Transportation Safety Board
Symbol of the Government of Canada
Skip to content | Skip to institutional links

Common menu bar links

REPORTS > AVIATION > 2005 > A05F0047

Institutional links

  AVIATION Reports - 2005 - A05F0047

Table of Contents

  1. 1.0 Factual Information
    1. 1.1 History of the Flight
    2. 1.2 Injuries to Persons
    3. 1.3 Damage to the Aircraft
    4. 1.4 Personnel Information
    5. 1.4.1 Captain Information
    6. 1.4.2 First Officer Information
    7. 1.4.3 Flight Attendants
    8. 1.5 Aircraft Information
    9. 1.5.1 General Information
    10. 1.5.2 Aircraft History
    11. 1.5.3 Vertical Tail Plane Design
    12. 1.5.4 Rudder Information
    13. 1.5.4.1 General
    14. 1.5.4.2 Rudder Design
    15. 1.5.5 Rudder Manufacturing Method
    16. 1.5.6 Rudder Manufacturing Records
    17. 1.5.7 Rudder Modification Status
    18. 1.5.8 Rudder Control System
    19. 1.5.8.1 Rudder Control System Components
    20. 1.5.8.2 Rudder Control System Operation
    21. 1.5.8.3 Dutch Roll Description
    22. 1.5.8.4 Dutch Roll Recovery Training
    23. 1.5.8.5 On-Board Documentation
    24. 1.5.9 Certification Information
    25. 1.5.9.1 Type Certificate
    26. 1.5.9.2 Rudder Certification Tests
    27. 1.5.10 Inspection Schedule
    28. 1.5.10.1 Scheduled Inspection Cycle
    29. 1.5.10.2 Scheduled Rudder Inspections
    30. 1.5.10.3 Recently Completed Inspections
    31. 1.5.10.4 Rudder Damage Structural Repair Manual Limits
    32. 1.5.11 Maintenance Actions
    33. 1.5.11.1 General
    34. 1.5.11.2 Rudder Synchronization Check
    35. 1.5.11.3 Lightning Protection Plate Replacement
    36. 1.5.11.4 Lightning Strike Repair
    37. 1.5.11.5 Miscellaneous Rudder Servo-Controls Maintenance
    38. 1.5.11.6 Maintenance Facilities
    39. 1.6 Meteorological Information
    40. 1.7 Aids to Navigation
    41. 1.8 Communications
    42. 1.8.1 Air Traffic Control
    43. 1.8.2 Crew/Company Communications
    44. 1.8.3 Communication Between the Flight Deck and the Flight Attendants
    45. 1.9 Aerodrome Information
    46. 1.10 Flight Recorders
    47. 1.10.1 Digital Flight Data Recorder
    48. 1.10.2 Cockpit Voice Recorder
    49. 1.10.3 Direct Access Recorder
    50. 1.10.4 Data Sampling Rates
    51. 1.10.5 Filtering of Recorded Data
    52. 1.10.6 Summary of Flight Recorder Data
    53. 1.11 Wreckage and Impact Information
    54. 1.11.1 Miscellaneous Damage
    55. 1.11.2 Vertical Tail Plane Damage
    56. 1.11.2.1 General
    57. 1.11.2.2 Main Attachment Fittings
    58. 1.11.2.3 Hinge Arms
    59. 1.11.3 Rudder Damage
    60. 1.11.3.1 General
    61. 1.11.3.2 Detailed Description of Rudder Damage
    62. 1.11.4 Chemical Attack and Contamination
    63. 1.11.5 System Inspection and Testing
    64. 1.11.6 High-Intensity Radiated Fields Investigation
    65. 1.11.7 Examination of Pre-Occurrence Photos
    66. 1.12 Tests and Research
    67. 1.12.1 General
    68. 1.12.2 Examination of Two Sister Rudders
    69. 1.12.3 Elasticity Laminate Checker Test
    70. 1.12.3.1 Elasticity Laminate Checker Test Description
    71. 1.12.3.2 ELCH 1-Complete Grid Examination of 24 Rudders of Similar Design
    72. 1.12.3.3 ELCH 2-Focused Examination of Rudders
    73. 1.12.4 Examination of Other Rudders
    74. 1.12.5 Fluid Contamination Program
    75. 1.12.6 Impact Damage Tests
    76. 1.12.7 Laboratory Tests of Rudder Residuals
    77. 1.12.7.1 General
    78. 1.12.7.2 Bond Between Honeycomb and Face Sheets
    79. 1.12.7.3 Bond at z Section
    80. 1.12.7.4 Inter-laminar Bond Between Face Sheet Layers
    81. 1.12.7.5 Splice Bond
    82. 1.12.7.6 Type of Resins
    83. 1.12.7.7 Cure of Resins
    84. 1.12.7.8 Lightning Protection Plate Replacement
    85. 1.12.7.9 z Strut Paint Chips
    86. 1.12.7.10 Explosion Damage
    87. 1.12.8 Double Cantilever Beam Tests
    88. 1.12.9 Disbond Growth
    89. 1.12.9.1 History of Earlier Design Aramid Fibre-Reinforced Plastic Rudders
    90. 1.12.9.2 Temperature Effects
    91. 1.12.9.3 Vacuum Cycling Tests
    92. 1.12.10 Computer Simulation of Disbond Growth
    93. 1.12.11 Effects of Temperature and Moisture
    94. 1.12.12 Age-Related Structures and Materials Degradation
    95. 1.12.13 Flight Dynamics Analysis
    96. 1.12.13.1 Background
    97. 1.12.13.2 Initial Simulations
    98. 1.12.13.3 Simulations to Determine the Lateral Force at Tail During the Event
    99. 1.12.13.4 Simulations to Determine the Longitudinal/Vertical Force at Tail During the Event
    100. 1.12.13.5 Additional Simulations
    101. 1.12.13.6 Yaw Damper Modelling
    102. 1.12.14 Effect of Disbond Bubble on Static Aerodynamic Loads
    103. 1.12.15 Flutter Analysis
    104. 1.12.15.1 Analysis of a Dynamic Event
    105. 1.12.15.2 Method of Analysis
    106. 1.12.15.3 Baseline Analysis
    107. 1.12.15.4 Failure Scenarios
    108. 1.12.15.5 Summary of Flutter Analyses
    109. 1.12.16 Time-Domain Flutter Analysis
    110. 1.12.16.1 General
    111. 1.12.16.2 Method of Analysis
    112. 1.12.16.3 Results
    113. 1.12.17 Summary of Flutter and Time-Domain Flutter Analyses
    114. 1.12.18 National Transportation Safety Board Radar Data Analysis Study
    115. 1.12.19 Other Aircraft in Vicinity
    116. 1.12.20 Space Objects
    117. 1.13 Organizational and Management Information
    118. 1.13.1 Company Operations
    119. 1.13.2 Maintenance Organization
    120. 1.14 Additional Information
    121. 1.14.1 All Operators Telex-Fleet Inspection of Rudder
    122. 1.14.1.1 AOT-1-Fleet Inspection of Rudder Exteriors
    123. 1.14.1.2 AOT-2-Fleet Inspection of Rudder Interiors
  2. 2.0 Analysis
    1. 2.1 General Information
    2. 2.2 Flight Control System
    3. 2.2.1 General
    4. 2.2.2 Ability to Diagnose the Source of Flight Control Difficulty
    5. 2.2.3 Dutch Roll Recovery
    6. 2.2.4 Decision to Return to Varadero
    7. 2.2.5 Decision not to Declare an Emergency
    8. 2.2.6 Crew Communication and Decision Making
    9. 2.3 Maintenance
    10. 2.3.1 Maintenance Program
    11. 2.3.2 Maintenance Records
    12. 2.3.3 Hinge Bearing Condition
    13. 2.3.4 Adequacy of Rudder Inspection Program
    14. 2.4 Recorders
    15. 2.4.1 Cockpit Voice Recorder Duration
    16. 2.4.2 Digital Flight Data Recorder Data Sampling
    17. 2.4.3 Digital Flight Data Recorder Filtered Data
    18. 2.4.4 Preservation of Recorder Information
    19. 2.5 Analysis of Rudder Failure Mechanism
    20. 2.5.1 General
    21. 2.5.2 Static Loading Phenomenon
    22. 2.5.2.1 Large Rudder Deflection
    23. 2.5.2.2 High Static Load
    24. 2.5.3 Dynamic Loading Phenomenon
    25. 2.5.3.1 High-Frequency Control Input
    26. 2.5.3.2 Flutter
    27. 2.5.4 Possible Causes of Flutter
    28. 2.5.4.1 Flutter without Prior Structural Deviation
    29. 2.5.4.2 Flutter Following Structural Deviation
    30. 2.5.5 Growth of Rudder Damage
    31. 2.5.6 Possible Causes of Rudder Damage
    32. 2.5.6.1 Manufacturing Process
    33. 2.5.6.2 Material Degradation
    34. 2.5.6.3 Mechanical Damage
    35. 2.5.7 Failure Scenarios
    36. 2.5.7.1 Summary of Important Points
    37. 2.5.7.2 Most Likely Failure Scenario
  3. 3.0 Conclusions
    1. 3.1 Findings as to Causes and Contributing Factors
    2. 3.2 Findings as to Risk
    3. 3.3 Other Findings
  4. 4.0 Safety Action
    1. 4.1 Action Taken
    2. 4.1.1 Transportation Safety Board of Canada
    3. 4.1.1.1 TSB Recommendations-Airbus Composite Rudder Inspectio Program
    4. 4.1.1.2 TSB Safety Advisory-Cockpit Voice Recorder Duration
    5. 4.1.1.3 TSB Safety Advisory-Digital Flight Data Recorder Recording of Filtered Data
    6. 4.1.1.4 TSB Safety Advisory-Digital Flight Data Recorder Low Recording Rates
    7. 4.1.1.5 TSB Safety Advisory-Dutch Roll Recovery Procedure
    8. 4.1.2 National Transportation Safety Board
    9. 4.1.3 Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
    10. 4.1.4 Airbus
    11. 4.1.4.1 All Operators Telex (AOT-1)
    12. 4.1.4.2 All Operators Telex (AOT-2)
    13. 4.1.5 Air Transat
    14. 4.1.5.1 Abnormal Situation
    15. 4.1.5.2 Preservation of Recorder Information
  5. Appendices
    1. Appendix A - Direct Access Recorder/Digital Flight Data Recorder Data Comparison
    2. Appendix B - Glossary
  6. Photos
    1. Photo 1 - Right-Side View of Vertical Tail Plane and Rudder Residuals
    2. Photo 2 - Removal of the VTP and a View of the Position of the Main Attachment Fittings
    3. Photo 3 - Left-Side View of VTP and Rudder Residuals
    4. Photo 4 - Pre-Occurrence Photograph of Aircraft
    5. Photo 5 - MSN 361 Honeycomb Showing Stain Caused by Hydraulic Fluid Ingress
    6. Photo 6 - Fluid Accumulation in the Nose of the Rudder of Aircraft MSN 701
    7. Photo 7 - Damage Growth After one Vacuum Cycle (Rudder of Aircraft MSN 361)
  7. Figures
    1. Figure 1 - Schematic of the Vertical Tail Plane
    2. Figure 2 - Schematic of Hinge Arm Details
    3. Figure 3 - Schematic of the Rudder
    4. Figure 4 - Rudder Side Panel Construction
    5. Figure 5 - Schematic of Rudder Hinge Fitting Details
    6. Figure 6 - Low Bonding Pressure Next to the z-Section
    7. Figure 7 - Disbond Scenarios Studied in Flutter Analysis
    8. Figure 8 - Typical Load Response from Time-Domain Flutter Analysis
    9. Figure 9 - Schematic of AOT-1 Areas of Inspection
    10. Figure 10 - Schematic of AOT-2 Areas of Inspection

Previous | Next

Date Modified: 2008-07-31
Return to the top of the page
Top of Page
Important Notices