Bureau Enquêtes-Accidents REPORT TRANSLATION on the accident on 12 November 1999 North of Pristina (Kosovo) to the ATR 42-300 registered F-OHFV operated by SI FLY F-FV991112A MINISTERE DE L'EQUIPEMENT, DES TRANSPORTS ET DU LOGEMENT INSPECTION GENERALE DE L'AVIATION CIVILE ET DE LA METEOROLOGIE FRANCE F O R E W O R D This report presents the technical conclusions reached by the BEA on the circum- stances and causes of this accident. In accordance with Annex 13 of the Convention on International Civil Aviation, with EC directive 94/56 and with Law N°99-243 of 29 March 1999, the analysis of the accident is intended neither to apportion blame, nor to assess individual or collec- tive responsibility. The sole objective is to draw lessons from this occurrence which may help to prevent future accidents or incidents. Consequently, the use of this report for any purpose other than for the prevention of future accidents could lead to erroneous interpretations. SPECIAL FOREWORD TO ENGLISH EDITION This report has been translated and published by the BEA to make its reading easier for English-speaking people. As accurate as the translation may be, please refer to the original text in French. F-OHFV - 12 November 1999 - 2 - Table of Contents F O R E W O R D ________________________________________________ 2 SYNOPSIS_________________________________________________ 9 ORGANISATION OF THE INVESTIGATION __________________________ 10 1 - FACTUAL INFORMATION _____________________________________ 11 1.1 History of Flight _____________________________________________ 11 1.2 Injuries to Persons___________________________________________ 12 1.3 Damage to Aircraft___________________________________________ 12 1.4 Other Damage ______________________________________________ 12 1.5 Personnel Information________________________________________ 12 1.5.1 Flight Crew ______________________________________________ 12 1.5.1.1 Captain ______________________________________________ 12 1.5.1.2 Copilot ______________________________________________ 14 1.5.1.3 Flight Attendant _______________________________________ 16 1.5.2 Air Traffic Controller _______________________________________ 16 1.6 Aircraft Information __________________________________________ 17 1.6.1 Airframe_________________________________________________ 17 1.6.2 Engines _________________________________________________ 17 1.6.3 Equipment_______________________________________________ 17 1.6.4 Weight and Balance _______________________________________ 20 1.6.5 Maintenance _____________________________________________ 20 1.7 Meteorological Conditions ____________________________________ 20 1.7.1 General Situation _________________________________________ 20 1.7.2 Situation at the Aerodrome __________________________________ 21 1.7.3 Observations at the Site ____________________________________ 21 1.8 Aids to Navigation ___________________________________________ 21 1.9 Telecommunications_________________________________________ 23 1.9.1 Communications with Pristina Approach________________________ 23 1.9.2 Radar Data ______________________________________________ 25 F-OHFV - 12 November 1999 - 3 - 1.10 Aerodrome Information ______________________________________ 26 1.10.1 History_________________________________________________ 26 1.10.2 Infrastructure____________________________________________ 27 1.10.3 Airspace _______________________________________________ 27 1.11 Flight Recorders ___________________________________________ 28 1.11.1 Types and Readout Operations _____________________________ 28 1.11.1.1 Cockpit Voice Recorder ________________________________ 28 1.11.1.2 Flight Data Recorder __________________________________ 28 1.11.2 CVR Readout ___________________________________________ 29 1.11.3 Readout of FDR Data _____________________________________ 30 1.12 Wreckage and Impact Information _____________________________ 32 1.12.1 Description of Site and Area ________________________________ 32 1.12.2 Information Gathered from the Wreckage______________________ 34 1.13 Medical and Pathological Information __________________________ 34 1.14 Fire ______________________________________________________ 35 1.15 Survival Aspects ___________________________________________ 35 1.16 Tests and Research_________________________________________ 35 1.16.1 Identification of the CRC___________________________________ 35 1.16.2 History of the GPWS and the Radio Altimeter __________________ 36 1.16.3 GPWS_________________________________________________ 37 1.16.3.1 Examination _________________________________________ 37 1.16.3.2 Simulations__________________________________________ 37 1.16.3.2.1 AlliedSignal Simulation _____________________________ 37 1.16.3.2.2 Aérospatiale Matra