islamic republic of iran - cao republic of iran civil aviation organization aircraft accident...

Safety & Accident

Investigation Department

Accident Final Report

Islamic Republic of IRAN

Civil Aviation Organization

State File Number: A13880431UPI6208

Type of Occurrence: Accident

Date of Occurrence: July 22th

2009

Place of Occurrence: I.R.IRAN - Mashhad

Aircraft Type: IL-62M

Registration: UP-I6208

Operator: Aria

Islamic Republic Of Iran

Civil Aviation Organization

Aircraft Accident Investigation Department

Final Report

Basic Information

Type of occurrence: Accident

Date: 24.Jul.2009

Location: Mashhad International Airport/ I.R of Iran

Aircraft: Airplane

Model: IL-62M

Registration: UP-I6208

Owner: DETA Airline

Operator: ARIA Airline

Date of Issue: 05 Jun 2010

Civil Aviation Organization of I.R. of Iran

Aircraft Accident Investigation Department

Mehrabad International Airport

PBO: 13445-1795 Tehran/Iran

Fax: + 98 21 6601 8659

Tel.: + 98 21 6604 7965

E-mail: [email protected]

http://www.cao.ir

--------------------------------------------------------------------------------------------

‌

mailto:[email protected]

http://www.cao.ir/

2

Foreword:

Civil Aviation Organization is responsible for supervision on correct

implementation of laws and regulations and flight standards in civil Aviation industries of

the country, according to international commitments and domestic laws of the Islamic

Republic of Iran; in this respect, the accidents are investigated , in order to identify

threaten resources of safety ratio of flights, based on international regulations and

compiled guidelines of International Civil Aviation Organization, ICAO (annex 13).

After identifying main causes and contributive factors of the accident, safety

recommendations are issued in order to consider flight standards and regulations, as well

as more attention to flight safety for preventing the same accidents.

Written matters in annex 13 of ICAO and relevant appendixes emphasize on this matter

that “The sole objective of the investigation of an accident or incident shall be the

prevention of accidents and incidents. It is not the purpose of this activity to apportion

blame or liability”

The main objective of investigating accidents is to achieve main causes and roots for

preventing similar accidents in the future.

About IL-62M airplane accident, owned by DETA Airline, Kazakhstan, (leased by Aria

Airline) in July 24, 2009, at 08:05 local time (13:35 UTC) on Shahid Hasheminejad

International Airport/ Mashhad, The Accident Investigation Team was attended in the

place of accident immediately and gathered information; this team receives FDR and

CVR of the plane, in order to analyze them.

In this direction, there has been taken necessary actions for correct investigation of

technical – operational documents and study about the accident site and body of the plane

in order to identify main and contributive causes of this accident and issue safety

recommendations for preventing such same occurrences.

The accident investigation team however appreciates Interstate Aviation

Commission (IAC) for mutual cooperation in the investigation of accident involving IL-

62M with registration, UP-I6208 and preparing final report of this accident.

3

Synopsis:

Illyushin, model IL-62M Type of the aircraft

UP-I6208 Registration mark

DETA Airline, Kazakhstan Owner

Aria Airline Operator

July 24,2009 Date of accident

18:05 local time (13:35 UTC) Time of accident

End of left band of Mashhad International

Airport

Place of accident

Destroyed Damage to airplane

156 person No of passengers

17 persons& one additional crews group No of crews

16 persons No of fatal

31persons No of injured person

Aircraft accident investigation &safety

Dept. I.R of Iran

Responsible for accident

investigation

(IAC) Interstate Aviation

Committee/(Russia ، Kazakhstan Civil

Aviation Authority

Foreign cooperator

commission

crews mistakes Main cause of accident

4

1. Factual Information

1.1 History of the flight:

At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline

with registration, UP-I6208 and flight no. IRX.1525 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.

5

1.2 Injuries to persons:

Injured persons of this accident were carried to hospitals of Mashhad

city, after search and rescue operation, bodies of victims were transferred

to the legal medicine. The following table shows overview of body injuries

to passengers of this aircraft:

Others Passenger Crew Injuries

0 5 11 Fatal

0 1 2 Serious Injuries

0 28 0 Minor

0 122 7 None

0 156 17 Total

1.3 Damage to aircraft:

The aircraft fuselage destroyed totally due to impact to wall of the

airport and it caused destroying cockpit and nose section airframe and it

can't be reconstructed.

1.4 Other Damage:

Due to impact of aircraft landing gears with net barrier in shoulder of

RWY 13L, it has major damages on it and some damages to PAPI light in

beginning of RWY 31R.

6

1.5 Personnel Information:

1.5.1 Pilot in Command :( PF)

1957 Birth year

Class one validity date

28/OCT/09 Kind of certificate and validity date

Without medicine limitation and

it is valid until 28/Aug/09

Medicine condition

14200 Total flight hours

1500 Total flight hours with IL-62

10/Mar/09 Russia Date and place of last simulator

None Prior accident

ok License for international flight

ok License for radio communication

19 July 2009 Entrance date to Iran

24 July 2009 Date of first flight in Iran

6 flights No of flight in Iran

According to available documents, he has done Radio communication

but the level of his English conversation was not suitable.

1-5-2 Copilot:

1962 Date of Birth

Class 2 validity date24/Feb/2010 Kind of certificate and validity date

Without medical limitation and it

is valid until 24/Feb/2010

Medical condition


1319 Total flight hours with IL-62

10/MAY/2009 Russia Date and place of last simulator

7

none Prior accident



19 July 2009 Entrance date to Iran

24 July 2009 Date of first flight in Iran


1-5-3 Flight Engineer:

1957 Date of Birth

Class 1 validity

date28/OCT/09 Kind of certificate and validity date

Without medicine limitation

and it is valid until

28/0CT/09

Medical condition


1697 Total flight hours with IL-62airline

10/MAY/09 Russia Date and place of last simulator

None Prior accident



July , 17,2009 Entrance date to Iran

July , 23,2009 Date of first flight in Iran


8

1.6 Aircraft Information:

The Ilyushin aircraft IL-62M with S/N: 1951525 have been

manufactured at 09.06.1989 in Ilyushin Aircraft Factory, and its owner is

DETA Air Company, Kazakhstan. It has been registered at June 16, 2008

with UP-U6208, by Civil Aviation Authority of Kazakhstan. It has also

received its last certificate of Airworthiness at Jan. 28, 2009 from this state,

which it was valid until Jan. 28, 2010.

This airplane has been exploited after upgrading its navigation and

telecommunication, as well as installing its passenger oxygen system for

flight operation in Iran.

This airplane has been arrived in I.R of Iran Territory , due to

agreement No. 002/ IL-62M/ACMI, dated on Nov. 16, 2008 as "wet lease

agreement (ACMI) for aircraft IL-62M, between DETA Air, as Lesser and

Aria Airline as Lessee at Jan. 17, 2007.

State registry number

UP-I6208

Manufacture number

№ 1951525

Owners

Eugeny V. Zhigayev

Ibragim A. Paskachev

9

Operator

ARIA airline. The aircraft owned by D.E.T.A.

AIR airline was leased under an agreement and

operated by the airline “ARIA AIR” (IR of

Iran).

Date of release 09 June 1989

State registration certificate

No.538 dated 16 June 2008

(Kazakhstan)Republic) Airworthiness aircraft certificate

No.0538 dated January 28, 2009 valid till

January 28, 2010

Assigned life time and service life

35000 hours, 7500 landings., 20 years

(Bulletin No.1440-БЭ),

Bulletin No. 291-62M was fulfilled on January

20, 2009, so in accordance with the bulletin the

assigned service life was extended to 20 years 4

months, till September 29 2009.

Overhaul life and service time

10200 hours, 2700 landings (Bulletin No.1399

БЭ), 14 years

Operating time since new(TSN)

Operating time since the last overhaul(TSO)

13573 hours, 3987 landings

7876 hours, 2458 flights

Number of overhauls, date of the last overhaul

One overhaul, September 29, 1995

Overhaul life rest

2384 hours, 242 landings

Last periodic technical maintenance

According to the logbook – March 29, 2009,

form Ф-1К with operating time 7666 hours and

2338 landings, maintenance sheet №9

Last periodic maintenance

Form Б 15 July 2009, maintenance sheet

51, Teheran

Fuelling

20 tons

Fuel type

Jet -A1

Insurance certificate Kazakhinstrakh, Insurance agreement No.

17/303/08/891

10

Engines installed in the aircraft:

Engine type D-30KU-2 D-30KU-2 D-30KU-2 D-30KU

Serial № 51148802221 51248802214 51219002225 0304022212226

Manufacturer JSC “Rybinskiye

motory”

JSC “Rybinskiye

motory”

JSC “Rybinskiye

motory”

JSC “Rybinskiye

motory”

Date of

manufacture

22 November1988 26 October1988 11 March1990 30 April1982

Operating time

since new

7261 hours,

1836 cycles

7425 hours,

1890 cycles

7307 hours,

1729 cycles

14046 hours,

3536 cycles

Place of the

last overhaul

JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn

Date of the

last overhaul

30 December 1999

23 October 2001 14 May 2002 30 March 2000.

Operating time

since the last

overhaul

3574 hours

928 cycles

3119 hours

779 cycles

1806 hours

438 cycles

3567 hours

925 cycles

Overhaul life

time

3637 hours

901 cycles

3330 hours

767 cycles

3000 hours

543 cycles

3627 hours

898 cycles

Overhaul life

time rest

63 hours,

-27 cycles

210 hours,

-12 cycles

1194 hours,

105 cycles

60 hours,

-27 cycles

Engines, APU TA-6A, units and assembly parts were operated in

compliance with the effective operating regulations.

All four engines had sufficient life times in operation hours to perform

flights. According to bulletins No. 1770 and No. 1844 of the engine

manufacture JSC NPO Saturn, effective dates February 08, 2002 and June

29, 2007, the first, second and fourth engines had exceeded life time in

cycles (27, 16(12), 27 correspondingly). Life times were extended by the

JSC “Aerotechservice” (Nikolayev, Ukraine) and JSC “Engine” (Perm).

11

Engine maintenance performed:

№ APU Periodical maintenance Current maintenance

PU 1 Ф-1К – 21 April 2009 ФБ – 19 July 2009


PU 3 Ф-1К - 29 April 2009 ФБ – 15 July 2009


The airframe, assemblies and units has life time sufficient to perform flight

tasks except for the cycle life time for AP units 1, 2, 4. The aircraft had no

malfunctions before the accident flight on July 24, 2009.

No complaints were made on technique functioning during the flight.

According to information of the flight date recorders, engine and aircraft

system operating parameters were in compliance with the assigned modes.

1.7 Meteorological information:

According to the meteorological office report, status of the current air

(METAR), in the accident time in Mashhad International Airport (Shahid

Hasheminejad) at 24.07.2009 was according to the following table:

ICAO ID:OIMM Time Wind

Visibility ديد افقي

Cloud ميزان و

ارتفاع ابر

TEMP/DEW

دما و نقطه شبنم

Pressure

Density

altitude (feet) UTC

LMT زمان

محلي

DIRECTION

(DEG)

سمت

SPEED(KT(

سرعتHPA INCH

RH رطوبت نسبي

11:50 02:61 60 12 CAVOK

53/M05 1013 62.91 6299

7.52 %

12:50 17:20 80 14 CAVOK

34/M03 1012 29.89 6235

9.24 %

13:50 18:20 60 14 CAVOK 33/M04

1012 29.90 6124 9.06 %

12

There were not any effective metrological factors that could affect on

operation of the aircraft.

1.8 Aids to navigation:

Mashhad international airport is equipped with aid to navigation

systems as below:

NDB 385KHZ

DVOR/DME 11400 MHZ

LLZ 109.900MHZ

ILSGP 333.800MHZ

ILS/DME CH36X

According to available documents at accident time, all navigational

systems operations were normal

1.9 Communication:

Mashhad international airport equipped to communication system as

below:

Frequency Time Notes

APP: 127.300 MHZ H24

121.500 MHZ H24 Emergency

frequency

353.800 MHZ H24 Military frequency

TWR: 118.100 MHZ H24

121.700 MHZ H24

121.900 MHZ H24

257.800 MHZ H24 Stand by For all VHF

243.000 MHZ H24 UDF, Military

Aircraft Military

Emergency

ATIS (INFO) 126.400 MHZ

Communication and conversation from the flight control units & CVR of

aircraft have shown the correct operation of these systems.

