TAROM Flight 381 accident

The TAROM Flight 381 accident (Taromu Kōkū 381-bin jiko) was an aviation accident that occurred on 24 September 1994. TAROM Flight 381 (Airbus A310-325), flying from Aurel Vlaicu International Airport to Paris-Orly Airport, stalled and dived while approaching Orly Airport. All 186 crew and passengers were safe.

Accident aircraft

The accident aircraft, an Airbus A310-325 (YR-LCA), was delivered to TAROM on 17 December 1992. It continued to be operated after the accident and was sold to Armenia Airways in 2018.

Course of the accident

Flight 381 took off from Aurel Vlaicu International Airport and was scheduled to arrive at Paris-Orly Airport at around 10:40.

Orly ATIS reported that runway 26 was in use, visibility was 10 km and there was cloud at 2,400 ft. At 10:30 the aircraft began its descent from its cruising altitude of 35,000 ft, and at 10:38:39 Flight 381 passed the Melun VOR at a speed of 400 kn and an altitude of 6,600 ft. At 10:41:01 the controller instructed it to change heading to 310 degrees for an ILS approach to runway 26. As runway 26 was in sight, the captain continued the landing approach on autopilot. At 10:42:53 the flaps and slats were set to 15 degrees.

Before lining up with the runway, while passing the OYE beacon on autopilot at 250 kn, the captain noticed that the glideslope had not been captured. The captain disengaged the autopilot and continued the approach manually, but the autothrottle was not disengaged.

At 10:43:22 the flaps were set to 20 degrees. At this time the speed was about 195 kn, about 2 kn above the speed at which the flaps can be extended to 20 degrees. When the flaps were extended, the throttles advanced and the speed increased.

To stop the aircraft climbing as lift increased, the captain pushed the sidestick forward. The throttles were retarded to idle, but the horizontal stabiliser trim moved towards the nose-up position.

As the increased trim caused the nose to start rising, the pilots pushed the sidestick forward again. The trim moved to the maximum nose-up position and the elevators were moved to the maximum nose-down position. The throttles also rapidly retarded to idle.

Within a few seconds the aircraft's climb angle increased to nearly 60 degrees. Witnesses saw Flight 381 climbing steeply. It climbed to 4,100 ft and its speed decreased to 35 kn. The aircraft stalled and fell towards the ground at a descent angle of 33 degrees. During the descent the captain radioed "Mayday! (Mayday!)" to the controller. The controller said "Uh, TAROM 381, turn left heading 180 (Euh... Tarom

three eight one turn...

left if you want heading

one eight zero)", and a few seconds later responded "TAROM 381, do you hear me? (Tarom three eight

one do you hear me?)". The ground proximity warning also activated during the dive. The captain succeeded in recovering the aircraft at around 800 ft. At 10:52 Flight 381 made another landing approach and landed at Orly Airport.

Accident investigation

The French Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) investigated the accident. The final report stated that the aircraft's abnormal nose-up and stall were due to the horizontal stabiliser moving to its nose-up limit position. These occurred because the captain did not understand the reversion of the autopilot. Faced with the sudden nose-up, the pilots were unable to make a corrective input using the elevators.

Procedures were omitted because the descent was late and a high-speed landing approach was forced.

Crew resource management was inadequate.

The go-around altitude was set too early.

The speed protection function activated because the flaps and slats were abruptly set to 20 degrees.