air nz - airbus a320-232

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Ministre de l cologie, de l nergie, du dveloppement durable et de la mer, en charge des technologies vertes et des ngociations sur le climatBureau dEnqutes et dAnalysespour la scurit de l aviation civileBureau dEnqutes et dAnalysespour la scurit de laviation civileZone Sud - Btiment 153200 rue de ParisAroport du Bourget93352 Le Bourget Cedex - FranceT : +33 1 49 92 72 00 - F : +33 1 49 92 72 ReportAccident on 27 November 2008 off the coast of Canet-Plage (66)to the Airbus A320-232registered D-AXLAoperated by XL Airways GermanyPublished September 2010N ISBN: 978-2-11-099128-7 D-AXLA - 27 November 20081Thi s report expresses the concl usi ons of the BEA on the ci rcumstances and causes of thi s acci dent.I n accordance wi th Annex 13 to the Conventi on on I nternati onal Ci vi l Avi ati on, wi th EC di recti ve 94/56 and wi th the French Ci vi l Avi ati on Code (Book VI I ), the i nvesti gati on was not conducted so as to apporti on bl ame, nor to assess i ndi vi dual or col l ecti ve responsi bi l i ty. The sol e obj ecti ve i s to draw l essons from thi s occurrence whi ch may hel p to prevent future acci dents.Consequentl y, the use of thi s report for any purpose other than for the preventi on of future acci dents coul d l ead to erroneous i nterpretati ons.SPECIAL FOREWORD TO ENGLISH EDITIONThi s report has been transl ated and publ i shed by the BEA to make i ts readi ng easi er for Engl i sh-speaki ng peopl e. As accurate as the transl ati on may be, the ori gi nal text i n French i s the work of reference.ForewordD-AXLA - 27 November 20083Table of ContentsFOREWORD 1GLOSSARy 7SyNOPSIS 11ORGANISATION OF THE INVESTIGATION 131 FACTUAL INFORMATION 151.1 History of Flight 151.2 Injuries to Persons 211.3 Damage to Aeroplane 211.4 Other Damage 211.5 Personnel Information 211.5.1 Flight crew 211.5.2 Other persons on board 231.6 Aircraft Information 241.6.1 Airframe 241.6.2 Engines 241.6.3 Background 251.6.4 Maintenance 251.6.5 Weight and balance 251.6.6 Angle of attack sensors 251.6.7 Flight control laws 271.6.8 Angle of attack protections in normal law 291.6.9 Stall warning 301.6.10 Angle of attack information on board the aeroplane 311.6.11 Surveillance of angle of attack values 321.6.12 Speed information on board the aeroplane 331.7 Meteorological Conditions 331.7.1 Significant messages 341.7.2 Information supplied to the crew 341.7.3 Geographical area where the local angleof attack values stopped evolving 341.7.4 Meteorological conditions at Perpignanfrom 24 to 26 November 2008 341.8 Aids to Navigation 341.9 Telecommunications 351.9.1 En-route control centres 351.9.2 Perpignan ATC services 351.10 Aerodrome Information 36D-AXLA - 27 November 200841.11 Flight Recorders 361.11.1 Cockpit Voice Recorder (CVR) 361.11.2 Flight Data Recorder (FDR) 361.11.3 Data Readout 371.12 Wreckage and Impact Information 371.13 Medical and Pathological Information 371.14 Fire 371.15 Survival Aspects 371.16 Tests and Research 371.16.1 Angle of attack sensors 371.16.2 Function of Systems during the flight 481.16.3 Underwater search 501.16.4 Reconstitution of the radar trajectory 501.17 Information on Organisations and Management 511.17.1 Statutory Aspects 511.17.2 Information on air traffic organisation 521.17.3 Information on Airbus 551.17.4 Information on EAS Industries 611.17.5 Information on the Operators 631.17.6 D-AXLAs leasing contract 671.17.7 Maintenance operations 681.17.8 Tests flights Provided for in the Leasing Contract 701.18 Additional information 771.18.1 Witness Statements 771.18.2 Telephone calls 791.18.3 Flights by the B737-800, Registered D-AXLH,Operated by XL Airways Germany 791.18.4 Other events 801.18.5 FAA safety message 822 - ANALySIS 832.1 Analysis of the Sequence of Events that led to the Accident 832.1.1 Context of the flight 832.1.2 Planning and preparation of the flight 832.1.3 Management and conduct of the flight 842.1.4 Low speed check in landing configuration 862.1.5 Loss of control 862.2 Angle of attack sensors 872.2.1 Origin of the blockage 872.2.2 Painting Operations 882.2.3 Angle of attack sensors exposure to water projection 902.3 Non-revenue Flights in Leasing Contracts 912.3.1 Status 912.3.2 Performance 912.4 Functioning of the Automated Systems 92D-AXLA - 27 November 200853 - CONCLUSIONS 953.1 Findings 953.2 Causes of the accident 984 - SAFETy RECOMMENDATIONS 994.1 Non-revenue Flights 994.2 Equipment Qualification 1004.3 Consequences of Reconfigurations of Flight Control Laws 1004.4 Approach-to-Stall Recovery Technique and Procedure 101LIST OF APPENDICES 103D-AXLA - 27 November 20087GlossaryC Degrees CelsiusAAIB Air Accident Investigation Branch (United Kingdom)ADIRU Air Data and Inertial Reference UnitADR Air Data ReferenceEASA European Aviation Safety AgencyAFS Automatic Flight SystemAGL Above Ground LevelAMM Aircraft Maintenance ManualAMSL Above Mean Sea LevelAP Auto-PilotAPU Auxiliary Power UnitA/THR Auto-thrustATIS Automatic Terminal Information ServiceATM Air Traffic ManagementATP Acceptance Test ProcedureATPL(A) Air Transport Pilots License (aeroplane)ATL Aircraft Technical LogATSB Australian Transport Safety BureauBFU Bundesstelle fr Flugunfalluntersuchung (German federal bureau of aircraft accident investigation)BKN Broken cloud (5 to 7 octas)CAM Cockpit Area MicrophoneCAM Customer Acceptance ManualCAS Computed AirspeedCEPHISMER French undersea diving intervention unit (Cellule de plonge humaine et dintervention sous la mer)CCER Test trial acceptance centre (Centre de Contrle Essais Rception)CER Trial and acceptance traffc (Circulation dEssais et de RceptionCEV French flight test centre (Centre dEssais en Vol)cm CentimetreCRM Crew Resource ManagementCRC Continuous Repetitive ChimeCRNA Regional ATC centre (Centre Rgional de la Navigation Arienne)CROSSMED Mediterranean rescue and surveillance centre (Centre Rgional Oprationnel de Surveillance et de Sauvetage en Mditerrane)CTR Control zoneDGAC French civil aviation directorate (Direction Gnrale de lAviation Civile)D-AXLA - 27 November 20088DMC Display Management ComputerDME Distance Measuring EquipmentDSNA Direction des Services de la Navigation ArienneECAM Electronic Centralized Aircraft MonitoringECS Environmental Control SystemEGPWS Enhanced Ground Proximity Warning SystemELAC Elevator Aileron ComputerEPR Engine Pressure RatioETOPS Extended Twin OperationEU-OPS European Union aviation operations regulationsF/O First OfficerFAA Federal Aviation AdministrationFAC Flight Augmentation ComputerFCOM Flight Crew Operating ManualFD Flight DirectorFEW Few clouds (1 to 2 octas)FL Flight LevelFMS Flight Management SystemFPV Flight Path VectorFSK Frequency Shift Keyingft FeetFTO Flight Training OrganisationFWC Flight Warning ComputerGAT General Air TrafficGSAC Civil aviation safety group (Groupement pour la Scurit de lAviation Civile)HDG Heading modehPa HectopascalIAE International Aero EnginesIFR Instrument Flight RulesILS Instrument Landing SystemIRS Inertial Reference SystemISATM In Service Aircraft Test ManualJAR25 Joint Aviation Requirements 25 Large AeroplanesJAR-FCL Joint Aviation Requirements Flight Crew Licenceskg Kilogramkm KilometrekPa Kilopascalkt Knotl/h Litres per hourm MetreD-AXLA - 27 November 20089MCDU Multi Purpose Control and Display UnitMEL Minimum Equipment ListMETAR Aviation meteorological messageMMO Maximum Operating MachMTOW Maximum Take-Off WeightNAV Navigation mode NTSB National Transportation Safety Board (USA)ICAO International Civil Aviation OrganisationOAT Operational Air TrafficOFC Operational flight checkOM Operating ManualOP DES Vertical descent modePATM Production Aircraft Test ManualPFD Primary Flight DisplayPF Pilot Flying PNF Pilot not FlyingPPG PerpignanQFE Atmospheric pressure at the aerodrome altitude QNH Altimeter setting to obtain aerodrome elevation when on the groundQRH Quick Reference Handbook RTCA Radio Technical Commission for AeronauticsRTL Rudder Travel LimitSA CAM Single Aisle Customer Acceptance ManualSAMAR Sea rescueSAMU Emergency medical service (Service dAide Mdicale Urgente)SAT Static Air TemperatureSFCC Slat / Flap Control ComputerAIP Aviation Information PublicationSID Standard Instrument DepartureSOP Standard Operating ProceduresSSCVR Solid State Cockpit Voice RecorderSSFDR Solid State Flight Data RecorderSTAR Standard ArrivalSTBY StandbyTAF Terminal Area ForecastTAIC Transport Accident Investigation Commission (New Zealand)TAT Total Air TemperatureTEMSI Chart of significant meteorological conditionsTO/GA Take off / go aroundTRE Type Rating ExaminerD-AXLA - 27 November 200810TRI Type Rating InstructorTSO Technical Standard OrderULB Underwater location beaconUTC Universal Time CoordinatedV/S Vertical speed modeVAC Volt Alternative CurrentVFR Visual Flight RulesVHF Very High FrequencyVLS Lowest Selectable SpeedVmin Minimum Operating SpeedVMO Maximum Operating SpeedVOR Visual Omni RangeSV Synthetic voiceVSW Stall Warning SpeedY/D Yaw DamperD-AXLA - 27 November 200811SynopsisDate of accidentThursday 27 November 2008 at 15 h 46(1)Place of accidentOff the coast of Canet-Plage (66)Type of flightFlight at end of leasing agreementAircraftAirbus A320 232 MSN 2500registered D-AXLA(1)All times in this report are UTC, except where otherwise specifed. One hour should be added to express offcial time in metropolitan France on the day of the accident.OwnerAir New Zealand Aircraft Holdings LimitedOperatorXL Airways Germany GmbH(under a leasing agreement)Persons on board2 Flight Crew, 5 passengersSummaryFlight GXL888T from Perpignan Rivesaltes aerodrome was undertaken in the context of the end of a leasing agreement, before the return of D-AXLA to its owner. The programme of planned checks could not be performed in general air traffic, so the flight was shortened. In