The Aviation Herald Last Update: Monday, Sep 9th 2019 22:31Z

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Events from Jun 19th 1999 to Sep 9th 2019 www.avherald.com Incidents and News in Aviation List by: Filter: Crash: Saratov A148 at Moscow on Feb 11th 2018, lost height after departure, pitot heatings off

By Simon Hradecky, created Sunday, Feb 11th 2018 13:55Z, last updated Friday, Jun 28th 2019 15:03Z A Saratov Airlines Antonov AN-148-100, registration RA-61704 performing flight 6W-703 from Moscow Domodedovo to Orsk (Russia) with 65 passengers and 6 crew, was climbing out of Moscow's runway 14R when the aircraft reached a maximum altitude of 6000 feet then descended again and disappeared from radar at about 14:28L (11:28Z). The aircraft was subsequently found crashed in an open field about 18nm southeast of the aerodrome near the village Stepanovskoye in Dergayevo in the Ramensky District, coordinates approximately N55.3 E38.41, no survivors were found, about 50 bodies were recovered. The wreckage was distributed over a distance of about 1000m, no fire occurred.



Russian News Agencies Lenta and Interfax reported initially but later retracted the remains of a second aircraft, a helicopter, were found near the crash site, the two aircraft collided in midair.



Russia's Ministry of Emergency Situations confirmed flight 6W-703 crashed and was found near the village of Stepanovskoye in Ramensky district. Rescue forces including helicopters have been dispatched on site. The Ministry reported no other aircraft was found near the crash site. In the evening the Ministry reported one of the black boxes has been found and was recovered.



Russia's Post Office reported there was a bag of about 20kg mail on board of the AN-148. The bag may have triggered the agency reports of a midair collision with a post office helicopter, however Russia's Post Office does not operate helicopters in the Moscow region.



Russia's Interregional Transport Prosecution Office opened a criminal investigation into the crash verifying compliance with legislation, in particular technical maintenance and dispatch of the aircraft.



The Interstate Aviation Committee (MAK) reported the Saratov Airlines AN-148 registration RA-61704 from Moscow Domodedovo to Orsk departed Domodedovo Airport at 14:21L. Communication with the aircraft was lost at 14:28L, the radar target disappeared about the same time. The aircraft was found in the village Argunovo in Ramensky district. An accident investigation commission has been dispatched on site, an investigation was opened.



According to ATC recordings communication with the aircraft was normal until 11:28Z, when the crew no longer responded to calls from ATC and other stations.



On Feb 12th 2018 the MAK reported, that one flight data recorder has been recovered and has been sent to the laboratory for read out and decoding. Ukraine's Accident Investigation representing the state of aircraft developer has been informed and assigned an accredited representative to the investigation. Later the day the MAK reported that both flight data and cockpit voice recorders have been received by the MAK and are being opened for determination of the status of the recording media.



On Feb 12th 2018 the Investigative Committee of the Russian Federation (Sledcom) reported that the aircraft was intact until impact with the ground, an explosion occurred upon impact with the ground (editorial note: compare the video of the moment of impact below which immediately suggested this conclusion). Both black boxes have been found. The aerial video released by Sledcom suggests the wreckage is located at position about N55.3 E38.41, the point of first impact appears to be at N55.2994 E38.4052.



On Feb 13th 2018 the MAK reported that the flight data recorder needed to be torn down, the memory modules were removed from the FDR and inserted in a new electronics. Thereafter it was possible to read out all data which consist of 16 flights including the accident flight. The work to decode the data has started. The media of the voice recorder are currently being prepared for download.



