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每日航空事故及事故征候(事件)簡報(67) 2023.3.8

2023-03-08 20:31 作者:YuhanZhaoYZ  | 我要投稿

本系列希望為各位帶來最詳細的每日航空事故及事故征候(事件)信息(本系列信息全部來源于ASN數(shù)據(jù)庫, 由于數(shù)據(jù)庫更新時間等原因之限制每日簡報將報告前一日之內(nèi)容)

ASN數(shù)據(jù)庫會有信息延遲, 部分事故或事故征候(事件)無法及時(在發(fā)生后第二天)出現(xiàn)在簡報中, 現(xiàn)決定第一天的中午到晚上發(fā)布當天的簡報, 第二天上午修改前一天的簡報.在發(fā)生第二天之后更新至ASN的事故我將不會再次添加至專欄

簡報不包括軍航事故, ASN資料庫簡報內(nèi)會寫出事故航班之 "nature", 如此項為"Military"(軍事)則該事故不會出現(xiàn)在本簡報中

簡報最后的"歷史上的今天"部分是當天內(nèi)容, 選取的事故與ASN主頁相同部分一樣

至文章發(fā)出時, ASN已記錄2023年事故/事故征候598起

ASN資料庫記錄2023年3月7日發(fā)生之事故/事故癥候7起(兩起軍航事故,另有一起事故確認為重復(fù)報告但ASN簡報目前并未刪除只是標為“Accident Dual Entry”所以仍需算為一起事故但并不會出現(xiàn)在本簡報內(nèi),ASN簡報也應(yīng)該會在幾小時內(nèi)被刪除), 具體信息如下:

1: ASN事故號:308980

事故時間:0438

機型:Cessna A185F Skywagon

航空器運行及擁有者:私人

航班號:

注冊號:N9697Q

制造商序列號:18503788

生產(chǎn)地:

首飛日期:

試飛注冊號:

機齡:

機隊編號:

引擎:

構(gòu)型:

總?cè)藬?shù): 1

死亡人數(shù):1

非機上人員死亡人數(shù):0

航空器損壞情況: 嚴重損壞

事故分類: 事故

事故地點:霍莫機場(HOM/KHOM),美利堅合眾國

事故發(fā)生的飛行階段: 降落

飛行性質(zhì): 私人

起飛機場:?埃爾門多夫空軍基地(KEDF),美利堅合眾國

目的地機場:霍莫機場(HOM/KHOM),美利堅合眾國

具體信息:

2: ASN事故號:308985

事故時間:1400當?shù)貢r間(1900協(xié)調(diào)世界時)

機型:Piper J3C-65 Cub

航空器運行及擁有者:Jack Brown's Seaplane Base Inc

航班號:

注冊號:

制造商序列號:

生產(chǎn)地:

首飛日期:

試飛注冊號:

機齡:

機隊編號:

引擎:

構(gòu)型:

總?cè)藬?shù): 2

死亡人數(shù):2

非機上人員死亡人數(shù):2

航空器損壞情況: 損壞無法修復(fù),航空器注銷

事故分類: 事故

事故地點:靠近溫特哈文斯吉爾伯特機場(GIF/KGIF),美利堅合眾國

事故發(fā)生的飛行階段: 巡航

飛行性質(zhì): 私人

起飛機場:?溫特哈文斯市立機場(GIF/KGIF),美利堅合眾國

目的地機場:溫特哈文斯市立機場(GIF/KGIF),美利堅合眾國

具體信息:

空中相撞,另一架機信息見簡報3

3: ASN事故號:308988

事故時間:1400當?shù)貢r間(1900協(xié)調(diào)世界時)

機型:Piper PA-28-161 Warrior II

航空器運行及擁有者:Sunrise Aviation Inc

航班號:

注冊號:

制造商序列號:

生產(chǎn)地:

首飛日期:

試飛注冊號:

機齡:

機隊編號:

