Iran Aseman AT72 at Tehran on Jun 11th 2018, approach in turbulent conditions, captain refused diversion
Last Update: June 3, 2019 / 22:14:00 GMT/Zulu time
Incident Facts
Date of incident
Jun 11, 2018
Classification
Accident
Airline
Iran Aseman Airlines
Flight number
EP-845
Departure
Rasht, Iran
Destination
Tehran Mehradbad, Iran
Aircraft Registration
EP-ATX
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
Airport ICAO Code
OIII
Iran's CAO reported in their preliminary report in Persian that the captain decided to not divert to the planned alternate Isfahan (Iran) and to continue the landing into Mehrabad despite the weather reports and recommendation by the first officer to divert.
The aircraft sustained foreign object damage to the first officer's windshield, a hard landing inspection needed to be carried out, following parts also needed to be examined for damage: static dischargers, L/H & R/H FW & AFD ice window outer pane probe, R/H pitot probe, L/H AFT & FWD side window, R/H ram air control valve, L/H & R/H nose wheels, Body cabin window outer pane and ECU isolation valve.
The occurrence was rated a serious incident due to the serious hazard to the safety of the flight and is being investigated.
On Jun 3rd 2019 Iran's CAO released their final report in Persian (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 Persian 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; thanks a lot to a native Persian speaker who volunteered to help with the translation). The report concludes the probable causes of the incident were:
There was a chain of mistakes and infractions by the captain that lead to the incident:
- Adherence to none of the 12 items listed in OM Part A page 134 “Approaching the thunderstorm area”
- Adherence to none of the 4 items listed in OM Part A page 136a “Take-off and Landing” especially: “2- Do not take-off or land if a thunderstorm is within 5 NM of airport following by lightning and wind shear”
- No CRM. During various phases of the flight, the F/O repeatedly suggested diverting, holding and going around. The captain however, without taking time to consider the suggestions, stood with his initial decision to land at Mehrabad all costs. It shows that his CRM teachings have not been effective even after more than 7000 hours of airline flight.
- Lack of situational awareness regarding all the warnings issued by ATS units, company dispatch and nearby flights.
- He had been complacent for the duration of flight and trusted his own visual perceptions of the weather conditions instead of considering all the warnings he had been receiving.
The CAO reported the captain (ATPL, 7,126 hours on type, thereof 826 hours in command) was pilot flying, the first officer (CPL, 3,315 hours on type) was pilot monitoring.
The CAO stated the approach and landing was done in poor weather conditions, which caused a non-stabilized approach and high accelerations. A GPWS warning activated at 810 feet AGL, the aircraft encountered 168 KIAS below 2000 feet AGL with a limit of 145 KIAS, high vertical speed at -1033 fpm at 850 feet AGL, below 500 feet AGL the rate of descent was low, at 300 feet AGL the rate of descent was -300 fpm, the drift angle changed from -1 to +11 degrees below 2000 feet.
The aircraft bounced 4 times upon landing in Tehran causing accelerations of up to +1.93G vertically and 0.5G laterally.
The CAO analysed that the captain's claim of a wrong weather report provided by dispatch has no bearing into the occurrence as the captain had ample warning about the weather conditiosn through ATIS, first officer, ATC and other flights. The aircraft carried more than sufficient fuel for a diversion to Isfahan according to flight plan, the captain's claim of insufficient fuel for the diversion is therefore disputed. The vertical acceleration of +1.93G and lateral acceleration of 0.5G were both within permitted limits and did not require any checks after landing. The captain's decision to land was against standard operating procedures set by the operator and had no valid safety reason in support. Cockpit management as well CRM were not satisfactory, the captain's dominant role with regards to landing was against aviation safety principles.
Metars:
OIII 111900Z 30004KT 9999 TS SCT030CB BKN090 26/04 Q1007 A2974 TEMPO 30008G15MPS 4000 TSRA SCT035CB BKN090=
OIII 111843Z 34006KT 9999 TSRA SCT030CB BKN090 26/05 Q1006 A2973=
OIII 111841Z 00000KT 9999 -SHRA SCT030CB BKN090 26/03 Q1006 A2973=
OIII 111830Z 35010KT 9999 FEW035 FEW040CB SCT100 26/03 Q1007 A2975=
OIII 111800Z 36018KT 9999 VCTS FEW030 FEW035CB SCT090 24/05 Q1008 A2977=
OIII 111749Z 36010KT 9999 VCTS FEW030 FEW035CB SCT090 23/06 Q1008 A2978=
OIII 111730Z 35024KT 9999 TS FEW030 SCT035CB BKN090 23/06 Q1009 A2981=
OIII 111714Z 34020KT 8000 TSRA FEW030 SCT035CB BKN090 23/07 Q1009 A2981=
OIII 111700Z 33022G34KT 6000 +TSRA BKN030CB OVC080 22/08 Q1009 A2981=
OIII 111643Z 27032G46KT 4000 +TSRA BKN030CB BKN080 23/11 Q1009 A2980=
OIII 111636Z 27026G48KT 0900 +TSRA +DS BKN030CB BKN080 26/06 Q1008 A2978=
OIII 111632Z 27044G60KT 0100 +TS +DS VV003 27/04 Q1007 A2975=
OIII 111630Z 25030G40KT 0800 TS DS FEW025 SCT030CB BKN080 29/03 Q1006 A2971=
OIII 111623Z 25024G40KT 2000 TS FEW025 SCT030CB BKN080 30/00 Q1006 A2971=
OIII 111620Z 28020G32KT 8000 TS FEW030 SCT035CB BKN090 31/M00 Q1006 A2973=
OIII 111600Z 32004KT 9999 TS SCT035CB BKN100 31/M06 Q1005 A2969 TEMPO 32012G17MPS 4000 TSRA/SA SCT035CB SCT035 BKN080=
OIII 111530Z 35008KT 9999 TS SCT035CB BKN100 31/M07 Q1005 A2969=
OIII 111500Z 33010KT 9999 TS SCT035CB SCT080 31/03 Q1005 A2970 30012G17MPS 4000 TSRA/SA SCT030CB SCT035 BKN090=
OIII 111430Z 02004KT 9999 SCT035CB 32/02 Q1005 A2969=
OIII 111400Z 21004KT 9999 FEW035TCU FEW040CB 32/03 Q1005 A2969 NOSIG=
OIII 111330Z 06004KT 9999 FEW035TCU 33/03 Q1005 A2969=
OIII 111300Z 11004KT 9999 FEW035TCU 33/03 Q1005 A2969 NOSIG=
OIII 111230Z 27004KT 9999 FEW035TCU 33/03 Q1005 A2970=
Incident Facts
Date of incident
Jun 11, 2018
Classification
Accident
Airline
Iran Aseman Airlines
Flight number
EP-845
Departure
Rasht, Iran
Destination
Tehran Mehradbad, Iran
Aircraft Registration
EP-ATX
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
Airport ICAO Code
OIII
This article is published under license from Avherald.com. © of text by Avherald.com.
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