Falcon 50EX F-GLSA 20.10.2014

Accident date20.10.2014
Investigation status
Aircraft registration numberF-GLSA
Place of aircraft departureMoscow
Airport of departureVnukovo
Intended destinationFrance
Intended Airport of arrival
Accident sitein airport Vnukovo
Latitude
Longitude
Aircraft typeFALCON 50
Serial №
Aircraft operatorUnijet
Aircraft owner
The date of the completion of the investigation (report)24.10.2016
Number of fatalities4
Victims accuracy
Degree of aircraft destructionaircraft destroyed
Report

Final_Report_eng_F-GLSA.pdf (23.02 MB)

Aviation typeCommercial
Works type
Note

21 october 2014

     The accident with Falcon 50EX, F-GLSA register number (France) operated by Unijet airlines occurred in Vnukovo airport (Moscow).
     During takeoff operation from RWY 06 in accelerating run the aircraft collision with snow cutter blow occurred. Crew (three people) and one passenger (all citizens of France) were killed, the aircraft was destroyed.
     After recieving information the Interstate Aviation Committee has immediately formed the Investigation team, it proceeded to work.
     On the basis of Annex 13 "Accident and incident investigation" to the Convention on International Civil Aviation the notification about the accident was sent to the accident investigation authority (BEA) of France - state of aircraft designer, manufacture, registration and operator. In the nearest time french specislists will arrive in Moscow in order to participate in the investigation.
      At the moment the recorders are being delivered to the IAC laboratory.
      The Investigation team has been carrying out works on decoding data of ground recorders (ATC recorder, radars, surveillance cameras), weather conditions evaluation, aircraft condition and damage, actions of ATM specialists, airport service and aircraft crew.
    

21 october 2014

     The IAC Investigation team of the fatal accident with Falcon 50EX F-GLSA aircraft informs that in compliance with the ICAO standards (Annex 13 of Chicago Convention) the France accident investigation authorized body (BEA) - state of aircraft designer, manufacture, registration and operator assigned accredited representative and advisers. 
     Accredited representative and 5 advisers (BEA, Dassault - aircraft designer and Unijet - airline representatives) are arriving on 21 October, 2014 in the Moscow in order to participate in the investigation.
     In the IAC it was decided not to open the aircraft flight data recorders until the arrival of specialists from France. Further works on fatal accident investigation will be conducted in close collaboration with french colleagues in compliance with the ICAO standards within the framework of IAC-BEA Agreement and on the basis of long-term collaboration.
     

22 october 2014

     The Chairperson of the Interstate Aviation Comittee (IAC) Tatiana Anodina expresses again sincere condolences to the families and relatives of those killed of the mishap of Falcon aircraft at Vnukovo airport on behalf of the IAC and on her own behalf, to all french people who on October 20 suffered a huge loss and assures that the IAC will do its best in order to conduct comprehensive, thorough and independent investigation of this tragedy.
      On October 20 late in the evening performing take-off run the aircraft collided with the snow cutter blower that resulted in aircraft destruction and the passenger and crew members fatality.
      After recieving the information at night on October 21 the Investigation team of the accident was immediately formed and it started its work. The Investigation team consists of the most professional experts who immediately proceede to the field phase of the investigation
      In accordance to the Annex 13 to the Convention on the international civil aviation of the ICAO (International Civil Aviation Organisation) regulating accident investigations the notification about the accident was sent to the BEA - accident investigation body of France and to the ICAO. France in this case is the state of the aircraft design, manufacture, registration and operator. BEA of france has appointed the authorized representative and advisers who came to Moscow last night and joined the investigation work. These are specialists of the Investigation Bureau of the Dassault Company - aircraft design and manufacture and of the Unijet Airlines operating this aircraft. The ICAO Annex 13 in strict accordance with which the IAC always conducts accident investigation, provides certain rights and obligations of the states involved in the event to participate in the investigation, provide information, provide access to the accident site, technical assistance, etc. The IAC conducted more than 570 investigations in 76 countries including major disasters in collaboration with french colleagues. In our relations with french specialists we are guided not only by the ICAO standards but also by the provisions of the Agreement signed between the IAC and BEA as well as close professional contacts thay have developped in the course of 22 yeaars of cooperation.
      BEA of France as well as the IAC is a member of the International Transport Safety Accosiation (ITSA) which unites 15 independent investigation bodies and is one of the most professional and respected organisations in accident investigation in the world, we value our relationship.
      At the moment the IAC Investigation team continues its work at the crash site. Fragments of aircraft structure are being inspected, scheme of the accident is being made (so called "sketch maps"). At the same time at the airport the information is being collected and analysis of ATM, ATC services, airport and emergency services actions is being made. Experts recieved and study the data of radar picture of the aerodrome field, ATC services records and ATM data first and the data from all servillance cameras. Experts evaluate the meteorological conditions at the time of the accident, analysis of all necessary documentation including related preflight preparation.
      Yesterday flight recorders (FDR and CVR) were removed from the accident site and in agreement of the RF IC transfered and delivered to the IAC. Today inspection and successful download of the flight recorders data is held jointly  with experts from the BEA of France and in the presence of the Russian Federation Investigative Committee representative. The aircraft was equipped with modern, well-protected recorders in good condition which allowed to carry out those activities effectively. Currently experts have started data processing and decoding. In the nearest future the CVR data will be transfered to the investigation for the CVR transcript. After decoding CVR data will go to flight and engeneering experts for investigation. 
      Activities at the accident site will be continued with our French colleagues.
      The purpose of the investigation conducted by the IAC in accordance with the ICAO standards is not ascertaining someone's guilt (it is prerogative of the criminal of the criminal investigation authorities and courts), but objective and independent determination of the accident causes and making recommendations aimed at preventing similar events in the future.   
     The Interstate Aviation Committee is confident that jointly with our french colleagues and aviation experts thorough, independent and impartial investigation will be held. Complete and impartial information on the investigation progress will be regularly updated on the Interstate Aviation Committee website.

