本系列希望為各位帶來(lái)最詳細(xì)的每日航空事故及事故征候(事件)信息(本系列信息全部來(lái)源于ASN數(shù)據(jù)庫(kù), 由于數(shù)據(jù)庫(kù)更新時(shí)間等原因之限制每日簡(jiǎn)報(bào)將報(bào)告前一日之內(nèi)容)、

ASN數(shù)據(jù)庫(kù)會(huì)有信息延遲, 部分事故或事故征候(事件)無(wú)法及時(shí)(在發(fā)生后第二天)出現(xiàn)在簡(jiǎn)報(bào)中, 現(xiàn)決定第一天晚上發(fā)布當(dāng)天的簡(jiǎn)報(bào), 第二天修改前一天的簡(jiǎn)報(bào).在發(fā)生第二天之后更新至ASN的事故我將不會(huì)再次添加至專(zhuān)欄

簡(jiǎn)報(bào)不包括軍航事故, ASN資料庫(kù)簡(jiǎn)報(bào)內(nèi)會(huì)寫(xiě)出事故航班之 "nature", 如此項(xiàng)為"Military"(軍事)則該事故不會(huì)出現(xiàn)在本簡(jiǎn)報(bào)中

"歷史上的今天"部分是當(dāng)天內(nèi)容, 選取的事故與ASN主頁(yè)相同部分一樣

事故/事故征候調(diào)查報(bào)告部分每周更新一次

至文章發(fā)出時(shí), ASN已記錄2022年事故/事故征候418起

ASN資料庫(kù)記錄2023年2月18日發(fā)生之事故/事故征候3起, 具體信息如下:?

1: ASN事故號(hào):308444

事故時(shí)間:

機(jī)型:Cessna T337H Turbo Super

航空器運(yùn)行及擁有者:Skymaster

航班號(hào):

注冊(cè)號(hào):LV-ZZN

制造商序列號(hào):33701875

生產(chǎn)地:

首飛日期:

試飛注冊(cè)號(hào):

機(jī)齡:

機(jī)隊(duì)編號(hào):

引擎:

構(gòu)型:

總?cè)藬?shù):?

死亡人數(shù):0

非機(jī)上人員死亡人數(shù):0

航空器損壞情況: 嚴(yán)重?fù)p壞

事故分類(lèi): 事故征候

事故地點(diǎn):蒙得維的亞-天使·S·阿達(dá)米機(jī)場(chǎng)（SUAA），烏拉圭東岸共和國(guó)

事故發(fā)生的飛行階段: 降落

飛行性質(zhì):?

起飛機(jī)場(chǎng):?

目的地機(jī)場(chǎng):蒙得維的亞-天使·S·阿達(dá)米機(jī)場(chǎng)（SUAA），烏拉圭東岸共和國(guó)

具體信息:

進(jìn)行緊急機(jī)頭起落架收上著陸時(shí)滑出跑道

2: ASN事故號(hào):308448

事故時(shí)間:

機(jī)型:

航空器運(yùn)行及擁有者:

航班號(hào):

注冊(cè)號(hào):

制造商序列號(hào):

生產(chǎn)地:

首飛日期:

試飛注冊(cè)號(hào):

機(jī)齡:

機(jī)隊(duì)編號(hào):

引擎:

構(gòu)型:

總?cè)藬?shù): 1

死亡人數(shù):0

非機(jī)上人員死亡人數(shù):0

航空器損壞情況: 嚴(yán)重?fù)p壞

事故分類(lèi): 事故

事故地點(diǎn):靠近布克漢農(nóng)，美利堅(jiān)合眾國(guó)

事故發(fā)生的飛行階段:?

飛行性質(zhì):?

起飛機(jī)場(chǎng):?

目的地機(jī)場(chǎng):

具體信息:

3: ASN事故號(hào):308429

事故時(shí)間:0646

機(jī)型:Cessna 340A

航空器運(yùn)行及擁有者:私人

航班號(hào):

注冊(cè)號(hào):RP-C2080

制造商序列號(hào):340A-0917

生產(chǎn)地:

首飛日期:

試飛注冊(cè)號(hào):

機(jī)齡:

機(jī)隊(duì)編號(hào):

引擎:

構(gòu)型:

總?cè)藬?shù): 4

死亡人數(shù):

非機(jī)上人員死亡人數(shù):0

航空器損壞情況: 航空器失聯(lián)

事故分類(lèi): 事故征候

事故地點(diǎn):菲律賓共和國(guó)

事故發(fā)生的飛行階段: 巡航

飛行性質(zhì): 客運(yùn)

起飛機(jī)場(chǎng):?萊加茲皮比科爾國(guó)際機(jī)場(chǎng)(LGP/RPLK), 菲律賓共和國(guó)

目的地機(jī)場(chǎng):馬尼拉尼諾伊·阿基諾國(guó)際機(jī)場(chǎng)（MNL/RPLL），菲律賓共和國(guó)

具體信息:

