Transport Accident and Incident Investigataion BureauTransport Accident and Incident Investigataion Bureau
 
 
 
 

FINAL REPORT OF THE SERIOUS INCIDENT

"TYROLEAN AIRWAYS" WITH AIRCRAFT

FOKKER  F28 Mk100 "OE-LVI" Nr.3/2005

 In accordance with Annex 13 of the Convention of Chicago as well as the Directive 94/56/EC of 21 November 1994 establishing the fundamental principles governing the investigation of civil aviation accidents and incidents of the Council of the European Union, the purpose of an investigation conducted under the responsibility of the Latvian Accident and incident investigation division is not to apportion blame or liability.

 Head of Accident and incident

Investigation division

 Riga, July 2005

 CONTENTS

 GENERAL INFORMATION OF THE SERIOUS INCIDENT

 THE INVESTIGATION

 SYNOPSIS

 1. FACTUAL INFORMATION

1.1 History of Flight

1.2 Injuries to Persons

1.3 Damage to Airplane

1.4 Other Damage

1.5 Personnel Information

1.6.Airplane Information

1.7 Meteorological Information

1.8 Aids to Navigation

1.9 Communications

1.10 Airport Information

1.10.1 Air Traffic Control Information

1.11 Flight Recoders

1.11.1 Cockpit Voice Recoder

1.12 Wreckage and Impact Information

1.13 Medical Information

1.14 Fire

1.15 Survival Aspects

1.16 Tests and Research

1.17 Organizational and Management Information

1.18 Additional Information

 2 ANALYSIS

 3 CONCLUSIONS

 4 PROBABLE CAUSE

 5 RECOMMENDATIONS

 6 APPENDICES

 GENERAL INFORMATION OF THE SERIOUS INCIDENT

 Unless stated otherwise all times in this report are UTC time.

 Registered Owner:                     Austrian Airlines Lease and

Finance Company Ltd

 Operator:                                   Tyrolean Arways

 Aircraft type:                              Fokker F28 Mk100

 Nationality:                                Austria

 Registration:                     OE-LVI

 Place of Serious Incident:          Riga International Airport

 Date and Time:                          19 May 2005 at 13.15 hrs UTC

  THE INVESTIGATION

 The serious incident was notified to the Aircraft Accident and Incident Investigation Division of the Ministry of Transport of the Republic of Latvia on May 19th 2005 at 13.15 UTC and the investigation began on 19 May 2005. when additional details of the incident became known.

The Aircraft Accident and Incident Investigation team comprised Mr Ivars Gaveika (Investigator-in- Charge), Mr Ivars Zorgenfreijs (Operations )

  Synopsis

 The incident occurred at the route St.Petersburg-Vienna. During cruise at FL340 the crew noticed an increase in cabin altitude without any crew action to the pressurization system. The crew requested and initiated a descent after coordination and approval from ATC. During descent at the same time ”Cabin ALT” warning comes on. This was followed by an emergency descent and the Captain decided to perform landing in Riga International Airport. Oxygen masks dropped out automatically during descent at cabin altitude of 14 500 feet. After passing the altitude of 5000 feet pressurization system start’s to operate normally again. Landing was performed without any remarks.

   Meteorological condition in EVRA 191250Z 32008KT 9999 13/00 Q1022 NOSIG.

  1. Factual Information

 1.1 History of the incident

 -Flight number – OS 612, 50 passengers and 5 crew on board

-Point of departure – St.Petersburg (ULLI)

-Time of departure – 11.54UTC

-Point of destination – Vienna (LOWW)

-Point of landing – Riga (EVRA)

-Time of landing – 13.15 UTC

 The slow decompression occurred during cruise FL340. At the same time ”Cabin Alt” warning comes on. Captain decided to perform emergency landing in Riga International Airport. Oxygen masks dropped out automatically during emergency descent when cabin altitude reached 14500 feet. During descent after passing the altitude 5000 feet pressurization system start’s to operate normally again. Landing was performed without any remarks.

 1.1.1.Fokker F28 Mark100 REG:OE-LVI, FLN OS 612 after landing at Riga airport (EVRA) on 19.05.2005.

 1.1.2. Oxygen masks dropped out automatically during emergency descent Fokker F28 Mark100, REG: OE-LVI, FLN: OS612, on 19.05.2005. (right side).

 1.1.3. Oxygen masks dropped out automatically during emergency descent Fokker F28 Mark100, REG: OE-LVI, FLN: OS612, on 19.05.2005. (left side).

 1.2 Injuries to persons

 None.

 1.3 Damage to aircraft

 None

 1.4 Other damage

 None

. 1.5 Personnel information

 The flight crew on aircraft was qualified and current to operate the flights on Fokker F70/100.

The Captain, age 52,  of ,,Tyrolean Airways” aircraft Fokker F 28 Mk0100 OE-LVI flight number OS 612 had a total of 16100 flying hours of which 8000 hours were on type, including flight hours as a Captain on Fokker F28 Mk0100.

By day of the incident had a total 04.45 flight hrs and 09.30 hrs duty time.

He held an airline transport pilot certificate and medical certificate valid until 13.11.2005. Proficiency check 13.11.2005.

 The First Officer, age 50, of ,,Tyrolean Airways” aircraft F 28 Mk0100 OE-LVI had a total of 8500 flying hours of which 21 hours were on type. By day of the incident had a total 03.12 flight hrs and 05.05 hrs duty time.

 He held an airline transport pilot certificate and medical certificate valid until 11.09.2005. Proficiency check 06.07.2003.

