OccurenceReport UPI6208

You might also like

Download as pdf or txt
Download as pdf or txt
You are on page 1of 47

Islamic Republic of IRAN

Civil Aviation Organization

Accident Final Report

State File Number:

A13880431UPI6208

Type of Occurrence:

Accident

Date of Occurrence:

July 22th 2009

Place of Occurrence:

I.R.IRAN - Mashhad

Safety & Accident

Aircraft Type:

IL-62M

Registration:

UP-I6208

Investigation Department

Operator:

Aria

Islamic Republic Of Iran


Civil Aviation Organization
Aircraft Accident Investigation Department

Final Report
Basic Information
Type of occurrence:

Accident

Date:

24.Jul.2009

Location:

Mashhad International Airport/ I.R of Iran

Aircraft:

Airplane

Model:

IL-62M

Registration:

UP-I6208

Owner:

DETA Airline

Operator:

ARIA Airline

Date of Issue:

05 Jun 2010

Civil Aviation Organization of I.R. of Iran


Aircraft Accident Investigation Department
Mehrabad International Airport
PBO: 13445-1795 Tehran/Iran
Fax: + 98 21 6601 8659
Tel.: + 98 21 6604 7965
E-mail: AIG@cao.ir
http://www.cao.ir

--------------------------------------------------------------------------------------------

Foreword:
Civil Aviation Organization is responsible for supervision on correct
implementation of laws and regulations and flight standards in civil Aviation industries of
the country, according to international commitments and domestic laws of the Islamic
Republic of Iran; in this respect, the accidents are investigated , in order to identify
threaten resources of safety ratio of flights, based on international regulations and
compiled guidelines of International Civil Aviation Organization, ICAO (annex 13).
After identifying main causes and contributive factors of the accident, safety
recommendations are issued in order to consider flight standards and regulations, as well
as more attention to flight safety for preventing the same accidents.
Written matters in annex 13 of ICAO and relevant appendixes emphasize on this matter
that The sole objective of the investigation of an accident or incident shall be the
prevention of accidents and incidents. It is not the purpose of this activity to apportion
blame or liability
The main objective of investigating accidents is to achieve main causes and roots for
preventing similar accidents in the future.
About IL-62M airplane accident, owned by DETA Airline, Kazakhstan, (leased by Aria
Airline) in July 24, 2009, at 08:05 local time (13:35 UTC) on Shahid Hasheminejad
International Airport/ Mashhad, The Accident Investigation Team was attended in the
place of accident immediately and gathered information; this team receives FDR and
CVR of the plane, in order to analyze them.
In this direction, there has been taken necessary actions for correct investigation of
technical operational documents and study about the accident site and body of the plane
in order to identify main and contributive causes of this accident and issue safety
recommendations for preventing such same occurrences.
The accident investigation team however appreciates Interstate Aviation
Commission (IAC) for mutual cooperation in the investigation of accident involving IL62M with registration, UP-I6208 and preparing final report of this accident.

Synopsis:

Type of the aircraft

Illyushin, model IL-62M

Registration mark

UP-I6208

Owner

DETA Airline, Kazakhstan

Operator

Aria Airline

Date of accident

July 24,2009

Time of accident

18:05 local time (13:35 UTC)

Place of accident

End of left band of Mashhad International


Airport

Damage to airplane

Destroyed

No of passengers

156 person

No of crews

17 persons& one additional crews group

No of fatal

16 persons

No of injured person

31persons

Responsible for accident

Aircraft accident investigation &safety

investigation

Dept.

Foreign cooperator

(IAC) Interstate Aviation

commission

Committee/(Russia Kazakhstan Civil

I.R of Iran

Aviation Authority
Main cause of accident

crews mistakes

1. Factual Information
1.1 History of the flight:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline
with registration, UP-I6208 and flight no. IRX.1525 of Aria Airline flight
with 169 passengers from Mehrabad International Airport/ Tehran, and it
has landed at 18:05 local time on RWY 13 L in Mashhad International
Airport; then it has run off from end of the runway, without considerable
reduction in aircraft speed and it collided with wall of the airport and it was
stopped after approximately 185 m.
The mentioned aircraft has been leased by Aria Airline as ACMI,
according to contract No. 002/IL-62M/ACMI.
Subsequently, the ground safety unit of the airport has attended in place of
occurring accident, by breaking protective fences and barbed wires of the
airport, and then they evacuated passengers and extinguished fire outside of
aircraft by carrying out necessary actions.

1.2

Injuries to persons:
Injured persons of this accident were carried to hospitals of Mashhad
city, after search and rescue operation, bodies of victims were transferred
to the legal medicine. The following table shows overview of body injuries
to passengers of this aircraft:

1.3

Injuries

Crew

Passenger

Others

Fatal

11

Serious Injuries

Minor

28

None

122

Total

17

156

Damage to aircraft:

The aircraft fuselage destroyed totally due to impact to wall of the


airport and it caused destroying cockpit and nose section airframe and it
can't be reconstructed.
1.4

Other Damage:

Due to impact of aircraft landing gears with net barrier in shoulder of


RWY 13L, it has major damages on it and some damages to PAPI light in
beginning of RWY 31R.

1.5 Personnel Information:

1.5.1 Pilot in Command :( PF)


Birth year

1957

Kind of certificate and validity date

Total flight hours

Class one validity date


28/OCT/09
Without medicine limitation and
it is valid until 28/Aug/09
14200

Total flight hours with IL-62

1500

Date and place of last simulator

10/Mar/09 Russia

Prior accident

None

License for international flight

ok

License for radio communication

ok

Entrance date to Iran

19 July 2009

Date of first flight in Iran

24 July 2009

No of flight in Iran

6 flights

Medicine condition

According to available documents, he has done Radio communication


but the level of his English conversation was not suitable.
1-5-2 Copilot:
Date of Birth

1962

Kind of certificate and validity date Class 2 validity date24/Feb/2010


Medical condition
Total flight hours

Without medical limitation and it


is valid until 24/Feb/2010
8294

Total flight hours with IL-62

1319

Date and place of last simulator

10/MAY/2009 Russia

Prior accident

none

License for international flight

ok

License for radio communication

ok

Entrance date to Iran

19 July 2009

Date of first flight in Iran

24 July 2009

No of flight in Iran

6 flights

1-5-3 Flight Engineer:


Date of Birth

1957

Kind of certificate and validity date

Total flight hours

Class 1 validity
date28/OCT/09
Without medicine limitation
and it is valid until
28/0CT/09
8747

