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measures described in the operator’s AOM for dealing with a nose-down attitude
assumed only the case of full flap landings, and the First Officer considered difficulty to
land an aircraft with a nose-down attitude.
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It is considered possible that the low-level wind shear had originated due the effects of
ground topography on the surface boundary layer under conditions of strong winds
accompanied by gusts.
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5 FINDINGS
5.1 Flight Crew Training and the Development of Standards related to Wind Shear
(1) In flight crew wind shear training, it is necessary for operators to draw attention to not
only downbursts but also to other causes of wind shear including the effects of
topography on the surface boundary layer.
(2) Since it is sometimes difficult to forecast wind shear, flight crews should be aware of the
possibility of encountering wind shear during approaches and landings where there are
strong winds accompanied by large wind speed fluctuations, and should be thoroughly
trained to give priority to safety in setting the approach speed, engine thrust etc.
(3) Operators should thoroughly train flight crews to determine approach speed by following
the specified rules, rather than by using simple computation methods as in this accident.
Further, operators should grasp line operating practices while considering means of
addressing flight crews’ concerns and misgivings. Thence, operator should notify these
points to their flight crews whenever required.
(4) Under conditions of strong winds accompanied by large wind speed fluctuations, as at the
time of the accident, it is desirable for flight crew members to confirm with each other
clearly and positively their intentions regarding the setting of final approach speed,
which is considered to be a large element for ensuring flight safety during approach and
landing. It is also considered that this point should be emphasized in flight crew training.
(5) Regarding procedures to deal with possible wind shear encounter, the AOM issued by the
operator contained a cautionary note that “Thrust should not be greatly reduced even in
the event of a sudden increase in airspeed, because of the possibility that airspeed may
subsequently decrease”. It is considered necessary that this cautionary note be
emphasized, since is important for preventing recurrence of accidents of this kind.
Furthermore, it is considered appropriate to always consider this caution when
conducting approaches and landings under conditions of strong winds with large wind
speed fluctuations. Moreover, it is necessary that this point be thoroughly driven home by
flight crew training.
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5.2 Technical Study on the Establishment by Operators of Operating Procedures different
from those recommended by the Aircraft Manufacturer
(1) In connection with this accident, regarding the establishment of approach speed for A321
aircraft under the management of “SELECTED SPEED” and “MANAGED SPEED”
modes, if the procedure for determining the approach speed in aircraft operations differs
from that recommended by the manufacturer, it is considered necessary that operators
should decide on the establishment of procedures based on adequate technical studies on
the problems etc. of each procedure relating to company operations while grasping the
background and rationale of the manufacturer’s recommended procedure. It is considered
that the effects of each considered procedure on the pilots’ workload and actions be
adequately examined, with examination of the adequacy of pilot common-knowledge
information and training as necessary.
(2) In particular, when pilots transition to an aircraft with markedly different operating
procedures than their currently qualified aircraft, it is considered that sufficient flight
crew training be conducted on actual operating procedures based on a grasp of the
background and rationale of the manufacturer’s recommended procedures.
5.3 Shock Absorption Characteristics of Cabin Attendant Crew Seats
Although in this accident there were no injuries to passengers or the flight crew due to
the shock of the lower surface of the aft fuselage striking the ground, three of the four CAs
sustained minor injuries. The fact that the thickness of the seat padding of the cabin crew
seats was less than one third of that of passenger seats and the reclining angle of a CA seat
was almost vertical with no armrest might be considered a contributory factor in this
accident.
Given the safety role of cabin crew in guiding passenger evacuation etc. in emergencies,
it is considered necessary to study the means to reduce the possibility of injuries to CAs.
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