Scheduled Revenue Flight

Inadequate observation of the Ground Movement Area by the “Mulag” tractor operator.
Contributing factors:
1. Heavy rain and lightning.
2. Light reflections on the aerodrome surface which hindered observation from the tractor cab.
3. Construction of the "Mulag” tractor cab, left side of which could partially or completely obscure silhouette of the airplane.
4. Short distance between a service road and taxiway "O2".

Human Factors
Medical Aspect
- Anxiety
The perception of danger especially by the first officer affected the communication between the pilots and may have inhibited a more assertive attitude, which could have led to an emergency landing on the beach, minimizing the consequences of the accident.
Psychological Aspect
- Attitude
Operational decisions during the emergency may have resulted from the high confidence level, that the captain had acquired in years of flying and experience in aviation, as well as the captain's resistance to accept opinions different to his own.
- Emotional state
According to CVR recordings there was a high level of anxiety and tension even before the abnormal situation. These components may have influenced the judgment of conditions affecting the operation of the aircraft.
- Decision making
The persistence to land on runway 36 during the emergency, even though the first officer recognized the conditions no longer permitted to reach the airport, reflects misjudgment of operational information present at the time.
- Signs of stress
The unexpected emergency at takeoff and the lack of preparation for dealing with it may have invoked a level of stress with the crew, that negatively affected the operational response.
Psychosocial Information
- Interpersonal relations
The historical differences between the two pilots possibly hindered the exchange of information and created a barrier to deal with the adverse situation.
- Dynamic team
The present diverging intentions of how to proceed clearly show cooperation and management issues in the cockpit. This prevented the choice of best alternative to achieve a safe emergency landing when there were no options left to reach the airport.
- Company Culture
The company was informally divided into two groups, whose interaction was impaired. It is possible that this problem of interaction continued into the cockpit management during the in flight emergency, with one pilot belonging to one and the other to the other group.
Organizational Information
- Education and Training
Deficiencies of training provided by the operator affected the performance of the crew, who had not been sufficiently prepared for the safe conduct of flight in case of emergency.
- Organizational culture
The actions taken by the company indicate informality, which resulted in incomplete operational training and attitudes that endangered the safety.
Operational Aspects
According to data from the flight recorder the rudder pedal inputs were inadequate to provide sufficient rudder deflection in order to compensate for asymmetric engine power.
The values of side slip reached as result of inadequate rudder pedal inputs penalized the performance of the aircraft preventing further climb or even maintaining altitude.
In the final phase of the flight, despite the airspeed decaying below Vmca, despite continuous stall warnings and despite calls by the first officer to not hold the nose up in order to not stall the captain continued pitch up control inputs until the aircraft reached 18 degrees nose up attitude and entered stall.
- Crew Coordination
The delay in retracting the landing gear after the first instruction by the captain, the instruction of the captain to feather the propeller when the propeller had already been feathered as well as the first officer's request the captain should initiate the turn back when the aircraft was already turning are indicative that the crew tasks and actions were not coordinated.
Emergency procedures provided in checklists were not executed and there was no consensus in the final moments of the flight, whether the best choice (least critical option) was to return to the runway or land on the beach.
- Oblivion
It is possible in response to the emergency and influenced by anxiety, that the crew may have forgotten to continue into the 3rd segment of the procedure provided for engine failure on takeoff at or above V1 while trying to return to the airfield shortly after completion of the 2nd segment while at 400ft.
- Pilot training
The lack of training of engine failures on takeoff at or above V1, similar as is recommended in the training program, led to an inadequate pilot response to the emergency. The pilots did not follow the recommended flight profile and did execute the checklist items to be carried out above 400 feet.
- Pilot decisions
The pilots assessed that the priority was to return to land in opposite direction of departure and began the turn back at 400 feet, which added to the difficulty of flying the aircraft. At 400 feet the aircraft maintained straight flight and a positive rate of climb requiring minor flight control inputs only, which would have favored the completion of the emergency check list items in accordance with recommendations by the training program.
After starting the turn the crew would needed to adjust all flight controls to maintain intended flight trajectory in addition to working the checklists, the turn thus increased workload. It is noteworthy that the remaining engine developed sufficient power to sustain flight.
- Supervision by Management
The supervision by management did not identify that the training program provided to pilots failed to address engine failure above V1 while still on the ground and airborne.
It was not identified that the software adopted by the company to dispatch aircraft used the maximum structural weight (6,600 kg) as maximum takeoff weight for departures from Recife.
On the day of the accident the aircraft was limited in takeoff weight due to ambient temperature. Due to the software error the aircraft took off with more than the maximum allowable takeoff weight degrading climb performance.
Mechanical Aspects
- Aircraft
Following the hypothesis that the fatigue process had already started when the turbine blade was still attached to the Russia made engine, the method used by the engine manufacturer for assessment to continue use of turbine blades was not able to ensure sufficient quality of the blade, that had been mounted into position 27 of the left hand engine's Gas Generator Turbine's disk.
- Aircraft Documentation
The documentation of the aircraft by the aircraft manufacturer translated into the English language did not support proper operation by having confusing texts with different content for the same items in separate documents as well as translation errors. This makes the documentation difficult to understand, which may have contributed to the failure to properly implement the engine failure checklists on takeoff after V1.
An especially concerning item is the "shutdown ABC (Auto Bank Control)", to be held at 200 feet height, the difference between handling instructed by the checklist and provided by the flight crew manual may have contributed to the non-performance by the pilots, aggravating performance of the aircraft.

The Interstate Aviation Committee (MAK) released their final report in Russian concluding the probable causes of the accident were:
The catastrophe of the AN-24 RA-47302 occurred when ditching became necessary due to a fire in the left hand engine's nacelle. The destruction of the aircraft and loss of life was caused by collision with underwater obstacles that the crew could not anticipate or avoid. The fire in the left hand engine nacelle was caused by the fracture of a centrifugal breather releasing an air-fuel emulsion into the engine compartment as well as a delayed reaction to shut the engine down by the crew following an magnetic chip detector indication together with indications of oil pressure fluctuations, a burning smell and a low oil pressure indication. A delay in indicating engine vibrations to the crew as result of degradation of the engine vibration sensoring equipment, most likely caused by changes of the rotor speed of the engine as result of the aft bearing failure of the compressor rotor and/or misalignment of the sensor, which probably influenced the decision of the crew to shut the engine down with a delay. Cause of the fracture of the centrifugal breather was the destruction of the impeller due to prolonged exposure to hot air-fuel emulsion due to the failure of the aft compressor rotor support bearing. It was not possible to determine the cause of the destruction of the aft compressor rotor support bearing due to significant secondary damage. Most likely the destruction was caused by misalignment such as:
- Incorrect assembly of support parts mating with the compressor rotor during on-condition engine repairs,
- Or deviations from required geometry of support parts mating with the compressor rotor.
Contributing factors were:
- Psychological unpreparedness of the captain to shut the engine down due to lack of experience with the aircraft on one engine inoperative
- Late detection of the fire and as a consequence late attempts to extinguish the fire, it was however not possible to establish why the fire was detected late due to lack of objective information about the performance of the fire alarm systems.

In a preliminary report, DRC authorities pointed out the following factors:
- The flight crew misjudged weather conditions,
- The airline assigned unqualified/non-licensed crew to operate the Boeing 727-100 (the pilot's licence was not up to date),
- Tower controllers were not licensed (two ATC's did not have a proper licence and above legal age)
- Tower control staff was insufficient (six only for the complete roster),
- Tower controllers provided erroneous/false weather data to flying crew,
- The airport authority lacked security plans,
- Phonic records between tower control and crew were erased (destroyed) before the commission of inquiry can start any investigation.

Findings as to Causes and Contributing Factors:
Runway conditions, the pilot's takeoff technique, and possible shifting wind conditions combined to reduce the rate of the aircraft's acceleration during the takeoff roll and prevented it from attaining takeoff airspeed. The pilot rejected the takeoff past the point from which a successful rejected takeoff could be completed within the available stopping distance. The steep drop-off and sharp slope reversal at the end of Runway 33 contributed to the occupant injuries and fuel system damage that in turn caused the fire. This complicated passenger evacuation and prevented the rescue of the injured passenger. The deceased passenger was not wearing the available shoulder harness. This contributed to the serious injuries received as a result of the impact when the aircraft reached the bottom of the ravine and ultimately to his death in the post-impact fire.
Findings as to Risk:
If pilots are not aware of the increased aerodynamic drag during takeoff while using soft-field takeoff techniques they may experience an unexpected reduction in takeoff performance. Incomplete passenger briefings or inattentive passengers increase the risk that they will be unable to carry out critical egress procedures during an aircraft evacuation. When data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety. Although the runway at Pukatawagan and many other aerodromes are compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond the runway ends may increase the likelihood of damage to aircraft and injuries to crew and passengers in the event of an aircraft overrunning or landing short. TC's responses to TSB recommendations for action to reduce the risk of post-impact fires have been rated as Unsatisfactory. As a result, there is a continuing risk of post-impact fires in impact-survivable accidents involving these aircraft. The lack of accelerate stop distance information for aircraft impedes the crew's ability to plan the takeoff-reject point accurately.
Other finding:
Several anomalies were found in the engine's power control hardware. There was no indication that these anomalies contributed to the occurrence.

When the aircraft approached the airfield in weather below minimums for the aerodrome descending on autopilot at a fixed vertical speed, crew failed to decide to go around in absence of visual contact with approach lights and landmarks and permitted the aircraft to descend below minimum descent altitude, which led to impact with trees and the ground in controlled flight.
Following factors were considered as contirbutory:
- unsatisfactory crew resource management by the commander who effectively removed the first officer from the control loop in the final stages of the accident flight and who subordinated himself to the navigator showing increased activity however in the state of mild alcoholic intoxication.
- the navigator was in the state of mild alcoholic intoxication
- unjustified weather forecasts by height of cloud base, visibility and severe weather including fog as well as the non-conformity of weather data of Petrozavodsk Airport transmitted to the crew 30 and 10 minutes prior to estimated landing.
- Failure to use indications by the ADFs and other devices of the aircraft while using indications by an unapproved satellite navigation system KLN-90 in violation of flight manual supplements for the TU-134.

During a commercial, domestic passenger flight, while cruising, the crew lost control of the aircraft, which uncontrollably impacted the ground due to severe ice formation caused by the following factors:
- Entering an area with icing conditions without adequately monitoring the warning signals from the external environment (temperature, cloudiness, precipitation and ice accumulation) or the internal (speed, angle of attack), which allowed for prolonged operations in icing conditions to take place.
- Receiving a forecast for slight icing - given that the aircraft encountered sever icing conditions - which led to a lack of understanding regarding the specific meteorological danger.
- Inadequately evaluating the risks, which led to mitigating measures such as adequate briefing (distribution of tasks in the cockpit, review of the de-icing systems, limitations, use of power, use of autopilot, diversion strategy etc.) not being adopted.
- Levels of stress increasing, due to operations not having the expected effects, which led the crew to lose focus on other issues.
- Icing conditions that surpassed the aircraft's ice protection systems, which were certified for the aircraft (FAR 25 Appendix C).
- Inadequate use of speed, by maintaining the speed close to stall speed during flight in icing conditions.
- Inadequate use of the autopilot, by not selecting the IAS mode when flying in icing conditions.
- Partially carrying out the procedures established in the Flight Manual and the Operations Manual, when entering into areas with severe icing conditions.
- Realizing late that the aircraft had started to stall, because the buffeting that foretells a stall was confused with the vibrations that signify ice contamination on the propellers.
- Activation of the Stick Shaker and Stall Warning at a lower speed than expected in icing conditions.
- Using a stall recovery technique which prioritized the reduction of the angle of attack at the expense of altitude loss, and which was inappropriate for the flight conditions.
- The aileron flight controls reacting in an unusual manner when the aircraft lost control, probably due to the accumulation of ice in the surfaces of these, which made it impossible for the aircraft to recover. The increasingly stressful situation of the crew, which affected its operational decision-making.

FINDINGS:
1. The aircraft was airworthy prior the accident. There is no evidence that the aircraft had malfunction during the flight.
2. The crew had valid flight license and medical certificate. There was no evidence of crew incapacitation.
3. In this flight the SIC acted as Pilot Flying until the PIC took control of the aircraft at the last part of the flight.
4. According to company operation manual (COM), in a VMC (Visual Meteorological Condition), a “minimum, minimum” EGPWS alert while the approach was not stabilized should be followed by the action of abandoning the approach.
5. The cockpit crew did not conduct any crew approach briefing and checklist reading.
6. As it was recorded in the CVR during the final segment of the flight, both crews member were looking out-side to look for the runway. It might reduce the situational awareness.
7. At the final segment of the flight, the FDR recorded as follows:
• The approach was discontinued started at 376 feet pressure altitude (250 feet radio altitude) and reached the highest altitude of 585 feet pressure altitude. While climbing the aircraft was banking to the left reaching a roll angle of 38 degree. The torque of both engines was increased reaching 70% and 82% for the left and right engine respectively.
• During the go-around, the flaps were retracted to 5 and subsequently to 0 position, and the landing gears were retracted. The aircraft started to descend, and the pitch angle reached 13 degree nose down.
• The rate of descend increased significantly reaching about 3000 feet per minute, and finally the aircraft crashed into the shallow sea.
8. The rapid descent was mainly a result of a combination of situations such as high bank angle (up to 38 deg to the left) and the flaps retracted to 5 and subsequently to 0 position, and also the combination of other situations: engine torque, airspeed, and nose-down pitch.
9. The ERS button was determined in the CRUISE mode instead of TOGA mode. This had led the torque reached 70% and 82% during discontinuing the approach.
10. The flaps were retracted to 5 and subsequently to 0, while the MA-60 standard go-around procedure is to set the flaps at 15.
11. There was limited communications between the crew along the flight. This type of interaction indicated that there was a steep trans-cockpit authority gradient.
12. The SIC was trained in the first three batches which was conducted by the aircraft manufacturer instructor and syllabus, while the PIC was trained by Merpati instructor using modified syllabus. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.
13. The investigation found that the Flight Crew Operation Manual (FCOM) and Aircraft Maintenance Manual (AMM) used non-standard English Aviation Language. This finding was supported by a review performed by the Australian Transport Safety Bureau (ATSB).
OTHER FINDINGS:
1. The DFDR does not have the Lateral and Longitudinal acceleration. These two parameters which were non safety related items were mandatory according to the CASR parts 121.343 and 121.344, and at the time of the MA 60 certification, the CCAR 121 did not require those two parameters.
2. Due to impact forces and immersion in water, the Emergency Locator Transmitter (ELT) did not transmit any signal.
FACTORS:
Factors contributed to the accident are as follows:
1. The flight was conducted in VFR in condition that was not suitable for visual approach when the visibility was 2 km. In such a situation a visual approach should not have been attempted.
2. There was no checklist reading and crew briefing.
3. The flight crew had lack of situation awareness when tried to find the runway, and discontinued the approach.
4. The missed approach was initiated at altitude 376 feet pressure altitude (250 feet radio altitude), the pilot open power to 70% and 82% torque followed by flap retracted to 5 and subsequently to 0. The rapid descent was mainly caused by continuously increase of roll angle up to 38 degree to the left and the retraction of flaps from 15 to 0 position.
5. Both crew had low experience/flying time on type.
6. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.

Failure of the brakes is suspected.