Narrative:
Saratov Airlines flight 703, an Antonov An-148, was destroyed after impacting terrain near Stepanovskoye, Russia. All 65 passengers and 6 crew members were killed.
The aircraft took off from runway 14R at Moscow's Domodedovo Airport at 14:21 hours local time (11:21 UTC). Weather about the time of departure at Domodedovo Airport included limited visibility (2100m) during light snowfall. Temperature was -5°C, overcast cloud deck at 2600 feet AGL.
The Interstate Aviation Committee stated that, prior to departure, the heating of the three pitot tubes had not been turned on.
After takeoff, at an altitude of 130-150 m (425-490 ft) above ground level, the autopilot was switched on. Flaps were raised as the aircraft climbed through an altitude of 550 m (1800 feet).
About 2 minutes 30 seconds after the takeoff, at an altitude of about 1300 meters (4265 feet) and an instrument speed of 465-470 km/h, there were discrepancies between the air speed readings on the captain's side compared to the standby airspeed indicator. The airspeed on the copilot's side is unknown as this parameter was not registered by the flight data recorder. There were no significant difference in the altitude indications. After another 25 seconds, the discrepancies reached about 30 km/h with the speed on the captain's side being greater.
After about 50 seconds, at an altitude of about 2000 meters (6560 ft), the airspeed on the standby airspeed indicator was higher and continued to increase while the airspeed on the captains ASI continued to decrease.
The flight crew then disconnected the autopilot. The airspeed on the captain's side continued to decrease, while the standby ASI showed 540-560 km/h. About 50 seconds after the autopilot was turned off, the flight passed an altitude of 1700-1900 m (5580-6230 ft) with vertical loads ranging from 1.5 to 0.5 g. Subsequently the aircraft entered a steep descent with the ASI on the captain's side showing 0 km/h, and the standby ASI showing 200 km/h. The pitch angle decreased to -30/-35 degrees with a vertical load factor of 0 g.
The aircraft impacted a snowy field around 14:27:05 and disintegrated. Before the collision with the ground, the standby ASI had increased to 800 km/h with the captain's ASI still displaying 0 km/h.
The captain of the An-148 had 2168 hours on type, of which 58 as captain. The first officer had 672 hours on type.
The AN-148-100V RA-61704 crash occurred due to erroneous actions of the crew at the stage of climbing in instrument weather conditions at unreliable readings of instrument speed caused by icing (blockage of ice) of all three pitot tubes, which led to the loss of control over the parameters of the aircraft, its transfer to dive and collision with the ground. The accident was classified as a loss of control in flight (LOC-I).
The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements.
The most likely contributing factors were:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time;
- Skipping by the crew of the operation to switch on the pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action;
- design features of the An-148 aircraft in terms of the restrictions on the duration of pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START";
- systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of pitot tube heating;
- design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects;
- low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS;
- Failure to take necessary measures in case of detection of previous facts of untimely activation of pitot tube heating by crews based on the results of express analysis of flight information;
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm;
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation;
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128;
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases;
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters;
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources;
- individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system;
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures;
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain;
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.
Loss of control
» Flightradar24
UUDD 111030Z 14005MPS 2500 R14R/1800U R14L/P2000D -SHSN BKN007 BKN026CB M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1000 SHSN
11:00 UTC / 14:00 local time:
UUDD 111100Z 14006MPS 1800 R14R/1900U R14L/1800U SHSN BKN007 BKN026CB M05/M06 Q1019 R14R/590293 R14L/590392 NOSIG
11:30 UTC / 14:30 local time:
UUDD 111130Z 13006MPS 2100 -SN SCT008 OVC026 M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1200 SHSN BKN012CB
12:00 UTC / 15:00 local time:
UUDD 111200Z 13005MPS 1900 R14R/2000D R14L/1900D SN SCT007 OVC026 M05/M06 Q1019 R14R/590293 R14L/590491 TEMPO 1200 SHSN BKN012CB
accident date: 11-02-2018
type: Antonov An-148-100
registration: RA-61704
altitude profile
RA-61704
RA-61704
RA-61704
accident date: 11-02-2018
type: Antonov An-148-100
registration: RA-61704
| Status: | Accident investigation report completed and information captured |
| Date: | Sunday 11 February 2018 |
| Time: | 14:27 |
| Type: |  Antonov An-148-100B |
| Operator: | Saratov Airlines |
| Registration: | RA-61704 |
| MSN: | 27015040004 |
| First flight: | 2010 |
| Total airframe hrs: | 16249 |
| Cycles: | 8397 |
| Engines: | 2 Progress D-436-148 |
| Crew: | Fatalities: 6 / Occupants: 6 |
| Passengers: | Fatalities: 65 / Occupants: 65 |
| Total: | Fatalities: 71 / Occupants: 71 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | near Stepanovskoye, Ramenskoye district ( Russia)
|
| Phase: | En route (ENR) |
| Nature: | Domestic Scheduled Passenger |
| Departure airport: | Moskva-Domodedovo Airport (DME/UUDD), Russia |
| Orsk Airport (OSW/UWOR), Russia | |
| Flightnumber: | 6W703 |
Saratov Airlines flight 703, an Antonov An-148, was destroyed after impacting terrain near Stepanovskoye, Russia. All 65 passengers and 6 crew members were killed.
