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Nagoya A300 Accident Report

Aircraft Accident Investigation Commission
Ministry of Transport
[Japan]

Prepared for the WWW by

Hiroshi Sogame
Safety Promotion Comt.
All Nippon Airways

Peter Ladkin
Universität Bielefeld
Germany

Section 2

July 19, 1996


2. FACTUAL INFORMATION

2.1 Flight History

China Airlines' Flight 140 (from Taipei International Airport to Nagoya Airport), B 1816, took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 (hereinafter all times shown are Coordinated Universal Time, unless otherwise specified), carrying a total of 271 persons consisting of 2 flight crew members, 13 cabin crew members and 256 passengers (including 2 infants).

The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:

Flight rule: IFR, Aerodome of departure: Taipei International Airport, Destination@Aerodome: Nagoya Airport, Cruising speed: 465 knots, Level: FL 330, Route: Al SUC-JAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodome: Tokyo International Airport.

DFDR shows that the aircraft reached FL 330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.

DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:

The aircraft which was controlled by the F/O, while cruising at FL 330 was cleared at 1047:35 to descend to FL 210 by the Tokyo Area Control Center and commenced descent.

For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the FIO on approach and landing.

At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.

At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 0100. Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower.

After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 ft pressure altitude, AP No.2 was engaged during climb, cruise and descent. At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No.1 was also engaged. Later, at 1111:36, both AP No.1 and 2 were disengaged by the FIO.

The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance

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from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots.
  Under manual control, the aircraft continued normal ILS approach.
  At 1114:05, however, while crossing approximately 1,070 ft pressure altitude, the FIO inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust.
  The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 ft pressure altitude (at a point some 5.5 km from the Runway).
  The CAP instructed the F/O to correct the descent path which had become too high. The FIO acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path.
  During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
  At 1114:18, both AP No.2 and No.1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 ft pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from 5~30 to 12.30, which is close to the maximum nose-up limit. The THS remained at 12.30 until 1115:11. During this period, the elevator was continually moved in the nose-down direction.

In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 ft pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the F/O that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.

At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The FIO reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the THS decreased from 12.30 to 7~40, and SLATS/FLAPS were retracted from 30/40 to 15/15 after the FIO reported "Go Around" to Nagoya Tower.

At 1115:17, the GPWS activated Mode S warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.

At 1115:31, after reaching about 1,730 ft pressure altitude (about 1,790 ft radio altitude), the aircraft lowered its nose and began to dive.

At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall

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warning sounded from 1115:40 to the time of crash.

At about 1115:45, the aircraft crashed into the landing zone close to the E1 taxiway.

The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45 (2015:45 JST) (see attached Figures 1,2,3,4,5 and Photographs 1, 2 and 3).

2.2 Injuries to Persons

Crew Passengers Others
Fatal 15 249 -
Serious - 7 -
Minor/None - - -

2.3 Damage to aircraft

2.3.1 Extent of damage

The aircraft was destroyed.

2.3.2 Damage to Aircraft by Part

(1) Flight control system

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(2)Wings

(3) LH main landing gear

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(4) RH main landing gear

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(5) Nose landing gear

(6) Fuselage

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(7) No.1 engine

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8 No.2 engine

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vanes were bent in the direction of rotation.

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(9) Cockpit

(10) Cargo-related

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(11) Others

2.3.3 Distribution of Wreckage, etc.

Before the investigation started, some pieces of wreckage had been moved from their original positions in order to facilitate rescue activities. At the time of investigation, the wreckage was scattered as follows:

Due to the impact of the crash, the wreckage of the aircraft except the RH and LH wings, the vertical and horizontal tail planes, the tail section of the fuselage, and the engines, was scattered over an approximately 140 meters long and 60 meters wide area to the east-northeast of the LH main landing gear's ground scar. Fragments of the destroyed skin of the nose and forward fuselage sections were strewn over an approximately 40 meters long and 30 meters wide area, some 120 meters away from the LH main landing gear's ground scar to the east-northeast direction. No signs of damage by fire were found on the nose and forward sections of the fuselage. The lower skin of the fuselage center and aft sections, almost entirely fragmented, were scattered over an approximately 40 meters wide area that extended approximately 60 meters to the east-northeast from. the LH main landing gear's ground scar. Other parts of the center and aft fuselage sections except a part of the skin, were almost entirely ruined by fire. The wings ripped from the fuselage, were found at a point approximately 80 meters to the east-northeast of the LH main gear's ground scar. The LH outer wing was torn from the wing, and the RH outer wing, broken into several fragments, was also separated from the wing. They were burnt and discovered near the wings and the water gate, respectively. The LH engine was torn from the wing pylon and was found near the wing, while the RH engine remained barely attached to its pylon. The fan hubs of both engines were broken and detached.

The horizontal tail plane and tail cone were broken and torn from the fuselage, and were

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found at a point approximately 30 meters to the east-northeast of the LH main landing gear's ground scar. The vertical tail plane was broken and separated from the fuselage together with the upper rear part of the fuselage. It was burnt and found over the irrigation water channel approximately 65 meters to east-northeast of the LH main landing gear's ground scar.

An approximately 50 meters long and 20 meters wide scorch mark of fire were detected on the ground, each extending to the east-northeast from the vicinities of the ground scars of the LH and RH wing flap tracks, and the trees near the water gate were burnt. Signs of fire were also detected on the ground near where the wings were found (see attached Figures 11 ,12 and Photographs 2 and 3).

2.4 Damage to Other than the Aircraft

A stretch of the lawn under cultivation in the landing zone was burnt and flowed off within an approximately 10,300 m2 area.

The protection wall of the irrigation water channel at Komaki Air Base of the Air Self-Defense Force (hereinafter referred to as "Komaki Air Base") was destroyed over a length of 30 meters, and the water gate was damaged.

Of the trees in the soundproofing tree fence in the Komaki Air Base, those within an approximately 2,000 m2 area were burnt.

2.5 Crew Information

2.5.1 Flight Crew

Captain: Male, aged 42
Airline transport pilot license No.10991 Issued July 1, 1991
Type rating
Airbus A300-600R Issued July 31, 1992
Term of validity Until July 30, 1994
Class 1 airman medical certificate Issued November 2, 1993
Term of validity Until May 31, 1994
Total flight time 8,340 h 19 min
Total hours on A300 - 600R 1,350 h 27 min
Flight time during the last 90 days 217 h 56 min
Flight time during the last 30 days 71 h 11 min
Latest training on emergency procedures September 15, 1993
Rest period prior to the flight 15 h 30 min
Note: The captain joined the company on February 1, 1989
Copilot: Male, aged 26

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Commercial pilot license No.30701 Issued September 5, 1992
Type rating
Airbus A300-600R Issued December 29, 1992
Term of validity Until December 28, 1994
Class 1 airman medical certificate Issued March 1, 1994
Term of validity Until September 30, 1994
Total flight time 1,624h 11 min
Total hours on A300-600R 1,033 h 59 min
Flight time during the last 90 days 196 h 30 min
Flight time during the last 30 days 71 h 53 min
Latest training on emergency procedures September 14, 1993
Rest period prior to the flight 39 h 00 min
Note: The copilot joined the company on April 16, 1990

2.5.2 Cabin Attendants

A. Flight attendant/Manager (female, aged 54)
Qualification as attendant Issued September 14, 1970
Total flight time 12,225 h
Latest training on emergency procedures June 10, 1993
Rest period prior to the flight More than 18 h
B. Flight attendant/Purser (male, aged 44)
Qualification as attendant Issued July 1, 1976
Total flight time 15,050 h
Latest training on emergency procedures June 22, 1993
Rest period prior to the flight More than 18 h
C. Flight attendant(male, aged 40)
Qualification as attendant Issued June 1, 1985
Total flight time 6,891 h
Latest training on emergency procedures June 8, 1993
Rest period prior to the flight More than 18 h
D. Flight attendant (female, aged 29)
Qualification as attendant Issued April 24, 1987
Total flight time 5,048 h
Latest training on emergency procedures June 29, 1993
Rest period prior to the flight More than 18 h
E. Flight attendant (female, aged 32)
Qualification as attendant Issued June 30, 1988
Total flight time 4,205 h

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Latest training on emergency procedures June 29, 1993
Rest period prior to the flight More than 18 h
F. Flight attendant (female, aged 28)
Qualification as attendant Issued May 18, 1989
Total flight time 3,545 h
Latest training on emergency procedures July 19, 1993
Rest period to the flight More than 18 h
G. Flight attendant (female, aged 24)
Qualification as attendant Issued September 5, 1989
Total flight time 3,306h
Latest training on emergency procedures July 5, 1993
Rest period prior to the flight More than 18 h
H. Flight attendant (female, aged 27)
Qualification as attendant Issued September 5, 1989
Total flight time 3,306h
Latest training on emergency procedures July 9, 1993
Rest period prior to the flight More than 18 h
I. Flight attendant (female, aged 24)
Qualification as attendant Issued May 4,1992
Total flight time 1,513 h
Latest training on emergency procedures July 2, 1993
Rest period prior to the flight More than 18 h
J. Flight attendant (female, aged 25)
Qualification as attendant Issued June 2, 1992
Total flight time 1,401 h
Latest training on emergency procedures July 1, 1993
Rest period prior to the flight More than 18 h
K. Flight attendant (female, aged 24)
Qualification as attendant Issued August 20, 1992
Total flight time 1,289h
Latest training on emergency procedures July 14, 1993
Rest period prior to the flight More than 18 h
L. Flight attendant (female, aged 23)
Qualification as attendant Issued April 26, 1993
Total flight time 720 h
Latest training on emergency procedures June 30, 1993
Rest period prior to the flight More than 18 h

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M. Flight attendant (female, aged 23)
Qualification as attendant Issued January 4, 1994
Total flight time 170h
Latest training on emergency procedures January 4, 1994
Rest period .pnor to the flight More than 18 h

2.6 Aircraft Information

2.6.1 Aircraft

Type Airbus Industrie A300B4-622R
Serial No. 580
Date of manufacture January 29, 1991
Certificate of airworthiness 83-01-05
Valid until January 15, 1995
Total aircraft flight time 8,572 h 12 min

2.6.2 Engines

Type Pratt and Whitney PW-4 158
No.1 No.2
Serial No. 724082 724025
Date of manufacture December 13, 1990 October 5, 1989
Total hours of operation 5,776 h 8,783 h

2.6.3 Weight and Center of Gravity

The weight of the aircraft at the time of the accident is estimated to have been approximately 290,900 lbs, with its center of gravity at 30.6% MAC, both being within permissible limits (maximum landing weight being 308,651 lbs, with the allowable range of center of gravity corresponding to the weight at the time of landing, 20.0 to 33.6% MAC).

According to the Flight Clearance and Log of China Airlines, the aircraft loaded approximately 50,7OOlbs of fuel before takeoff The amount of fuel remaining at the time of the accident is estimated to have been approximately 22,000lbs.

2.6.4 Fuel and Lubricating Oil

The fuel on board was JET A-1, and the lubricating oil was Esso Turbo Oil 2380 (MIL-L-23699), both being authorized for aircraft use.

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2.7 Meteorological Information

2.7.1 Synoptic Weather

The synoptic weather announced by the Nagoya District Weather Service Center of the Meteorological Agency at 1100 (JST) on April 26, 1994 was as follows:

A region of high atmospheric pressure, centered above the Korean Peninsula and the East China Sea covers almost all of Japan. Meanwhile, a front associated with a low pressure system hovers above the ocean to the south of Japan, and another low pressure system is centered over the ocean to the northeast of Hokkaido. Thus, the weather is fine throughout the country, except on the Pacific side of eastern Japan, and northern Japan, where it is cloudy.

Weather is fine in the Chubu region, in both the Tokai and Hokuriku areas. Also, the temperature is high. (See attached Figures 6 and 7).

2.7.2. Aeronautical Meteorological Observations and Reports

(1) Aeronautical meteorological observations at Nagoya Airport.
The routine and special aeronautical meteorological observations by the Aviation Weather Service Center at Nagoya Airport in the time zones relating to the accident (times indicated are JST) were:
19:30 Wind direction/speed: 280°/10 kts.
Visibility: 15 km
Cloud: 1/8 cumulus 3,000 ft 6/8 unknown
Temperature/dew point: 20°C/5°C QNH: 29.84 inHg
20:00 Wind direction/speed: 280°/8 kts.
Visibility: 20 km
Cloud: 1/8 cumulus 3,000 ft 6/8 unknown
Temperature/dew point: 20°C/4°C QNH: 29.86 inHg
20:19 Wind direction/speed: 280°/6 kts.
Visibility: 20km
Cloud: 1/8 cumulus 3,000 ft 6/8 unknown
Temperature/dew point: 19°C/4°C QNH: 29.87 inHg
20:30 Wind direction/speed: 280°/7 kts.
Visibility: 20 km
Cloud: 1/8 cumulus 3,000 ft 4/8 unknown
Temperature/dew point: 19°C/4°C QNH: 29.87 inHg

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(2) Aeronautical meteorological reports at Taipei International Airport
Aeronautical meteorological reports by the Taiwanese civil aviation authorities in the time zones relating to the departure of the aircraft were:
8:00 Wind direction/speed: 50°/14 kt
Visibility: 8 km, light rain
Cloud: SCT 600 ft, BKN 1,000 ft, OVC 4,OOOft
Temperature/dew point: 23°C/19°C QNH: 29.83 inHg
8:30 Wind direction/speed: 050°/11 kt Gust 22 kt
Visibility: 8 km, light rain
Cloud: SCT 500 ft, BKN 1,000 ft, OVC 4,000 ft
Temperature/dew point: 22°C/19°C QNH: 29.83 inHg
9:00 Wind direction/speed: 070°/8 kt Gust 18 kt
Visibility: 5 km, light showery rain
Cloud: SCT 500 ft, BKN 1,000 ft, OVC 4,000 ft
Temperature/dew point: 23°C/19°C QNH: 29.82 inHg

2.8 Navigation Aids

All navigation aids at Nagoya Airport required for aircraft the operation of the aircraft concerned were in working normally during the time zone related to the flight.

2.9 Communications

The aircraft maintained communication with Tokyo Control (133.5 MHz and 125.7 MHz), Nagoya Approach (120.3 MHz) and Nagoya Tower (118.7 MHz). Communication with these facilities was good.

2.10 Airport and Ground Facility Information

Nagoya Airport is located in Toyoyama-cho, Nishikasugai County, Aichi Prefecture, about 10 kilometers north-northeast of Japan Railways' Nagoya Station, and is administered by the Ministry of Transport.

Field elevation of the airport is 14 meters. The runway, 16 and 34, is 2,740 meters long and 45 meters wide. It is paved with asphalt concrete, and has grooving over a 2,708-meter long and 30-meter wide area.

The runway was in normal operation at the time that the aircraft was making its landing approach. (See attached Figure 8.)

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2.11 Information on DFDR and CVR

The aircraft was equipped with a Sundstrand model 980-4100-BXUS DFDR (serial No. 1006) and a Fairchild model Al OOA CVR (serial No. 25153).(See attached Photographs 43 and 44)

The DFDR case was partially crushed and damaged when recovered. However, its magnetic tape that had recorded signals during the flight, was found intact.

The DFDR record is attached herewith as Appendix 6.

The CVR was also recovered with its case partially crushed and damaged, but its tape, containing a record of voices and sounds was not damaged.

The CVR had four recording channels, each channel being assigned to an input source as shown below, and recorded radio communication and other voices.
The CVR transcriptions are shown in Appendix 7.

Channel 1: Input from the audio selector panel of the jump seat (3rd)
Channel 2: Input from the audio selector panel of F/O's seat (F/O)
Channel 3: Input from the audio selector panel of CAP's seat (CAP)
Channel 4: Input from the area microphone (AREA MIC)

It should be noted that Channels 2 and 3, including radio communication, are identical because the CAP and the F/O always used the cockpit intercom system.

2.12 Medical Information

2.12.1 Autopsies of CAP, FIO and Purser

Information supplied by Aichi Prefectural Police Headquarters is as follows:

(1) Damage to bodies and handling of remains prior to autopsies

The CAP's body had open wounds running from the right shoulder to the right breast.

Open wounds were also found from the left breast to the left abdomen of the F/O's body, and his stomach and intestines were damaged. Open damage was barely noticeable on the breast and abdomen of the purser's body.

The three remains were placed in Hangar 1 of the Komaki Air Base immediately after their recovery.

Later, no special measures, such as preservation by freezing, were taken for the remains prior to their transfer to three medical colleges/university for judicial autopsies.

