July 19, 1996

3. ANALYSIS

3.1 Analysis

3.1.1 Establishments of the times recorded on CVR and DFDR

3.1.1.1 CVR Recordings

3.1.1.2 DFDR Recordings

Various data are recorded continuously in digital PCM signals onto magnetic tape in the DFDR at various with its sampling rates ranging from eight (8) times per second to every 4 seconds.

Data regarding altitude, speed, and bearing are recorded every second. Data regarding time and engine are recorded every four (4) seconds. Data such as acceleration are recorded at a higher sampling rate of four (4) to eight (8) times per second. All the data are incremented every 4 seconds as one frame.

The cockpit clock times on the panel on F/O's side are also recorded on the DFDR. However, the times are not necessarily synchronized with UTC, so the DFDR times were calibrated as follows: radio communications keying data were recorded on DFDR. By correlating these keying data to the times contained on the CVR transcript for the ATC radio communications, the times recorded on DFDR were established.

Data up until 1115:43 were recorded on the DFDR. Since the DFDR manipulates data in the method that one second of data are temporarily accumulated in buffer (as a subframe) and are recorded on magnetic tape within next 0.5 second, by taking into account possible errors in the correlation process, it is recognized that the DFDR stopped operating at approximately 1115:45.

3.1.2 Flight of the Aircraft

3.1.2.1 Estimation of Flight History

0853 (1700 JST)	The aircraft took off from Taipei International Airport.
ca.0914 (1800 JST)	The aircraft reached FL 330, and flew in accordance with its flight plan toward Nagoya Airport.
1040:17 (1900 JST)	The aircraft was cleared by Tokyo Control to PROCEED DIRECT XMC (Kowa VOR/TAC), and the aircraft flew according to this clearance.
1045:45 (1900 JST)	The F/O(PF) briefed the CAP (PNF) on the approach procedure to Nagoya Airport, go-around procedure, etc.
1047:35	While cruising at FL 330, the aircraft was cleared by Tokyo Control to descend to FL 210, and began its descent.
ca.1049:00-ca.1056,00	During this period, the CAP (PNF) gave general guidance to the F/O(PF) on flight procedure and control during approach and landing.
1058:18	The aircraft's radio communication was transferred from Tokyo Control to Nagoya Approach, and the aircraft continued its approach.
1059:04	The F/O(PF) said "CHECKLIST". It is considered that he requested the CAP (PNF) to conduct the approach checklist.
1 l00:05(2OOOJST)	The CAP (PNF) said to the F/O: "OK, FASTEN LEFT, APPROACH CHECKLIST COMPLETED."
1100:11	The CAP (PNF) instructed the F/O (PF) to control the aircraft at his own discretion and the F/O (PF) responded by saying "YES".
1100:12	The SLATS/FLAPS lever was moved from 0/0 to 15/0.
1102:35	The SLATS/FLAPS lever was moved from 15/0 to 15/15.
1107:22	Until this time AP No.2 had been engaged; at this time AP No.1 was additionally engaged.
1108:26 - 1110:54	Since the F/O(PF) was concerned about wake turbulence, the CAP (PNF) taught him how to deal with it, instructing him to reduce the speed from 180 kt to 170 kt in order to extend the separation between themselves and the aircraft flying ahead.
1110:52	The sound of a seat being adjusted was recorded. This is estimated from the sound spectrum of the CVR recordings which indicate that the CAP adjusted his seat upward in preparation for approach.

1111:35	With the CAP's (PNF) consent, the F/O(PF) disengaged both AP No.1 and No.2 in order to change from automatic operation to manual operation.
1111:45	The CAP (')NF) called out "GLIDE SLOPE ALIVE".
1111:46	The F/O(PF) acknowledged this and called out "go-around altitude 3,000 ft". And then GO AROUND ALTITUDE was set on ALT SEL before the FMA displayed GS STAR, as a result of which the altitude alert sounded at 1111:55. Both the CAP (PNF) and the F/O(PF) confirmed the above situation.
1112:19	The aircraft passed over the outer marker under manual control by the F/O(PF), and continued ILS approach.
1112:41	The F/O(PF) requested the CAP (PNF) to set "Flap 20", and in response to this the CAP (PNF) moved the SLATS/FLAPS lever from 15/15 to 15/20.
1112:56	The F/O(PF) requested "Gear Down" to the CAP(PNF), and the CAP responded by performing the Gear Down operation.
1113:14	The F/O(PF) called to the CAP (PNF) "30/40, speed V approach 140, landing checklist please"; the CAP moved the SLATS/FLAPS lever from 15/20 to 30/40 and called "Landing check list completed" at 13:27.
1114:05	At approximately 1,070 ft pressure altitude, the F/O(PF) triggered the GO lever. As a result, the engines' thrust began to increase, the aircraft developed a slight nose-up tendency and began to deviate above the ILS glide path. Speed also increased. Engine thrust increase was stopped at EPR 1.21 about 14:08, and was then slightly reduced to EPR between 1.17 and 1.18.
	In an attempt to recover the normal descent path, the F/O (PF) performed a nose-down operation by pushing the control wheel (The THS position did not change from -5.3°.)
	However, the aircraft did not descend and, around 1114:10, leveled off at approximately 1,040 feet pressure altitude.
1114:09	An aural LANDING CAPABILITY CHANGE WARNING was recorded on the CVR. This sound is considered to have been caused by the change from LAND mode to GO AROUND mode.
1114:10	The CAP (PNF) cautioned the F/O (PF) by saying " You, You triggered the GO lever,", and the F/O acknowledged, saying "Yes, Yes, Yes, I touched a little."
1114:12	The CAP (PNF) instructed the F/O (PF) to "disengage it", and the F/O (PF) answered "AY".
1114:16	The CAP (PNF) said " That" and the F/O (PF) said "AY"

1114:18	During level flight, both AP No.2 and No.1 were engaged in CMD almost simultaneously. As the FD was in GO AROUND mode, the APs were also engaged in GO AROUND. At this time, the elevators were at 3.5° nose-down with the F/O still pushing the control wheel.
1114:20	As the APs were engaged, the THS began to move from -5.3° toward the nose-up direction.
	In the meantime, the CVR had recorded a sound that is assumed to indicate activation of the pitch trim control switch.
	It is considered that the switch was activated by the F/O (PF) in an attempt to reduce the resistive force on the control wheel. However, trimming of the THS using the pitch trim control switch is inhibited during engagement of the AP(s), so the F/O's actions had no effect.
1114:23	The CAP (PNF) gave the F/O (PF) an order, saying "Push down, push it down, yeah". This is considered to have been an instruction to push the control wheel down in order to correct the descent path that had become too high.
1114:26	The CAP (PNF) told the F/O (PF) "You, that --- disengage that throttle". This is considered to have represented the CAP's (PNF) instruction to the F/O (PF) to manually adjust the thrust by moving the throttle toward its idle position (for the same purpose as in 1114:23, i.e., to correct the descent path that had become too high).
1114:29	The F/O said "Too high". This is considered to have meant that the aircraft was flying above the normal descent path.
1114:30	On noticing that the FMA was still displaying GO AROUND mode, the CAP (PNF) said to the F/O (PF), "You, you are using the GO AROUND mode", and then added "It's OK, disengage again slowly, with your hand on".
	There seems to be a possibility that in response to the CAP's instruction, the F/O took some action to change from GO AROUND mode to another mode, but this was not achieved. The words "with your hand on" seem to have two different meanings, the first being that the F/O should keep his hand on the thrust lever and the second that he should keep his hand on the button to change from GO AROUND mode to another mode.
1114:34	The CVR recorded a sound that is assumed to indicate activation of the pitch trim control switch. As at 1114:20, however, this operation had no effect.
1114:37	The THS moved to -12.30°.
1114:39	The CVR recorded a sound that is assumed to indicate activation of the pitch trim control switch. As at 14:20 and 1114:34, however, this operation had no effect.

1114:45	The CAP (PNF) again pointed out to the F/O (PF) "It's now in GO AROUND mode". The F/O answered, "Yes, sir".
	Although there seems to be a possibility that the F/O (PF) took some action to change from GO AROUND mode to another mode, no mode change was actually made. At and around this point of time, the pitch angle and AOA increased and the speed decreased, and to deal with this situation, the F/O increased the thrust slightly.
1114:49	The F/O (PF) said, "Sir, auto pilot disengaged" and disengaged both APs. This action was probably taken at the F/O's (PF) own discretion or under the CAP's (PNF) instruction, but it is not clear which was the case (the conversation in the CVR record just prior to the action had been masked by another ATC communication).
1114:50	The sound of Auto Pilot disengagement was recorded on CVR.
1114:51	The F/O (PF) said, "Sir, I still cannot push it down."
1114:57	With the pitch angle and AOA still increasing, the aircraft continued to its approach with decreasing speed. At approximately 570 feet pressure altitude, the thrust increased suddenly, reaching its maximum level at 1115:03.
	This is considered to have been caused by activation of the alpha floor function due to the AOA exceeding the threshold angle of 11.50 for SLATS/FLAPS 30/40 configuration.
1114:58	The CAP (PNF) said "I, that land mode?".
1115:02	The F/O (PF) reported to the CAP (PNF): "Sir, throttle latched again Activation of the alpha floor function displays a symbol "THR-L" on the FMA.
	Owing to the thrust increase following activation of the alpha floor function at 1114:57, the aircraft's speed and pitch angle increased; the aircraft stopped descending and began to climb.
	At 1115:03, the CAP told the F/O that he would take over the controls. After doing so, the CAP pushed the control wheel to the forward limit, but the aircraft still continued to climb. Around this time the thrust levers were also temporarily retarded, suggesting that the CAP still intended to continue approach.
1115:04	The F/O (PNF) said, "Disengage, disengage." Again at 1115:09, the F/O said "Disengage, dis...". This is interpreted as a request to the CAP (PF) for the A/THR to be disengaged.
1115:08	The CAP (PF) said, "What's the matter with this?". It is considered that the CAP's words expressed his puzzlement that the nose-up tendency was continuing, even though he had pushed the control wheel fully forward and decreased thrust.
1115:11	The CAP (PF) re-increased thrust (which he had earlier reduced) while calling "GO

	lever". At the same time, the CVR recorded the activation sound of the pitch trim control switch, and the DFDR recorded the movement of the THS in the nose-down direction.
	The CAP (PF) said "Damn it, how comes like this?". It is considered that the CAP's words expressed his puzzlement that the aircraft pitch angle was still increasing despite his actions to the contrary (pushing the control wheel fully forward and retarding the thrust levers).
	Owing to the re-increased thrust, the aircraft began a steep climb with increasing pitch angle. Speed, which had earlier increased, began to decrease.
1115:14	The F/O (PNF) reported go-around to Nagoya Tower.
1115:17	Mode 5 warning of the GPWS sounded "Glide Slope" once. It is estimated that this resulted from a detection of a pseudo-path angle that occurred at an angle 3 times greater than the normal path angle.
1115:18	The sound indicating passage of the SLATS/FLAPS lever through the baulk attached gates was recorded twice (see attached Figure 27).
	According to normal go-around procedure, the SLATS/FLAPS lever should be moved from the 30/40 position one step higher to 15/20. However, judging from the numbers of times the STATS/FLAPS lever sound was recorded, it may have been moved beyond the 15/20 position, perhaps to the even higher 15/0, or 0/0 position. Later, at 15:27, a sound presumably indicating the SLATS/FLAPS lever's downward movement passing through the baulk attached gate was recorded on the CVR. Also on the DFDR is a record showing that the SLATS/FLAPS lever was set on the 15/15 position at 1115:28.
1115:20	Both thrust levers were retarded almost simultaneously. At approximately 1115:23, the No.1 thrust lever was retarded to the vicinity of its idle position and the No.2 thrust lever was retarded slightly. At approximately 1115:27, both the levers were back almost to their full thrust positions.
1115:21	"He, if this goes on, it will stall," the CAP (PF) shouted. It is presumed that this remark reflected the CAP's (PF) shock either when he found the aircraft was continuing to climb steeply with increasing pitch angle while reducing speed, or when he noticed the position of the SLATS/FLAPS lever set by the F/O (PNF).
1115:23	The master caution (single chime) sounded. It was probably caused by the tripping of the yaw damper lever.
1115:25	The stall warning sounded for two (2) seconds and then stopped. This was probably due to the following:
	The stall warning began to sound at 1115:25 because the AOA reached

	approximately 16° at 15:22, exceeding the threshold angle of 15° for the configuration SLATS EXTENDED. However, Vc dropped below 75 kts. at 1115:27, so the ADC apparently judged the AOA to be "NO MORE VALID" and terminated the warning function.
	It is considered probable that around 1115:25, the aircraft fell into a stall, yet continued to climb until reaching its highest point. The aircraft remained in a stall condition until impact.
1115:26	The pitch angle of the aircraft reached the maximum angle of 52.56°.
1115:27	The THS returned to -7.4° from 12.30° where it had been at 1115:11, and then remained there until 1115:33.
	It is considered that this was probably caused by the tripping of the pitch-trim lever at 1115:27.
1115:28	The master caution (single chime) was recorded on CVR. It is considered that this was probably caused by the tripping of the pitch-trim lever.
1115:31	The master caution (single chime) was recorded on CVR. It is considered that this was probably caused by the tripping of the ATS Lever. On the CVR the F/O's words, "Set, set," are recorded. It is considered that these words were probably the F/O's request to reset something when he saw CAUTION MESSAGE displayed on the ECAM. Considering the fact that the THS was moved again after about 1115:35, the F/O probably reset the pitch trim.
	After reaching the highest point at approximately 1,730 ft pressure altitude, with a pitch angle of 43.80, the aircraft began to descend, while rolling and yawing greatly to the left and right. There are records showing that corrective actions were taken by the crew by means of the ailerons and rudder during this period.
1115:31	The thrust decreased temporarily.
	This was presumably caused by surges that occurred in both engines.
1115:34	From this point until just before the impact , the F/O (PF) shouted "Power" repeatedly. This was linked to his utterance of "Quick push nose down" at 1115:26 and is assumed to indicate a desire to increase thrust and thus recover lost speed.
1115:35	The CAP (PF) performed a nose-up operation using the control wheel.
	It is considered that the CAP had until then been applying nose-down input to the elevator in order to decrease the pitch angle, but at this moment he applied a nose-up input to the elevator in response to the decrease in pitch angle and the steep descent of the aircraft.
1115:37	The Mode 2 warning of the GPWS sounded "TERAAIN TERRAIN" once. Computation of the CAS and AOA that had earlier paused, now resumed.

1115:40	The aural stall warning, which had stopped at 1115:27, sounded again and continued until impact.
1115:45	From the conditions in which the CVR and DFDR recordings ended, it was estimated that the aircraft crashed at approximately 1115:45.