13

1.10 Aerodrome information:

Mashhad international Airport of (OIMM) has aerodrome reference

point with geographical coordination 361403N 0593842E in MAG 312 Deg

with elevation of 3226 FT RWY 13L threshold.

Its direction and distance is as East and 3 Km from Mashhad, its height

from sea level is 3263 ft, and its temperature degree reference is 34.1 C.

There are permission IFR/VFR flights in this airport. Fire fighting

facilities of Mashhad INTL Airport is in CAT7. It has two Runways in

direction of 13/31 L, R with 3811 * 45 m dimension. About this accident,

there weren’t any faults in this regard.

1.11 Flight Recorders:

FDR

The aircraft was equipped with flight data recorders MSRP-64 and MSRP-

12-96. A tripartite recorder K3-63 was not installed in the aircraft. The

recorders were retrieved from the accident site by Iranian accident

investigation team. Data readout was carried out at a facility of the “PARS

Aviation Service” company. The information from the MSRP-12-96

recorder was not downloaded. The cassette KS-13 of the accumulator KBN

as well as the magnetic tape of the tape media MLP-14-5 of the onboard

recorder MSRP-64 were in satisfactory condition and had the parametric

accident flight data recorded on them. On the pictures below some readout

results are shown:

14

AS

760

AFC

S.P

itA

FC

S.R

ol

GPW

SS

tab.p

LG

-ToExt

VH

Fke

yG

HLFai

GH

RFai

RA

.Glid

+R

A.L

ocz+

Elv

.l+С

GV

!

1200

1400

1600

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2000

2200

2400

2600

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3400

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8000

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9200

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9600

9800

[m]

Alt.

pr

0

100

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1100

[m]

Alt.

radi

50

100

150

200

250

300

350

400

450

500

550

600

[km

/h]

IAS

-202468

10

12

[deg]

AO

A

Pitc

h

0.4

0.6

0.81

1.2[g]

Vert

Acc

-150

-100

-500

50

100

150

[mm

]

CC

P

-15

-10-505

10

15

[deg]

Ele

v

0

10

20

30

[deg]

Fla

ps.l

Fla

ps.r

-4-20246

[deg]

Sta

bzr0

10

20

30

[deg]

Spoil.

l

Spoil.

r

13:2

1:0

013:2

2:0

013:2

3:0

013:2

4:0

013:2

5:0

013:2

6:0

013:2

7:0

013:2

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013:2

9:0

013:3

0:0

013:3

1:0

013:3

2:0

013:3

3:0

013:3

4:0

013:3

5:0

0

793.3

1.0

0

664.7

22.1

20.9

7.1 6

.8

364

Sta

b.p

0.0

87.5

265.6

325

279

-8.613.8

1.2

3

276

GPW

S

30.0

9538.5

Alt.

pr

VH

F k

eyin

g

514

IAS

: In

dic

ate

d a

irspeed

571

Alt.

radi:

Radio

alti

tude

793.3

Alt.

pr

2200.0

Alt.

radi

Landin

g g

ears

actu

ato

r to

exte

nd

CC

P: C

ontr

ol c

olu

mn p

ositi

on

Ele

v: Ele

vato

r positi

on

0.6

4.0

-6.3

Vert

Acc: V

ert

ical a

ccele

ratio

n1.0

0

1.1

7

AO

A: A

ngle

of

attack

Pitc

h: Pitc

h a

ngle

4.4

-0.6

8.8

8.4

9.0

3.2

-7.8

-0.7

24.0 24.2

-0.3

-1.0

Spoil.

r: S

poile

r (r

ight)

Spoil.

l: S

poile

r (left

)

AFC

S.R

ol:

AFC

S r

oll

channel O

N

AFC

S.P

it: A

FC

S p

itch c

hannel O

N

Fla

ps.r

: Fla

ps (

right)

Fla

ps.l:

Fla

ps (

left

)

0.2

0.0

15.6

Sta

bzr:

Sta

bilizer

positi

on

-1.4

4-1

.00

-2.7

9

AS

760: A

ltim

ete

r settin

g 7

60

3833.3

3388.9

479

3000.0

-5.6

0

-1.8

3

Left

gyro

horizon f

ailu

re

Rig

ht gyro

horizon f

ailu

re

СG

V m

alfunctio

n

Touchdown

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

2:5

7:2

2 #11 U

ser:

Zayko

(#3)

Pic

.1.1

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

15

1000

1200

1400

1600

1800

2000

2200

2400

2600

2800

3000

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3400

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8000

8200

8400

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8800

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9600

9800

10000

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10400

[m]

Alt.

pr

-500

50

100

150

200

250

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350

400

450

500

550

600

650

700

750

800

[m]

Alt.

radi

0

50

100

150

200

250

300

350

400

450

500

550

600

[km

/h]

IAS

-0.20

0.2

0.4

0.6[g]

LatA

cc

-20

-100

10

20

30

[deg]

Roll

Roll_

le

Roll_

ri 0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

[deg]

GM

H

-30

-20

-100

10

20

[deg]

CW

P

-5

-2.50

2.55

[deg]

Ail.

l

Ail.

r

-100

10

20

[deg]

Rudder

-150

-100

-500

50

100

150

[mkA

]

LocD

ev

13:2

1:0

013:2

2:0

013:2

3:0

013:2

4:0

013:2

5:0

013:2

6:0

013:2

7:0

013:2

8:0

013:2

9:0

013:3

0:0

013:3

1:0

013:3

2:0

013:3

3:0

013:3

4:0

013:3

5:0

0

793.3

664.7

0.1

30.0

1

364

0.0

87.5

265.6

325

279

276

9538.5

Alt.

pr

514

IAS

: In

dic

ate

d a

irspeed

571

Alt.

radi:

Radio

alti

tude

793.3

Alt.

pr

2200.0

Alt.

radi

AFC

S.R

ol:

AFC

S r

oll

channel O

N

3833.3

3388.9

479

3000.0

CW

P: W

heel p

ositi

on

Ail.

r: A

ilero

n p

ositi

on (

right)

Ail.

l: A

ilero

n p

ositi

on (

left

)

1.9

1.5

8.1

-30.0

7.6

-38.3

37.7

-2.9

Rudder:

Rudder

positi

on

0.0

21.9

-17.0

Roll:

Roll

angle

Roll_

ri: R

oll

angle

(right FD

)

Roll_

le: R

oll

angle

(le

ft F

D)

-18.4

24.5

0.0

0.0

-33.5

-28.9

LatA

cc: Late

ral a

ccele

ratio

n0.0

1

LocD

ev: Localis

er

devia

tion

114.1

5.8

-2.1

115.6

9.6

GM

H: M

agnetic

headin

g82.9

62.9

140.0

121.4

127.1

130.0

Touchdown

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

3:1

9:0

0 #12 U

ser:

Zayko

(#3)

Pic

.1.2

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

16

LG

-ToExt

VH

Fke

yD

Vib

rLO

PC

IO!