引擎:

構(gòu)型:

總?cè)藬?shù): 2

死亡人數(shù):2

非機上人員死亡人數(shù):2

航空器損壞情況: 損壞無法修復(fù),航空器注銷

事故分類: 事故

事故地點:靠近溫特哈文斯吉爾伯特機場(GIF/KGIF),美利堅合眾國

事故發(fā)生的飛行階段: 巡航

飛行性質(zhì): 訓(xùn)練

起飛機場:?溫特哈文斯市立機場(GIF/KGIF),美利堅合眾國

目的地機場:溫特哈文斯市立機場(GIF/KGIF),美利堅合眾國

具體信息:

空中相撞,另一架機信息見簡報2

4: ASN事故號:308986

事故時間:0501

機型:Cessna 172M Skyhawk

航空器運行及擁有者:Panair Flying Club Inc.

航班號:

注冊號:N64535

制造商序列號:17265291

生產(chǎn)地:

首飛日期:

試飛注冊號:

機齡:

機隊編號:

引擎:

構(gòu)型:

總?cè)藬?shù): 2

死亡人數(shù):0

非機上人員死亡人數(shù):0

航空器損壞情況:?

事故分類: 事故

事故地點:霍姆斯特德,美利堅合眾國

事故發(fā)生的飛行階段: 巡航

飛行性質(zhì):?

起飛機場: 邁阿密行政機場(TMB/KTMB),美利堅合眾國

目的地機場:

具體信息:

歷史上的今天

馬來西亞調(diào)查組發(fā)布的MH370號班機事故最終調(diào)查報告
MH370的1:400模型為本照片后面最左邊的那一架(注冊號9M-MRO,照片是UP自己拍的模型也是UP自己的)

2014年3月8日,由馬來西亞吉隆坡國際機場飛往中華人民共和國北京首都國際機場的馬來西亞航空370號班機在巡航過程中失聯(lián),事故班機由9M-MRO執(zhí)飛,機型為Boeing 777-2H6ER型客機,機上的239人全部失聯(lián),馬來西亞調(diào)查組認定事故發(fā)生的可能肇因為:“2014年3月8日,馬來西亞航空公司運營的一架從吉隆坡飛往北京的定期客運航班 MH370 在馬來西亞空中交通管制局(ATC)向越南空中交通管制總局(ATC)進行例行移交后不久失蹤。起飛后不到40分鐘,航空器通過IGARI航路點后失去了與其的通信。執(zhí)飛該航班的飛機是一架波音777-200ER,注冊號為9M-MRO。飛機上有12名機組人員和227名乘客(共239人)。

證據(jù)表明,MH370航班偏離了提交的飛行計劃航線。由于無法確定的原因,飛機的應(yīng)答機信號停止,然后在ATC雷達上不再可見。飛機通過航路點IGARI后,飛機飛行路徑的變化被民用和軍用雷達捕捉到。這些變化顯然被視為先向右轉(zhuǎn),然后向左轉(zhuǎn),然后飛越馬來西亞半島,然后在檳城島以南向西北方向右轉(zhuǎn),隨后(未記錄)轉(zhuǎn)向南印度洋,很難單獨歸因于異常的系統(tǒng)問題。無法確定飛機是否由飛行員以外的任何人駕駛。后來的飛行模擬器試驗證實,折返很可能是在飛機處于手動控制而不是自動駕駛的情況下進行的。

吉隆坡ATSC運營正常,在移交給越南ATC之前沒有明顯觀察。作為接受單位,HCM ACC未在控制轉(zhuǎn)移的預(yù)計時間后五分鐘內(nèi)與MH370建立雙向通信時通知轉(zhuǎn)移單位(KL ATSC)(2001年11月1日生效的DCA馬來西亞和越南空中交通管理局之間的運營LOA第11頁,建立通信)。同樣,KL ATSC應(yīng)該采取行動聯(lián)系HCM ACC,而不是依靠馬來西亞航空公司飛行運營部提供的飛機位置信息。此時,飛機已離開吉隆坡ATSC可見的雷達范圍。值得注意的是,距離MH370的最后一次發(fā)射信號和SSR從雷達上消失大約一分鐘。兩個中心的空中交通管制員當時都沒有按要求啟動各種緊急階段,從而推遲了警報和搜救行動的啟動。

