Accident Final Report

Islamic Republic of IRAN Civil Aviation Organization Accident Final Report

State File Number: A13880431UPI6208 Type of Occurrence: Accident Date of Occurrence: July 22th 2009 Place of Occurrence: I.R.IRAN - Mashhad Safety & Accident Aircraft Type: IL-62M Investigation Department Registration: UP-I6208

Operator: Aria

‌

Islamic Republic Of Iran Civil Aviation Organization Aircraft Accident Investigation Department

Final Report Basic Information Type of occurrence: Accident Date: 24.Jul.2009 Location: Mashhad International Airport/ I.R of Iran Aircraft: Airplane Model: IL-62M Registration: UP-I6208 Owner: DETA Airline Operator: ARIA Airline Date of Issue: 05 Jun 2010

Civil Aviation Organization of I.R. of Iran Aircraft Accident Investigation Department Mehrabad International Airport PBO: 13445-1795 Tehran/Iran Fax: + 98 21 6601 8659 Tel.: + 98 21 6604 7965 E-mail: [email protected] http://www.cao.ir

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Foreword: Civil Aviation Organization is responsible for supervision on correct implementation of laws and regulations and flight standards in civil Aviation industries of the country, according to international commitments and domestic laws of the Islamic Republic of Iran; in this respect, the accidents are investigated , in order to identify threaten resources of safety ratio of flights, based on international regulations and compiled guidelines of International Civil Aviation Organization, ICAO (annex 13). After identifying main causes and contributive factors of the accident, safety recommendations are issued in order to consider flight standards and regulations, as well as more attention to flight safety for preventing the same accidents. Written matters in annex 13 of ICAO and relevant appendixes emphasize on this matter that “The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability” The main objective of investigating accidents is to achieve main causes and roots for preventing similar accidents in the future. About IL-62M airplane accident, owned by DETA Airline, Kazakhstan, (leased by Aria Airline) in July 24, 2009, at 08:05 local time (13:35 UTC) on Shahid Hasheminejad International Airport/ Mashhad, The Accident Investigation Team was attended in the place of accident immediately and gathered information; this team receives FDR and CVR of the plane, in order to analyze them. In this direction, there has been taken necessary actions for correct investigation of technical – operational documents and study about the accident site and body of the plane in order to identify main and contributive causes of this accident and issue safety recommendations for preventing such same occurrences. The accident investigation team however appreciates Interstate Aviation Commission (IAC) for mutual cooperation in the investigation of accident involving IL- 62M with registration, UP-I6208 and preparing final report of this accident.

2 Synopsis:

Type of the aircraft Illyushin, model IL-62M Registration mark UP-I6208 Owner DETA Airline, Kazakhstan Operator Aria Airline Date of accident July 24,2009 Time of accident 18:05 local time (13:35 UTC) Place of accident End of left band of Mashhad International Airport Damage to airplane Destroyed No of passengers 156 person No of crews 17 persons& one additional crews group No of fatal 16 persons No of injured person 31persons Responsible for accident Aircraft accident investigation &safety investigation Dept. I.R of Iran Foreign cooperator (IAC) Interstate Aviation commission Committee/(Russia ، Kazakhstan Civil Aviation Authority Main cause of accident crews mistakes

3 1. Factual Information

1.1 History of the flight:

At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline

with registration, UP-I6208 and flight no. IRX.1525 of Aria Airline flight

with 169 passengers from Mehrabad International Airport/ Tehran, and it

has landed at 18:05 local time on RWY 13 L in Mashhad International

Airport; then it has run off from end of the runway, without considerable

reduction in aircraft speed and it collided with wall of the airport and it was

stopped after approximately 185 m.

The mentioned aircraft has been leased by Aria Airline as ACMI,

according to contract No. 002/IL-62M/ACMI.

Subsequently, the ground safety unit of the airport has attended in place of

occurring accident, by breaking protective fences and barbed wires of the

airport, and then they evacuated passengers and extinguished fire outside of

aircraft by carrying out necessary actions.

4 1.2 Injuries to persons:

Injured persons of this accident were carried to hospitals of Mashhad

city, after search and rescue operation, bodies of victims were transferred

to the legal medicine. The following table shows overview of body injuries

to passengers of this aircraft:

Injuries Crew Passenger Others

Fatal 11 5 0 Serious Injuries 2 1 0 Minor 0 28 0 None 7 122 0 Total 17 156 0

1.3 Damage to aircraft:

The aircraft fuselage destroyed totally due to impact to wall of the airport and it caused destroying cockpit and nose section airframe and it can't be reconstructed.

1.4 Other Damage:

Due to impact of aircraft landing gears with net barrier in shoulder of RWY 13L, it has major damages on it and some damages to PAPI light in beginning of RWY 31R.

5 1.5 Personnel Information:

1.5.1 Pilot in Command :( PF) Birth year 1957 Kind of certificate and validity date Class one validity date 28/OCT/09 Medicine condition Without medicine limitation and it is valid until 28/Aug/09 Total flight hours 14200 Total flight hours with IL-62 1500 Date and place of last simulator 10/Mar/09 Russia Prior accident None

License for international flight ok License for radio communication ok Entrance date to Iran 19 July 2009 Date of first flight in Iran 24 July 2009 No of flight in Iran 6 flights

According to available documents, he has done Radio communication but the level of his English conversation was not suitable.

1-5-2 Copilot:

Date of Birth 1962 Kind of certificate and validity date Class 2 validity date24/Feb/2010 Medical condition Without medical limitation and it is valid until 24/Feb/2010 Total flight hours 8294 Total flight hours with IL-62 1319 Date and place of last simulator 10/MAY/2009 Russia

6 Prior accident none

License for international flight ok License for radio communication ok Entrance date to Iran 19 July 2009 Date of first flight in Iran 24 July 2009 No of flight in Iran 6 flights

1-5-3 Flight Engineer:

Date of Birth 1957 Kind of certificate and validity date Class 1 validity date28/OCT/09 Medical condition Without medicine limitation and it is valid until 28/0CT/09 Total flight hours 8747 Total flight hours with IL-62airline 1697 Date and place of last simulator 10/MAY/09 Russia Prior accident None

License for international flight ok License for radio communication ok Entrance date to Iran July , 17,2009 Date of first flight in Iran July , 23,2009 No of flight in Iran 6 flights

7 1.6 Aircraft Information:

The Ilyushin aircraft IL-62M with S/N: 1951525 have been manufactured at 09.06.1989 in Ilyushin Aircraft Factory, and its owner is

DETA Air Company, Kazakhstan. It has been registered at June 16, 2008 with UP-U6208, by Civil Aviation Authority of Kazakhstan. It has also received its last certificate of Airworthiness at Jan. 28, 2009 from this state, which it was valid until Jan. 28, 2010.

This airplane has been exploited after upgrading its navigation and telecommunication, as well as installing its passenger oxygen system for flight operation in Iran.

This airplane has been arrived in I.R of Iran Territory , due to agreement No. 002/ IL-62M/ACMI, dated on Nov. 16, 2008 as "wet lease agreement (ACMI) for aircraft IL-62M, between DETA Air, as Lesser and

Aria Airline as Lessee at Jan. 17, 2007.

State registry number UP-I6208

Manufacture number № 1951525 Owners Eugeny V. Zhigayev Ibragim A. Paskachev

8 Operator ARIA airline. The aircraft owned by D.E.T.A. AIR airline was leased under an agreement and operated by the airline “ARIA AIR” (IR of Iran).

Date of release 09 June 1989 State registration certificate No.538 dated 16 June 2008 Airworthiness aircraft certificate No(Kazakhstan)Republic).0538 dated January 28, 2009 valid till January 28, 2010 Assigned life time and service life 35000 hours, 7500 landings., 20 years (Bulletin No.1440-БЭ), Bulletin No. 291-62M was fulfilled on January 20, 2009, so in accordance with the bulletin the assigned service life was extended to 20 years 4 months, till September 29 2009. Overhaul life and service time 10200 hours, 2700 landings (Bulletin No.1399 БЭ), 14 years Operating time since new(TSN) 13573 hours, 3987 landings Operating time since the last overhaul(TSO) 7876 hours, 2458 flights

Number of overhauls, date of the last overhaul One overhaul, September 29, 1995

Overhaul life rest 2384 hours, 242 landings

Last periodic technical maintenance According to the logbook – March 29, 2009, form Ф-1К with operating time 7666 hours and 2338 landings, maintenance sheet №9 Last periodic maintenance Form Б 15 July 2009, maintenance sheet

51, Teheran Fuelling 20 tons

Fuel type Jet -A1

Insurance certificate Kazakhinstrakh, Insurance agreement No. 17/303/08/891

9 Engines installed in the aircraft:

Engine type D-30KU-2 D-30KU-2 D-30KU-2 D-30KU

Serial № 51148802221 51248802214 51219002225 0304022212226

Manufacturer JSC “Rybinskiye JSC “Rybinskiye JSC “Rybinskiye JSC “Rybinskiye motory” motory” motory” motory” Date of 22 November1988 26 October1988 11 March1990 30 April1982 manufactureOperating time 7261 hours, 7425 hours, 7307 hours, 14046 hours, since new 1836 cycles 1890 cycles 1729 cycles 3536 cycles

Place of the JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn last overhaul

Date of the 30 December 1999 23 October 2001 14 May 2002 30 March 2000. last overhaul Operating time 3574 hours 3119 hours 1806 hours 3567 hours since the last 928 cycles 779 cycles 438 cycles 925 cycles overhaul Overhaul life 3637 hours 3330 hours 3000 hours 3627 hours time 901 cycles 767 cycles 543 cycles 898 cycles Overhaul life 63 hours, 210 hours, 1194 hours, 60 hours, time rest -27 cycles -12 cycles 105 cycles -27 cycles

Engines, APU TA-6A, units and assembly parts were operated in compliance with the effective operating regulations.

All four engines had sufficient life times in operation hours to perform flights. According to bulletins No. 1770 and No. 1844 of the engine manufacture JSC NPO Saturn, effective dates February 08, 2002 and June 29, 2007, the first, second and fourth engines had exceeded life time in cycles (27, 16(12), 27 correspondingly). Life times were extended by the JSC “Aerotechservice” (Nikolayev, Ukraine) and JSC “Engine” (Perm).

10 Engine maintenance performed: № APU Periodical maintenance Current maintenance PU 1 Ф-1К – 21 April 2009 ФБ – 19 July 2009 PU 2 Ф-1К – 29 April 2009 ФБ – 16 July 2009 PU 3 Ф-1К - 29 April 2009 ФБ – 15 July 2009 PU 4 Ф-1К – 21 April 2009 ФБ – 19 July 2009

The airframe, assemblies and units has life time sufficient to perform flight tasks except for the cycle life time for AP units 1, 2, 4. The aircraft had no malfunctions before the accident flight on July 24, 2009. No complaints were made on technique functioning during the flight. According to information of the flight date recorders, engine and aircraft system operating parameters were in compliance with the assigned modes.

