sleeves were not locked and that INOP SYS display is compatible with
single engine landing were free to move under aerodynamic loads. MEL.
In this case for ENGX REVERSE
UNLOCKED, the MEL says “NO DISPATCH”.
Figure 4
20
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Maintenance Operational
recommendations: recommendations:
It is absolutely necessary to strictly follow all Furthermore, only the required tooling must be The “ENGX REVERSE UNLOCKED” and the
steps of the relevant AMM Thrust reverser used (appropriate locking pins,…) “REV” Amber messages should not be present
de-activation procedure. on ECAM following a proper thrust reverser
Finally, “ENG X REVERSE UNLOCKED” warning deactivation. They are both NO DISPATCH
should not be displayed following reverser warnings.
deactivation.
In addition, the “EMER/CANC” button should
only be utilized to kill a permanent spurious
HCU Unlocked HCU Locked warning.
Actuator
Actuator locked unlocked
Figure 7: Normal Flight Condition & Deactivated Flight Figure 8: Maintenance Condition Only
Condition
Locking
Pin Placeholder Locking Pin
Installed
Locking Pin
Stowage
Figure 9: Normal Flight Condition Figure 10: Deactivated Flight Condition
22 23
• Establishes a summary of operational key Line pilots should review and compare the • Takeoff and departure operations By developing the concept of Flight Operations
points and training key points; recommendations, guidelines and awareness (e.g.: Understanding takeoff speeds, Revisiting Briefing Notes and by facilitating their wide
• Refers to associated or related Flight information with their current practices and the stop or go decision, …), dissemination to all actors of the aviation
Operations Briefing Notes; and, enhance their techniques and awareness level, community, Airbus acknowledges that safety
as required. • En-route climb and cruise management awareness information is a key element in further
• References related ICAO, U.S. FAR and
(e.g.: Managing buffet margin, overspeed enhancing flight safety.
European JAR regulatory documents.
Other actors in the global aviation system, such prevention / recovery, …),
as:
How to Use and • Air traffic control services;
• Navigation state agencies;
• Descent management
(e.g.: Being prepared for go-around, …),
Implement the Flight • Operational authorities;
• Service providers; and, • Approach techniques
CONTACT
Operations Briefing • Flight academies / flying colleges; (e.g.: Flying stabilized approaches, …), DETAILS
Notes? …should use the provision of the Flight Operations • Landing techniques AIRBUS
Briefing Notes to evaluate their possible (e.g.: Preventing tail strike at landing, …),
The Briefing Notes should be used by airlines to
contribution to the enhancement of ground and Michel TREMAUD
enhance the awareness of various operational
flight safety. • Ground handling Senior Director Safety and Security
and human factors, threats and hazards among
(e.g.: Refueling with passenger on board, …), Customer Services
flight crews and cabin crews.
Tel: +33 (0)5 61 93 30 04
Management pilots should review, customize (as What’s coming up? • Cabin operations Fax: +33 (0)5 61 93 29 68
(e.g.: Managing smoke issues in cabin, michel.tremaud@airbus.com
required) and implement the recommendations, The release of the Briefing Notes will span over emergency evacuation, …).
guidelines and awareness information, in the the years 2004-2006 and will cover the following
following domains: domains: Christophe LEMOZIT
The Flight Operations Briefing Notes are Manager Flight Operations Safety
progressively released on the Safety Library Enhancement
• Operational documentation: • Standard operating procedures room of the Airbus Safety First website: Customer Services, Flight Operations
- Standard operating procedures; and, (e.g.: Conducting effective briefings, …), http://www.airbus.com/about/safetylibrary.asp
- Procedures and techniques / supplementary Support & Line Assistance
They should be also disseminated to customers Tel.: +33 (0)5 62 11 82 90
techniques. • Human Performance once a year on CD-ROM and paper format.
(e.g.: Enhancing situational awareness, error Fax: +33 (0)5 61 93 29 68
• Training: management, …), christophe.lemozit@airbus.com
- Simulator Training, to develop new scenarios
for line oriented flight training (LOFT) or • Operating environment
Conclusion
special purpose operational training (SPOT); (e.g.: Bird strike threat awareness, …), Flight safety enhancement has been and
and/or, will continue to be the result of technological
- Crew resource management (CRM) training, • Adverse weather operations developments.
to develop new topical subjects to support (e.g.: Wind shear awareness, …),
CRM discussions. However, 85 % of accidents today are operational
• Runway and surface operations events that involve human performance at every
• Safety-awareness Information: (e.g.: Preventing runway incursions, …), stage of the safety chain.
- Flight crew bulletins;
- Airline’s safety magazine articles; • Supplementary techniques
- Classroom lectures; and/or, (e.g.: Preventing altitude deviations, …),
- Stand-alone reading.
26 27
360°
Andre MAUMUS Thierry THOREAU Michel PALOMEQUE
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Director of Flight Safety Director of Flight Safety Flight Safety Advisor
Head of Safety Strategy Developmt Head of International Cooperation To Single Aisle Chief Engineer
Phone + 33 (0)5 61 93 71 57 Phone + 33 (0)5 61 93 49 54 Phone + 33 (0)5 62 11 02 85
Fax + 33(0)5 61 93 98 21 Fax + 33(0)5 61 93 44 29 Fax + 33(0)5 61 93 44 29
E.Mail - andre.maumus@airbus.com E.Mail - thierry.thoreau@airbus.com E.Mail - michel.palomeque@airbus.com
Mobile +33(0)6 09 37 79 69 Mobile +33(0)6 88 06 47 91 Mobile +33(0)6 23 08 06 38 60
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