Kagoshima Airport
Aircraft Accident/Incident Report

Kagoshima
Tuesady, June 23, 2009 3:03 UTC

NTSB Narrative Summary Released at Completion of Accident

Both aircraft were in normal cruise flight at high altitude, in the vicinity of convective weather conditions, and both flight crews were aware of the weather. Crew statements and recorded data for both flights did not indicate any airplane anomalies prior to the events. Shortly before the unreliable airspeed events, each airplane encountered a visible effect of the weather conditions, the Northwest crew reported seeing moderate rain and hail, and the TAM crew reported an abrupt temperature change and St. Elmo’s Fire. Within seconds both airplane’s autopilot and autothrust disconnected, master warnings and cautions were indicated, primary airspeed display was lost or fluctuated, and the airplanes transitioned into Alternate Flight Law. According to Airbus documentation and analysis, if an airspeed discrepancy of more than 20kts or an altitude discrepancy of more than 400ft is detected between one ADR and the two others, the subject ADR is rejected. Then if a discrepancy occurs between the two remaining ADR, all auto flight functions are lost and autopilot, flight director, and autothrust disconnect. Applicable procedures for both airplanes call for autopilot and autothrust to be OFF, and for the pilot to pitch to 5 degrees and set thrust levers to the CLB detent. Both flight crews turned the airplanes to exit the weather area and the airspeed indications returned to normal within a short time. The behavior of the airplane systems is consistent with, and supports a brief and temporary blockage of two or more pitot probes likely by an accretion of ice crystals aloft. Existing airplane flight manual/QRH procedures were sufficient to prevent a dangerous situation from occuring, however the airplane would, as designed, be operating in a lower level of automation. The autopilot disengaged automatically as intended due to its airspeed monitoring function. The flight crew’s attempt to reengage the autopilot during the unreliable airspeed event, and erroneous altitude reading, followed by pilot side stick inputs, exacerbated the altitude excursion experienced by the TAM flight, however the airplane was not actually in danger of a stall.

NTSB Probable Cause Narrative

Brief and temporary blockage of the pitot probes in cruise flight, most likely due to ice crystals aloft, leading to erroneous airspeed indications and airplane automation degradation as designed. Contributing to the incidents were design features of the Thales AA probes which left them more susceptible to high altitude ice crystal icing than other approved pitot probe designs.

Event Information

Type of Event Incident
Event Date 6/23/2009
Event Day of the Week Tuesday
Time of Event 303
Event Time Zone Coordinated Universal Time? Same as GMT
Event City Kagoshima
Event State --
Event Country --
Zipcode of the event site --
Event Date Year 2009
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport Kagoshima
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Pilot
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 217
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) --
NTSB Notification Source Northwest
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 14 2011 2:55PM
User who most recently changed record schd
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N805NW
NTSB Number DCA09IA064
Missing Aircraft Indicator --
Federal Aviation Reg. Part Non-U.S., Commercial
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion --
Aircraft Manufacturer's Full Name AIRBUS
Aircraft Model A330-323
Aircraft Series Identifier --
Aircraft Serial Number 0552
Certified Max Gross Weight --
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection --
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name NORTHWEST AIRLINES INC
Aircraft Owner Street Address 7500 AIRLINE DR DEPT C8960
Aircraft Owner City MINNEAPOLIS
Aircraft Owner State MN
Aircraft Owner Country USA
Aircraft Owner Zipcode 55450-1101
Operator is an individual? No
Operator Name NORTHWEST AIRLINES INC
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
Operator Code --
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight International
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code --
Departure City Hong Kong
Departure State --
Departure Country CH
Departure Time --
Departure Time Zone --
Destination Same as Local Flt --
Destination Airport Code --
Destination City Tokyo
Destination State --
Destination Country JA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 26 2011 9:00AM
User who most recently changed record engb
Since inspection or accident --
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --