Crash-aerien 03 MAY 2006 d'un Airbus A320-211 EK32009

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Statuts:	Accident investigation report completed and information captured
Date:	mercredi 3 mai 2006
Heure:	02:13
Type/Sous-type:	Airbus A320-211
Compagnie:	Armavia
Immatriculation:	EK32009
Numéro de série:	547
Année de Fabrication:	1995-06-28 (10 years 10 months)
Heures de vol:	28234
Cycles:	14376
Moteurs:	2 CFMI CFM56-5A1
Equipage:	victimes: 8 / à bord: 8
Passagers:	victimes: 105 / à bord: 105
Total:	victimes: 113 / à bord: 113
Dégats de l'appareil:	Détruit
Conséquences:	Written off (damaged beyond repair)
Lieu de l'accident:	6 km (3.8 milles) SW de Adler/Sochi Airport (AER) ( Fédération de Russie)
Phase de vol:	En approche (APR)
Nature:	Transport de Passagers Intern.
Aéroport de départ:	Yerevan Airport (EVN/UDYZ), Arménie
Aéroport de destination:	Adler/Sochi Airport (AER/URSS), Fédération de Russie
Numéro de vol:	967

Détails:
Armavia flight 967 departed Yerevan (EVN) at 00:47 on a scheduled flight to Sochi (AER). Weather at Sochi was poor with rain and poor visibility. Radio contact with Sochi was established at 01:10. The flight crew discussed the current weather conditions at Sochi with the approach controller. At 01:26 the crew decided to return to Yerevan due to the below minima weather conditions at Sochi. At 01:30 the crew again requested the latest weather information. Visibility now was reported as 3600 m with a cloud base at 170 m. The captain now decided to continue to Sochi instead. Clearance was give to descent to an altitude of 3600 m. At 02:00 further descent instructions for 1800 m were issued by the air traffic controller. Weather conditions for an approach to runway 06 were now equal to the airport minima. Sochi Tower then cleared the flight to descend to 600 m. The glideslope was captured and the gear was lowered at 02:10. The crew reported ready and where cleared for landing. Weather was reported as 4000 m visibility with a cloud base at 190 m. Weather deteriorated quickly and thirty seconds later the controller reported that the cloud base was now at 100 m. He instructed the flight to abort the approach and told the crew to make a climbing right hand turn to an altitude of 600 m. The aircraft was flying at 300 m and performed a climbing turn to 450 m. Simultaneously the groundspeed dropped and the Airbus descended until it contacted the water and broke up. Wreckage sank to a depth of 700 m.

Probable Cause:

CONCLUSION: "The fatal crash of the Armavia A-320 EK-32009 was a CFIT accident that happened due to collision with the water while carrying-out a climbing manoeuvre after an aborted approach to Sochi airport at night with weather conditions below the established minima for runway 06. While performing the climb with the autopilot disengaged, the Captain, being in a psychoemotional stress condition, made nose down control inputs due to the loss of pitch and roll awareness. This started the abnormal situation. Subsequently the Captain's inputs in the pitch channel were insufficient to prevent development of the abnormal situation into the catastrophic one. Along with the inadequate control inputs of the Captain, the contributing factors to development of the abnormal situation into the catastrophic one were also the lack of necessary monitoring of the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot and the absence of proper reaction by the crew to the EGPWS warning.

Accident investigation:

Investigating agency:	MAK
Status:	Investigation completed
Duration:	285 days (10 months)
Accident number:	-
Download report:	Final report

Sources:

» SKYbrary
» Gazeta.ru
» MAK Interstate Aviation Committee (IAC)
» Ministry of Emergency Situations (MChS) of Russia

METAR Weather report:

22:00 UTC / 02:00 local time:
URSS 022200Z VRB01MPS 4000 -SHRA BR BKN006 OVC027CB 11/11 Q1018 TEMRO 1500 BR VV005 RMK G/~Z QFE762 SC05=
wind variable at 1m/sec, visibility 4000m, light rain showers, mist 5-7 oktas cloud at 600ft, 8 oktas overcast cloud at 2700ft with thunder clouds, temperature 11C dewpoint 11C, QNH 1018hPa, visibility 1500m mist vertical visibility 500ft

Opérations de secours

MAK issued 22 Safety Recommendations

Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (1)
To conduct briefings with the flight crews, controllers and technical and engineering personnel to review the circumstances and the causes of the accident.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (10)
To point out to aircraft crews that irrelevant conversations in the cockpit, especially during the climb and descent phases, are prohibited.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (11)
To consider the necessity of enhanced simulator training for A320 crews.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (12)
To develop a procedure for storage of A320 operational documentation that would regulate the conditions of keeping the originals and copies of the documents by both Sabena Technics and Armavia airline.
Issued: 12-FEB-2007	To: Federal Air Navigation Service of the Russian Federation	EK32009 (13)
To review the possibility of updating of AIP of the RF and other regulatory documents for the purpose of unification of ATC procedures for issuing instructions for go-arounds to aircraft operated by domestic and foreign airlines, and to incorporate the relevant amendments into the Rules and Phraseology for In-flight Radio Communications and ATC.
Issued: 12-FEB-2007	To: Federal Air Navigation Service of the Russian Federation	EK32009 (14)
To review the possibility of incorporation of the Air Traffic Service procedures in the aerodrome services provided in accordance with ICAO recommendations (Document 4444, Attachment 11) and the Order No. 103/DV-116 of 26.10.95 issued by Department of Air Transport.
Issued: 12-FEB-2007	To: Federal Service for Hydrometeorology and Environmental Monitoring	EK32009 (15)
To review the possibility of purchasing and installing of a new Doppler weather radar at the civil aviation meteorological station in Sochi.
Issued: 12-FEB-2007	To: Federal Service for Hydrometeorology and Environmental Monitoring	EK32009 (16)
To undertake measures to eliminate the shortcomings in the meteorological support to civil flight operations at Sochi aerodrome brought to light in the course of the investigation.
Issued: 12-FEB-2007	To: State Corporation for Air Traffic Management	EK32009 (17)
To restore complete ATIS broadcasting for Sochi aerodrome, including weather data.
Issued: 12-FEB-2007	To: State Corporation for Air Traffic Management	EK32009 (18)
To clarify to controllers of the Sochi Air Traffic Support of the groups of BECMG and TEMPO changes in the weather forecasts for the aerodrome and of the two-hour trend weather forecasts.
Issued: 12-FEB-2007	To: Airbus	EK32009 (19)
To eliminate the discrepancies in the documentation describing the logic of the binary signals recorded by the FDR.
Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (2)
To ensure fulfilment of the requirements of ICAO Annex 6 Part 1 Chapter 3 for mandatory analysis of performed flight operations based on the CVR and FDR recordings for the aircraft with a certified MTOW exceeding 27000 kg.
Issued: 12-FEB-2007	To: Airbus	EK32009 (20)
To introduce in the A320 FCOM information clarifying specific features of activation of the OPEN CLIMB mode in various flight conditions.
Issued: 12-FEB-2007	To: Airbus	EK32009 (21)
To introduce in the A320 FCOM a warning about possible activation of the LOW ENERGY WARNING, when the aircraft performs manoeuvres in the landing configuration with considerable changes in pitch and roll angles.
Issued: 12-FEB-2007	To: Airbus	EK32009 (22)
To review the expediency of alteration of the type and/or priority of the EGPWS warning to ensure more reliable pilots response to its activation.
Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (3)
To draw the attention of A320 crews to the necessity of immediate response to activation of the EGPWS warning (even if other warnings are on at the same time) in the case of instrument flight, or flight in difficult weather conditions, or flight in the mountains. To introduce the relevant exercises in the simulator training programmes to practice these actions. To consider the advisability of extending these recommendations to other aircraft types.
Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (4)
To review the necessity of enhancing crew simulator training in the section on flying in Flight Director mode, especially during approach and go-around.
Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (5)
To bring the content of the AIP, as well as the ATC controllers job descriptions and operations manuals, into compliance with the standards and practices recommended by ICAO, with regard to clearance for approach and landing.
Issued: 12-FEB-2007	To: CIS CAA's	EK32009 (6)
To organize and conduct research into the conditions under which a crew may lose spatial orientation and/or upset aircraft attitude may develop, and to issue practical recommendations to enhance flight safety. In particular, to evaluate the effect of in-flight acceleration illusions. Based on the research, to develop and introduce a specialized course for recurrent training of crews that should contain both classroom and flying training.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (7)
To include in the A320 FCTM the mandatory requirement for trainee Captains to pass the Upgrade to Captain programme.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (8)
To keep records on approaches performed in difficult weather conditions by A320 crews, in accordance with the regulatory documents relating to the organization of flight operations in civil aviation of the Republic of Armenia.
Issued: 12-FEB-2007	To: CAA Armenia; Armavia	EK32009 (9)
To organize FDR and CVR readouts for analysis of A320 flight operations, in order to reveal any errors and deficiencies in crews piloting technique, and to develop measures for their prevention.

Show all...

Photos

accident date: 03-05-2006
type: Airbus A320-211
registration: EK-32009

Plan

Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Yerevan Airport et Adler/Sochi Airport est de 516 km (323 miles).
Accident location: Approximate; accuracy within a few kilometers.

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.

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Airbus A320

4751+ built
12^ème loss
6^ème accident fatal
le accident 2^ème le plus grave (à ce moment là)
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Fédération de Russie

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