22 october 2014

      
      The examination and assessment of flight recorders condition are held in the IAC laboratory jointly with the french specialists in the presence of the Investigative Comittee of the Russian Federation specialist. Flight recorders don't have any traces of mecanic and temperature influence. Successful copying of CVR and FDR recorders data was held after preparation. Preliminary analysis of the registered data confirmed the availability of FDR and CVR records related to the last aircraft operation on October 20, 2014. Currently the data analysis and decoding are held.

24 october 2014

     The IAC Investigation team of the accident with the Falcon 50 EX F-GLSA aircraft informs that as a result of the preliminary decoding of flight (FDR and CVR) and ground-based (ATC monitoring and surveillance system) recording facilities it was established:
      • The takeoff was performed from RWY 06 (magnetic course 58 degrees) away from TWY А11. The distance from the start of takeoff to the point of collission with snow cutter blower was about 100 meters. The collision occured at the intersection of the runways (so called "the cross").
      • The following weather conditions were recorded at the moment of takeoff: surface wind: 120° - 3 mps; at the begining of the RWY 06: visibility - 350m, RVR¹ - 1000m; in the middle of RWY 06: visibility - 1000m, RVR - 2100m; drizzle, fog.
      • At the time of the event the aircraft was under the "Tower" ATC control. The aircraft control was exercised by a trainee controller under supervision of instructor.
      • In time of issuing an ATC permission to takeoff the RWY was free. The crew confirmed the clearance to takeoff.
      • After about 10 seconds after the takeoff clearance was confirmed by crew and airfield monitoring and surveillance system installed at the "Tower" ATC control has recordered the movement of the snow cutter blower along the left edge of the RWY 19 to the south towards "the cross".
      • No request for a clearance to cross the runway by snow cutter blower was issued to the "Tpwer" ATC controller. There no mo recorde on the ATC tape after the clearance to takeoff was confirmed by crew and prior the moment of the accident.
      • In about 14 seconds after the aircraft started take-off run the crew observed an object identified as "a car crossing the road" (French language). This object wasn't identified as a danger, the takeoff was continued in usual manner in compliance with the standard operating procedures. In another approx. 14 seconds collision has occured. The crew discoverd the snow cutter blower just before the crash, after the regular command to lift the nose gear.
      • At the moment of collission with the snow cutter blower the aircraft was in the air, airspeed was about 134 knots (~248 kph). After the collision the aircraft rapidly began to develop a right bank angle which led the aircraft to cillode with the ground.
      • No failures of aircraft systems or engines were revealed up to now prior to the collision with snow cutter blower.

