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AIRCRAFT ACCIDENT INVESTIGATION REPORT ALL NIPPON AIRWAYS FLIGHT 391 AIRBUS A321-131, JA104A HAKODATE AIRPORT, HOKKAIDO, JAPAN JANUARY 21, 2002 September 26, 2003 Aircraft and Railway Accidents Investigation Commission Ministry of Land, Infrastructure and Transport The investigation for this report was conducted by Aircraft and Railway Accidents Investigation Commission, ARAIC, about the aircraft accident of All Nippon Airways Airbus 321- 131 in accordance with Aircraft and Railway Accidents Investigation Commission Establishment Law and Annex 13 to the Convention of International Civil Aviation for the purpose of determining cause of the aircraft accident and contributing to the prevention of accidents and not for the purpose of blaming responsibility of the accident. This English version report has been published and translated by ARAIC to make its reading easier for English speaking people those who are not familiar with Japanese. Although efforts are made to translate as accurate as possible, only the Japanese version is authentic. If there is difference in meaning of the texts between the Japanese version and the English version, texts in the Japanese version are correct. Junzo Sato, Chairman, Aircraft and Railway Accidents Investigation Commission i Abbreviated words Abbreviated words used in this report are as follows: AOM : Airplane Operations Manual AOR : Airplane Operations Reference APPR : Approach ATIS : Automatic Terminal Information Service A/THR : Auto Thrust Function BEA : BUREAU D'ENQUETES ET D'ANALYSES POUR LA SECURITE DE L'AVIATION CIVILE (The French Bureau of Investigation and Analysis for Safety in Civil Aviation) CA : Cabin Attendant CAS : Computed Airspeed CA/SS : Captain's Sidestick CO/SS : Co-pilot's Sidestick CVR : Cockpit Voice Recorder CRM : Crew Resource Management DFDR : Digital Flight Data Recorder EGPWS : Enhanced Ground Proximity Warning System FAC : Flight Augmentation Computer FAF : Final Approach Fix FCOM : Flight Crew Operating Manual FD : Flight Director FL : Flight Level FMGC : Flight Management Guidance Computer ILS : Instrument Landing System MAC : Mean Aerodynamic Chord MCDU : Multipurpose Control and Display Unit OM : Operations Manual PF : Pilot Flying PFD : Primary Flight Display PNF : Pilot Not Flying P/FR : Pressure Falling Rapidly RET : Retract QAR : Quick Access Recorder i i SPD/MACH : Speed/Mach SRS : Speed Reference System TLA : Thrust Lever Angle TO/GA : Take-Off-Go-Around UTC : Coordinated Universal Time VHF : Very High Frequency VOR : VHF Omni-Directional Radio Range VOR/DME : VOR and DME Combination VAPP : Approach Speed Vα MAX : Speed for the Maximum Angle of Attack VLS : Lowest Selectable Speed VREF : Landing Reference Speed VS : Stalling Speed ii i CONTENTS 1 PROCESS AND PROGRESS OF THE ACCIDENT INVESTIGATION ··································2 1.1 Summary of the Accident·······························································································2 1.2 Outline of the Accident Investigation ··············································································2 www.aero.cn 航空翻译 www.aviation.cn 本文链接地址:航空资料33