PIC和FO持有有效的飛行員執(zhí)照和醫(yī)療證明。沒有證據(jù)表明PIC和FO最近經(jīng)歷了個人關(guān)系的變化或困難,或者他們之間存在任何沖突或問題。所有的飛行人員和機組人員都被證明適合飛行,在飛行時都在值班時間內(nèi),并得到了充分的休息。機組人員沒有財務(wù)壓力或即將破產(chǎn)、最近購買的或額外的保險或最近的行為變化。PIC和FO與空中交通管制員進行的無線電電話通信符合常規(guī)程序,通信中沒有發(fā)現(xiàn)焦慮或壓力的跡象。

飛機維修記錄表明,除了SSFDR ULB電池已過期外,飛機按照現(xiàn)行法規(guī)和批準程序進行了裝備和維修。該飛機具有有效的適航證書,并且在發(fā)布飛行時適航,并且沒有記錄或報告可能導(dǎo)致該事件的飛機缺陷或故障。盡管根據(jù)現(xiàn)有的有限證據(jù),無法最終排除飛機或系統(tǒng)故障是原因,但更可能的是,在改道前通信(VHF和HF通信、ACARS、SATCOM和轉(zhuǎn)發(fā)器)的丟失是由于系統(tǒng)手動關(guān)閉或電源中斷,或者在VHF和高頻未使用的情況下,無論是否出于意圖。搜救機構(gòu)或任何其他飛機均未報告飛機的ELT信號。衛(wèi)星通信數(shù)據(jù)顯示,飛機在空中飛行了7個多小時,這表明自動駕駛儀可能在運行,至少在基本模式下,飛機可以長時間飛行。這反過來表明,空氣和慣性數(shù)據(jù)可能對自動駕駛系統(tǒng)和/或機組人員可用。不同飛機系統(tǒng)運行的相互依賴性表明,飛機電力系統(tǒng)的重要部分可能在整個飛行過程中發(fā)揮作用??紤]到飛機所遵循的路線和飛行高度,受其性能和航程能力的限制,對相關(guān)飛機系統(tǒng)的分析并不表明飛機的機身、控制系統(tǒng)、燃料或發(fā)動機存在機械問題。

除第一份報告外,衛(wèi)星通信系統(tǒng)通常每30分鐘發(fā)送一次ACARS報告。最后七次衛(wèi)星通信“握手”的數(shù)據(jù)被用來幫助確定飛機在印度洋上空的大致路徑。初始登錄請求和每小時ping被稱為“握手”。衛(wèi)星通信傳輸表明,從2014年3月7日的1825 UTC到2014年3年8日的0011 UTC,有一條鏈路可用,但除了兩個未應(yīng)答的地面對空中電話呼叫外,沒有用于任何語音、ACARS或其他數(shù)據(jù)服務(wù)。飛機在協(xié)調(diào)世界時1825(2014年3月7日)和協(xié)調(diào)世界時0019(2014年4月8日)啟動了兩次登錄,很可能是由于衛(wèi)星通信航空電子設(shè)備斷電。1825 UTC之前的電力中斷可能是由于電力總線循環(huán),原因不明。直到0019 UTC的電力中斷可能是由于此時燃油不足導(dǎo)致兩臺發(fā)動機及其各自發(fā)電機的損失。APU可能有足夠的燃料啟動并運行足夠長的時間,以使其發(fā)電機為衛(wèi)星通信航空電子設(shè)備供電,從而啟動登錄請求。