Total flight hours with IL-62airline

1697

Date and place of last simulator

10/MAY/09 Russia

Prior accident

None

License for international flight

ok

License for radio communication

ok

Entrance date to Iran

July , 17,2009

Date of first flight in Iran

July , 23,2009

No of flight in Iran

6 flights

Medical condition

1.6 Aircraft Information:


The Ilyushin aircraft IL-62M with S/N: 1951525 have been
manufactured at 09.06.1989 in Ilyushin Aircraft Factory, and its owner is
DETA Air Company, Kazakhstan. It has been registered at June 16, 2008
with UP-U6208, by Civil Aviation Authority of Kazakhstan. It has also
received its last certificate of Airworthiness at Jan. 28, 2009 from this state,
which it was valid until Jan. 28, 2010.
This airplane has been exploited after upgrading its navigation and
telecommunication, as well as installing its passenger oxygen system for
flight operation in Iran.
This airplane has been arrived in I.R of Iran Territory , due to
agreement No. 002/ IL-62M/ACMI, dated on Nov. 16, 2008 as "wet lease
agreement (ACMI) for aircraft IL-62M, between DETA Air, as Lesser and
Aria Airline as Lessee at Jan. 17, 2007.
State registry number

UP-I6208

Manufacture number

1951525

Owners

Eugeny V. Zhigayev
Ibragim A. Paskachev

Operator

ARIA airline. The aircraft owned by D.E.T.A.


AIR airline was leased under an agreement and
operated by the airline ARIA AIR (IR of
Iran).

Date of release

09 June 1989

State registration certificate

No.538 dated 16 June 2008

Airworthiness aircraft certificate

(Kazakhstan)Republic)
No.0538
dated January 28, 2009 valid till

Assigned life time and service life

January 28, 2010


35000 hours, 7500 landings., 20 years
(Bulletin No.1440-),
Bulletin No. 291-62M was fulfilled on January
20, 2009, so in accordance with the bulletin the
assigned service life was extended to 20 years 4
months, till September 29 2009.
10200 hours, 2700 landings (Bulletin No.1399

Overhaul life and service time

), 14 years
Operating time since new(TSN)

13573 hours, 3987 landings

Operating time since the last overhaul(TSO)

7876 hours, 2458 flights

Number of overhauls, date of the last overhaul

One overhaul, September 29, 1995

Overhaul life rest

2384 hours, 242 landings

Last periodic technical maintenance

According to the logbook March 29, 2009,


form -1 with operating time 7666 hours and

Last periodic maintenance

2338 landings, maintenance sheet 9


Form 15 July 2009, maintenance sheet

Fuelling

51, Teheran
20 tons

Fuel type

Jet -A1

Insurance certificate

Kazakhinstrakh, Insurance agreement No.


17/303/08/891

Engines installed in the aircraft:


Engine type

D-30KU-2

D-30KU-2

D-30KU-2

D-30KU

Serial

51148802221

51248802214

51219002225

0304022212226

Manufacturer

JSC Rybinskiye

JSC Rybinskiye

JSC Rybinskiye

JSC Rybinskiye

motory

motory

motory

motory

Date of

22 November1988

26 October1988

11 March1990

30 April1982

Operating
time
manufacture

7261 hours,

7425 hours,

7307 hours,

14046 hours,

since new

1836 cycles

1890 cycles

1729 cycles

3536 cycles

Place of the

JSC NPO Saturn

JSC NPO Saturn

JSC NPO Saturn

JSC NPO Saturn

30 December 1999 23 October 2001

14 May 2002

30 March 2000.

Operating time

3574 hours

3119 hours

1806 hours

3567 hours

since the last

928 cycles

779 cycles

438 cycles

925 cycles

Overhaul life

3637 hours

3330 hours

3000 hours

3627 hours

time
Overhaul life

901 cycles
63 hours,

767 cycles
210 hours,

543 cycles
1194 hours,

898 cycles
60 hours,

time rest

-27 cycles

-12 cycles

105 cycles

-27 cycles

last overhaul
Date of the
last overhaul

overhaul

Engines, APU TA-6A, units and assembly parts were operated in


compliance with the effective operating regulations.

All four engines had sufficient life times in operation hours to perform
flights. According to bulletins No. 1770 and No. 1844 of the engine
manufacture JSC NPO Saturn, effective dates February 08, 2002 and June
29, 2007, the first, second and fourth engines had exceeded life time in
cycles (27, 16(12), 27 correspondingly). Life times were extended by the
JSC Aerotechservice (Nikolayev, Ukraine) and JSC Engine (Perm).

10

Engine maintenance performed:


APU

Periodical maintenance

Current maintenance

PU 1

-1 21 April 2009

19 July 2009

PU 2

-1 29 April 2009

16 July 2009

PU 3

-1 - 29 April 2009

15 July 2009

PU 4

-1 21 April 2009

19 July 2009

The airframe, assemblies and units has life time sufficient to perform flight
tasks except for the cycle life time for AP units 1, 2, 4. The aircraft had no
malfunctions before the accident flight on July 24, 2009.
No complaints were made on technique functioning during the flight.
According to information of the flight date recorders, engine and aircraft
system operating parameters were in compliance with the assigned modes.

1.7 Meteorological information:


According to the meteorological office report, status of the current air
(METAR), in the accident time in Mashhad International Airport (Shahid
Hasheminejad) at 24.07.2009 was according to the following table:
ICAO ID:OIMM
Time

Wind

Pressure
TEMP/DEW

UTC

LMT

11:50

02:61

DIRECTION
(DEG)

SPEED(KT(

Visibility

Cloud

RH

Density
altitude
HPA INCH
(feet)

60

12

53/M05
CAVOK

1013

62.91

6299

1012

29.89

6235

1012

29.90

6124

7.52 %
34/M03
12:50

17:20

80

14

CAVOK

13:50

18:20

60

14

CAVOK

9.24 %
33/M04
9.06 %

11

There were not any effective metrological factors that could affect on
operation of the aircraft.

1.8 Aids to navigation:


Mashhad international airport is equipped with aid to navigation
systems as below:
NDB
385KHZ
DVOR/DME
11400 MHZ
LLZ
109.900MHZ
ILSGP
333.800MHZ
ILS/DME
CH36X
According to available
documents at accident time, all navigational
systems operations were normal

1.9 Communication:
Mashhad international airport equipped to communication system as
below:

APP:

TWR:

ATIS (INFO)

Frequency

Time

127.300 MHZ
121.500 MHZ

H24
H24

353.800 MHZ

H24

118.100 MHZ
121.700 MHZ
121.900 MHZ
257.800 MHZ
243.000 MHZ

H24
H24
H24
H24
H24

Notes
Emergency
frequency
Military frequency

Stand by For all VHF


UDF, Military
Aircraft Military
Emergency

126.400 MHZ

Communication and conversation from the flight control units & CVR of
aircraft have shown the correct operation of these systems.

12

1.10 Aerodrome information:


Mashhad international Airport of (OIMM) has aerodrome reference
point with geographical coordination 361403N 0593842E in MAG 312 Deg
with elevation of 3226 FT RWY 13L threshold.
Its direction and distance is as East and 3 Km from Mashhad, its height
from sea level is 3263 ft, and its temperature degree reference is 34.1 C.
There are permission IFR/VFR flights in this airport. Fire fighting
facilities of Mashhad INTL Airport is in CAT7. It has two Runways in
direction of 13/31 L, R with 3811 * 45 m dimension. About this accident,
there werent any faults in this regard.
1.11 Flight Recorders:
FDR
The aircraft was equipped with flight data recorders MSRP-64 and MSRP12-96. A tripartite recorder K3-63 was not installed in the aircraft. The
recorders were retrieved from the accident site by Iranian accident
investigation team. Data readout was carried out at a facility of the PARS
Aviation Service company. The information from the MSRP-12-96
recorder was not downloaded. The cassette KS-13 of the accumulator KBN
as well as the magnetic tape of the tape media MLP-14-5 of the onboard
recorder MSRP-64 were in satisfactory condition and had the parametric
accident flight data recorded on them. On the pictures below some readout
results are shown:

13

30

20

10

5400

5200

5000

4800

-4

IAS

50

AS760
GPWS
VHFkey
RA.Glid+
GV!

Alt.radi

[m]

1100

1000

900

800

700

600

500

400

300

200

100

4200

4000

3800

3600

3400

3200

3000

2800

2600

2400

2200

2000

1800

1600

1400

1200

AFCS.Rol AFCS.Pit
Stab.p
LG-ToExt
GHLFai
GHRFai
RA.Locz+
Elv.l+

100

150

200

250

300

350

400

450

500

550

600

[km/h]

-2

4400

4600

[deg]

Stabzr

10

[deg]

[deg]

Spoil.l

Flaps.l

6400

5600

-2

6600

Spoil.r

5800

6800

0.4

20

7000

30

7200

0.6

Flaps.r

7400

0.8

6000

10

1.2

[g]

VertAcc

-15

-10

-5

13:21:00

Alt.radi: Radio altitude

13:22:00

IAS: Indicated airspeed

AS760: Altimeter setting 760

Stabzr: Stabilizer position

Flaps.l: Flaps (left)

Flaps.r: Flaps (right)

AFCS.Pit: AFCS pitch channel ON

514

-0.6

4.4

Spoil.l: Spoiler (left)


AFCS.Rol: AFCS roll channel ON

Spoil.r: Spoiler (right)

Pitch: Pitch angle

AOA: Angle of attack

1.00

13:23:00

793.3

-1.44

13:24:00

13:25:00

4.0

0.6

-1.00

13:26:00

571

13:27:00

479

3000.0

-2.79

8.8

13:29:00

13:30:00

Landing gears actuator to extend

3388.9

13:28:00

3833.3

24.2

24.0

1.17

-6.3

Pic.1.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

0.0

0.2

-1.0

-0.3

Elev: Elevator position

CCP: Control column position

VHF keying

VertAcc: Vertical acceleration

10 Alt.pr 9538.5

6200

12

7600

-150

8600

7800

-100

8800

[deg]

-50

9000

8000

9200

Pitch

50

9400

AOA

100

9600

8200

150

8400

[deg]

[mm]

[m]

9800

15

Elev

CCP

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:57:22 #11 User: Zayko (#3)

Alt.pr

13:31:00

Alt.pr

-0.7

8.4

13:32:00

2200.0

Alt.radi

793.3

664.7

30.0

13:33:00

364

15.6

20.9

22.1

9.0

7.1
6.8
-7.8

Left gyro horizon failure

3.2

1.23

-1.83

0.0

Stab.p

Time UTC

279
276

13:35:00

87.5

325

GPWS

-5.60

GV malfunction

Right gyro horizon failure

265.6

13:34:00

1.00

-8.6

13.8

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Touchdown

14

100

100

50

-50

-100

-150

6000

5800

5600

5400

5200

5000

60

[m]

800

750

700

650

600

550

500

450

400

350

300

250

200

150

100

50

-50

4600

4400

4200

4000

3800

3600

3400

3200

3000

2800

2600

2400

2200

2000

1800

1600

1400

1200

1000

50

100

150

200

250

300

350

400

450

500

550

600

[km/h]

IAS

20

40

80

4800 Alt.radi

120

140

160

180

200

220

240

150

280

6200

-0.2

6800

[deg]

260

7000

-20

GMH

[mkA]

0.2

7200

-10

6400

0.4

30

[deg]

6600 LocDev

0.6

8000 LatAcc

7400

-10

8200

7600

10

8400

[g]

20

10

8600

Roll

20

7800

Ail.l: Aileron position (left)

CWP: Wheel position


Ail.r: Aileron position (right)

514

82.9

13:21:00

13:22:00

AFCS.Rol: AFCS roll channel ON

1.9

0.01

1.5

13:23:00

793.3

-18.4

IAS: Indicated airspeed

Alt.radi: Radio altitude

GMH: Magnetic heading

LocDev: Localiser deviation

LatAcc: Lateral acceleration

Roll_ri: Roll angle (right FD)

Roll: Roll angle Roll_le: Roll angle (left FD)

Rudder: Rudder position

-2.5 Alt.pr 9538.5

8800

9400

Roll_le

-20

9600

[deg]

-10

9800

2.5

9000

10000

-5

10

10200

[deg]

Roll_ri

20

10400

Ail.l

9200 Rudder

[deg]

[m]

Ail.r

-30

CWP

0.0

13:25:00

62.9

13:26:00

571

13:27:00

3388.9

13:28:00

3833.3

114.1

24.5

13:29:00

479

3000.0

140.0

-30.0

8.1

9.6

13:30:00

-38.3

7.6

Pic.1.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:24:00

0.0

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:19:00 #12 User: Zayko (#3)

