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Safety First

The Airbus Safety Magazine

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# 01 January 2005
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EDITORIAL # 01 January 2005

CONTENT SAFETY FIRST


The Airbus Safety Magazine
Yannick MALINGE For the enhancement of safe flight through
Vice President Editorial increased knowledge and communications.
Flight Safety Y. Malinge .............................................. 2
Safety First is published by the Flight Safety Department The contents do not supersede any requirements
News of Airbus. It is a source of specialist safety information mandated by the State of Registry of the Operator’s aircraft
Dear Customers and Aviation Safety C. Courtenay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 for the restricted use of flight and ground crew members or supersede or amend any Airbus type-specific AFM,
Colleagues, who fly and maintain Airbus aircraft. It is also distributed AMM, FCOM, MEL documentation or any other approved
to other selected organisations. documentation.
Flight Safety has permanently improved Go-Arounds in Addis Ababa
Material for publication is obtained from multiple Articles may be reprinted without permission, except
from one aircraft generation to another and due to VOR Reception Problems
sources and includes selected information from the where copyright source is indicated, but with acknowl-
this trend continues. J. Daney ................................................. 5 Airbus Flight Safety Confidential Reporting System, edgement to Airbus. Where Airbus is not the author, the
There are several factors that have led to incident and accident investigation reports, system contents of the article do not necessarily reflect the
these positive results, one of them being tests and flight tests. Material is also obtained from views of Airbus, neither do they indicate Company policy.
the flow of information between the key The Importance of the pre-Flight, sources within the airline industry, studies and reports
actors of the aviation community. Even Flight Control Check from government agencies and other aviation sources. Contributions, comment and feedback are welcome.
though it is extremely difficult to quantify A. Urdiroz ............................................... 11 For technical reasons the editors may be required to
the benefit of information sharing, no one All articles in Safety First are presented for information make editorial changes to manuscripts, however every
can dispute the positive effect it has. only and are not intended to replace ICAO effort will be made to preserve the intended meaning of
A320 In-flight thrust guidelines, standards or recommended practices, the original. Enquiries related to this publication should
To further develop this information sharing, reverser deployment operator-mandated requirements or technical orders. be addressed to:
we re-launch our safety magazine. This is T. Thoreau .............................................. 17
Airbus
the objective of this first issue of the Airbus
Flight Safety Department (EI)
Safety Magazine called “Safety First” 1, rond point Maurice Bellonte
(which replaces the previously named Airbus Flight Safety
31707 Blagnac Cedex - France
“Hangar Flying” magazine). Manager Handbook E.mail: nuria.soler@airbus.com
It is intended to issue this on a regular basis C. Courtenay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Fax: +33 (0)5 61 93 44 29
as a hard copy and we also intend to send
it electronically. Flight Operations Briefing Notes Safety First
1 Safety First
The Airbus Safety Magazine
Airbus Flight Safety # 01 January 2005
This is not just a forum for Airbus to pass C. Lemozit & M. Tremaud .................... 23 Manager's Handbook
By: Christopher Courtenay
Director of Flight Safety Safety First is published
information to you. We want your participation. by Airbus S.A.S
Send us articles that you think are worth Airbus Flight Safety
1, rond point Maurice Bellonte

360°
© Airbus S.A.S. 2005 – All rights reserved. Confidential and proprietary documents.

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330
30°
31707 Blagnac Cedex / France
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°

company to comply with the following guidelines:


# 01 January 2005 Yannick Malinge,
 No other intellectual property rights are granted by the delivery of this Brochure than
120

Vice President Flight Safety


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I hope you will find useful information in

210
150
Christopher Courtenay, the right to read it, for the sole purpose of information.

