20-0002 ZB EN V02 U3 Final

Bundesstelle fürFlugunfalluntersuchung German Federal Bureau of Aircraft Accident Investigation

Interim Report Identification

Type of Occurrence: Serious incident

Date: 1 January 2020

Location: Frankfurt/Main Airport

Aircraft: Airplane

Manufacturer / Model: Airbus / A350-941

Injuries to Persons: No injuries

Damage: None

Other Damage: None

State File Number: BFU20-0002-EX

Factual Information

On the day of the occurrence take-off occurred at 1240 hrs1 at Phuket Airport,

Thailand. The flight was conducted in accordance with instrument flight rules to

Frankfurt/Main Airport. It was a scheduled passenger flight. During the approach to

runway 07R the minimum altitude was undershot and a go-around procedure

conducted. At 1945 hrs the airplane landed on runway 07R.

1All times local, unless otherwise stated.

Interim Report BFU20-0002-EX

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History of the Flight

The Pilot in Command (PIC) occupied the left-hand seat and was Pilot Monitoring

(PM). The co-pilot occupied the right-hand seat and was Pilot Flying (PF). During the

approach two additional co-pilots, as observers, were present in the cockpit. This

procedure was described in the operator’s Operations Manual Part B.

At about 1915 hrs, the aircraft was on the southern approach route of Frankfurt/Main

Airport (Fig. 1). The autopilot was engaged. According to the statement of the flight

crew and the documentation the operator provided, they followed a preceding

aircraft. The PM stated that he had assumed they would land after the preceding

aircraft on runway 07R.

At 1924:26 hrs, the radar approach controller (pick-up) asked the flight crew if it was

correct that they had an ill person on board. The crew confirmed this. The controller

also asked if they needed additional support. The crew confirmed that they had

already asked for medical assistance for the passenger at the parking position. This

had been preceded by a report via ACARS about 4 hours before the intended landing

at Frankfurt/Main Airport to the operator’s OPS-Center. This message included the

information that at the parking position an ambulance was needed for the passenger.

Fig. 1: Approach to runway 07R at Frankfurt/Main Airport Source: Chart AIP / flight path BFU


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Further course of the approach and the flight profile are depicted in Fig. 2. At

1927:22 hrs, the radar controller instructed the PM to change to the radio frequency

of the radar approach controller (feeder). The feeder instructed the flight crew at

1927:38 hrs to speed up the descent. At 1927:59 hrs, the controller issued the air

traffic control instruction to head towards 340° and descend to 3,000 ft AMSL. With

Fig. 2: Course of events until the go-around procedure during the first approach Source: BFU


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an additional directional instruction the controller instructed the flight crew to fly

towards 040° and simultaneously issued the clearance for the instrument approach

ILS 07R Z. The flight crew also received the instruction to fly with a speed of

170 kt IAS or faster.

The analysis of the FDR data showed that at about 1928:48 hrs at an altitude2 of

approximately 6,000 ft AMSL, the flaps were set in position 1 and about 18 s later in

position 2. Shortly afterwards, at about 5,100 ft AMSL the landing gear was

extended. In this flight phase rate of descent was approximately 2,000 ft/min. After

the aircraft had turned to the extended runway centre line of runway 07R and

reached about 4,000 ft AMSL, the rate of descent increased continuously.

At 1930:42 hrs, the CVR had recorded the automatic altitude announcement Two

Thousand Five Hundred. At the same time the autopilot was disengaged. At about

1930:55 hrs at about 1,900 ft AMSL, the FDR recorded the mode Autopilot Localizer

Engaged. Approximately 9 s later the CVR had recorded twice Sink Rate. Another

5 s later the CVR recorded One Thousand and 2 s after that Glideslope.

At 1931:16 hrs, the PF ordered the go-around and the PM reported this to the Tower

controller. This was the first contact with Frankfurt Tower. According to the FDR data,

at this time the aircraft was at 668 ft AGL (radio height) which equates to

936 ft AMSL. Distance to the runway threshold of runway 07R was 6.43 NM.

The second approach was conducted with the use of the ILS of runway 07R. The

height at the occurrence site (6.43 NM) was 2,228 ft AGL (Fig. 3).

