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Disaster averted; work to be done (CS-TNV incident Copenhagen) UPDATE FINAL REPORT

Updated: Feb 29



Credit to website avherald.com and its owner Simon Hradecky


UPDATE 29-Feb-2024

The final investigation report has been published by the Danish Havarkommissionen (Danish Transport Safety Investigation agency.

Link to report below


L_2022_Alvorlig hændelse_2022-150_CSTNV_Motorfly_København (EKCH)
.pdf
Download PDF • 25.57MB

The findings are extremely interesting!!

After landing a investigation team was set up and focussed obviously on the reverser inhibit logic which should prevent thrust reverser deployment in flight.

The key to this event was the fact that the aircraft indeed touched down briefly during the event, as opposed to initial reporting.

When the aircraft flared, it drifted to the side of the runway in the prevalent gusty conditions , which made the pilot to go around after initially deploying the thrust reversers. This is formally against published procedures but generally referred to as a balked landing.

After initial touch down the aircraft bounced slightly. Keep this in mind until further.


After safe landing the aircraft was grounded for inspection and investigation. Exhaustive functional tests and detailed component and subcomponent tests were conducted without revealing a conclusive fault that caused the reverser to partly deploy while airborne.


Finally the manufacturer successfully replicated the hypothesis that during the bounce the Left hand (LH) Weight On Wheel (WOW) sensor lost positive signal for a fraction,

. The Right Hand (RH) WOW sensor sensed positive because that landing gear strut remained compressed. At that exact time the trust levers were selected out of reverse and pushed all the way forward. Due to the interruption in WOW signal from the LH gear, the Engine Control Unit "missed " the signal to auto stow the reverser when power was selected and caused the engines to stay partly in reverse.


Interestingly the captain experienced a similar case of a reverser not latching stowed after a balked landing, albeit without staying deployed with the associated detrimental effect on aircraft handling.


Another interesting fact is that Canadian certification requirements do consider bounced aborted landings


One of the safety recommendations is to amend ECU software in order to prevent this glitch.

Another safety recommendation is to amend CS-25 (large aircraft certification code to address safety of bounced landings being aborted




On April 9th, 2022 an A320 approached Copenhagen Airport for a landing from a flight from Lisbon.

The crew decided to go around just before touchdown and had trouble controlling the aircraft; the aircraft veered to the left and lost airspeed to a dangerously low value and the airport perimeter fence was just cleared and the aircraft flew over residential area at an estimated 300 feet.

Eventually the crew was able to get the aircraft under control and gain sufficient airspeed for controlled flight.

After shutting down the left (LH) engine in flight, the crew brought the aircraft in for a safe landing.

During rollout it became clear to spectators that the LH thrust reverser remained deployed partially.


Below the text from Avherald.com (the go to website for global aviation safety incidents)


"A TAP Air Portugal Airbus A320-200, registration CS-TNV performing flight TP-754 from Lisbon (Portugal) to Copenhagen (Denmark) with 102 passengers and 7 crew, was landing on Copenhagen's runway 30 at about 12:05L (10:05Z), when according to ADS-B data transmitted by the aircraft the aircraft veered to the left, the speed over ground reduced sharply from about 133 to about 120 knots, the crew initiated a go around, the aircraft however did not climb but also did not build up speed. With the airport perimeter and houses of the Maglebylille community in the way the aircraft began to slowly climb and crossed the first houses at around 300 feet AGL, the speed over ground further reduced to 101 knots. Once the aircraft had climbed to about 900 feet AGL (1700 feet MSL according to standard pressure 1013 hPa, deduct 800 feet from all transponder altitude readings to get to AGL according to QNH 986 hPa) airspeed began to build up again. The aircraft levelled off at 3000 feet MSL and thereafter accelerated to normal speeds. The aircraft subsequently positioned for another approach to runway 22L and landed without further incident about 20 minutes after the go around."


The event is under investigation by the Danish accident investigation board "Havarikommissionen". Press release downloadable below.


l_2022_alvorlig-haendelse_2022-150_cstnv_motorfly_ekch
.pdf
Download PDF • 826KB

From the report it appears that the aircraft had not touched down during the go-around.

It is also remarked that three of the four thrust reverser doors were found open instead of all four.

This indicates that pilot error is not a contributing factor to the incident; in fact crew action prevented disaster of an aircraft that was operating out of its certification limits due to a technical defect as we will try to show later on.

A large aircraft is not supposed nor requited to be controllable with one engine operating normally and another in reverse thrust configuration. Refer to CS 25.147, downloadable below.


CS 25-147
.pdf
Download PDF • 86KB


The A320 thrust reverser system structural layout indicated below:





The A320 thrust reverser system has a number of inhibit logic parameters as shown below;


"Thrust reverser deploy sequence

Deploy sequence is only allowed on ground after actuation of the throttle control lever and requires actuation

logic:

. One ECU channel operating with its associated throttle reverse signal.

. SOV opening through the SEC and the static relay.

. Main gear compressed signal from at least one LGCIU.

. Throttle lever angle (TLA) reverse signal from at least one second.

Before the transit completion, the ECU sets the reverse idle thrust."


Clearly one of the inhibit parameters were breached.

This could have multiple causes; among which:

  • Incomplete (de)activation procedure carried out previously

  • Incomplete installation procedure allowing the reversers (pivoting doors) to unlock.

  • System failure at some point

There is much to investigate with respect to;

  • Trying to replicate the failure in order to determine the prevailing conditions

  • Maintenance conducted in these components previously

  • Maintenance records reviews

  • Interviews of maintenance personnel involved in previous maintenance

  • Condition of all system components

  • Review of the Digital Flight Data Recorder parameters

  • Interviews with the crew

Most likely this will result in service and regulatory action such as Service Information Letters os Service Bulletins and/or an Airworthiness Directive


Latest update (29-March-2023)

Basically the update contains confirmation that the aircraft and its components have been examined, stakeholders have communicated and all relevant data has been collected.and that a draft final report is in the works...

We will keep an eye!

L_2022_Alvorlig hændelse_2022-150_CSTNV_Motorfly_Kastrup Lufthavn
.pdf
Download PDF • 372KB

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