AIRBUS INDUSTRIE and China Airlines (CAL) have both been attributed with blame by a Japanese investigation into the April 1994 crash of an A300-600R at Nagoya.
A final report issued by Japan's Aircraft Accident Investigation Commission (AAIC) points to deficiencies in the design of the aircraft's flight-control computer system. The commission also cites pilot error and poor crew training, on the part of CAL. The sequence of events, leading to the crash, was triggered by the co-pilot inadvertently engaging the "go lever" putting the A300's auto-pilot into a go-around mode during its final approach to Nagoya Airport.
Rather than disengaging the mode, the crew tried to manually override the auto-pilot system. The system compensated for the pilot's nose-down input by putting the aircraft into a nose-up attitude. The A300 pitched up, stalled and crashed, killing 264 people on board.
Following earlier incidents, a software modification was available before the Nagoya crash. It would have allowed pilot pressure on the stick, to disengage the auto-pilot. Taiwan's Civil Aeronautics Administration (CAA) claims that Airbus failed to notify its customers of the necessary modification.
In addition to the needed software change, Japanese investigators have pointed to the absence of any cockpit warning-system to indicate that the aircraft was in the wrong mode. The flight manual has also been criticised for unclear instructions on how to correct such a mistake. The report blames the crew for a lack of familiarisation with the systems and poor pilot/co-pilot communications. The AAIC has asked Taiwan's CAA to direct CAL to improve pilot training and cockpit-resources management.
Source: Flight International
