Investigation Summary
The investigation revealed a significant breakdown in Cockpit Resource Management (CRM) and monitoring. The aircraft was being operated with the First Officer as the Pilot Flying (PF) and the Captain as the Pilot Monitoring (PM). As the aircraft approached V1 speed (145 knots), the Captain's mobile phone and a tablet computer fell into the rudder pedal well, distracting him. While distracted, the Captain unconsciously applied pressure to his left rudder pedal. Because the Airbus A319 rudder pedals are mechanically linked, this input was added to the First Officer's directional control inputs, leading to an uncommanded left deviation. The crew failed to use standard callouts to identify the deviation or the decision to abort. By the time the Captain reduced the throttle to idle, the aircraft's momentum and maximum braking force were insufficient to keep it on the paved surface. The aircraft crossed a rapid exit taxiway and struck a manhole cover and a drainage ditch, which acted as a 'trip' mechanism, shearing off the heavy components and rupturing fuel lines.
Final Conclusions
The Civil Aviation Administration of China (CAAC) concluded the accident was caused by human error. Specifically, the Captain's loss of situational awareness due to a minor cockpit distraction led to unintended flight control inputs at a critical high speed phase of takeoff. The crew's failure to follow standard operating procedures (SOPs) regarding callouts and corrective actions during the deviation further exacerbated the situation. As a result, the CAAC revoked the licenses of the Captain and the co-captain (who was also in the cockpit), suspended the First Officer for six months, and imposed heavy financial penalties on Tibet Airlines and its executive leadership.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Rudder Pedals
Mechanically linked pedals where inputs from both pilots are summed; the Captain's unintended input overrode or added to the First Officer's control.
CFM56-5B7/P Engines
Both engines detached from the wings after the aircraft struck a drainage ditch, leading to a fuel-fed fire.
Interesting Facts
- 01The aircraft was an Airbus A319-115 delivered in 2012 with over 28,000 airframe hours.
- 02There were 113 passengers and 9 crew members on board; all survived.
- 03The rejected takeoff was initiated at 145 knots, which is extremely close to the V1 (takeoff decision) speed.
- 04The aircraft was written off due to severe fire damage to the forward fuselage and structural failure of the wings and gear.
- 0540 people sustained minor injuries, mostly during the emergency evacuation process.
Safety Actions & Advisories
Regulatory Fines and License Revocations
The CAAC revoked the licenses of the Captain and co-captain, suspended the First Officer, and fined Tibet Airlines 900,000 Yuan for safety management failures.
Executive Accountability
Five airline executives were personally fined between 30% and 40% of their previous year's income as a penalty for the operational lapses leading to the accident.