From 18 to 22 hours had elapsed from the time of the accident to the transfer of the remains to the medical colleges/university for autopsy. During this period, the lowest and

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highest temperatures at Nagoya Airport were about 1 0°C and 23°C, respectively.
The temperature in the Hangar 1 of the Komaki Air Base, where remains were placed, is considered to have been somewhat higher then the value above.

(2) Judicial autopsies and extraction of samples for alcohol reaction tests (times are JST)

1 CAP
A post-mortem examination was conducted on the CAP's body at a dissection room of legal medicine at Department of Medicine, Nagoya University, between 17:55 and 23:00 on April 27.
Test samples were taken from the thoracic cavity using an anatomical spoon in a period between 20:00 and 21:00. Some 24 to 25 hours had elapsed from the time of the accident to when the samples were taken.
02 F/O
A post-mortem examination was conducted on the F/O's body at a dissection room of legal medicine and path9logy at Aichi Medical College, between 14:00 and 17:00 on April 27. Test samples were taken from the thoracic cavity with an anatomical spoon at about 15:00.
This was done approximately 19 hours after the time of the accident.
03 Purser
A post-mortem examination was conducted on the purser's body at a dissection room of legal medicine at School of Medicine, Fujita-Gakuen Health College, between 14:00 and 17:00 on April 27.
Test samples were taken from the heart using an anatomical spoon about 15:30, approximately 19 hours after occurrence of the accident.

(3) Alcohol reaction test

The test samples taken from the three remains were immediately placed in special plastic containers and sealed. After dissection, technical officers from Aichi Prefectural Police Headquarters who had witnessed the dissection, took the samples to Scientific Investigation Laboratory of Aichi Prefectural Police Headquarters for storage in a refrigerator.
1 Date of test and organization involved
An alcohol reaction test was conducted at the above-mentioned Scientific Investigation Laboratory in a period between 17:00 and 20:00 on April 28.
02 Test method
One milliliter of each test sample was subjected to test by the gas chromatography method using n-propanol as an internal standard. The concentration of ethanol was calculated by the calibration curve method.

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(3) Test results
The concentration of ethanol in each of the test samples was as follows:
(a) CAP    : 13mg/l00ml
(b) F/O      : 55mg/l00ml
(c) Purser : No ethanol detected

2.12.2 Injuries to survivors

Of the 271 persons aboard --256 passengers and 15 crew members --16 passengers were taken to hospital by ambulance. Six of them were found dead on arrival at the hospitals. In addition, three passengers died after hospitalization, on April 27, April 28, and May 1, respectively. Seven passengers survived -- all of them had been seated in Rows 7 through 15. Four had been in the right block of seats, two in the center block, and one in the left block. (See attached Figure 26.) At the time of hospitalization, all seven survivors were suffering from traumatic shock to various degrees. Various external wounds, primarily bone fractures caused by the impact, were found among the survivors, the locations of which differed from one to another. According to the diagnosis, those serious injuries would take from two months to an year to heal completely.

2.12.3 Damage to Bodies

According to the autopsy reports, a great number of the remains were bruised all over and had suffered multiple fractures caused by the impact. Nearly half of the remains had been burnt to various degrees.

2.13 Fire and Fire Fighting

2.13.1 Fire Fighting and Rescue System at Nagoya Airport

(1) Outline of fire fighting and rescue organizations at Nagoya Airport

The fire fighting and rescue service for civil aircraft at Nagoya Airport is to be provided by the Nagoya Airport Office (hereinafter referred to as "Airport Office") with assistance rendered to the office by the Komaki Air Base, in accordance with an agreement on mutual assistance in fire fighting and rescue activities made between the Administrator of Nagoya Airport Office of Osaka Regional Civil Aviation Bureau (hereinafter referred to as "Airport Office Administrator") and the commander of Komaki Air Base of Air Self-Defense Force.

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Also, an agreement was made with respect to the fire fighting service in and around Nagoya Airport between the Airport Office Administrator, and the Chief of Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, the Chief of Komaki City Fire Fighting Headquarters, the Chief of Kasugai City Fire Fighting Headquarters, and the Chief of Nagoya City Fire Fighting Bureau (hereinafter referred to as "Neighboring Fire Fighting Organizations"). This agreement allows the Airport Office Administrator to request assistance to these Neighboring Fire Fighting Organizations when necessary. Furthermore, an ambulance loaded with emergency medical materials and equipment was stationed at Nagoya Airport from March 1992, and the Airport Office commissioned the Air Safety Foundation to operate this vehicle.

(2) Fire fighting equipment and personnel at Nagoya Airport

The fire fighting equipment was not provided at the Airport Office. The Fire Fighting Platoon of the Base Operation Facilities Company of First Air Transport Squadron at Komaki Air Base (hereinafter referred to as "Fire Fighting Platoon"), is equipped with five chemical fire vehicles and one water supply wagon. This Fire Fighting platoon operates 24 hours a day, in shifts, at the station which contains a fire trucks and a command office, and is situated in the eastern part of Nagoya Airport.
Meanwhile, according to "Level of Protection to be provided" specified as a recommended practice in Annex 14 ("AERODROMES") to the Convention on International Civil Aviation, Nagoya Airport is classified as a Category 9 Airport. Nagoya Airport complies with the applicable level in terms of the amounts of water for foam production, fire-extinguishing agents and complementary agents, and response time. However, the airport did not meet the level in respect of the discharge rate for foam solution.
The chemical fire vehicles had a discharge distance of 30 m.