3.1.2.2 Analysis of Flight Conditions

(1) Concerning activation of the GO lever

It is recognized that the F/O (P/F) triggered the GO lever at 1114:05, judging from the following: the increase in engine thrust starting at 1114:05, as recorded on DFDR; the CAP's (PNF) utterance at 1114:06, the sound of LANDING CAPABWITY CHANGE at 1114:09, the CAP's caution at 1114:10, and the F/O's response at 1114:11, all of which were recorded on CVR.
The F/O activated the GO lever, causing the FD to change to GO AROUND mode, and the ATS to be engaged in THE mode.
It is considered that at 1114:06 the CAP said "EH. EH. AH," on seeing the display change on the FMA.
The F/O (PF) seems to have used ATS with his hand on the thrust levers, judging from the smooth transitions of both thrust levers recorded on DFDR until then.
It is considered that the F/O may have mistaken the GO lever for the AT disconnect push button in an attempt to change the ATS into manual thrust, or that he tried to move the thrust levers to control the thrust and thereby inadvertently triggered the GO lever. The reasons why are not clear, but, at any rate, he inadvertently triggered the GO lever.
The GO lever of the A300-600R type aircraft is positioned below the thrust lever knob. The direction that the GO lever is operated in is the same as the direction in which the thrust lever is retarded, or as the same direction that the fingers move when gripping the thrust lever knob With this arrangement, the possibility exists for an inadvertent activation of the GO lever during normal operation of the thrust levers (See attached Photograph 51).

(2) Concerning CAP's direction at 1114:12

The CAP gave an instruction to the F/O, saying "Disengage it". The definite meaning of the word "it" is not found in the CVR records, but there seem to be two possible meanings -- "Auto Throttle" and "GO AROUND mode" -- which it could represent. This is inferred from the following:

	The DFDR records show that activation of GO lever led to a thrust increase; the EPRs stopped at the value of 1.21 at 1114:08. It is considered that the F/O probably pushed the AT disconnect push button while holding the thrust levers -- which were moving forwards at the time -- and then retarded the thrust levers.
	After this action the EPRs were reduced slightly. It seems that before 1114:12 the Auto Throttle had already been disengaged by the F/O, and the FMA display had

	changed to "GO AROUND".
	It was most likely that the CAP's instruction in this situation meant that GO AROUND mode should be disengaged, because he must have seen the FMA display.

(3) Concerning the CAP's word at 1114:16

At 1114:16, the CAP said "That", and the F/O said "Aye". The precise meaning of the word "that" is not found in the CVR records, but there appear to be three possibilities:

	(1)	The CAP instructed the F/O to engage the AP(s).
	(2)	Because the CAP's instruction at 1114:12 had not been followed, he repeated it.
	(3)	The CAP's word did not represent an instruction, because the nuance is ambiguous. In this case, the F/O seemed to have given the CAP only a response.

However, it was not possible to determine which of the above scenarios is the correct one.

(4) Concerning use of AP

According to the DFDR records, both APs were engaged at 1114:18. Around this time, no verbal exchange as to AP engagement was recorded on CVR. However, there seem to be the following possibilities concerning engagement of APs:

	(1)	Possibility that the CAP instructed the F/O to engage the APs
		If it is assumed that the CAP's word at 1114:16 meant the item (3)-(1) above, the F/O might have engaged the APs in accordance with the CAP's instruction.
		According to the positions of the thrust levers (throttle resolver angles) recorded on DFDR from 1114:12 to around 1114:18 (which is recorded every 4 seconds with one second time gap between NO.1 and NO.2), the positions of the thrust levers varied slightly respectively, so taking into account the time allowance for the actions taken by the F/O, it is considered possible that the F/O tried to select the LAND mode at first, then once held the thrust levers after taking actions to change mode, and furthermore took action to engage the APs.
	(2)	Possibility that the CAP engaged the APs himself
	(3)	Possibility that F/O engaged the APs himself
		If it is assumed that the CAP's words at 1114:16 meant item (3)-02 or (3)-03 above, another possibility is that the F/O engaged the APs without the CAP's consent, or without notifying the CAP. In this case, according to the CVR records, because the F/O had so far operated during the whole flight based on the CAP's instructions, or with the CAP's consent in advance, there seems to be a possibility that the F/O instinctively engaged APs for their assistance.

However, it was not possible to determine which of the above scenarios is the correct one.

The reason why either the CAP or the F/O engaged the APs may have been that the crew intended to regain the normal glide path by selecting LAND mode and engaging the APs.

(5) Concerning the operation of Pitch Trim Control Switch

The activation sound of the pitch trim control switch was recorded on CVR at 1114:20, 1114:34, and 1114:39 respectively. If a hypothesis is made that the F/O knew that THS trimming operated by the pitch trim control switch was inhibited during AP engagement, the CAP may therefore have engaged the APs unknown to the F/O. However, from the fact that the F/O actually disengaged both APs at 1114:49, he may finally have recognized that the APs had been engaged by this time.
On the other hand, even though the F/O may have recognized AP engagement, it is still possible that he may have involuntarily operated the switch while pushing the control wheel.

(6) Concerning disengagement of GO AROUND mode

The CAP said "You, you triggered the GO lever" at 1114:10, and alerted the F/O (at 1114:30 and 1114:45) to the fact that GO AROUND mode had been engaged. This leads to the possibility that after the F/O had triggered the GO lever, the CAP, watching the FMA display, intended to disengage GO AROUND mode and instructed the F/O to do so. However, it is inferred from the following facts that GO AROUND mode remained engaged.

	(1)	THS moved in the direction opposite to the F/O's input at the control wheel.
	(2)	Disengagement of GO AROUND mode and engagement of other modes led AP No.2 to be disconnected, but no data concerning this was recorded on DFDR.
	(3)	CAP continued until 1114:45 to alert the F/O to the fact that GO AROUND mode was still engaged.

In order to disengage GO AROUND mode, both lateral mode and longitudinal mode (except LAND mode) must be selected. Direct access to the LAND mode button cannot disengage GO AROUND mode (by selection of either lateral or longitudinal mode a display of GO AROUND on FMA will turn oft).
However, judging that GO AROUND mode still remained engaged, it is estimated that what the crew's operation on FCU was not correct procedure to disengage it : he must only have pulled LAND mode button. And also, taking into account that the CAP said "I, that LAND mode?" at 1114:58, the CAP seemed to have intended to disengage the GO AROUND mode and select LAND mode.
The procedure for performing an approach by disengaging GO AROUND mode once engaged and then engaging LAND mode is unusual in the final phase of approach. However, the fact that the crew did not change modes as intended seems to have been due to their lack of understanding of the Automatic Flight System (AFS).

(7) Concerning the sequence leading up to the out-of-trim situation

After the GO lever was triggered, the sequence leading up to the out-of-trim situation was as follows:

(1) Just before 1114:05

In the landing configuration with landing gear down and SLATS/FLAPS at 30/40, the aircraft continued descent along 30 ILS glide path with a speed of approx. 140 kts., pitch angle of approx. 40, both EPR at approx. 1.1, THS at -5.3°, and the elevator angle (relative to THS) at 0° to 1° nose down.

(2) Just after 1ll4:05

While crossing approx. 1,070 ft pressure altitude, the GO lever was activated by the F/O, and when the EPRs increased to 1.21 at about 14:08, the thrust levers were manually pulled back slightly.

The aircraft increased its speed and pitch angle slightly, deviating above the ILS glide path. The F/O applied push-down input to the control wheel but it was insufficient and also he did not retard the thrust levers sufficiently. These circumstances led the aircraft to level off about 1 ,040ft pressure altitude around 1114:10. For a while the THS had stayed at 5.3° And pitch trim control switch was not operated.