RevS

hut1

RevS

hut4

FM

min

EngFire

Fire

BagS

MK

HS

P<

AC

1+

AC

2+

1200

1400

1600

1800

2000

2200

2400

2600

2800

3000

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3400

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9800

[m]

Alt.

pr

0

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200

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800

900

1000

1100

[m]

Alt.

radi

50

100

150

200

250

300

350

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450

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600

[km

/h]

IAS

0

20

40

[deg]

Thro

t1

Thro

t2

Thro

t3

Thro

t4

0

20

40

60

80

100

[%]

N1.1

N1.2

N1.3

N1.4

250

300

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650

[deg]

EG

T1

EG

T2

EG

T3

EG

T4

05

10

15

20

[mm

/sec]

Vib

Rm

1

Vib

Rm

2

Vib

Rm

3

Vib

Rm

4

0

0.2

0.4

0.6

0.8

[kgf/

sm

2]

Cab/A

tm

27.528

28.529

[V]

Ubus21A

Ubus22A

13:2

1:0

013:2

2:0

013:2

3:0

013:2

4:0

013:2

5:0

013:2

6:0

013:2

7:0

013:2

8:0

013:2

9:0

013:3

0:0

013:3

1:0

013:3

2:0

013:3

3:0

013:3

4:0

013:3

5:0

0

-34.2

-41.81

21.1

115.0

122.9

113.3

-41.8

83.3

82.7

13.8

605

570

366

345

435

497

30.3

33.8

26.8

16.6

39.7

30.6

793.3

487

435

664.7

364

0.0

87.5

265.6

325

279

276

9538.5

Alt.

pr

VH

F k

eyin

g

65.8

Thro

t4: Thro

ttle

positi

on 4

Thro

t1: Thro

ttle

positi

on 1

23.7

16.6

86.0

13.9

62.4

41.1

57.3

50.3

66.7

60.0

77.0

72.7

N1.4

: Low

pre

ssure

com

pre

ssor

rate

4

N1.1

: Low

pre

ssure

com

pre

ssor

rate

1

48.6

46.3

63.2

56.5

74.5

70.9

526

500

EG

T4: Exhauste

d g

az tem

p. 4

EG

T1: Exhauste

d g

az tem

p. 1

340

398

355

477

420

11.3

2.4

Vib

Rm

4: Engin

e r

ear

mount vib

ratio

n r

atio

# 4

Vib

Rm

3: Engin

e r

ear

mount vib

ratio

n r

atio

# 3

7.9

1.6

7.0

0.8

7.9

3.1

0.6

1C

ab/A

tm: C

abin

/atm

osphere

pre

ssure

ratio

0.5

0

Ubus22A

: B

us 2

2A

volta

ge

Ubus21A

: B

us 2

1A

volta

ge

28.3

28.2

28.3

28.2

0.1

1

514

IAS

: In

dic

ate

d a

irspeed

571

Alt.

radi:

Radio

alti

tude

793.3

Alt.

pr

2200.0

Alt.

radi

35.0

RevS

hut4

RevS

hut1

Landin

g g

ears

actu

ato

r to

exte

nd

Touchdown

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

1:1

8:2

4 #13 U

ser:

Zayko

(#3)

Pic

.1.3

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

17

GPW

SS

tab.p

VH

Fke

yG

HLFai

GH

RFai

RA

.Glid

+R

A.L

ocz+

Elv

.l+С

GV

!

0

10

20

30

40

50

60

70

80

90

100

110

[m]

Alt.

radi

100

120

140

160

180

200

220

240

260

280

300

320

[km

/h]

IAS

-6-4-202468

10

12

[deg]

AO

A

Pitc

h

0

0.2

0.4

0.6

0.81

1.2

1.4

1.6[g]

Vert

Acc

-150

-100

-500

50

100

150

[mm

]

CC

P

-15

-10-505

10

15

[deg]

Ele

v

-6-4-2024

[deg]

Sta

bzr

05

10

15

[deg]

Spoil.

l

Spoil.

r

13:3

4:4

513:3

4:5

013:3

4:5

513:3

5:0

513:3

5:1

013:3

5:1

513:3

5:2

013:3

5:2

513:3

5:3

013:3

5:3

513:3

5:4

013:3

5:4

513:3

5:5

013:3

5:0

0

7.1

6.8

Sta

b.p

0.0

325

279

-8.6

13.8

1.2

3

276

3.2

-7.8

-1.8

3

Left

gyro

horizon f

ailu

re

Rig

ht gyro

horizon f

ailu

re

СG

V m

alfunctio

n

VH

F k

eyin

g

2.6

6.8

CC

P: C

ontr

ol c

olu

mn p

ositi

on

Ele

v: Ele

vato

r positi

on

-67.3

Vert

Acc: V

ert

ical a

ccele

ratio

n1.0

0

AO

A: A

ngle

of

attack

Pitc

h: Pitc

h a

ngle

-2.2

Spoil.

l: S

poile

r (left

)

Spoil.

r: S

poile

r (r

ight)

2.5

Sta

bzr:

Sta

bilizer

positi

on

IAS

: In

dic

ate

d a

irspeed

GPW

S

Alt.

radi:

Radio

alti

tude

100.0

71.9

50.0

-5.6

0

31.3

318

-0.6

206

186

-1.7

-2.2

-6.1

7.8

-234.7

16.0

-7.0

111

129

1.7

717.0

Touchdown

Thrshould passing

End of the RWY

Ditch

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

2:5

8:2

9 #31 U

ser:

Zayko

(#3)

Pic

.3.1

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

18

0

10

20

30

40

50

60

70

80

90

100

110

120

[m]

Alt.

