从2009年2月25日波音737坠机事故中吸取的教训

H. Hecht
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引用次数: 2

摘要

土耳其航空公司1951号航班在2009年2月25日荷兰阿姆斯特丹史基浦机场的目的地跑道上坠毁。9人丧生,177人受伤,这架飞机完全失败了。左侧无线电高度表出现了设备故障,导致自动油门系统进入延迟闪光模式,预计飞机将在距离地面2000英尺的地方立即着陆。机组人员收到了这种情况的指示和警告,但他们被忽视了。油门减速也被飞机暂时掩盖,被指示从上方拦截航向仪,一个非常不寻常的程序。调查发现,事故飞机和其他飞机上都有很多低空读数的例子。此外,事故飞机在最近的飞行中经历了两次油门减速的情况。不良的报告实践导致制造商和认证机构低估了这种故障模式的普遍性。结论是,在许多情况下,行动和设计决策是基于进一步的条件将在正常范围内的假设。如果我们想保持商业航空的良好安全记录,这是一个必须避免的危险假设。
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So Much to Learn from One Accident Crash of 737 on 25 February 2009
Turkish Airlines Flight 1951 crashed short of its destination runway at Schiphol Airport, Amsterdam, Netherlands on February 25, 2009. Nine people lost their lives, 177 were injured, and the aircraft was a complete loss. There was an equipment failure in the left radio altimeter that caused the auto-throttle system to go into retard flare mode in anticipation of immediate landing when the aircraft was still near 2000 ft above terrain, There were indications and warnings of this condition to the crew but they were ignored. The throttle retardation was also temporarily masked by the aircraft being directed to intercept the localizer from above, a highly unusual procedure. The investigation found numerous instances of low altitude readings on the accident aircraft as well as on others. Also, the accident aircraft had experienced two instances of throttle retardation on recent flights. Poor reporting practices led the manufacturer and the certifying authorities to underestimate the prevalence of this failure pattern. It is concluded that in many instances actions and design decisions were based on the assumption further conditions will be within the normal envelope. This is a dangerous assumption that must be avoided if we want to maintain the fine safety record of commercial aviation.
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