[Peetwo]

Two+ years for this?  - AO-2015-032 Investigation status: Completed

Summary & findings:

What happened

On 14 March 2015 Malaysia Airlines Airbus A330, registered 9M-MTA, began its approach to Melbourne (Tullamarine) after a flight from Kuala Lumpur. In the final stages of the approach, at approximately 50 feet, the captain reported feeling the aircraft sink and manually increased the thrust to the engines in an attempt to slow the rate of descent. Despite this action, the aircraft experienced a hard landing of a magnitude requiring replacement of the aircraft’s main landing gear. There were no reported injuries as a result of the occurrence.

What the ATSB found

The ATSB found that as a result of the pilot flying’s control inputs after disengaging the autopilot (approximately 700 feet above the ground), the final approach had become unstable, descending below the desired vertical profile. The continuation of the approach and an inappropriate attempt to recover the situation led to a high rate of descent at touch down.

What has been done as a result

Soon after the event, the operator circulated a memorandum to their A330 flight crew highlighting the incident and advising of the relevant procedures intended to minimise the chances of a similar occurrence. The flight crew involved also undertook additional training and assessment before returning to flight duties.

Safety message

A stable approach significantly reduces the risk of a hard landing.

If an approach does become unstable, a rushed attempt to recover the approach may produce an undesirable aircraft response. There is also a risk of breaking down the shared understanding between the pilots, which in turn limits the opportunity of the other flight crew to detect or react to inappropriate actions.

When landing, pilots should maintain a safety philosophy of “if in doubt, go around”.

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Findings

From the evidence available, the following findings are made about the hard landing involving an Airbus A330-343, registered 9M-MTA that occurred at Melbourne Airport, Victoria on 15 March 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• The final approach became unstable at around 300 feet above the ground due to the control inputs from the captain.
  
• Inadequate monitoring and communication by the crew led to a lack of recognition of the undesirable flight state and the continuation of an unstable approach.
  
• Continuation of the unstable approach led to a high rate of descent at touchdown and resulted in a hard landing in excess of the aircraft design loads and short of the normal touchdown area.
  

Other safety factors

• The captain used an unapproved manual thrust procedure in an attempt to recover the approach.
  

 Bearing in mind there is a PAIN BRB review pending but at 1st glance I have to ask WTD was the hold-up? Maybe the PC commissioners were waiting for diplomatic approval to quietly release what had the potential to be a serious accident...  


MTF...P2

Ps Still waiting for the 3rd anniversary interim report for the VARA ATR broken tail accident investigation, that saw a VARA ATR flying for 5 days and 13 additional sectors since the horizontal stabiliser was initially structurally damaged.     

The ATSB reported: "The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser."