Crashed during approach, Boeing 737 800, near Amsterdam Schiphol Airport, 2009.pdf

Crashed during approaCh, Boeing 737-800,

near amsterdam sChiphol airport,

25 February 2009

The Hague, May 2010 (project number M2009LV0225_01)

The reports of the Dutch Safety Board are available to the public.

All reports are also available on the website of the Dutch Safety Board www.safetyboard.nl

the dutCh saFetY Board

The Dutch Safety Board was established to investigate and determine the causes or probable

causes of individual incidents or categories of incidents in all sectors. The sole purpose of a Dutch

Safety Board investigation is to prevent future accidents or incidents and, if outcomes give cause

to do so, issue associated recommendations. The organisation consists of a board with five perma-

nent members, a professional Bureau manned by investigators and support staff and a number of

permanent committees. Guidance committees are set up to oversee specific investigations.

Board advisory Committee

Chairman: Prof. Pieter van Vollenhoven Chairman: J.A. Hulsenbek

Vice chairman J.A. Hulsenbek

Annie Brouwer-Korf

Prof. F.J.H. Mertens

J.P. Visser

Prof. F.J.H. Mertens

E.J. Burmeister

J. Marijnen

Prof. J.A. Mulder

H. Munniks de Jongh Luchsinger

J.G.W. van Ruitenbeek

General

Secretary:

M. Visser

Project leader: J.W. Selles

Visitors

address:

Anna van Saksenlaan 50

2593 HT Den Haag

Correspondence

address:

P.O. Box 95404

2509 CK Den Haag

Telephone: +31 (0)70 333 7000

Fax:

+31 (0)70 333 7077

Internet: ww w.safetyboard.nl

This report is published in the Dutch and English languages.

In the event of conflict in interpretation, the Dutch text will be deemed binding.

Contents

Consideration ...................................................................................................................5

list of abbreviations .......................................................................................................14

1 introduction ..........................................................................................................17

1.1 Immediate cause..................................................................................................... 17

1.2 The investigation ..................................................................................................... 17

1.3 Reader’s guide ........................................................................................................ 19

2 Factual information ...............................................................................................21

2.1 Introduction ........................................................................................................... 21

2.2 Boeing 737-800 relevant systems .............................................................................. 21

2.3 Other terms and concepts that are important .............................................................. 24

2.4 History of the light .................................................................................................. 25

2.5 Injuries to persons .................................................................................................. 29

2.6 Damage to aircraft .................................................................................................. 29

2.7 Other damage ......................................................................................................... 29

2.8 Personnel information .............................................................................................. 29

2.9 Aircraft information ................................................................................................. 30

2.10 Meteorological information ........................................................................................ 30

2.11 Aids to navigation.................................................................................................... 30

2.12 Communications ..................................................................................................... 30

2.13 Aerodrome information ............................................................................................ 31

2.14 Flight recorders ....................................................................................................... 31

2.15 Wreckage and impact information .............................................................................. 31

2.16 Medical and pathologic information ............................................................................ 32

2.17 Fire ....................................................................................................................... 32

2.18 Survival aspects ...................................................................................................... 32

2.19 Tests and research .................................................................................................. 33

2.20 Organisational and management information .............................................................. 33

2.21 Additional information .............................................................................................. 33

3 assessment framework .........................................................................................35

3.1 General .................................................................................................................. 35

3.2 Legislation and regulations ....................................................................................... 35

3.3 Guidelines .............................................................................................................. 37

3.4 Assessment framework for safety management ........................................................... 38

4 involved parties and their responsibilities ............................................................41

4.1 Crew light TK1951 .................................................................................................. 41

4.2 Turkish Airlines ....................................................................................................... 41

4.3 Turkish Technic Inc. ................................................................................................. 42

4.4 Ministry of Transport (Turkey) ................................................................................... 42

4.5 Boeing ................................................................................................................... 42

4.6 Federal Aviation Administration (United States of America) ........................................... 42

4.7 European Aviation Safety Agency .............................................................................. 42

4.8 Dutch Ministry of Transport, Public Works and Water Management ................................. 43

4.9 Air Trafic Control the Netherlands ............................................................................. 43

5 analysis ................................................................................................................45

5.1 Introduction ........................................................................................................... 45

5.2 Technology ............................................................................................................. 45

5.3 Air trafic control ..................................................................................................... 52

5.4 Available information with regard to the automatic light system .................................... 57

5.5 Interception of the localizer signal and glide slope signal .............................................. 61

5.6 Completion of the landing checklist ............................................................................ 63

5.7 Speed reduction during the ILS approach ................................................................... 63

5.8 Stabilised approach versus aborting the approach ........................................................ 65

5.9 Line lying under supervision ..................................................................................... 66

5.10 Calling out light mode annunciations ......................................................................... 67

5.11 Recovery procedure ................................................................................................. 68

5.12 Crew resource management ..................................................................................... 70

5.13 Training ................................................................................................................. 72

5.14 Guaranteeing Safety at Turkish Airlines ...................................................................... 73

5.15 Certiication and oversight ........................................................................................ 74

5.16 Survival factors ....................................................................................................... 77

5.17 Measures taken after the accident ............................................................................. 78

6 Conclusions ...........................................................................................................81

7 recommendations .................................................................................................85

glossary .......................................................................................................................87

APPENDIX A: Justification of Investigation ..........................................................................93

APPENDIX B: Comments parties involved ...........................................................................96

APPENDIX C: Type Qualification and recurrent training type ................................................175

APPENDIX D: ATIS messages ..........................................................................................177

APPENDIX E: Exploratory study survival aspects ...............................................................178

APPENDIX F: Cockpit crew Information ............................................................................181

APPENDIX G: Aircraft data ..............................................................................................184

APPENDIX H: Transcript air traffic control .........................................................................185

APPENDIX I: Last 40 seconds flight data recorder data ......................................................187

APPENDIX J: Relevant cockpit voice recorder data .............................................................189

APPENDIX K: Damage to the aircraft ...............................................................................193

APPENDIX L: Miscellaneous investigations ........................................................................196

APPENDIX M: Simulator tests ..........................................................................................200

APPENDIX N: Similar occurrences ....................................................................................204

APPENDIX O: Assessment framework ...............................................................................206

APPENDIX P: Reliability monitoring programme .................................................................213

APPENDIX Q: Automatic flight system investigation ............................................................214

APPENDIX R: Air traffic control approach procedures ..........................................................219

APPENDIX S: Interception of the glide slope signal ............................................................221

APPENDIX T: Flight mode annunciations during approach ...................................................222

APPENDIX U: Approach to stall recovery procedure ............................................................223

APPENDIX V: Certification ..............................................................................................224

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: