Crash of a Britten-Norman BN-2A-8 Islander off Kralendijk: 1 killed

Date & Time: Oct 22, 2009 at 1017 LT
Type of aircraft:
Operator:
Registration:
PJ-SUN
Survivors:
Yes
Schedule:
Willemstad – Kralendijk
MSN:
377
YOM:
1973
Flight number:
DVR014
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1738
Captain / Total hours on type:
565.00
Aircraft flight hours:
16670
Circumstances:
On 22 October the pilot concerned got up at 05.00 and drove towards the airport at about 05.30. After preparing the aircraft, with registration PJ-SUN, he piloted two return flights from Curaçao International Airport (hereinafter to be referred to as Hato airport) to Bonaire International Airport (hereinafter to be referred to as Flamingo airport). No problems occurred during these four flights. The departure for the next flight, “DVR014”, was planned at 09.30. The nine passengers booked for this flight, who had already had their luggage weighed, had to wait before they could board because the pilot had ordered the aircraft to be refuelled prior to this flight. The refuelling invoice of flight DVR014 specifies that fuel was taken up between 09.28 and 09.38. The luggage of these passengers and some additional cargo consisting of a few boxes had already been loaded on to the aircraft. The passengers were welcomed by the pilot when they boarded. The pilot informed them they should keep their waist belts fastened during the flight and that the safety cards were located in the seat pockets. From the passenger statements it can be deduced that these instructions were not heard by all of the passengers. The pilot and the passenger seated next to him fastened their waist and shoulder belts. Approximately ten minutes after the estimated time of departure, after having received the required approval from the Hato Tower air traffic control tower (hereinafter to be referred to as Hato Tower) via the on-board radio the engines were started without any problems. The flight manual engine ground checks were not extensively performed because these are part of the first flight of the day engine checks in accordance with the General Operating Manual. Around 09.47 the PJ-SUN took off for a flight with visual flight rules (VFR) to Bonaire. After take-off the aircraft climbed to flight level 035 (FL035). Some of the passengers had flown for some years, several times in a week with Divi Divi Air. From the passenger statements it can be deduced that the pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. The passenger next to the pilot stated that engine power ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Some passengers reported they felt a jolt that moment. Some passengers reported the engine sputtered shortly before it ceased. No sound from which a mechanical problem was heard and no smoke was detected. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09.52 the pilot reported to the Hato Tower controller: Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines. The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control (hereinafter to be referred to as Flamingo Tower) at 09.57 and reported: 014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18. The Flamingo Tower controller authorized the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did. The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing. According to the statements of a few of the passengers, the aircraft pitch attitude increased during the descent of the aircraft and it was higher than usual. The indicated airspeed on the airspeed indicator was lower than when flying with two working engines. The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water. At 10.08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10.12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorized the landing. At 10.14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10.15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing. There were life jackets for all people on-board. The pilot, the passenger seated next to him and two passengers seated in the back row did not have their life jackets on. The passengers in rows two through to four had put on their life jackets. One passenger had put on his life jacket back to front. According to the statements of the passengers, the stall warning (loud tone) was activated on and off during this last part of the flight. A short time before the emergency landing until the moment of impact with the water the stall warning was continuously audible. From the statements of the passengers it follows the all cabin doors were closed throughout the descent and the landing. The passenger’ statements differ in describing the last part of the flight until the impact of the aircraft with the water surface. One passenger stated that the aircraft fell down from a low height and impacted the water with a blow. Other passengers mentioned a high or low aircraft pitch attitude during impact. Most of the passengers stated that during impact the left wing was slightly down. The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact. The aircraft was lying horizontally in the water. The height of the waves was estimated 0.5 meter by one of the passengers. The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. The passenger behind the pilot was trapped, but was able to free herself from this position. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene. Divers from the first boat tried to localise the sunken aircraft based on indications from the passengers. The people on the other boat took nine passengers out of the water and set course to Kralendijk where they arrived at approximately 10.37. The police and other emergency services personnel were awaiting the passengers on the quay. Six passengers were transported to the hospital where they were discharged after an examination. The other three went their own way.
Probable cause:
The following factors were identified:
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors:
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors:
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (Copi) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organized and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.
Final Report:

Crash of a PZL-Mielec AN-28 in Kwamalasamutu

Date & Time: Oct 15, 2009 at 1400 LT
Type of aircraft:
Operator:
Registration:
PZ-TST
Survivors:
Yes
Schedule:
Paramaribo - Kwamalasamutu
MSN:
1AJ008-04
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at the Kwamalasamutu Airstrip, the twin engine aircraft went out of control, lost its undercarriage and came to rest. Three passengers were slightly injured while the captain was seriously injured. All four other occupants escaped unhurt. The aircraft was damaged beyond repair.