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歷史上的今天

1984年2月19日，西班牙航空610號(hào)班機(jī)，一架Boeing 727-256型客機(jī)在巡航時(shí)撞山（CFIT-M），機(jī)上148人全部罹難無(wú)人生還，西班牙CIA（全稱(chēng)不確定）認(rèn)定事故發(fā)生的可能肇因?yàn)椋骸八麄儗?duì)高度警報(bào)系統(tǒng)自動(dòng)捕獲的信心、對(duì)其警告的誤解，以及可能對(duì)高度表的誤讀，使得機(jī)組人員在安全高度以下飛行，撞上電視天線的基座，從而失去左翼，在無(wú)法控制飛機(jī)的情況下墜落至地面?！保═heir confidence on the automatic capture performed by the Altitude Alert system, the misinterpretation of its warnings, as well as a probable misreading of the altimeter made the crew to fly below the safety altitude, colliding into the television antennas' base, thus losing the left wing, falling to the ground with no possible control of the aircraft.）

航空事故/事故征候調(diào)查報(bào)告更新

法國(guó)民用航空安全調(diào)查及分析局（BEA,?Bureau?d'Enquêtes et d'Analyses?pour?la?sécurité?de?l'aviation?civile）發(fā)布了發(fā)生于2021年2月8日的力士翼航空301號(hào)班機(jī)的事故最終調(diào)查報(bào)告，認(rèn)定事故發(fā)生的可能肇因?yàn)椋骸霸陂_(kāi)始下降至目的地之前，機(jī)組人員聽(tīng)取了Le Bourget機(jī)場(chǎng)ATIS的報(bào)告，該報(bào)告顯示在3000至5000英尺之間存在嚴(yán)重結(jié)冰

因此，機(jī)組人員選擇的進(jìn)近速度（Vref 97 kt）比結(jié)冰條件下的進(jìn)近轉(zhuǎn)速低22 kt，根據(jù)制造商的說(shuō)法，接近冰污染情況下的失速轉(zhuǎn)速。

在3000英尺處，機(jī)組人員啟動(dòng)機(jī)翼和穩(wěn)定器除冰系統(tǒng)21秒，這相當(dāng)于一個(gè)完整的除冰循環(huán)。機(jī)組人員表示，他們通過(guò)駕駛艙窗戶(hù)觀察到機(jī)翼前緣積冰已經(jīng)破裂。然后，他們停用了除冰系統(tǒng)，不再啟用。這一決定完全基于對(duì)機(jī)翼前緣的目視觀察。

事故發(fā)生后觀察到機(jī)翼和穩(wěn)定器前緣結(jié)冰，這表明飛機(jī)在最后時(shí)刻結(jié)冰。因此，可以做出以下假設(shè)：

?光線和云層不允許機(jī)組人員確定機(jī)翼的實(shí)際污染程度。

?或者從駕駛艙可以看到積冰的形狀和厚度，在這種情況下：

在停用除冰系統(tǒng)后，機(jī)組人員不再主動(dòng)監(jiān)測(cè)前緣以確保不形成冰，

機(jī)組們觀察到了冰層的堆積，但低估了其后果。

在當(dāng)天的條件下，飛機(jī)的重量和機(jī)組人員選擇的配置，如果遵守制造商在結(jié)冰條件下進(jìn)近的程序，這意味著飛機(jī)將無(wú)法在勒布爾熱機(jī)場(chǎng)著陸。這是因?yàn)槭紫?，在一臺(tái)發(fā)動(dòng)機(jī)不工作的復(fù)飛情況下，飛機(jī)的爬升率不足以安全地飛越障礙物。其次，可用的著陸距離小于飛機(jī)所需的著陸距離。機(jī)組人員告訴BEA，他們甚至在起飛前就意識(shí)到了這些限制，他們知道如果在著陸前必須持續(xù)啟動(dòng)除冰系統(tǒng)，他們就必須備降。

鑒于嚴(yán)格遵守程序不可能滿(mǎn)足操作限制，機(jī)組人員選擇的策略是根據(jù)制造商的程序在非結(jié)冰條件下進(jìn)近和著陸，同時(shí)確保飛機(jī)上沒(méi)有結(jié)冰。機(jī)長(zhǎng)解釋說(shuō)，這是對(duì)程序的標(biāo)準(zhǔn)調(diào)整。

除冰系統(tǒng)的停用產(chǎn)生以下后果：

?水平穩(wěn)定器前緣可能積存的冰可能尚未完全破碎。

?進(jìn)近結(jié)束時(shí)，飛機(jī)上再次結(jié)冰。

?失速警告保護(hù)系統(tǒng)（SWPS）未配置為在事故結(jié)冰條件下有效切入：PFD上顯示的速度帶未配置為警告機(jī)組人員他們以接近失速速度的速度飛行，聲音失速警告和失速震桿保護(hù)未配置為以適當(dāng)?shù)墓ソ菃?dòng)。

就在撞擊發(fā)生之前，飛機(jī)正以低速和高攻角飛行，如果飛機(jī)結(jié)構(gòu)受到冰污染，飛機(jī)可能會(huì)失速。記錄的飛行數(shù)據(jù)無(wú)法確定確切的污染程度，但在事故發(fā)生后觀察到的機(jī)翼前緣和水平安定面結(jié)冰情況證實(shí)，飛機(jī)上已經(jīng)結(jié)冰?！保˙efore starting the descent to destination, the crew listened to the Le Bourget airport ATIS which indicated the presence of severe icing between 3,000 and 5,000 ft. They carried out the approach applying the manufacturer’s normal procedure for an approach in non-icing conditions, the?

approach speed selected by the crew (Vref 97 kt) was thus 22 kt below the approach speed in icing conditions and was, according to the manufacturer, close to the stall speed in the event of ice contamination.

