The flight conditions at night are complicated, and there is no instrument landing system (commonly known as ILS), only two-way 420-meter simple approach lights, and no runway centerline lights. In the third part of the document "Operation Safety Measures of Yichun/Duling Airport" issued by the Operation Safety Technology Department of China Southern Airlines Heilongjiang Branch on August 27th, 2009, the first item is "Yichun Airport will not fly at night in principle after September 1 day", and the others are "It doesn't rain during the day and it doesn't rain at night" and "It's forbidden to take off and land with the wind".
Violation of approach procedure
Yichun Dulin Airport has no instrument landing system, so there is no precision instrument approach procedure, only non-precision instrument approach procedure. Specifically, runway 30 has VOR/DME program, and runway 12/30 has a set of NDB/DME program. According to the airport operation rules, runway 30 approaches according to VOR/DME procedure, and the minimum visibility requirement is 2800 meters. When the crew manipulated the aircraft to approach, it violated the relevant provisions of CCAR 12 1.667 on the minimum landing standard: "When the visibility is lower than the minimum visibility specified in the instrument approach procedure used, the aircraft shall not fly over the final approach location to continue the approach." Until 2 1: 56, Henan airlines dispatchers repeatedly used the system to send messages to urge the plane to return.
In the final approach stage, the transition from non-precision instrument approach procedure to visual flight must meet two conditions: First, it must be after the final approach positioning point. Second, sufficient visual reference must be established. The latest time is the go-around point; The best time is to complete the landing checklist at an altitude of 1000 feet. When you can see and confirm that the runway is correct, gradually switch to visual flight. According to Article 9 1. 157 of General Operation and Flight Rules of Civil Aviation Administration of China, visual flight can only be carried out when the visibility is greater than 1600 meters in the final approach stage. "Even if this information (meaning that the weather is not up to standard) is not passed to the pilot, it is illegal for the pilot to see that the runway is still landing. Judging from the initial situation, Henan Airlines has weak links in flight, maintenance and dispatch. " Li Jiaxiang, director of the Civil Aviation Administration, said.
Meteorological conditions that night
1. At 9 o'clock that night, the information in the aviation meteorological periodic observation report (METAR) of Yichun Dulin Airport is as follows:
METAR ZYLD 24 1300 z 1500 1 MPs 8000 NSC 13/ 13 q 10 14 =
That is to say, the meteorological conditions of 201013 (Beijing time 2 1) at Yichun Dulin Airport are: wind direction 150 degrees, wind speed 1m/s, visibility of 8000m.
2. At 10 that night, the meteorological information of Yichun Dulin Airport was as follows:
METAR ZYLD 24 1400 z 1500 1 MPs 1000 BR NSC 12/ 12 q 10 14 =
That is to say, the meteorological conditions of Yichun Dulin Airport at 20 10 14 UTC (22: 00 Beijing time) are: wind direction 150 degrees, wind speed 1m/s, visibility 1000m, foggy and foggy.
3. The meteorological information of Yichun Dulin Airport 1 1 that night is as follows:
METAR ZYLD 24 1500 z 00000 MPs 0600 FG NSC 13/ 13 q 10 15 =
That is to say, the meteorological conditions of Yichun Dulin Airport on October 24th, 2065 10 UTC (23: 00 Beijing time) are: no wind, visibility of 600 meters, fog, no important clouds, temperature 13 degrees Celsius, dew point 13 degrees Celsius.
An inexperienced route
The round-trip route between Harbin and Yichun of Henan Airlines, which suffered an air crash, was officially opened by Henan Airlines on August 20 10/0. Flying every Tuesday, Thursday and Saturday, operated by ERJ- 190 regional aircraft. This is also the seventh time that the plane flew from Harbin to Yichun.
The Central and South Bureau of Civil Aviation once issued the captain of an airport to fly to Yichun. The captain of the wrecked plane flew to Yichun for the first time, and no one took the flight, which seriously violated the regulatory requirements put forward by the Central South Bureau. It was initially found that the Central South Bureau sent this document to Henan Airlines, which was recorded in writing. The data of Yichun airport is not in the general database, so it needs to be manually entered according to the latitude and longitude, route distance and other factors before each flight.
Tower air traffic control responsibilities
Some experts have analyzed that if the visibility in Yichun is really insufficient this time, the air traffic control should advise not to land. "If there is no prompt, the air traffic controller will bear a lot of responsibility." The air traffic control system staff who once worked at Xinzheng Airport in Henan told this reporter that "air traffic control only gives suggestions on various standards, but the final decision is in the hands of the captain who flies the plane." There are a few flights at Yichun airport, and only this plane was there that day. All the attention of the tower should be focused on this plane. "In this accident, it was initially found that there was no major problem with the air traffic control, but the plane landed at a distance of 1.200m and scraped the treetops at more than 2,000m. If the air traffic controllers remind them in time, they can see it. According to the work requirements, the tower staff can see it after careful observation. " Li Jiaxiang, director of the Civil Aviation Administration of China, said.
The captain is not qualified
It was just over a year before EMB 190 took off on April 7, 2009 before the accident. The captain's "inexperience and poor quality" is one of the reasons that the senior officials of the Civil Aviation Administration of China think may lead to the plane crash.
The captain of the wrecked plane is Quan Jun, 40 years old, with a total flight time of 4,250 hours. He is a pilot who has been transferred from the army to the people and holds a driver's license for air transportation. /kloc-0 entered the air force aviation school in August, 1990, and started flying in October. He has a bachelor's degree, and the planes he has flown are J-6, K44 and Yun 7-65438. ERJ- 190, March 6, 2009, the aircraft of ER-J 190 was modified, and the training was conducted on March 23, 2009. On April 7th, 2009, ERJ- 190 was the captain's route inspection, and EMB- 190 was the general manager.
A leader of the Civil Aviation Administration of China learned from Shenzhen Airlines after the incident that the whole army used to fly a small plane in the army, jumped ship at the age of 33, and then entered the civil aviation aircraft modification team. At one time, he was considered to have reached the standard of Boeing 737 captain, but Shenzhen Airlines did not give him the qualification of Boeing 737 captain, and finally gave him the qualification of ERJ 190 captain. The investigation report of Henan Airlines Co., Ltd. on the "August 24" catastrophic plane crash in Yichun, Heilongjiang Province has been closed in the State Council and released on June 28, 20 12. The report pointed out the direct and indirect causes of the accident.
Three direct causes
First, the captain violated the relevant provisions of the Flight Operation Manual of Henan Airlines, and still carried out the approach when it was lower than the company's minimum operating standard (according to the relevant provisions of Henan Airlines, the minimum visibility standard for the captain's first flight mission at Yichun Airport was 3,600 meters, and the visibility notified by the controller of Yichun Airport to the flight crew before the incident was 2,800 meters).
Second, the flight crew violated the relevant provisions of the Civil Aviation Administration's Rules for Examination and Approval of Operating Qualification of Large Aircraft Public Air Transport Carriers. When the aircraft entered the radiation fog, it did not see the airport runway and did not establish the necessary landing visual reference, but still landed at the lowest descent altitude.
Third, the flight crew did not take go-around measures and continued to land blindly before the plane hit the ground, causing the plane to hit the ground.
Four indirect reasons
First, the aviation safety management in Henan is weak.
(1) flight technology management problems are outstanding. Some pilots of Henan Airlines have some outstanding problems, such as great flight randomness and lax operation manual of the implementation company. According to the flight technology management records of Henan Airlines, the overflight events of the captain's whole army are numerous, diverse and long-span, especially those related to approach and landing, such as large approach slope, deviation from or lower than the glide slope, large descent rate and large visual deviation of landing, etc., frequently occur. Henan Airlines ignored the long-standing problems of the captain's entire army, such as rough control technology and unstable approach and landing.
(2) unreasonable deployment of flight crew and poor coordination among members. The flight crew performed the Yichun airport mission for the first time, which increased the safety risk; Poor communication among members has not played a role in reminding and verifying each other and reducing human errors.
(3) The emergency training of flight attendants does not meet the relevant regulations of the Civil Aviation Administration and the requirements of Henan Aviation Training Program. Shenzhen Flight Attendant Training Center, which is responsible for Henan flight attendant emergency training, has no E- 190 hatch trainer and wing exit hatch trainer. The actual operation training of flight attendants is carried out on E 190 aircraft, and some flight attendants have not been trained to open the doors. Henan Airlines used an alternative method to conduct emergency training for flight attendants, and did not modify the training outline and reported it to the Henan Supervision Bureau of Civil Aviation, which violated the Civil Aviation Administration's Standards for Cabin Training Equipment and Facilities and Related Issues on Training Flight Attendants by Licensed Personnel in Non-affiliated Training Institutions, affected the quality of emergency training for flight attendants, and it was difficult to guarantee the emergency handling ability of flight attendants.
Second, Shenzhen Airlines has insufficient investment and poor management in Henan Airlines.
(1) During July 2006 to April 20 10, when Huirun Investment was holding Shenzhen Airlines, Shenzhen Airlines did not have enough financial and technical support for the safe operation of Henan Airlines, the registered capital was not in place, and the management team of Henan Airlines was frequently mobilized, which affected the stability, safety and quality management of the staff.
(2) After Air China controlled Shenzhen Airlines in May, 2065438+00, the new leadership of Shenzhen Airlines realized the seriousness of the existing problems in aviation safety management in Henan and conducted special safety supervision, but failed to effectively solve many problems in aviation safety management in Henan in a short time.
Third, the supervision of relevant civil aviation management agencies is not in place.
(1) Henan Supervision Bureau of Civil Aviation violated the relevant regulations of Central South Regional Administration of Civil Aviation, and approved the operation license of Harbin-Yichun route without Henan Airlines' operation license, and did not know or master the specific operation situation of the route; Problems such as weak aviation safety management, insufficient safety investment and weak flight technology management in Henan are not in place.
(2) The Central South Regional Administration of Civil Aviation did not strictly check the qualification examination and approval of the main operating base of Henan Airlines, and found that the cabin crew did not meet the relevant provisions of the Rules for the Qualification Examination and Approval of Large Aircraft Public Air Transport Carriers and lacked 1 flight attendants;
(3) When examining and approving the operating license of the Harbin-Yichun route of Henan Airlines, the Northeast Regional Administration of Civil Aviation replied that the telegram was signed earlier and the leader issued it later, and did not inform the Heilongjiang Supervision Bureau of Civil Aviation and other relevant civil aviation administrations as required, and the procedures for issuing the Harbin-Yichun domestic route operating license registration certificate to Henan Airlines were not standardized.
Fourth, there are loopholes in the safety management of Central South Air Traffic Control Bureau.
On July 27th, 2009, the administrator of the meteorological database system of Central South Air Traffic Control Bureau (hereinafter referred to as Central South Air Traffic Control Bureau) mistakenly set the address code ZYLD of Yichun Airport Special Weather Report to ZYID, which made the airport special weather report unable to enter the aviation meteorological database of Central South Air Traffic Control Bureau. Although the controller of Yichun Airport had informed the flight crew of the actual weather at that time before the incident, Henan Airlines could not obtain the special weather report of Yichun Airport through the internal website of aviation meteorology of Central South Air Traffic Control Bureau, which led to the failure of Henan Aviation Operation Control Center to give necessary reminders and suggestions to the flight crew according to its duties.