radi

50

75

100

125

150

175

200

225

250

275

300

325

350

[km

/h]

IAS

-0.20

0.2

0.4[g]

LatA

cc

-15

-10-505

10

[deg]

Roll

Roll_

le

Roll_

ri

120

125

130

135

[deg]

GM

H

-30

-20

-100

10

20

[deg]

CW

P

-5

-2.50

2.55

[deg]

Ail.

l

Ail.

r

-20

-100

10

20

30

[deg]

Rudder

-10-505

[deg]

Spoil.

l

Spoil.

r 0

50

100

150

200

250

[mkA

]

LocD

ev

13:3

4:4

513:3

4:5

013:3

4:5

513:3

5:0

513:3

5:1

013:3

5:1

513:3

5:2

013:3

5:2

513:3

5:3

013:3

5:3

513:3

5:4

013:3

5:4

513:3

5:5

013:3

5:0

0

7.1

6.8

0.0

87.5

325

279

276

37.7

21.9 -2

.1

115.6

127.1

130.0

-5.6

-1.0

-18.9

12.7

0.1

4

-0.3

6

318 31.3

127.1

GM

H: M

agnetic

headin

g

IAS

: In

dic

ate

d a

irspeed

Alt.

radi:

Radio

alti

tude 50.0

LocD

ev: Localis

er

devia

tion

59.3

-2.1

115.6

Ail.

l: A

ilero

n p

ositi

on (

left

)

CW

P: W

heel p

ositi

on

Ail.

r: A

ilero

n p

ositi

on (

right)

3.8 0

.6

Spoil.

l: S

poile

r (left

)

Spoil.

r: S

poile

r (r

ight)

Roll:

Roll

angle

Roll_

ri: R

oll

angle

(right FD

)

Roll_

le: R

oll

angle

(le

ft F

D)

0.0 -3

.8-2

.5

2.9

6.6-3.3

31.7

37.7

-5.2

-0.6

6.9

3.9

-18.0

9.4 -1

.2

0.6

3.2

4.2

19.3

-16.5

206

186

111

LatA

cc: Late

ral a

ccele

ratio

n

Rudder:

Rudder

positi

on

Touchdown

Threshould passing

End of the RWY

Ditch

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

3:3

5:0

5 #32 U

ser:

Zayko

(#3)

Pic

.3.2

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

19

VH

Fke

yLO

PR

evS

hut1

RevS

hut4

Fire

BagS

MK

HS

P<

AC

1+

AC

2+

0

10

20

30

40

50

60

70

80

90

100

110

[m]

Alt.

radi

100

120

140

160

180

200

220

240

260

280

300

320

[km

/h]

IAS

0

20

40

[deg]

Thro

t1

Thro

t2

Thro

t3

Thro

t4

0

20

40

60

80

100

120

[%]

N1.1

N1.2

N1.3

N1.4

250

300

350

400

450

500

550

600

650

[deg]

EG

T1

EG

T2

EG

T3

EG

T4

05

10

15

20

25

[mm

/sec]

Vib

Rm

1

Vib

Rm

2

Vib

Rm

3

Vib

Rm

4

24

26

28

30

32

[V]

Ubus21A

Ubus22A

13:3

4:4

513:3

4:5

013:3

4:5

513:3

5:0

513:3

5:1

013:3

5:1

513:3

5:2

013:3

5:2

513:3

5:3

013:3

5:3

513:3

5:4

013:3

5:4

513:3

5:5

013:3

5:0

0

-34.2

-41.8

121.1

115.0

122.9

113.3

-41.8

83.3

82.7

570

366

345

435497

30.3

33.8

26.8 16.6

0.0

87.5

325

279

276

RevS

hut4

RevS

hut1

128.7

121.4

28.1

24.7-0.81.8

249

238

359

339

602

11.4

6.0

139

Thro

t4: Thro

ttle

positi

on 4

Thro

t3: Thro

ttle

positi

on 3

N1.4

: Low

pre

ssure

com

pre

ssor

rate

4

N1.1

: Low

pre

ssure

com

pre

ssor

rate

1

EG

T4: Exhauste

d g

az tem

p. 4

EG

T2: Exhauste

d g

az tem

p. 2

18.8

91.6

4.2

61.1

2.0

Engin

e r

ear

mount vib

ratio

n r

atio

# 2

Engin

e r

ear

mount vib

ratio

n r

atio

# 4

5.0

2.0

Bus 2

1A

volta

ge

Bus 2

2A

volta

ge

28.2

28.2

Alt.

radi:

Radio

alti

tude

IAS

: In

dic

ate

d a

irspeed

318

31.3

50.0

3.1

VH

F k

eyin

g

Hydra

ulic

syste

m o

il pre

ssure

is lo

w

Low

oil

pre

ssure

in a

ny e

ngin

e

206

186

111

Touchdown

Threshould passing

End of the RWY

Ditch

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 IN

TER

STA

TE A

VIA

TIO

N C

OM

ITTEE P

rinte

d: 02.0

8.2

009 2

2:0

4:5

0 #33 U

ser:

Zayko

(#3)

Pic

.3.3

. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ahra

bad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e U

TC

20

-505

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

[m]

Alt.

radi

80

100

120

140

160

180

200

220

240

260

280

300

320

340

360

380

400

420

440

460

480

500

[km

/h]

IAS

0

20

40

60

[deg]

Thro

t1

Thro

t2

Thro

t3

Thro

t4

0

20

40

60

80

100

120

[%]

N1.1

N1.2

N1.3

N1.4

200

250

300

350

400

450

500

550

600

650

[deg]

EG

T1

EG

T2

EG

T3

EG

T4

13:3

4:4

513:3

4:5

013:3

4:5

513:3

5:0

513:3

5:1

013:3

5:1

513:3

5:2

013:3

5:2

513:3

5:3

013:3

5:3

513:3

5:4

013:3

5:4

513:3

5:5

013:3

5:0

0

-34.2

-41.8

121.1

115.0

122.9

113.3

-41.8

83.3

82.7

570

366

345

435497

30.3

33.8

26.8 16.6

0.0

87.5

325

279

276

RevS

hut4

RevS

hut1

128.7

121.4

249

238

359

339

602

11.4

6.0

139

Thro

t4: Thro

ttle

positi

on 4

Thro

t3: Thro

ttle

positi

on 3

N1.4

: Low

pre

ssure

com

pre

ssor

rate

4

N1.1

: Low

pre

ssure

com

pre

ssor

rate

1

EG

T4: Exhauste

d g

az tem

p. 4

EG

T2: Exhauste

d g

az tem

p. 2

91.6

23.1

61.1

11.1

IAS

: In

dic

ate

d a

irspeed

318

31.3

50.0

3.1

VH

F k

eyin

gH

ydra

ulic

syste

m o

il pre

ssure

is lo

w

Low

oil

pre

ssure

in a

ny e

ngin

e

206

186

121

NAV: Kilometer

Crew: Switching on.