1.7 Meteorological information: According to the meteorological office report, status of the current air (METAR), in the accident time in Mashhad International Airport (Shahid Hasheminejad) at 24.07.2009 was according to the following table:

ICAO ID:OIMM Time Wind Pressure TEMP/DEW Density دما و نقطه شبنم Cloud LMT DIRECTION Visibility altitude ميزان و )SPEED(KT DEG) HPA INCH) زمان UTC (feet) ديد افقي RH ارتفاع ابر سرعت سمت محلي رطوبت نسبي

53/M05 11:50 02:61 60 12 CAVOK 1013 62.91 6299 7.52 % 34/M03 12:50 17:20 80 14 CAVOK 1012 29.89 6235 9.24 %

33/M04 13:50 18:20 60 14 CAVOK 1012 29.90 6124 9.06 %

11 There were not any effective metrological factors that could affect on operation of the aircraft.

1.8 Aids to navigation: Mashhad international airport is equipped with aid to navigation systems as below: NDB 385KHZ DVOR/DME 11400 MHZ LLZ 109.900MHZ ILSGP 333.800MHZ ILS/DME CH36X According to available documents at accident time, all navigational systems operations were normal

1.9 Communication: Mashhad international airport equipped to communication system as below:

Frequency Time Notes APP: 127.300 MHZ H24 121.500 MHZ H24 Emergency frequency 353.800 MHZ H24 Military frequency

TWR: 118.100 MHZ H24 121.700 MHZ H24 121.900 MHZ H24 257.800 MHZ H24 Stand by For all VHF 243.000 MHZ H24 UDF, Military Aircraft Military Emergency ATIS (INFO) 126.400 MHZ

Communication and conversation from the flight control units & CVR of aircraft have shown the correct operation of these systems.

12 1.10 Aerodrome information:

Mashhad international Airport of (OIMM) has aerodrome reference point with geographical coordination 361403N 0593842E in MAG 312 Deg with elevation of 3226 FT RWY 13L threshold.

Its direction and distance is as East and 3 Km from Mashhad, its height from sea level is 3263 ft, and its temperature degree reference is 34.1 C.

There are permission IFR/VFR flights in this airport. Fire fighting facilities of Mashhad INTL Airport is in CAT7. It has two Runways in direction of 13/31 L, R with 3811 * 45 m dimension. About this accident, there weren’t any faults in this regard.

1.11 Flight Recorders: FDR

The aircraft was equipped with flight data recorders MSRP-64 and MSRP- 12-96. A tripartite recorder K3-63 was not installed in the aircraft. The recorders were retrieved from the accident site by Iranian accident investigation team. Data readout was carried out at a facility of the “PARS Aviation Service” company. The information from the MSRP-12-96 recorder was not downloaded. The cassette KS-13 of the accumulator KBN as well as the magnetic tape of the tape media MLP-14-5 of the onboard recorder MSRP-64 were in satisfactory condition and had the parametric accident flight data recorded on them. On the pictures below some readout results are shown:

13 -7.8 6.8 -1.83 Time UTC Time 7.1

279 Touchdown Stab.p 13.8 0.0 276 -8.6 malfunction СGV 1.23 3.2 13:35:00 325 87.5 Leftgyro failure horizon GPWS Right gyro failure horizon Right -5.60 265.6 13:34:00 1.00 664.7 30.0 9.0 22.1 20.9 793.3 13:33:00 364 15.6 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C Alt.radi 13:32:00 2200.0 -0.7 Alt.pr 8.4 13:31:00 -6.3 8.8 13:30:00 -2.79 479 3000.0 13:29:00 Landing gears extend actuator to Landing 24.2 3388.9 24.0 1.17 13:28:00 3833.3 13:27:00 571 13:26:00 -1.00 13:25:00 4.0 0.6 13:24:00 Pic.1.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.1.1. IL-62M -1.0 0.0 0.2 -0.3 793.3 13:23:00 -1.44 4.4 -0.6 1.00 Elev: Elevator position Elevator Elev: 13:22:00 CCP: Control column position column Control CCP: VHF keying VHF IAS: Indicated airspeed Indicated IAS: Flaps.l: Flaps (left) Flaps Flaps.l: Pitch: Pitch angle Pitch Pitch: Spoil.l: Spoiler (left) Spoiler Spoil.l: Flaps.r: Flaps (right) Flaps Flaps.r: AOA:of Angle attack 13:21:00 Spoil.r: Spoiler (right) Spoiler Spoil.r: Stabzr: Stabilizer position Stabilizer Stabzr: AFCS.Rol: AFCS roll channel ON channel roll AFCS AFCS.Rol: 9538.5 AS760: Altimeter setting 760 setting Altimeter AS760: 514 VertAcc:Vertical acceleration Alt.radi: Radio altitude Radio Alt.radi: Alt.pr ON channel pitch AFCS AFCS.Pit: 5 0 1 0 6 4 2 0 -5 -2 -4 15 10 [g] 30 20 10 50 1.2 0.8 0.6 0.4 -10 -15 IAS 600 550 500 450 400 350 300 250 200 150 100 Elev [deg] [deg] [deg] СGV! Spoil.l [km/h] Spoil.r GPWS Stabzr AS760 VHFkey VertAcc RA.Glid+ 0 8 6 4 2 0 0 0 -2 50 12 10 30 20 10 [m] -50 150 100 900 800 700 600 500 400 300 200 100 CCP [mm] -100 -150 Pitch AOA [deg] [deg] 1100 1000 Flaps.l Stab.p Flaps.r Alt.radi GHLFai AFCS.Pit RA.Locz+ [m] WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:57:22 #11 User: Zayko (#3) Zayko User: #11 22:57:22 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32 9800 9600 9400 9200 9000 8800 8600 8400 8200 8000 7800 7600 7400 7200 7000 6800 6600 6400 6200 6000 5800 5600 5400 5200 5000 4800 4600 4400 4200 4000 3800 3600 3400 3200 3000 2800 2600 2400 2200 2000 1800 1600 1400 1200 Elv.l+ Alt.pr GHRFai LG-ToExt AFCS.Rol

