Re: [討論] 關於華航名古屋空難
以下摘錄自調查報告英文版第四章：
AIRCRAFT ACCIDENT INVESTIGATION REPORT 96-5
China Airlines
Airbus Industrie A300B4-622R, B1816
Nagoya Airport
April 26, 1994
Aircraft Accident Investigation Commission
Ministry of Transport
[Japan]
4 CAUSES
While the aircraft was making an ILS approach to runway 34 of Nagoya
Airport, under manual control by the F/O, the F/O inadvertently activated the
GO lever, which changed the FD (Flight Director) to GO AROUND mode and caused
a thrust increase. This made the aircraft deviate above its normal glide path.
The APs were subsequently engaged, with GO AROUND mode still engaged. Under
these conditions the F/O continued pushing the control wheel in accordance
with the CAP's instructions. As a result of this, the THS (Horizontal
Stabilizer) moved to its full nose-up position and caused an abnormal out-of-
trim situation.
The crew continued approach, unaware of the abnormal situation. The AOA
increased the Alpha Floor function was activated and the pitch angle increased.
It is considered that, at this time, the CAP (who had now taken the controls),
judged that landing would be difficult and opted for go-around. The aircraft
began to climb steeply with a high pitch angle attitude. The CAP and the F/O
did not carry out an effective recovery operation, and the aircraft stalled
and crashed.
The AAIC determined that the following factors, as a chain or a combination
thereof, caused the accident:
1. The F/O inadvertently triggered the Go lever
It is considered that the design of the GO lever contributed to it: normal
operation of the thrust lever allows the possibility of an inadvertent
triggering of the GO lever.
2. The crew engaged the APs while GO AROUND mode was still engaged, and
continued approach.
3. The F/O continued pushing the control wheel in accordance with the CAP's
instructions, despite its strong resistive force, in order to continue
the approach.
4. The movement of the THS conflicted with that of the elevators, causing an
abnormal out-of-trim situation.
5. There was no warning and recognition function to alert the crew directly
and actively to the onset of the abnormal out-of-trim condition.
6. The CAP and F/O did not sufficiently understand the FD mode change and
the AP override function.
It is considered that unclear descriptions of the AFS (Automatic Flight
System) in the FCOM (Flight Crew Operating Manual) prepared by the aircraft
manufacturer contributed to this.
7. The CAP's judgment of the flight situation while continuing approach was
inadequate, control take-over was delayed, and appropriate actions were
not taken.
8. The Alpha-Floor function was activated; this was incompatible with the
abnormal out-of-trim situation, and generated a large pitch-up moment.
This narrowed the range of selection for recovery operations and reduced
the time allowance for such operations.
9. The CAP's and F/O's awareness of the flight conditions, after the PlC
took over the controls and during their recovery operation, was inadequate
respectively.
10. Crew coordination between the CAP and the F/O was inadequate.
11. The modification prescribed in Service Bulletin SB A300-22-602 1 had not
been incorporated into the aircraft.
12. The aircraft manufacturer did not categorise the SB A300-22-6021 as
"Mandatory", which would have given it the highest priority. The
airworthiness authority of the nation of design and manufacture did not
issue promptly an airworthiness directive pertaining to implementation of
the above SB.
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