(3) 1114:18

	While the aircraft continued level flight, both APs were engaged in CMI) with the FD already in GO AROUND mode, and the APs, were brought into GO AROUND mode.
	In the meantime, the F/O (PF) had been pushing the control wheel since 14:05, when he had activated the GO lever, in an effort to return to the normal descent path.
	At the time when the APs were engaged in CMI), the elevator angle was 3~50 nose-down. The angle decreased to 2.80~2.40 temporarily in the period between 1114:19 and 1114:20, but the nose-down angle gradually increased thereafter.
	GO AROUND mode was engaged while the F/O was pushing the control wheel. The AP attempted to move the elevators and THS toward the nose-up direction, but this resulted in the elevators' function being overridden and the THS beginning to move in the nose-up direction from 5.3°
	However, the nose-down operation of the elevators performed by the F/O canceled the aerodynamic effect of the THS nose-up which was controlled by the AP, and the aircraft temporarily continued level flight. The surface area of THS (including the elevators) is approximately three times that of the elevators. The aerodynamic effect per unit travel angle of the THS is therefore considerably greater than that of the elevators.

(4) 1114:24

To correct the descent path, the F/O (PF) began to retard the thrust levers and reduced the EPRs from approx. 1.17 to approx. 1.00 by 1114:31.

As a result, the speed began to decrease from 146 kts., causing the nose-up tendency also to decrease. This retard operation of the thrust levers and the push-down operation of the control wheel by the F/O against the movement of the THS in nose-up direction, together caused the pitch angle to decrease, and the aircraft began to descend around 14:26.

(5) 1114:30

	The pitch angle which had decreased to 1.20 again began to increase.
	This is considered to be due to the fact that the pitch-up effect generated by the nose-up movement of the THS became larger than the pitch-down effect brought about by the push-down operation of the control wheel from that time on.
	The speed continued to decrease slowly. As the pitch angle increased, the AOA also began to increase.

(6) 1114:37

	While crossing approx. 880 ft pressure altitude, the THS reached the full nose-up position of ~12.30, and the elevator was moved to 8.50 in the nose-down direction. Around this time, the descent rate was approximately 1,000 ft/mm.
	Although the control wheel was still being pushed, the pitch angle and AOA continued to increase, while the speed continued to decrease. In order to deal with the continuous decrease in speed, the F/O increased the thrust slightly.

(7) 1114:49

While crossing approx. 700 ft pressure altitude, the APs were disengaged, but THS remained ~12.30, and out-of-trim condition continued.

(8) Concerning activation of Alpha Floor Function (Refer to 3.1.11.6)

Just after the APs were disengaged at 1114:49, the mobility of the control wheel (being pushed by the F/O(PF)) increased a little, thereby moving elevators in the nose-down direction; and pitch angle and AOA decreased. A few seconds later, forward pressure on the control wheel was loosened a little, and pitch angle and AOA increased again. When the aircraft crossed approximately 570 ft pressure altitude at 14:57, as airspeed was 127 kts., both EPRs were 1.04 and pitch angle was 8.60 and AOA exceeded threshold angle of 11.50 for the configuration of SLATS/FLAPS 30/40, the alpha floor function was activated.

Although at this point of time, THS was ~l2.30 and the elevator angle was 9~90, the sudden increase of power due to the out-of-trim condition and the activation of the alpha floor function generated a pitch up moment. As for the fact that the F/O (PF) loosened forward pressure on the control wheel a little several seconds after AP was disengaged, it is considered likely that he did so in order to correct the pitch angle. However, even if the F/O (PF) had not loosened forward pressure on the control wheel at this point of time, the AOA, sooner or later, must have been exceeded threshold angle of 11.50 due to the trend of speed,

pitch angle and the AOA if the aircraft had continued to approach under the above-mentioned out-of-trim condition.

(9) Concerning continued approach

The CAP (PNF) had had the F/O perform the PF duty while making an WS approach. Judging that although the aircraft once deviated above the glide path after the F/O triggered the Go lever, it began to return to the normal glide path due to the F/O's fully forward pressure on the control wheel and reducing the thrust following the CAP's instruction, and the runway was visible to the crew due to good weather condition and sufficient visibility, the CAP probably intended to have the F/O continue the approach. It is considered that the CAP paid his attention outside to assess the aircraft position and the descent flight path from the view of the runway and the CAP would have instructed the F/O only to have the aircraft recover the normal glide path.

(10) Concerning override of the AP

The CAP (PNF) instructed the F/O (PF) repeatedly to push the control wheel. There seem to be the following possibilities as to why he did so:

(1) The CAP did not recognize that the APs were engaged.

(2) The CAP recognized that the APs were engaged, but he believed that the F/O had disengaged GO AROUND mode either when the CAP instructed him to do so or when he had pointed out that GO AROUND was still engaged.

(3) The CAP recognized that the APs were engaged, but he thought that he could manually override the AP, based on his flight experience of B747-200 and 400 aircraft.

The aircraft incorporates a supervisory override function which allows pilots to assist the AP by applying a force on the control wheel when capturing the Glide Slope, the Localizer or the VOR course. There seems to be a possibility that the crew's experience in using this function led to their mistaken belief that they could override the APs during all phases of approach. This could have led them to override the APs while in GO AROUND mode.

The hazard of overriding the elevator by operating the control wheel while the APs are engaged in GO AROUND mode is described as a "CAUTION" in the FCOM. The reason why the crew took actions which nevertheless resulted in an out-of-trim condition, is presumed to be that they had not properly understood the contents of these cautions, and of other related descriptions in the FCOM. As mentioned later, the fact that descriptions in the FCOM are not easy for pilots to understand, and functions to alert pilots of THS movement are not properly incorporated, probably affected this outcome as a background factor (Refer to 3.1.11.3 and 3.1.11).

(11) Concerning the CAP's remarks at 11 14:58

At 14:58, CAP (PNF) said," I, that LAND mode?". This may be interpreted as follows:

	(1)	At 14:12, CAP (PNF) instructed the F/O (PF), saying, "Disengage it." (Disengagement of GO AROUND mode was very likely).
	(2)	Twice after this, the CAP (PNF) cautioned the F/O (PF) that GO AROUND mode was still engaged.
	(3)	CAP instructed the F/O (PF) repeatedly to push the control wheel.
		It is considered likely that the CAP said "I, that LAND mode?" in puzzlement on realizing that the aircraft was still not adopting the proper attitude for descent, in spite of his above-mentioned instructions and cautions.

(12) Concerning timing of control take-over

After the APs had been engaged, the F/O attempted to recover the normal descent path, but could not maintain airspeed and aircraft altitude to do so.
To deal with this situation, the F/O (PF) disengaged both APs at 14:49, saying "Sir, auto pilot disengaged."
At 14:51, the F/O (PF) reported to the CAP (PNF), saying "Sir, I still cannot push it down, yeah", probably because the pitch angle was still high, and the aircraft was still not responding to his actions. Again at 15:02, the F/O (PF) reported, saying "Sir, throttle latched again."
Until then, the CAP (PNF) appears not to have fully grasped the flight situation. Hearing the F/O's (PF) report above, the CAP (PNF) seems to have decided to take over the controls to deal with the unusual situation. At 15:03, CAP took over the controls. However, even at this point, the CAP (PF) still seems to have been unaware that the THS was at the nose-up limit.
Although the CAP (PNF) would have been unable to experience directly the unusually strong resistive force of the control wheel until he took the controls, in view of the points described below, he could still have recognized to some extent that an abnormal flight condition had arisen.