迄今為止,盡管在南印度洋進行了4年的搜索,MH370的主要殘骸仍未找到。然而,可能來自MH370的殘骸已經(jīng)被發(fā)現(xiàn),最北至坦桑尼亞東部海岸,最南至南非東部海岸。除此之外,還有非洲大陸東海岸的幾個島嶼和島國。其中,襟翼、一部分右側(cè)外側(cè)襟翼和一部分左側(cè)外側(cè)襟翼被證實來自MH370。其他幾塊碎片被確定幾乎可以肯定來自MH370,其中包括一些機艙內(nèi)部物品。對右側(cè)外側(cè)襟翼的恢復(fù)部分進行的損傷檢查,以及在右側(cè)襟翼上發(fā)現(xiàn)的損傷,得出的結(jié)論是,右側(cè)外側(cè)襟翼最有可能處于縮回位置,而右側(cè)襟翼在與機翼分離時可能處于或接近中立位置。機艙內(nèi)部碎片的恢復(fù)表明,飛機很可能已經(jīng)解體。然而,沒有足夠的信息來確定飛機是在空中還是在與海洋碰撞時破裂。除上述內(nèi)容外,無法從碎片的性質(zhì)和損壞程度推斷出有關(guān)飛行中緊急情況、飛機配置或影響的其他信息。

MH370沒有攜帶任何被列為危險品的貨物。MH370上搭載的兩件引人注意的貨物(鋰離子電池和山竹)也在事件前后通過馬來西亞航空公司的定期航班運輸。這些物品按照標準操作程序進行包裝和裝載。

由于發(fā)現(xiàn)的問題,調(diào)查已發(fā)布安全建議,以加強航空系統(tǒng)的安全性。所提出的建議涉及馬來西亞和外國的空中交通監(jiān)控系統(tǒng)、貨物掃描、機組人員醫(yī)療和培訓(xùn)記錄、機組人員心理健康報告和跟蹤、飛行跟蹤系統(tǒng)、制定運行控制快速參考和ELT有效性。

應(yīng)當認識到,調(diào)查組缺乏足夠的證據(jù)來確定飛機偏離其提交的飛行計劃路線的原因。然而,飛行路徑的變化可能是由人工輸入引起的。缺乏證據(jù)包括主要飛機殘骸的確切位置和處置情況以及它可以提供的證據(jù)、飛行數(shù)據(jù)記錄器、駕駛艙語音記錄器和飛機上其他記錄設(shè)備上記錄的信息,以及沒有任何飛機語音或數(shù)據(jù)傳輸可以表明飛機為何飛往南印度洋。

由于沒有對飛機殘骸和記錄的飛行數(shù)據(jù)信息進行檢查,調(diào)查無法確定任何可能導(dǎo)致觀察到的系統(tǒng)失效、偏離已提交的飛行計劃路線和飛機后續(xù)飛行路線的飛機或系統(tǒng)故障模式。然而,同樣缺乏證據(jù),使調(diào)查無法明確排除這種可能性。也不能排除第三方介入的可能性。

MH370的失蹤和搜索工作在商業(yè)航空史上是前所未有的。必須采取改進措施,以確保盡快識別此類事件,并建立機制,以跟蹤因任何原因未遵守其備案飛行計劃的飛機。

近年來,一些國家花費了大量資金和資源,在遙遠的海洋地點尋找失蹤的商用飛機,包括AF447和MH370。在這個技術(shù)時代,國際航空界需要向旅行的公眾提供保證,即當前一代商用飛機的位置始終是已知的。否則是不可接受的。

結(jié)論為,調(diào)查組無法確定 MH370 失蹤的真正原因?!保∣n 08 March 2014, MH370, a scheduled passenger flight from Kuala Lumpur to Beijing, operated by MAS went missing soon after a routine handover from the Malaysian ATC to Viet Nam ATC. Communications with the aircraft were lost after it passed waypoint IGARI, less than 40 minutes after take-off. The aircraft operating the flight was a Boeing 777-200ER, registered 9M-MRO. On board the aircraft were 12 crew and 227 passengers (239 persons in total).

Evidence shows that Flight MH370 diverted from the Filed Flight Plan route. The aircraft’s transponder signal ceased for reasons that could not be established and was then no longer visible on the ATC radar display. The changes in the aircraft flight path after the aircraft passed waypoint IGARI were captured by both civilian and military radars. These changes, evidently seen as turning slightly to the right first and then to the left and flying across the Peninsular Malaysia, followed by a right turn south of Penang Island to the north-west and a subsequent (unrecorded) turn towards the Southern Indian Ocean, are difficult to attribute to anomalous system issues alone. It could not be established whether the aircraft was flown by anyone other than the pilots. Later flight simulator trials established that the turn back was likely made while the aircraft was under manual control and not the autopilot.

KL ATSC operation was normal with no significant observation until the handover to Viet Nam ATC. Being the accepting unit, HCM ACC did not notify the transferring unit (KL ATSC) when two-way communication was not established with MH370 within five minutes of the estimated time of the transfer of control point (Establishment of Communications, page 11 of Operational LOA between DCA Malaysia and Vietnam Air Traffic Management effective 1 November 2001). Likewise, KL ATSC should have taken action to contact HCM ACC, instead, relied on position information of the aircraft provided by MAS Flight Operations. By this time, the aircraft had left the range of radars visible to the KL ATSC. It is noted that about one minute elapsed from the last transmission from MH370 and the SSR being lost from the radar display. The Air Traffic Controllers of both Centres did not initiate the various emergency phases as required then, thereby delaying the activation of the alerting and Search and Rescue operations.

The PIC and FO held valid airman licences and medical certification. There is no evidence to suggest that the PIC and FO experienced recent changes or difficulties in personal relationships or that there were any conflicts or problems between them. All the flight and cabin crew were certified fit to fly and were within duty-time limits at the time of the flight and were adequately rested. There had been no financial stress or impending insolvency, recent or additional insurance coverage purchased or recent behavioural changes for the crew. The radio-telephony communications conducted by the PIC and the FO with the Air Traffic Controllers conformed to the routine procedure and no evidence of anxiety or stress was detected in the communications.

The aircraft maintenance records indicated that the aircraft was equipped and maintained in accordance with existing regulations and approved procedures, except for the instance of the SSFDR ULB battery which had expired. The aircraft had a valid Certificate of Airworthiness and was airworthy when released for the flight and there was no record or report of any defect or malfunction in the aircraft that could have contributed to the event. Although it cannot be conclusively ruled out that an aircraft or system malfunction was a cause, based on the limited evidence available, it is more likely that the loss of communications (VHF and HF communications, ACARS, SATCOM and Transponder) prior to the diversion is due to the systems being manually turned off or power interrupted to them or additionally in the case of VHF and HF, not used, whether with intent or otherwise. No ELT signal from the aircraft was reported by the Search and Rescue agencies or any other aircraft. The SATCOM data indicated that the aircraft was airborne for more than 7 hours suggesting that the autopilot was probably functioning, at least in the basic modes, for the aircraft to be flown for such a long duration. This in turn suggests that the air and inertial data were probably available to the autopilot system and/or the crew. The inter-dependency of operation of the various aircraft systems suggests that significant parts of the aircraft electrical power system were likely to be functioning throughout the flight. The analysis of the relevant aircraft systems taking into account the route followed by the aircraft and the height at which it flew, constrained by its performance and range capability, does not suggest a mechanical problem with the aircraft’s airframe, control systems, fuel or engines.