GPWS: Pull up.

Crew: Is the idle on?

РИ: Minimum, minimum.

NAV: 40 meters

RWY threshouldNAV: 25

NAV: 30NAV: 20

GPWS: Pull up.NAV: 15FE: ... eversed.

NAV: 12NAV: 10NAV: 8NAV: 6

NAV: 5

NAV: 4

NAV: 3NAV: 2

NAV: 1Crew: (Reverse)(?)

NAV: about 0.5 meterToushdown

NAV: landing, speed 26… 270.

NAV: ...270

NAV: 260

NAV: 270 speed.

FO: Did you turn on the reverse?

NAV: Speed is increasing, speed is increasing!Crew: Turned on.

FE: Thrust reversal ...NAV: Speed is increasing!

Pax: Berast, bersat (Pers.)FO: Go around, let's go around!

Pax: Berast, bersat (Pers.)

Pax: Right, right, right.

NAV: Emergent breaking!

КВС: Emergent.

FO: What's up? Why reverse don't switch?

FE: Because there was no thrust reversal displacement.

NAV: Turn to the left.

End of the RWY

Noize at the cabine.NAV: Turn to the left. To the left!

Ditch

Impact with a wall.

A/C

type:IL

-62M

Reg.N

o.:U

P-I6208 D

ate

:24.0

7.0

9 F

light:1525

W

inA

rm32 P

rinte

d: 03.0

9.2

009 1

4:5

7:4

1 #44 U

ser:

Зайко

(#3)

Pic

.3.3

.1. A

ircra

ft IL

-62M

UP-I6208 2

4.0

7.2

009 a

t M

ashhad a

ccid

ent FD

R (

MS

RP-6

4)

flig

ht para

mete

rs. (P

relim

inary

)

Tim

e R

ela

tive

21

2n

m

4n

m

6n

m

8n

m

10

nm

2n

m

4n

m

6n

m

8n

m

13

:27

:00

.0

13

:28

:00

.0

13

:29

:00

.0

13

:30

:00

.0

13

:31

:00

.0

13

:32

:00

.0 1

3:3

3:0

0.0

13

:34

:00

.0

13

:35

:00

.0

Pic

. 5

b.

Aircra

ft I

L-6

2M

UP

-I6

20

8 o

n 2

4.0

7.2

00

9 a

t M

ash

had

airp

ort

flig

ht

path

(F

DR

data

). (

Pre

limin

ary

)

Win

Arm

32

Ти

п:I

L-6

2M

Б

ор

т:U

P-I

62

08

Д

ата

:24

.07

.09

Р

ей

с:1

52

5

U

ser:

Зай

коd

:\u

p-i6

20

8.И

л-6

2М

.Ир

ан.2

00

9\m

ap

\up

-i6

20

8_

1b

.tra

22

CVR:

The aircraft IL-62M was equipped with a CVR MARS-BM with a

total record time of 30 minutes. The recorder was retrieved from the

accident place by Iranian accident investigation team. The information

readout was performed at a facility of “PARS-Aviation Service Company”.

The magnetic tape of the recorder was in a satisfactory condition so the

accident flight data was recorded. Preliminary download of the cockpit

conversation and voice identification was also conducted by representatives

of Kazakhstan Civil Aviation Committee and D.E.T.A. AIR airline. The

final transcript of cockpit radio communication with time synchronization

was made by the Air Accident Investigation Scientific and Technical

Support Commission of the IAC.

1.12 Wreckage and Impact information:

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).

23

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.

Layout of accident site:

24

Detailed description of aircraft, systems and engines damage

25

After landing at the RWY13 the aircraft ran over the RWY at a high

speed. The aircraft passed the RWY end with breaking the protective net

barrier. Further the aircraft moved along the stop way deviating to the right

and then to the left at a soil road. There were tracks of aircraft movement at

the soil road after running over the RWY. The tracks looked like tracks from

the front, left and right landing gear wheels.

Photo 1. Tracks of aircraft movement over the dirt road after running over the RWY

Photo 2. Tracks of aircraft movement over the dirt road after running over the RWY

26

Due to emergency braking after running over the RWY the front right wheel

of the right main gear was destroyed. The aircraft ran over the RWY at a

speed of about 200 km per hour.

The aircraft moved to the right and broke several approach lights at a

concrete footing. When moving over a rough terrain due to a high speed,

the aircraft front gear was broken. At a distance of 350m from the

runway , there was a ditch 2m wide and 1m in depth. As the aircraft got

into the ditch at a speed of about 185 km per hour the front gear was

completely broken. Further the left main gear got into the ditch followed

by aircraft turning to the left. As the front gear was broken the aircraft

moved on sliding on the airframe nose. Further the aircraft hit the brick

wall concrete base 2,5 m high at a speed of 120 km per hour. This

resulted in destruction of the cockpit and the airframe up to frame 22 (6th

seat row). The distance from the RWY end to the place of the collision

with the fence was 880m. Then the aircraft moved 160m more and came

to stop. There was no fire on board.

Wires of the power line passing outside the aerodrome were ruptured by

airframe structure elements.

The aircraft leaned on the tail part of the airframe with a little bank to the port

side. The flaps were fully extended, spoilers retracted, reverse flaps open; the

stabilizer was set 1,8 degrees pitch up.

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Photo 3. Aircraft post-accident overall view

During the accident the aircraft got sever damage as follows:

- The cockpit and the cabin up to the frame 22 (the 6th seat row) were

totally wrecked.

- The nose part and lower wing panels were heavily damaged.

- The right flaps (inner and outer) were sheared off.

- The left flap had got substantial damage.

- The front gear was torn out from the attachment points, between main

gears, between frames 58 and 62.

