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weight, the optimum cruising level derived by the FMS would have
been in excess of FL 410, at all temperatures, at speeds up to
M 0.82. Furthermore, at this weight, the bracket of speeds
available, from the Lowest Selectable Speed (Vls) to the Maximum
Operating Speed (Vmo) was 210 – 254 knots (M 0.73 – M 0.86) i.e.
a range of 44 knots. The intended cruising speed on this occasion
was at M 0.80 to M 0.81, which was close to the mid-point of the
speed bracket. Thus the decision to climb from FL 370 to FL 410
was in accordance with normal operating practice, notwithstanding
the subsequent unforeseen encounter with severe turbulence and
the resultant exceedance of aircraft operating ceiling and
Vmo/Mmo limits.
35
2.4.4. The operator’s Standard Operating Procedure for turbulence
penetration is specified in the Quick Reference Handbook (QRH).
This requires a turbulence penetration speed of 260 knots/M 0.78,
with FSBS selected ON, Autopilot to remain Engaged. When the
thrust changes become excessive, the Autothrust is to be
disconnected. The engine thrust setting is then adjusted, in
accordance with the “Speed and Thrust Setting for Turbulence
Speed Table” in the QRH, which is based on the aircraft weight, to
obtain a smoother ride.
2.4.5. Pilots experience turbulence of differing degrees on most flights,
particularly in tropical latitudes. The recommended turbulence
penetration speed as specified in the QRH is for SEVERE
turbulence, which all pilots seek to avoid, and is thus rarely
experienced. The common practice is to reduce speed
progressively as light or moderate turbulence is experienced,
towards the turbulence penetration speed. On this occasion, as the
aircraft had been experiencing only light turbulence prior to the
occurrence, a cruising speed of M0.80 – M0.81 was reasonable.
2.4.6. Given the insignificant weather information presented on the ND,
and the fact that the aircraft was only experiencing light turbulence
prior to the encounter, the crew’s decision to select the FSBS ON
and to allow the cabin crew to continue with meal services was
considered not unreasonable, under the circumstances.
36
2.5. Decision to Continue the Flight to Hong Kong
At the point of the severe turbulence encounter, the aircraft was at a position
260 NM west of Manila and 610 NM south-southeast of Hong Kong.
Subsequent to the occurrence, both the Co-pilot and the PIC inspected the
cabin in turn. The PIC conferred with the doctor on board to assess the
conditions of those injured. Considering the less favourable weather
conditions in Manila than in Hong Kong, the relative positions of the
airports, and more importantly, the fact that the injured were in a stable
condition, the decision to continue the flight to Hong Kong was a logical one.
2.6. Crew Training and Documentation
2.6.1. Use of Weather Radar
2.6.1.1. In addition to those contained in A330 FCOM 3, the
company instruction on the use of weather radar as
stated in Operations Manual Volume 8 (Appendix 12
refers), in its entirety, is as follows:
Section 8.1.1 Page 15 Para. 33:
“If it is anticipated that the weather radar will be
required shortly after take off, it is to be selected ON
whilst lining up for take off.”
2.6.1.2. Apart from the very brief instruction given in the above
paragraph and the procedures in FCOM 3, no
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supplementary procedures or guidance material to flight
crew as to the use of weather radar could be found. At
interview, the PIC asserted that he could not recall any
classroom discussion on severe turbulence.
2.6.1.3. The investigation team reviewed the training records of
the flight crew concerned and noted that “Use of
Radar/Weather Avoidance” was one of the “Discussion
Items” in the check list used for Line Training but was
not included as a “Practice Item”. The record of the
PIC’s A330 Line Training that was completed in
September 1995 used a training checklist that did not
include “Use of Radar/Weather Avoidance” as one of
the discussion items. His supplementary Line Training
conducted in December 1998 showed that the boxes
against “Use of Radar/Wx Avoidance” were vacant
suggesting that this item had not been discussed. The
training record of the Co-pilot showed that “Use of
Radar/Wx Avoidance” had been discussed twice during
his Line Training conducted between March and June
2003. However, as this item did not constitute a
“Practice Item”, there was no clear evidence that the use
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