TECHNICAL COMMISSION HAS FINISHED INVESTIGATION OF ACCIDENT OF THE AIRPLANE TU-134 OF THE AIRLINE UTAIR, WHICH HAVE OCCURRED ON MARCH, 17 AT THE AIRPORT OF SAMARA
The technical commission of Interstate aviation committee which structure includes official representatives of: Rostransadzor, Rosaeronavigatcia, Rosgidromet and Rosprom according to Rules of investigation of aviation incidents and incidents with civil airplanes in the territory of the Russian Federation, authorized by the Government of the Russian Federation on June, 18, 1998 № 609, has finished investigation of accident of the airplane TU-134А RA-65021of airline UTair which have occurred on March, 17, 2007 at the airport of Samara.
During investigation the full complex of works by an estimation of flight and technical documentation for operation of the airplane and preparation of crew, decoding and analysis of the data of onboard and ground means of the objective control is carried out. Is executed the estimation of actual meteorological conditions at the Kurumoch airport. Is executed the flight estimation of airplane behaviour and actions of crew in the last flight. Estimation of the normative-legal documentation determining work of services of flights provision (weather services, services of flights control etc.) is carried out. The independent expert estimation of circumstances of the given accident, executed by employees of Flights safety service of aviation of Armed forces of the Russian Federation is received. All kept safe elements of the airplane and engines are investigated.
By results of all works carried out during investigation by the technical commission corresponding conclusions are prepared, the lacks opened during investigation are marked, and are developed the recommendations directed on increasing of flight safety and prevention of similar aviation incidents.
The final report of aviation incident investigation is signed by all members of the commission. Representatives Rosaeronavigatcia and Rosgydromet have signed the final report everyone with the "special opinion". "Special opinions" are considered by the Commission, materials are enclosed to the Final report.
On August, 2 the results of investigation are reported at session of the Governmental Commission headed by the Deputy Minister of Transport of the Russian Federation which structure includes representatives of the federal ministries and departments.
According to the Appendix 13 to Chicago convention of ICAO and Rules of investigation of aviation incidents and incidents with civil airplanes by courts in the Russian Federation, authorized by the Decision of the Government of the Russian Federation from June, 18 № 609, the Interstate aviation committee brings up the official information of aviation incident and results of investigation to information of the public, legal persons and citizens.
The technical commission has come to the following conclusion:
"The reason of accident of the airplane Tu-134А RA-65021 during landing approach on aerodrome Samara (Kurumoch), with the conditions which were essentially worse than the meteorological minima established for aerodrome, airplane and crew, was destruction of Aircraft at movement on the ground after its rough landing at 300 m distance before Artificial run-way, more to the right of approach rate to 100 m. Aviation incident became possible as a result of organizational - technological and procedural lacks of work and interaction of services of meteorological maintenance and management of air traffic control, and also mistakes in crew actions. The lacks of normative and technological documents AMC (aero-meteorological service) Samara, have not allowed to transfer in time to ATC the data measured by aerodrome automatic meteorological station KRAMS-4 for crew informing, about deterioration of metrological conditions below established minimum of aerodrome. At decision height, in conditions of absence of reliable visual contact with approach lights and ground orienting points, crew captain has not made the duly decision on leaving on the second circle. Non-use by the landing dispatcher of all technical opportunities of landing radar because of the contradiction in the normative documents determining the order and technology of its work, and also indistinct interaction in crew and overdue actions on leaving on the second circle, have not allowed to prevent transition of a situation in catastrophic. Absence of Federal rules of performing of flights in a complex regulating flight activity, activity of Air Traffic control services, meteorological providing and other services of flight maintenance which are taking into consideration the international and domestic experience in the field of complex support of flights safety - promoted the given aviation incident ".
Extract from special opinion of Rosaeronavigatcia representative:
"The reason of aviation incident was the combination of the following factors:
- the infringement by the crew of the requirements of the point 6.5.3 & 6.5.4. of the FOM of the airplane Tu-134А regarding the acceptance of the decision on the leaving on the second circle at inadmissible deviations from glideslope (more than one point on a rod of glideslope on NKP-4) and the continuation of the landing approach at the non landing position of the airplane;
- infringement by crew of requirements of points 2.4.2, 2.4.6, 2.4.10, 7.6.15 of he General Flight Maneuvers Manual, expressed in default of leaving on the second circle at impossibility to come into reliable visual contact to approach lights and ground orienting point;
- unsatisfactory interaction in crew, with the infringements of requirements p.3.7.1-of the "Instruction on the interaction and the technology of the work of the crew members of the airplane Tu-134A", in result of what after the flyover of the decision' height the deviation on the rate and glideslope have remained outside of the control over the members of crew;
- the infringement by crew of the requirements of point 4.6.1 (0.6) FOM of the airplane Tu-134 and the item 3.10 of the "Instruction on interaction and technology of the work of crew members of the airplane Tu-134А" at the performance of the leaving on the second circle;
- unsatisfactory meteorological maintenance of flights at the airport Kurumoch (Samara) as result of what the Air traffic control and crew of an airplane have not been informed about the actual weather conditions at landing, landing approach was carried out with the infringement of the established minima".
Special opinion of Rosgidromet representative:
"In section 3 Conclusion of the project of the Final report of the reasons of accident of the airplane Tu-134А RA-65021 the text "Aviation incident began possible…" to change and state the in the following edition: "Aviation incident became possible as a result of organizational - technological and procedural lacks of work and interaction of services of air traffic control and meteorological maintenance, and also mistakes in actions of the crew".
The text: "At decision height, in conditions of absence of reliable visual contact to approach lights and ground orienting point, crew captain has not made the duly decision on leaving on the second circle" to place before the paragraph: "Aviation incident became possible as a result of organizational - technological and procedural lacks of work and interaction of services of meteorological maintenance and air traffic control, and also mistakes in actions of crew".
Other remarks and offers on the Conclusion about the reasons of accident are not presented". Source: the organization"Interstate aviation committee"
It is published: 03.08.2007