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Final Report Boeing 747-412F TC-MCL 1

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Final Report Boeing 747-412F TC-MCL 1 This document is an English translation of the Final Report on the fatal accident involving the Boeing 747-412F aircraft registered TC-MCL that occurred on January 16th, 2017 at Manas International Airport, Bishkek, Kyrgyz Republic. The translation was done as accurate as a translation may be to facilitate the understanding of the Final Report for non-Russian-speaking people. The use of this translation for any purpose other than for the prevention of future accidents could lead to erroneous interpretations. In case of any inconsistence or misunderstanding, the original text in Russian shall be used as the work of reference. INTERSTATE AVIATION COMMITTEE AIR ACCIDENT INVESTIGATION COMMISSION FINAL REPORT ON RESULTS OF THE AIR ACCIDENT INVESTIGATION Type of occurrence Fatal accident Type of aircraft Boeing 747-412F Registration mark TC-MCL Owner LCI Freighters One Limited (Ireland) Operator ACT Airlines Aviation Authority Directorate General of Civil Aviation of Turkey (Turkish DGCA) Place of occurrence Near Manas International Airport, Bishkek, Kyrgyz Republic, coordinates: N 43°03.248' E 074°2.271' Date and time 16.01.2017, 07:17 local time (01:17 UTC), night time INTERSTATE AVIATION COMMITTEE Final Report Boeing 747-412F TC-MCL 2 1. FACTUAL INFORMATION ..................................................................................................................... 10 1.1. HISTORY OF FLIGHT .................................................................................................................................... 10 1.2. INJURIES TO PERSONS ................................................................................................................................. 11 1.3. DAMAGE TO AIRCRAFT ............................................................................................................................... 11 1.4. OTHER DAMAGE ......................................................................................................................................... 26 1.5. PERSONNEL INFORMATION ......................................................................................................................... 27 1.5.1. Crew Members Information ....................................................................................................... 27 1.5.2. ATC Personnel Information ....................................................................................................... 29 1.6. AIRCRAFT INFORMATION ............................................................................................................................ 31 1.7. METEOROLOGICAL INFORMATION .............................................................................................................. 35 1.8. AIDS TO NAVIGATION, LANDING AND ATC ................................................................................................ 41 1.9. COMMUNICATION AIDS .............................................................................................................................. 48 1.10. AERODROME INFORMATION ....................................................................................................................... 48 1.10.1. Aerodrome Equipment ............................................................................................................... 49 1.10.2. Electrical and Airfield Lighting Support Equipment ................................................................. 49 1.11. FLIGHT RECORDERS.................................................................................................................................... 55 1.12. INFORMATION ON CONDITIONS OF AIRCRAFT FRAGMENTS AND THEIR LOCATION AT THE ACCIDENT SITE ... 58 1.13. MEDICAL INFORMATION AND SHORT SUMMARY OF AUTOPSY EXAMINATION RESULTS ............................... 67 1.14. SURVIVAL ASPECTS .................................................................................................................................... 67 1.15. SEARCH AND RESCUE OPERATIONS ............................................................................................................ 68 1.16. TESTS AND EXAMINATIONS ......................................................................................................................... 69 1.16.1. Fuel samples examination ......................................................................................................... 69 1.16.2. FCC examinations ..................................................................................................................... 