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surface wind recorded by the anemometer throughout the period of this
event was well below the caution wind speed of 15 kts. It is therefore
improbable that the phenomenon that gave rise to this caution was a factor
in this event.
3. Conclusions
3.1 Findings
3.1.1 The aircraft had been properly maintained and its documentation was in
order. The weight and centre of gravity were within authorised limits.
3.1.2 The crew were properly licensed, medically fit and rested to conduct the
flight.
3.1.3 The aircraft encountered turbulence and crosswind on the approach,
particularly in the earlier phases of the approach. Light downdrafts may
also have been present.
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3.1.4 The aircraft failed to establish itself correctly on the approach with respect
to glideslope. There were also significant speed fluctuations during the
approach. Engine power was varied by large amounts during the approach.
The approach was not stabilised.
3.1.5 The initial hard touchdown was caused by landing from an approach
which had not been stabilised, in particular with regard to an excessively
high rate of descent, combined with a late flare with increased engine
power, and high speed in the later stages.
3.1.6 The ground spoilers did not fully deploy during the first touchdown due to
the manual movement of the throttles above the flight idle position in the
final stages of the approach.
3.1.7 The initial hard landing resulted in a bounce. The bounce was aggravated
by the non-deployment of the ground spoilers. A nose-down input of 9
during the bounce caused the aircraft to enter a nose down attitude, with
the effect that the subsequent touchdown was on the nose wheel, with a
nose pitch down angle of 3 to 4. This second touchdown, on the nose
wheel, caused the damage sustained by the aircraft.
3.1.8 The application of nose down elevator during the bounce was
inappropriate, and contrary to the aircraft’s FCOM procedures.
3.1.9 There are no indications that dangerous wind shear was present at the time
of the approach or landing. In particular, the aircraft’s systems did not
detect wind shear, thereby indicating that significant wind shear was not
encountered.
3.1.10 There may have been a change of wind direction immediately prior to
touchdown. However the wind was light, and no indications of sudden
variations of wind speed were found at that time.
3.1.11 While conditions of turbulence and light wind shear were present during
the approach, and there may have been light downdrafts during the
approach and a possible change of wind direction immediately prior to
touch-down, the weather conditions should have presented no difficulties
in the course of a normally conducted stabilised approach and landing.
However, when such conditions were added to an unstable approach, the
handling pilot was faced with a difficult situation.
3.1.12 The cockpit indications of a sudden increase of wind speed to 47 kts
during the landing roll were erroneous, and were as a result of damage to
the IRS units, sustained in the high G landing.
3.1.13 There are indications of a breakdown of good CRM practises during the
approach.
3.1.14 The weather conditions were not primary factors in this accident.
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3.2 Causes
3.2.1 The aircraft experienced a hard landing following an un-stabilised
approach, combined with a late flare, increased engine power prior to
touchdown and high speed at touchdown.
3.2.2 The aircraft bounced as a result of the hard landing. The bounce was
aggravated by the closing of the ground spoilers, which was in turn due to
the selected throttle position.
3.2.3 During the bounce there was an inappropriate control input. This resulted
in the aircraft landing again heavily on its nose-wheel thereby damaging
the nose structure of the aircraft.
3.2.4 The decision of the PF to continue the approach and landing from an
unstable approach, aggravated by moderate turbulence and light wind
shear, and possible downdrafts.
4. Safety Recommendations
4.1 The operator should review the effectiveness of its CRM programme with
special emphasis on ensuring that standard procedures for both PF and
PNF are followed, subsequent to a role change from PF to PNF during an
approach. (SR 12 of 2001)
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ANNEX A
Shannon Anemometer B wind speed and direction data as recorded on 27 December
1999 from 15.00 to 17.00 hrs UTC
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ANNEX B
Shannon weather radar as recorded at 16.01 hrs UTC on 27 December 1999
Circle represents 50 km radius
Pixels are 1 km x 1 km
20
ANNEX C
Shannon weather radar as recorded at 16.16 hrs UTC on 27 December 1999
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