曝光台 注意防骗
网曝天猫店富美金盛家居专营店坑蒙拐骗欺诈消费者
Photograph-5: Damage of the Aft Bulkhead・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・68
Photograph-6: Cabin Attendants Seat・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・69
Photograph-7: Seat Comparison of CA with Passenger・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・69
APPENDIX: Analysis of CVR Recording・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・70
1
AIRCRAFT ACCIDENT INVESTIGATION REPORT
ALL NIPPON AIRWAYS FLIGHT 391
AIRBUS A321－131, JA104A
HAKODATE AIRPORT, HOKKAIDO, JAPAN
AT ABOUT 13:03 JST, JANUARY 21, 2002
September 10, 2003
Decision by the Aircraft and Railway Accidents Investigation
Commission (Air Sub-committee Meeting)
Chairman Junzo Sato
Member Ryouhei Katsuno
Member Susumu Kato
Member Sumio Matsuura
Member Yukiko Kakimoto
Member Kozaburo Yamane
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1 PROCESS AND PROGRESS OF THE ACCIDENT INVESTIGATION
1.1 Summary of the Accident
On Monday January 21, 2002, an Airbus A321-131 of All Nippon Airways, registration
JA104A, departed Nagoya Airport as scheduled passenger flight 391 to Hakodate Airport. At
around 13:03, while the aircraft executed a recovery manoeuvres as wind shear warning
issued during approach to Hakodate Airport, the aft fuselage contacted the ground and as a
result the aircraft sustained substantial damage.
Of the 93 persons aboard flight 391 - 87 passengers and six crewmembers - three cabin
attendants sustained minor injuries.
1.2 Outline of the Accident Investigation
1.2.1 The Organization of the Investigation
On January 21, 2002, the Aircraft and Railway Accident Investigation Commission
(ARAIC) assigned an investigator-in-charge and two other investigators.
On October 5, 2002, a new investigator-in-charge was assigned as a result of personnel
transfers, and an additional investigator was also assigned.
1.2.2 Accredited representative and adviser by Foreign Authorities
Accredited representatives from the French republic, the state of design and
manufacture of the aircraft, participated in the investigation of this serious incident.
1.2.3 The Implementation of the Investigation
The investigation proceeded as follows.
January 22–23, 2002 On-site and aircraft investigation
January 22–April 23, 2002 Interviews the crew and eyewitnesses
January 22–February 22, 2002 Analysis of Digital Flight Data Recorder
(DFDR) and Cockpit Voice Recorder (CVR)
recordings
February 1, 2002 Assignment of Accredited Representatives
from the state of manufacture
April 9, 18 and November 21, 2002 Flight tests using a flight simulator
1.2.4 Hearings from Persons relevant to the Cause of the Accident
Hearings were held.
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1.2.5 Report and Disclosure to Public
Regarding the process of the accident investigation, ARAIC had submitted the interim
report to the Minister of Land, Infrastructure and transport and made disclosure to public
on January 31, 2003.
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2 FACTUAL INFORMATION
2.1 History of Flight
2.1.1 Outline of the Flight based on the DFDR and CVR, etc.
On January 21, 2002, an Airbus A321-131 of All Nippon Airways, registration JA104A,
was operating as scheduled flight 391 from Nagoya to Hakodate.
The flight plan of the aircraft which was submitted to the Nagoya Airport Office of
Japan Civil Aviation Bureau (CAB) was as follows:
FLIGHT RULES: IFR, DEPARTURE AERODROME: Nagoya Airport, EOBT: 11:45,
CRUISING SPEED: 436kt, CRUISING ALTITUDE: FLIGHT LEVEL 370, ROUTE OF
FLIGHT: KROBE–Y13–MRE–V31–HWE, DESTINATION AERODROME: Hakodate Airport,
TOTAL EET: 1 hours 01 minutes, ENDURANCE: 4 hrs 19 minutes, PERSONS ON BOARD:
93.
The flight crew were briefed for the flight by the dispatcher before departure from
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