Except for the first report, the ACARS reports normally sent every 30 minutes by the SATCOM system were not received. Data from the last seven SATCOM ‘handshakes’ were used to help establish the approximate path of the aircraft over the Indian Ocean. The initial log-on request and the hourly pings have been termed as ‘handshakes'. SATCOM transmissions indicated that a link was available from 1825 UTC on 07 March 2014 to 0011 UTC on 08 March 2014 although not used for any voice, ACARS or other data services apart from two unanswered ground-to-air telephone calls. Two log-ons, at 1825 UTC (07 March 2014) and 0019 UTC (08 March 2014), were initiated by the aircraft most likely due to power interruptions to the SATCOM avionics. The power interruption leading up to 1825 UTC was probably due to power bus cycling, the reason for it being unknown. The power interruption leading up to 0019 UTC was probably due to low fuel at this time resulting in the loss of both engines and their respective generators. There was probably enough fuel for the APU to start up and run long enough for its generator to power the SATCOM avionics to initiate a log-on request.

To date, the main wreckage of MH370 has still not been found despite a 4-year search in the South Indian Ocean. However, items of debris possibly from MH370, have been found as far north as the eastern coast of Tanzania and far south as the eastern coast of South Africa. This is in addition to several islands and island nations off the east coast of the African continent. Of these, the flaperon, a part of the right outboard flap and a section of the left outboard flap were confirmed to be from MH370. A few other pieces of debris were determined to be almost certain from MH370 which included some cabin interior items. Damage examination on the recovered part of the right outboard flap, together with the damage found on the right flaperon has led to the conclusion that the right outboard flap was most likely in the retracted position and the right flaperon was probably at, or close to, the neutral position at the time they separated from the wing. Recovery of the cabin interior debris suggests that the aircraft was likely to have broken up. However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean. Apart from the above, no other information about in-flight emergencies, aircraft configuration or impact could be inferred from the nature and damage of the debris.

MH370 did not carry any cargo classified as dangerous goods. Two cargo items of interest (the Lithium ion Batteries and Mangosteens) which were carried on MH370 had also been transported via scheduled flights on MAS before and after the event. These items were packed and loaded according to standard operating procedures.

As a result of the identified issues, the investigation has issued safety recommendations to enhance the safety of the aviation system. The recommendations made address the Malaysian and foreign air traffic surveillance systems, cargo scanning, flight crew medical and training records, reporting and following-up of crew mental health, flight-following system, development of a Quick Reference for Operations Control and ELT effectiveness.

It should be recognised that there is a significant lack of evidence available to the Team to determine with any certainty the reasons that the aircraft diverted from its filed flight plan route. However, the change in flight path likely resulted from manual inputs. The lack of evidence includes the exact location and disposition of the main aircraft wreckage and the evidence that it could provide, the information recorded on the Flight Data Recorder, Cockpit Voice Recorder and other recording devices on the aircraft and the absence of any aircraft voice or data transmissions that could indicate why the aircraft flew to the Southern Indian Ocean.

Without the benefit of the examination of the aircraft wreckage and recorded flight data information, the investigation was unable to identify any plausible aircraft or systems failure mode that would lead to the observed systems deactivation, diversion from the filed flight plan route and the subsequent flight path taken by the aircraft. However, the same lack of evidence precluded the investigation from definitely eliminating that possibility. The possibility of intervention by a third party cannot be excluded either.

The disappearance of MH370 and the search effort are unprecedented in commercial aviation history. Improvements must be undertaken to ensure that this type of event is identified as soon as possible, and mechanisms are in place to track an aircraft that is not following its filed flight plan for any reason.

In recent years, several States have expended significant amounts of funds and resources searching for missing commercial aircraft in remote oceanic locations, including AF447 and MH370. In this technological epoch, the international aviation community needs to provide assurance to the travelling public that the location of current-generation commercial aircraft is always known. It is unacceptable to do otherwise.

In conclusion, the Team is unable to determine the real cause for the disappearance of MH370.)

每日航空事故及事故征候(事件)簡報(67) 2023.3.8的評論 (共 條)

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