In the afternoon of Feb 13th 2018 the MAK reported, that decoding of the FDR data has been completed. Preliminary analysis shows, that the pitot heatings for all three pitot probes were off while the pitot heatings had been turned on prior to departure on the previous 15 flights. About 2:30 minutes after becoming airborne a special situation developed at about 1300 meters of height and a speed of 465-470 kph (250 KIAS) when a disagreement between the speed readings #1 and #3 developed with the speed reading #2 not registering, #1 was showing about 30kph (15 knots) more than #3, an according message was issued. No significant altitude deviations between the pitot systems were noticed. At about 2000 meters height speed reading #1 began to reduce while #3 increased, another speed disagree message was issued. The crew disconnected the autopilot and continued in manual control. Speed readings from #3 reached 540-560 kph (290-300 KIAS), #1 speed readings continued to decrease. 50 seconds after the autopilot was disconnected the aircraft experienced vertical loads between 0.5 and 1.5G, the #1 speed reading reached 0, the #3 began to decrease reaching 200 kph (108 KIAS), the aircraft pitched down to about 30-35 degrees below horizont, the vertical load was 0G. Before collision with the ground #3 speed readings began to rapidly increase reaching 800 kph (432 KIAS) just before impact, #1 speed readings remained at 0. The pitch angle remained at 30 degrees below horizont until impact, 5 seconds prior to impact a right bank of 25 degrees developed. The MAK wrote: "A preliminary analysis of the recorded information, as well as an analysis of similar cases that occurred in the past, suggest that the development of a special situation in the flight could be caused by incorrect data on the flight speed on the pilots indicators, which in turn was apparently due to icing of the pitot probes when the heating systems are off."



On Feb 13th 2018 Russia's Ministry of Emergency Situations reported that all 30 hectares of the crash site have been surveyed, the recovered body parts have been sent for DNA identification, more than 500 fragments of the aircraft have been found in the survey. DNA samples from 66 relatives of the victims have been collected. More than 1000 people and 200 pieces of equipment participated in the search so far. In the afternoon the Ministry reported the search area has been expanded, 663 fragments of the aircraft have been found so far.



On Feb 15th 2018 (effectively only Feb 16h 2018 due to a crash of the MAK website) the MAK announced that the data carriers of the cockpit voice recorder were installed on a new device, the data were successfully downloaded. The recording of the accident flight is available and confirms the information recorded by the FDR. The data are now being analysed.



On Feb 18th 2018 Russia's Ministry of Emergency services reported that the survey of 50 hectares at the crash has been completed, more than 4700 pieces of wreckage were recovered. The MAK also have completed their on site work. The recovery personnel are now being withdrawn from the crash site.



On Feb 22nd 2018 Rosaviatsia recommended based on preliminary findings (without disclosing those findings) to pay attention to following points:

- preparation of aircraft for flight and decision making about conducting a flight with delayed failures and malfunctions in accordance with minimum equipment list requirements

- interaction between crew members, in particular to continue running the relevant checklists after being interrupted or when a checklist section has not been completed (e.g. turn on heating of pitot probes)

- performance of standard operating procedures in standard, non-normal and emergency operation

- crew actions in case of aircraft system failures (flight and navigation systems, control systems)



On Mar 20th 2018 Russia's Ministry of Transport (Rostransnadzor) issued a directive to suspend all flights on any aircraft type operated by Saratov Airlines as result of violations having been found. An assessment of risks and corrective actions to maintain an acceptable level of safety and to eliminate identified violations of air legistlation, is to be undertaken. Based on the results of the checks of the AN-148s of Saratov Airlines Rostransnadzor is going to undertake also unscheduled inspections of AN-148s operated by other airlines to ensure compliance with airworthiness requirements. Based on the results of those inspections further decisions may be taken.



Following Rostransnadzor's instructions Russia's Civil Aviation Authority (Rosaviatsia) instructed Saratov Airlines to suspend all flights with AN-148s and limited the validity of the air operator's certificate until April 27th 2018, until which date all pending violations as well as inconsistencies with respect to aviation legislation were to be elimated. Based on the work performed by the operator Rosaviatsia is going to take further decisions about the operator's future activities. The operations of AN-148s operated by other airlines are not affected.



On Apr 18th 2018 Rosaviatsia released additional information stating that throughout the taxi and flight the crew were shown indications "Pitot 1: No Heating", "Pitot 2: No Heating" and "Pitot 3: No Heating" amongst other messages. The operator had moved the items to activate the Pitot Heatings to the pre-takeoff checklist. The crew taxied the aircraft out and were cleared for takeoff, the "pre-takeoff" checklist was not read. At a height of 1300 meters (4265 feet) the airspeeds began to differ (as described earlier already).