69 1.16.3. Flight test of the ILS .................................................................................................................. 70 1.17. INFORMATION ON ACCIDENT-RELATED ORGANIZATIONS AND ADMINISTRATIVE ACTIVITIES ...................... 70 1.18. ADDITIONAL INFORMATION ........................................................................................................................ 71 1.18.1. On amendments to training programs, procedures and related documentation of ACT Airlines 71 1.19. NEW METHODS, USED DURING INVESTIGATION ........................................................................................... 72 2. ANALYSIS ................................................................................................................................................... 73 3. CONCLUSION .......................................................................................................................................... 115 4. SHORTCOMINGS, REVEALED DURING THE INVESTIGATION ................................................ 117 5. SAFETY RECOMMENDATIONS.......................................................................................................... 118 INTERSTATE AVIATION COMMITTEE Final Report Boeing 747-412F TC-MCL 3 ABBREVIATIONS AC Advisory Circular ACP Audio Control Panel AD Airworthiness Directive AFCS Automatic Flight Control System AFDS Autopilot Flight Director System AFM Aircraft Flight Manual AGL Above Ground Level AIP Aeronautical Information Publication ALT Altitude AMC Aeronautical Meteorological Centre A/P Autopilot APU Auxiliary Power Unit AS Aerodrome Service ARP Aerodrome Reference Point ASS Aviation Security Service ATC Air Traffic Control ATS Air Traffic Service CAS Calibrated Airspeed CAT Category CDU Control Display Unit CG Center of Gravity cd Candela (unit for measuring light intensity) cm centimeter CRM Crew Resource Management CVR Cockpit Voice Recorder DFCS Digital Flight Control System DA Decision Altitude DA(H) Decision Altitude (Height) DFDAC Digital Flight Data Acquisition Card DFDR Digital Flight Data Recorder DGCA Directorate General of Civil Aviation (Turkey) INTERSTATE AVIATION COMMITTEE Final Report Boeing 747-412F TC-MCL 4 DH Decision height DME Distance Measuring Equipment DNA Desoxyribonucleic acid E Eastern longitude EFIS Electronic Flight Instrument System EGPWS Enhanced Ground Proximity Warning System EICAS Engine Indication and Crew Alerting System ELP English Language Proficiency ELT Emergency Locator Transmitter ERFSS Emergency Rescue and Fire Protection Flight Support Service FAA Federal Aviation Administration, USA FAF Final Approach Fix FCC Flight Control Computer FAP Final Approach Point FAR Federal Aviation Regulations FCT-747 (TM) Boeing 747 Flight Crew Training Manual FCOM Flight Crew Operations Manual FCTM Flight Crew Training Manual FD Flight Director FDR Flight Data Recorder FIR Flight Information Region FL Flight Level FLTA Forward looking terrain alerting FMA Flight Mode Annunciator (on PFD) FMC Flight Management Computer FO First Officer ft feet ft/min feet per minute GCU Generator Control Unit GS Glideslope h hour INTERSTATE AVIATION COMMITTEE Final Report Boeing 747-412F TC-MCL 5 HAT Height Above Terrain, Height Above Touchdown HF High frequency HPC High Pressure Compressor Hz Hertz IAC Interstate Aviation Committee IAS Indicated air speed ICAO International Civil Aviation Organization IDG Integrated Drive Generator illeg illegible ILS Instrument Landing System IRS Inertial Reference System IST Ataturk Airport, Istanbul (IATA Code) JED King Abdulaziz International Airport, Jeddah, Saudi Arabia (IATA Code) КАIK Accident Investigation Board, Turkey kg kilogram km kilometer kt knot kVA kilovolt-ampere LH Left-hand LIM Localizer Inner Marker LOC Localizer LTD Limited LOM Localizer Outer Marker IATA International Air Transport Association ICAO International Civil Aviation Organization IFR Instrument Flight Rules ILS Instrument Landing System IOSA IATA Operational Safety Audit LPC Line Proficiency Check or Low Pressure Compressor (by context) LPT Low Pressure Turbine INTERSTATE AVIATION COMMITTEE Final Report Boeing 747-412F TC-MCL 6 LTBA Ataturk Airport, Istanbul (ICAO Code) m meter MAP Navigation display mode MCP Mode Control Panel MDH Minimum Decision Height METAR Meteorological Aerodrome Report MFD Multifunction Display MHz megahertz min minute mps meters per second MSN Manufacturer Serial Number N Northern latitude N/A Not applicable ND Navigation Display nm nautical mile NOSIG No significant changes NTSB National Transportation Safety Board, USA OM Operations Manual OPC Operational Proficiency Check OPER Operation OVI-I Level I High-Intensity Lighting System OVI-II Level II High-Intensity Lighting System PAPI Precision Approach Path Indicator PF Pre-flight PFD Primary
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