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180°
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

The analysis revealed that at some point on both


approaches the aircraft had passed over a ridge Navigational of the VOR transmitter had revealed a 2°error in
the radiation pattern and that an alternative
The airport has been undergoing significant
development in recent years and has recently
of high ground not normally encountered on the
25L approach. At the point at which the second
Considerations transmitter was in service. Calibration of the
alternative transmitter appeared to have been by
seen the construction of a new terminal building
and the new 07R/25L runway. The new runway
go-around had been initiated the aircraft had All Airbus A320 aircraft are fitted with triple Inertial pilot report from GPS equipped inbound aircraft lays parallel to and approximately 400m south of
passed over the ridge with a clearance of 55’ as Reference Systems (IRS). The navigation function and it was stated that the pattern was correct. the original 07L/25R. The ADS VOR was moved
shown by the radio altimeter recording. At no is performed by the dual Flight Management & to its current location south of the two runways
time were the crew aware of this close proximity Guidance Computers using the outputs from the At a subsequent meeting with the Flight Safety during the development.
to the ground. IRS and refining the combined IRS position with Officer of Ethiopian Airways it was stated that
radio navigation aid or GPS satellite information. there had been concerns from Ethiopian Airways In current operations 07R/25L is used as the
A full company investigation into the circumstances The involved aircraft is not fitted with GPS satellite pilots that the inbound leg of the 25L VOR/DME main runway with the old runway designated as
of the incident continued independently of the navigation equipment and the position refinement procedure was “taking aircraft too far north of taxiway “Foxtrot”. However, 07L/25R is still used
official investigations initiated by the state authorities is taken from ground radio navigation aids only, the ideal track”. It was not clear whether these as an active runway by local traffic.
concerned and with the assistance of the Airbus typically DME/DME, VOR/DME or VOR/VOR concerns had been relayed to the Ethiopian
Flight Safety Department. Following the outcome crosscuts depending on local availability. CAA, although it was stated that Ethiopian The only instrument approach procedures
of the company investigation, the company has Airlines was putting pressure on the CAA too currently available to the operator at the time
put in place measures to minimise the risk of In the area of Addis Ababa the only suitable radio install an ILS for this runway prior to the rainy were the VOR/DME procedures for 25L and
similar incidents which include: navigation aid was the “ADS” VOR/DME located season that starts around July/August. 25R. Landings on runway 07R are achieved by
• HAAB to be treated as a Category ‘C’ airport, between the two runways at Bole Airport at carrying out the 25L VOR/DME procedure and
position N08 58.7 E038 47.9. It follows, therefore, The following day, the company Flight Safety breaking left for a visual circling approach to 07R.
• Operations to HAAB to be conducted by GPS
that any error in the transmitted data from this Manager was subsequently contacted by Bole The Ethiopian CAA has promulgated a GPS/RNAV
equipped aircraft only,
VOR would result in a corresponding error in the ATC and advised that the ADS VOR had been procedure for runway 07R and will shortly
• Approach to be discontinued if VOR indications computed FMGC position. Such errors could taken out of service following a fault caused by the promulgate one for 25L. The involved operator
differ from GPS derived FMGS indications by result from faulty operation of the VOR/DME heavy rain that had occurred during that evening. does not currently hold an approval for GPS/RNAV
more than 5°, facility, radio frequency interference with the The company flight for that day had already approaches. Full ILS procedures for both 25L
• The MDA for the 25L VOR/DME procedure transmitted data or anomalous radiation caused departed and was diverted to Khartoum. A further and 25R are now promulgated.
raised to 9380’ amsl (1790’ aal) in association by local terrain (sometimes referred to as call from Bole ATC confirmed that the VOR was
with a minimum visibility of 5KM, “scalloping”). back in service and fully serviceable. The diverted In addition to the ADS VOR, there were two MF
• Approach to be discontinued if no visual contact flight arrived at HAAB with no reported problems. locator beacons, ‘AB’ 333 KHz and ‘BL’ 352
with the runway approach lights at ADS DME The possibility of faulty airborne equipment had KHz, situated on the original ILS approach path
5nm (FAF). (ie MAP is ADS 5DME) to be considered but this is unlikely as similar to 25R. There were no ILS procedures
anomalous VOR indication behaviour was Addis Ababa Bole promulgated for the airport at the time, although
Note: The last two restrictions have since been observed during a subsequent approach by the original 25R ILS localiser was believed to be
relaxed as confidence in the “ADS VORDME was another A320 fitted with a GPS. This latter International Airport still radiating on 110.3 MHz. New aids have now
regained. The airport authorities have also
installed an ILS on this runway and a new
occurrence was witnessed by the Flight Safety
Manager.
(HAAB) been installed as stated above.

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

Terrain Terrain Profiles 12000

11000

Considerations The following approach and terrain profiles were 10000

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

from VOR/DME position The terrain clearance at the point of go-around is


one EGPWS alert, a “Too Low Terrain” call just Figure 1
• 10167’ amsl 120°T / 11.5nm 55’.
after initiation of the second go-around believed
• 9200’ amsl 230°T / 9nm to have been triggered by the Terrain Clearance Figure 1 shows the profiles for the approach
Floor mode. The QAR recorded a short duration carried out on the return from Djibouti which was
There is a significant ridge running approximately Mode 4 ”Too Low Terrain” warning at about the carried out visually. The terrain profile is typical Aircraft Position
135°T from the first of the above peaks and same time. for a correct approach path with the characteristic
The only position information available from the
running out into the plain at about 6nm from the gentle slope of the plain from west to east. Other
QAR was the recorded FMGC latitude and
VOR. This ridge is the one referred to in later characteristic features are the river valley at 6.5D
longitude. Since the FMGC position was IRS
sections of this report. A further ridge runs and the double depression on the final approach
position corrected by radio position and the only
approximately 215°T from the same peak to the threshold.
radio position was based on the suspect
towards the eastern outskirts of the city. This VOR/DME facility, no reliance can be placed on
runs out into the plain approximately 3.5nm The distance scale on this figure can be directly
the accuracy of the recorded position information.
north of the airport. related to DME distance from the “ADS”. In
Figures 2 & 3, the 13nm marker can be taken as
One point of interest was the behaviour of the
Terrain information is provided for the crew by 13D from the “ADS”, but other distances do not
recorded FMGC position immediately after each
the following: relate to DME as the aircraft was not flying
go-around. The standard missed approach
towards the DME facility. The distances have
procedure for the 25L VOR/DME approach
• EAG Aerad charts N1/N2 been corrected to take account of the varying
This photograph shows the NW to SE ridge running down towards states “Left (max 185kt) as soon as practicable
these show “safety contours” and Sector Safe groundspeed during each approach.
the approach path. It was taken from near the village of onto ADS 193R to 13500 5910 then right to ADS
Altitudes for the four prime sectors within 25nm Leghedadi 10nm NW of the airport looking WSW from a range of 12000
and hold or as directed”. (EAG Aerad Chart N1
approximately 5nm. 11000
of the aerodrome reference point. At Addis, the dated 20 FEB 03). On both go-arounds the
10000
SSA for all sectors is shown as 13500’. No 9000 recorded heading information suggests that
detailed terrain information is shown. 8000 the aircraft followed this procedure. The FMGC
7000
position data, however, indicates a right turn
6000
• EAG Aerad Terrain Chart 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 immediately after each go-around followed later
A large scale chart showing the main features in by an abrupt left turn onto a southerly track.
Figure 2
a large area around Addis. No fine detail of The crew report stated that during each
terrain around the airport is shown. Figure 2 shows the profiles for the first approach approach the VOR indications were lost just prior
at HAAB. Notable points are the non-sloping to the go-around, but came back as the
• Military ONC Chart nature of the terrain between 15nm and 6nm and go-around proceeded. During the approach
A 1:1000000 scale chart of the region the high point at just over 5nm. There is also a made by the GPS fitted aircraft the following
This picture shows the same ridge from a range of about 8nm
from the NW of Leghedadi.
marked valley at 9nm and a lesser one at 6.5nm. behaviour was observed:
10
10 11