      The investigation team of the IAC is finalizing activities at the accident site with the France BEA colleagues. The anakysis of all recordings is going on as well as the factual data collected and flight and engineering documentation evaluation, ATC and meteo materials, data related to coordiantion of services. The synchronolization of CVR, FDR and ATC data is also unerway. Activities planned to be done in the most expeditious manner. The information about investigation preliminary results is going to be published in accordance to the ICAO Annex 13 standard.


___________________________
¹ RVR, runway visual range is the distance over which a pilot of an aircraft on the centreline of the runway can see markings delineating the runway or identifying its centre line.

14 november 2014

     The Interstate Aviation Committee Investigation team of the fatal accident with Falcon 50EX F-GLSA aircraft informs that the field stage of the investigation at the accident site is completed. Aircraft fragments and damaged rotary snow cutter blower are put in secure storage.
      Examination of aircraft structure, its components and analysis of flight recorders data didn't detect failures in aircraft systems and engines operation up to the moment of collision with the rotary snow cutter blower.
      According to the results of special investigation of rotary snow cutter blower electric bulbs the anti-collission beacon installed on it was on at the moment of collision.
      Active artificial RWY-1 lighting was in normal state. No comments regarding airfield surveillance radar operation were made by ATC personnel.
      Aircraft collision with the snow cutter blower occured at the intersection of artificial RWY-1 and artificial RWY-2.
      It is determined that visibility meters fixed in the approach end, midpoint and stop end of artificial RWY-1 and RWY-2 recorded visibility at the moment of the accident in 3 points of each artificial RWY: visibility measured in the midpoint of artificial RWY-1 and artificial RWY-2 (approximately in the area of runways "cross", point of aircraft collission with the vehicle) was about 1000 meters.
     The analysis of recorders data, assessment of airworthiness and technical documentation is in progress. Detailed analysis of ATM and aerodrome services work is being carried out.

30 april 2015

     The Interstate Aviation Committee Investigation team of the fatal accident with Falcon 50EX F-GLSA aircraft informs that the meeting of the IAC and the Aviation Accident Investigation Board (BEA) of France experts was held in the Interstate Aviation Committee on April 22...23.
      At the meeting the IAC and BEA informed each other about the course of work on investigation of this fatal accident. 
      The IAC experts presented the results of flight and engineering and technical subcommissions, materials on studying ATM and aerodromes services activity. BEA presented the results on mathematic simulation of aircraft motion on the RWY held jointly with the aircraft designer - Dassault company.
      The IAC and BEA agreed upon the further regular information exchange including information about operation of motion control system NPT A3000 of airoport Vnukovo presented by Transportation Safety Board of the Netherlands jointly with the system designer - Saab Technologies B.V. company.

19 october 2015

     In accordance with Standard 6.6 of Annex 13 of "Aircraft Accident and Incident Investigation" to Convention International Civil Aviation the Chairperson of the Investigation team of the accident with  Falcon 50EX F-GLSA aircraft occurred in Vnukovo airport (Moscow) on October 20, 2014 informs that the Investigation team has almost completed the range of activities necessary for determining the causes, circumstances and factors of the accident and prevention of the similar fatal accidents in the future and for the Final Report preparation as well. The main of them are:
      • field stage of the investigation including making sketch maps of the crash site and examination of the aircraft fragments;
      • decoding and analysis of flight and ground recorders data, surveillance cameras and Vnukovo airport perimeter as well;
      • studying the aircraft maintenance procedure and evaluation of the aircraft, engines and their systems operability during emergency flight;
      • evaluation of the crew proficiency and actions during emergency flight;
      • mathematical flight simulation including evaluation of take-off abort possibility at different run stages by the crew;
      • evaluation of operability and information analysis of Advanced Surface Movement Guidance and Control System (А-SMGCS) installed in Vnukovo Airport;
      • evaluation of air traffic management control in Vnukovo ATC center including the analysis of FO SMS implementation level;
      • evaluation of proficiency and actions of ATC service specialists including with regard to Advanced Surface Movement Guidance and Control System (А-SMGCS) operation;
      • evaluation of aerodrome service management in Vnukovo airport including the analysis of FO SMS implementation level;
      • evaluation of proficiency level and actions of aerodrome service specialists;
      • evaluation of aerodrome service emergency vehicles operability;
      • analysis of actual meteorological conditions, runway condition and aerodrome lighting facilities operability;
      • analysis of following work-rest cycle by the crew, ATC and aerodrome service specialists;
      • analysis of medical documents as well as the results of forensic and medical examinations of the crew members, ATC and aerodrome service specialists;
      • evaluation of emergency rescue operations performance and management;
      • study of RWY incursion statistical data and measures to reduce this risk level.
      According to the ICAO standards the Investigation team work was held in cooperation with accredited representative of Accident Investigation Bureau (BEA) of France - as the State of aircraft design, manufacture, registration and operator, as well as of Dutch Safety Board (DSB) - as the State of Advanced Surface Movement Guidance and Control System (А-SMGCS) design. Today the finalization of materials received from A-SMGCS system designer is being held.
      Today works of all formed subcommissions and study groups have been completed, all necessary volume of information has been received and analyzed. The Investigation team is completing the coordination of the Final Report project which after signing by all Investigation team members will be sent to the States which participate in the investigation process in accordance with Standard 6.3 of Annex 13.
     After receiving and considering States comments and if it is necessary introduction of amendments into the Final report project by the Investigation team, the Final Report will be adopted and published at the Interstate Aviation Committee official web-site.

