Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.1. |
Communicate information on the accident to civil flight operations personnel, ATM personnel and airdrome service personnel. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.10. |
Clarify (improve) the training and authorization procedure for accredited instructors to be authorized to work as an out of staff ATC instructor. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.11. |
Develop unified rules of ATC personnel individual log books maintenance. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.12. |
Due to a big number of hazards identified as to the Vnukovo Airport and Vnukovo ATC Center airdrome service operations, consider conducting a re-assessment of pertinent risks and taking risk mitigation actions. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.13. |
Develop technical specifications and operation procedures for the Surface Movement, Guidance and Control Systems (SMGCS). |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.14. |
Introduce requirements for the SMGCS system similar to those in Section 9.8 of ICAO Annex 14 Airdromes, Volume I and ICAO Doc 9476 and 9830 into the national aviation regulations on certification and operation of airdromes. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.15. |
Ensure documentation and implementation within Airdrome Operators SMS of a procedure to conduct medical checks (pre-duty and post-duty) as well as oversight during shifts to mitigate the risk of drivers doing their duties being under the influence of alcohol. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.16. |
Consider the practicability of amending the applicable regulations to include a requirement to fit the airfield surveillance and control systems (in case they are installed at an airdrome) with MLAT/ADSB functions. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.2. |
Consider the practicability of developing additional measures to prevent runway incursions taking into account ICAO Doc 9870 AN/463 "Manual on the Prevention of Runway Incursions". |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.3. |
Consider the practicability of developing additional action plans to monitor that the runway is clear of foreign objects during takeoff run and landing roll. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.4. |
Consider amending the aviation regulations to add a requirement of mandatory monitoring of ATC objects with the help of background recording and video monitoring of ATC working positions. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.5. |
Consider mandating the check of airdrome vehicle drivers performing airfield operations for alcohol influence during the medical check before and after the duty shift. Introduce a standardized form of the medical check log for drivers of airdrome vehicles. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.6. |
Conduct a re-assessment of ATC personnel working stations paying special attention to the field of view and mutual positioning of the screens providing necessary information to conduct the ATC. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.7. |
Eliminate the contradiction between the provision of Para 1, Article 53 of the Air Code of the Russian Federation and Para 18, Section III of Order 93 of the Russian Ministry of Transport as of 14.04.2010 in terms of the possibility of air traffic control being provided by trainee controllers not holding aviation personnel licenses. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.8. |
Consider the practicability of introducing additions to FAR-262 in terms of mandating the marking of runway holding points at runway/runway intersections. |
Issued: 25-OCT-2016 | To: Russian Aviation Authorities | 1.9. |
Bring the Instruction 82 provisions into compliance with the ones of FAR-362 with regard to all the vehicles, performing works on the runway, to be equipped with the devices for the permanent listening to the radio exchange at the departure controllers frequency. |
Issued: 25-OCT-2016 | To: ATM State Corporation | 2.1. |
In cooperation with the Vnukovo ATC Center management arrange training for their personnel on the use of the airfield surveillance and control system A3000. Improve Working Instructions to include provisions on the recommended settings of the A3000 system depending on the working position as well as guidance on attention allocation while operating the system and reaction to various types of alerts. Consider the applicability of this recommendation to other ATC Centers where the same or similar system is used. |
Issued: 25-OCT-2016 | To: ATM State Corporation | 2.2. |
Consider revoking authorizations for work as out of staff instructors of ATC controllers issued with violation of Supplement to Order 93 of Russian Ministry of Transport as of 14.04.2010. |
Issued: 25-OCT-2016 | To: ATM State Corporation | 2.3. |
Consider introducing standardized OJT logs for all ATC personnel for use during on-thejob probation training. |
Issued: 25-OCT-2016 | To: ATM State Corporation | 2.4. |
Maintain records of annual practical checks of instructor training for instructor controllers, both staff and out of staff ones, in the personal ATC controller log books. |
Issued: 25-OCT-2016 | To: Moscow ATM Center of ATM State Corporation | 3.1. |
Take measures to prevent falsification of records in personnel documents. With regard to the previous recommendation, consider conducting an internal investigation on falsification of records in the individual log book and Log of Simulator Training on the simulator training of the instructor controller on the day of the accident (20.10.2014). |
Issued: 25-OCT-2016 | To: Moscow ATM Center of ATM State Corporation | 3.2. |
Consider revoking authorizations for work as instructors of ATC controllers authorized to be out of staff instructor controllers by orders 601 by Moscow ATM Center of State ATM Corporation as of 01.09.2011 921 as of 11.12.2012 4.1.1-08801 as of 17.08.2011. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.1. |
Improve its SMS taking into account the results of this investigation paying special attention to the functioning of the voluntary reporting system. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.10. |
Ensure terminology used in the Job Description of ATC Shift Supervisor of Vnukovo DI-GK-1616.01-683) complies with the pertinent regulations. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.11. |
Conduct training for ATM personnel on the usage of Terma Scanter 2001 Airfield Surveillance Radar and airfield surveillance and control subsystem A3000. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.12. |
Consider clarifying the contents of exercises in Task 2 of the Arrangement and Conduct of Vnukovo ATC Center Peronnel Simulator Training Procedure P-GK-1616.07-1247) to specify exercises to train personnel actions during runway and taxiway incursions. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.13. |
Develop and enforce Instruction on Management Personnel Actions, Responsibilities and Accountabilities in Case of Accidents and have it accepted by the Central Territorial Office of Rosaviatsiya in compliance with Para 2.3 of PRAPI-98. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.2. |
Develop a procedure for and accomplish the setting of Reserved Lines of the airfield surveillance and control system A3000 in the area of the big runway crossing. Assess the necessity of placing and/or correcting Reserved Lines in other locations. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.3. |
Consider changing the format and duration of the sound alarm when various alert modes are activated to ensure a more attracting effect. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.4. |
Arrange regular checks of ATC controllers in terms of efficiency of their operation of the airfield surveillance and control subsystem A3000 using readouts of the systems recorder. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.5. |
Determine criteria to be used by the ATC shift supervisor when deciding to join ATC sectors. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.6. |
Ensure compliance of radio exchange and reference radio communication by the Tower ATC units with the Coordination Procedure of Airdrome Service with Vnukovo ATC Center and Other Ground Support Services at Vnukovo Airdrome. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.7. |
Ensure compliance of background recording and video monitoring of ATM working positions at Moscow ATM Center of State ATM Corporation with the Provision of Usage of Recording Devices and Data during ATM at Moscow ATC Center, State ATM Corporation DI-GK-1601-250). |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.8. |
Ensure compliance of ATM personnel simulator training with Order 182 of State ATM Corporation as of 16.04.2014. |
Issued: 25-OCT-2016 | To: Vnukovo ATC Center of Moscow ATM Center, ATM
State Corporation | 4.9. |
In cooperation with MAMC, ensure automatic notification of the meteorologist of the main observation post upon the Emergency Landing (Alarm) signal. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.1. |
Improve its SMS considering the investigation findings and take efficient measures to prevent runway incursions taking into account the peculiarity of the airdrome (two intersecting runways). |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.10. |
Bring the Interaction Procedure of Airdrome Service with Vnukovo ATC Center into compliance with the FAR-362 provisions with regard to all the vehicles, performing works on the runway, to be equipped with the devices for the permanent listening to the radio exchange at the departure controllers frequency. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.11. |
Ensure compliance of the Interaction Procedure of Airdrome Service with Vnukovo ATC Center with the requirements of Para 36 of Instruction No 82 in terms of maintaining reference radio exchange. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.12. |
Consider revising the procedure for radio communication for vehicles operating on runways to make it compliant with Para 4.2.6 of ICAO Doc 9870. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.13. |
Ensure the observer at the departure search and rescue station at departure area of RWY 2 (01) when on duty should pay special attention to complying with the requirements of Para 8 of the Instruction for Search and Rescue Station Observer as of 12.07.2012 in terms of taking a place at the observation post that ensures uninterrupted visual observation of aircraft takeoff and landing. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.14. |
Ensure the radio exchange between the airdrome service dispatcher, airdrome service shift supervisors and vehicle drivers conducting airfield operations is recorded. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.2. |
Ensure a check and, if required, provision of proper airdrome signage and marking prescribed by applicable regulations. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.3. |
Ensure medical checks of airdrome vehicle drivers of Vnukovo AP are conducted in compliance with the requirements of the Instruction on Airdrome Vehicles Traffic Management at Vnukovo Airdrome before and after the duty shift. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.4. |
Determine the actions of a person in charge of the airfield operations in case they lose visual contact with vehicles or in case of a vehicle failure. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.5. |
Determine the actions of a vehicle driver in case they lose visual contact with the airfield operations supervisor or spatial orientation on the airfield. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.6. |
Provide training for vehicle drivers on elements of airdrome lighting. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.7. |
Consider the practicability of introducing qualification requirements as to English proficiency for airfield operations supervisors. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.8. |
Require that reference radio communication is maintained by airdrome operations supervisors in accordance with the Interaction Procedure of Airdrome Service with Vnukovo ATC Center. |
Issued: 25-OCT-2016 | To: Vnukovo Airport | 5.9. |
Revise the Interaction Procedure of Airdrome Service with Vnukovo ATC Center to add callsigns for all types of vehicles belonging to organizations operating on the airfield. |
Issued: 25-OCT-2016 | To: VIPPORT LTD | 6.1. |
Ensure timely provision of meteorological information to aircraft crews in accordance with the regulations. |
Issued: 25-OCT-2016 | To: VIPPORT LTD | 6.2. |
Ensure the rectification of the raised findings including reporting to pertinent services in case the departure time is postponed. |
Issued: 25-OCT-2016 | To: Unijet | 7.1. |
Consider the practicability of improving their SMS in terms of recommended crew actions in case they detect an obstacle on the runway during takeoff or landing. |
Issued: 25-OCT-2016 | To: Unijet | 7.2. |
Re-assess the risks of transfer of aircraft control during the takeoff roll when the FO is the PF on aircraft where nose wheel steering is only possible from the LH seat. If necessary amend the FOM accordingly. |
Issued: 25-OCT-2016 | To: EASA | 8.1. |
Consider the practicability to make mandatory for newly certified airplane (as per CS-25, AR-25 or equivalent) the installation of a nose wheel steering accessible by each flight crew member at their duty position. |
Issued: 25-OCT-2016 | To: ICAO | 9.1. |
Consider the practicability of introducing additions to Standard 2.10.7 of ICAO Annex 14, Volume 1 Airdrome Design and Operations (Edition 6, July 2013) in terms of marking the runway holding point at the runway/runway intersection even if there are no standard taxiing routes passing through the location. |