Crash of an Antonov AN-24RV in Zarafshon

Date & Time: Aug 31, 2009
Type of aircraft:
Operator:
Registration:
UK-46658
Flight Phase:
Survivors:
Yes
MSN:
4 73 093 04
YOM:
1974
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from Zarafshon Airport, the undercarriage were prematurely retracted by the crew. The aircraft sank on its belly and slid for few dozen metres before coming to rest. There were no injuries but the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in August 2009.
Probable cause:
Premature retraction of the landing gear during the takeoff procedure.

Crash of a Cessna 208B Grand Caravan off La Tortuga

Date & Time: Aug 26, 2009 at 0814 LT
Type of aircraft:
Operator:
Registration:
YV1183
Flight Phase:
Survivors:
Yes
Schedule:
Los Roques - Porlamar
MSN:
208B-0690
YOM:
1998
Flight number:
TUY202
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21109
Captain / Total hours on type:
2216.00
Copilot / Total flying hours:
1986
Copilot / Total hours on type:
48
Aircraft flight hours:
8392
Aircraft flight cycles:
8897
Circumstances:
The single engine aircraft departed Los Roques Airport at 0734LT on a schedule service to Porlamar, carrying 11 passengers and two pilots. At 0804LT, while cruising at an altitude of 11,500 feet, the engine exploded the vibrated. The crew shut down the engine, declared an emergency and reduced his altitude. Ten minutes later, in a 30° flaps down configuration, the crew ditched the aircraft at low speed about 7,4 km north of La Tortuga Island. All 13 occupants were quickly rescued and the aircraft was damaged beyond repair.
Probable cause:
Engine failure after the disintegration of several blades on the compressor disk. Technical analysis were unable to determine the exact cause of this disintegration.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Operator:
Registration:
P2-MCB
Survivors:
No
Site:
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of an ATR72-212A in Koh Samui: 1 killed

Date & Time: Aug 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
HS-PGL
Survivors:
Yes
Schedule:
Krabi – Koh Samui
MSN:
670
YOM:
2001
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following an uneventful flight from Krabi, the crew started the approach to Koh Samui Airport. Conditions at destination were marginal with stormy weather, winds and turbulences. Upon landing on runway 35, the aircraft bounced then landed a second time. It deviated from the centerline to the left, veered off runway, rolled through a grassy area and eventually collided with the concrete structure of the airport tower. The captain was killed and the copilot was seriously injured as the cockpit area was destroyed upon impact. 26 other people were injured.

Incident with a Boeing 707-3J9C in Ahwaz

Date & Time: Aug 3, 2009 at 1000 LT
Type of aircraft:
Operator:
Registration:
EP-SHK
Flight Phase:
Survivors:
Yes
Schedule:
Ahwaz - Tehran
MSN:
21128/917
YOM:
1976
Flight number:
IRZ124
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
162
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Ahwaz Airport, while in initial climb, the engine n°2 suffered an uncontained failure. The crew informed ATC about the situation and was cleared for an immediate return. The aircraft landed safely 10 minutes later and was stopped on the main runway. All 174 occupants were rescued, among them two passengers were slightly injured. The aircraft was considered as damaged beyond repair as n°1 engine and the left wing were also damaged due to debris from the n°2 engine's compressor.
Probable cause:
It appears that a stage of the high pressure compressor in the n°2 engine disintegrated during initial climb. Elements punctured the nacelle and hit the left wing and the n°1 engine. After the n°2 engine failed, the n°1 engine lost power.