	(1)	GO-AROUND mode continued to be displayed on the FMA.
	(2)	The CAP had earlier instructed the F/O to push the control wheel and retard the thrust levers in order to regain the normal glide path. However ,the aircraft did not respond as the CAP had intended when he issued his instructions.
	(3)	The CAP had had to give directions and cautions (such as item 02 above) to the F/O, one after another. This fact itself suggests that the F/O must no longer have been in a condition to perform PF duty adequately.

However, it is considered that the CAP's situational awareness as PlC for the flight was inadequate, control take-over was delayed, and appropriate actions were not taken.

(13) Concerning GO AROUND after CAP took over controls

Immediately after the CAP took over the controls, he retarded the thrust levers to reduce the power before calling "GO lever" at 15:11.
It is considered that when CAP took control, although he was aware of an unusually strong resistive force on the control wheel, he still intended to make a landing; so he pulled the thrust levers to try to reduce the pitch angle which was increasing. However, judging that the CAP was unable to stop the pitch angle (which was increasing in nose-up direction), it is estimated that he gave up landing, uttering "How come like this?", decided to go around and then called out "GO LEVER" while increasing the thrust, which had earlier been reduced, to full thrust.
In normal go-around procedure, PF calls "go around flap" as he operates the GO lever, PNF moves the SLATS/FLAPS lever one step up, and after calling "positive climb" PNF performs a gear up operation following PF' 5 order.
In this case, however, the correct procedure was not followed as stated. After "GO lever" was called, it took about seven (7) seconds before initial movement of the SLATS/FLAPS lever in the retract direction took place.
While the SLATS/FLAPS lever should be moved from 30/40 to 15/20, from the CVR record it is considered possible that the lever was moved to 15/0 or even higher, to the 0/0, before being lowered again to the 15/15 position. The landing gears were left in the down position (See attached Figure 27.).

(14) Concerning operations performed to deal with increasing pitch angle and steep climb

(1) 1114:57

In a pitch-up side out-of-trim condition with the THS at -l2.3° and the elevators at 9.9°, the alpha floor function was activated, suddenly increasing the thrust and which caused a large pitch-up moment to be generated.

(2) 1115:03

The pitch angle did not stop increasing despite the CAP's (PF) efforts who, after taking the controls, pushed the control wheel to the forward limit and retarded the thrust levers.
Around 15:04, the aircraft which had, until that point, been descending, began to climb from approx. 500 ft pressure altitude (approx. 360 ft radio altitude).

(3) 1115:11

When the CAP(PF) increased the thrust again and called, "GO lever", the aircraft was climbing through approx. 600 ft pressure altitude with pitch angle at 21.5°.
The pitch angle was further increased by a large pitch-up moment generated by the increase of thrust under the pitch-up side out-of-trim condition.
Speed began to decrease from 137 kt around 15:08.

(4) 1115:12

It is considered that the CAP (PF) continued to push the control wheel fully to reduce the pitch angle, and intermittently operated the pitch trim control switch in the pitch down direction, as indicated by the slow return of the THS from the limit angle of -12.3° to -l0.9° by 15:19. (Intermittent use of the switch does not generate the "Whooler" tone.)
Thereafter, the THS moved again from -10.9° at 15:21 to -7.4° at 15:27. It is considered possible that the alpha trim function activated because the AOA at 15:23 was approx. 18°, which exceeded the threshold angle of 17° for SLATS/FLAPS 15/20 and 15/15 configurations.
It was not determined whether or not the manual trim had been operated during the above period.
During the period from 15:27 to 15:33, the THS remained at -7.4°
The CAP (PF) operated the pitch-trim only intermittently during the go around. Consequently, it is considered that he was not aware of the THS state.

(5)1115:20

There are three feasible ways to reduce increasing pitch angle: to push the control wheel, to regain trim, and to reduce the thrust. Under the conditions of steep climb and continued decrease of speed, it seems that the CAP(PF) hesitated to reduce the thrust.
However, at this point of time, when the speed had decreased to 115 kts., the pitch angle had increased to an abnormal 40.3°, it is considered that the CAP (PF) retarded the thrust levers to reduce pitch angle.
At approximately 15:23 No.1 thrust lever was retarded to a position near idle and No.2 thrust lever was retarded slightly. This is probably because, although the CAP was hastily attempting to retard the thrust levers in an effort to correct the aircraft attitude which continued to climb steeply, the CAP's (PF) hand came off the thrust levers at the above-mentioned position while continuing to push the control wheel with the aircraft's steep nose-up attitude.
Around 14:27, the thrust levers were moved to a position close to full thrust. This seemed to result from the fact that either the CAP or the F/O pushed the thrust levers forward in an attempt to recover lost speed.
It is also presumed that the aircraft's nose-up pitching moment was further increased as a result of the SLATS/FLAPS retracting from 30/40 to 15/15.

(15) Concerning crew coordination between the CAP and the F/O (See Appendix 2-1)

(1) At 1059:04 and 1113:14, the CAP (PNF) read out the approach checklist and the landing checklist at the request of the F/O (PF), but these were not performed in the proper manner because the CAP (PNF) read the items only to himself, including those to which the CAP and F/O (PF) should responded together.

(2) At 1114:18, both APs were engaged, but nothing was said that expressed definite

instructions or intentions to make the F/O (PF) change mode or engage the APs.
The CAP's words when instructing the F/O to disengage GO AROUND mode were only "Disengage it". These words did not describe a definite operation.

(3) At 1114:12, the CAP said, "Disengage it." At 14:30, he said, "You, you are using the GO AROUND mode." At 14:45, he said, "It's now in the go around mode." By these words, the CAP pointed out the current mode and instructed the F/O to change the mode.
In response to this, it seems that the F/O took some action to change modes, but was unable to successfully engage LAND mode in the end. In this case, the F/O did not immediately report to the CAP (PNF) that he could not change modes (or that did not know how to change modes).
In the meantime, after the CAP pointed out the current mode and instructed the F/O to change modes, it is considered that the CAP did not check the FMA display properly on each occasion to see whether the mode had actually changed or not.

(4) When the F/O was instructed by the CAP ("Push more.") he did not report the abnormally strong resistive f6rce of the control wheel to the CAP. As a result, it is probable that the CAP was not fully aware of the situation and that his instructions to the F/O were therefore inadequate.

The F/O must have perceived the abnormally strong resistive force of the control wheel, but he, who was under high stress from the following factors, probably delayed reporting the situation properly to the CAP:

• The F/O had been instructed to control the aircraft at his own discretion, for as long as he could.
  
• He had inadvertently triggered the GO lever.
  
• The CAP had pointed out to the above actions to the F/O. Subsequently the CAP had given a series of instructions and cautions to the F/O about control and operation of the aircraft, one after another.
  
• The F/O was so busy following the CAP's instructions and cautions, thereby losing his initiative as PF, that he had almost no room left to take the appropriate measures by himself
  

(5) During approach, the CAP had instructed the F/O to perform PF duty, but after the F/O triggered the GO lever, the CAP gave a series of instructions and cautions to the F/O about control and operation of the aircraft, one after another. As a result the CAP made the F/O lose his autonomy and disregard their duty assignment, namely, that the CAP was the PNF and the F/O was PF.

(6) The FCOM 2.03.18 (page 3) stipulates under the title of "STANDARD OPERATING PROCEDURES - STANDARD/APPROACH" that if the speed exceeds VAPP +10 Kts. or becomes less than VAPP -5 Kts. ,or if the aircraft deviates a dot or more from the glide slope during an approach, the PNF should call out the fact.

At 1114:17, the aircraft deviated more than a dot upward from the glide slope, and speed decreased to less than -5 Kts. from the VAPP of 140 KCAS as the aircraft continued approach. Despite this, the CAP did not call out these facts as PNF.

(16) Concerning the tones of MASTER CAUTION record on CVR.

	There is a possibility that audible tones of MASTER CAUTION (SINGLE CHIME) recorded on CVR at 1115:23, 15:28 and 15:31 were set off respectively by the tripping of the yaw damper levers, pitch trim levers and ATS lever.
	These CAUTIONs were triggered because the input sensor data were judged as "INVALID" and the systems relating to the above mentioned levers were disconnected.
	Because the aircraft's attitude and speed changed rapidly during this phase of the flight, the possibility that the MASTER CAUTIONs were generated by a different cause cannot be ruled out.
	However, if the conditions on which these CAUTIONs sounded , the relations among these occurrences around the time when they sounded, and the analysis of the sound spectrum of the CVR recordings are considered together, it would be highly possible that these CAUTIONs are the same as the ones described at each of the times in paragraph 3.1.2.1.

3.1.3 Estimation of crash time

As described in 3.1.1, it is estimated that the CVR and DFDR stopped recording around 1115:45. This was probably caused by the breaking of cables on impact. The time of the crash is estimated to be around 1115:45 (when the CVR and DFDR stopped recording).

3.1.4 Attitude of Aircraft at the Time of Crash and Damage to Aircraft

3.1.4.1 Attitude of Aircraft at the Time of Impact

From the DFDR records, it is estimated that the aircraft stalled, then 4escended steeply with wildly changing roll angle, and impacted the ground.

The spot where the aircraft hit the ground was an unpaved, flat landing area. There were marks left on the ground surface that clearly identified those portions of the aircraft which had hit the ground. From the shapes of the marks and these positional relationships as well as the condition of destroyed landing gears, it is inferred that on impact, the aircraft was in a somewhat left-wing down, nose-up attitude, and was in an almost level attitude.

3.1.4.2 Investigation of Broken Landing Gears

The broken nose and main landing gear were investigated in order to analyze the conditions of the landing gear, the aircraft attitude, and other associated conditions of the aircraft at the

time of the crash.

All of the broken landing gears had signs of compressed oleo struts with buckled cylinders, which implies that the gears received an upward thrust, and so that the aircraft had impacted the ground with all landing gears extended.

The rear bogey beam of the LH main gear, which presumably touched the ground first, was sheared off in a ring shape at a relatively thin portion beside the strut attaching part. The rear inner wheel (with tire still inflated) of the LH main gear and the accompanying brake assembly, were flung away furthest to a point approximately 190 meters from the point of impact. It seems that this occurred because of a rupture that occurred at the moment of impact, when the kinetic energy was greatest and its loss was minimum, and also by a high rebound force brought about by the tire.

The damage to the two (2) front tires of the LH main gear was extensive, with outer tires burnt and inner tire burst owing to impact. An assumption from these conditions is that breakage occurred at the front and rear of the bogey beam, with subsequent impact transmitted directly from the ground to the strut. The direction of lacerations on the tires suggested that they skidded to the right.

3.1.4.3 Crash Circumstances and Damage to Aircraft

The crash process from when the aircraft first hit the ground to when it was destroyed is estimated to be as follows:

(1)	The LH main gear of the aircraft impacted the ground first, and at this point of time, there were no other parts in contact with the ground.
	Compared with the wheelbase of the aircraft, the measurement between the scars on the ground was greater. This implies that the aircraft was moving forward in a slightly nose-up attitude.
	At this point in time, the aircraft's magnetic heading was approximately 15 degrees (015°) and its side-skid angle was approximately seven degrees (7°) to the right, judging from the aircraft's attitude, that was almost level, and the direction of motion of the aircraft deduced from the marks left on the ground.
	Since the LH main gear impacted the ground first, the aircraft's began to turn counterclockwise as viewed from above.
(2)	The RH main gear impacted the ground a little later than the LH main gear.
	The fact that the ground scars of both main gears were not long in comparison with the track of the wheels suggests that the aircraft was descending at a steep flight path angle. The pitch angle at this time was approximately four degrees (4°) nose-up, as calculated from the geometrical characteristics of the aircraft, the conditions of the broken LH main gear, and the position of the nose gear.
(3)	At the moment the LH engine impacted the ground (receiving the strongest shock), the RH

	engine was beginning to receive the impact from the ground. Both the main gears were being destroyed in that while.
	The roll angle at this time was approximately three degrees (3°) to the left as determined from the positions of both main gears, nose gear, and LH engine.
(4)	By the time the nose landing gear impacted the ground, and was under maximum shock, both main gears had already been destroyed and the LH engine was in the process of destruction.
(5)	At the above point in time, the LH wing-tip also hit the ground.
	Judging from the positions where the marks of the LH wing tip and RH engine were found, all the landing gears were destroyed and the bottom of fuselage started breaking. The aircraft received an additional counter-clockwise moment after touching the ground and the entire airframe was distorted.
	The recovered LH wing-tip had a deformation showing an impact it had received from contact with the ground at its lower, slightly inboard section. On the other hand, the LH wing tip was damaged on its upper part, indicating that it was damaged when the RH wing was destroyed.
(6)	After the LH wing-tip had been destroyed, the LH flap track touched the ground. Destruction of the fuselage progressed to the lower part of the floor, and shortly afterwards, the horizontal stabilizer was flung onto the ground almost in a level attitude.
	The direction of the scratch marks left on the lower access panel of the THS corresponds roughly to the direction in which the debris were strewn (22 degrees (022°) in magnetic heading).
	From extrapolation using the DFDR records, the trajectory angle at the time of impact was estimated to be approximately 32°.

3.1.4.4 Condition of Wreckage

After the aircraft had impacted against the ground, the major parts of the wreckage are estimated to have been in the conditions described below.

From the scattered condition of wreckage, it is estimated that the momentum vector of the aircraft in the level plane when it crashed was approximately 22 degrees (022°) from magnetic north and approximately 42 degrees (42°) to the right of the centerline of the runway 34.

(1)	The LH engine, having dropped from the wing pylon, tumbled forward; the lower skin of the aft fuselage remained in the vicinity of the spot where it had first contacted the ground, and the horizontal tail plane and APU compartment were ruptured and had separated.
(2)	The outer flap, center flap, and outer wing of the LH wing were ruptured and had separated from the wing.

(3)	The outer flap, center flap, inner flap, spoiler, outer wing and other components on the RH wing were ruptured and had separated from the wing, and were strewn as far as the irrigation ditch.
(4)	The upper portions of the forward and aft fuselage sections, along with the portion of wing that remained attached to them, tumbled to the vicinity of the irrigation ditch, together with the ruptured and separated vertical tail plane and upper portion of the aft fuselage, all in broken state.
(5)	The cargo loaded on board was scattered in the area between the spot where the aircraft hit the ground and the vicinity of the irrigation ditch, and almost all ruptured seats were found near the irrigation ditch.
(6)	The fuel that had leaked from the broken LH wing when the aircraft crashed into the ground splashed over the area from the vicinity of the spot where the LH wing first hit the ground to where the center of the wing had come to rest, and fuel from the RH wing was scattered widely, together with debris of the RH wing, as far as the vicinity of the irrigation ditch.
	It is estimated that among the wreckage strewn forward, by the forward-acting inertial force generated when the aircraft crashed, were items such as the fuselage section aft of the central wing section, functional components, cabin furnishings, seats, and cargo burned when the fuel ignited, and were destroyed by expanding fire.

3.1.5 Investigation of Engines and FADEC

Investigation of the dismantled engines revealed that damage to components of both engines were indicative of their rapid destruction. Rotors blades were torn and deformed in the direction opposite to that of rotation. All these conditions support the assumption that the engines had been running at high speed until the aircraft crashed.