14 0.13 -2.1 -17.0 21.9 130.0 Time UTC Time -2.9 37.7

279 115.6 Touchdown 276 0.0 13:35:00 127.1 325 87.5 0.01 265.6 13:34:00 664.7 5.8 121.4 793.3 13:33:00 364 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C -33.5 Alt.radi 13:32:00 2200.0 0.0 Alt.pr 13:31:00 -28.9 9.6 7.6 -38.3 13:30:00 479 140.0 3000.0 8.1 -30.0 13:29:00 24.5 3388.9 13:28:00 3833.3 114.1 13:27:00 571 13:26:00 62.9 13:25:00 0.0 Pic.1.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.1.2. IL-62M 13:24:00 0.0 0.01 1.9 1.5 793.3 13:23:00 -18.4 82.9 13:22:00 Roll_le: Roll angle (left FD) angle Roll Roll_le: IAS: Indicated airspeed Indicated IAS: 13:21:00 Ail.l: Aileron position (left) position Aileron Ail.l: LatAcc:acceleration Lateral CWP: Wheel position Wheel CWP: AFCS.Rol: AFCS roll channel ON channel roll AFCS AFCS.Rol: Roll: Roll angle Roll Roll: LocDev: Localiser deviation Localiser LocDev: GMH: Magnetic heading Magnetic GMH: 9538.5 Roll_ri: Roll angle (right FD) (right angle Roll Roll_ri: Ail.r: Aileron position (right) position Aileron Ail.r: 514 Rudder: Rudder position Rudder Rudder: Alt.radi: Radio altitude Radio Alt.radi: Alt.pr 5 0 0 0 0 -5 30 20 10 80 60 40 20 50 2.5 -10 -20 Ail.l Roll IAS 280 260 240 220 200 180 160 140 120 100 600 550 500 450 400 350 300 250 200 150 100 Ail.r -2.5 GMH [deg] [deg] [deg] [km/h] Roll_ri Roll_le 0 0 0 0 0 20 10 20 10 [g] 50 50 [m] 0.6 0.4 0.2 -10 -20 -30 -10 -50 -50 150 100 800 750 700 650 600 550 500 450 400 350 300 250 200 150 100 -0.2 -100 -150 CWP [deg] [deg] [mkA] Alt.radi Rudder LatAcc LocDev WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:19:00 #12 User: Zayko (#3) Zayko User: #12 23:19:00 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32 [m] 9800 9600 9400 9200 9000 8800 8600 8400 8200 8000 7800 7600 7400 7200 7000 6800 6600 6400 6200 6000 5800 5600 5400 5200 5000 4800 4600 4400 4200 4000 3800 3600 3400 3200 3000 2800 2600 2400 2200 2000 1800 1600 1400 1200 1000 Alt.pr 10400 10200 10000

15 -41.8 113.3 122.9 Time UTC Time

121.1 115.0 366 345 279

570 605 13.8 83.3 82.7 Touchdown 276 0.0 -34.2 -41.8 497 435 33.8 30.3 16.6 26.8 13:35:00 RevShut1 325 RevShut4 87.5 265.6 487 435 13:34:00 30.6 39.7 664.7 35.0 793.3 13:33:00 364 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C Alt.radi 13.9 7.9 13:32:00 3.1 70.9 74.5 86.0 2200.0 0.11 28.3 28.2 66.7 60.0 Alt.pr 477 420 13:31:00 50.3 41.1 63.2 56.5 62.4 57.3 13:30:00 13:29:00 Landing gears extend actuator to Landing 13:28:00 0.8 7.0 13:27:00 46.3 571 48.6 398 355 13:26:00 13:25:00 23.7 16.6 0.50 7.9 1.6 13:24:00 Pic.1.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.1.3. IL-62M 28.2 28.3 N1.1: Low N1.1: pressure compressor 1 rate 340 N1.4: Low N1.4: pressure compressor 4 rate 793.3 13:23:00 Throt1: Throttle position 1 position Throttle Throt1: Throt4: Throttle position 4 position Throttle Throt4: 13:22:00 EGT4: Exhausted gaz temp. 4 gaz temp. Exhausted EGT4: VHF keying VHF IAS: Indicated airspeed Indicated IAS: EGT1: Exhausted gaz temp. 1 gaz temp. Exhausted EGT1: Ubus22A: Bus 22A Bus voltage Ubus22A: Cab/Atm: Cabin/atmosphere pressure ratio Cabin/atmosphere Cab/Atm: Ubus21A: Bus 21A Bus voltage Ubus21A: 13:21:00 VibRm4: Engine rear mount vibration ratio # 4 # ratio vibration rear mount Engine VibRm4: VibRm3: Engine rear mount vibration ratio # 3 # ratio vibration rear mount Engine VibRm3: 9538.5 2.4 11.3 514 526 65.8 500 77.0 72.7 altitude Radio Alt.radi: 0.61 Alt.pr 0 5 0 80 60 40 20 20 15 10 29 28 50 [V] [%] IAS 100 600 550 500 450 400 350 300 250 200 150 100 Fire LOP 28.5 27.5 N1.4 N1.3 N1.2 N1.1 AC1+ [km/h] VibRm4 VibRm3 VibRm2 VibRm1 [mm/sec] Ubus22A Ubus21A LG-ToExt RevShut4 0 0 0 40 20 [m] 0.8 0.6 0.4 0.2 650 600 550 500 450 400 350 300 250 900 800 700 600 500 400 300 200 100 CIO! [deg] [deg] 1100 1000 EGT4 EGT3 EGT2 EGT1 AC2+ FMmin Throt4 Throt3 Throt2 Throt1 Alt.radi VHFkey Cab/Atm BagSMK [kgf/sm2] [m] WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 21:18:24 #13 User: Zayko (#3) Zayko User: #13 21:18:24 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32 9800 9600 9400 9200 9000 8800 8600 8400 8200 8000 7800 7600 7400 7200 7000 6800 6600 6400 6200 6000 5800 5600 5400 5200 5000 4800 4600 4400 4200 4000 3800 3600 3400 3200 3000 2800 2600 2400 2200 2000 1800 1600 1400 1200 Alt.pr HSP< DVibr EngFire RevShut1

16 111 Time UTC Time -7.0 129 -7.8 16.0 13:35:50 1.77

17.0 -6.1 Ditch -234.7 13:35:45

7.8

186 -2.2 End of the RWY the of End 13:35:40 206 -1.7 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C 13:35:35 VHF keying VHF -1.83 6.8 13:35:30 СGV malfunction СGV Leftgyro failure horizon 13:35:25 7.1 Right gyro failure horizon Right 13:35:20 279 Stab.p 13:35:15 13:35:10 13.8 -67.3 0.0

