Petropavlovsk-Kamchatsky AN28 near Palana on Sep 12th 2012, missing aircraft impacted a slope

Last Update: February 6, 2013 / 17:02:48 GMT/Zulu time

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Incident Facts

Date of incident
Sep 12, 2012

Classification
Crash

Aircraft Registration
RA-28715

Aircraft Type
Antonov An-28

ICAO Type Designator
AN28

The Interstate Aviation Committee (MAK) have released their final report in Russian concluding the probable causes of the crash were:

non-compliance of the crew with the published approach procedure, descending below minimum height prematurely while flying in mountaineous terrain in weather conditions that prevented consistent visual contact with the ground. This led to a controlled flight into the slopes of a mountain, the destruction of the aircraft and fatalities amongst the crew and passengers.

Alcohol was found in the blood of both flight crew.

Contributing factors were:
- low level of discipline of staff and inadequate supervision of pre-flight preparation and implementation of approaches by the airline
- lack of alertness by the crew when the radio altimeter reached a dangerous height
- the presence of a GPWS could possibly have averted the accident

Following deficiencies were identified leading to the crash:

- the blood of both flight crew contained alcohol in violation of Russian regulations
- during pre-flight checks both flight crew were permitted to conduct the flight despite their intoxication in violation of Russian regulations
- in violation of Airline regulations the captain did not ensure a pre-flight examination was conducted
- according to tape recordings the decision to depart was made by the first officer of another crew, which is in violation of Russian and Airline regulations
- No ground proximity warning system (GPWS) was installed on the aircraft
- the flight crew did not track along the planned trajectory and entered the approach procedure not at the published entry point
- the flight crew provided air traffic control with wrong position reports
- nearing the aerodrome of Palana the crew performed a premature descent and flew an arbitrary trajectory in violation of the approach procedure
- near the aerodrome of Palana the flight crew again provided a false position report to ATC
- ATC cleared the aircraft to intercept the turn to final at an altitude, which violated the instrument approach procedure
- The "uncertainty phase" was not declared by the aerodrome preventing taking measurements of weather data
- the operations manuals at Palana aerodrome do not provide limiting values in altitude and bearings to air traffic controllers vectoring aircraft in the terminal area

The MAK reported the crew comprised the captain (48, ATPL, 8,955 hours total, 7,732 hours on type, 6,192 hours in command on type) and another captain assuming the role of the first officer (41, ATPL, 6,543 hours total, 6,347 hours on type, 2,746 hours in command on type).

Prior to the flight both crew reported to the medical center at the airport of Petropavlosk-Kamchatsky for the required medical examination, both flight crew were permitted to fly.

The MAK annotated (editorial note: without naming the suspicion in the clear that arises out of their annotation), that a second crew and a second aircraft, RA-28714, were present at the aerodrome at the time ready to jump in as backup, they had been assigned flight number 9402 on the same route as flight 251. All discussions/negotiations at the medical center however concerned flight 251 (editorial note: it is unclear where the 251 comes from, the published schedule of the airline at the time of the accident showed flight 215) and RA-28715.

The crew of RA-28714 (named reserve crew in the following) collected weather data and other pre flight data on request of the commander of RA-28715, who was engaged in a safety inspection with the chief inspector regarding aircraft documentation. The crew of RA-28715 thus did not collect data pertinent to their flight themselves in violation of regulations, the decision to depart was thus taken by the first officer of the reserve crew, who had also taken care of the loading of the accident aircraft.

Prior to departure the commander of RA-28715 did not conduct a pre-flight briefing. About 110 minutes after departure the crew reported at Palana Aerodrome estimating their arrival 18 minutes later. The weather was reported at overcast cumulonimbus at 450 meters, visibility +10 (10km), no precipitation, winds from 160 degrees at 3 meters/second, mountains partically obscured, approach control cleared the aircraft to proceed to the turn to final at FL070. 8 minutes after contacting Palana the crew reported reaching the turn to final was cleared to descend to 1200 meters. 3 minutes later the crew reported at 1200 meters, received instruction to set QFE and was cleared for the approach. The crew acknowledged the QFE and clearance for the approach. There was no further transmission from the aircraft.

A helicopter found the wreckage of the aircraft at the slopes of the Pyatibratka mountain 10.7km from the aerodrome reference point. Both crew and 8 passengers were killed in the impact, 4 passengers received serious injuries. The aircraft was destroyed.

4 minutes after the estimated arrival of the aircraft at Palana air traffic control filed a first message of loss of radio contact with the aircraft. 16 minutes later the district office of civil defense at Palana was notified of the aircraft missing at Mount Pyatibratka. The emergency ministry at Petropavlovsk was notified another 4 minutes later, Kamchatka's provincial government declared "increased readiness" 37 minutes after the estimated arrival of the aircraft, another 5 minutes later a helicopter departed Palana and reported the aircraft found about 45 minutes later and landed close to the crash site about 15 minutes later. Rescuers and medical personnel reached the crash site 97 minutes after estimated arrival.