 1.6 Aircraft information

 The Aircraft Fokker F Mk0100, OE-LVI serial number 11468, manufacture by Fokker Aircraft Corporation at 1993, had a total of 39800 flying hours and 23038 landings.

Take-off weight actual – 40400 kg. (Max take off weight 44450 kg).

Balance – according operation limits and requirements.

Landing weight actual – 38 800 kg

Take-off fuel – 5900 kg

Type of fuel used – JET A-1,

  1.7 Meteorological information

 1.7.1 SALV31 METAR EVRA 191250z :

32008KT 9999 SCT049 13/00 Q1022 NOSIG.

 1.7.2 SARS31 METAR ULLI 191045Z 191221 23008MPS 6000 BKN010CB

TEMPO 1218 1500SHRA BKN005 TEMPO 1821 0400 FG VV002

 1.8 Aids to Navigation

 - VOR/DME – RIX – 113,700 MHz – H24;

- LLZ RWY 36 ILS CAT 1 – IRP - 110,300 MHZ – H24;

- GP RWY 36 – 335,000 MHz – H24;

- DME RWY 36 – IRP – 1001,000 MHz, 1064,000 MHz – H24

  1.9 Communications

 The correct phraseology, to be used by air traffic controllers, is to be found in International Civil Aviation Organisation Doc.4444 Procedures for Air Navigation Services ,,Air Traffic management’’Chapter 7 – Aerodrome and Meteorological Information item 7.3.1.2.1 and 7.3.1.2.2.

 1.10 Aerodrome information

 Riga International Airport is served by one Runway18/36.

 Dimensions of Rwy (M) – 2550x45

Slope of Rwy 18 – 0,05%; Rwy 36 – 0,05%;

TORA – 2550m;

TODA – 2950m;

ASDA – 2550m;

LDA –   2550m.

 Surface of Rwy – Asphalt-Concrete. Note – composite construction.

PCN: 110/F/A/W/T.

Approach and Runway Lighting:

 Rwy18:

-APSH LGT Type LEN INST – ALSF-1 (CAT 1) 900m spacing 30m; LIH

-THR LGT color WBAR – Green;

-VASIS (MEHT) PAPI – PAPI left GP 3,00 degrees (62,7 feet);

-TDZ LGT LEN – NIL;

-Rwy Centre Line LGT Length spacing color, INTST –NIL;

-Rwy edge LGT LEN spacing color, INTST – 2550m , 60m white, last 600m yellow,

LIH.

-Rwy End LGT Length spacing, color, WBAR – Red.

- SWY LGT LEN (m) colour – NIL

 Rwy36:

APSH LGT Type LEN INST – ALSF-1 (CAT 1) 840m spacing 30m; LIH

-THR LGT color WBAR – Green;

-VASIS (MEHT) PAPI – PAPI left GP 3,00 degrees (68,2 feet);

-TDZ LGT LEN – NIL;

-Rwy Centre Line LGT Length spacing color, INTST –NIL;

-Rwy edge LGT LEN spacing color, INTST – 2550m , 60m white, last 600m yellow,

LIH.

-Rwy End LGT Length spacing, color, WBAR – Red.

- SWY LGT LEN (m) colour – NIL

  1.11 Flight recorders

 Flight Data Recorder (FDR) read out copy provided by the aircraft operator. See Appendix 2 and 3.

1.12 Wreckage and impact information

 Not applicable.

  1.13 Medical and pathological

 There were no medical aspects relevant to the incident.

  1.14 Fire

 Not applicable.

 1.15 Survival aspects

 Not applicable.

 1.16 Tests and research

 Not applicable.

 1.17 Organizational and management information

 None

 1.18 Additional information

 None

 1.19 New investigation techniques

 None

  2. Analysis

Meteorological condition at the passengers boarding time was complicated, changeable weather with shower.Due to rain, the water ingresses into pressurization seal of the entrance door. During aircraft climb temperature quickly fell down. Due to the presence of water in the pressure seal, the water drainage holes possibly were blocked by ice and its cause the failure of the maintaining the pressure in pressure seal of the door. Because of that huge air leakage appears in the area of the entrance door and pressurization system could not maintain normal pressure in the cabin. When the pressure in the cabin reaches the value of the cabin pressure sensor switching the Cabin Alt warning comes on. As well at the pre-set value of cabin pressure oxygen masks automatically dropped out.

 The captain decided to perform landing in the Riga International Airport.

During descent outside temperature increases and ice blockage in the door pressurization seal was melted, that restores the normal operation of the pressurization system.

 3.  Conclusions

 3.1. Findings

 1. The aircraft was fully serviceable.

2. The flight crew was properly licensed to perform the flight. 

 The reason of the decompression in the passenger cabin during the aircraft cruise at FL340 was the entrance door’s pressurization seal drainage holes blockage due to frozen water.

 3.1.1. Bay of passenger entrance door where pressurization seal drainage holes blockage due to frozen water.

 4. Safety Recommendations 2005-7

 In the airline (operator of the aircraft involved in the incident) the procedures to be introduced for strongly monitoring the entrance door opening at the rainy weather conditions. Of course it is understandable that impossible to avoid opening the door at heavy rain. But the door opening to be limited as much as possible and to be monitored by flight crew and/or handling organization.

 24.10. 05.

 Investigator-in -charge

Head of Division Aircraft Accident and Incident

Investigation Ministry of Transport of the Republic

of Latvia                                                                                              Ivars Gaveika