The importance of the


• During the outbound leg of the procedure, the Initially, as the procedure is commenced, the
pre-flight, flight controls
VOR bearing information correlated with the FMGC track and still track appear to be following
GPS derived FMGC data on the Navigation
Display (ND).
the procedural 094°T track. The FMGC track
then starts to deviate to the south and the
check
• As the aircraft turned left to intercept the aircraft is turned left to correct taking the still air
249°M track inbound to the VOR, the beam track to the north of the required track. This By: Albert Urdiroz
Flight Safety Manager
bar initially moved in as expected to near correction brings the FMGC position slowly back
centre. to the required track, but the still air track is
• As the wings were levelled on a heading that moving well north.
should have followed the correct track, the
beam bar moved back out to the right and
settled at about half to two thirds full scale
deflection. Airbus Policy
• The crew flew by visual reference to the runway
This Airbus policy is concerning the use of GPS
1 Introduction On any Airbus aircraft, the F/CTL check involves
the elevators, ailerons, spoilers and rudder
using the GPS derived navigation data to
position for TAWS operations. Note that the As far as aeronautics systems are concerned, control systems. Not only the components
follow the correct inbound track and the VOR
TAWS is also known as EGPWS (Enhanced the pre-flight flight controls (F/CTL) check has activated with the control wheel, control column
indication remained steady at the deflection
Ground Proximity Warning System) or T2CAS existed since before the first powered flight. It and pedals, but the whole system. Let us refer to
stated above.
(Traffic and Terrain Collision Avoidance System). aims at ensuring that flight controls respond figure 1 and take the rudder axis of an A310 as
• At about 3.5D, the beam bar quickly moved
to the pilot inputs, i.e. with no jamming, or an example in order to illustrate this comment.
back to the central position.
The TAWS computer has an internally loaded movement limitation, or stiffness, or delayed or
Consider now each of the 4 items we have
terrain database and uses position information inadequate response. It is thus a key factor in the
mentioned and review which systems are involved.
from the FMS. The FMS uses ADIRU position safe operation of the aircraft.
1- In direction;
and radio position update. It can also use a GPS The pre-flight F/CTL check has been made on a
2- In amount of travel;
position source when available. flight basis by pilots since they flew an airplane
3- In return to neutral;
The use of the GPS with multimode receivers for the very first time.
4- In feeling.
(MMR) provides improved navigation and Being so familiar with it, one may fall in the trap
surveillance functions. Therefore Airbus strongly of routine and neglect the importance of it. One
The majority of the components represented in
recommends the use of a GPS source in the may also believe that the aircraft’s self-monitoring
figure 1 are involved:
global architecture of the TAWS system. capabilities are sufficient to provide the adequate
- Obviously rudder pedals, mechanical linkage
information, but they are not. Improper maintenance
and servocontrols;
Airbus offers an upgrade package that includes or components failure are to be considered also.
- Any inopportune rudder trim that would shift
installation of 2 multimode receivers (MMR) and Here we review the scope of the pre-flight F/CTL
the rudder from neutral would be detected with
Green line = FMGC Position Plot from QAR 2 GPS antennas. check, and demonstrate based on in-service
criteria 3;
Red Line = Derived Still Air Plot Using Heading However some aircraft configurations may need examples, how topical it still is.
and Ground Speed from QAR - Artificial Feel Mechanism with criteria 4;
upgrade of other aircraft equipment to make full
Blue Pecked Line = 25L VOR/DME Procedure Outbound Track 094°T - Detection of any offset from Yaw Damper
benefit of the MMR system. The Airbus upgrade
Magenta Pecked Line= 25L VOR/DME Procedure Inbound Track 251°T
services will define everything needed during the 2 Scope of the system with criteria 3;
- Rudder Travel Limiting Systems with criteria 2.
Figure 4 RFC/RFO process.
F/CTL check We may come to similar conclusions on other
The two approaches flown during the incident For more information see OIT/FOT ref SE
flight were both conducted in IMC with only one An efficient F/CTL check ensures that the axis, and/or other aircraft types. Note on fly-by-wire
999.0015/04/VHR, dated 05 Feb 2004
glimpse of ground lights during the first systems respond adequately: systems, it would be electrical wiring instead of
approach. 1- In direction – for instance elevator moves mechanical linkage.
down when the control column or the
Figure 4 on shows the track for the second sidestick is pushed; The F/CTL check is thus not limited to the
approach. 2- In amount of travel, up to full deflection; relationship in between the servocontrols, observed
3- In return to neutral; with the surface position indicators, and the
4- In feeling. controls at cockpit. The whole system is checked.
12
12 13

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.

3.2 Response in opposite direction 3.3 Lack of response


We will here discuss an in-flight turn back due to Another example is an in-flight turn back due to
Inverted Roll Command experienced with an A320. reduced ability to turn left experienced just after
taking off with an A320. Almost full left sidestick
The F/CTL check was performed with no inputs were required in order to laterally control
anomalies noticed by the crew. At take-off, the the aircraft. At 1500ft, ECAM warning “F/CTL
Captain applied a lateral sidestick input to the SPLR FAULT” came up with all right hand roll
right, but the aircraft banked to the left. The F/O spoilers shown inoperative.
Figure 1 : A330 moder system schematic took over, and successfully landed the aircraft.
Rudder trim actuator (RTA) had to be at neutral During a previous maintenance task, R/H spoilers 2
3 Take-off after also. Indication was erroneous. Upon troubleshooting, a maintenance error was to 5 were left in the maintenance position. After
found. A wiring inversion had been made lift-off, they deployed to the zero hinge moment
F/CTL check failed Rudder trim indication was manually brought between the transducer unit of Captain roll positions and would not respond to inputs.
back to neutral with no further check. This shifted sidestick and ELAC 1, on both the COMMAND &
We will here go through some examples gathered the rudder, the rudder trim actuator and the pedals MONITOR channel. With this double inversion, Preventive instructions have been added in
from in-service experience, when crew did not out of neutral. ELAC 1 was receiving consistent signals, and AMM, and monitoring has been improved to trigger
strictly adhere to the golden rules of F/CTL thus could not detect the anomaly and could not an ECAM warning in such condition. But it could
check. RTI RTA trigger a warning to the crew (Figure 3). also have been detected by carefully performing
R 10.0 deg 0 deg the existing SOP F/CTL Check (Figure 4).
At end of flight ELAC 2
3.1 Surfaces not at neutral with controls controls check
COM
not at neutral
MON
Let’s come back on an event that was evoked in RTA, pedals and rudder at neutral
issue 7 dated October 2001 of Hangar flying under
title “A310/A300-600 – Rudder trim incorrect ELAC 1
CPT F/O
RTI RTA COM
indication – ATA 27”, and also commented in 00.0 deg L 10 deg MON
OIT/FOT Ref. AI/SE 999.0030/00/CL dated 14
February 2000. At take-off
Figure 3: Cross connection of sidestick roll signals to F/CTL
At the end of the F/CTL check, rudder trim computer
indicator (RTI) was showing some rudder trim RTA, pedals and rudder shifted No deflection of RH
input. However rudder and rudder pedals were roll spoilers
at neutral. Pedals and rudder trim are linked. Figure 2 : incorrect rudder trim indication

