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Circular 296
Aircraft Accident Digest No. 39 - 1992
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ICAO CIRCULAR - CIRCULAIRE OACl - CIRCULAR OACI Aircraft Accident Digest Recueil d'accidents d'aviation Recopilacion de accidentes de aviacion No. - No - Num. 39 Approved by the Secretary General and published under his authority Approuvd par le Secdtaire gdndral et publib sous son autorite Aprobada por el Secretario General y publicada bajo su responsabilidad INTERNATIONAL ClVlL AVIATION ORGANIZATION ORGANISATION DE L'AVIATION ClVlLE INTERNATIONALE ORGANIZACION DE AVIACION ClVlL INTERNACIONAL
Published by authority of the Secretary General of the International Civil Aviation Organization, to whom all correspondence, except orders and subscriptions, should be addressed. Publii sous I'autoritC du Secritaire gidral de I'Organisation l'aviation civile interntionale, ii qui toute correspondance, ii l'exception des commandes et des abonnements, doit Stre adressie. Publicado bajo la responsabilidad del Secretario General la Organizacidn de Aviacidn Civil Interncional, a quien be dirigirse toah la correspondencia, con excepcidn de 10s pedidos y suscripciones. Orders should be sent to one of the following addresses, together with the appropriate remittance by bank draft, cheque or money order in U.S. dollars or the currency of the country in which the order is placed. Credit card orders American Express, MasterCard and Visa are accepted at ICAO Headquarters. Envoyer les co,mmandes ti l'une des adresses suivantes en y joignant le montant correspondant par cheque, chtque bancaire ou mandat en dollars des Etats-Unis ou dans la monnaie du pays d'achat. Les commandes par carte de credit American Express, Mastercard et Visa sont accepths au Sibge de I'OACI. Los pedidos deben dirigirse a una de las direcciones siguientes junto con la correspondiente remesa mediante giro bancario, cheque o giro intemacional en d6lares estadounidenses o en la moneda del pais de compra. En la Sede de la OACI se aceptan pedidos pagaderos con tarjetas de cddito American Express, MasterCard y Visa. International Civil Aviation Organizatwn. Attention Document Sales Unit 999 University Street, Montreal, Quebec, Canada H3C 5H7 Telephone 1 514 954-8022 Facsimile 1 514 954-6769 Sitatex YULADYA E-mail salesicao.int Egypt. ICAO Regional Director, Middle East Office, Egyptian Civil Aviation Complex, Cairo Airport Road, Heliopolis, Cairo 1 1776 Telephone 20 2 267-4840 Facsimile 20 2 267-4843 Sitatex CAICAYA France. Directeur regional de I'OACI, Bureau Europe et Atlantique Nord, 3 bis, villa fimile-ergerat, 92522 Neuilly-sur-Seine Cedex Telephone 33 1 46 41 85 85 Fax 33 1 46 41 85 00 Sitatex PAREUYA India. Oxford Book and Stationery Co., Scindia House, New Delhi 110001 or 17 Park Street, Calcutta 700016 Telephone 91 11 331-5896 Facsimile 91 11 332-2639 Japan. Japan Civil Aviation Promotion Foundation, 15-12, 1-chome, Toranomon, Minato-Ku, Tokyo Telephone 81 3 3503-2686 Facsimile 81 3 3503-2689 Kenya. ICAO Regional Director, Eastern and Southern African Office, United Nations Accommodation, P.O. Box 46294, Nairobi Telephone 254 2 622-395 Facsimile 254 2 226-706 Sitatex NBOCAYA Mexico. Director Regional de la OACI, Oficina Norteamerica, Centroamerica y Caribe, Masaryk No. 29-3er. piso, Col. Chapultepec Morales, Mtxiw, D.F., 11570 Telefono 52 55 52 50 32 11 Facsimile 52 55 52 03 27 57 Sitatex MEXCAYA Nigeria Landover Company, P.O. Box 3165, Ikeja, Lagos Telephone 234 1 4979780 Facsimile 234 1 4979788 Sitatex LOSLORK Peru. Director Regional de la OACI, Oficina Sudamkrica, Apartado 4127, Lima 100 Telefono 51 1 302260 Facsimile 51 1 640393 Sitatex LIMCAYA Russian Federation. Aviaizdat, 48, 1. Franko Street, Moscow 121351 Telephone 7 095 417-0405 Facsimile 7 095 417-0254 Senegal. Directeur regional de I'OACI, Bureau Afrique occidentale et centtale, Boite postale 2356, Dakar Telephone 221 8-23-54-52 Fax 221 8-23-69-26 Sitatex DKRCAYA Slovakia. Air Traffic Services of the Slovak Republic, Letovt prevhdzkovb sluzby Slovenskej Republiky, State Enterprise, Letisko M.R. Stefhika, 823 07 Bratislava 21, Slovak Republic Telephone 421 7 4857 11 11 Facsimile 421 7 4857 2105 South Africa. Avex Air Training Pty Ltd., Private Bag X102, Halfway House, 1685, Johannesburg, Republic of South Africa Telephone 27 1 1 315-000314 Facsimile 27 1 1 805-3649 E-mail avexiafrica.com Spain. A.E.N.A. - Aeropuertos EspaAoles y Navegaci6n ACrea, Calle Juan Ignacio Luca de Tena, 14. Planta Tercera, Despacho 3. 11, 28027 Madrid Telefono 34 91 321-3148 Facsfmile 34 91 321-3157 Cm-e sscc.ventasoaciaena.es Thailand. ICAO Regional Director, Asia and Pacific Office, P.O. Box 11, Samyaek Ladprao, Bangkok 10901 Telephone 66 2 537-8189 Facsimile 66 2 537-8199 Sitatex BKKCAYA United Kingdom. Airplan Flight Equipment Ltd. AFE, la Ringway Trading Estate, Shadowmoss Road, Manchester M22 5LH Telephone 44 161 499 0023 Facsimile 44 161 499 0298 E-mail enquiriesafeonPne.com World Wide Web http//www.afeonline.com 2M3
