A321, Hurghada Egypt, 2013
A321, Hurghada Egypt, 2013
Summary
On 28 February 2013, the initial night landing attempt of a Ural Airlines Airbus A321 at Hurghada was mishandled in benign conditions resulting in a tail strike due to over-rotation. The Investigation noted that a stabilised approach had been flown by the First Officer but found that the prescribed recovery from the effects of a misjudged touchdown had not then been followed. It was also concluded that communication between the two pilots had been poor and that the aircraft commander's monitoring role had been ineffective. The possibility of the effects of fatigue was noted.
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Actual Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Landing
General
Tag(s)
Extra flight crew (no training)
HF
Tag(s)
Fatigue,
Flight / Cabin Crew Co-operation,
Ineffective Monitoring,
Manual Handling,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
LOC
Tag(s)
Temporary Control Loss,
Extreme Pitch,
Unintended transitory terrain contact
Outcome
Damage or injury
Yes
Aircraft damage
Minor
Non-aircraft damage
No
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Operation
Safety Recommendation(s)
Group(s)
Aircraft Operation
Investigation Type
Type
Independent
Description
On 28 February 2013, an Airbus 321 (VQ-BOC) being operated by Ural Airlines on a scheduled passenger flight (3027) from Perm to Hurghada with an augmented crew sustained a tail strike during the initial night landing attempt at destination after a Visual Meteorological Conditions (VMC) approach before successfully completing a second landing attempt on the same runway. Inspection of the aircraft after flight revealed that the lower tail section of the aircraft was structurally damaged.
Investigation
An Investigation was carried out by the Egyptian Ministry of Transport Air Incident Investigation Central Directorate (AAICD). Recorded data relevant to the Investigation was recovered from both the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR). It was noted that a third pilot formed part of the operating crew for the flight concerned.
It was noted that both operating pilots were familiar with Hurghada. It was also found that whilst the total flying experience of the First Officer (over 15,000 hours) was almost five times that of the aircraft commander, a lot of this had been obtained on the Tu154 and relatively very little of it (757 hours) on the A320 series, on which type the commander had obtained the majority of his 3498 hours.
After examination of all the relevant evidence, it was determined that there was no pre-existing relevant airworthiness, operational or aircraft loading context for the tail strike and that it had been the result of mishandling of the aircraft by the First Officer (PF) after a normal, stabilised approach had been flown.
The geometric maximum pitch attitude during the first landing attempt was found to have been 10.8°. FDR data showed that this figure had been reached over an average of four consecutively recorded FDR pitch angles whilst the aircraft main landing gear assemblies had both been in contact with the runway during the first attempted landing and to have been exceeded in the case of the final one of these readings just before the aircraft became airborne again.
It was noted that both pilots had believed at the time that the aircraft had bounced and was floating close to the ground whereas DFDR data showed that both main landing gears had been compressed. It was found that the likely cause of such an illusion might be a combination of a barely perceptible bounce followed by a soft touchdown in an abnormal pitch attitude due to the nose of the aircraft being held high to prevent a hard landing. Such a technique was noted to be contrary to both the recommended technique in the FCTM and the aircraft operator's SOPs for a bounced landing. It was therefore considered that the Captain had failed, as PM, to monitor the pitch attitude during landing and make timely calls as exceedance of this parameter looked possible.
The Investigation determined that the Probable Cause of the accident was "deviation from normal technique" and that when the First Officer making the landing did not handle the aircraft properly, the aircraft commander had not intervened at the proper time in an attempt to prevent the limiting on-ground pitch attitude being exceeded.
It was additionally determined that Contributory Factors might have included:
- An effect on the performance of both operating pilots of fatigue arising from their long duty period and high actual flying hours during the 24 hours prior to the event (11 hours 24 minutes) and the early time of day (just after 0400 Local Time) - although the duty being performed was confirmed as being in strict compliance with Ural Airlines' duty time regulations.
- The First Officer's judgement of the touchdown being adversely affected by glare from the runway lighting - although he did not announce this at the time.
- The greater overall flying experience of the First Officer relative to the Captain may have led to the latter perceiving a low probability that the former would mishandle the aircraft and lulled him into an inappropriate relaxed state.
- Overall, communication between the Captain and the First Officer throughout the event was not sufficiently effective.
Four Safety Recommendations were made as a result of the Investigation as follows:
- that the Relevant Organisation should review training concerning landing technique.
- that the Relevant Organisation should issue instructions to the cockpit crew to strictly adhere to the SOP (Standard Operation Procedure) and the normal techniques.
- that the Relevant Organisation should ensure adherence to Flight Duty Period limits
- that the Relevant Organisation should assure the implementation of Human Factors and CRM techniques especially in the area of maintaining 'Situational Awareness' and communicating and sharing any difficulty with other crew members.
The Final Report was issued on 17 November 2013.
