Does anyone have the black box recording of the China Southern Airlines crash in 1997?

Here: /97.mp3

Related discussion: /posts/242/topic-00111-2420045.html

Accident investigation report:

Travel situation

19:45

Flight B2925 took off from Chongqing Jiangbei Airport and is expected to arrive at Shenzhen Huangtian Airport at 21:30.

21: 07

Establish contact with Shenzhen Airport approach control and approach runway 33 according to normal procedures.

21:17

Establish contact with the tower. The tower told the crew, "It's raining heavily on the five sides, so call when you see the runway."

21:18:07

The crew reported "blind landing established".

21:18:53

The crew reported " "Seeing the introduction light", the tower commanded the aircraft to "check it and it's ready for landing." Near the aircraft's approach platform, the tower saw the aircraft's landing lights, but the lights were unclear in the rain. Ground radar showed that the aircraft's track and glide altitude were normal.

21:19:33

The plane touched down at the south end of the runway for the first time. After touching down, the plane jumped three times and then went around. After the go-around, the aircraft turned left and climbed to 1,200 meters. The tower reminded the crew to turn on the transponder, but there was no display on the secondary radar.

21:23:57

The crew reported a three-sided position and requested other aircraft to avoid.

21:23:40

The crew once again asked other aircraft to avoid the incident and reported an "emergency situation." Various warnings appeared in the cockpit. The tower informed other aircraft to give way.

21:24:58

The crew asked for fire trucks and ambulances after landing, and the tower told the crew that they were ready. Then the plane made another circle and reported that it was preparing to land in the south. The tower agreed to land in the south and told crew 2925, "The crew landing in front reported that the weather was good in the north and heavy rain in the south." The crew answered clearly and said "I'm ready to land."

21:28:30

The plane landed. After landing, the plane disintegrated and caught fire.

Site survey situation

(1)

The first landing from south to north. After entering the runway, 388.5 meters from the south end of the runway, the first small tire fragment was found. The first metal fragment was found 502 meters from the southern end of the runway. 561 meters from the southern end of the runway, 25 meters to the left of the runway center line, a torn tire piece 54 cm long and 28 cm wide was found. 570 meters from the southern end of the runway and 20 meters to the left of the center line, the nose landing gear left wheel blade was found, 46 cm long and 21 cm wide. 580.5 meters from the south end of the runway, near the center line, the aircraft's main wheel anti-stagnation brake electromagnetic valve was found. Near the center line, 801 meters from the southern end of the runway, the inner ring of the left wheel hub of the nose landing gear was found (the edge was irregularly broken). The above situation shows that after the front wheel touched the ground when the aircraft landed for the first time, the left front wheel exploded and debris was scattered on the runway.

From 388 meters to 801 meters from the southern end of the runway, there are many rivets (mostly shear marks) on the road surface, as well as a small amount of metal sheets, hoses, fixed clips and other scattered objects. The above situation indicates that the aircraft structure was damaged during the first landing.

(2)

After the plane went around, it landed from north to south for the second time. After entering the runway, 427.2 meters from the north end of the runway and 4.5 meters to the right of the center line, there were obvious traces of the lower part of the fuselage wiping the ground. On the right front of this mark, 4.8 meters to the right of the center line of the fuselage scratch, there is a mark of the right engine wiping the ground. On the left front of the scratch mark on the lower part of the fuselage, 4.9 meters to the left of the center line of the scratch on the fuselage, there is a mark of the left engine scratching the ground. 441 meters away from the north end of the runway, three obvious scratches appeared near the center line of the road surface. The deepest scratches were 2 cm and the widest were 12 cm. After verification, the three scratches were the grooves made by the front landing gear left wheel shaft (left side), the tractor lug and the front wheel turning actuator touching the ground.

After the plane wiped the ground, it slid for about 600 meters and then disintegrated. The middle part of the aircraft and the trailing edge of the right wing were severely burned. This location is 1,200 meters away from the north end of the runway. There are nose landing gear, flaps, slat fragments, luggage racks, cabin seats, etc. near the runway center line or 105.7 meters to the side. Scattered objects; the front section of the fuselage is 12 meters long, partially damaged, with tumbling but no signs of burning. The nose is facing north, the cockpit is partially deformed, there is a lot of mud on the instrument panel and central console, the landing gear handle is in the neutral position, and the lower part of the nose The lower part of the weather radar antenna is dented and bent backwards. 1,370 meters from the north end of the runway and 79.4 meters to the right of the runway centerline, there is a relatively complete rear fuselage. The left main landing gear and right engine were scattered on the left side of the runway. The bottom of the left engine was severely worn, and the fan blades were partially broken and partially bent. The right main landing gear was scattered on the right side of the runway. The inner tire of the right main landing gear burst, and the bottom of the right engine was severely worn. In an area of ??approximately 1,230 meters by 250 meters, aircraft debris and debris were distributed on the road surface north of the center circle of the runway and on the grass on both sides.