Simulation________________________ 37 1.16.4 Examination of GPS ______________________________________ 38 1.16.5 Crew Fatigue____________________________________________ 38 1.17 Information on Organisations and Management _________________ 39 1.17.1 Information on the Operator ________________________________ 39 1.17.1.1 History and Structure __________________________________ 39 1.17.1.2 Operational Documentation _____________________________ 40 1.17.1.2.1 Operations Manual ________________________________ 40 1.17.1.2.2 Manuale Operativo ________________________________ 41 1.17.1.2.3 Instructions for Operations on the Rome-Pristina Line _____ 42 1.17.1.2.4 Aeronautical Documentation _________________________ 43 1.17.1.3 Entry into Service of Rome-Pristina Line ___________________ 43 1.17.1.3.1 History __________________________________________ 43 1.17.1.3.2 Flight preparation__________________________________ 44 1.17.1.4 Operation of the Rome-Pristina Line ______________________ 44 1.17.2 Information on the Organisation of Pristina Aerodrome ___________ 45 1.17.3 Operational Procedures used by the Pristina ATC organisation ____ 45 1.18 Supplementary Information __________________________________ 47 1.18.1 Aeronautical Documentation________________________________ 47 F-OHFV - 12 November 1999 - 4 - 1.18.1.1 Aeronautical Information Manual _________________________ 47 1.18.1.2 Air traffic flow management Information Messages ___________ 48 1.18.1.3 SPINS______________________________________________ 49 1.18.1.4 NOTAMs issued by KFOR ______________________________ 49 1.18.1.5 Summary ___________________________________________ 50 1.18.2 Terminology ____________________________________________ 50 1.18.3 Use of Radar on Approach _________________________________ 50 1.18.4 Testimony ______________________________________________ 52 1.18.4.1 Si Fly’s Director of Operations ___________________________ 52 1.18.4.2 Si Fly’s Technical Director ______________________________ 53 1.18.4.3 ATC Personnel _______________________________________ 53 1.18.4.4 French Military Pilots __________________________________ 54 1.18.5 Other Airlines Serving Pristina ______________________________ 54 2 - ANALYSIS __________________________________________________ 56 2.1 Conduct of the Flight_________________________________________ 56 2.2 GPWS Serviceability _________________________________________ 57 2.3 The Operator and the Oversight________________________________ 58 2.4 Approach Control ___________________________________________ 60 2.5 Aeronautical Information _____________________________________ 62 3 - CONCLUSIONS ______________________________________________ 64 3.1 Findings ___________________________________________________ 64 3.2 Causes ____________________________________________________ 66 4 - RECOMMENDATIONS ________________________________________ 67 F-OHFV - 12 November 1999 - 5 - Table of illustrations Figure 1 : Track of the accident flight_________________________________________________________ 11 Figure 2 : Captain’s activity in the week preceding the accident____________________________________ 14 Figure 3 : Copilot’s activity in the week preceding the accident ____________________________________ 15 Figure 4 : GPWS and GS push buttons_______________________________________________________ 18 Figure 5 : Three-position GPWS switch in NORMAL position______________________________________ 18 Figure 6 : Three-position GPWS switch in OFF position__________________________________________ 18 Figure 7 : Crew Alert Panel ________________________________________________________________ 19 Figure 8 : Situation at altitude, 12 november 1999 at 10 h 30 UTC _________________________________ 20 Figure 9 : Radar Data_____________________________________________________________________ 25 Figure 10 : Track of KSV 3275______________________________________________________________ 26 Figure 11 : View of accident site ____________________________________________________________ 32 Figure 12 : Side view of site________________________________________________________________ 32 Figure 13 : Accident site seen from above ____________________________________________________ 33 Figure 14 : Debris________________________________________________________________________ 34 Figure 15 : Radar Vector Chart _____________________________________________________________ 46 Figure 16 : Organisation of airspace in Kosovo_________________________________________________ 47 Figure 17 : Track of F-OHFV on 10 November 1999 ____________________________________________ 57 Figure 18 : Relative position of aircraft F-OHFV and HCN 993 when HCN 993 took number one position for landing ________________________________________________________________________________ 61 F-OHFV