ATR-72 VP-BYZ 02.04.2012

     Investigation team of the Interstate Aviation Committee completed preparation of the Final report draft in accordance with the investigation results of the fatal accident with ATR72-201 VP-BYZ aircraft occured near Roschino Airport (Tyumen, RF) on April 2, 2012. 
      In accordance with Standard of the Annex 13 "Aircraft accident and incident investigation" to the Convention on International civil aviation organisation the Final report draft was sent to France (the state of aircraft designer and manufacturer) and also to other states participating in the investigation. After receiving and consideration of commentaries from states participating in the investigation, in accordance with the Standard of International Civil Aviation Organization and Russian Legislation the Final report will be published in accordance with the established procedure. 
      Necessary information and operative recommendations on flight safety development were presented to the concerned authorities organisations during investigation progress.
     

    The Chairperson of the Investigation team of the accident with ATR72-201 VP-BYZ aircraft occured in the area of Roschino airport (Tyumen, RF) on April 2, 2012 informs that in accordance with Annex 13 Standard "Aircraft Accident and Incident Investigation" to Convention on international civil aviation the Investigation team received official commentaries on Final report Draft from France (state of aircraft designer and manufacturer) and also from Great Britain (aircraft was registered in overseas territory of Great Britain - Bermuda). After commentaries consideration by the Investigation team the Final report based on the investigation results will be published in accordance with the established procedure.  

     The Interstate Aviation Committee Investigation team has completed the investigation of the accident with ATR72-201 VP-BYZ aircraft owned by "UTair "Aviation Company" Ltd occurred near Roschino Airport of Tyumen (RF) on April 2, 2012.  
      The fatal accident with АТR72-201 VP-BYZ aircraft was caused by PIC's indecision for departure (In violation of requirements of FAR-128 clause 2 and FOM ATR72) without deicing procedure given ice and snow deposits on aircraft surface detected by the crew during taxiing operation that resulted in deterioration of aircraft aerodynamic performance and its stall during climb after take off and non-recognition of this mode by the crew followed by nonacceptance of measures for aircraft recovery into flight operation modes. Aircraft stall occured at operational angles-of-attack immediately after flaps retraction at activated autopilot before stall warning (later the warning was actuated normally) in accordance with logic.
      Systemic cause of the accident were deficiencies in aircraft ground service management and "UTair-Technic" personnel training that became possible due to lack of effective monitoring from Technical Directorate and Directorate of "UTair" Airlines" inspection for compliance with requirements of developped own documents on ground service and protection of Airlines aircraft from ground icing and without shift foreman monitoring resulted in faulty assessment of aircraft by PIC and aircraft surface condition by aircraft mechanic after its long ground time in conditions of heavy ground icing and aircraft operation without deicing procedure.      
      Contributing factors were:
      • Deficiencies in flight safety control system of "UTair" Airlines" JSC containing mainly general provisions and specific measures not adapted for implementation in all areas of Airlines activity that prevented the timely identification and elimination of the risks effecting flight safety. 
      • Deficiencies in "UTair-Technic" Ltd quality mangement system resulted in non-compliance with a number of requirements of "UTair" Airlines" JSC aircraft ground service manual in part of personnel training and monitoring for aircraft de-icing procedures resulted in authorization of persons without special training in accordance with Airlines requirements for aircraft ground service (including aircraft surface condition).
      • Lack of valid fundamental document at the time of the accident (In accordance with implementation of Commission recommendations made until completion of the investigation, on February 5, 2013 Federal Air Transport Agency prepared recommendations "Aircraft protection from ground icing" which are recommended for use by all operators. Also from July 1, 2012 GOST R 54264-2010 "Aircraft de-icing methods and procedures" determining state requirements in the field of aircraft ground service management including their protection from ground icing including requirements for licensing of organisations and personnel performing relevant activities became valid. 
      • Deficiencies in initial and periodic crew members training in understanding of operation hazard level with not eliminated ground icing, its effect on aircraft aeroperformance and purpose and procedure of aircraft de-icing system use that prevented the crew from taking the only correct decision to return from taxiway route and perform de-icing procedure given snow and ice formation on a wing after de-icing system application in de-icing mode during aircraft taxiing to perform take-off. 
      • Methodological imperfection ground and simulator training of crew members on prevention of stall entry, aircraft stall recognition and timely actions on aircraft operational flight modes entry.
      • Increasing need for crew strength increase in order to perform large volume of production programme in a steady growth of transport volumes, lack of effective FO SMS resulted in formality and methodological deficiencies in training personnel work on PIC training, not acquiring skills on taking informed decisions and strict compliance with specified training and flight operation regulations. 
        Possible crew members fatigue due to violation of work-rest cycle with devided flight duty periods and heavy vacation pay liability.
      The appropriate safety recommendations based on the investigation results were developed.