(3) Fire fighting and rescue training for aircraft accidents

Fire fighting and rescue training for aircraft accidents were held at Nagoya Airport on October 16, 1989 and May 24, 1993, under the auspices of the Airport Office. Personnel from Self-Defense Force, Neighboring Fire Fighting Organizations, Airport Police Station, Aichi Prefecture Medical Association, and other organizations participated in these training.
In order to train its fire fighting personnel, the Fire Fighting Platoons conduct drills involving actual fires once a quarter-year and practice water spraying once a week.

2.13.2. Fire Fighting Activities (times are JST)

(1) Request for mobilization and turning out of fire vehicles

At about 2016, via an emergency telephone call, an Air Traffic Controller of the Airport Office ( hereinafter referred to as "Controller" ) requested the Fire Fighting Platoon and an Air Traffic Information Officer (hereinafter referred to as "Information Officer") to dispatch fire

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services for an aircraft crash in which fire had broken out.
At about 2017 the Fire Fighting Platoon dispatched three chemical fire vehicles.
Meanwhile, as specified in the emergency notification network chart, the Information Officer requested the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association and Airport Police Station to request assistance.
The Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association relayed the information to the Kasugai city Fire Fighting Headquarters, Nagoya City Fire Fighting Bureau, and the Komaki City Fire Fighting Headquarters.
At about 2019 three chemical fire vehicles of Fire Fighting Platoon were the first to arrive at the crash site, and immediately began fire extinguishing activities.
At approximately 2027, one chemical fire vehicle, one water tank truck, one rescue vehicle, and one ladder truck, all from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, as well as two chemical fire vehicles, two water tank trucks, and two rescue vehicles from the Kasugai City Fire Fighting Headquarters, entered the airport through the No.2 West Gate and proceeded to the crash site under the guidance of Airport Office personnel, where they commenced fire extinguishing activities.
Around 2030 two chemical fire vehicles, one ordinary fire vehicle, one water supply wagon, one cargo truck, one water spray truck, two mobile cranes, one light wrecker, one fork-lift, and one tractor, all from the Fire Fighting Platoon, reached the site as second group, and commenced fire fighting activities.
At approximately 2042, one chemical fire vehicle, one water tank truck, and one rescue vehicle from the Komaki City Fire Fighting Headquarters entered the airport after cutting two sets of security chains at the North Gate and opening the gate, arrived at the crash site, and commenced fire fighting activities. In addition, about 2054, a chemical fire vehicle from the Nagoya City Fire Fighting Bureau entered the airport through the No.2 West Gate and went into action at the crash site.

(2) Fire extinguishing activities

Fire fighting personnel who were dispatched from the standby station of Fire Fighting Platoon described the fire fighting activities as follows:
At approximately 2016 of that day, the Controller informed the Fire Fighting Platoon via an emergency telephone that "a China Airlines' aircraft has burst into flames on the runway" and requested fire services. The Fire Fighting Platoon dispatched three chemical fire vehicles around 2017.
The Fire Fighting Platoon personnel, who were at their standby station, had not heard the impact sound of the aircraft crash.
Upon receipt of the report, two chemical fire vehicles left the station and sped along Taxiway E4 and the runway to the southern end of the airport where flames and smoke were billowing in the air. About 2019, another chemical fire vehicle arrived at the site via Taxiway EP 1.
The aircraft had fragmented into pieces, losing its original shape so badly that the only way to distinguish the wings was by identifying the vague shape of the engines.
Fire broke out, and flames as high as a three-storied building enveloped an area more than 100 meters wide. Booming sounds were heard three times at internals.

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Going into action immediately, the Fire Fighting Platoon, staying clear of widely scattered aircraft fragments, advanced to about 20 meters from the wing and discharged fire extinguishing agents.
At approximately 2027, a chemical fire vehicle, a water tank truck and a ladder truck from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, plus two chemical fire vehicles and two water tank trucks from the Kasugai City Fire Fighting Headquarters arrived at the crash site and went into action. Flames under the wings, however, did not abate easily.
About 2030, a second party dispatched by the Fire Fighting Platoon, consisting of two chemical fire vehicles, one water supply truck, one ordinary fire vehicle, one cargo truck and so on arrived at the site. They backed up the chemical fire vehicles that had arrived earlier and provided them with additional water and fire extinguishing agents.
Around 2042, a chemical fire vehicle and a water tank truck from the Komaki City Fire Fighting Headquarters arrived at the crash site and joined the fire extinguishing activities.
Later, about 2054, a chemical fire vehicle from the Nagoya City Fire Fighting Bureau arrived at the site and also joined the fire fighting activities.
About 2110, aircraft components smoldering near the irrigation water channel were cut open with axes and tobiguchi (fireman's hooks) and sprayed with agents and water. The fire was finally extinguished around 2148.

2.14 Information on Search, Rescue and Evacuation Relevant to Survival, Death or Injury

2.14.1 Information on Search and Rescue Activities (times are JST)

(1) Removal of passengers After confirming the crash site, the personnel from the Self-Defense Force, Neighboring Fire Fighting Organizations, Police, and Airport Office conducted search and rescue activities throughout the area.
Reports from the various parties are summarized as follows:
Ambulances from Komaki Air Base arrived at the crash site at about 2019 and 2023.
At about 2027, ambulances and other vehicles from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association and the Kasugai City Fire Fighting Headquarters entered the airport through the No.2 West Gate and, upon arriving at the site, commenced search and rescue operations promptly.
At approximately 2031, ambulances from Nagoya City Fire Fighting Bureau entered the airport through the No.2 West Gate and proceeded to the crash site. Upon arrival, the ambulance men started confirming whether there were any survivors and conducting first aid to the injured. Actual work to confirm the presence of survivors began about 2032. However, flames raging in the central part of the fuselage hampered search and rescue activities.
A male passenger was found around 2035, and two female passengers and an infant were removed from the site about 2037. These four people were carried to hospital in an ambulance from Komaki Air Base.
Around 2042, ambulances from the Komaki City Fire Fighting Headquarters entered the airport