ICAO Circular 296-AN11 70 FOREWORD General 1. The purpose of the Aircraft Accident Digest is to disseminate accident report information to Contracting States. Publication of the Digest began in 1951. Over the years States have reiterated their interest in the Digest not only as a valuable source of information for accident prevention, but also as a training aid for investigators and educational material for technical schools. Selection of accidents 2. The Digest contains accident reports selected by the Secretariat from those sent by States. Reports were selected on the basis of a their contribution to accident prevention or b the successful employment of useful or effective investigative techniques and c compliance with Annex 13 provisions including the format of the Final Report. The Digest should not be seen as being statistically representative of the world distribution of accidents. Editorial practices 3. The Final Reports are usually published as received. Accordingly, some deviations from standard ICAO editorial practices may occur. Lengthy reports may be abbreviated by omitting redundant information, appendices, attachments or diagrams. Minor changes in presentation and terminology may be introduced to ensure compliance with Annex 13 provisions. States' cooperation 4. States are encouraged to send to ICAO those Final Reports which meet the criteria of 6.7 in Annex 13. The reports are normally submitted in one of the working languages of ICAO and should be in the format presented in the Appendix to Annex 13. Digest publication 5. The Digest is produced once each year and includes accidents and incidents which occurred during a one-year period.
Circulaire OACl 296-AN11 70 AVANT-PROPOS Generalites 1. Le recueil d'accidents d'aviation a pour but de communiquer a tous les tats contractants certains renseignements sur les rapports d'accidents. La publication du recueil a commence en 1951. Au cours des annees, les tats ont manifeste a plusieurs reprises leur interet pour le recueil, parce qu'il constitue non seulement une source precieuse d'information pour la prevention des accidents, mais aussi une aide de formation pour les enqueteurs et un manuel educatif pour les ecoles techniques. Selection des accidents 2. Le recueil contient des rapports d'accidents choisis par le Secretariat parmi ceux communiques par les tats. Ce choix repose sur les criteres suivants a interet du rapport pour la prevention des accidents b utilisation fructueuse de techniques d'enquete utiles ou efficaces c conformite aux specifications de I'Annexe 13, y compris celles concernant la presentation du rapport final. Le present recueil ne saurait etre considere comme representatif, du point de vue statistique, de la repartition des accidents dans le monde. Normes de redaction 3. Les rapports finals sont generalement publies tels qu'ils sont reps. Par consequent, ils peuvent presenter certaines differences par rapport aux normes OACl de redaction. Certains rapports particulierement longs sont abreges par I'omission de renseignements redondants, d'appendices, de pieces jointes ou de schemas. De legeres modifications sont parfois apportees a la presentation, ainsi qu'a la terminologie, afin d'assurer la conformite avec les dispositions de I'Annexe 13. Cooperation des tats 4. Les tats sont invites a envoyer a I'OACI des rapports finals conformes aux criteres de 6.7 de I'Annexe 13. Les rapports sont normalement rediges dans I'une des langues de travail de I'OACI et doivent etre presentes comme il est indique dans I'Appendice a I'Annexe 13. Publication des recueils d'accidents 5. Le recueil est publie une fois par an et comprend des comptes rendus d'accidents et d'incidents survenus au cours d'une annee. ii
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Table Of Contents
COVER PAGE
FOREWORD
TABLE OF CONTENTS
No. 1
No. 2
No. 3
No. 4