Technical and physical conditions of the flight crew

(1) Technical conditions

Captain: Lin Yougui (left seat), male, born in July 1960, weather Standard: 1/2.

The total flight time was 12,738:08 hours, including 9,084:51 hours as an operator and 3,654:12 hours as a pilot.

Aircraft types flown: TB-20 (120 hours), Y-7 (52: 14 hours)

Current aircraft type: Boeing 737-300 Flight 3482:04 hours (22 hours of solo flight)

Passed the technical inspection on December 29, 1996.

Co-pilot: Kong Dexin (right seat), male, born in April 1952, weather standard: 1/2. The total flight time was 15537:01 hours, including 11203:25 hours as a mechanic and 4334:36 hours as a pilot.

Aircraft types flown: TB-20 (130 hours), Cheyenne (36 hours)

Current aircraft type: Boeing 737-300 Flight 4158: 36 hours (single 88 hours of flight)

The technical inspection passed on December 25, 1996.

Observer: Xiao Rong, male, born in July 1948, total flight time: 5179:53 hours, only 123:43 hours of simulator training on Boeing 737-300. Last technical inspection time: April 18, 1997.

(2) License status

Lin Yougui, the driver’s license is valid until November 1997, and the physical examination certificate is valid until October 1997;

Kong Dexin , the driver's license is valid until July 1997, and the physical examination certificate is valid until October 1997;

Xiao Rong, the driver's license is valid until April 1998, and the physical examination certificate is valid until September 1997 ;

(3) Physical health

The crew members’ 1997 annual physical examination concluded that they were all qualified to fly. Before this flight, all crew members underwent pre-departure physical examinations in accordance with regulations. No crew members were found to have consumed alcoholic beverages or taken medication 8 hours before the flight. Through the analysis of cabin sound records and the understanding from the flight attendants of the same crew, it was found that there were no physical abnormalities among the crew members during the flight, ruling out that the crew was incapacitated in the air.

Weather and communication and navigation equipment support status

Shenzhen Terminal Weather Forecast: 17:00 on May 8 to 02:00 on May 9, 170 degrees wind 7 meters/ Seconds, visibility is 6000 meters, weak showers, clouds at 1500 meters, sometimes winds of 15 meters/second, wind direction is uncertain, visibility is sometimes 1500 meters, strong thundershowers, 5 to 7 clouds at 300 meters, 3 to 4 The individual cumulonimbus clouds are 900 meters high, and the sky is full of clouds 1,200 meters high.

Dangerous weather "Airport Alert" issued at 16:40:

Due to the influence of frontal thunderstorms, there will be a wide range of unstable weather in our area from tonight to tomorrow morning Development, thunderstorms and strong winds will occur at this site in the short term, please pay attention to relevant units.

A revised weather forecast was issued at 16:50:

170 degrees wind 7 meters/second, gust 15 meters/second, wind direction uncertain, visibility 1500 meters, severe thunderstorm, 1~ 2 clouds measuring 240 meters, 5 to 7 clouds measuring 300 meters, 3 to 4 cumulonimbus clouds measuring 900 meters, and clouds filling the sky at 1,200 meters.

Dangerous weather "Airport Alert" issued at 18:00:

Notify the airport site, air traffic control, airline dispatch and other units: thunderstorms and strong winds will occur at this site, please contact us The unit pays attention and notifies the crew about to take off.

21:00 Weather Live:

290 degree wind 7 meters/second, visibility 1500 meters, runway visual range in the direction of Runway 33 1400 meters, moderate showers, 1 to 2 amounts Cumulonimbus 1200 meters, 5 to 7 gauge clouds 1200 meters, temperature 23℃, dew point 23℃, field pressure 1010HPA.

21:33 Special weather report:

240 degrees wind 7 meters/second, visibility 2000 meters, moderate showers, 1 to 2 low clouds 210 meters, 3 to 4 The individual cumulonimbus clouds are 1200 meters, the 5-7 meter clouds are 1200 meters, the temperature is 22℃, the dew point is 22℃, and the field pressure is 1010HPA.