The data recorded in all the channels of both FADECs show that surges occurred in both engines, indicating a sudden drop of combustion chamber pressure during the flight.

Also, engine data recorded by the DFDR show that the engine pressure ratio, fuel flow rate, and high-pressure shaft rotating speed dropped for short periods at 1115:31 for the No.1 engine and at 1115:32 for the No.2 engine, to values lower than those that should normally result in response to the thrust lever operation performed. This could have been due to the FADEC counteracting the engine surge. Subsequently these engine parameters returned rapidly to values that normally correspond to the thrust lever movements, and no abnormalities caused by surges of the engines were subsequently detected.

When engine surging occurs, flames sometimes shoot out from the front and rear of the engines. Both engines may therefore have emitted light as the aircraft fell into an abnormal

condition during stall.

It is estimated that the engine surge which occurred when the aircraft fell into a stall condition was due to a phenomenon called "inlet distortion" in which uniform air flow through the engine air inlets is not available owing to a high AOA.

It is estimated that the AOA at this point of time was far greater than the range for normal operation, exceeding the engine air intake airflow angle limit permitted for the aircraft.

3.1.6 Results of Investigation of Computers and Other Equipment

3.1.6.1 Computer Memories

The memories of one FAC, one FMC, one SGU-EFIS, two SGU-ECAMs, one FWC, two ADCs, three IRUs, two GCUs, and one ILS receiver could be read out, but there nothing was recorded that might have been of relevance to the accident.

3.1.6.2 Investigation of Disassembled Components and Others

Of the components recovered from the crash site, 54 items (128 Units) including the AP pitch actuator, elevator actuators, trim actuator gear box, and center pedestal and so on, were analyzed by means of disassembly and other methods. Nothing abnormal was found except the damage inflicted at the time of the accident.

3.1.6.3 IRS Mode Selectors

As shown in 2.15.2, IRS mode selector No.3 was in the NAV position, while the No.1 and No.2 selectors were in the OFF and ATT positions, respectively. The IRS is an essential system for engaging the APs, and the DFDR records indicate that both AP No.1 and No.2 were engaged. Also after that, the CVR records did not contain any data that suggests failure of the IRS s, and further, there were no evidence showing changeover of the selector in the Left side Instrument Switchings record. These facts imply that the No.1 and No.2 IRS mode selectors were moved by the impact at the time of ground impact, or later.

3.1.6.4 SLATS/FLAPS Positions and THS Angle

(1) SLATS/FLAPS positions

By comparing the screw jack nut positions of the SLATS/FLAPS actuators of an aircraft of the same type with those of the crashed aircraft, the nuts of the crashed aircraft were to be at the positions corresponding to 15/15.
These positions are almost in agreement with the last SLATS/FLAPS angles of 17.05°/8.25° (15/15 position) recorded on the DFDR.
Also, the shaft of the broken SLATS/FLAPS command sensor unit was found seized up at the

15/15 position.
Judging from the above findings, it seems that the SLATS/FLAPS lever position of 15/20 shown in paragraph(2), Section 2.15.2, was a result of a movement that might have occurred as a result of impact, or some time afterward.

(2) THS angle

The THS angle was determined to have been approximately 8° as a result of a comparison made between the THS screw jack nut position of the crashed aircraft and that of an aircraft of the same type. This angle roughly agrees with the last THS angle of -7.4° recorded on the DFDR.
It was also found that the pitch trim control cable system was broken. The conclusion from the above is that the THS position indicator reading of -9.4° / 9.5° shown in paragraph(2), Section 2.15.2, is a result of a movement in the indicator that might have occurred at impact or thereafter.

3.1.7 Seated Positions of CAP and F/O

3.1.7.1 Analysis Based on CVR Records

3.1.7.2 Analysis Based on Wreckage of Seats (See attached Figures 24 and 25)

3.1.7.3 Seated Positions

From the implication of the CVR record concerning the wearing of the shoulder harnesses, and by comparison of the vertical and longitudinal positions of both seats estimated from the damage marks to the seat wreckage, as described in sections 3.1.7.1 and 3.1.7.2, it is considered that the CAP and the F/O were seated in their formal positions: the CAP in the left seat, and the F/O in the right seat.

3.1.8 Injury to Passengers and Seat Assignment (See attached Figure 26)

3.1.8.1

The number of survivors of this accident was seven (7), all being seriously injured. As noted in section 2.12.2, 16 passengers were taken to several hospitals by rescue workers.

(1)	Among passengers hospitalized, six (6) persons were found dead on arrival. The cause of death of four (4) of the six (6) was whole body contusion and fractures; the other two (2) died of whole body contusion and thermal injuries.
	It is estimated that four out of the six (6) were seated in the forward section of the cabin and the other two (2) in the aft section.
(2)	Three (3) out of the (10) seriously injured passengers died on April 27, April 28, and May 1, respectively, at the hospitals to which they had been admitted. The cause of death of these three (3) was whole body contusion and fractures.
	The estimated seat assignment for two (2) of the three (3) was in the forward section of the cabin and one (1) in the aft section.

(3)	The remaining seven (7) seriously injured were diagnosed as suffering from traumatism and various external injuries, primarily bone fractures.
	All of these seven (7) passengers were seated in the forward section of the cabin, in front of the wings.

3.1.8.2

According to the post-mortem report, the cause of death of those passengers who died before hospitalization was determined to be whole body contusion, fractures, and thermal injuries.

The positions where the passengers suffering whole body contusion and fractures were seated extended over the whole cabin area, from the front to the rear of the cabin, while thermal injury was noted in many of the passengers who are estimated to have been seated behind the main wing where the fire started.

3.1.9 Detection of Ethanol in Remains of CAP and F/O

The remains of CAP, F/O, and purser were stored in the hangar after the accident, and underwent autopsies at different colleges. During the autopsies, samples were collected from the remains, and taken to the Scientific Investigation Labs of Aichi Prefectural Police Headquarters, where they were stored in refrigeration. On the following day, alcohol reaction tests were performed at the Labs. The results are summarized below.

	Time elapsed after death and before sample was taken	Sample	Ethanol concentration
CAP	Approx. 24 to 25 hours	Pleural fluid	13 mg/ 100 ml
F/O	Approx. 19 hours	Pleural fluid	55 mg/ 100 ml
Purser	Approx. 19 hours	Blood in heart	Not detected

Ethanol was detected in the samples from the remains of the CAP and the F/O, which is considered to be due to one or more of the following three causes.

It is also considered that two or three of the following causes were combined.

(1)	Post-mortem ethanol production
(2)	Alcohol ingestion before death
(3)	Mixture with alcoholic drinks on board

Each of the three causes were analyzed as described in the following sections.

3.1.9.1 Possibility of Post-Mortem Ethanol Production

According to legal medical documents, there are confirmed cases where ethanol has been

detected in the body of a person who never ingested any alcohol before death. It is understood that progress in decomposition of the body after death results in microbial fermentation, which produces ethanol.