Figure 4: Lack of response from RH spoilers to sidestick inputs


14
14 15

4 Efficiency of the 5 Completion of the


F/CTL check F/CTL check
Some events, including recent ones, have 17 December 2003 entitled “ATA 27– elevator All of the above-mentioned events have calls out the results of his/her visual check of
highlighted the importance of the F/CTL check. dropped down – Cracked mode selector valve confirmed that the crew properly performing each of the PF’s sidestick/rudder pedal stops
Indeed anomalies were detected which required transducer at servocontol in damping position”; Flight Control Checks remains the last safety net. inputs. This allows the PNF to still closely
correction before flight, when aircraft systems - OIT Ref. SE 999.0066/04/BB Rev. 01 dated 11 However, training feedback and line observations monitors the correct sense, full deflection and
did not trigger any failure warning to the crew. June 2004 and FOT Ref. STL 999.0061/04 have revealed that the F/CTL checks were not return to neutral of all surfaces as previously
Here after are some of them. dated 10 June 04 entitled “ATA 27 – Right elevator always performed properly because: recommended, and in addition:
stuck down in full pitch down position caused - Checks were routinely performed; - Avoids the PNF from being influenced by the
4.1 Lack of response by double failure. - The PF moved the sidestick too quickly and PF callouts
A few events of this kind have been experienced the PNF had insufficient time to efficiently - Ensures that the PNF efficiently checks all
with aircraft of the A340 family. The crew detected 4.2 Limited deflection perform the checks; surface motions
during the pre-flight F/CTL check that one elevator One last example is an event of undue rudder - The PNF may be out of the monitoring loop. - Obliges the PF to pause the sidestick/rudder
was stuck down (Figure 5). The loss of the travel limitation on ground. pedals at each stop
elevator control was not indicated to the crew by SOP F/CTL checks have been reviewed with a - Allows the PF to detect a failure, if callout is
any warning. The Rudder Travel Limitation Unit (RTLU) had reinforcement of the role of the PNF who now not in line with the PF’s input.
failed closed in the high-speed configuration.
The ECAM warning “F/CTL TRAVEL LIM FAULT”
dedicated to the monitoring of the RTLU position
was not displayed.

Indeed, at that time, FCSC which is the computer


that controls the RTLU and PTLU did not monitor
their behaviour during phases when they are not
electrically supplied and thus not supposed to
move. However the RTL system failed and RTLU
closed during such a phase of no monitoring on
ground. Monitoring has since been reviewed.

NORMAL CONFIGURATION EVENT CONFIGURATION


Figure 5

These events resulted from failure of the servo-


control in damping mode failed. Investigating
these events has allowed definition of
modifications to both the servocontrols and the
F/CTL computers in order to prevent similar
events. Appropriate ECAM warnings are
triggered for crew annunciation. For these Low speed position High-speed position
events, detection was ensured by carefully
Figure 6: Full rudder deflection not archieved
performing the existing SOP F/CTL Check only.
Additional information about these event is The failure was thus detected only by performing
available with the existing SOP F/CTL Check, and the right
- OIT/ FOT Ref. SE 999.0149/03 dated decision to return to the gate could be taken.
Figure 7: Extract of A330 SOP – FCOM 3.03.10 Rev. 19
16
16 17

A320 In-flight thrust


6 Conclusion
reverser deployment
In comparison with conventional aircraft, "Fly by
wire" architecture provides an additional flight By: Thierry Thoreau
controls systems monitoring in order to ensure Director of Flight Safety
flight controls availability and safe aircraft operation.

Airbus' priority is to continuously meet these


objectives, if possible, via monitoring enhancements.
However, EFCS monitoring features cannot
possibly detect all failure cases.

