Final Aircraft Accident Report

Regarding The Airbus 310-324 Accident on 10/06/2008 Registration ST-ATN

Presented by

The Investigation Board which was formed by The Minister, and being nominated by the Deputy DGCA at the time of the accident

The Board Comprises : Eng. Sirelkhatim Kambal Head of Board Mr. Kamil Ahmed Member Mr. Abdelkariem A/Lateef Member Mr. Mohmed Elhassan Member Cap. Osman Alsaied Member Cap. Abdelfatah Satti Member Eng. Abdelgadir Sirelkhatim Member Mr. Abdelmuniem Tyfor Member mr. Abdelsamie Adam Member

BEA (Accident Investigation Bureau) of France appointed Mr. Francois Hochart Accredited representative Assisted by Mr. Vincent Ecalle Airbus Industry investigators team Mr. Albert Urdiroz Flt. Safety director Mr. Xavier Barriola Flt. Safety Mr. Jean Philippe Propulsion system Mr. Jean Paul Structure Mr. Christophe Duphil Systems

International Statistic about the Airbus 310 Serial Number 548 (current ST-ATN) The First Flight was On 23/08/1990 Delivered to Singapore On 22/10/1990 Registered as 9V-STU Leased to Air India by Owner (Osprey Aircraft Leasing Limited of Cayman Islands) Registered as VT-EVF and issued Indian Airworthiness Certification On 7/2/2001 Delivered to Sudan On 14/09/2007 Registered as ST- ATN

Ref Airliners.net
The accident was 9th loss of Airbus 310 at that date 7th worst accident involving A310 at that time

6th worst accident in Sudan

From general history

The A310 serial number 548 accomplished the C1 + C2 in the period 06 March 2007 26 August 2007 at Jordan Aircraft Maintenance Limited Which covered Routine, zonal, structural task, ADs, SBs provided by Air India i.a.w the Approved Main. Program.

During the check 41 Discrepancies were found and being repaired. This includes Fuel leakage at (L/H wing) Aft pylon fitting, lower surface, wing inner tank wing jacking fitting through access panel 575DB, etc (R/H wing) Lower surface, aft pylon fitting, drain hole at slat 2 screw jack alignment, at lower I/B area I/B of pylon In addition to corrosion areas and spots and reinforcement panels cracks

Objective of the Investigation

In accordance to Annex 13 Para The sole objective of the investigation is to draw lessons from the occurrences that may help to prevent future accidents and incidents and NOT. NOT To apportion blame or to assess individual or collective responsibility

Number of witnesses being interviewed by the Investigation Board were as follows :Sudan Airways personnel The Flying Captain The First Officer 7 Cabin Crew members The Flying Security Officer Others 3 Police officers different ranks 9 Citizens ( passengers)

Brief description of the accident flight On 10th of June 2008 A310 serial number 548 Arrived Khartoum Airport from Cairo With a deactivated No. 1 engine Thrust reverser. As it was previously scheduled for a flight to Oman The designated Captain for that flight accepted to fly the aircraft as being labelled according the MEL requirement.

Flight to Amman via Damascus was uneventful.

On the return flight there were 203 passengers and eleven crew members on board. On Approaching Khartoum that day in the afternoon and due to bad weather conditions The Captain of the flight decided to divert to Port Sudan and landed safely. 20 tons of fuel topped up at Port Sudan

The captain said he was on contact with Khartoum enquiring about the weather. After staying at Port Sudan for 1:15 hrs he was informed that the weather is getting better. He decided to return to Khartoum He initiated a night approach for R/W 36 after being cleared to land The Tower provided the flight with Wind information as { 320/7 Kt} and R/W condition {Wet}

At that moment the actual METAR was

10/1830 150/10 Kt 9/9 few CB 050 to E SCT 056 SCT 056 Q 1010

The Accident
Most important remarks obtained from witnesses interview were as follows :The Flying pilot stated The weather was somehow bad and the hold took a long time before being cleared to land and he was always asking the First officer to monitor him The touchdown was very smooth and it was within the required distance

He did not select autobrake for passenger comfort on landing Autobrake was not a must as it is a recommendation at that time After selected both engines reverse the aircraft slipped rightward Due to that he deselect the reverse and managed to return the aircraft to R/W centreline by using differential brakes Using brakes the deceleration was abnormal Called the F/O to assist on brakes

Approaching the end of the R/W he selected reverse and aircraft did not decelerate The aircraft overrun the R/W and burst on fire Right hand slides could not be deployed Passengers and crew vacated from the left front slide Two of the occupant stated that they saw fire on the right wing during aircraft rolling on R/W

FDR Information
The flying pilot was the captain The aircraft was fully and properly configured for landing The AP was disconnected at 800 ft with Athr engaged till landing Both thrust levers set to idle for touchdown Touchdown at 132 kt IAS, 155Kt ground speed Touchdown was smooth at about 800 meters after R/W threshold

FDR event (UTC time )

16 h 12 16 h 30 16 h 47 17 h 02 min 15 s 17 h 06 min 52 s 17 h 09 min 43 s Takeoff Level off at FL310 Top of descent Level off at 7000 ft Level off at 5000 ft Spoiler 5 FAULT/OFF parameter turns to FAULT Master warning Capt (2 s) VFE exceedance due to slats Deployment CAS 250 kt, VFE 245 kt

17 h 13 min 48 s

17 h 14 min 58 s

Level off at 4000 ft CAS 202 kt

17 h 17 min 18 s
17 h 22 min 57 s

Level off at 3000 ft CAS 206 kt

Top of final descent Zp 2800 ft CAS 153 kt, GS 152 kt A/THR engaged in SPEED mode A/P 1 engaged in CMD

