Ababeel IL76 at Khartoum on June 30th 2008, hit ground immediately after takeoff
Last Update: May 19, 2013 / 23:09:43 GMT/Zulu time
Incident Facts
Date of incident
Jun 30, 2008
Classification
Crash
Aircraft Type
Ilyushin Il-76
ICAO Type Designator
IL76
- Fatigue, negligence of safety procedure, check lists, regulation and alcohol advert effect on some members of the crew lead to the accident.
- Absence of adequate auditing and supervision and thorough revision of documents and crew history and operations been conducted by the operators and maintenance organization considered to be a contributory factor to this accident.
The flight crew consisted of a captain (57, ATPL, 15,634 hours total, 4,794 hours on type), a first officer (47, ATPL, no experience data known), a flight engineer (54, F/E license, no experience data known) and a navigator (44, Nav. License, 15,592 hours total, 8,963 hours on type).
The SAAICD reported that a ground witness was concerned with the engine sound while the aircraft was maneouvering around another aircraft out of the parking stand, which only worked in a third attempt. The engine #2 (inboard left) seemed unstable and moving sideways, the witness reported. The AAICD added, that the vibration meter of that engine was found stuck at 60% after the crash. At about that time one crew member, supposedly the navigator, inquired about the engine status, the captain replied all 4 engines were okay.
The aircraft managed to maneouver around the other aircraft in the third attempt, moving forward and backward (using reverse thrust) resulting in dust and small foreign objects being blown up, and taxied to the departure runway 18.
The aircraft was cleared for takeoff and began its departure roll with flaps retracted, according to flight data recorder. The aircraft rotated at 280 kph (151 knots) and became airborne at 288 kph (155 knots) at an angle of attack of about 8-9 degrees. Tyre marks on the runway showed, that the aircraft had gone past the end of the runway, the main tyres had impacted runway end lights and the tyre tracks continued past the paved surface of the stopway. Climbing through 15 feet the pilot flying commanded the gear up and increased the pitch angle, the angle of attack increased to more than 10 degrees while the gear doors opened for gear retraction increasing the drag of the aircraft, which began to slow, the speed reduced to 305 kph (164 knots), stall speed for the takeoff weight, and the left wing began to stall, the angle of attack increased to 17 degrees, the aircraft at a height of 5-7 meters/15-23 feet. The pilot flying tried to counteract the roll to the left by fully applying left aileron which also deployed the right wing spoilers, right rudder input was provided. The pilot flying instructed the flight engineer to NOT retract flaps indicative neither pilot was aware the flaps were up. Following that instruction the flight engineer selected the flaps down, the aircraft speed was 300 kph (162 knots) and the aircraft in an unrecoverable stall with no height left.
The left hand wing struck a high voltage mast about 1200 meters past the runway end at a height of 5.4 meters (18 feet) shearing off the left wing tip, contacted the flag post at the entrance of the Green Square, the left wing contacted the stem of a tree at a height of about 40cm (1.3 feet) separating the ailerons and causing fuel spilling from the left wing, the aircraft broke through the eastern brick wall of Green Square, collided with two more electric poles causing engine #4 to separate 1504 meters from the end of the runway and impacted ground at 30 degrees nose down, 30 degrees left bank. Debris was distributed over a length of more than 500 meters, the aircraft burst into flames. All 4 crew perished in the crash, 4 people on the ground received serious, 3 more received minor injuries.
Following the recovery of the bodies of the crew blood and urine samples were taken, one of the samples showed positive alcohol, the sample was identified to be taken from the flight engineer.
The AAICD analysed that maintenance was performed by a certified organisation outside of Sudan and stated: "In spite of the certificates being issued by the maintenance organization still it does not give a clear vision about the aircraft serviceability as there is no a short period close follow up of the aircraft documentation and serviceability by the Airworthiness inspectors due to the fact that no defect being recorded on the Technical log sheets and all defects are relayed to the maintenance organization during the periodic inspection."
The AAICD analysed that the aircraft was prepared for departure by an employee on behalf of the duty officer, the documentation carried the signature of the duty officer however and not of the person who did prepare the documentation and aircraft. The AAICD stated: "This behavior shows the irresponsibility and ignorance and weak or inadequate operation procedure followed by the company and its personnel and also there was a difference in their statements about the number of trucks that brought the cargo to be loaded."
The AAICD continued analysis stating: "From the CVR recording it appeared that no check list had been used during all phases from engine start up, taxiing and take off. Ababeel company does not keep any records or files regarding the crew flying experience. They joined the company about four months before the accident."
The AAICD analysed that the aircraft performance was not up to speed. Engine #1 showed only 96.2% N1 and thus delivered less thrust than the other three engines, engine #4 showed a 30 degrees higher EGT than the other engines indicating that the engine was not in a satisfactory condition requiring the temperature limiter to be switched off to enable the engine to deliver the thrust needed.
According to the FCOM the aircraft would need 2850 meters takeoff distance at 188 tons takeoff weight with flaps at 30 degrees and slats at 14 degrees. The AAICD stated: "As the crew did not use the check lists, either they were used to extend the flaps and slats after the aircraft gained certain speed and their attention was being drawn by monitoring the engine which the navigator asked about or another serious defect or they forgot to extend the flaps due to fatigue caused by alcohol consumption by the flight engineer and short periods of rest for the first officer. The clean aircraft lift off after rolling for a distance of 2380 meters for take off which was a very short distance for such weight and temperature of 27 degrees. Retracting of landing gear immediately within lift-off increased drag before the aircraft gained positive lift."
The AAICD analysed that the aircraft never climbed above 7 meters (23 feet) above ground.
The AAICD analysed that the aircraft had an automatic configuration warning which would activate at 70 +/- 15 kph, if the flaps were not extended. This system however could be switched off, or might have been malfunctioning, it did not activate during the takeoff run.
Numerous safety recommendations were released as result of the investigation.
Incident Facts
Date of incident
Jun 30, 2008
Classification
Crash
Aircraft Type
Ilyushin Il-76
ICAO Type Designator
IL76
This article is published under license from Avherald.com. © of text by Avherald.com.
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