Bagan F100 near Heho on Dec 25th 2012, landed on road outside airport

Last Update: February 27, 2017 / 17:25:56 GMT/Zulu time

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Incident Facts

Date of incident
Dec 25, 2012

Classification
Accident

Aircraft Registration
XY-AGC

Aircraft Type
Fokker 100

ICAO Type Designator
F100

The Aviation Herald was able to obtain a copy of the final report concluding the probable causes were:

Primary Cause

- During the final approach, the aircraft descended below the MDA and the crew did not follow the operator SOP's.

- The pilots had no corrective action against to change VMC to IMC during bad weather condition and insufficient time for effective respond to last moment.

Secondary Cause

- Captain of the aircraft had insufficient assessment on the risk that assigned the FO as PF.

- There may be under pressure by the following aircrafts as the first plane on that day to Heho.

Myanmar's Directory of Civil Aviation (DCA) reported the aircraft was performing an NDB approach to Heho's runway 36, MDA at 530 feet, the first officer (29, CPL, 849 hours total, 486 hours on type) was pilot flying, the captain (49, ATPL, 5,937 hours total, 2,547 hours on type) was pilot monitoring.

The crew had properly briefed a go around.

After joining the final approach the aircraft descended with flaps at 42 degrees, there were cloud between aircraft and the runway threshold. The pilot flying therefore was looking down onto the panel flying the instruments, the pilot monitoring was watching the outside.

As the aircraft descended through 660 feet the pilot flying called "I visual".

About 2.5nm before the runway threshold the EGPWS called "500", the aircraft was descending at 700fpm at 139 KIAS. The aircraft continued to descend, at 108 feet AGL the captain called "Not OK" and pushed the ALT HLD button, the EGPWS announced "100", "50", "40", "30", sounds of impact were heard in the cockpit while the aircraft collided with a 66 kV power line, trees, telephone cables, a fence and collided with the ground coming to a stop 0.7nm before the runway threshold, aircraft debris struck motorcyclists. One passenger and one motorcyclist died in the accident, another motor cyclist and the remaining occupants of the aircraft survived, 2 crew and 7 passengers with serious injuries, 4 crew and 57 passengers with minor or no injuries. The aircraft was destroyed.

The DCA reported the captain commented "Not OK" just prior to 100 feet EGPWS call and pushed the ALT HLD button just when the EGPWS sounded "100", however, the first sounds of impact occurred at the same time.

The DCA analysed:

During the approach to Heho airport, there were foggy conditions reported in the Heho area, including low fog on the approach to runway 36. As the aircraft descended on the approach, the crew briefed for a possible go-around. However, during the final approach, the aircraft passed through the MDA and the crew continued the approach in reducing visibility conditions. Due to the low fog, it is likely that the crew were not aware of the tress, power lines and other obstacles short of the runway.

The DCA analysed:

During the approach to Heho, the crew briefed for a possible go-around, which is normally action when the aircraft reaches the MDA and the crew decide to continue, based on remaining visual with the runway or, if not visual, conduct a go-around. The MDA at Heho was 530ft.

While on final approach at an altitude of 660 ft, the pilot flying called "I visual", however there was no similar call when the aircraft reached the MDA at 530 ft. At 500ft, the EGPWS aural alert sounded"500" with no response from either crew member. The approach was continued without any crew call out on the visual conditions at the time until. at 02:23:04, at eight of just above 100 ft, the PIC called "Not OK, indicated that the crew were previously satisfied that the crew likely maintained some visibility of the runway or the runway environment. However, by not calling out the standard MDA call at 530 ft, the crew missed an opportunity to ensure that the approach was still within all normal parameters at a point where they could execute a successful go-around.

In addition, the aircraft EGPWS aural alert announced callout heights of "100","50", "40", "30". These callouts are standard alerts to provide height cues to the crew during the flare and landing and are not used for terrain avoidance. Despite the EGPWS callouts, there were no further actions taken by the crew apart from activating the Alt Hold function at a height that was too low to prevent terrain collision.

...

The Air Bagan Standard Operating Procedures (SOP) for a non-precision approach were clear in their guidance in regard to calling "visual" at the MDA of and approach and that if the aircraft entered IMC after passing the MDA, the crew were to conduct a go-around.

It is apparent that from the recorded evidence that the crew did not follow the requirements of the Air Bagan SOP's and Heho NDB letdown procedure during the approach to Heho.

The report analyses critical of Air Bagan's safety management and safety overview as well as DCA's overview of the airline, however, without identifying specific points related to the accident flight.

The DCA issued following safety recommendations however:

- Department of Civil Aviation ensure the Air Operator's implementation of FDR analyses Programmes.

- Air Bagan operation ensure the qualitative requirements of operational personal with non-precision NDB approach training with IMC, awareness of MDA, and EGPWS alert.

- Air Bagan operation ensure to access multi-crew operation of CRM training, supervision of captain and the risk FO to perform the PF.
Incident Facts

Date of incident
Dec 25, 2012

Classification
Accident

Aircraft Registration
XY-AGC

Aircraft Type
Fokker 100

ICAO Type Designator
F100

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