At 3,000 ft, the crew activated the wing and stabilizer de-ice system for a period of 21 s which corresponded to a complete de-ice cycle. The crew indicated that they observed through the cockpit window that the ice which had built up on wing leading edges had broken up. They then deactivated the de-ice system and did not active it again. This decision was solely based on the visual observation of the wing leading edges.

The presence of ice on the wing and stabilizer leading edges observed after the accident shows that ice built up on the aeroplane on final. The following hypotheses can thus be made:

? Either the light and clouds did not allow the crew to determine the actual degree of contamination of the wings.

? Or the shapes and thickness of this built-up ice were visible from the cockpit and in this case:

after deactivating the de-ice system, the crew no longer actively monitored the leading edges to ensure that there was no formation of ice or,

the crew observed this build-up of ice but underestimated the consequences of this.?

In the conditions of the day, the aeroplane’s weight and the configuration selected by the crew, compliance with the manufacturer’s procedure for an approach in icing conditions would have meant that the aeroplane would not be able to land at Le Bourget airport. This was because firstly, in the event of a go-around with one engine inoperative, the aeroplane’s climb rate was not sufficient to safely clear obstacles. Secondly, the landing distance available was less than the landing distance required by the aeroplane. The crew told the BEA that they were aware of these limitations even before taking off and that they knew that if they had to continuously activate the de-ice system until landing, they would have to divert.?

Given that it was impossible to meet the operational constraints by strictly complying with the procedure, the strategy chosen by the crew was to carry out the landing according to the manufacturer's procedures for an approach and landing in non-icing conditions while ensuring that ice had not built up on the aeroplane. The captain explained that this was a standard adaptation of the procedure.

The deactivation of the de-ice system had the following consequences:

? The ice that may have built up on the leading edge of the horizontal stabilizer may not have been completely broken up.

? Ice built up again on the aeroplane at the end of the approach.

? The Stall Warning Protection System (SWPS) was not configured to cut in effectively in the icing conditions of the accident: the speed tape displayed on the PFD was not configured to alert the crew that they were flying at a speed close to the stall speed and the aural stall warning and the Stick Pusher protection were not configured to activate at the appropriate angles of attack.?

Just before the impact, the aeroplane was flying in low speed and high angle-of-attack envelopes where the aircraft was likely to stall in case of ice contamination of its structure. The recorded flight data did not enable the exact degree of contamination to be determined, but the presence of ice on the leading edges of the wings and horizontal stabilizer observed after the accident confirmed that ice had built up on the aeroplane.）

南非民用航空總局發(fā)布了發(fā)生于2022年1月3日的南非空連航空Z(yǔ)S-NRJ機(jī)的事故最終調(diào)查報(bào)告，認(rèn)定事故發(fā)生的可能肇因?yàn)椋骸傍B(niǎo)擊中螺旋槳導(dǎo)致槳葉過(guò)載斷裂和分離失效?！保ˋ bird strike on the propeller blade caused the overload fracture and separation failure of the blade.）

南非民用航空總局發(fā)布了發(fā)生于2022年9月20日的佩普科爾集團(tuán)ZS-PKR機(jī)的事故最終調(diào)查報(bào)告，認(rèn)定事故發(fā)生的可能肇因?yàn)椋骸霸谄痫w滑跑過(guò)程中，2號(hào)發(fā)動(dòng)機(jī)在一只鳥(niǎo)飛入發(fā)動(dòng)機(jī)后受到嚴(yán)重?fù)p壞，推力迅速降至零；機(jī)組人員進(jìn)行了一次成功的RTO（終止起飛）?！保―uring the take-off roll, the No.2 engine spooled down to zero after suffering substantial damage after a bird flew into the engine; the crew conducted a successful RTO.）

尼泊爾文化、旅游和民航部航空事故調(diào)查委員會(huì)發(fā)布了發(fā)生于2023年1月15日的雪人航空691號(hào)班機(jī)的事故調(diào)查初期報(bào)告，其中提到調(diào)查范圍將集中于：“兩個(gè)螺旋槳都進(jìn)入順槳狀態(tài)的情況

人為因素

進(jìn)入博卡拉國(guó)際機(jī)場(chǎng)的目視進(jìn)場(chǎng)程序，包括國(guó)內(nèi)和國(guó)際機(jī)場(chǎng)的同時(shí)運(yùn)行?！保?.1 The investigation will focus on:

The Circumstances under which both propellers went into the feathered condition

Human Factors

Visual approach procedures into Pokhara International Airport including simultaneous operation of both national and international airports.）