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latent critical fuel scenarios capt. raimund zopp flugwerkzeuge aviation software • Airbus 310, Charter flight from Chania/Greece to Hannover/Germany • Landing gear retraction fault at takeoff in Chania • Flight continuation to reach commercially favorable alternate • fuel planning exclusively by FMS • Repeated replanning to MUC and then to VIE after FMS fuel prediction deteriorates • Early start of descent 90NM before optimum • Fuel below original final reserve and fuel low level warning abeam ZAG, 133NM out of VIE • Emergency declared 8 minutes later • Both engine flame-out short before outer marker • Crash landing on grass 500m before runway • Only light injuries, aircraft written off HLF 3378 (Vienna, July 2000) HLF3378 Flightpath Overview 35,00 36,00 37,00 38,00 39,00 40,00 41,00 42,00 43,00 44,00 45,00 46,00 47,00 48,00 49,00 50,00 15,00 16,00 17,00 18,00 19,00 20,00 21,00 22,00 23,00 24,00 25,00 26,00 Longitude Latitude Reconstr ACARS Airports DR_Path CFPWpts SRKOR VIE GRZ BUD MBX ZAG SPL DBV BDS CFU SKG ATH CHQ TIA aber jetzt hamm wir 800 Kilo (CVR/CM1) Fuel low level warning (ACARS) EFOB VIE below Holding Fuel (Estimate) FQ below Holding fuel (Estimate) HER • Aircraft operated beyond range capability with landing gear down • FMS fuel predictions used as sole means of fuel planning • No ground support for fuel planning • Subtle loss of situational awareness • Violation of rules in final stage: no diversion to ZAG or GRZ when fuel quantity dropped below final reserve official report should be available soon on http://versa.bmvit.gv.at HLF 3378 (Vienna, July 2000) HLF3378 Fuel Situation -500 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 09:30:00 09:45:00 10:00:00 10:15:00 10:30:00 10:45:00 11:00:00 11:15:00 11:30:00 UTC Est FQ on Indicators EFOB MUC / FMS EFOB VIE / FMS 30 min Holding Fuel Tanks Empty abeamZAG FQ Low Level Warning EFOB VIE goes below Holding Fuel • repeated replanning and shortcuts gave impression that FMS fuel prediction was still reliable • documentation confusing and incomplete • no other method for fuel planning considered swiss cheese model of accident causation according to j. reason in the case of HLF3378, active inflight support from dispatch would have been one of the defense layers one of several safety recommendation: (free translation from German language, since official translation not yet available) .... application of support to cockpit crew by the flight dispatcher as required by ICAO Annex 6 and the quality manual of the operator .... remaining crucial questions: • is the dispatcher obliged to support the flight crew only on request ? • does his support involve a fuel recalculation ? • can (or shall) the dispatcher initiate an emergency ? • how shall a dispatcher perform the neccessary calculations ? HLF 3378 accident investigation HLF3378 - just a singular case? • actual case: gear-down diversion due to weather / hydraulic loss – loss of hydraulic system early during flight – continuation to destination with approaching frontal weather – go-around due to weather – gear retraction impossible – diversion with gear down – severe fuel situation / landing below final reserve – loss of gear retraction capability was known for hours – documentation gives no advice to adjust fuel planning • potential case: engine fail with locked rotor – quiz: how much does the fuel burn increase? commercial pressure as a risk factor ? 2000/07/12 HFL3378 • prolonged gear down flight from Greece to Vienna • uncritical weather • good communication • strong commercial motivation to continue • insufficient ground support • loss of situational awareness • all engine flame-out • crash 2005/02/19 BA268 • with a failed engine from US west coast to UK • uncritical weather • good communication • strong commercial motivation to continue www.aero.cn 航空翻译 www.aviation.cn 本文链接地址：航空资料32
