Date & Time: Apr 2, 2012 at 0735 LT
Type of aircraft:
ATR72-200
Operator:
Registration:
VP-BYZ
Flight Phase:
Takeoff (climb)
Survivors:
Yes
Schedule:
Tyumen - Surgut
MSN:
332
YOM:
1992
Flight number:
UT120
Country:
Russia
Region:
Asia
Crew on board:
4
Crew fatalities:
4
Pax on board:
39
Pax fatalities:
29
Other fatalities:
0
Total fatalities:
33
Captain / Total flying hours:
2602
Captain / Total hours on type:
2522
Copilot / Total flying hours:
1825
Copilot / Total hours on type:
1765
Aircraft flight hours:
35523
Aircraft flight cycles:
49663
Circumstances:
After take off from runway 21, during initial climb, aircraft reach a height of 210 meters when it banked 35° degrees to the left. Pilots tried to regain control but aircraft lost height, banked to the right at an angle of 50° and crashed in an snowy field some 2,5 km from runway end. All four crew and 27 passengers were killed while 12 other occupants were seriously injured. On 12APR and 19APR, two survivors died from their injuries. Weather conditions at the time of the accident were marginal with icing conditions.
Causes:
In violation of procedures set forth in the flight manuals the crew performed the takeoff without having the surfaces of the aircraft deiced, although the crew detected snow and ice deposits during taxi. Consequently the aerodynamic properties of the aircraft deteriorated so that it stalled during initial climb, the crew did not recognize the stall and thus was not able to return the aircraft to within flight envelope.
Contributing factors:
- Deficiencies in UTAir Safety Management, that exists only on general terms and is not adopted to address specific activites in all areas of the company, which prevents timely detection and addressing risks affecting safety of flights
- Deficiencies in UTAir Technik in terms of staff training and work supervision in relation to deicing processes, manifested in a number of non-compliances with requirements of manuals, leading to admission of non-trained staff for assessment of necessity of de-icing and application of de-icing procedures
- Deficiencies in the initial and recurrent training of flight crew to understand the severity of takeoff without de-icing applied and the consequences for aerodynamic properties as well as the purpose and use of aircraft anti-ice systems, which prevented the crew to abort taxi for departure and apply de-icing procedures after detecting snow and ice deposits.
- Methodical shortcomings of programmes for simulator training for flight crew detect onset of stall, recognize stall patterns and avoid entering stall.
- Increasing demand of training facilities due to increasing number of flight crew to satisfy growth of traffic together with the absence of a safety management system leading to formalism and methodical omissions in the work of instructors preparing flight crew to develop skills in making informed decisions and strict observance of rules and procedures.
- Possible crew fatigue to violations of work and rest times
Final Report:
VP-BYZ.pdf10.05 MB