There is a possibility that the ethanol detected in the remains of the CAP and the F/O was due to a post-mortem ethanol production for the following reasons:

(1)	The remains of the cockpit crew were stored in a hangar after the accident, and approximately 18 to 22 hours elapsed before they underwent autopsies. During this period, special measures, such as placing the remains in refrigerated storage, were not taken.
	The lowest and highest atmospheric temperatures at Nagoya Airport area during this period were approximately 1 0°C and 23°C, respectively. The temperatures in the hangar where the remains were kept is assumed to have been somewhat higher than the above-mentioned temperatures.
	Furthermore, it was noted that the remains of CAP and F/O had deep open wounds. In particular, the body of F/O was significantly damaged.
	The long time interval from occurrence of the accident to the autopsies, the environmental temperatures, and the existence of open wounds are considered to satisfy the conditions for post-mortem ethanol production.
(2)	The concentrations of ethanol detected in the bodies of the CAP and the F/O were 13 mg/1 00 ml and 55 mg/i 00 ml respectively; these concentrations are considered to be comparable with those normally detected as a result of post-mortem production.
(3)	Regarding the difference in concentration between the ethanol found in the body of the CAP and that in the body of the F/O, when the difference in temperature resulting from the difference in location within the same hangar and the difference in severity of open wounds between them are taken into account, the variation in concentration is considered to be within a conceivable range. On the other hand, ethanol was not detected in the pursers body which had a few open wounds.

3.1.9.2 Possibility of Alcoholic Ingestion before Death

Collected samples from the bodies of the CAP and the F/O in this case consisted only of pleural fluids, probably because damage to the bodies was extremely extensive. If the crew drank any alcohol before death, ethanol may have been detected in their pleural fluids (as ethanol in the blood is absorbed into other internal organs some time after alcohol is ingested). From the fact that the open wounds of the bodies of both the CAP and F/O were extensive, it is considered possible that blood became mixed with their pleural fluids.

If this is the case, the concentration of ethanol detected in the samples should be the concentration of ethanol produced post-mortem described in section 3.1.9.1 plus the concentration of ethanol resulting from alcoholic ingestion, but the possibility of alcohol ingestion before death and the extent thereof could not be determined.

3.1.9.3 Possibility of Mixture of Alcohol from Scattered Liquor Containers

Adjacent to the cockpit and behind the F/O's seat, a galley (No.1 galley, see attached Figure 26) was located in which liquors (about 40 bottles of whiskey and other liquors) were stored for passenger service. Also on board were bottles of alcoholic liquor carried by passengers.

It seems possible that destruction of the partition between the cockpit and galley by the impact caused liquors and other alcoholic drinks from broken bottles to be scattered over the bodies of the crew (who had open wounds). However, it could not be confirmed.

3.1.10 China Airlines' Operation and Training Rules and Handling of Service Bulletins

3.1.10.1 Operation

China Airlines has an Operations Policy Manual and an Air Crew Manning and Dispatch Manual that were prepared according to the requirements stipulated by the Taiwanese civil aviation authorities, and operate their aircraft in compliance with those manuals.

(1)	Qualifications for Flight Crew
	According to an Operations Policy Manual, the flight crew shall consist of personnel of good character, clear-cut features, and sufficient technical knowledge, and shall in addition satis~ the following conditions.
	It is recognized that the CAP and F/O of the aircraft held valid licenses and satisfied the required number of hours' flight experience.
	(1) CAP
	a. Shall have an ATR license (airline transport pilot license) and a type rating certificate issued by the Taiwanese civil aviation authorities and an airman worker card (identification card) issued by China Airlines. b. Shall have a valid airman medical certificate issued by the Aviation Medical Center. c. Shall have not less than 1,000 hours' flight experience with China Airlines. d. Shall have not less than 3,500 hours' flight experience overall. e. Shall have passed the captain training tests.
	(2) F/O a. Shall have an SCP license (commercial pilot license) and a type rating certificate issued by the Taiwanese civil aviation authorities and an airman worker card (identification card) issued by China Airlines. b. Shall have a valid airman medical certificate issued by the Aviation Medical Center. c. Shall have passed the flight officer training tests.
(2)	Requirements for Flying Aircraft by F/O in Revenue Flights
	According to "AIR CREW MANNING AND DISPATCH MANUAL", requirements for

	flying aircraft by F/O in revenue flights are stipulated as follows. (item (1) through (4) )
	(1) China Airlines shall have F/Os fly a certain aircraft type in take-off and landing phases at least three times every three months to maintain their flying skills.
	(2) When an F/O is to control an aircraft type in a revenue flight, the F/O shall be seated in the right seat.
	(3) When an F/O is to control an aircraft type in a revenue flight, the CAP shall strictly supervise the F/O's operation, shall assume all responsibilities for safety, and shall observe the following: a. CAP shall have not less than 1,000 hours' flight experience on the aircraft type concerned. b. The weather conditions at the origin and destination airports shall be VMC, the runway shall be in good and dry condition and be sufficiently long, and the cross wind velocity shall be not more than 15 kts. c. Both take-off and landing weights shall be not more than 85 % of the maximum design weights of the aircraft type concerned. d. When the F/O performs operations in critical phases of flight such as take-off climb, and approach and landing, the CAP shall always strictly supervise the operation and keep his hands and feet in position on the control wheel, rudder pedal, and thrust lever. In cases of an abnormal or emergency condition, the CAP shall immediately take controls and call, "I HAVE CONTROLS", and F/O shall call, "ROGER".
	(4) When flying, if 1) the weather conditions do not meet VMC criteria, 2) a fault occurs in the aircraft, 3) a clearance given by ATC is inappropriate, 4) the F/O carries out a procedure that exceeds the safety limits of the aircraft, or 5) if an emergency arises, the CAP, in the interest of safety, shall make a quick decision to take control.
	It is recognized that items O,(c) and (c)-a, b and c above were satisfied in this case, i.e., that the F/O was flying the aircraft in revenue flight.
	Considering item (c) above, whether the CAP kept his hands and feet in the appropriate positions during the approach and landing phases could not be determined. However, from the CVR record, it is recognized that he took over the controls to deal with the abnormal situation, saying "I have got it" at 1115:03.
	Concerning item (4) above, as described in Paragraph 3.1 .2.2.(12), it is considered that the CAP's judgment situational awareness was inadequate, and that he was delayed in taking over the controls.
(3)	Utilization of Operation Technical Reports
	China Airlines used the technical report on the incident of the A3 10 aircraft that had occurred on February 11, 1991 in Moscow for the training of the crew members concerned. However, there are no records indicating that they used the reports on other cases for training purposes. The CAP and F/O involved in the accident did not attend the training that utilized the above technical report, as at the time they were not yet been assigned to A300-600R aircraft.

3.1.10.2 Training

(1) Training

China Airlines has established a training program according to the requirements stipulated by Taiwanese civil aviation authorities to conduct the following training courses in the classroom, simulator, and aircraft.

The CAP and F/O are recognized to have finished the training established by China Airlines. In the case of the A300-600R aircraft training program, the company basically employs the syllabus established by Airbus Industrie, the manufacturers of the aircraft, as their syllabus with the training standard times set themselves.

(1)	New qualification acquisition training
	Training performed to give experience, knowledge, and skill required for obtaining flight crew qualifications.
(2)	Promotion training Training performed to give experience, knowledge, and skill required for obtaining higher level flight crew qualifications.
(3)	Type transfer training
	Training performed for flight crew who are to serve in an aircraft of a type different from the one in which they are currently serving or in which they served in the past to give experience, knowledge, and skill required for obtaining identical class flight crew qualifications.
(3)	Periodic training
	Training performed periodically for flight crew to maintain and improve their knowledge and skill.

(2) Simulator training

(1)	China Airlines did not have simulators for the A300-600R aircraft. Therefore, they conducted simulator training for the said aircraft type by using simulators owned by Thai International Airways of Thailand and Aeroformation of France (China Airlines contracted part of pilot training to Airbus Industrie, and Airbus Industrie subcontracted this to Aeroformation.).
(2)	The CAP underwent simulator training for the A300-600 aircraft type in the Thai International Airways' simulator approved by the Thai aviation authorities. The F/O underwent this same training for the