- The right main gear flap was sheared off.

- Main gears had major damage and the right gear front right wheel was

wrecked.

- Lower flaps of power units 1 and 4 and flap control elements had

significant damage.

- Control linkage was totally destroyed up to the airframe nose destruction

line; beyond this no damage found.

28

Photo 4. Airframe nose (destroyed up to frame 22)

Photo 5. Left wing structures damage

29

Photo 6. Right wing structures damage

Photo 7. Right (outer) flap’s damage

30

Photo 8. Front right gear (torn out of attachment points), destroyed right inner flap

Photo 9. Right main gear flap sheared off

31

Photo 10. Right main gear destroyed wheel

Photo 11. Power unit 1 reverse flaps

32

Photo 12. Power unit 4 reverse flaps

Photo 13. Power unit 4 front power lever

33

Photo 14. Power unit 4 rudder shackle of padlock

As the cockpit was completely destroyed it appeared not possible to

determine throttle positions, instrument data and switches positions.

All structure damages occurred once after the aircraft had run over the RWY,

when it was moving over terrain, and resulted from the collision with

obstacles (the ditch, lights concrete footing and brick wall). There were no

tracks of destruction resulting from fatigue.

No evidences of ailerons, rudders and elevator jamming were found. Spoilers

were in the retracted position. The flaps were fully extended.

The aft fuselage had no visible damage. The stabilizer setting was

changed by the crew during the landing run from 5,6 degrees pitch up to

1,8 degrees pitch up (according to the MSRP–64). The rudders were not

fixed. There was no stabilizer position indication on the fin.

34

Photo 15. Stabilizer position – 1,8 degrees

1.13 Medical and pathological information:

Crew of this flight has valid medical license from Kazakhstan civil

Aviation Authority and they had not medical problem for the flight.

By considering to collision the airplane with the wall, flight crew and

front passengers have been injured by hitting it, and they have been dead,

because of this collision. After transferring bodies to the forensic medicine

of Mashhad, necessary pathological test were carry out ,and samplings

from the flight crew was done, and it was determined that they don't have

an especial deficiencies about using drugs and alcohol.

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1.14 Fire:

After this accident, the ground safety of Mashhad Airport sent fire

extinguish vehicles to the site of this accident immediately, but they only

extinguished a small fire in plants and thorns of around the airplane caused

by friction, because there wasn't observed a considerable fire in the airplane.

As wreckage of the airplane has been located near the flammable gas line,

these vehicles have remained in this site until carrying out it to a safe place,

in order to prevent fire and explosion of the pipe.

1.15 Survival aspects:

After this accident, ground security and research & rescue units of

Shahid Hashemijejad Airport (Mashhad) began their efforts, in order to

allocate place of accident, to rescue passengers and crew. By considering to

condition of the region and location of the airplane outside of the airport,

there were taken necessary actions by cooperating ground safety and

extinguish staffs, and other research and rescue organs; the passengers were

evacuated from aircraft wreckage, and injured persons were transferred to

hospitals of Mashhad.

36

1.16 Test and Research:

None

1.17 Organizational and management information:

According to contents ATC records of Shahid Hashemijejad Airport

(Mashhad), after this accident, the control tower in Mashhad Airport has

reported this accident to the relevant authorizations, which there have been

taken necessary actions, in order to initiate search and rescue operation.

There have been carried out all actions about search and rescue,

transferring bodies to the forensic medicine of Mashhad and identify their

identity, flight crew and passengers.

1.19 Useful or effective investigation Techniques:

The standard and normal techniques were applied.

37

2. ANALYSIS:

After joining landing course the flight altitude was 7000 ft, distance from

the RWY end 22 km. The aircraft was preceded by another aircraft

approaching to land, which had been cleared to land earlier. Being instructed

by a controller to reduce speed due to the proceeding traffic, approaching to

land, the captain decided to make left orbit and informed the crew about that.

Upon a navigator’s request the controller cleared to perform left orbit

maintaining 7000 ft.

No evidences of task sharing regarding flying the aircraft before

descending from the FL to approach to land were recorded. By some

navigator’s words one can judge that it was the captain who was the flying

pilot: Kolya, 7000, climb, climb Kolya!.

The aircraft landing weight was 93.7 tons. Data on the landing weight,

landing approach speed, approach chosen, and alternate aerodrome were not

voiced during the pre-landing preparation (not proceeding check list). After

joining landing course the controller cleared to descend to 6000 ft, at a

distance of 13 km from the RWY end. As the aircraft approached to the

RWY the navigator reported the distance: Distance 6, distance 5, flying

above. After crossing the 5 km distance the navigator without a captain’s

command read out the checklist: landing gear down, brakes, spoilers, altitude

selector. No answers to the voiced checklist points were recorded.

Further the navigator goes on counting distance: distance 2 km,

distance 1, altitude 40m. When passed distance 1 km, the co-pilot gave a

command (which was supposed to be given by the PIC) to set idle: “Idle”.

The flight engineer confirmed: “Idle”, but according to the MSRP-64 data

idle was set before the command. Flight speed along the glide path was 325

km/h, which was 50 km/h more than the assigned speed for a landing weight

of 93 tons. The rate of descent was 10 m/sec. During the descent the GPWS

38

warning activated several times. The RWY end was crossed at a height of 31

m and at a speed of 310 km/h.

At a height of 22m the flight engineer shifted trust reverses to a reverse

thrust position without a captain’s command. No report “Lever latched

lights on” about the shift was made. The landing was performed (according

to the calculation made) at a distance of 1000 m from the RWY threshold at

a speed of 275 km/h (instrument speed).

According to the MSRP record before landing the flight engineer

shifted engine’s 1 and 4 trust reversers to the forward thrust. After landing

and extending the front gear down, the co-pilot (it is a captain who should

give command) gave the command “Reverse”, without any monitoring by

either of them of engine trust reversers position indication at the instrument

panel. The flight engineer without checking out the thrust reverse lever

position and trust reversers position indication and reading back (“roger,

reverse on”) set throttles of engines 1 and 4 at the maximum trust.

Note: It should be noted that as for that aircraft type, if the reverse lever is

in the “Reverse” position, throttles cannot, due to their design, be set at a

position over the “Nominal” mode (80…90 degrees according to thrust

mode indicator).