17 may 2016

The Commission of the Interstate Aviation Committee (IAC) completed the range of activities on the investigation of the fatal accident with Falcon 50EX F-GLSA aircraft operated by Unijet Airlines.

All necessary workscope was held during the investigation including the field phase of the investigation as well as making sketch-maps of the fatal accident site, decoding and analysis of flight recorders and ground-based recording facilities including A3000 airfield surveillance and monitoring subsystem data; mathematical flight simulation; studying data on ATC service, aerodrome and crew members experts training, as well as on work-rest cycle; analysis of flight safety control systems in Vnukovo airport, ATM Vnukovo center and airline; studying of medical documents and forensic and medical examination results; studying of presented data on aircraft maintenance procedure.

The Final Report draft is made in accordance with the Commission work results. 

In accordance with the civil aviation International organisation Standards the report draft is directed to the accredited representatives: Bureau of Enquiry and Analysis for civil aviation safety of France (BEA) and Dutch Safety Board. Given states participated in the investigation process.

After receiving and considering states comments the Final Report will be published at the IAC official web-site. 

20 october 2016

The Interstate Aviation Committee (IAC) informs that the investigation of the fatal accident involving the Falcon 50 EX F-GLSA aircraft that occurred on 20.10.2014 at Vnukovo Airport (Moscow) has been completed.

Based on the investigation results the investigation team has completed a Final Report. The Bureau d’Enquêtes et d’Analyse pour la sécurité de l’aviation civile (BEA) and the Dutch Safety Board (DSB) that participated in the accident investigation do not have any comments on the Final Report.

In the near future, as soon as the technical procedures as prescribed by ICAO Standards and Rules for investigation of Accidents and Incidents Involving Civil Aircraft in the Russian Federation have been completed, the Final Report will be published on the official IAC website.

25 october 2016

The Interstate Aviation Committee has completed the investigation of the fatal accident involving the Falcon 50 EX F-GLSA aircraft that occurred on 20.10.2014 at Vnukovo Airport (Moscow).

The accident occurred at nighttime under foggy conditions while the aircraft was taking off after cleared by the controller due to collision with the snowplow that executed runway incursion and stopped on the runway.

Most probably, the accident was caused by the combination of the following contributing factors[1]:

- lack of guidance on loss of control over an airdrome vehicle and/or situational awareness on the airfield in pertinent documents defining the duties of airdrome service personnel (airdrome shift supervisor and vehicle drivers);

- insufficient efficiency of risk mitigation measures to prevent runway incursions in terms of airdrome peculiarities that is two intersecting runways;

- lack of proper supervision from the airdrome service shift supervisor, alcohol detected in his organism, over the airfield operations: no report to the ATM or request to the snowplow driver as he lost visual contact with the snowplow;

- violation by the airdrome service shift supervisor of the procedure for airdrome vehicles operations, their entering the runway (RWY 2) out of operation (closed for takeoff and landing operations) without requesting and receiving clearance from the ground controller;

- violations by the medical personnel of Vnukovo AP of vehicle driver medical check requirements by performing formally (only exterior assessment) the mandatory medical check of drivers after the duty, which significantly increased the risk of drivers consuming alcohol during the duty. The measures and controls applied at Vnukovo Airport to mitigate the risk of airdrome drivers doing their duties under the influence of alcohol were not effective enough;

- no possibility for the snowplow drivers engaged in airfield operations (due to lack of pertinent equipment on the airdrome vehicles) to continuously listen to the radio exchange at the Departure Control frequency, which does not comply with the Interaction Procedure of the Airdrome Service with Vnukovo ATC Center.

