Lao ATR72 crash a Pakse (Laos)

[karmakoma]

http://www.reuters.com/article/2013/10/ ... GH20131016

Bad news

R.I.P. alle vittime

[77W]

http://avherald.com/h?article=46a05359&opt=0

Confermato che non vi sono superstiti.

La macchina coinvolta era un ATR 72-600 consegnato lo scorso marzo, e dovrebbe anche essere il primo incidente fatale per la versione -600.

[JT8D]

Sì, è il primo incidente per la più recente serie della famiglia ATR 42/72. Come già sottolineato, la macchina era stata consegnata da pochi mesi.

Paolo

[JT8D]

Da quanto ultimamente riportato su AvHerald: "had approached Pakse's runway 15 in poor weather conditions and had gone around. The aircraft attempted to join downwind for another approach but impacted Mekong River at about 15:55L (08:55Z).
............
The French BEA reported on Oct 21st 2013, that their investigators have reached the crash site on Oct 18th, equipment provided by the BEA was able to hear and locate the acoustic signals by the flight data and cockpit voice recorders. The violence of river Mekong at this time of the season and the low visibility however did not permit recovery of the recorders so far.

On Oct 22nd the French BEA reported in their weekly bulletin, that the aircraft had approached Pakse's runway 15, had gone around, turned right and crashed. All 49 occupants of the aircraft perished in the crash.".
(http://avherald.com/h?article=46a05359&opt=0)

Paolo

[JT8D]

E' stata rilasciata una sintesi del Final Report relativa a questo evento:

http://www.mpwt.gov.la/attachments/arti ... 72-600.pdf

http://avherald.com/h?article=46a05359/0000&opt=0

"Analysis
Under IMC conditions, with no reference to the ground, the SOPs lead to conducting an instrument approach. In Pakse the VOR DME approach procedure is in force. There is no radar service. The flight crew has to fly to the initial approach fix or the intermediate fix at an altitude above 4600ft, then start the descent to 2300ft until final approach fix. Finally the flight crew descends to the minima (990ft), if visual references with the ground are available and sufficient the flight crew may continue until touchdown. If ground visual references are not available or not sufficient, the flight crew may level off up to the missed approach point and then must start the missed approach procedure. From the FOR data, the flight crew set 600 ft as the minima. This is contrary to the published minima of 990 ft. Even if the flight crew had used the incorrect height as published in the JEPPESEN Chart at that time the minima should have been set to 645 ft or above. The choice of minima lower than the published minima considerably reduces the safety margins. Following the chart would lead the flight crew to fly on a parallel path 345 ft lower than the desired indicated altitude. The recordings show that the flight crew initiated a right turn according to the lateral missed approach trajectory without succeeding in reaching the vertical trajectory. Specifically, the flight crew didn't follow the vertical profile of missed approach as the missed approach altitude was set at 600 ft and the aircraft system went into altitude capture mode. When the flight crew realized that the altitude was too close to the ground, the PF over-reacted, which led to a high pitch attitude of 33°. The aircraft was mostly flying in the clouds during the last part of flight".

"Causes of the Accident:

The probable cause of this accident were the sudden change of weather condition and the flight crew's failure to properly execute the published instrument approach, including the published missed approach procedure, which resulted in the aircraft impacting the terrain.

The following factors may have contributed to the accident:

- The flight crew's decision to continue the approach below the published minima

- The flight crew's selection of an altitude in the ALT SEL window below the minima, which led to misleading FD horizontal bar readings during the go-around

- Possible Somatogravic illusions suffered by the PF

- The automatic reappearance of the FD crossbars consistent with the operating logic of the aeroplane systems, but inappropriate for the go-around

- The inadequate monitoring of primary flight parameters during the go-around, which may have been worsened by the PM's attention all tunneling on the management of the aircraft flap configuration

- The flight crew's limited coordination that led to a mismatch of action plans between the PF and the PM during the final approach."

Paolo