FLAPS 41, SLATS 25

17 h 23 min 45 s

17 h 23 min 52 s
17 h 25 min 06 s

Spoiler 5 FAULT/OFF parameter turns to NO FAULT A/P disengaged CAS 142 kt, GS 148 kt Thrust levers pulled to idle position Both EPR decrease to around 1 CAS 139 kt, GS 159 kt

17 h 25 min 10 s

17 h 25 min 12 s

Touchdown (LH then RH main landing gears compressed) A/THR disengaged All spoilers deploy except LH and RH number 5 spoilers CAS 132 kt, GS 154 kt Thrust levers pulled to full reverse position Engine 2 thrust reversers deploy and EPR of engine 2 start to increase CAS 132 kt, GS 150 kt

17 h 25 min 13 s

17 h 25 min 15 s 17 h 25 min 20 s

Spoiler 5 FAULT/OFF parameter turns to FAULT CAS 131 kt, GS 148 kt Nose gear compressed CAS 126 kt, GS 142 kt Max EPR of engine 2 reached at 1.2 Thrust levers pushed to idle position EPR of engine 2 start to decrease CAS 103 kt, GS 128 kt

17 h 25 min 28 s

17 h 25 min 30 s

17 h 25 min 38 s

GPWS Terrain warning (2 s) CAS 95 kt, GS 111 kt GPWS Whoop whoop pull up warning (22 s) CAS 90 kt, GS 106 kt Thrust levers pulled to full reverse position CAS 79 kt, GS 93 kt

17 h 25 min 46 s 17 h 25 min 54 s

17 h 25 min 56 s
17 h 26 min 10 s

Runway excursion CAS 54 kt, GS 76 kt Spoilers retract CAS NCD (<30 kt), GS 17 kt Aircraft stop CAS NCD (<30 kt), GS 2 kt END OF FDR RECORDING

CVR Readout
The readout was done at the BEA laboratory

The recording contains the following tracks: 3 tracks corresponding to the last 30 minutes of recording containing VHF and crew communications (Captain, First Officer, CAM) 1 track corresponding to the 2 hours of recording containing the Public Address signal 1 track corresponding to the 2 hours of recording containing the signal of the first three channels mixed together

Note: this track allocation is not standard since the signal from the cockpit area microphone should always be recorded separately and during two hours on this type of CVR. This unusual track allocation could be related to the wiring of the CVR. Samplitude audio editing software was used to perform the read out of the audio files. It was confirmed that the event was recorded. The overall quality of the recording is acceptable

Reading indicated that

* The captain got clearance to perform approach R/W 36 * Aircraft configured for landing, checks completed * Captain got clearance for landing * Controller informed the flight wind 320/07kt and R/W condition (rain, wet)

* Co-pilot suggested the use of Auto-brake and captain decided not to use it * Co-pilot announced centre line * Co-pilot announced centre line left * A single chime was recorded about 20 seconds after touchdown * GPWS warnings were triggered several times prior to overrun TerrainPull up

As the readout of FDR could not provide accurate information about the low deceleration, the Board, Airbus and BEA suggested to again to review aircraft Maintenance documentation To examine wreckage parts by appropriate laboratories in France under supervision of the board through BEA Such parts are as Parking brakes, the tyres, the brakes, remaining computers, the anti-skid switch

Unfortunately no remaining computers were found

Review of log books show 1- No braking issue was highlighted 2- No report about the GPWS was highlighted 3- Engine No. 1 thrust reverser was found stuck in open position after landing on 22/04/2008 and was deactivated up to 10/05/2008 when the RH master actuator was replaced 4- No tyre inflation information is recorded as the aircraft was not equipped with TPIS

The aircraft was fitted an EGPWS P/N 965-0976003-206-206 The aural warning Terrain, Pull up were trigged 19 seconds after touchdown Such warnings are Mode 2 which based on radio altitude and closure rate associated Below 30 ft no warnings should be triggered The A310 MSN 548 was not covered by Airbus Service BulletinA310-34-2163 That is its installation was not defined by Airbus

Unfortunately no computers were found

The brake units were tested locally at Sudan Airways facility attended by representatives from :Sudan Investigation Board The BEA Sudan Airways Airbus

The aim of the test was to determine the status of both normal and alternate braking systems Visual inspection revelled that
* All brakes were in good shape within wear limit * No hydraulic leak was evidenced * There several impacts due to accident * Pistons were covered with dirt from accident site * Some pistons covered with melted aluminium

On hydraulic Test

* All pistons were active under low pressure with no leak * At low pressure ( 200 psi) pistons were observed moving, discs were not free to rotate, pistons applied pressure on thrust plate
* At high pressure (2000 psi) no leak was seen * According to the test no failure was evident due to brakes

Also According to FDR analysis The left main gear braking system was working about 10 seconds after touchdown when the captain succeeded to bring the aircraft back on the centre line by differential brakes as he stated. No failure of brakes was recorded on the FDR and According to the rubber marks at the end of the R/W due to wheel lock , braking system failure appears to be unlikely

Tyres Examination
The tyres were shipped to France and being examined in a French Laboratory the Centre dEssais Aeronautique de Toulouse (CEAT) Conclusion of examination 8 tyres show flat spot on the tread The flat spot damage were due to locking of the wheels 7 tyres were burst except tyre No. 1 (LH/MLG) No evidence of hydroplaning Wheels rim had no wear marks indicating the rim did not touch R/W surface, no scraping

Antiskid
The BRK A/SKID lever was found hanging from the 401VU panel, in the position indicated in the photo. This position was consistent with the switch being set to ALTN/OFF Alternate braking/Antiskid off The 3 push buttons of AUTO BRK selection were severely damaged by fire.