By listening to land and air call recordings, watching radar videos, and consulting relevant information, we confirmed that the communications, navigation, radar and other support equipment at that time were working normally; the weather was in compliance with the airport opening standards.

Accident conclusion

The aircraft encountered heavy rain during the final approach. When the crew could not see the road clearly, they violated regulations and descended blindly; due to inaccurate altitude judgment, the aircraft The aircraft did not maintain a correct touchdown attitude, resulting in a heavy landing jump, and the captain's handling errors were the direct causes of this major accident. After the go-around, because the aircraft was severely damaged and part of the control system failed, the crew was unable to control the landing attitude of the aircraft. As a result, when the aircraft landed for the second time, it touched the ground at a high speed in a downward pitch, causing the aircraft to disintegrate and crash. This is a major liability accident caused by human factors.

Lessons

This accident exposed the problems existing in the technical quality, organizational discipline, ideological style and organizational leadership of the company’s flight personnel. The lessons are extremely profound:

1. The crew behaved laxly and flew illegally

Although the crew of this flight saw the runway at the decision altitude, they encountered heavy rain during the final approach and could not see the runway clearly. The crew did not follow the instructions of the General Administration. "Eight should be opposed" and the company's regulations of "no landing in heavy rain" made a decisive go-around, blindly and recklessly, and barely landed. According to the investigation, the crew of aircraft No. 2925 performed the flight mission without serious preparation for the flight. The weather situation in Shenzhen that day was a high-altitude trough line combined with a front, with thunderstorms of strong intensity and large area. The crew had insufficient understanding of the complex weather, insufficient preparation, and did not formulate a specific flight plan. Faced with the special situation of flying in heavy rain on the final flight, the visibility was poor and the road surface could not be seen clearly. The crew did not cooperate well. No one reported the flight altitude, speed and related data, which caused the captain to lose important reference basis.

2. Flight technical management is lax and some captains have low technical quality

When the visibility was poor before landing and the road surface could not be seen clearly, the captain lacked experience in flying in heavy rain and did not press the button. The normal control method was to reduce the throttle and lever, and make the aircraft exit the glide attitude according to the changes in runway lights. When the aircraft jumped up, the captain took the wrong action of pushing the stick, causing the aircraft to jump higher and higher, causing serious damage and loss. the last chance to avoid an accident.

After reviewing the flight technical files of the crew, it was found that from October 11, 1994 to September 18, 1995, the captain's technical inspection records included three times of "late exit from the glide attitude and small landing angle" record, such technical quality is not enough to be a captain. Due to leadership's accommodating and caring behavior and lax technical control, the actual operating level of some of the company's flight personnel did not match the technical standards.

3. Lack of strict safety management and dereliction of duty by leading cadres

China Southern Shenzhen Company did not implement safety production rules and regulations, and lacked effective measures for some important links. The crew configuration of this flight was unreasonable. Both pilots were converted to driving from other aircrew jobs, and their solo flight time was short (the left-seat pilot flew solo for 22 hours; the right-seat pilot flew solo for 88 hours). The overall strength of the crew was weak and their technical level was low. It is not capable of flying missions under complex weather conditions at night.

From 16:40 to 18:00 that day, the Shenzhen Air Traffic Control Station Meteorological Station issued two "dangerous weather warnings" and a revised weather forecast, and notified relevant airport units. When the "dangerous weather warning" was first issued, aircraft No. 2925 had not yet taken off at Shenzhen Airport, but the company's duty leaders failed to pay attention to it and did not take effective measures in a timely manner.

4. The idea of ??“safety first” is not strong, and the organization and leadership are weak

Southern Airlines’ safety situation has been poor since last year. The leaders have insufficient understanding of the situation and are blindly optimistic and complacent. Emotions, failure to fundamentally take measures to reverse the passive situation, poor handling of the relationship between safety and development, efficiency and other work, and insufficient energy invested in safety. The company introduced too many aircraft, spread out too many stalls, dispersed the layout, and failed to keep up with the management work. These are important reasons for the decline in the technical quality of the flight personnel. After the adjustment of the leadership team of the Shenzhen company last year, the work intensity was not enough and the existing safety hazards were ignored. Failure to take timely and decisive measures to solve the problem.

Accident Investigation Team of the Civil Aviation Administration of China June 28, 1997