Alt.pr

Alt.pr

13:31:00

-28.9

0.0

13:32:00

2200.0

Alt.radi

-33.5

13:33:00

364

793.3

121.4

664.7

5.8

13:34:00

265.6

0.01

0.0

-2.1

130.0

Time UTC

279
276

13:35:00

87.5

325

127.1

115.6

0.13

-17.0

21.9

-2.9

37.7

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Touchdown

15

16

10

EGT2

EGT1

[deg]

650

600

550

500

450

400

350

300

250

Cab/Atm

0.6 Ubus22A

0.4 Ubus21A

0.2

7800

7600

7400

7200

7000

6800

6600

6400

6200

6000

5800

5600 [kgf/sm2]

0.8

8000

5400

5200

5000

4800

4600

1100

1000

900

800

700

600

500

400

300

200

100

3400

3200

3000

2800

2600

2400

2200

2000

1800

1600

1400

1200

DVibr
RevShut1
EngFire
HSP<

IAS

[m]

3600

VHFkey LG-ToExt
LOP
CIO!
FMmin RevShut4
Fire
BagSMK
AC1+
AC2+

50

100

150

200

250

300

350

400

450

500

550

600

[km/h]

27.5

Alt.radi

3800

28

4200

4000

28.5

4400

29

[V]

15

20

[mm/sec]

VibRm1

VibRm2

VibRm3

VibRm4

20

40

60

80

100

[%]

N1.1

8200

20

9000

N1.2

N1.3

EGT3

40

9200

8400

[deg]

9400

340

13:21:00

13:22:00

IAS: Indicated airspeed

Ubus21A: Bus 21A voltage

Ubus22A: Bus 22A voltage

13:23:00

793.3

28.2

28.3

Cab/Atm: Cabin/atmosphere pressure ratio

VibRm4: Engine rear mount vibration ratio # 4


0.50

13:25:00

13:26:00

571

355

398

46.3

48.6

13:27:00

0.8

7.0

13:28:00

13:29:00

13:30:00

Landing gears actuator to extend

56.5

28.3
28.2

793.3

13:33:00

364

664.7

35.0

30.6

39.7

13:34:00

265.6

435

487

0.0

-41.8

Time UTC

279
276

345

366

570

13:35:00

87.5

325

435

497

13.8
605

30.3

33.8

82.7
-41.8

-34.2
83.3

16.6

26.8

121.1122.9
RevShut1
115.0113.3

RevShut4

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Alt.radi

13:32:00

2200.0

3.1

7.9

70.9

74.5

13.9

86.0

0.11

60.0

66.7

Alt.pr

420

477

13:31:00

41.1

50.3

63.2

57.3

62.4

Pic.1.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:24:00

1.6

7.9

N1.1: Low pressure compressor rate 1

VibRm3: Engine rear mount vibration ratio # 3

EGT1: Exhausted gaz temp. 1

16.6

23.7

N1.4: Low pressure compressor rate 4

Throt1: Throttle position 1

Throt4: Throttle position 4

EGT4: Exhausted gaz temp. 4

VHF keying

Alt.radi: Radio altitude

514

0.61

2.4

11.3

500

526

72.7

77.0

65.8

N1.4 Alt.pr 9538.5

Throt1

9600

EGT4

Throt2

9800

8600

Throt3

[m]

8800

Throt4

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 21:18:24 #13 User: Zayko (#3)

Alt.pr

Touchdown

0.6

0.4

0.2

Spoil.l

[deg]

15

10

-4

-6

Stabzr

[deg]

280

260 Alt.radi: Radio altitude

240

220

200

180

160

140

120

100

90

80

70

60

50

40

30

20

10

GPWS
Stab.p
VHFkey
GHLFai
GHRFai
RA.Glid+
RA.Locz+
Elv.l+
GV!

300

100

50.0

GPWS

13:34:45

71.9

325

320

110

100.0

IAS

[km/h]

[m]

IAS: Indicated airspeed

Stabzr: Stabilizer position

Spoil.r: Spoiler (right)

Spoil.l: Spoiler (left)

-2.2

Pitch: Pitch angle

318

AOA: Angle of attack

VertAcc: Vertical acceleration

Elev: Elevator position

CCP: Control column position

Alt.radi

-6

-4

-2

Spoil.r

-2

0.8

1.2

[deg]

10

1.4

AOA

12

1.6

Pitch

[g]

VertAcc

-15

-150

-5

50

-10

10

100

-50

15

-100

[deg]

150

13:34:50

31.3

-0.6

1.00

Thrshould passing

[mm]

-5.60

2.5

13:34:55

3.2

13:35:05

0.0

-67.3

13:35:10

13.8

Stab.p

13:35:15

279

13:35:20

6.8

-1.83

13:35:25

13:35:30

GV malfunction

13:35:35

VHF keying

Left gyro horizon failure


Right gyro horizon failure

7.1

Pic.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:35:00

276

2.6

6.8

1.23

-8.6

Touchdown

Elev

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:58:29 #31 User: Zayko (#3)

206

-1.7

13:35:40

186

-2.2

-6.1

-234.7
17.0

7.8

13:35:45

111
Time UTC

-7.0

13:35:50

129

-7.8

1.77

16.0

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

End of the RWY

CCP

Ditch

17

-2.5

-5

-10

-20

-30

-5

-10

-15

0.4

-10

-20

200

150

10

[mkA]

250

20

30

-0.2

LocDev

[deg]

0.2 Rudder

-10

[g]

IAS

[km/h]

350

325

300

275

250

225

200

175

150

125

100

75

50

Alt.radi

[m]

120

110

100

90

80

70

60

50

40

30

20

10

120

125

130

135

[deg]

GMH

50

100

Roll: Roll angle

Spoil.r: Spoiler (right)

Spoil.l: Spoiler (left)

Ail.r: Aileron position (right)


CWP: Wheel position

Ail.l: Aileron position (left)

13:34:45

50.0

Alt.radi: Radio altitude

87.5

325

IAS: Indicated airspeed

GMH: Magnetic heading

LocDev: Localiser deviation

13:34:50

31.3

318

59.3

13:34:55

127.1

Roll_le: Roll angle (left FD)

127.1

Rudder: Rudder position

LatAcc: Lateral acceleration

-5 Roll_ri: Roll angle (right FD)

10

LatAcc

Roll

[deg]

[deg]

Roll_ri

2.5

Roll_le

10

Spoil.l

[deg]

20

Spoil.r

Ail.l

Threshould passing

[deg]

276

13:35:05

0.0

115.6

12.7

13:35:10

13:35:15

-2.5

279

13:35:20

115.6

6.6

-3.3

31.7

-2.1

13:35:25

7.1

-5.6

-1.0

37.7

130.0

6.8

-5.2

-0.6

37.7

13:35:30
Pic.3.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:35:00

-3.8

0.0

0.6

3.8

Touchdown

Ail.r

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:35:05 #32 User: Zayko (#3)

13:35:35

-18.9

4.2

-18.0

0.14

-2.1

21.9

6.9
3.9

13:35:40

206

19.3

3.2

-1.2

0.6

9.4

-16.5

13:35:45

186

-0.36

13:35:50

2.9

Time UTC

111

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

End of the RWY

CWP

Ditch

18

[%]

120

100

80

60

40 N1.4: Low pressure compressor rate 4

EGT4

EGT3

EGT2

EGT1

[deg]

25

20

300

250

320

300

280

260

240

220

200

180

160

140

120

100

100

90

80

70

60

50

40

30

20

10

VHFkey
LOP
RevShut1
RevShut4
Fire
BagSMK
HSP<
AC1+
AC2+

[km/h]

[m]

110

Alt.radi

24

26

28

30

32

IAS

Ubus21A

[V]

Ubus22A

10

15

VibRm1

450

[mm/sec]

VibRm2

500

350

VibRm3

550

400

VibRm4

600

20

N1.1

20

13:34:45

50.0

Alt.radi: Radio altitude

87.5

325

IAS: Indicated airspeed

Bus 21A voltage

Bus 22A voltage

Engine rear mount vibration ratio # 4

Engine rear mount vibration ratio # 2

EGT2: Exhausted gaz temp. 2

EGT4: Exhausted gaz temp. 4

13:34:50

31.3

318

N1.1: Low pressure compressor rate 1

Threshould passing

650

N1.2

40

Throt3: Throttle position 3

N1.3

[deg]

Throt4: Throttle position 4

N1.4

Throt1

Throt2

Throt3

13:34:55

28.2

2.0

5.0

3.1

28.2

13:35:05

0.0
13:35:10

-41.8

-34.2

121.4

128.7

602

18.8

11.4

13:35:20

366
345

279

28.1

570

13:35:15

82.7

83.3

121.1
115.0

1.8

13:35:25

13:35:30

13:35:35

VHF keying

91.6

Low oil pressure in any engine

24.7

-0.8

Pic.3.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:35:00

276

497

435

30.3

33.8

16.6

26.8

RevShut1

Touchdown

RevShut4

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:04:50 #33 User: Zayko (#3)

206

13:35:40

-41.8

113.3

122.9

359

238

339

4.2

186

13:35:45

13:35:50

139

Time UTC

111

Hydraulic system oil pressure is low

249

6.0

2.0

61.1

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

End of the RWY

Throt4

Ditch

19

N1.3

N1.2

N1.1

[%]

60

40

20

400

380

360

340 IAS: Indicated airspeed

320

300

280

260

240

220

200

180

160

140

120

75

70

65

60

55

50

45

40

35

30

25

20

15

10

80

420

80

100

440

85

460

90

-5

480

95

13:34:45

50.0

500

100

325

IAS

[km/h]

[m]

87.5

EGT2: Exhausted gaz temp. 2

Crew: Switching on.

Alt.radi

200

250

300

350

NAV: Kilometer

400

GPWS: Pull up.

450

: Minimum, minimum.

500

Crew: Is the idle on?

550

31.3

318

13:34:50

NAV: 40 meters

600

EGT4: Exhausted gaz temp. 4

13:34:55

3.1

435

497

20 N1.1: Low pressure compressor rate 1

40

[deg]

NAV: 20

650

33.8
30.3

N1.4: Low pressure compressor rate 4

60

EGT1

16.6

26.8

EGT2

GPWS: Pull up.


NAV: 15 FE: ... eversed.

80

NAV: 12
NAV: 10
NAV: 8
NAV: 6

EGT3

NAV: 5

100

Throt3: Throttle position 3

Throt4: Throttle position 4

NAV: 3
NAV: 2

EGT4

120

N1.4

[deg]

NAV: 4

Throt1

NAV: 30

NAV: 25

RWY threshould

Crew: (Reverse)(?)

276

13:35:00

NAV: 1

NAV: ...270

NAV: 270 speed.

13:35:10

602
570

13:35:15

82.7

83.3

345

366

279

121.1

11.4

115.0

13:35:20

: Emergent.

91.6

NAV: Emergent breaking!

13:35:25

13:35:30

13:35:35

VHF keying

Low oil pressure in any engine

FO: What's up? Why reverse don't switch?

FO: Did you turn on the reverse?

NAV: 260

NAV: landing, speed 26 270.

Pic.3.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mashhad accident FDR (MSRP-64) flight parameters. (Preliminary)

13:35:05

0.0

-41.8

-34.2

121.4

NAV: Speed is increasing, speed is increasing!


Crew: Turned on.

128.7

FE: Thrust reversal ...


NAV: Speed is increasing!

RevShut1

Pax: Berast, bersat (Pers.)

Throt2

Pax: Berast, bersat (Pers.)


FO: Go around, let's go around!

Throt3

Pax: Right, right, right.

RevShut4

206

13:35:40

-41.8

113.3

122.9

359

238

339

23.1

186

13:35:45

13:35:50

139

Time Relative

121

Hydraulic system oil pressure is low

249

6.0

11.1

61.1

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Impact with a wall.

Printed: 03.09.2009 14:57:41 #44 User: (#3)

NAV: about 0.5 meter


Toushdown

FE: Because there was no thrust reversal displacement.

WinArm32

Ditch

Throt4

End of the RWY

NAV: Turn to the left. To the left!


Noize at the cabine.

20

NAV: Turn to the left.

21

13:28:00.0

WinArm32

13:29:00.0

13:30:00.0

13:33:00.0

8nm

6nm

4nm

2nm

2nm

4nm

6nm

8nm

10nm

13:34:00.0

13:31:00.0

User:

13:35:00.0

d:\up-i6208.-62..2009\map\up-i6208_1b.tra

Pic. 5b. Aircraft IL-62M UP-I6208 on 24.07.2009 at Mashhad airport flight path (FDR data). (Preliminary)

13:32:00.0

:IL-62M :UP-I6208 :24.07.09 :1525

CVR:
The aircraft IL-62M was equipped with a CVR MARS-BM with a
total record time of 30 minutes. The recorder was retrieved from the
accident place by Iranian accident investigation team. The information
readout was performed at a facility of PARS-Aviation Service Company.
The magnetic tape of the recorder was in a satisfactory condition so the
accident flight data was recorded. Preliminary download of the cockpit
conversation and voice identification was also conducted by representatives
of Kazakhstan Civil Aviation Committee and D.E.T.A. AIR airline. The
final transcript of cockpit radio communication with time synchronization
was made by the Air Accident Investigation Scientific and Technical
Support Commission of the IAC.

1.12 Wreckage and Impact information:


Accident site inspection revealed that the aircraft position had coordinates
N 36,218 E 59,666, at a road in the vicinity of the aerodrome, 1km away
from the RWY-31R threshold (130 MH or 133, 5 TH) of the Mashhad
airport with the azimuth of 125 (true).
Power line along the road was destroyed by the right aircraft wing. Wing
fuel tanks of the right wing were damaged evidenced by fuel leaking. Main
and emergency exits were open. An inflatable slide was dropped down from
the port side. No evidences of fire on board and at the accident site were
found.
First tracks of intensive braking (black tire tracks) were found at the
concrete at a distance of 550 m from the departure threshold of RWY31R.
The track of the main gear wheels was going along the RWY in its left part,
and diverging further to the right beyond the departure threshold. At about
100m away from the threshold at the end portion of the braking way, a net
barrier was found (textile aerodrome emergency braking unit).
22

The aircraft ran over the RWY when moving along the right side of the
stop way, 300m long. Beyond the end of the RWY landing gear wheels track
could be clearly seen passing over a rough partly grassed surface, and
crossing a dirt road. At a distance of 100m from the RWY end, where the
right gear crossed the road, a destroyed tire tube was found, which
presumably belonged to the right gear front wheel.
At a distance of 160m from the RWY end smashed approach lights were
found, and after that point the gear wheel track started to diverge to the left
from the RWY centerline. The front gear wheel track further merged with
the left gear wheel track and extended joining the forward airframe track. At
a distance of 320 m from the RWY end another line of broken approach
lights were found. Airframe structures were found before the approach lights
(along the aircraft way). From that point small aircraft structure pieces were
found along the whole aircraft path. 40m past the destroyed approach lights
line a ditch of 0,51m in depth was found (with an underground pipeline)
which was crossing this area from the south to the north.
The south-eastern part of the aerodrome was fenced with a brick wall of
2,5m high and 0,4m thick with a concrete strip foundation. It went along the
RWY there. The aircraft collided with the fence at a distance of 820m from
the departure threshold (520m past the stop way end) with a heading of 105
degrees. The fence was destroyed throughout 70m.
Debris of the nose part of the airframe, cockpit, passenger seats, aircraft
cabin parts were found behind the fence. Earlier aerodrome employees,
police and medical services found at the site and evacuated crew bodies, as
well as killed and injured passengers. After the collision with the fence the
aircraft kept moving for 160 m with a heading of 105 degrees and came to a
stop at the road.

Layout of accident site:

23

Detailed description of aircraft, systems and engines damage

24

After landing at the RWY13 the aircraft ran over the RWY at a high
speed. The aircraft passed the RWY end with breaking the protective net
barrier. Further the aircraft moved along the stop way deviating to the right
and then to the left at a soil road. There were tracks of aircraft movement at
the soil road after running over the RWY. The tracks looked like tracks from
the front, left and right landing gear wheels.

Photo 1. Tracks of aircraft movement over the dirt road after running over the RWY

Photo 2. Tracks of aircraft movement over the dirt road after running over the RWY

25

Due to emergency braking after running over the RWY the front right wheel
of the right main gear was destroyed. The aircraft ran over the RWY at a
speed of about 200 km per hour.
The aircraft moved to the right and broke several approach lights at a
concrete footing. When moving over a rough terrain due to a high speed,
the aircraft front gear was broken. At a distance of 350m from the
runway , there was a ditch 2m wide and 1m in depth. As the aircraft got
into the ditch at a speed of about 185 km per hour the front gear was
completely broken. Further the left main gear got into the ditch followed
by aircraft turning to the left. As the front gear was broken the aircraft
moved on sliding on the airframe nose. Further the aircraft hit the brick
wall concrete base 2,5 m high at a speed of 120 km per hour. This
resulted in destruction of the cockpit and the airframe up to frame 22 (6 th
seat row). The distance from the RWY end to the place of the collision
with the fence was 880m. Then the aircraft moved 160m more and came
to stop. There was no fire on board.
Wires of the power line passing outside the aerodrome were ruptured by
airframe structure elements.

The aircraft leaned on the tail part of the airframe with a little bank to the port
side. The flaps were fully extended, spoilers retracted, reverse flaps open; the
stabilizer was set 1,8 degrees pitch up.

26

Photo 3. Aircraft post-accident overall view

During the accident the aircraft got sever damage as follows:


- The cockpit and the cabin up to the frame 22 (the 6th seat row) were
totally wrecked.
- The nose part and lower wing panels were heavily damaged.
- The right flaps (inner and outer) were sheared off.
- The left flap had got substantial damage.
- The front gear was torn out from the attachment points, between main
gears, between frames 58 and 62.
- The right main gear flap was sheared off.
- Main gears had major damage and the right gear front right wheel was
wrecked.
- Lower flaps of power units 1 and 4 and flap control elements had
significant damage.
- Control linkage was totally destroyed up to the airframe nose destruction

line; beyond this no damage found.

27

Photo 4. Airframe nose (destroyed up to frame 22)

Photo 5. Left wing structures damage

28

Photo 6. Right wing structures damage

Photo 7. Right (outer) flaps damage

29

Photo 8. Front right gear (torn out of attachment points), destroyed right inner flap

Photo 9. Right main gear flap sheared off

30

Photo 10. Right main gear destroyed wheel

Photo 11. Power unit 1 reverse flaps

31

Photo 12. Power unit 4 reverse flaps

Photo 13. Power unit 4 front power lever

32

Photo 14. Power unit 4 rudder shackle of padlock

As the cockpit was completely destroyed it appeared not possible to


determine throttle positions, instrument data and switches positions.
All structure damages occurred once after the aircraft had run over the RWY,
when it was moving over terrain, and resulted from the collision with
obstacles (the ditch, lights concrete footing and brick wall). There were no
tracks of destruction resulting from fatigue.
No evidences of ailerons, rudders and elevator jamming were found. Spoilers
were in the retracted position. The flaps were fully extended.
The aft fuselage had no visible damage. The stabilizer setting was
changed by the crew during the landing run from 5,6 degrees pitch up to
1,8 degrees pitch up (according to the MSRP64). The rudders were not
fixed. There was no stabilizer position indication on the fin.