13:35:05 Touchdown 1.23 -8.6 276 2.6 6.8 Pic.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.3.1. IL-62M 13:35:00 3.2 13:34:55 2.5 -5.60 -0.6

31.3 1.00 passing Thrshould 318 13:34:50 50.0 GPWS 325 71.9 AOA:of Angle attack 13:34:45 -2.2 Spoil.l: Spoiler (left) Spoiler Spoil.l: Pitch: Pitch angle Pitch Pitch: Spoil.r: Spoiler (right) Spoiler Spoil.r: Stabzr: Stabilizer position Stabilizer Stabzr: IAS: Indicated airspeed Indicated IAS: VertAcc:Vertical acceleration Elev: Elevator position Elevator Elev: CCP: Control column position column Control CCP: 100.0 Alt.radi: Radio altitude Radio Alt.radi: 5 0 1 0 5 0 -5 15 10 [g] 15 10 1.6 1.4 1.2 0.8 0.6 0.4 0.2 -10 -15 IAS 320 300 280 260 240 220 200 180 160 140 120 100 Elev [deg] [deg] СGV! Spoil.l [km/h] Spoil.r GPWS GHRFai VHFkey VertAcc RA.Locz+ 0 8 6 4 2 0 4 2 0 0 -2 -4 -6 -2 -4 -6 50 12 10 90 80 70 60 50 40 30 20 10 [m] -50 150 100 110 100 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:58:29 #31 User: Zayko (#3) Zayko User: #31 22:58:29 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32 CCP [mm] -100 -150 Pitch AOA [deg] [deg] Elv.l+ Stab.p Stabzr Alt.radi GHLFai RA.Glid+

111

Time UTC Time

13:35:50

2.9

-0.36

-16.5 Ditch

13:35:45

186

-1.2

0.6

9.4

19.3

3.2

End of the RWY the of End

13:35:40

206

-18.9

A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C

4.2

6.9

3.9

-18.0

0.14

-2.1

21.9

13:35:35

130.0

6.8

-0.6

37.7

-5.2

13:35:30

13:35:25

7.1

37.7

-1.0

-2.1

-5.6

13:35:20

115.6

-3.3

279

6.6

31.7

13:35:15

-2.5

13:35:10

12.7

0.0

115.6

13:35:05

Touchdown Touchdown

276

Pic.3.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.3.2. IL-62M

13:35:00

-3.8

0.6

0.0

3.8

13:34:55

127.1

59.3

31.3

318 passing Threshould

Roll_le: Roll angle (left FD) angle Roll Roll_le:

13:34:50

127.1

50.0

325

Roll: Roll angle Roll Roll:

13:34:45

Spoil.l: Spoiler (left) Spoiler Spoil.l:

Rudder: Rudder position Rudder Rudder:

Spoil.r: Spoiler (right) Spoiler Spoil.r:

CWP: Wheel position Wheel CWP:

87.5

Ail.r: Aileron position (right) position Aileron Ail.r:

Ail.l: Aileron position (left) position Aileron Ail.l:

LatAcc:acceleration Lateral

Alt.radi: Radio altitude Radio Alt.radi:

IAS: Indicated airspeed Indicated IAS:

GMH: Magnetic heading Magnetic GMH:

LocDev: Localiser deviation Localiser LocDev:

Roll_ri: Roll angle (right FD) (right angle Roll Roll_ri:

-5

2.5

-20

-10

-15

-10

IAS

Roll

Ail.l

100

125

150

175

200

225

250

275

300

325

350

-2.5

Ail.r

[deg]

[km/h]

Roll_ri

Roll_le

Rudder

WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:35:05 #32 User: Zayko (#3) Zayko User: #32 23:35:05 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32

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113.3 122.9 End of the RWY the of End 13:35:40 206 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C 13:35:35 VHF keying VHF 91.6 1.8 13:35:30 -0.8 24.7 Lowpressure any engine in oil 13:35:25 121.1 115.0 11.4 18.8 13:35:20 366 345 279 28.1 570 602 13:35:15 82.7 83.3 121.4 13:35:10 128.7 -34.2 -41.8 0.0

13:35:05 Touchdown 276 497 435 Pic.3.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mahrabad at 24.07.2009 UP-I6208 Aircraft Pic.3.3. IL-62M 13:35:00 33.8 30.3 16.6 26.8 3.1 28.2 5.0 RevShut1 2.0 28.2 13:34:55 RevShut4

31.3 318 Threshould passing Threshould 13:34:50 50.0 325 13:34:45 Bus 22A Bus voltage Bus 21A Bus voltage 87.5 Throt3: Throttle position 3 position Throttle Throt3: Throt4: Throttle position 4 position Throttle Throt4: EGT2: Exhausted gaz temp. 2 gaz temp. Exhausted EGT2: Alt.radi: Radio altitude Radio Alt.radi: Engine rear mount vibration ratio # 4 # ratio vibration rear mount Engine Engine rear mount vibration ratio # 2 # ratio vibration rear mount Engine airspeed Indicated IAS: EGT4: Exhausted gaz temp. 4 gaz temp. Exhausted EGT4: N1.1: Low N1.1: pressure compressor 1 rate N1.4: Low N1.4: pressure compressor 4 rate 0 5 0 80 60 40 20 25 20 15 10 [%] IAS 120 100 320 300 280 260 240 220 200 180 160 140 120 100 Fire N1.4 N1.3 N1.2 N1.1 HSP< AC2+ [km/h] VibRm4 VibRm3 VibRm2 VibRm1 VHFkey [mm/sec] RevShut1 0 0 40 20 32 30 28 26 24 90 80 70 60 50 40 30 20 10 [V] [m] WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:04:50 #33 User: Zayko (#3) Zayko User: #33 22:04:50 02.08.2009 Printed: COMITTEE AVIATION INTERSTATE WinArm32 650 600 550 500 450 400 350 300 250 110 100 LOP [deg] [deg] EGT4 EGT3 EGT2 EGT1 AC1+ Throt4 Throt3 Throt2 Throt1 Alt.radi BagSMK Ubus22A Ubus21A RevShut4

