NAME: ROSE TIPATET
SUBJECT: HUMAN PERFORMANCE
AIRCRAFT ACCIDENT
WHEN
The accident occurred on 18 July 2003
WHERE
The flight was En-route from Kota Kinabalu to Hong Kong along Route M754 within the Manila FIR cruising at Flight Level (FL) 410.
Operator: Hong Kong Dragon Airlines Limited
Aircraft Type: Airbus A330
Registration: B-HYA
Flight Number: HDA060
WHAT
The aircraft encountered severe turbulence as it flew into an area of turbulent weather caused by strong convective activity associated with a tropical depression.
WHY
The flight crew had not been provided with sufficient technical and guidance information nor were they adequately trained to operate the Honeywell RDR-4B Weather Radar for weather avoidance. Pilot error (weather related) live ware-environment.
HOW
Prompted by weather returns displayed on the weather radar, the flight crew requested permission from Air Traffic Control (ATC) in Manila to deviate right of track to avoid weather. Not long after take-off, the airplane experienced serious turbulence.
At the time of the occurrence, the Fasten Seat Belt Signs (FSBS) were selected ON and all passengers were seated with their seat belts fastened. However, as the cabin crew were serving meals along the aisles and galley areas they were not strapped in. Based on the Digital Flight Data Recorder (DFDR) data, during the turbulence encounter, the cruising level varied between FL 408 and FL 416. The aircraft experienced a rapid sequence of jolts that resulted in various degrees of injuries to all twelve cabin crew members. Of the 236 passengers on board, three sustained minor injuries. The accident did not cause any damage to the primary structure of the aircraft. However, there was minor damage to the interior fittings within the aircraft cabin area.
The accident occurred within the Manila Flight Information Region (FIR) where a tropical depression had just moved to an area over the sea to the west of the Philippines, moving on a track of west-northwest and was forecast to intensify over water. At the time of the accident, the aircraft was deviating 6 NM to the right of Route M754 northbound at a position approximately 160 NM to the west-northwest of the center of the tropical depression.
After the accident, the aircraft was promptly accorded priority landing at Hong Kong. It subsequently landed safely at Hong Kong International Airport (HKIA).
CONCLUSION
As the occurrence resulted in serious injuries, in the form of bone fractures, to persons on board, it was classified as an aircraft accident. The Chief Inspector of Accidents therefore ordered an Inspector’s Investigation be carried out in accordance with the Hong Kong Civil Aviation (Investigation of Accidents) Regulations 1983.
The investigation concluded that the aircraft inadvertently flew into an area of turbulent weather caused by strong convective activity associated with the tropical depression. Based on the evidence as to the way in which the weather radar was operated, it was highly probable that the flight crew were not presented with the optimum weather radar picture that would have enabled a full appreciation of the intensity and extent of the weather in the vicinity of the aircraft. As a result, the deviation around weather was not initiated early enough, nor was the deviation large enough to avoid the weather.
RECOMMENDATION
It is recommended that the operator should strengthen the training of flight crew on the use of weather radar for weather avoidance.
