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AIRCRAFT ACCIDENT INVESTIGATION REPORT 96-5

China Airlines
Airbus Industrie A300B4-622R, B1816
Nagoya Airport
April 26, 1994

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

Contents

July 19, 1996

This report on the accident of China Airlines B 1816 has been prepared based upon the investigation carried out by the Aircraft Accident Investigation Commission, in accordance with Annex 13 to the Convention on International Civil Aviation and Article 20 of Aircraft Accident Investigation Commission Establishment Law of Japan.

Kazuyuki Takeuchi
Chairman
Aircraft Accident Investigation Commission

Abbreviations used in this report are as follows:

AD :Airworthiness Directive
ADC :Air Data Computer
AFS :Automatic Flight System
ALT : Altitude
ALT SEL : Altitude Selector
AOA : Angle of Attack
AP : Auto-Pilot
APU : Auxiliary Power Unit
A/THR : Automatic Thrust
AT : Auto Throttle
ATS : Auto-Throttle System
ATT : Attitude
BEA : Bureau Enquêtes Accidents
BKN : Broken
CAP : Captain
CAS : Computed Airspeed
CGCC : Center of Gravity Control Computer
CAT : Category
CMD : Command
CN : Consigne de Navigabilite
CVR : Cockpit Voice Recorder
CWS : Control Wheel Steering
CFDR : Digital Flight Data Recorder
DGAC : Direction Générale de l' Aviation Civile
ECAM : Electronic Centralized Aircraft Monitoring
BFCU : Electronic Flight Control Unit
EFIS : Electronic Flight Instrument System
ENG : Engine
EPR : Engine Pressure Ratio
FAA : Federal Aviation Administration
FAC : Flight Augmentation Computer
FADEC : Full Authority Digital Electronic Control
FCC : Flight Control Computer
FCOM : Flight Crew Operating Manual
FCU : Flight Control Unit
FD : Flight Director
FIDC : Fault Isolation and Detection Computer
FIDS : Fault Isolation and Detection System
FL : Flight Level
FMA : Flight Mode Annunciator
FMC : Flight Management Computer
FMS : Flight Management System
F/O : First Officer
FMC : Flight Warning Computer

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GCU : Generator Control Unit
GPWC : Ground Proximity Warning Computer
GPWS : Ground Proximity Warning System
GS : Glide Slope
HDG : Heading
HDG/SEL : Heading Selector
HPC : High Pressure Compressor
HPT : High Pressure Turbine
ICAO : International Civil Aviation Organization
IGS : Instrument Guidance System
IGV : Inlet Guide Vane
IND : Indicator
ILS : Instrument Landing System
IRS : Inertial Reference System
IRU : Inertial Reference Unit
LAND : Landing
L/D : Landing
LIG : Landing Gear
LOC : Localizer
LPC : Low Pressure Compressor
LPT : Low Pressure Turbine
LVL/CH : Level Change
MAC : Mean Aerodynamic Chord
MAN THR : Manual Thrust
MIC : Microphone
MTP : Maintenance and Test Panel
NAV : Navigation
NTSB : National Transportation Safety Board
OVC : Overcast
PCM : Pulse Code Modulation
PF : Pilot Flying
PFD : Primary Flight Display
PlC : Pilot in Command
PNF : Pilot Not Flying
QNH : Pressure Setting to Indicate Elevation above Mean Sea Level
R ALT : Radio Altitude
RET : Retract
RMI : Radio Magnetic Indicator
RWY : Runway
SB : Service Bulletin
SCT : Scattered
SGU : Symbol Generator Unit
SPD : Speed
SPD/MACH: Speed/Mach
SRS : Speed Reference System
SW : Switch
TCC : Thrust Control Computer
TCD : Ministry of Transport Civil Aviation Bureau Directive
THR : Thrust

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THR L : Thrust Latch
THS : Trimmable Horizontal Stabilizer
TIPS : Technical Instruction Processing Sheet
TRP : Thrust Rating Panel
VAPP : Approach Target Speed
VOR : VHF Omnidirectional Radio Range
V/S : Vertical Speed
Vs : Stall Speed
VTG : Target Speed
W.STA : Wing Station

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CONTENTS

1 PROGRESS AND PROCESS OF THE AIRCRAFT ACCIDENT INVESTIGATION 1-1

  1.1 Summary of the Aircraft Accident 1-1
1.2 Outline of the Aircraft Accident Investigation 1-1
1.2.1 Organization for Investigation 1-1
1.2.2 Implementation of investigation 1-2
1.2.3 Hearings from the Persons Relevant to the Cause of the Accident 1-2
1.2.4 Public Hearing 1-2
1.2.5 Reporting and Publication 1-3

2 FACTUAL INFORMATION 2-1

2.1 Flight History 2-1
2.2 Injuries to Persons 2-3
2.3 Damage to Aircraft 2-3
2.3.1 Extent of Damage 2-3
2.3.2 Damage to Aircraft by Part 2-3
2.3.3 Distribution of Wreckage, etc. 2-12
2.4 Damage to Other than the Aircraft 2-13
2.5 Crew Information 2-13
2.5.1 Flight Crew 2-13
2.5.2 Cabin Attendants 2-14
2.6 Aircraft Information 2-16
2.6.1 Aircraft 2-16
2.6.2 Engines 2-16
2.6.3 Weight and Center of Gravity 2-16
2.6.4 Fuel and Lubricating Oil 2-16
2.7 Meteorological Information 2-17
2.7.1 Synoptic Weather 2-17
2.7.2 Aeronautical Meteorological Observation and Reports 2-17
2.8 Navigational Aids 2-18
2.9 Communications 2-18
2.10 Airport and Ground Facility Information 2-18
2.11 Information on DFDR and CVR 2-19
2.12 Medical Information 2-19
2.12.1 Autopsies of CAP, F/O and Purser 2-19
2.12.2 Injuries to Survivors 2-21
2.12.3 Damage to Bodies 2-21
2.13 Fire and Fire Fighting 2-21
2.13.1 Fire Fighting and Rescue System at Nagoya Airport 2-21
2.13.2 Fire Fighting Activities 2-22
2.14 Information on Search, Rescue and Evacuation relevant to Survival, Death or Injury 2-24
2.14.1 Information on Search and Rescue Activities 2-24
2.15 Tests and Research to Find Facts 2-27
2.15.1 Investigation of Traces Left on the Ground 2-27
2.15.2 Indication of Major Instruments and Positions of Switches and Levers 2-28
2.15.3 Disassembly Inspection of Engines 2-28

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2.15.4 Investigation of FADECs 2-29
2.15.5 Investigation of Computer Memories 2-29
2.15.6 Information on Seating Positions of CAP and F/O 2-30
2.16 Other Necessary Information 2-32
2.16.1 Flight Experience of CAP and F/O 2-32
2.16.2 Qualification Requirements for CAP and F/O, and Promotion System 2-32
2.16.3 Automatic Flight System (AFS) 2-34

3 ANALYSIS 3-1

 
3.1 Analysis 3-1
3.1.1 Establishments of the times recorded on CVR and DFDR 3-1
3.1.2 Flight of the Aircraft 3-1
3.1.3 Estimation of Crash time 3-18
3.1.4 Attitude of Aircraft at the time of Crash and Damage to Aircraft 3-18
3.1.5 Investigation of Engines and FADEC 3-21
3.1.6 Results of Investigation of Computers and Other Equipment 3-22
3.1.7 Seated Positions of CAP and F/O 3-23
3.1.8 Injury to Passengers and Seat Assignment 3-24
3.1.9 Detection of Ethanol in Remains of CAP and F/O 3-25
3.1.10 China Airlines' Operation and Training Rules and Handling of Service Bulletins 3-27
3.1.11 Automatic Flight System 3-32
3.1.12 Fire Fighting and Rescue 3-38
3.2 Summary of Analysis 3-42
3.2.1 General 3-42
3.2.2 Flight Sequence of the Aircraft 3-42
3.2.3 Control and Operation by the Crew 3-43
3.2.4 Crash and Destruction of Aircraft 3-44
3.2.5 Investigation of Ethanol 3-44
3.2.6 Operations and Training of China Airlines and Handling of Service Bulletins 3-44
3.2.7 Automatic Flight System 3-45
3.2.8 Fire Fighting and Rescue System 3-46

4 CAUSES 4-1

5 REFERENCES 5-1

 
5.1 Measures taken after the Accident 5-1
5.1.1 Taiwanese civil aviation authorities 5-1
5.1.2 China Airlines 5-1
5.1.3 Bureau Enquêtes Accidents (BEA), Direction Générale de l' Aviation Civile (DGAC), France 5-1
5.1.4 Airbus Industrie 5-2
5.1.5 Civil Aviation Bureau, Ministry of Transport of Japan 5-2
5.1.6 National Transportation Safety Board (NTSB) and Federal Aviation Administration (FAA), U.S.A 5-3