Metars:

UUDD 111330Z 14006MPS 4000 -SHSN BKN007 BKN030CB M05/M07 Q1019 R14R///99// R14L/590392 TEMPO 1200 SHSN

UUDD 111300Z 14006MPS 9999 -SN BKN007 M05/M07 Q1019 R14R/590293 R14L/590392 TEMPO 1200 SHSN BKN012CB

UUDD 111230Z 13005MPS 8000 -SHSN FEW008 BKN026CB M05/M07 Q1019 R14R/590293 R14L///99// TEMPO 1200 SHSN

UUDD 111200Z 13005MPS 1900 R14R/2000D R14L/1900D SN SCT007 OVC026 M05/M06 Q1019 R14R/590293 R14L/590491 TEMPO 1200 SHSN BKN012CB

UUDD 111130Z 13006MPS 2100 -SN SCT008 OVC026 M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1200 SHSN BKN012CB

UUDD 111100Z 14006MPS 1800 R14R/1900U R14L/1800U SHSN BKN007 BKN026CB M05/M06 Q1019 R14R/590293 R14L/590392 NOSIG

UUDD 111000Z 14005MPS 8000 -SN BKN009 M05/M07 Q1019 R14R/590293 R14L/590392 TEMPO 1000 SHSN BKN012CB

UUDD 110930Z 14006MPS 9999 SCT009 BKN036 M05/M06 Q1019 R14R/590293 R14L/590392 TEMPO 1000 SHSN BKN012CB

UUDD 110900Z 15006MPS 9999 BKN020CB M05/M06 Q1019 R14R/590293 R14L/590392 NOSIG

UUDD 110830Z 13005MPS 5000 -SN SCT007 M05/M06 Q1020 R14R///99// R14L/590392 TEMPO 0700 +SHSN BKN010CB

UUDD 110730Z 14005MPS 2600 -SN SCT008 OVC030 M05/M07 Q1020 RESN R88/590392 TEMPO 1000 SHSN BKN015CB

UUDD 110700Z 14005MPS 1400 1000NE R14R/1400N R14L/1100D SHSN SCT006 BKN026CB M05/M07 Q1020 R14R/590392 R14L///99// TEMPO 1000 SHSN



Aerial overview of crash site (Video: Sledcom):

https://www.youtube.com/watch?v=RRtU3e0z4m0



The difficult search and recovery works (Video: Russia's Ministry of Emergency Situations):

https://www.youtube.com/watch?v=mvXC-Q_6dmo



Surveillance Camera capturing the moment of impact (Video:Kullverstukas):

https://www.youtube.com/watch?v=fQktxb4eEG8



Scenes from the crash site and rescue services (Video: Russia's Ministry of Emergency Situations):

https://www.youtube.com/watch?v=5uxUCY7_34Q



Impressions from the crash site:













Map (Graphics: AVH/Google Earth):









By Simon Hradecky, created Friday, Jun 28th 2019 15:01Z, last updated Friday, Jun 28th 2019 15:06Z



The report concludes the probable causes of the crash were:



The crash of the An-148-100B RA-61704 was caused by erroneous actions of the crew during departure in instrumental weather conditions in relation to unreliable indications of the air speed caused by the icing (ice blockage) of all three dynamic probes of the pitot system, which led to the loss of control over the parameters of the aircraft's flight resulting in a dive and collision with the ground.



The accident falls into the category loss of control in flight (LOC-I).



The investigation revealed systemic deficiencies in the assessment of risk as well as risk control, the failure of the airline's flight safety management system as well as lack of supervision of training of flight crew by aviation authorities at all levels, which led to the issuances of certificates to aviation personnel and crew, who did not fully qualify.



The most likely contributing factors were:



- Crew's rush in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" time;



- The crew's failure to turn on the heating of the pitot probes before take-off and non-compliance with/non-execution of the "BEFORE TAKEOFF" checklist, which provides for this action.



