AIRCRAFT ACCIDENT
INVESTIGATION REPORT
ALL NIPPON AIRWAYS FLIGHT 391
AIRBUS A321－131, JA104A
HAKODATE AIRPORT, HOKKAIDO, JAPAN
JANUARY 21, 2002
September 26, 2003
Aircraft and Railway Accidents Investigation Commission
Ministry of Land, Infrastructure and Transport
The investigation for this report was conducted by Aircraft and Railway Accidents
Investigation Commission, ARAIC, about the aircraft accident of All Nippon Airways Airbus 321-
131 in accordance with Aircraft and Railway Accidents Investigation Commission Establishment
Law and Annex 13 to the Convention of International Civil Aviation for the purpose of
determining cause of the aircraft accident and contributing to the prevention of accidents and not
for the purpose of blaming responsibility of the accident.
This English version report has been published and translated by ARAIC to make its reading
easier for English speaking people those who are not familiar with Japanese. Although efforts are
made to translate as accurate as possible, only the Japanese version is authentic. If there is
difference in meaning of the texts between the Japanese version and the English version, texts in
the Japanese version are correct.
Junzo Sato,
Chairman,
Aircraft and Railway Accidents Investigation Commission
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Abbreviated words
Abbreviated words used in this report are as follows:
ＡＯＭ ： Airplane Operations Manual
ＡＯＲ ： Airplane Operations Reference
ＡＰＰＲ ： Approach
ＡＴＩＳ ： Automatic Terminal Information Service
Ａ／ＴＨＲ ： Auto Thrust Function
ＢＥＡ ： BUREAU D'ENQUETES ET D'ANALYSES POUR LA SECURITE
DE L'AVIATION CIVILE (The French Bureau of Investigation and
Analysis for Safety in Civil Aviation)
ＣＡ ： Cabin Attendant
ＣＡＳ ： Computed Airspeed
ＣＡ／ＳＳ ： Captain's Sidestick
ＣＯ／ＳＳ ： Co-pilot's Sidestick
ＣＶＲ ： Cockpit Voice Recorder
ＣＲＭ ： Crew Resource Management
ＤＦＤＲ ： Digital Flight Data Recorder
ＥＧＰＷＳ ： Enhanced Ground Proximity Warning System
ＦＡＣ ： Flight Augmentation Computer
ＦＡＦ ： Final Approach Fix
ＦＣＯＭ ： Flight Crew Operating Manual
ＦＤ ： Flight Director
ＦＬ ： Flight Level
ＦＭＧＣ ： Flight Management Guidance Computer
ＩＬＳ ： Instrument Landing System
ＭＡＣ ： Mean Aerodynamic Chord
ＭＣＤＵ ： Multipurpose Control and Display Unit
ＯＭ ： Operations Manual
ＰＦ ： Pilot Flying
ＰＦＤ ： Primary Flight Display
ＰＮＦ ： Pilot Not Flying
Ｐ／ＦＲ ： Pressure Falling Rapidly
ＲＥＴ ： Retract
ＱＡＲ ： Quick Access Recorder
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ＳＰＤ／ＭＡＣＨ ： Speed/Mach
ＳＲＳ ： Speed Reference System
ＴＬＡ ： Thrust Lever Angle
ＴＯ／ＧＡ ： Take-Off-Go-Around
ＵＴＣ ： Coordinated Universal Time
ＶＨＦ ： Very High Frequency
ＶＯＲ ： VHF Omni-Directional Radio Range
ＶＯＲ／ＤＭＥ ： VOR and DME Combination
ＶAPP ： Approach Speed
Ｖα MAX ： Speed for the Maximum Angle of Attack
ＶLS ： Lowest Selectable Speed
ＶREF ： Landing Reference Speed
ＶS ： Stalling Speed
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CONTENTS
1 PROCESS AND PROGRESS OF THE ACCIDENT INVESTIGATION ··································2
1.1 Summary of the Accident·······························································································2
1.2 Outline of the Accident Investigation ··············································································2
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