Valan AN26 at Abidjan on Oct 14th 2017, came to stop in the sea
Last Update: August 12, 2019 / 16:16:11 GMT/Zulu time
Incident Facts
Date of incident
Oct 14, 2017
Classification
Accident
Airline
Valan Air Cargo
Departure
Ouagadougou, Burkina Faso
Destination
Abidjan
Aircraft Registration
ER-AVB
Aircraft Type
Antonov An-26
ICAO Type Designator
AN26
Initial reports by the airport had suggested the aircraft had just attempted to depart but overran runway 21.
Later emergency services reported the aircraft was arriving from Burkina Faso on approach from the sea side in thunderstorms, gusting winds and lightning when the aircraft ended up in the waters ahead of the runway.
Cote de Ivoire's Minister of Interior reported there were 4 fatalities and 6 injured. 6 occupants were Moldovans, 4 were French, all French are amongst the survivors.
On Oct 15th 2017 the airline reported after talking to their technician on board and surviving the accident, that the aircraft was on final approach to Abidjan arriving from Ouagadougou, both engines were working normally, when the aircraft impacted waters. It is unclear why the aircraft fell into the waters, the weather characterized by thunderstorms accompanied by lightning and heavy precipitation may have played a role. The captain (63) had accumulated more than 24,000 hours of total flying experience, 13,000 of which were on the AN-26, the first officer - youngest crew member - had accumulated 2,200 hours of flying experience. Both were killed in the accident, in addition to the flight engineer and another company technician. The black boxes were recovered, the Moldovian CAA is going to join the investigation. The aircraft had last been at the Antonov facilities in February 2017 and had been issued a certificate of airworthiness by Antonov.
According to the aircraft registry by the CAA Moldova (list compiled on Oct 10th 2017) Valan Air operates AN-26s with the tailnumbers ER-AVA, ER-AVB and ER-AZO.
In August 2019 Cote de Ivoire's BEA released their final report in French only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a French only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe). The report concludes the probable causes of the accident were:
The probable cause of the accident was the continuation of the approach below Minimums without required visual contact with the runway references and without proper monitoring of the aircraft's descent. The application of the company's strict Standard Operating Procedures would have necessitated a go around.
The following factors contributed to the accident:
- Underestimation of the adverse weather conditions below Minimum
- Lack of knowledge of the environment of Abidjan Airport and insufficient situational awareness, in particular on the vertical profile
- Inadequate monitoring of flight instruments and flight path (in particular altitude and speed) in poor weather conditions
- high workload due to continued instructions while on final approach and distractions unrelated to the conduct of flight
- De-activation of EGWS audible warnings due to nuisance alerts
- unbalanced Cockpit Resource Management due to the captain's authority over the other crew members
- Strict non-compliance with company Standard Operating Procedures
Descending towards Abidjan the aircraft was sent into a hold at FL160 due to weather conditions. About 10 minutes after entering the hold at GUPEX waypoint the crew inquired again about weather and was told runway 21 was in use, winds from 270 degrees at 7 knots, visibility 4000 meters and QNH 1012. The crew briefs for the approach, the captain (63, ATPL, 23,766 hours total, 10,133 hours on type, pilot monitorig) queries the first officer (30, ATPL, 2,250 hours total, 2,080 hours on type, pilot flying) whether ILS 21 was servicable, the first officer reported ILS 21 had not been tested in flight but was working well on the ground. The captain instructed to use the RNAV procedure therefore. The briefing continues with the captain providing instructions.
During the approach the captain detects that neither VOR nor ADF signals from Abidjan can be picked up and queries the ground equipment of Abidjan.
ATC clears the aircraft to descend to 2700 feet and for the ILS Z runway 21 procedure. The crew reads back the instructions. ATC informs the runway is wet. A number of instructions are provided to the first officer by the captain.
About 40nm from the airport a SPECI Metar is being released indicating the runway in use is now 03, wind from 040 at 12 knots, 4000 meters visibility, light rain, scattered cloud at 150 and 330 meters (500 and 1000 feet), some CBs at 600 meters (2000 feet), QNH 1013, trend visibility 2500 meters with moderate thunderstorms.
ATC changes the clearance to VOR Z runway 03. About 30nm from touchdown the crew performs a new approach briefing including the VOR Z runway 03 go around procedure. The CVR however does not record any update of the Minimums for the approach. While the checklists are being run the captain again provides instructions to the first officer.
About 25nm before touchdown ATC asks the crew whether they could switch to runway 21 again, winds were now from 060 at 13 knots. The crew stated they'd continue the VOR Z runway 03. ATC accepts and hands the aircraft off to tower.
Passing through FL050 the crew contacts tower advising they were on approach to runway 03. Tower clears to descend to 2200 feet on a VOR Z runway 03 approach and requests a position report at TUTEL waypoint.
A discussion arises between captain and first officer about the approach procedure at TUTEL, the captain provides instructions on engine speeds and headings. The VOR is still not received.
The crew performs the checklist on landing. The flight engineer queries Decision Altitude at 60 meters (the ILS 21 minimum), the captain replies "DA positioned at 60 everywhere". Throughout the approach to captain comments and provides instructions like "bad weather! Clouds ... We were given 900m .... We see the earth ...... Clouds ... Near 400m and no more ...... And it's raining more ... We're in full M .... Boats ... it's clear here, now we're going back to those bad conditions ... "
The crew intercepts final course, sets the flaps to 15 degrees and lowers the landing gear. At 7nm before touchdown the crew provides the requested position report and receives the clearance to land on runway 03, tower reports runway in wet, winds were from 040 degrees at 10 knots. The captain reminds the first officer to use the GPS (RNAV) for landing. The flaps are extended to 30 degrees, windscreen wipers on, landing lights on. The captain calls high rate of descent and low speed.
In the meantime a Boeing 737-400 is taxiing to the hold short line for departure.
Tower adjusts runway lights to intensity 4 of 5 and PAPIs to intensity 2 of 3. The captain continuously reads sink rate and speeds to the first officer of what speed (in kph) the first officer has to maintain: "Sink 34 Speed 220, Sink 24 Speed 230, Sink 20 Speed 245, Speed 200."
The GPWS announces "Minimums". The captain responds: "Land". About 10 seconds later the captain emits a scream and another 2 seconds later the aircraft collides with the water.
Tower lost the transponder signal 2.7nm before the runway threshold, queres the waiting 737 whether they could see the aircraft on approach, the 737 crew reported they were not able to see the approaching aircraft. About a minute later the crew of the 737 informs tower they receive an ELT transmission. Tower activates emergency services. About 40 minutes after contact was lost an emergency vehicle spots the aircraft in the waters on about the center line of runway 03.
All three crew and one passenger were killed, three passengers received serious and three passengers minor injuries.
The BEA reported the EGPWS was found fully and properly working, however, even on the previous flights the EGPWS had been sounding premature terrain warnings obviously related to an incorrect altitude reported by the Air Data Computer. A difference of about 700 feet between altitudes reported by ADC and radio altimeter was recorded. While the GPS data appeared correct and agree with the radio altimeter, the ADC data transmitted via ARINC 204 bus appeared incorrect.
The BEA annotated: "The regular presence of untimely (premature) Alerts from the EGPWS may have encouraged the crew to ignore these alerts, probably going so far as to disable them."
The altimeter instrument readings were found accurate within 120 feet (altimeters indicating about 120 feet above actual altitude at impact), the investigation could not establish whether this was the reading at impact or slightly before.
The BEA analysed that the aircraft had been loaded properly, the systems were working, the engines were operating normally, the crew was not fatigued, there was no time pressure to land.
The BEA analysed that the VOR Z runway 03 approach minima were 120 meters (400 feet). The minimum altitude however was not adjusted during the re-briefing for approach to runway 03. SOP by the airline suggests:
"it is required to set the altitude adjuster:
- to the decision altitude if the value is not exceeding 60 meters
- to 60 meters if the decision altitude is exceeding 60 meters"
As the VOR could not be received the captain instructed the first officer to use the GPS for the approach. The GPS was approved for RNAV and was interfaced with the Air Data Computer via an altitude converter, the database contained detailed information on the airfields. Although the crew used the GPS they did not tell tower about the use of GPS.
30 meters above decision altitude the flight engineer was required to call "approaching Minimums" (Assessment), this call however was not recorded by the CVR. The decision altitude call (as well as the GPWS aural indication) was recorded on the CVR however. At this point the captain decided to "Land". At this point visual contact with the runway must have been established, in the absence of reliable visual contact a descent below DA is prohibited and a go around must be initiated.
It is likely, the BEA continued analysis, that around the DA call the crew was focussed to detect visual cues of the runway and thus overlooked the developing steep descent in the last 12 seconds of flight.
The EGPWS nuisance alerts were confirmed to have been present for a number of flights, however, had never been reported to the company. Therefore no action to identify and correct the malfunction were undertaken. A reliable Terrain Warning would certainly have made the crew aware of the vertical profile and correct their flight path to climb.
With respect to CRM the BEA analysed the captain certainly appeared to have asserted his seniority over the other crew members, there were only a very few reactions audible on the CVR. The crew appeared to have expected seeing the runway from one moment to the next.
Metars:
DIAP 141021Z VRB02KT 7000 SCT011 FEW020CB OVC030 23/23 Q1013 NOSIG=
DIAP 141000Z 04003KT 7000 TS SCT011 FEW020CB OVC030 23/22 Q1013 BECMG NSW=
DIAP 140952Z 04003KT 340V070 7000 TS SCT011 FEW020CB OVC030 23/22 Q1013 BECMG NSW=
DIAP 140930Z 04005KT 6000 -TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1013 TEMPO 4000 TSRA=
DIAP 140900Z 03008KT 6000 -TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1013 RERA TEMPO 4000 TSRA=
DIAP 140857Z 03008KT 6000 -TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1013 RERA TEMPO 4000 TSRA=
DIAP 140838Z 03010KT 2700 TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1013 TEMPO 1300 TSRA=
DIAP 140830Z 06012KT 4000 -TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1014 TEMPO 2500 TSRA=
DIAP 140803Z 06016KT 4000 -TSRA SCT005 SCT011 FEW020CB OVC030 23/22 Q1013 TEMPO 2500 TSRA=
DIAP 140800Z 06016KT 4000 -RA SCT005 SCT011 FEW020CB OVC030 24/23 Q1013 TEMPO 2500 TSRA=
Incident Facts
Date of incident
Oct 14, 2017
Classification
Accident
Airline
Valan Air Cargo
Departure
Ouagadougou, Burkina Faso
Destination
Abidjan
Aircraft Registration
ER-AVB
Aircraft Type
Antonov An-26
ICAO Type Designator
AN26
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Newest articles
Fleet type match
ANZ B789 over Timor Sea on Apr 16th 2024, turbulence injures passenger
An ANZ Air New Zealand Boeing 787-9, registration ZK-NZC performing flight NZ-65 from Denpasar (Indonesia) to Auckland (New Zealand), had just…
Fleet type match
Southwest B38M at Washington on Apr 18th 2024, runway incursion forces rejected takeoff
A Southwest Airlines Boeing 737-8 MAX, registration N8710M performing flight WN-2937 from Washington National,DC to Orlando,FL (USA), was taxiing for…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways