If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

MD81, Grenoble France, 2010

From SKYbrary Wiki

Summary
On 5 February 2010, a McDonnell Douglas MD 81 being operated by SAS on a non scheduled passenger flight from Copenhagen to Grenoble carried out a normal ILS approach to runway 09 in dark night VMC conditions, but the touchdown was made with the aircraft at an excessive pitch angle and higher than normal rate of descent and a tail strike occurred. Serious damage was caused to the rear lower fuselage but none of the 131 occupants were injured and a normal taxi-in and disembarkation followed.
Event Details
When February 2010
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Night
Flight Conditions VMC
Flight Details
Aircraft MCDONNELL DOUGLAS MD-81
Operator SAS
Domicile Sweden
Type of Flight Public Transport (Passenger)
Origin Copenhagen Airport, Kastrup
Actual Destination Grenoble
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Grenoble
General
Tag(s) Inadequate Airport Procedures
HF
Tag(s) Authority Gradient,
Ineffective Monitoring,
Manual Handling,
Procedural non compliance
LOC
Tag(s) Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.,
Extreme Pitch
Outcome
Damage or injury Yes
Aircraft damage Major
Causal Factor Group(s)
Group(s) Aircraft Operation,
Airport Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Airport Management
Investigation Type
Type Independent


Description

On 5 February 2010, a McDonnell Douglas MD 81 being operated by SAS on a non scheduled passenger flight from Copenhagen to Grenoble carried out a normal ILS approach to runway 09 in dark night Visual Meteorological Conditions (VMC) conditions, but the touchdown was made with the aircraft at an excessive pitch angle and higher than normal rate of descent and a tail strike occurred. Serious damage was caused to the rear lower fuselage but none of the 131 occupants were injured and a normal taxi-in and disembarkation followed.

Investigation

An Investigation into the accident was carried out by the French BEA. Flight Data Recorder (FDR) data was available but it was found that the 30 minute Cockpit Voice Recorder (CVR) recording had been overwritten as a result of the failure of the Operator to ensure that the recorder remained unpowered after the aircraft arrived on stand after the incident landing.

It was established that the First Officer had been PF for the approach and landing and noted that a significant gap in age and experience, including type experience, had existed between the two pilots. It was also noted that, after a period on sick leave due to stress, the First Office was serving a period of notice prior to redundancy.

It was confirmed that after establishing visual contact with the landing runway at a range of about 10nm, the coupled approach had been normal with AP disconnection being made at 1000ft aal. It was noted that the runway had no Visual Approach Slope Indicator Systems or Visual Approach Slope Indicator Systems installation. The landing lights were set to ‘dim’, in accordance with a normal SAS practice which nevertheless left the final decision on setting to the aircraft commander. At 200 feet agl, the PM had disconnected the Autothrottle, not normal procedure for SAS but requested by the PF on this occasion, and thereafter, there was a slight rearward movement of the thrust levers and thereafter a reducing speed to just above the applicable Reference Speed (Vref) of 132 KIAS at 30 feet agl and, 2 seconds before a firm touchdown ahead of the TDZ on the 3050 metres long runway by 160 metres, there had been a sudden nose up elevator movement to a pitch of 10.7°, more than 4° above the angle at which tail strike will occur with the main landing gear compressed.

It was noted that the proprietary charts supplied by Navtech/EAG and carried on the aircraft for Grenoble, where neither pilot had landed before, had been in conflict as to the extent of approach lighting for 09, although the error, showing more lighting than existed, had been in the aerodrome chart rather than the ILS procedure chart.

The Investigation noted that:

“the presence of a visual approach slope indicator system would have facilitated the transition between flight with instrument references and flight with external visual references. This would have made it possible for the crew not to focus their resources on visual flying and keeping to the approach slope. In addition, Annex 14 indicates that a visual approach slope indicator system “shall be provided (…) if the runway is used by turbojet”, which was the case for runway 09 at Grenoble.

The Conclusion of the Investigation was that “the accident was due to continuing to land when the crew’s situational awareness had deteriorated. This led to an erroneous appreciation of the height in relation to the trajectory aiming point and the absence of a flare.”

It was also noted that the following Contributory Factors had prevailed:

  • The crew did not select the maximum lighting level for their landing lights
  • Runway 09 at Grenoble-Isère aerodrome did not have a visual approach slope indicator system
  • Thrust management in manual was inappropriate for the landing

Two Safety Recommendations were made:

(1) That the DGAC ensure that paragraph 5.3.5.1 of ICAO Annex 14 is respected for all French aerodromes concerned.

(2) That the Danish Civil Aviation Administration (SLV) check that the instructions for operators under its oversight make it possible to ensure the rapid preservation of CVR recordings, after an accident or serious incident, in accordance with the obligations in EU OPS No 859/2008 and European regulation No 996/2010 (article 13.3).

The Final Report of the Investigation Accident Report oy-p100206a was published on 7 October 2011.

Further Reading