The aircraft took off from runway 14R at Moscow's Domodedovo Airport at 14:21 hours local time (11:21 UTC). Weather about the time of departure at Domodedovo Airport included limited visibility (2100m) during light snowfall. Temperature was -5°C, overcast cloud deck at 2600 feet AGL.
The Interstate Aviation Committee stated that, prior to departure, the heating of the three pitot tubes had not been turned on.
After takeoff, at an altitude of 130-150 m (425-490 ft) above ground level, the autopilot was switched on. Flaps were raised as the aircraft climbed through an altitude of 550 m (1800 feet).
About 2 minutes 30 seconds after the takeoff, at an altitude of about 1300 meters (4265 feet) and an instrument speed of 465-470 km/h, there were discrepancies between the air speed readings on the captain's side compared to the standby airspeed indicator. The airspeed on the copilot's side is unknown as this parameter was not registered by the flight data recorder. There were no significant difference in the altitude indications. After another 25 seconds, the discrepancies reached about 30 km/h with the speed on the captain's side being greater.
After about 50 seconds, at an altitude of about 2000 meters (6560 ft), the airspeed on the standby airspeed indicator was higher and continued to increase while the airspeed on the captains ASI continued to decrease.
The flight crew then disconnected the autopilot. The airspeed on the captain's side continued to decrease, while the standby ASI showed 540-560 km/h. About 50 seconds after the autopilot was turned off, the flight passed an altitude of 1700-1900 m (5580-6230 ft) with vertical loads ranging from 1.5 to 0.5 g. Subsequently the aircraft entered a steep descent with the ASI on the captain's side showing 0 km/h, and the standby ASI showing 200 km/h. The pitch angle decreased to -30/-35 degrees with a vertical load factor of 0 g.
The aircraft impacted a snowy field around 14:27:05 and disintegrated. Before the collision with the ground, the standby ASI had increased to 800 km/h with the captain's ASI still displaying 0 km/h.
The captain of the An-148 had 2168 hours on type, of which 58 as captain. The first officer had 672 hours on type.
Probable Cause:
The AN-148-100V RA-61704 crash occurred due to erroneous actions of the crew at the stage of climbing in instrument weather conditions at unreliable readings of instrument speed caused by icing (blockage of ice) of all three pitot tubes, which led to the loss of control over the parameters of the aircraft, its transfer to dive and collision with the ground. The accident was classified as a loss of control in flight (LOC-I).
The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements.
The most likely contributing factors were:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time;
- Skipping by the crew of the operation to switch on the pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action;
- design features of the An-148 aircraft in terms of the restrictions on the duration of pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START";
- systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of pitot tube heating;
- design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects;
- low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS;
- Failure to take necessary measures in case of detection of previous facts of untimely activation of pitot tube heating by crews based on the results of express analysis of flight information;
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm;
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation;
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128;
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases;
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters;
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources;
- individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system;
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures;
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain;
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.
Accident investigation:
 |
|
Classification:
Pitot head issuesLoss of control
Sources:
» RT.com» Flightradar24
METAR Weather report:
10:30 UTC / 13:30 local time:UUDD 111030Z 14005MPS 2500 R14R/1800U R14L/P2000D -SHSN BKN007 BKN026CB M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1000 SHSN
11:00 UTC / 14:00 local time:
UUDD 111100Z 14006MPS 1800 R14R/1900U R14L/1800U SHSN BKN007 BKN026CB M05/M06 Q1019 R14R/590293 R14L/590392 NOSIG
11:30 UTC / 14:30 local time:
UUDD 111130Z 13006MPS 2100 -SN SCT008 OVC026 M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1200 SHSN BKN012CB
12:00 UTC / 15:00 local time:
UUDD 111200Z 13005MPS 1900 R14R/2000D R14L/1900D SN SCT007 OVC026 M05/M06 Q1019 R14R/590293 R14L/590491 TEMPO 1200 SHSN BKN012CB
Photos
accident date: 11-02-2018
type: Antonov An-148-100
registration: RA-61704
altitude profile
RA-61704
RA-61704
RA-61704
accident date: 11-02-2018
type: Antonov An-148-100
registration: RA-61704
Aircraft history
| date | registration | operator | remarks |
|---|---|---|---|
| May 2010 | RA-61704 | first flight | |
| 23 June 2010 | RA-61704 | Rossiya | registered |
| 28 July 2013 | RA-61704 | Rossiya | engine shut down after surges |
| 23 August 2013 | RA-61704 | Rossiya | nose gear tyre failure on takeoff |
| 14 April 2015 | RA-61704 | Rossiya | stored at St. Petersburg |
| 8 February 2017 | RA-61704 | Saratov Airlines | leased |
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Moskva-Domodedovo Airport to Orsk Airport as the crow flies is 1441 km (901 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Moskva-Domodedovo Airport to Orsk Airport as the crow flies is 1441 km (901 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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