6 SAFETY RECOMMENDATIONS 6-1

7 PROPOSALS 7-1

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Figures

 
Figure 1 Planned Flight Route A 1
Figure 2 Estimated Flight Route A 2
Figure 3 ILS Approach Chart (Nagoya WS RWY 34) A 3
Figure 4 Approximate Flight Track A 4
Figure 5 Enlarged Flight Track A 5
Figure 6 Surface Chart (ASAS) At 15:00, April 26, 1994 A 6
Figure 7 Surface Chart (ASAS) At 21:00, April26, 1994 A 7
Figure 8 Drawing of Nagoya Airport A 8
Figure 9 Sketch of Wreckages on the Ground after the Crash A 9
Figure 10 Enlarged Sketch of Wreckage on the Ground A10
Figure 11 Main Wreckage of the Accident Aircraft A11
Figure 12 Traces of Fire A12
Figure 13 State of Damage to Fuselage Skin A13
Figure 14 Airbus Industrie A300B4-622R Three Views A 14
Figure 15 Control Wing Section A15
Figure 16 Fuselage Stations-i A16
Figure 17 Fuselage Stations-2 A17
Figure 18 Fuselage Stations-3 A18
Figure 19 Wing Stations A19
Figure 20 Engine Sectional View A20
Figure 21 Engine External View A21
Figure 22 Controls, Displays, and Indicators in Cockpit A22
Figure 23 Layout of Lighting Switches in Cockpit A24
Figure 24 External View of Pilot's Seat A25
Figure 25 Set Positions of Captain's and First Officer's Seats A26
Figure 26 Seat Arrangement Chart A27
Figure 27 Sketch of SLATS/FLAPS Control Lever Gate and Balk A28
Figure 28 Operation of THS A29
Figure 29 Assumed FMA Displays A30

Photographs

 
Photograph 1 Site Where the Accident Occurred A31
Photograph 2 Site Where the Accident Occurred and Its Vicinity A32
Photograph 3 Whole Scene of the Crash Site A33
Photograph 4 Rescue Activities A34
Photograph 5 Left Aileron A35
Photograph 6 Right Aileron A35
Photograph 7 Right No.6 Spoiler and Left No.7 Spoiler A36
Photograph 8 Vertical Stabilizer and Rudder A36
Photograph 9 Left Elevator A37
Photograph 10 Right Elevator A37
Photograph 11 THS A38
Photograph 12 THS Screw Jack A38
Photograph 13 Left Center Flap A39
Photograph 14 Left Flap's NO.3 Screw Jack A39
Photograph 15 Right Flap's NO.2 Track A40
Photograph 16 Right Center Flap A40
Photograph 17 Left Outer Slat A41

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Photograph 18 Right Outer Slat A41
Photograph 19 Left Wing A42
Photograph 20 Fractures of the Right Wing A42
Photograph 21 Shock Absorber of the Left Main Landing Gear A43
Photograph 22 Tire and Brake Assembly of the Left Main Landing Gear A43
Photograph 23 Shock Strut of the Right Main Landing Gear A44
Photograph 24 Tires of the Right Main Landing Gear A44
Photograph 25 Leg Assembly of the Nose Landing Gear A45
Photograph 26 Tires of the Nose Landing Gear A45
Photograph 27 Front Windows and Upper Surface of the Cockpit A46
Photograph 28 Part of Outside Surface of the R1 Door A46
Photograph 29 Surface of Front Fuselage A47
Photograph 30 Burnt Fuselage Surface A47
Photograph 31 NO.1 Engine A48
Photograph 32 NO.1 Engine FADEC A48
Photograph 33 NO.2 Engine A49
Photograph 34 NO.2 Engine Pylon A49
Photograph 35 Center Pedestal 1 A5O
Photograph 36 Center Pedestal 2 A5O
Photograph 37 Thrust Lever and Go Lever A51
Photograph 38 SLATS/FLAPS Lever A51
Photograph 39 THS Manual Trim Wheel A52
Photograph 40 LIG Lever A52
Photograph 41 Outward Appearance of Display Unit with Broken Indicators A53
Photograph 42 Captain and Center Light Panel A53
Photograph 43 DFDR A54
Photograph 44 CVR A54
Photograph 45 CAP's Seat A55
Photograph 46 F/O's Seat A55
Photograph 47 Passenger Seats (for Business Class) A56
Photograph 48 Passenger Seats (for Economy Class) A56
Photograph 49 Impact Mark of the Left Main Gear on the Ground A57
Photograph 50 Impact Mark of the Right Main Gear on the Ground A57
Photograph 51 GO Lever Alignment with Thrust Lever A58

Appendix

Appendix 1 Outline of automatic flight system A59
Appendix 2 An Extract from A300-600 FCOM A69
Appendix 3 Examples of the previous incidents and Measures taken after the Incidents A77
Appendix 4 Changes to AFSs on A300-600 A87
Appendix S Airport Service Manual (Extract) A88
Appendix 6 DFDR Records A92
Appendix 7 CVR Records A113

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8

      

Comments from France and Taiwan, and the Notice from the USA

8-1
Comments from France 8-2
Comments from Taiwan 8-24
Notice from the USA 8-50

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