INTERSTATE AVIATION COMMITTEE AIR ACCIDENT INVESTIGATION COMMISSION FINAL REPORT ON RESULTS OF INVESTIGATION OF ACCIDENT Type of accident Fatal accident Type of aircraft АTR72-201 aeroplane Registration VP-BYZ, Bermudas Owner BLF Limited Operator UTAir Aviation, JSC Place of accident 1500 m from RWY 21 threshold; cross-track deviation about 400 m, Roschino aerodrome, Tyumen. Coordinates: N 57°09.440′ E 065°16.000´ Date and time of accident 02.04.2012, 01:35 UTC (07:35 local time), day time In accordance with ICAO standards and recommended practices, it is not the purpose of this report to apportion blame or liability. The sole objective of the investigation and the Final Report is the prevention of accidents. Criminal aspects of the accident are investigated within the framework of a separate criminal case. Draft Final Report ATR72-201 VP-BYZ 2 Table of contents LIST OF ABBREVIATIONS ..................................................................................................................................... 4 SYNOPSIS ................................................................................................................................................................. 10 1. FACTUAL INFORMATION.......................................................................................................................... 11 1.1. FLIGHT HISTORY ....................................................................................................................................... 11 1.2. INJURIES TO PERSONS ............................................................................................................................... 13 1.3. DAMAGE TO AIRCRAFT ............................................................................................................................. 13 1.4. OTHER DAMAGE ........................................................................................................................................ 20 1.5. PERSONNEL INFORMATION ........................................................................................................................ 20 1.5.1. Flight Crew Information ...................................................................................................................... 20 1.5.2. Technical Personnel Information ........................................................................................................ 35 1.6. AIRCRAFT INFORMATION .......................................................................................................................... 40 1.6.1. АТR72-201 ice protection system schematic diagram ......................................................................... 43 1.7. METEOROLOGICAL INFORMATION ............................................................................................................ 44 1.8. AIDS TO NAVIGATION ............................................................................................................................... 53 1.9. COMMUNICATIONS .................................................................................................................................... 53 1.10. AERODROME INFORMATION ...................................................................................................................... 53 1.11. FLIGHT AND GROUND RECORDERS ............................................................................................................ 55 1.11.1. On-board recorders ............................................................................................................................. 55 1.11.2. Readout and timing of the CVR and ground recorders data ............................................................... 58 1.11.3. Surveillance cameras’ video data analysis .......................................................................................... 62 1.12. WRECKAGE AND IMPACT INFORMATION.................................................................................................... 64 1.13. MEDICAL AND PATHOLOGICAL INFORMATION .......................................................................................... 70 1.14. SURVIVAL ASPECTS .................................................................................................................................. 73 1.15. SEARCH AND RESCUE OPERATIONS .......................................................................................................... 76 1.16. TESTS AND RESEARCH .............................................................................................................................. 82 1.16.1. Engineering Simulation ....................................................................................................................... 82 1.16.2. FFS Test Flight .................................................................................................................................... 91 1.16.3. Review of Standard Operating Procedures (SOP) .............................................................................. 93 1.16.4. MFC Study ........................................................................................................................................... 94 1.16.5. Fuel and Lubricants Analysis .............................................................................................................. 95 1.16.6. Aircraft Trajectory Computation ......................................................................................................... 95 1.17. ORGANIZATIONAL AND MANAGEMENT INFORMATION ............................................................................. 97 1.18. ADDITIONAL INFORMATION .................................................................................................................... 101 1.18.1. Flight Operations at UTAir ............................................................................................................... 101 1.18.2. Results of UTAir-Technic audit performed by EASA ......................................................................... 107 1.18.3. Significant Extracts from Available Current Regulations on De-/Anti-Icing and Staff Training ...... 108 1.18.4. Eye-Witness Explanations Confirming Presence of Contamination on the Aircraft Surface ............ 128 1.18.5. Information on De/Anti-Icing of Other Aircraft on 02.04.2012......................................................... 130 1.18.6. Information on the Movement of De/Anti-Icing Vehicles .................................................................. 130 1.18.7. Accidents Caused by Ground Icing and Aircraft Stall ....................................................................... 131 1.18.8. Information on the PIC's Initial Training at a Flight School ............................................................ 133 1.18.9. English language proficiency assessment .......................................................................................... 134 1.18.10. FAP "Certification of Airports. Procedures" .................................................................................... 142 1.18.11. Of the aviation organizations inspection order ................................................................................. 142 2. ANALYSIS ..................................................................................................................................................... 144 2.1. THE ANALYSIS OF THE CLAUSES OF THE DOCUMENTS THAT DETERMINE THE AIRCRAFT ANTI-ICING/DE- ICING PROCEDURE AND THE REQUIREMENTS FOR THE PERSONNEL QUALIFICATION TOGETHER WITH THEIR ACCOMPLISHMENT IN RELATION TO THE ACCIDENT FLIGHT .................................................................................... 144 2.2. THE ANALYSIS OF THE SMS IMPLEMENTATION IN UTAIR ....................................................................... 152 2.3. AIRCRAFT PRE-FLIGHT PREPARATION .................................................................................................... 155 2.4. THE FLIGHT DESCRIPTION AND THE ANALYSIS OF THE AIRCRAFT MOTION ............................................... 163 2.5. ANALYSIS OF THE CREW WORK AND REST BALANCE ............................................................................... 171 2.6. THE ANALYSIS OF THE REQUIREMENTS ON PRE-FLIGHT AIR CREWS METEOROLOGICAL SUPPORT ............ 173 2.7. THE ANALYSIS OF THE CREW QUALIFICATION AND ACTIONS ................................................................... 173 INTESTATE AVIATION COMMITTEE 3. CONCLUSION .............................................................................................................................................. 186 3.1. FINDINGS ................................................................................................................................................ 186 3.2. CAUSES ................................................................................................................................................... 192 4. OTHER SHORTCOMINGS REVEALED BY THE INVESTIGATION ................................................ 195 5. SAFETY RECOMMENDATIONS .............................................................................................................. 196 5.1. TO RUSSIAN AVIATION AUTHORITIES ..................................................................................................... 196 5.2. TO AIRLINES’ MANAGEMENT ................................................................................................................. 197 5.3. TO ATR 42/72