2The altitude of the FDR was corrected in regard to the METAR information (QNH 1,032 hPa and temperature 1°C at Frankfurt/Main Airport at the time of the occurrence.


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At 1945 hrs the aircraft landed on runway 07R without further problems.

Personnel Information

Pilot in Command

The 43-year-old PIC held an Air Transport Pilot’s Licence (ATPL(A)) issued on

10 January 2008 by the Thai civil aviation authority. The licence was valid until

9 January 2023.

The licence listed the following ratings:

Aircraft type Licence entry: Valid: Airbus A330 and A350 PIC IR 21 June 2020

The licence also listed the Language Proficiency Level 4 for English in accordance

with ICAO Annex 1. The BFU was provided with a class 1 medical certificate, valid

until 5 December 2020.

According to the PIC’s statement, he had a total flying experience of about

8,000 hours, of which about 400 hours were flown on Airbus A350.

For the PIC this was the first flight of the day.

Fig. 3: Vertical profile of the two approaches to runway 07R Source: BFU


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Co-pilot

The 36-year-old PIC held an ATPL(A) issued by the Thai civil aviation authority on

20 December 2016. The licence was valid until 19 December 2021.

The licence listed the following ratings:

Aircraft type Licence entry: Valid: Airbus A330 and A350 COP IR 30 September 2020

The licence also listed the Language Proficiency Level 5 for English in accordance

with ICAO Annex 1. The BFU was provided with a class 1 medical certificate, valid

until 20 September 2020.

According to the statement of the co-pilot, he had a total flying experience of

approximately 4,000 hours; of which about 1,500 hours of flight time were flown on

A350.

For the co-pilot this was the first flight of the day.

Additional Co-pilots

The two additional co-pilots held ATPL(A) licences issued by the Thai civil aviation

authority. The licences were valid and listed the type ratings for A330 and A350.

Flight Duty and Rest Time

The operator provided the BFU with the duty roster of the flight crew.

This showed that the flight crew checked in at Phuket, Thailand, at 1110 hrs local

time. Departure was at 1240 hrs and landing at Frankfurt/Main at 1945 hrs. This

results in 14:05 hours of flight duty time, including 30 min check-out. According to the

Operational Manual Part A, Chapter 7.3.1 FDP Extension for Flight Deck Crew, Rev

15, maximum flight duty time was 20 hours.

The two actively flying pilots had had a day off in Phuket.

Air Navigation Service Provider

Approach Radar Controller (Pick-up)

The 26-year-old controller held an air traffic controller’s licence issued by the Federal

Supervisory Authority for Air Navigation Services (BAF), valid until 19 January 2021.


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Approach Radar Controller (Feeder)

The 53-year-old controller held an air traffic controller's license issued by the BAF,

valid until 26 August 2020.

Aircraft Information

The Airbus A350-941 of Airbus S.A.S. is a twin-engine low-wing aircraft, with a two-

aisle interior design for long haul operations.

It is equipped with 2 Rolls Royce Trent XWB-84 turbofan engines.

The aircraft had a Thai certificate of registration and was operated by a Thai operator

in commercial passenger transport.

The two-way view in Fig. 4 shows the dimensions of the aircraft. It was copied from

the Flight Crew Operating Manual (FCOM, Chapter DSC-20-20-10, 10.11.2016). The

BFU has added the metric measurements.


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Manufacturer Airbus S.A.S.

Year of manufacture 2017

MSN (Manufacturer Serial Number) 00123

Operating Time 11,577 hours

Landings 1,987

Engines Rolls Royce Trent XWB-84

MTOM 275,000 kg

MLM 207,000 kg

Fig. 4: Two-way view of the Airbus A350-900 Source: FCOM, adapted by BFU


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Meteorological Information

At the time of the incident it was night. According to the aviation routine weather

report (METAR) of Frankfurt/Main Airport at 2020 hrs horizontal visibility was more

than 10 km. Wind direction was 060° at 8 kt. The cloud base was not determined.

The temperature was 1°C, dewpoint -1°C, and QNH 1,032 hPa.

Aids to Navigation

The approach was conducted as ILS CAT I to runway 07R.