Impact with a wall. a with Impact

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NAV: Turn to the left. To the left! the To left. the to Turn NAV:

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122.9 A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525 Date:24.07.09 Reg.No.:UP-I6208 type:IL-62M A/C

End of the RWY the of End

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NAV: Turn to the left. the to Turn NAV:

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91.6 displacement. reversal thrust no was there Because FE:

FO: What's up? Why reverse don't switch? don't reverse Why up? What's FO:

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Pax: Berast, bersat (Pers.) bersat Berast, Pax: 279

570 increasing! is Speed NAV:

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Pic.3.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mashhad accident FDR (MSRP-64) flight parameters. (Preliminary) parameters. flight (MSRP-64) FDR accident Mashhad at 24.07.2009 UP-I6208 Aircraft Pic.3.3.1. IL-62M Toushdown

NAV: about 0.5 meter 0.5 about NAV:

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Crew: Is the idle on? idle the Is Crew: 50.0

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N1.1: Low N1.1: pressure compressor 1 rate

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WinArm32 Printed: 03.09.2009 14:57:41 #44 User: Зайко (#3) User: #44 14:57:41 03.09.2009 Printed: WinArm32

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d:\up-i6208.Ил-62М.Иран.2009\map\up-i6208_1b.tra 13:35:00.0 8nm 6nm 4nm 2nm 2nm 4nm 6nm 8nm 10nm 13:34:00.0 13:31:00.0 13:33:00.0 13:32:00.0 Pic. IL-62M 5b. UP-I6208 Aircraft on 24.07.2009 (Preliminary) flight pathdata). (FDR Mashhad airport at 13:30:00.0 13:29:00.0 WinArm32 Тип:IL-62M Борт:UP-I6208 Дата:24.07.09 Рейс:1525 Зайко User:

13:28:00.0

21 13:27:00.0 CVR:

The aircraft IL-62M was equipped with a CVR MARS-BM with a total record time of 30 minutes. The recorder was retrieved from the accident place by Iranian accident investigation team. The information readout was performed at a facility of “PARS-Aviation Service Company”. The magnetic tape of the recorder was in a satisfactory condition so the accident flight data was recorded. Preliminary download of the cockpit conversation and voice identification was also conducted by representatives of Kazakhstan Civil Aviation Committee and D.E.T.A. AIR airline. The final transcript of cockpit radio communication with time synchronization was made by the Air Accident Investigation Scientific and Technical Support Commission of the IAC.

1.12 Wreckage and Impact information: Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).

22 The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.

Layout of accident site:

Detailed description of aircraft, systems and engines damage

24 After landing at the RWY13 the aircraft ran over the RWY at a high speed. The aircraft passed the RWY end with breaking the protective net barrier. Further the aircraft moved along the stop way deviating to the right and then to the left at a soil road. There were tracks of aircraft movement at the soil road after running over the RWY. The tracks looked like tracks from the front, left and right landing gear wheels.

Photo 1. Tracks of aircraft movement over the dirt road after running over the RWY

Photo 2. Tracks of aircraft movement over the dirt road after running over the RWY

25 Due to emergency braking after running over the RWY the front right wheel of the right main gear was destroyed. The aircraft ran over the RWY at a speed of about 200 km per hour. The aircraft moved to the right and broke several approach lights at a concrete footing. When moving over a rough terrain due to a high speed, the aircraft front gear was broken. At a distance of 350m from the runway , there was a ditch 2m wide and 1m in depth. As the aircraft got into the ditch at a speed of about 185 km per hour the front gear was completely broken. Further the left main gear got into the ditch followed by aircraft turning to the left. As the front gear was broken the aircraft moved on sliding on the airframe nose. Further the aircraft hit the brick wall concrete base 2,5 m high at a speed of 120 km per hour. This resulted in destruction of the cockpit and the airframe up to frame 22 (6 th seat row). The distance from the RWY end to the place of the collision with the fence was 880m. Then the aircraft moved 160m more and came to stop. There was no fire on board. Wires of the power line passing outside the aerodrome were ruptured by airframe structure elements.

The aircraft leaned on the tail part of the airframe with a little bank to the port side. The flaps were fully extended, spoilers retracted, reverse flaps open; the stabilizer was set 1,8 degrees pitch up.

Photo 3. Aircraft post-accident overall view

During the accident the aircraft got sever damage as follows: - The cockpit and the cabin up to the frame 22 (the 6th seat row) were totally wrecked. - The nose part and lower wing panels were heavily damaged. - The right flaps (inner and outer) were sheared off. - The left flap had got substantial damage. - The front gear was torn out from the attachment points, between main gears, between frames 58 and 62. - The right main gear flap was sheared off. - Main gears had major damage and the right gear front right wheel was wrecked. - Lower flaps of power units 1 and 4 and flap control elements had significant damage. - Control linkage was totally destroyed up to the airframe nose destruction line; beyond this no damage found.

Photo 4. Airframe nose (destroyed up to frame 22)

Photo 5. Left wing structures damage

Photo 6. Right wing structures damage

Photo 7. Right (outer) flap’s damage

Photo 8. Front right gear (torn out of attachment points), destroyed right inner flap

Photo 9. Right main gear flap sheared off

Photo 10. Right main gear destroyed wheel

Photo 11. Power unit 1 reverse flaps

Photo 12. Power unit 4 reverse flaps

Photo 13. Power unit 4 front power lever

Photo 14. Power unit 4 rudder shackle of padlock As the cockpit was completely destroyed it appeared not possible to determine throttle positions, instrument data and switches positions.

All structure damages occurred once after the aircraft had run over the RWY, when it was moving over terrain, and resulted from the collision with obstacles (the ditch, lights concrete footing and brick wall). There were no tracks of destruction resulting from fatigue.

No evidences of ailerons, rudders and elevator jamming were found. Spoilers were in the retracted position. The flaps were fully extended.

The aft fuselage had no visible damage. The stabilizer setting was changed by the crew during the landing run from 5,6 degrees pitch up to 1,8 degrees pitch up (according to the MSRP–64). The rudders were not fixed. There was no stabilizer position indication on the fin.

Photo 15. Stabilizer position – 1,8 degrees

1.13 Medical and pathological information:

Crew of this flight has valid medical license from Kazakhstan civil

Aviation Authority and they had not medical problem for the flight.

By considering to collision the airplane with the wall, flight crew and

front passengers have been injured by hitting it, and they have been dead,

because of this collision. After transferring bodies to the forensic medicine

of Mashhad, necessary pathological test were carry out ,and samplings

from the flight crew was done, and it was determined that they don't have

an especial deficiencies about using drugs and alcohol.

1.14 Fire:

After this accident, the ground safety of Mashhad Airport sent fire extinguish vehicles to the site of this accident immediately, but they only extinguished a small fire in plants and thorns of around the airplane caused by friction, because there wasn't observed a considerable fire in the airplane.

As wreckage of the airplane has been located near the flammable gas line, these vehicles have remained in this site until carrying out it to a safe place, in order to prevent fire and explosion of the pipe.

1.15 Survival aspects:

After this accident, ground security and research & rescue units of

Shahid Hashemijejad Airport (Mashhad) began their efforts, in order to allocate place of accident, to rescue passengers and crew. By considering to condition of the region and location of the airplane outside of the airport, there were taken necessary actions by cooperating ground safety and extinguish staffs, and other research and rescue organs; the passengers were evacuated from aircraft wreckage, and injured persons were transferred to hospitals of Mashhad.

1.16 Test and Research: None 1.17 Organizational and management information:

According to contents ATC records of Shahid Hashemijejad Airport

(Mashhad), after this accident, the control tower in Mashhad Airport has reported this accident to the relevant authorizations, which there have been taken necessary actions, in order to initiate search and rescue operation.

There have been carried out all actions about search and rescue, transferring bodies to the forensic medicine of Mashhad and identify their identity, flight crew and passengers.

1.19 Useful or effective investigation Techniques:

The standard and normal techniques were applied.

36 2. ANALYSIS:

After joining landing course the flight altitude was 7000 ft, distance from the RWY end 22 km. The aircraft was preceded by another aircraft approaching to land, which had been cleared to land earlier. Being instructed by a controller to reduce speed due to the proceeding traffic, approaching to land, the captain decided to make left orbit and informed the crew about that. Upon a navigator’s request the controller cleared to perform left orbit maintaining 7000 ft. No evidences of task sharing regarding flying the aircraft before descending from the FL to approach to land were recorded. By some navigator’s words one can judge that it was the captain who was the flying pilot: Kolya, 7000, climb, climb Kolya!. The aircraft landing weight was 93.7 tons. Data on the landing weight, landing approach speed, approach chosen, and alternate aerodrome were not voiced during the pre-landing preparation (not proceeding check list). After joining landing course the controller cleared to descend to 6000 ft, at a distance of 13 km from the RWY end. As the aircraft approached to the RWY the navigator reported the distance: Distance 6, distance 5, flying above. After crossing the 5 km distance the navigator without a captain’s command read out the checklist: landing gear down, brakes, spoilers, altitude selector. No answers to the voiced checklist points were recorded. Further the navigator goes on counting distance: distance 2 km, distance 1, altitude 40m. When passed distance 1 km, the co-pilot gave a command (which was supposed to be given by the PIC) to set idle: “Idle”. The flight engineer confirmed: “Idle”, but according to the MSRP-64 data idle was set before the command. Flight speed along the glide path was 325 km/h, which was 50 km/h more than the assigned speed for a landing weight of 93 tons. The rate of descent was 10 m/sec. During the descent the GPWS

37 warning activated several times. The RWY end was crossed at a height of 31 m and at a speed of 310 km/h. At a height of 22m the flight engineer shifted trust reverses to a reverse thrust position without a captain’s command. No report “Lever latched lights on” about the shift was made. The landing was performed (according to the calculation made) at a distance of 1000 m from the RWY threshold at a speed of 275 km/h (instrument speed). According to the MSRP record before landing the flight engineer shifted engine’s 1 and 4 trust reversers to the forward thrust. After landing and extending the front gear down, the co-pilot (it is a captain who should give command) gave the command “Reverse”, without any monitoring by either of them of engine trust reversers position indication at the instrument panel. The flight engineer without checking out the thrust reverse lever position and trust reversers position indication and reading back (“roger, reverse on”) set throttles of engines 1 and 4 at the maximum trust.

Note: It should be noted that as for that aircraft type, if the reverse lever is in the “Reverse” position, throttles cannot, due to their design, be set at a position over the “Nominal” mode (80…90 degrees according to thrust mode indicator).

The actual record of the MSRP-64 contained record of the flight mode implied on engines 1 and 4, which is possible only in case reverse thrust lever is set at the “forward thrust” mode. There was no reporting “reverse engaged”.

