Accident investigation report completed and information captured
Narrative: During landing on the water of the lake, the plane flipped over. The pilot was slightly injured.
CONCLUSION The primary cause of the AT802A aircraft accident that occurred on July 21, 2015, on Lake Skadar was human error: a mistake by the aircraft crew, who left the landing gear extended during a water landing, which caused the aircraft to overturn. The aircraft sustained significant damage in the accident, while the crew remained uninjured.
The secondary cause, no less important than the primary one, was the absence of prescribed and approved procedures (such as a prescribed method, operations manual, methodological instructions, task execution program, or similarly named document) for carrying out such flights within the Aviation Unit of the Ministry of the Interior (AHJ MUP).
The existing "work organization" does not include procedures for monitoring the psychophysical condition of crews performing flights, does not track the extent of their flying outside the unit, and does not monitor their preparation for flights within the AHJ.
The organizational setup of the AHJ MUP of Montenegro leaves room for improvisation in the execution of flight operations for which it is intended, which negatively affects flight safety.
The investigation revealed a series of weaknesses and shortcomings which, while not the direct cause of the accident, created conditions that allowed it to happen. These shortcomings reflect the state of the following areas: - Rules and regulations for performing “special flights” - Work organization within the AHJ MUP of Montenegro - Approach to pilots’ protective equipment - The work of air traffic control