UTAir Ukraine CRJ2 at Moscow on Apr 1st 2013, descended dangerously below minimum safe altitude

Last Update: July 13, 2013 / 15:19:32 GMT/Zulu time

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Incident Facts

Date of incident
Apr 1, 2013

Classification
Incident

Airline
UTAir Ukraine

Flight number
QU-119

Departure
Donetsk, Ukraine

Destination
Moscow Vnukovo, Russia

Aircraft Registration
UR-UTZ

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

A UTAir Ukraine Canadair CRJ-200, registration UR-UTZ performing flight QU-119 from Donetsk (Ukraine) to Moscow Vnukovo (Russia), was on approach to Vnukovo's runway 19 about to turn final when the aircraft descended below the minimum safe altitude of 400 meters/1300 feet reaching a minimum of 144 meters/470 feet during the turn onto final. ATC instructed the aircraft to immediately climb to 900 meters, the crew complied and thus avoided obstacles raising up to 108 meters/350 feet. The aircraft positioned for a second approach and landed safely.

Ukraine's State Aviation Service reported in their delayed monthly newsletter released on Jul 3rd 2013, that the aircraft was flown by a captain with 5100 hours total flying experience, thereof 80 hours on type. The first officer had a total experience of 4970 hours, thereof 436 hours on type.

The aircraft had been dispatched in Donetsk under minimum equipment list requirements with the APU inoperative. The aircraft departed and following an uneventful cruise the aircraft was descending towards Moscow, when the captain initiated the depressurization of the cabin in accordance with the procedures according to MEL. While he was working on the checklist to depressurize the cabin and not monitoring radio communication, ATC advised about a QNH of 981 hPa, which was read back by the first officer, however, was not inserted into the altimeter settings. The aircraft therefore continued the descent on standard pressure 1013hPa resulting in the altimeters indicating 258 meters/850 feet higher than actual altitude. Due to the depressurization the crew also missed to action the approach checklist. Consequently the aircraft descended below assigned altitudes of 600 and 400 meters, the air traffic controller noticed the aircraft descended below safe altitude when the aircraft reached 330 meters and queried the crew to report their altitude, which was not responded to, the captain later explained he did not hear the query because of still being busy with the depressurization. The controller issued the instruction to stop the descent, again without reply. A third instruction to stop the descent and climb to 400 meters was acknowledged by the crew, power was applied for about 30 seconds and the aircraft climbed to 350 meters, then descended again. The controller queried "Confirm QNH 981 is set?", the crew responded affirmative, however, the altimeters remained set at 1013 hPa. The approach controller subsequently cleared the aircraft for the approach and handed the aircraft off to tower. The aircraft descended through 200 meters, tower instructed the aircraft to climb by 200 meters, the captain was puzzled as he believed to be above the minimum safe altitude, at this time the EGPWS sounded "TOO LOW! TERRAIN!" as the aircraft descended through 170 meters, the rate of descent reduced thereafter. The controller instructed the aircraft to climb to 900 meters, after which the aircraft began to climb after reaching a minimum altitude of 144 meters. During the climb the crew recognized their error and established proper QNH setting at their altimeters, positioned for another approach and landed safely.

The State Aviation Service reported that the investigation also revealed the EGPWS procedures were described erroneously in the flight crew operating manual.
Incident Facts

Date of incident
Apr 1, 2013

Classification
Incident

Airline
UTAir Ukraine

Flight number
QU-119

Departure
Donetsk, Ukraine

Destination
Moscow Vnukovo, Russia

Aircraft Registration
UR-UTZ

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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