Crash of a De Havilland DHC-6 Twin Otter 300 near Oksibil: 15 killed

Date & Time: Aug 2, 2009 at 1100 LT
Operator:
Registration:
PK-NVC
Flight Phase:
Survivors:
No
Site:
Schedule:
Jayapura - Oksibil
MSN:
626
YOM:
1979
Flight number:
MZ9760D
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
8387
Captain / Total hours on type:
8387.00
Copilot / Total flying hours:
1207
Copilot / Total hours on type:
1207
Aircraft flight hours:
27336
Circumstances:
On the morning of Sunday, 2 August 2009, a de Havilland DHC-6 Twin Otter aircraft, registered PK-NVC, operated by PT. Merpati Nusantara Airlines as flight number MZ-7960D, departed from Sentani Airport, Jayapura for Oksibil Airport. The flight was planned in accordance with the visual flight rules (VFR). There were 15 persons on board; two pilots, one engineer, 10 adult passengers and two infants. The estimated flight time was 50 minutes. The fuel on board was sufficient for 2 hours and 50 minutes flight time. About 15 minutes prior to the estimated time of arrival at Oksibil the crew of another aircraft informed the Twin Otter crew that the weather in the Oksibil area was partly cloudy. There were no further reports of radio transmissions from the Twin Otter, and it did not arrive at Oksibil. A search was initiated at the time the aircraft would have run out of fuel. On the morning of 4 August 2009, searchers located the wreckage of the Twin Otter at an elevation of about 9,300 feet about 6 Nm from Oksibil. The aircraft was destroyed by impact forces, and all of the occupants were fatally injured.
Probable cause:
The pilots did not maintain visual flight procedures when flying below lowest safe altitude, and the aircraft was flown into cloud in the vicinity of gap north west of Oksibil. In conclusion, the accident was consistent with controlled flight into terrain.
Final Report:

Crash of an Ilyushin II-62M in Mashhad: 16 killed

Date & Time: Jul 25, 2009 at 1805 LT
Type of aircraft:
Operator:
Registration:
UP-I6208
Survivors:
Yes
Schedule:
Tehran - Mashhad
MSN:
19 51 5 2 5
YOM:
1989
Flight number:
IRX1525
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
14200
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
8294
Copilot / Total hours on type:
1319
Aircraft flight hours:
13573
Aircraft flight cycles:
3987
Circumstances:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline with registration, UP-I6208 and flight IRX1525 of Aria Airline flight with 169 passengers from Mehrabad International Airport/ Tehran, and it has landed at 18:05 local time on RWY 13 L in Mashhad International Airport; then it has run off from end of the runway, without considerable reduction in aircraft speed and it collided with wall of the airport and it was stopped after approximately 185 m. The mentioned aircraft has been leased by Aria Airline as ACMI, according to contract No. 002/IL-62M/ACMI. Subsequently, the ground safety unit of the airport has attended in place of occurring accident, by breaking protective fences and barbed wires of the airport, and then they evacuated passengers and extinguished fire outside of aircraft by carrying out necessary actions. 16 people were killed, 11 crew members and five passengers. All other occupants were rescued, among them 30 were injured. Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.
Probable cause:
The following findings were identified:
- The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.
- The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.
- The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)
- There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.
- The flight crew did not pay attention to EGPWS warning, and did not take corrective action.
- The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.
- The flight crew had not good English language proficiency. And they were poor in England language conversation.
- The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit. (lack of Cockpit Resource Management).
- There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.
- The crew has had disagreement about “Go around” due to unsuitable landing situations.
- Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.
- The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

Main Cause :
Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
- The copilot and the flight engineer had self activity& decision without the (PIC) coordination.
- The cockpit crew was careless and not paying proper attention toward EGPWS warning.
- Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

Violation & other deficiencies:
The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as:
- Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.
- The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.
- It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.
- The crew was not familiar with Iranian AIP completely.
- The total on board persons was not according to written load sheet.
Final Report:

Crash of a Tupolev TU-154M near Qazvin: 168 killed

Date & Time: Jul 15, 2009 at 1133 LT
Type of aircraft:
Operator:
Registration:
EP-CPG
Flight Phase:
Survivors:
No
Schedule:
Tehran - Yerevan
MSN:
87A-748
YOM:
1987
Flight number:
RV7908
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
168
Aircraft flight hours:
26593
Aircraft flight cycles:
16248
Circumstances:
The three engine aircraft departed Tehran-Imam Khomeiny Airport at 1117LT on a regular schedule flight to Yerevan, carrying 158 passengers and 10 crew members. Sixteen minutes after takeoff, while cruising over Qazvin at FL340, the aircraft suddenly changed its heading to 270° and then entered a rapid descent, losing 20,000 feet in 90 seconds. In a near vertical attitude, the aircraft crashed in an open field, causing a large crater. The aircraft disintegrated on impact and all 168 occupants were killed.
Probable cause:
Failure of the first stage of the high compressor disk on the left engine while the aircraft was flying at FL340, due to fatigue cracks. Debris punctured the engine nacelle, and several hydraulic and fuel lines were cut while all control systems were unserviceable. A huge fire spread on the left side of the airplane and the airplane entered an uncontrolled descent until impact.
Final Report: