Accidents Database

dft-avsafety-pdf-031785.pdf

1 Lockheed L1011-500 Tristar, CS-TMP AAIB Bulletin No: 10/2004 Ref: EW/C2003/08/04 Category: 1.1 Aircraft Type and Registration: Lockheed L1011-500 Tristar, CS-TMP No & Type of Engines: 3 Rolls-Royce RB 211-524B turbofan engines Year of Manufacture: 1983 Date & Time (UTC): 19 August 2003 at 1106 hrs Location: Runway 23 at Stansted Airport, Essex Type of Flight: Public Transport (Positioning) Persons on Board: Crew - 13 Passengers - None Injuries: Crew - None Passengers - N/A Nature of Damage: Scoring and deformation to underside of aft fuselage, damage to No 2 engine translating cowl and hot stream duct Commander's Licence: Airline Transport Pilot's Licence and Type Rating Instructor Commander's Age: 54 years Commander's Flying Experience: 11,300 hours (of which 1,200 were on type) Last 90 days - 60 hours Last 28 days - 28 hours Information Source: AAIB Field Investigation Synopsis The accident occurred during an automatic landing at Stansted when the rear of CS-TMP struck the ground on landing. The recorded airspeed on touchdown was 120 kt, while the calculated V ref was 145 kt. During the final stages of approach, the Auto Throttle System was inoperative but the crew did not detect the consequent diverging parameters of aircraft attitude and airspeed. Background The aircraft left Lisbon Airport at 0845 hrs for a positioning flight to Stansted to pick up passengers for an onward flight. The positioning flight was being used for a final line check to upgrade a company pilot to commander. Lockheed L1011-500 Tristar, CS-TMP 2 The pilot being upgraded was seated in the left cockpit seat. He was the holder of a current Airline Transport Pilot's Licence and had a total of 5,700 hours flying experience, of which 1,800 hours were on type. The designated commander for the flight was seated in a jump seat directly behind the left- seat pilot. The pilot in the right cockpit seat was the holder of a current Commercial Pilot's Licence and had a total of 337 hours, of which 37 hours were on type; she had completed her company training. An experienced flight engineer was also in the cockpit seated at his usual position. There were no significant defects recorded in the aircraft Technical Log. Initially, the crew stated that no unserviceabilities had been noted pre-flight or during the flight prior to the ILS approach. Later, it was reported that Autopilot (A/P) 'A' had failed at least one pre-flight check. It was checked during the flight and, although it appeared to work correctly, the crew decided to use A/P 'B' for the cruise. There was no reference to this in the aircraft's technical log, either before or after the accident. As part of his command upgrade, the left-seat pilot was required to complete a Category II Autoland and he briefed the crew for this approach before commencing descent towards Stansted Airport. Accident flight Prior to the approach, the crew received ATIS information 'Tango' timed at 1050 hrs. This indicated that Runway 23 was in use with the following weather: Surface wind 260°/ 08 kt variable between 220° and 290°; visibility greater than 10 km; cloud BKN 5,000 feet amsl; temperature 21° C/ dew point 6° C; QNH 1020 hPa. The following sequence of events has been derived from information provided by the crew and data from the FDR. During the transit, A/P 'B' had been engaged and, after the 'Approach' mode had been armed, A/P 'A' was also engaged. The aircraft was fully configured with the gear down and with Flap 33 prior to glideslope capture. By 3,000 feet amsl, CS-TMP was fully established on both the localiser and glideslope. The AutoThrottle System (ATS) was already engaged and the speed appeared steady at approximately 150 kt; V ref had been calculated as 145 kt. In accordance with company procedures, at 1,500 feet amsl, the first officer called "Approach and landing, I have control". Then, at about 400 feet radio height, A/P 'A' disengaged and an amber 'NO DUAL' annunciation was displayed on the Avionic Flight Control System (AFCS) warning panel in front of each pilot. The commander instructed the crew to re-engage A/P 'A' and this was done successfully. Around this time, the flight engineer called "three hundred feet". Then, at the decision height (DH) of 100 feet, the flight engineer called "Decide" and the left-seat pilot responded with "Landing, I have control". At 50 feet radio height, the first officer saw 'FLARE' displayed on the AFCS Mode Panel and called this out. At about this time, the left-seat pilot felt the thrust levers retard. The commander's impression was that the aircraft flared as normal but that the flare continued past the normal landing attitude of about 7° nose up. Touchdown was firm and the commander heard a 'metallic' noise from the rear of the aircraft. At about this time, the A/Ps disconnected, the left-seat pilot lowered the nosegear to the runway and then selected reverse thrust on all three engines. On the landing roll, the crew were advised on R/T that the tail of the aircraft had struck the runway on landing. Once clear of the runway, the aircraft was stopped to allow the Airport Fire Service (AFS) to review the damage. The AFS then followed the aircraft to its assigned parking area. An aircraft had been cleared to line-up once CS-TMP had landed. The commander of this aircraft subsequently stated that CS-TMP appeared to be in the landing attitude at about 50 feet agl and that the nose attitude continued to increase until the point of touchdown. He considered that the aircraft landed in a three-point attitude with the tail and the main gear touching the runway simultaneously. Lockheed L1011-500 Tristar, CS-TMP 3 Flight data recorder information The aircraft was fitted with a Flight Data Recorder (FDR) 1 capable of recording a range of flight parameters on a continuous 25-hour tape loop whenever power was applied to the aircraft. Analysis of the FDR data for this accident was made difficult because, for each flight recorded, the FDR only started receiving data late into the climb or during the cruise portion of the flight, and therefore did not record any takeoffs 2 . The aircraft was also fitted with a Cockpit Voice Recorder (CVR) 3 which recorded crew speech and area microphone inputs on a continuous 30-minute tape loop whenever power was applied to the aircraft. The 30 minutes duration was, however, insufficient to capture the approach and landing phases of the accident flight because it had been overwritten with more recent information after the landing, while the aircraft was stationary on the ground with electrical power on. A time history of the relevant parameters during the landing at Stansted is shown in Figure 1. From this figure, it can be seen that A/P 'B' was already engaged when A/P 'A' was selected during the descent, at about 3,750 feet amsl, just under 5 minutes before touch down. No other distinct A/P mode discrete parameters, such as ATS or Approach/Land Mode, were available on the FDR. At A/P 'A' engagement, the localiser and glideslope deviation signals become active shortly followed by changes in the engine pressure ratios (EPRs), which had remained fairly constant at values between 1.02 and 1.05, for the previous 100 seconds. These changes in the EPRs were consistent with the ATS being active. Figure 1 Salient FDR Parameters 1 Lockheed 209F FDR: Part Number 10077A500, Serial Number 2524. 2 Takeoffs are important as they enable many recorded parameters to be calibrated or verified against known or expected values: eg calibrating or verifying control wheel movement against control surface deflection. 3 Fairchild A100A CVR: Part Number 93-A100-80, Serial Number 55562. Lockheed L1011-500 Tristar, CS-TMP 4 Just ove