Aerodrome Information

The following information was copied from the Aeronautical Information Publication

(AIP), of 25 April 2019.

Frankfurt/Main Airport (EDDF) is located 12 km south-west of Frankfurt. Aerodrome

elevation is 364 ft AMSL. Runway 07R has the orientation 70°. It had an asphalt

surface and the dimensions 4,000 m long and 45 m wide. It was equipped with

approach lighting with Light Intensity High (LIH) and sequence flashing and a

Precision Approach Path Indicator (PAPI). The touch-down zone of the runway was

also equipped with LIH lights.

Communications

The air navigation service provider provided the BFU with the transcripts of the radio

communications of the flight crew with the radar approach controllers (pick-up and

feeder) and the tower controller. Communications were conducted by everyone

involved in English.

Flight Recorders

The aircraft was equipped with a FDR and a CVR.

Manufacturer FDR L-3 Aviation Recorders

Model FA 2100

Part number 2100-4245-00

Serial number 001207389

L-3 Aviation Recorders


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Manufacturer CVR

Model FA 2100

Part number 2100-1227-02

Serial number 001203075

After seizing the FDR and the CVR, the data was read-out at the BFU laboratory.

Both recorders were undamaged. The data was read out using a Hand Held Multi-

Purpose Interface. Subsequently, the data was decompressed and saved. There

were 4 audio files (Captain, First Officer, Mixed and Area Channel). The 4 channels

had a recording time of 2 hours and 4 minutes. The audio quality of all 4 channels

was assessed as “good”.

It has to be noted that in the background on the channels of the PIC and the co-pilot

the on-board entertainment music can quietly be heard.


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Depiction of the FDR Data

The parameters of the FDR were used to depict the occurrence flight.

Fig. 5 shows the overview of the approach phase from the first approach starting at

about 5,000 ft AMSL, including the occurrence close to the ground with the

subsequent go-around, the second approach and the landing on runway 07R. Based

on the International Standard Atmosphere (IAS) (mean northern latitude of 40°,

temperature of 15°C and QNH of 1,013.25 hPa) the flight altitude was corrected by

the values of QNH and temperature.

Fig. 5: Approach phase from about 5,000 ft AMSL on Source: BFU


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Fig. 6 shows a section of the occurrence close to the ground during the first

approach. At 1831:20 UTC the lowest altitude of 668 ft AGL or 936 ft AMSL,

respectively, was recorded.

Fig. 6: Occurrence close to the ground Source: BFU


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Radar Data of the Air Navigation Service Provider

The BFU was provided with the radar data of the flight path recorded by the air

navigation service provider. The radar data only allows an approximate position and

time determination of the aircraft and give the altitude as secondary radar

information.

The BFU compared the radar data of the air navigation service provider with the

corresponding parameters of the FDR. The position data, which the aircraft

determined, and the position data of the radar unit are chronologically synchronous.

The BFU processed the joint data, depicted them three-dimensional using Google

Earth at the reference system WGS 84 (Fig. 7). They were also depicted over the

approach chart of the air navigation service provider (Fig. 1).

Investigator in charge: Norman Kretschmer

Assistance: Ekkehart Schubert, Christian Blanke, Berndt Dreyer

Fig. 7: Flight path reconstruction Source: Google Earth TM, air navigation service provider, BFU


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This investigation is conducted in accordance with the regulation (EU) No. 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and the Federal German Law relating to the investigation of accidents and incidents associated with the operation of civil aircraft (Flugunfall-Untersuchungs-Gesetz - FlUUG) of 26 August 1998. The sole objective of the investigation is to prevent future accidents and incidents. The investigation does not seek to ascertain blame or apportion legal liability for any claims that may arise. This document is a translation of the German Investigation Report. Although every effort was made for the translation to be accurate, in the event of any discrepancies the original German document is the authentic version.

Published by: Bundesstelle für Flugunfalluntersuchung Hermann-Blenk-Str. 16 38108 Braunschweig Phone +49 531 35 48 - 0 Fax +49 531 35 48 - 246 Mail [email protected] Internet www.bfu-web.de

Documents

20-0002 ZB EN V02 U3 Final