Serious incident Tupolev Tu-154M RA85794, Tuesday 4 January 2005
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Date:Tuesday 4 January 2005
Time:09:31
Type:Silhouette image of generic T154 model; specific model in this crash may look slightly different    
Tupolev Tu-154M
Owner/operator:Yakutia Airlines
Registration: RA85794
MSN: 93A-978
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: Substantial, repaired
Category:Serious incident
Location:Kittilä Airport (KTT/EKFT) -   Finland
Phase: Landing
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Moskva-Vnukovo Airport (VKO/UUWW)
Destination airport:EKFT
Investigating agency: AIB Finland
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Yakutia Airlines flight SYL9923, a Tupolev Tu-154, undershot the runway during landing at Kittilä Airport (KTT), Finland.
The aircraft landed short, touching the paved section of runway 34 thirty (30) metres before the threshold. The tail section of the fuselage was the first section to make contact with the ground and sustained major damage. None of the passengers or crew members were injured.


The flight originated Moscow and proceeded to Finland. Once Rovaniemi Area Control Centre (ACC) first cleared the airliner to descend to FL150 and later to FL100, the airliner left its cruising altitude at the normal position. At 07:19 Rovaniemi ACC recleared the aircraft to continue its descent and a moment later cleared it to leave controlled airspace. The ACC also informed it that radar service was terminated and instructed the aircraft to contact Kittilä Aerodrome Flight Information Service (AFIS). The aircraft contacted Kittilä but the flight crew did not understand that the Air Traffic Service (ATS) in Kittilä was AFIS service. The aircraft maintained FL100, even though under the AFIS procedure it should have continued to descend on own navigation for the approach. The aircraft finally left FL100 11.5 NM (21 km) from the Kittilä runway. This distance represents approximately one third of the normal distance from where descents commence. The aircraft did not intercept the ILS precision approach as per published procedure nor in accordance with regulated company procedures at any phase of the approach. Nor did it follow and maintain the ILS glidepath at any time during the approach. Kittilä aerodrome has a published racetrack procedure and had the aircraft followed it, it could have descended and intercepted the glidepath from the position at which it was when it passed locator KIT. The subsequent descent angle was approximately three times greater than the normal 3.4° path angle, established for the approach. During final approach the engine RPMs were at idle, running at ca. 30%. As per regulations, the engines should have been running at the minimum RPM of 61% and at 75% below 200 m. All engine RPMs began to spool up 6 seconds before touchdown. The aircraft touched down at an abnormal attitude; nose high with the tail section of the fuselage touching the ground first. The Flight Data Recorder (FDR) recorded a +3.5 g vertical acceleration at touchdown.

The investigation revealed that the flight crew were unaware of how the AFIS service worked, of the temporarily changed airspace structure in Kittilä as well as of the type of ATS service provided in Kittilä at any given time. Some of the crew members had flown to Kittilä the previous week, at which time Air Traffic Control (ATC) services had been available. The crew used the Jeppesen Licensed to Russia airway manual. However, the description of AFIS procedures in Finland contained therein was both inadequate and erroneous. Regulations on Finnish AFIS procedures as well as AFIS standard phrases were published in aeronautical information circulars (AIC) disseminated in Finland.

Multi Crew Cooperation during the approach did not function as intended, nor did the crew fully comply with the regulations in the company's manuals. The crew did not have sufficient command of the English language.

The direct causal factors of the incident were:
- The crew were unaware of the fact that they were flying in an AFIS environment. Nor were they familiar with the principles of AFIS procedures.
- The crew commenced the descent too late at a distance which was approximately three times shorter than normal procedure.
- The pilot-in-command decided to execute a straight-in approach even though the aircraft was approximately three times higher than that required at the time.

Even though the parameters for a safe landing were not fulfilled, the pilot-in-command decided to land.

Contributing causal factors were:
- Finnish ATS arrangements with regard to AFIS service differ from ICAO definitions. No descriptions on Finnish AFIS service characteristics existed which could appropriately reach all airlines that fly to Finnish AFIS aerodromes. This, especially, applies to foreign airlines. When the flight crew briefed for the flight, they did not have full access to information regarding the type of ATS service that is available in Kittilä at any given time. This information is included in NOTAMs meant for pilots.
- The present ATS provider practice of only publishing AFIS procedures domestically does not facilitate the dissemination of complete information to operators or flight crews. This, for its part, shows that the risks inherent in this type of air traffic service have not been analysed. Whilst AFIS service has been considered appropriate even at aerodromes where scheduled and chartered commercial aviation takes place, neither AFIS procedures nor information on them are adequately tailored to correspond to traffic volume requirements. Individual aerodromes have tried to manage air traffic volumes by instituting various temporary arrangements. However, no uniform practice among Finnish aerodromes exists.
- There are no explicit requirements concerning AFIS training in international or JAR flight crew certifications.
- Multi Crew Cooperation did not work as intended. The co-pilot's and the flight engineer's remarks on abnormal flight parameters did not carry sufficient weight and the pilot incommand, who was the Pilot Flying (PF), disregarded them.
- The flight crew's proficiency in the English language was inadequate. Communication with air traffic control during the phases of flight preceding the approach did not fully comply with standard phraseology. The air traffic controller and the AFIS officer had little possibility of steering the operation of the flight crew in the desired direction. No international standard AFIS phraseology exists. Examples of standard AFIS phrases are published in domestic regulations; however, no one has seen to it that this information reaches operators or pilots.

Accident investigation:
cover
  
Investigating agency: AIB Finland
Report number: B1/2005L
Status: Investigation completed
Duration: 2 years
Download report: Final report

Sources:

https://www.jetphotos.com/photo/407966
https://www.jetphotos.com/photo/413203
https://www.jetphotos.com/photo/408519
https://www.jetphotos.com/photo/408515

Revision history:

Date/timeContributorUpdates
24-Aug-2024 07:13 Justanormalperson Added
24-Aug-2024 07:22 ASN Updated [Time, Nature, Departure airport, Narrative, Accident report, ]
24-Aug-2024 07:24 ASN Updated

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