- loss of situational awareness by the snowplow driver, alcohol detected in his organism, while performing airfield operations that led to runway incursion and stop on the runway in use. His failure to contact the airdrome service shift supervisor or ATC controllers after situational awareness was lost;

- ineffective procedures that resulted in insufficiently trained personnel using the airfield surveillance and control subsystem A3000 of A‑SMGCS at the Vnukovo ATC Center, for air traffic management;

- no recommendation in the SOP of ATM personnel of Vnukovo ATC Center on how to set up the airfield surveillance and control subsystem A3000, including activation and de-activation of the Reserved Lines and alerts (as a result, all alerts were de-activated at the departure controller and ground controller’s working positions) as well as how to operate the system including attention allocation techniques during aircraft takeoff and actions to deal with the subsystem messages and alerts;

- the porting of the screen second input of the A3000 A-SMGCS at the ATC shift supervisor WP for the display of the weather information  that is not envisaged by the operational manual of the airfield surveillance and control subsystem. When weather information is selected to be displayed the radar data and the light alerts (which were present during the accident takeoff) become unavailable for the specialist that occupies the ATC shift supervisor’s working position;

- the ATC shift supervisor’s decision to join the sectors at working positions of Ground and Departure Control without considering the actual level of personnel training and possibilities for them to use the information of the airfield surveillance and control system (the criteria for joining of sectors are not defined in the Job Description of ATC shift supervisor, in particular it does not take into account the technical impossibility to change settings of the airfield surveillance and control system);

- failure by the ground controller to comply with the SOPs, by not taking actions to prevent the incursion of RWY 2 that was closed for takeoff and landing operations by the vehicles though having radar information and alert on the screen of the airfield surveillance and control system;

- failure by the out of staff instructor controller and trainee controller (providing ATM under the supervision of the instructor controller) to detect two runway incursions by the snowplow on the runway in use, including after the aircrew had been cleared to take off (as the clearance was given, the runway was clear), provided there was pertinent radar information on the screen of the airfield surveillance and control subsystem and as a result failure to inform the crew about the obstacle on the runway;

- lack of recommendations at the time of the accident in the Operator’s (Unijet) FOM for flight crews on actions when external threats appear (e.g. foreign objects on the runway) during the takeoff;

- the crew failing to take measures to reject takeoff as soon as the Captain mentioned «the car crossing the road». No decision to abort takeoff might have been caused by probable non-optimal psycho-emotional status of the crew (the long wait for the departure at an unfamiliar airport and their desire to fly home as soon as possible), which might have made it difficult for them to assess the actual threat level as they noticed the snowplow[2] after they had started the takeoff run;

- the design peculiarity of the Falcon 50EX aircraft (the nose wheel steering can only be controlled from the LH seat) resulting in need to transfer aircraft control at a high workload phase of the takeoff roll when the FO (seated right) performs the takeoff.

The appropriate safety recommendations based on the investigation results have been drawn.

The Final Report is released on the IAC website.


Reconstruction Falcon 50 F-GLSA Unijet Vnukovo

[1] In accordance with the Manual of Aircraft Accident and Incident Investigation (ICAO Doc. 9756 AN/965), the factors are given in the logical sequence, without priority assessment. The identification of contributing factors is not to apportion blame or liability.



[2] The investigation team concluded that it was exactly the snowplow that the PIC detected due to the fact that there were no other moving objects within the PIC’s estimated visual range at that moment



Прикрепленные документы:

Special opinion of Rosaviatsiya (562.84 KB)

Response to the special opinion of Rosaviatsiya (602.27 KB)

Special opinion of the State ATM Corporation (543.27 KB)

Response to the special opinion of the State ATM Corporation (569.21 KB)

Final Report Falcon F-GLSA (23.02 MB)