- Design features of the An-148 aircraft which restrict the duration of pitot heating while on the ground, which required to move the items pitot heating into the "BEFORE TAKEOFF" checklist rather than the "ENGINE START" checklist, which creates additional risks of missing these operations.



- Systematic failure by airline crews to comply with the principle of "dark cockpits" and the requirements of the pitot system, which contributed to the "habit" of taking off despite the presence of emergency and warning messages on the electronic indication and alarm system (KISS) and failing to identify the fact that the heating of the pitot probes is not included. Six warning messages were displayed on KISS before departure for the accident flight including three relating to the absence of pitot probes' heating.



- Design features of the An-148 aircraft which disabled removal of KISS messages related to system defects which have been deferred under MEL.



- Low safety culture within the airline which led to non-entries of inflight problems into the tech logs as well as performing flights with issues that were neither rectified nor deferred with the relevant fault messages displayed at KISS and failure to identify the KISS messages and analyse them to identify lack of pitot probe heating.



- The crew's unpreparedness when the ALARM "SPEED DISAGREE" was issued because of lack of theoretical training, lack of according simulator training and lack of according training on aircraft. This resulted in the failure to follow the proper procedures once the alarm was raised.



- Lack of supervision by the Civil Aviation Authority in certifying the flight simulator according to Russian Air Code



- Approval of the An-148 flight simulator without consideration to their ability to reproduce special cases in flight as stipulated in Russian Air Code and FAR-128.



- Lack of specific guidance on values of flight parameters that must be sustained in case of "SPEED DISAGREE" alarm respective lack of an unreliable airspeed procedure.



- Increased psycho-emotional stress by flight crew members during the final stages of flight due to the inability to understand the speed fluctuations. As result the captain suffered "tunnel view" on his speed indications for speed control rather than considering all flight parameters.



- Insufficient training of flight crew with respect to human factors, cockpit resource management, threat management and error management.



- Individual psychological characteristics by both flight crew, for the captain reduction of intellectual and behavioural flexibility, fixation on own position and inability to hear prompts from the first officer, for the first officer problems in organisation and sequencing actions) which in the stressful situation with inadequate CRM became apparent.



- Loss of psychological efficiency the captain (resulting on psychological incapacitation) which led to complete loss of spatial orientation and did not permit to respond properly to correct advice offered by the first officer or the EGPWS PULL UP warning.



- Absence of criteria to determine psychological incapaciation/loss of health which did not permit the first officer to take more efficient measures.



- Large arrear of annual leave that could have caused accumulation of fatigue and might have adversely affected the efficiency of the captain.



- System operations features not described in operations manual.



- elevator control offset during reconfiguration mode with unreliable airspeed doubles elevator deflection with same control input and has the elevator deflected nose down with the control in neutral position for about 60 seconds which reduced time available to the crew to recognize the situation.



Due to the excessive time and workload needed to translate this highly technical russian final report as well as the risk to misunderstand the report (and thus go wrong in the summary), The Aviation Herald is not going to provide a summary of the factual portion or the analysis portion of the report. An official English version of this report is badly needed.

On Jun 27th 2019 Russia's MAK released their final report in Russian only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Russian only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).The report concludes the probable causes of the crash were:Due to the excessive time and workload needed to translate this highly technical russian final report as well as the risk to misunderstand the report (and thus go wrong in the summary), The Aviation Herald is not going to provide a summary of the factual portion or the analysis portion of the report. An official English version of this report is badly needed.

By Simon Hradecky on Tuesday, Mar 6th 2018 16:34Z





By 727driver on Thursday, Jul 4th 2019 15:39Z





By SOdell on Tuesday, Jul 2nd 2019 21:19Z





By Sarah on Tuesday, Jul 2nd 2019 01:59Z





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By (anonymous) on Friday, Jun 28th 2019 23:12Z





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By Mikie on Friday, Mar 23rd 2018 20:45Z





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Russian investigators say the flight crew received indications of a failure in the heating for the pitot-static system, which measures parameters including airspeed. The crew received mismatching airspeed information prior to the crash near Moscow. All 71 on board died.