Scat CRJ2 at Almaty on Jan 29th 2013, impacted ground near airport

Last Update: March 2, 2015 / 18:47:21 GMT/Zulu time

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Incident Facts

Date of incident
Jan 29, 2013

Classification
Crash

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

On Mar 2nd 2015 the Interstate Aviation Committee (MAK) released their final report in Russian concluding the probable causes of the crash were:

The crash of the CRJ-200 occurred after the crew initiated a missed approach in instrument meteorologic conditions, that became necessary due to lack of visual references visible on the ground (vertical visibility in fog did not exceed 40 meters), the missed approach became necessary due to actual weather conditions being below minima required for the approach. During the missed approach the elevator was deflected to lower the nose instead of rising the nose resulting in a steep dive and impact with ground. The investigation was unable to determine the cause of the elevator movement to pitch down. The investigation did not find evidence of any system malfunction or evidence of external influences like icing, windshear or wake turbulence while the aircraft attempted the go-around.

The most likely scenario to cause the reversed pitch commands was:

- a partial incapacitation of the pilot flying (captain)
- insufficient cockpit resource management resulting in the first officer diverting attention to radio communication instead of following the principle aviate, navigate, communicate, which resulted in the lack of monitoring of flight parameters
- lack of response to EGPWS alerts
- somatogravic illusion causing perceiption of a pitch up
- increased emotional stress by crew associated with the failed expectation of improving weather conditions at the time of approach
- failure to comply with requirements to medically assess flight crew, which led to the captain being assigned to the flight without needed rehabilitation and assessment following a surgery

The MAK reported the captain (56, ATPL, 18,194 hours total, 1,010 hours on type as commander) was pilot flying, the first officer (44,CPL, 3,507 hours total, 132 hours on type) was pilot monitoring, a pilot (700 hours on AN-24, theoretical examination on CRJ-200 passed) occupied the observer's seat.

The MAK reported that the captain had accumulated hours first on an Antonov 2, AN-24, IL-76 and YAK-42. In 2010 the captain converted to a Boeing 737-500 and became CAT II approved. After 1227 hours on the 737 the captain converted to the CRJ-200 in October/November 2011 and was checked out as commander with CAT I approval. In 2012 the captain also added the type rating for the CRJ-700 and was assigned flight instructor for the CRJ-200, in 2013 the captain was appointed flight examiner on the CRJ-200.

The captain had been in hospital from Nov 28th 2012 to Dec 4th 2012, where he underwent surgery for varicose veins. He was to undergo a rehabilitation period of three months following discharge from hospital.

The MAK annotated that the captain's records of the last quarterly medical examination were missing from his documentation as were the records of the examination after the sick leave that lasted for more than 30 days.

The first officer had started his flying career on Antonov 2 and AN-24s, then converted to the Yak-42 before converting to the CRJ-200 in 2012 being checked out as first officer with CAT I approval.

The MAK reported that the aircraft contacted ground first about 1600 meters short of the threshold runway 23R with a pitch attitude of 20 degrees nose down, wings level. At that time the flaps were between 15 and 10 degrees and the stabilizer trim was at -3.5 degrees. Debris of the aircraft spread until 1408 meters before the runway threshold over an area of 192 meters along the extended runway center line.

The MAK summarized medical forensic examination reporting that the captain was in his seat and in an active working position, feet on the pedals, hands on the yoke, at the time of the crash, however, there was no active participation in the aircraft control. His right hand showed injuries inconsistent with activity on the control yoke indicative that the right hand perhaps was involved in activity not associated with the control of the aircraft (the MAK suggests the seat position may have been adjusted around that time). The captain showed extensive injuries to his chest consistent with impact with the control column suggesting that his shoulder harness was not tight.

The autopsy also revealed that the captain had suffered from chronic coronary heart disease, which could result in sudden cardiac death, angina, myocardial infarct, heart rythm disturbance or heart failure. The MAK therefore analysed that a sudden partial incapacitation of the captain appears possible as result of the heart disease.

The MAK reported, that the first officer was also found in working position with his hands on the control yoke and his feet on the rudder pedals.

The MAK analysed that the flight was uneventful until the aircraft reached decision height of 185 meters, at which point the commander called "go-around" due to lack of visual reference, there was no violation of flight rules. The first officer confirmed "go", the captain instructed the flaps to be retracted to position 8. The autopilot gets disconnected, the engines accelerate for go-around, the flaps start retracting, the stabilizer trim remained in its position at -3.5 degrees, the elevator remained in its position initially but about 4 seconds after the autopilot was disconnected began to deflect commanding the nose down. At that time the first officer radioed ATC about the go-around, there was no action to arrest the descent. The EGPWS sounded "Sink Rate" and "TERRAIN", however, despite the alarms the first officer continued the radio transmissions.

The aircraft impacted ground 15 seconds after the autopilot was disconnected.

The MAK analysed that the last audio received from the captain was when he commanded the flaps to 8 degrees while initiating the go-around.

Editorial note: without mentioning this possible scenario the MAK creates the impression that the captain, after initiating the go-around and commanding the flaps to 8 degrees, became unwell, released his shoulder harness and attempted to adjust his seat but slumped forward onto the control yoke causing the pitch down without the first officer noticing in time.
Incident Facts

Date of incident
Jan 29, 2013

Classification
Crash

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

This article is published under license from Avherald.com. © of text by Avherald.com.
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