A comprehensive flight controls integrity check


relies on the crew's accurate completion of pre- The in-flight thrust reverser deployment is one of - Crew then made a safe precautionary landing
flight control checks. the most feared situation by all pilots. It has back to departing airport.
always been under the extensive scrutiny of both
The new SOP procedure increases the efficiency the engines and airframe manufacturers as well
of the F/CTL checks, in association with the as by the Airworthiness Authorities. This particular Findings:
F/CTL monitoring systems: The PF and PNF are attention was even reinforced after the tragic
accident which occurred on Lauda Air B767 - Upon landing, the engine N° 1 reverser was
definitively in the monitoring loop.
flight NG004 in May 1991. This has lead to the found almost fully deployed.
The key message Airbus implementation of additional modifications to
would like to convey is: further decrease the probability of occurrence of
TAKE YOUR TIME such event.
PROPER F/CTL CHECKS = SAFER FLIGHT
Despite all protective measures in place, the
Note: The F/CTL checks have been discussed event described hereafter occurred in March
during the 11th Flight Safety Conference held in 2004 on an A320 aircraft equipped with IAE
Toulouse in September 2004. CD's of this V2500-A1 engines.
conference may be requested to the Nuria Soler,
nuria.soler@airbus.com.
Sequence of events:
- While the aircraft was on a transit check for a
scheduled flight, airline’s maintenance found an Figure 1
hydraulic leak from the engine N° 1 inboard
lower thrust reverser actuator. - The thrust reverser sleeve locking pins (2) were
not found, while the lock-out assembly was
- Airline’s maintenance deactivated the reverser intact.
for an aircraft dispatch under M.E.L. - After opening the fan cowls, both locking
actuators were found lock wired in the unlock
- In climb phase, approximately 15 nm from the position. The HCU was properly deactivated.
departing airport, engine N° 1 reverser got
deployed.

- As per check-list, engine N° 1 was shutdown


by the crew
18
18 19

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
20 21

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.

Figure 5: Normal Flight Condition Figure 6: Deactivated Flight Condition

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

Airbus Flight Safety Flight operations


Manager's Handbook briefing notes
A Tool For Flight Operations Safety Enhancement
By: Christopher Courtenay
Director of Flight Safety
By: Christophe LEMOZIT
Manager Flight Operations Safety Enhancement, Customer Services
and: Michel TREMAUD
Senior Director Safety and Security, Customer Services

On many occasions, the Flight Safety Dept in


Airbus were receiving request from newly Flight Safety and the positive feedback received from
customers have prompted Airbus to initiate the
established and charter airlines for assistance in
setting up a Flight Safety function. Enhancement – development of new sets of Briefing Notes, in
order to cover the entire flight profile and address

At that time, Airbus being a manufacturer rather


In Need of the main threats and hazards to flight operations
safety.
than an operator, felt we did not have the
competence to offer this experience. However,
a Global Approach
there were many airlines around the world that
already had in place a well run Flight Safety
Aviation safety, measured in terms of number of
hull losses per departure, has reached a mature
Accident-prevention
function. So it was logical to request the but stable level. Strategy
well-established airlines to assist other airlines.
Any further enhancement of this achievement To support this strategy, each Flight Operations
So the project was launched by Airbus to create requires a systemic approach where the aircraft, Briefing Note:
a kind of guide book (a What to Do and How to requests for copies. This handbook was later the operations and the operating environment • Presents the subject and its associated hazard
Do) that would enable a newly appointed Flight used by GAIN as a basis to create an expanded are considered globally. to flight operations safety, using background
Safety Manager to set up his function. We were version. The book was so successful it was a information and statistical data;
quite fortunate at this time to recruit Mr Dennis finalist in the Flight International Safety awards.
Johnson who had just retired from Virgin Atlantic The award judges considered the Airbus approach Introducing the Flight • Emphasizes the applicable standards and best
practices (e.g., standard operating procedures
as their Flight Safety Manager. Dennis was the “as just what the industry needs providing a first
principle author of what later became the Airbus class template for any new flight safety Operations Briefing [SOPs], supplementary techniques, operational
recommendations and training guidelines);
Flight Safety Manager's Handbook. During the
drafting of this handbook, there were several
operation". One major airline's senior air safety
investigator described it as "unique in its scope
Notes Concept • Lists and discusses the operational and human
round-the-table reviews of the contents with where all aspects of a flight safety management The Flight Operations Briefing Notes have been factors that may cause flight crews to deviate
several airlines who were kind enough to actively programme are addressed, from corporate designed to allow an eye-opening and from applicable standards;
participate; namely, Aer Lingus, Airtours commitment through accident/incident self-correcting accident-prevention strategy. This section constitutes an eye-opener to
International, Gulf Air, Royal Jordanian, Transaer investigations, to listings of available safety assist the reader in assessing his/her own
together with many others (Airtours International, resources". The initial set of Approach-and-Landing Flight exposure;
China Airlines, Costa Rica DGAC, Eyptair, TAM Operations Briefing Notes has been developed • Provides or suggests company accident-
and TransAsia) sending in their comments. If airlines wish to receive copies of this by Airbus in the frame of the Approach-and- prevention-strategies and/or personal lines-of-
handbook, simply contact Airbus Flight Safety. Landing Accidents Reduction (ALAR) Task Force defense;
The handbook was finally published in March Contact: Mrs Nuria Soler led by the Flight Safety Foundation (FSF).
1999 and up until today we still receive many nuria.soler@airbus.com. This section will assist the reader in identifying
The wide acceptance of the Approach-and- company or personal prevention strategies
Landing Briefing Notes by the pilots’ community and/or corrective actions;
24
24 25