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through the main gate of Komaki Air Base and commenced search and rescue activities.
Two injured passengers, who had received first aid from the rescue personnel assigned to a Nagoya City Fire Fighting Bureau ambulance, were rushed to hospital.
Around 2049, an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association carried three passengers to hospital.
Around 2055, two ambulances from the Kasugai City Fire Fighting Headquarters took three passengers to hospital.
Around 2100, a male passenger about 40 years old, trapped between seats, was rescued by removing the seats with a power cutter. A female passenger about 35 years old was also rescued. Those two passengers were carried to hospital in an ambulance from the Kasugai City Fire Fighting Headquarters.
Around 2100, a male child passenger was taken to hospital in an ambulance from the Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association.
At approximately 2122, an emergency medical treatment and transport vehicle arrived at the crash site.
Around 2124, an ambulance from Nagoya City Fire Fighting Bureau carried a male passenger to hospital.
Around 2140, rescue teams began setting up rescue stations (three air tents). Around 2148, the fire was finally extinguished. Wreckage was pulled up from the irrigation water channel with cranes and other equipment, and the search for missing persons continued. From about 2220 the remains found around the wings and the irrigation water channel were taken to the rescue stations (air tents).
On request from the Airport Office Administrator, troops of 10th Division, with Ground Self-Defense Force, from Monyama Base, arrived at the site about 2225, and commenced search and rescue activities.
Around 2325, the remains of persons considered to be crew members were found near the cockpit and taken to a rescue station (air tent) set up near the crash site.
Around 0445 on April 27, transfer of remains from the rescue stations (air tents) to Hangar No. 1 at Komaki Air Base, for temporary storage, started.
Around 1340, the final remain was transferred from the site. (See attached Photograph 4.)

(2) Rescue activities conducted by the organizations involved
1 On April 26, based on a decision made at a cabinet meeting immediately after the accident, Japan's national government established "China Airlines Aircraft Accident Countermeasure Headquarters", with the Minister of Transport as its head. The government decided to spare no effort in rescuing survivors, recovering the remains and keeping close contact with the organizations involved.
2 Immediately after the accident, the Airport Office set up "Accident Emergency Countermeasure Headquarters" with the Airport Office Administrator as its head and mobilized 119 employees through emergency call. The Airport Office also organized "Nagoya Airport Aircraft Rescue Unit" and conducted its activities using the following personnel, materials and equipment:
        Personnel         406 persons (including 102 of Rescue Unit and other

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        airport personnel concerned)
Materials and equipment 28 vehicles (including an emergency medical treatment and transport vehicle) and 3 air tents
03 With a request from the Airport Office Administrator for disaster dispatch immediately after the accident, the 10th Division of Ground Self Defense Force and the 1st Air Transport Squadron of Air Self-Defense Force participated in the rescue and other activities by providing:
        Personnel 1,900 persons (1,200 at the site and 700 for backup duties)
Materials and equipment 25 vehicles
Floodlight projectors 16
04 The Fire Fighting Headquarters of Nishikasugai County East Fire Fighting Association, Kasugai City Fire Fighting Headquarters, Komaki City Fire Fighting Headquarters, and Nagoya City Fire Fighting Bureau participated in rescue and other activities at the request of the Airport Office, by providing:
        Personnel 546 persons (534 dispatched and 12 on standby)
Materials and equipment 116 vehicles
Helicopter 1 (operated by Nagoya City Fire Fighting Air Force; used illuminate the crash site and assess the scope of the disaster by flying over the site)
(5) In accordance with the "Agreement on Medical Treatment and Rescue Activities at Nagoya Airport" made with the Airport Office, the Aichi Prefecture Medical Association conducted their rescue activities by providing:
        Dispatched 64 persons (47 doctors and 17 nurses)
On standby 164 persons (76 doctors, 51 nurses and 37 clerks and others)
(6) The Aichi Prefecture Branch of Japanese Red Cross Society conducted activities, including autopsies, post-mortem examinations, reconstruction, cleansing and identification, by providing:
        Personnel 102 persons (14 doctors, 55 nurses and 33 clerks and others)
07 The Aichi Prefectural Police Medical Association performed post-mortem examinations by providing:
        Personnel 79 persons
(8) The Aichi Prefecture Dental Association was engaged in identification activities by providing:
        Personnel 134 persons (107 dentists, 7 dental hygienists, and 20 police doctors)

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(9) Upon receipt of the accident report from the Airport Office immediately after the crash, the Aichi Prefectural Police Headquarters conducted rescue activities and policed the site of disaster by providing:
        Personnel 1,700 persons (1,100 dispatched and 600 others)

2.15 Tests and Research to Find Facts

2.15.1 Investigation of Traces Left on the Ground

At the crash site, there were clear scars that had been left on the ground when the tail assembly, trailing edges of both LH and RH wings, LH and RH main landing gears, LH and RH engines, nose landing gear, and other aircraft parts had first hit the ground. There were also linear scars extending through the area to where the wreckage was strewn.

The aircraft first impact point was in the landing area, some 110 meters east-northeast from the center of the end of Runway 34. The crash site was covered with earth and sand, and the ground was relatively soft.