38 No command was given to activate spoilers, which were not extended upon landing. The co-pilot set the stabilizer from 5, 6 degrees pitch up to 1, 8 degrees pitch up. Just at the same time upon landing (2 seconds later) inner engines were shut down by the flight engineer. Nevertheless the aircraft did not brake as the trust reversers were shifted to forward thrust. The mode was maintained for 12 seconds. According to navigator’s reports, which were consistent with the MSRP record, the speed began to increase. The navigator informed the crew about increase of speed. According to the MSRP a speed of 280 km/hour was reached. After the navigator informed about increase of the speed, the flight engineer shut down engines no. 1 and 4. The MARS-BM record contains crew members’ voices record: Co-pilot – “Leaving”, Navigator – “Brakes”, Co-pilot – “Why isn’t reverse functioning?” the PIC – “because flaps are not shifted”, Navigator – “Emergency braking”. MSRP-64 record contains multiple change of throttle position of engines 2-3 and 1-4 before the flight mode, as well as shifting trust reversers, but it was done with engines disengaged. Crew’s actions, engine parameters, flaps position are consistent with the readout chart. It should be noted that crew’s actions when landing did not comply with the Crew Interaction and Procedure Instruction for the case of landing with reverse engaged, under the Operating Manual of the IL-62 type (Tab 4.1). Wheel Braking, including emergency braking, was not effective. The aircraft ran over the RWY at a speed of 200 km/hour, deviated to the right after the front right wheel tire of the front right gear blew out. Further on, it broke some approach lights, with a concrete base, crossed the net barrier had its front gear broken and then at a speed of 185 km/hour got into the ditch, up to 1 m in depth and 2m in width, which traversed the aircraft’s path at an angle, had its front gear broken down. Then due to its left gear getting into

39 the ditch as well, turned to the left facing the brick wall with a concrete foundation. As the front gear was broken, the aircraft moved on its forward fuselage and at a speed of 120 km/hour collided with the concrete foundation of the brick wall 2,5 m high. As a result of the front impact the cockpit and airframe up to frame 22 (6th seat row) were totally ruined. The crew and some passengers, who were in the first cabin, were killed. The aircraft moved on over the dirt for 160m, broke the power line and came to a stop. There was no fire on the aircraft after the stop. It should be noted that several accidents with aircraft IL62M took place before, which occurred due to the lack of accurate interaction between captain and crew during landing with thrust reverse involved. In most cases these accidents were a result of non-authorized flight engineer’s actions to shift engine trust reversers at heights more than these recommended in the FM, followed by their shifting to forward thrust and setting engines 1 and 4 at the flight mode. Another cause was an unmonitored thrust lever position (not latched) and position of engine trust reversers indication before setting engines at the maximum braking mode, which resulted in running over the RWY.

Table 4.1. Il-62M crew interaction checklist to be fulfilled at landing with thrust reverse engaged Flight At the command of captain “Idle”, read it back and reduce engineer engine power to idle. PIC By the end of flaring at the idle mode give the command: “Shift flaps” (with a glide path angle under 3 degrees 30 min. At a height of no more than 5 m give the command “Shift flaps” (with a glide path angle no more than 3 degrees 30 min) Flight At the captain’s command “Shift flaps” read it back. Shift the engineer reverse control lever of engines 1-2 from the position

40 “REVERSE OFF” to the position “REVERSE ON”. Check by the indication display whether the reverse flaps are shifted and report “Lever latched lights on”. PIC At a height of 1-2m, if necessary, give the command “Reverse”. By the end of flaring prevent increase of pitch angle and touch down the RWY by the main wheels. Upon landing manipulating the rudder, match the aircraft axis with the RWY centre line, put down at the RWY the front gear (in 2-3 seconds), give the command “Reverse” (if reverse was not engaged earlier) and activate the front gear control. Fix the control column in the “Push” position; give the command “Spoilers”. Flight On the captain’s command “Reverse” read it back, set engines engineer 1 and 4 throttles at the maximum reverse thrust mode (to the “Reverse” stop) and report: ”Reverse engaged”. Upon the captain’s command “Spoilers” read it back, extend spoilers to the maximum angle and report: “Spoilers extended”. Make sure that the engines 1 and 4 parameters are consistent with the reverse thrust mode.

41 THROTTLES AND THRUST REVERSE LEVER CONTROL SYSTEM

Thrust reverse lever

Nominal mode stops

42 Middle thrust reverse lever position latch

43 3. CONCLUSIONS: 3-1 Findings:

 The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.

 The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.

 The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)

 There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.

 The flight crew did not pay attention to EGPWS warning, and did not take corrective action.

 The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.

 The flight crew had not good English language proficiency. And they were poor in England language conversation.

 The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit.( lack of Cockpit Resource Management).

 There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.  The crew has had disagreement about “Go around” due to unsuitable landing situations.

 Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.

44  The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and supervise the matter accordingly.

3-2 Main Cause :

Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

3-3 Contributive Factors : Some of contributive factors for this accident occurrence are noted as:

. The copilot and the flight engineer had self activity& decision without the (PIC) coordination.

. The cockpit crew was careless and not paying proper attention toward EGPWS warning.

. Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

3-4 Violation &other deficiencies:

The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as: . Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.

. The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.

. It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.

. The crew was not familiar with Iranian AIP completely.

. The total on board persons was not according to written load sheet.

4- SAFETY RECOMMENDATIONS:

In order to prevent the similar events, the Aircraft Accident Instigation &Safety of IRI CAO recommends:

 .A special working group (Board) between Iranian airlines which used Russian leased aircraft and Russian airlines, be established and study how to obtain life extensions and modifications from Russian authorities as a state of design & manufacture.

 Those Iranian airliners that are willing to have foreign pilots shall provide training courses, such as Iran routs and necessary arrangements for crew members just before beginning of their flights.

 All foreign pilots should be checked by a related instructor pilot or a CAO designee pilot.

 The IL-62 cockpit should be equipped with flight engineer headset by the ILYUSHIN Design Bureau.

 The ILYUSHIN Design Bureau should study and investigate why ELT has not activated by the sever impact.

 Presence and entering passengers or any other persons than crew should really be forbidden during landing and take off by airlines.

 The Interstate Aviation Committee (MAK) and Aircraft Accident Investigation Department of IRI CAO should deliver notified findings of this accident to related airlines.

 It is recommended that a correct procedure of foreign pilot operation in the Iran territory should be defined by operation department of IRI CAO with cooperation of airlines.

 All airlines that are willing to use leased aircrafts should have sufficient supervision just before to start operation, should check and accomplish the written MOU between authorities and also consider those items in "Art 83 Bis ".