30 minutes after the aircraft went missing employees at Palana Airport took weather measurements indicating at that time: winds from 220 degrees a 3 meters per second, visibility above 10km, no precipitation, few clouds (1-2 octers) ceiling 270 meters, cumulonimbus at 540 meters, broken clouds at 3000 meters, temperature +11 degrees C, dew point +10 degrees C, QNH 1005 hPa, mountains partially covered in cloud. Weather forecasts available to the crew before the flight indicated winds from 120 degrees at 5 meters/second, visibility at 6000 meters, light rain showers, fog, broken cloud and cumulonimbus ceiling 600 meters, overcast 3000 meters, temperature and dew point at +9 degrees C, moderate turbulence below 2700 meters, at times visibility could reduce to 2000 meters in rain showers and haze, cloud ceilings could reduce to 210 meters at times.

Palana Aerodrome features a NDB instrument approach only. The approach procedure requires the aircraft to overfly the aerodrome NDB at FL070, set their altimeters to QFE before descending to 1200 meters in the holding pattern over the NDB. After passing the NDB at 1200 meters the aircraft would further descend to 600 meters or 700 meters on the downwind leg (depending on landing direction), after the turn onto final the aircraft, still at 600 meters, would transition to visual flight rules about 20km before the threshold of the runway, a further descent to 400 meters 5.4km before the runway threshold is safe provided there is visual contact with the runway and ground.

In addition to the instrument approach procedures the visual charts plotted a number of entry points recommended to begin a visual approach. However, there are no recommendations of what minimum height/altitude these points should be overflown, what minimum conditions should exist, in addition these entry points required the presence of a GPS on board, not available on most aircraft. The airline procedures did also not state how and under what minimum conditions to transition from IFR to VFR.

Data off the flight data recorder suggested that the aircraft contacted first tree tops at an altitude of 330 meters at a heading of about 020-040 degrees, the aircraft came to rest about 500 meters further at a height of 190 meters on a heading of 225 degrees (almost opposite to direction of movement) on a slope of about 30 degrees.

By law each aircraft with more than 5700kg of maximum takeoff weight had to be equipped with a ground proximity warning system at the latest by Jan 1st 2012, the deadline however had been extended until Jul 1st 2012 by the Ministry of Transport. A further extension to Oct 1st 2012 had been announced but not properly registered by the Ministry of Transport and thus had not become legally effective. As a result, operation of such aircraft without GPWS on or past July 1st 2012 became illegal.

The MAK analysed, that there was no doubt about the condition of the crew during their pre-flight medical examination, yet, the crew was found in the state of alcoholic intoxication in post accident examination (editorial note: the analysis again stops at this point without speaking out any further conclusion or possibility).

The MAK further analysed that given the weather reported on approach the continuation of the approach was legal.

The MAK analysed that when the crew reported at FL070 over the aerodrome the position was report was false, the aircraft in fact was at 1700 meters (about 5570 feet) of altitude about 80km from the aerodrome and 37km outside the control zone of Palana based on data taken off the GPS available on board of the aircraft.

The controller violated procedures when he cleared the aircraft to continue to the turn to final at FL070 instead of clearing the aircraft to overfly the NDB at FL070, set QFE and descend to 1200 meters in the holding pattern over the NDB.

When the crew reported at the turn, the aircraft in reality was at 1600 meters 40km from the airport. After receiving the clearance to descend and for the approach, the crew initiated their descent with the intention to fly below the clouds and turned left to join the coast line thus inadvertently flying into Mount Pyatibratka. The crew descended to 600 meters permitted after the turn to final although not yet have established in the turn to final and continued to descend to 400 meters and below even though permitted only after the final turn with runway and ground visual contact.

The gradually rising terrain would have triggered a GPWS alarm in time to alert the crew of the terrain in time to prevent a collision with the terrain, the MAK continued to analyse. The presence of a GPWS thus could have prevented the crash.

About 3 seconds prior to first impact a sharp elevator control input was recorded indicative that the crew became aware of obstacles at about that time, however, there was no possibility to avoid the collision with terrain at that point anymore.

When the helicopter arrived at the crash site, the helicopter could not land at the crash site due to clouds down to 250 meters, a landing near the crash site became possible only later after the clouds had shifted. Similiar conditions may have existed at the time of the accident.

The first impact with the tree tops damaged both propellers and engines to a point that both engines triggered the auto-feather and auto-shut down sequences. There was no anomaly in these reactions of the systems. However, the flaps auto-retracted upon first contact with trees, too, which most likely was the effect of damage to a flaps sensor due to the impact.
Incident Facts

Date of incident
Sep 12, 2012

Classification
Crash

Aircraft Registration
RA-28715

Aircraft Type
Antonov An-28

ICAO Type Designator
AN28

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