Measurements of the major marks are as follows:
Width (cm) Length (cm) Depth (cm) Angle of Entry(°)
Nose landing gear 130 to 150 440 41 42
LH main landing gear 170 to 220 470 67 23
RH main landing gear 30 to 210 500 38 16
LH engine 150 to 320 920 73 10
RH engine 170 to 390 910 68 12
LH No.2 flap track 27 to 46 375 10 24
LH No.3 flap track 21 to 38 510 29 34
LH No.4 flap track 26 to 47 570 -- 25
LH No.5 flap track 25 to 43 560 21 26
LH No.6 flap track 20 to 46 540 30 30
RH No.2 flap track 38 to 48 -- 20 14
RH No.3 flap track 27 to 38 210 10 14
RH No.4 flap track 28 to 44 530 18 20
RH No.5 flap track 24 to 39 410 24 16
RH No.6 flap track 33 to 80 270 33 20

The positions of the marks left by the nose landing gear, LH and RH main landing gears, LH and RH engines, LH and RH wingtips, and THS are as shown in attached Figure 10.

The direction of the linear marks which are made when the center section of the fuselage scratched the ground, coincided with magnetic bearing of about 220. (See attached Figures 9 ,10, and Photographs 49 and 50.)

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2.15.2 Indications of Major Instruments and Positions of Switches and Levers

Regarding indications of major instruments as well as the positions of switches/levers in the cockpit, the following are identified.

1) Indications of major instruments
  • Altimeter (unknown whether LH or RH):
  • QNH 29.82/1010 80 ft
  • Rate of climb indicator (unknown whether LH or RH):
  • -6,000 ft
  • RMI (unknown whether LH or RH):
  • Heading 020°
  • ENG oil pressure indicator/oil quantity gauge:
  • No.1 225 psi/12.5 Qr No.2 -/-

    (2) Positions of switches and levers
  • IRS mode selectors:
  • No.1: OFF, No.2: ATT, No.3: NAV
  • ENG IGN selectors:
  • No.1: Cont Relight, No.2: Cont Relight
  • L/G lever:
  • Intermediate position between Neutral and Down
  • SLTS/FLPS lever:
  • 15/20°
  • THS trim indicators 9.4°/9.5°
  • SPD brake lever:
  • RET
  • ENG SWs:
  • No.1:ON, No.2:ON
  • THR levers:
  • No.1: 34°, No.2:34°
  • THR reverser levers RET
  • Fire handles:
  • Handles for No.1 engine, No.2 engine and APU had not been activated. (See attached Photographs 35,36,37,38,39,40 and 41.)

    2.15.3 Disassembly Inspection of Engines

    A thorough investigation of the engines was conducted through the methods, including teardown inspection. With respect to No.1 engine, the investigation focused on parts between LPC and LPT rotors. Investigation of No.2 engine covered parts between the core of LPC and HPT rotor (stage No.2 ). In addition, following items of both engines are also investigated: Principal accessories (fuel oil coolers, stator vane actuators, 2.9 bleed valves, fuel metering units, fuel and oil pumps), and oils collected at the crash site (fuel, engine oil, and hydraulic fluid). The results of the investigation are as follows:
    (1) The fracture surfaces of all broken parts of both engines showed signs of rapid destruction, but there was no indications of fatigue damage or melting. The damage to the No.1 engine was more prominent than to the No.2 engine.

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    (2) Rotor blades had been torn/deformed in the direction opposite to that of engine rotation. Stator vanes and nozzle guide vanes had been torn/deformed in the direction of engine rotation.
    (3) The external surfaces of both engines showed evidence of burns. The No.2 engine was burnt more extensively than the No. 1 engine, with its HPC blade surface, front case and so on surfaces partially blackened. There was no indication of in-flight fire; all signs of fire indicated that fire had broken out only after the engines were destroyed.
    (4) Nothing indicative of operational abnormality was found in the damage to major accessories. The fracture surfaces of all broken and damaged accessories showed signs of rapid destruction.
    (5) All oils collected at the crash site (fuel, engine oil, and hydraulic fluid) contained a great deal of foreign matter such as water, mud, grains of sand, and other fiber-like objects, and they were found polluted and deteriorated, making it difficult to determine the conditions they had been in before the crash. (See Attached Figure 20 and 21.)

    2.15.4 Investigation of FADECs

    The aircraft engines were equipped with Full Authority Digital Electronic Controls (FADECs) manufactured by Hamilton Standard of United Technologies Corp. (Serial No.: 4000-0519 for No.1 engine and 4000-0674 for No.2 engine).

    The connectors of both FADECs had broken; the FADEC for the No.2 engine was recovered with its case cracked.

    The FADECs had a dual system consisting of channels A and B. Their disassembly inspection showed that the processor boards for both channels in each FADEC were in good conditions. The fault memories storing the engine control failure condition records were readable on all the channels. As a result of the analysis of these records, evidence of surges which indicate a rapid drop of pressure in the engine combustor in flight before crash, was detected in channels A and B of the FADEC for both engines (See Photograph 32).

    2.15.5 Investigation of Computer Memories

    Computers with non-volatile memories, which are considered useful for crash cause determination, were recovered, from the site.

    All these computers were damaged by the impact. The memories from all recovered computers, except heavily damaged ones, were investigated. These computers are the following.

    Marked with asterisks (*) are computers whose memories were not readable owing to internal damage.

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    * (1) Flight control computer (FCC) 1 pc
    (2) Flight augmentation computer (FAC) 2 pcs
    (3) Flight management computer (FMC 1 pc
    * (4) Center of gravity control computer (CGCC)1 pc
    (5) Symbol generating unit - Electronic flight instrument system (SGU-EFIS) 3 pcs
    (6) Symbol generating unit - Electronic centralized aircraft monitor (SGU-ECAM) 2 pcs
    (7) Flight warning computer (FWC) 1 pc
    (8) Air data computer (ADC) 2 pcs
    (9) Inertial reference unit (IRU) 3 pcs
    (10) Generator control unit (GCU) 2 pcs
    * (11) Maintenance and test panel (MTP) 1 pc
    * (12) Ground proximity warning computer (GPWC)1 pc
    (13) Instrument landing system (ILS) receiver1 pc

    2.15.6 Information on Seating Positions of CAP and FIO

    2.15.6.1 CVR records

    The voice records on CH2 and CH3 of CVR, including radio communications, were identical because the cockpit intercom transmission system was always used by the CAP and the F/O. So which of the two seats the CAP or the F/O occupied could not be determined from the CVR. However, the transcripts are as follows:

    (1) Conversation made between 1046:59 and 1047:35
    The conversation is concerned with the operation of "lights".
    Lights in the cockpit consists of the following:
            (1) Lights operated from CAP's seat through controls on CAP and center light panel located at the left end of the instrument panel:
    - CAP and center instrument light
    - Main instrument panel floodlight
    - Console floodlight
    - Map light
    (2) Lights operated from F/O's seat through controls on F/O instrument light panel at the right end of the instrument panel:
    - F/O instrument light
    - Console floodlight
    - Map light
    (3) Lights operated from CAP's or F/O's seat through a knob located at the center of the overhead panel:
    - Reading light

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            (4) Lights operated from CAP's or F/O's seat through a knob on the pedestal:
    - Pedestal and overhead panel light
            (5) Lights operated from CAP's seat (also from F/O's seat) through controls on the 'cockpit light panel in front of the overhead Panel CAP's seat:
    - Dome light
    - Storm light
            (6) Lights operated from CAP's or F/O's seat through theglareshield lightning controls:
    - Each window of the glareshield panel
    - Push-button switch integrated light (See attached Figure 23 and Photograph 42.)
    (2) Conversation started at 1100:02
    The conversation was concerned with the wearing of shoulder harnesses.

    2.15.6.2 Setting of CAP's seat and F/O's seat

    Investigation was made on the wreckage of the CAP's seat and RH(F/O) crew seats as to marks left presumably by the impact on the column assemblies, which are related to the seats' vertical positions, and those on the seat position track, which are related to the seats' longitudinal positions. Measurements obtained from these marks were as follows:

    Column assembly Seat position track
    LH (Captain) Seat Approx. 70 mm upward from the lowest position Probably near the forward-most position
    RH(F/O) Seat Approx. 30 mm upward from the lowest position Approx. 33mm rearward from the forward-most position

    Note: The mark found at a point 170 mm from the forward limit position of the LH(Captain) seat is not considered to be primary damage caused by the crash impact -- it is regarded as secondary damage caused afterward.

    The position where the LH side rudder pedals had been placed was judged to be approximately 17 mm forward of its rearmost position, based on a mark left on the recovered rudder pedal adjuster. The right-side rudder pedal adjuster was not recovered.

    According to their airman medical certificates, the CAP and the F/O were 162.5 cm and 178.1 cm tall, respectively. (See attached Figures 24 and 25.)

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    2.16 Other necessary Information

    2.16.1 Flight Experience of CAP and FIO

    The following information has been obtained from China Airlines:

    2.16.2 Qualification Requirements for CAP and FIO, and Promotion System

    China Airlines established its internal rules and regulations in accordance with Taiwanese laws, and set up criteria for qualification and promotion as described below. Both the CAP and the F/O satisfied the qualification requirements for their respective duties to fly aircraft of

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    the type in question.

    (1) Qualification Requirements

    1 CAP
    Age: 54 or younger
    Competence qualification: Airline transport pilot
    Experience: Not less than 2 years' service as F/O with qualification for promotion to CAP
    Medical certificate: Class 1
    Flight hours: Not less than 3,500 hours
    (2) F/O
    From military service
    Academic background: Graduate of Aviation Department of Air Staff College, Air Force
    Age: 33 to 45
    Competence qualification: Commercial pilot
    Medical certificate: Class 1
    Flight hours: Not less than 1,300 hours : age 33
    Not less than 1,400 hours : age 34
    Not less than 2,500 hours : age 45
    Trained by the Chinese Airline
    Academic background: Graduate of Engineering Department of Junior College or higher
    Age: Less than 28
    Competence qualification: Commercial pilot
    Airman medical certificate: Class 1
    Flight hours: Not less than 588 hours

    (2) Promotion system to F/O and CAP

    F/O for light aircraft type (C-90A, C-i 900, etc.)

    -->

    F/O for lower-ranked aircraft type (B737, A300B4, A300-600)

    -->

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    -->

    F/O for higher-ranked aircraft type (B747-200, B747-400, MD1 1)

    -->

    F/O recommended as candidate for CAP by the company

    -->

    CAP for lower-ranked aircraft type (B737, A300B4, A300-600)

    -->

    CAP for higher ranked aircraft type (B747-200, B747-400, MD1 1)

    (Note): Depending on education and career, some pilots may become F/O for higher ranked aircraft from the start.

    2.16.3 Automatic Flight System (AFS) ( See Attachment 1)

    (1) Summary of AFS of A300-600R type aircraft
    Summary of APS of A300-600R type aircraft is shown in Appendix 1
    (2) Caution against FCOM concerning the AP override.
    With regard to the aircraft involved in the accident, when the AP is engaged in LAND and GO AROUND modes, movement of the elevators by the AP can be one overridden by pushing and/or pulling the control wheel. In this case, however, the AP autotrim orders are not canceled, and the AP will move the THS so as to maintain the aircraft on the scheduled flight path. The aircraft will eventually read to out-of-trim condition. With regard to this hazardous situation, a" CAUTION" is provided in the FCOM. (Refer to Appendix 2-2)

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    Peter B. Ladkin, 1999-02-08
    Last modification on 1999-06-15
    by Michael Blume