33

Photo 15. Stabilizer position 1,8 degrees

1.13 Medical and pathological information:


Crew of this flight has valid medical license from Kazakhstan civil
Aviation Authority and they had not medical problem for the flight.
By considering to collision the airplane with the wall, flight crew and
front passengers have been injured by hitting it, and they have been dead,
because of this collision. After transferring bodies to the forensic medicine
of Mashhad, necessary pathological test were carry out ,and samplings
from the flight crew was done, and it was determined that they don't have
an especial deficiencies about using drugs and alcohol.
34

1.14 Fire:
After this accident, the ground safety of Mashhad Airport sent fire
extinguish vehicles to the site of this accident immediately, but they only
extinguished a small fire in plants and thorns of around the airplane caused
by friction, because there wasn't observed a considerable fire in the airplane.
As wreckage of the airplane has been located near the flammable gas line,
these vehicles have remained in this site until carrying out it to a safe place,
in order to prevent fire and explosion of the pipe.

1.15 Survival aspects:


After this accident, ground security and research & rescue units of
Shahid Hashemijejad Airport (Mashhad) began their efforts, in order to
allocate place of accident, to rescue passengers and crew. By considering to
condition of the region and location of the airplane outside of the airport,
there were taken necessary actions by cooperating ground safety and
extinguish staffs, and other research and rescue organs; the passengers were
evacuated from aircraft wreckage, and injured persons were transferred to
hospitals of Mashhad.
35

1.16 Test and Research:


None
1.17 Organizational and management information:
According to contents ATC records of Shahid Hashemijejad Airport
(Mashhad), after this accident, the control tower in Mashhad Airport has
reported this accident to the relevant authorizations, which there have been
taken necessary actions, in order to initiate search and rescue operation.
There have been carried out all actions about search and rescue,
transferring bodies to the forensic medicine of Mashhad and identify their
identity, flight crew and passengers.
1.19 Useful or effective investigation Techniques:

The standard and normal techniques were applied.

36

2. ANALYSIS:
After joining landing course the flight altitude was 7000 ft, distance from
the RWY end 22 km. The aircraft was preceded by another aircraft
approaching to land, which had been cleared to land earlier. Being instructed
by a controller to reduce speed due to the proceeding traffic, approaching to
land, the captain decided to make left orbit and informed the crew about that.
Upon a navigators request the controller cleared to perform left orbit
maintaining 7000 ft.
No evidences of task sharing regarding flying the aircraft before
descending from the FL to approach to land were recorded. By some
navigators words one can judge that it was the captain who was the flying
pilot: Kolya, 7000, climb, climb Kolya!.
The aircraft landing weight was 93.7 tons. Data on the landing weight,
landing approach speed, approach chosen, and alternate aerodrome were not
voiced during the pre-landing preparation (not proceeding check list). After
joining landing course the controller cleared to descend to 6000 ft, at a
distance of 13 km from the RWY end. As the aircraft approached to the
RWY the navigator reported the distance: Distance 6, distance 5, flying
above. After crossing the 5 km distance the navigator without a captains
command read out the checklist: landing gear down, brakes, spoilers, altitude
selector. No answers to the voiced checklist points were recorded.
Further the navigator goes on counting distance: distance 2 km,
distance 1, altitude 40m. When passed distance 1 km, the co-pilot gave a
command (which was supposed to be given by the PIC) to set idle: Idle.
The flight engineer confirmed: Idle, but according to the MSRP-64 data
idle was set before the command. Flight speed along the glide path was 325
km/h, which was 50 km/h more than the assigned speed for a landing weight
of 93 tons. The rate of descent was 10 m/sec. During the descent the GPWS

37

warning activated several times. The RWY end was crossed at a height of 31
m and at a speed of 310 km/h.
At a height of 22m the flight engineer shifted trust reverses to a reverse
thrust position without a captains command. No report Lever latched
lights on about the shift was made. The landing was performed (according
to the calculation made) at a distance of 1000 m from the RWY threshold at
a speed of 275 km/h (instrument speed).
According to the MSRP record before landing the flight engineer
shifted engines 1 and 4 trust reversers to the forward thrust. After landing
and extending the front gear down, the co-pilot (it is a captain who should
give command) gave the command Reverse, without any monitoring by
either of them of engine trust reversers position indication at the instrument
panel. The flight engineer without checking out the thrust reverse lever
position and trust reversers position indication and reading back (roger,
reverse on) set throttles of engines 1 and 4 at the maximum trust.

Note: It should be noted that as for that aircraft type, if the reverse lever is
in the Reverse position, throttles cannot, due to their design, be set at a
position over the Nominal mode (8090 degrees according to thrust
mode indicator).

The actual record of the MSRP-64 contained record of the flight mode
implied on engines 1 and 4, which is possible only in case reverse thrust
lever is set at the forward thrust mode. There was no reporting reverse
engaged.

38

No command was given to activate spoilers, which were not extended


upon landing. The co-pilot set the stabilizer from 5, 6 degrees pitch up to 1, 8
degrees pitch up.
Just at the same time upon landing (2 seconds later) inner engines were
shut down by the flight engineer. Nevertheless the aircraft did not brake as
the trust reversers were shifted to forward thrust. The mode was maintained
for 12 seconds. According to navigators reports, which were consistent with
the MSRP record, the speed began to increase. The navigator informed the
crew about increase of speed. According to the MSRP a speed of 280
km/hour was reached. After the navigator informed about increase of the
speed, the flight engineer shut down engines no. 1 and 4.
The MARS-BM record contains crew members voices record: Co-pilot
Leaving, Navigator Brakes, Co-pilot Why isnt reverse
functioning? the PIC because flaps are not shifted, Navigator
Emergency braking.
MSRP-64 record contains multiple change of throttle position of
engines 2-3 and 1-4 before the flight mode, as well as shifting trust reversers,
but it was done with engines disengaged. Crews actions, engine parameters,
flaps position are consistent with the readout chart.
It should be noted that crews actions when landing did not comply with
the Crew Interaction and Procedure Instruction for the case of landing with
reverse engaged, under the Operating Manual of the IL-62 type (Tab 4.1).
Wheel Braking, including emergency braking, was not effective. The
aircraft ran over the RWY at a speed of 200 km/hour, deviated to the right
after the front right wheel tire of the front right gear blew out. Further on, it
broke some approach lights, with a concrete base, crossed the net barrier had
its front gear broken and then at a speed of 185 km/hour got into the ditch,
up to 1 m in depth and 2m in width, which traversed the aircrafts path at an
angle, had its front gear broken down. Then due to its left gear getting into

39

the ditch as well, turned to the left facing the brick wall with a concrete
foundation. As the front gear was broken, the aircraft moved on its forward
fuselage and at a speed of 120 km/hour collided with the concrete foundation
of the brick wall 2,5 m high. As a result of the front impact the cockpit and
airframe up to frame 22 (6th seat row) were totally ruined. The crew and
some passengers, who were in the first cabin, were killed.
The aircraft moved on over the dirt for 160m, broke the power line and
came to a stop. There was no fire on the aircraft after the stop.
It should be noted that several accidents with aircraft IL62M took
place before, which occurred due to the lack of accurate interaction
between captain and crew during landing with thrust reverse involved.
In most cases these accidents were a result of non-authorized flight
engineers actions to shift engine trust reversers at heights more than these
recommended in the FM, followed by their shifting to forward thrust and
setting engines 1 and 4 at the flight mode. Another cause was an
unmonitored thrust lever position (not latched) and position of engine trust
reversers indication before setting engines at the maximum braking mode,
which resulted in running over the RWY.

Table 4.1. Il-62M crew interaction checklist to be fulfilled at landing


with thrust reverse engaged
Flight

At the command of captain Idle, read it back and reduce

engineer

engine power to idle.

PIC

By the end of flaring at the idle mode give the command: Shift
flaps (with a glide path angle under 3 degrees 30 min. At a
height of no more than 5 m give the command Shift flaps
(with a glide path angle no more than 3 degrees 30 min)

Flight

At the captains command Shift flaps read it back. Shift the

engineer

reverse control lever of engines 1-2 from the position

40

REVERSE OFF to the position REVERSE ON. Check by


the indication display whether the reverse flaps are shifted and
report Lever latched lights on.
PIC

At a height of 1-2m, if necessary, give the command


Reverse. By the end of flaring prevent increase of pitch angle
and touch down the RWY by the main wheels. Upon landing
manipulating the rudder, match the aircraft axis with the RWY
centre line, put down at the RWY the front gear (in 2-3
seconds), give the command Reverse (if reverse was not
engaged earlier) and activate the front gear control. Fix the
control column in the Push position; give the command
Spoilers.

Flight

On the captains command Reverse read it back, set engines

engineer

1 and 4 throttles at the maximum reverse thrust mode (to the


Reverse stop) and report: Reverse engaged.
Upon the captains command Spoilers read it back, extend
spoilers to the maximum angle and report: Spoilers extended.
Make sure that the engines 1 and 4 parameters are consistent
with the reverse thrust mode.

41

THROTTLES AND THRUST REVERSE LEVER CONTROL


SYSTEM

Thrust reverse
lever

Nominal mode
stops

42

Middle thrust
reverse lever
position latch

43

3. CONCLUSIONS:
3-1 Findings:
The crew was not trained &acquainted with flight conditions in
the Iran territory with an Iranian instructor pilot and the operation
unit of Aria Airline has acted so weak regarding those mentioned
subjects.
The approach speed of aircraft was higher than recommended
available airport charts & aircraft weight, however it was
controllable if the crew could proceed to land correctively.
The crew had not done correct procedure according to the aircraft
Standard Operation Procedure (SOP) to use related check lists.
(Descend-Approach-Landing)
There was lack of precise coordination between flight crew on
their self responsibility during the approach and landing.
The flight crew did not pay attention to EGPWS warning, and did
not take corrective action.
The crew did not use engine reverser and spoiler systems correctly
to reduce aircraft speed during the landing and consequently it
caused to loose long Runway distance.
The flight crew had not good English language proficiency. And
they were poor in England language conversation.
The Capitan of the aircraft as the pilot in command had not
sufficient force and efficient management in the cockpit.( lack of
Cockpit Resource Management).

There were unauthorized actions of flight engineer for shifting


engine reversers as well as lack of mutual oversight by crew
members in checklist accomplishment during approach and landing.
The crew has had disagreement about Go around due to
unsuitable landing situations.
Presence of General Director of airline in the cockpit had adverse
psychological effect on crew efficiency behaviors.

44

The DETA airline did not use correct procedure to extend engines
No; 1-2-4 life time from Ukrainian company (Aerotechservice
co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.
3-2 Main Cause

Considering those items in factual information and analysis, the main cause
of this accident is weak Cockpit management between the crew to use
correct landing techniques same as releasing Engine trust reversers
Engine shut down in unsuitable time - .
3-3 Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
The copilot and the flight engineer had self activity& decision without
the (PIC) coordination.
The cockpit crew was careless and not paying proper attention toward
EGPWS warning.
Psychological adverse effect on cockpit crew because of presence of
General Director of Aria airline
3-4 Violation &other deficiencies:
The accident investigation team encountered some violations and
deficiencies with ICAO Standards and Iran Local Authority regulation
(CAO) which are descript as:
Poor and in-sufficient supervision controlled of operation &technical
manger of Aria Airline.
The DETA airline has not used proper procedure to receive life time
extension of engine and has not passed necessary information to
Iranian and Kazakhstan Authorities.
It has not been designed a headset for flight engineer to make more
coordination between the crew, by the aircraft design bureau.
The crew was not familiar with Iranian AIP completely.
The total on board persons was not according to written load sheet.
45

4- SAFETY RECOMMENDATIONS:
In order to prevent the similar events, the Aircraft Accident Instigation
&Safety of IRI CAO recommends:
.A special working group (Board) between Iranian airlines which used
Russian leased aircraft and Russian airlines, be established and study
how to obtain life extensions and modifications from Russian
authorities as a state of design & manufacture.
Those Iranian airliners that are willing to have foreign pilots shall
provide training courses, such as Iran routs and necessary
arrangements for crew members just before beginning of their flights.
All foreign pilots should be checked by a related instructor pilot or a
CAO designee pilot.
The IL-62 cockpit should be equipped with flight engineer headset by
the ILYUSHIN Design Bureau.
The ILYUSHIN Design Bureau should study and investigate why
ELT has not activated by the sever impact.
Presence and entering passengers or any other persons than crew
should really be forbidden during landing and take off by airlines.
The Interstate Aviation Committee (MAK) and Aircraft Accident
Investigation Department of IRI CAO should deliver notified findings
of this accident to related airlines.
It is recommended that a correct procedure of foreign pilot operation
in the Iran territory should be defined by operation department of IRI
CAO with cooperation of airlines.
All airlines that are willing to use leased aircrafts should have

sufficient supervision just before to start operation, should check and


accomplish the written MOU between authorities and also consider
those items in "Art 83 Bis ".

46

You might also like