• 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

The Airbus Flight Safety Team


Yannick MALINGE Albert URDIROZ Panxika CHARALAMBIDES Jérôme PAULHET
Vice President Flight Safety Flight Safety Manager Flight Safety Manager Flight Safety Advisor
Phone + 33 (0)5 61 93 43 60 Phone + 33 (0)5 62 11 01 20 Phone + 33 (0)5 62 11 80 99 To Long Range Chief Engineer
Fax + 33(0)5 61 93 44 29 Fax + 33(0)5 61 93 44 29 Fax + 33(0)5 61 93 44 29 Phone + 33 (0)5 62 11 01 91
E.Mail - yannick.malinge@airbus.com E.Mail - albert.urdiroz@airbus.com E.Mail - panxika.charalambides@airbus.com Fax + 33(0)5 61 93 27 60
Mobile +33(0)6 73 19 53 50 Mobile +33(0)6 21 50 14 65 Mobile +33(0)6 03 03 42 85 E.Mail - jerome.paulhet@airbus.com
Mobile +33(0)6 23 08 06 26

Jean DANEY Armand JACOB Nuria SOLER Eric MICHONNEAU


Director of Flight Safety Test Pilot Flight Safety Dept Secretary Flight Safety Advisor
Head of In-Service Safety Operational Advisor to the Vice Phone + 33 (0)5 61 93 45 19 To Wide Body Chief Engineer
& Incident Investigation President Flight Safety Fax + 33(0)5 61 93 44 29 Phone + 33 (0)5 62 11 80 40 / 09 79
Phone + 33 (0)5 61 93 35 17 Phone + 33 (0)5 61 93 47 92 E.Mail - nuria.soler@airbus.com Fax + 33(0)5 61 93 48 28
Fax + 33(0)5 61 93 44 29 Fax + 33(0)5 61 93 29 34 E.Mail - eric.michonneau@airbus.com
E.Mail - jean.daney@airbus.com E.Mail - armand.jacob@airbus.com Mobile +33(0)6 09 37 58 25
Mobile +33(0)6 08 67 02 48 Mobile +33(0)6 22 10 36 09

360°
Andre MAUMUS Thierry THOREAU Michel PALOMEQUE


°

33
30
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
°

Geoff CORLETT Christopher COURTENAY


Flight Safety Manager Director of Flight Safety 90°

Phone + 33 (0)5 61 93 40 76 Head of Safety Information


Fax + 33(0)5 61 93 44 29 Dissemination
E.Mail - geoff.corlett@airbus.com Phone + 33 (0)5 62 11 02 84
Mobile +33(0)6 71 92 53 02 Fax + 33(0)5 61 93 44 29
E.Mail - christopher.courtenay@airbus.com
Mobile +33(0)6 71 63 19 03
12

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