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As a result, the deviation around weather was not initiated early
enough, nor was the deviation large enough to avoid the weather.
(Ref. Para. 2.3.8)
3.1.9. The flight crew had not been provided with sufficient technical and
guidance information, nor was there clear evidence that they were
adequately trained to operate the Honeywell RDR-4B Weather
Radar. (Ref. Para. 2.6.1.5)
3.1.10. The cabin crew were qualified and adequately trained to handle the
unusual situation after the accident. The cabin crew functioned
effectively as a team in a demanding situation. The CP
demonstrated competence and professionalism in cabin resource
management to ensure that the injured were attended to. (Ref. Para.
2.7)
3.1.11. The operator runs separate CRM courses for flight crew and cabin
crew. Annual CRM recurrent training is provided only to cabin
crew but not to flight crew. (Ref. Para. 2.8.5)
3.1.12. The FSBS were selected ON before the turbulence encounter. (Ref.
Para. 2.9.2)
3.1.13. Handling of the flight by Manila and Hong Kong ATC was in order.
Emergency units were alerted in a timely manner and adequate
52
resources were provided to transport the injured persons to
hospitals. (Ref. Para. 2.10.3)
3.1.14. No data could be retrieved from the QAR concerning the flight
from Hong Kong to Kota Kinabalu and return. (Ref. Para. 2.11.2)
3.1.15. After parking, the “Push to Erase” button on the CVR was operated.
This contravenes the company’s instruction with regard to
preservation of flight records. (Ref. Para. 2.12.1 & Para 2.12.2)
3.1.16. The aircraft behaved normally during the period of severe
turbulence encounter with no system anomaly found. (Ref. Para.
2.13)
3.2. Cause
3.2.1. The aircraft encountered severe turbulence as it flew into an area of
turbulent weather caused by strong convective activity associated
with a tropical depression. (Ref: Para. 2.3.7)
3.3. Contributing Factors
3.3.1. It was highly probable that the weather radar was operated in such
a way that it did not achieve optimum detection and indication of
the position and intensity 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. (Ref: Para. 2.3.8)
53
3.3.2. 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.
(Ref: Para. 2.6.1.5)
4. SAFETY RECOMMENDATIONS
4.1. Recommendation 11-2004
It is recommended that the operator should review and augment the relevant
parts of the A330 FCOM 3 and FCOM 8 to provide more details on the
technique in the operation of weather radar. (Ref. Para. 2.6.1.1 & 2.6.1.2)
4.2. Recommendation 12-2004
It is recommended that the operator should strengthen the training of flight
crew on the use of weather radar for weather avoidance. (Ref. Para. 2.6.1.3)
4.3. Recommendation 13-2004
It is recommended that the regulatory authority should consider stepping up
regulatory oversight on the training standards of operators with a view to
ensuring a more comprehensive coverage of weather radar operation and
weather avoidance procedures for flight crew. (Ref. Para. 2.6.1.5)
54
4.4. Recommendation 14-2004
It is recommended that the operator should review its CRM training
programme so as to conform to the CAD 360 requirements. (Ref. Para.
2.8.5)
4.5. Recommendation 15-2004
It is recommended that the operator should consider issuing additional
instructions to flight crew and maintenance staff with regard to the need for
preserving the integrity of DFDR and CVR data, or alternatively, to
incorporate the instruction into FCOM 8. (Ref. Para. 2.12.2)
Colman S.C. Ng
Inspector of Accidents
Accident Investigation Division
Civil Aviation Department
Hong Kong Special Administrative Region
China
55
References
Cathay Pacific Airways Weather Radar Manual (1997) – Published by Cathay Pacific
Airways Ltd.
Dragonair A330 FCOM 3, A320/A321/A330 Operations Manual Volume 8 and 12 –
Published by Hong Kong Dragon Airlines Ltd.
Dragonair Severe Turbulence Event Report and Analysis – Published by Airbus
Honeywell RDR-4B Forward Looking Windshear/Weather Avoidance Radar System
User’s Manual – Published by Honeywell International Inc.
Acknowledgement
The invaluable contributions and assistance offered by the following organizations in
the investigation are gratefully acknowledged: -
中国航空网 www.aero.cn
航空翻译 www.aviation.cn
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