The actual record of the MSRP-64 contained record of the flight mode

implied on engines 1 and 4, which is possible only in case reverse thrust

lever is set at the “forward thrust” mode. There was no reporting “reverse

engaged”.

39

No command was given to activate spoilers, which were not extended

upon landing. The co-pilot set the stabilizer from 5, 6 degrees pitch up to 1, 8

degrees pitch up.

Just at the same time upon landing (2 seconds later) inner engines were

shut down by the flight engineer. Nevertheless the aircraft did not brake as

the trust reversers were shifted to forward thrust. The mode was maintained

for 12 seconds. According to navigator’s reports, which were consistent with

the MSRP record, the speed began to increase. The navigator informed the

crew about increase of speed. According to the MSRP a speed of 280

km/hour was reached. After the navigator informed about increase of the

speed, the flight engineer shut down engines no. 1 and 4.

The MARS-BM record contains crew members’ voices record: Co-pilot

– “Leaving”, Navigator – “Brakes”, Co-pilot – “Why isn’t reverse

functioning?” the PIC – “because flaps are not shifted”, Navigator –

“Emergency braking”.

MSRP-64 record contains multiple change of throttle position of

engines 2-3 and 1-4 before the flight mode, as well as shifting trust reversers,

but it was done with engines disengaged. Crew’s actions, engine parameters,

flaps position are consistent with the readout chart.

It should be noted that crew’s actions when landing did not comply with

the Crew Interaction and Procedure Instruction for the case of landing with

reverse engaged, under the Operating Manual of the IL-62 type (Tab 4.1).

Wheel Braking, including emergency braking, was not effective. The

aircraft ran over the RWY at a speed of 200 km/hour, deviated to the right

after the front right wheel tire of the front right gear blew out. Further on, it

broke some approach lights, with a concrete base, crossed the net barrier had

its front gear broken and then at a speed of 185 km/hour got into the ditch,

up to 1 m in depth and 2m in width, which traversed the aircraft’s path at an

angle, had its front gear broken down. Then due to its left gear getting into

40

the ditch as well, turned to the left facing the brick wall with a concrete

foundation. As the front gear was broken, the aircraft moved on its forward

fuselage and at a speed of 120 km/hour collided with the concrete foundation

of the brick wall 2,5 m high. As a result of the front impact the cockpit and

airframe up to frame 22 (6th

seat row) were totally ruined. The crew and

some passengers, who were in the first cabin, were killed.

The aircraft moved on over the dirt for 160m, broke the power line and

came to a stop. There was no fire on the aircraft after the stop.

It should be noted that several accidents with aircraft IL62M took

place before, which occurred due to the lack of accurate interaction

between captain and crew during landing with thrust reverse involved.

In most cases these accidents were a result of non-authorized flight

engineer’s actions to shift engine trust reversers at heights more than these

recommended in the FM, followed by their shifting to forward thrust and

setting engines 1 and 4 at the flight mode. Another cause was an

unmonitored thrust lever position (not latched) and position of engine trust

reversers indication before setting engines at the maximum braking mode,

which resulted in running over the RWY.

Table 4.1. Il-62M crew interaction checklist to be fulfilled at landing

with thrust reverse engaged

Flight

engineer

At the command of captain “Idle”, read it back and reduce

engine power to idle.

PIC By the end of flaring at the idle mode give the command: “Shift

flaps” (with a glide path angle under 3 degrees 30 min. At a

height of no more than 5 m give the command “Shift flaps”

(with a glide path angle no more than 3 degrees 30 min)

Flight

engineer

At the captain’s command “Shift flaps” read it back. Shift the

reverse control lever of engines 1-2 from the position

41

“REVERSE OFF” to the position “REVERSE ON”. Check by

the indication display whether the reverse flaps are shifted and

report “Lever latched lights on”.

PIC At a height of 1-2m, if necessary, give the command

“Reverse”. By the end of flaring prevent increase of pitch angle

and touch down the RWY by the main wheels. Upon landing

manipulating the rudder, match the aircraft axis with the RWY

centre line, put down at the RWY the front gear (in 2-3

seconds), give the command “Reverse” (if reverse was not

engaged earlier) and activate the front gear control. Fix the

control column in the “Push” position; give the command

“Spoilers”.

Flight

engineer

On the captain’s command “Reverse” read it back, set engines

1 and 4 throttles at the maximum reverse thrust mode (to the

“Reverse” stop) and report: ”Reverse engaged”.

Upon the captain’s command “Spoilers” read it back, extend

spoilers to the maximum angle and report: “Spoilers extended”.

Make sure that the engines 1 and 4 parameters are consistent

with the reverse thrust mode.

42

THROTTLES AND THRUST REVERSE LEVER CONTROL

SYSTEM

Thrust reverse

lever

Nominal mode

stops

43

Middle thrust

reverse lever

position latch

44

3. CONCLUSIONS:

3-1 Findings:

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.

45

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.

3-2 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 - ….

3-3 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

3-4 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.

46

4- SAFETY RECOMMENDATIONS:

In order to prevent the similar events, the Aircraft Accident Instigation

&Safety of IRI CAO recommends:

.A special working group (Board) between Iranian airlines which used

Russian leased aircraft and Russian airlines, be established and study

how to obtain life extensions and modifications from Russian

authorities as a state of design & manufacture.

Those Iranian airliners that are willing to have foreign pilots shall

provide training courses, such as Iran routs and necessary

arrangements for crew members just before beginning of their flights.

All foreign pilots should be checked by a related instructor pilot or a

CAO designee pilot.

The IL-62 cockpit should be equipped with flight engineer headset by

the ILYUSHIN Design Bureau.

The ILYUSHIN Design Bureau should study and investigate why

ELT has not activated by the sever impact.

Presence and entering passengers or any other persons than crew

should really be forbidden during landing and take off by airlines.

The Interstate Aviation Committee (MAK) and Aircraft Accident

Investigation Department of IRI CAO should deliver notified findings

of this accident to related airlines.

It is recommended that a correct procedure of foreign pilot operation

in the Iran territory should be defined by operation department of IRI

CAO with cooperation of airlines.

All airlines that are willing to use leased aircrafts should have

sufficient supervision just before to start operation, should check and

accomplish the written MOU between authorities and also consider

those items in "Art 83 Bis ".

islamic republic of iran - cao republic of iran civil aviation organization aircraft accident...

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