On 12 September 2012 at about 12:20 local time (00:20 UTC), Petropavlovsk-Kamchatsky Air Flight 251, operated by an Antonov An-28, crashed while attempting to land at Palana Airport in Russia.[1]
Both pilots were killed, together with 8 of the 12 passengers. All 4 survivors were in serious condition. The aircraft descended below minima on approach in instrument meteorological conditions and impacted a forested slope. Alcohol was found in the blood of both flight crew.
The aircraft was a twin-turboprop Antonov An-28, registration RA-28715, built in 1989 with serial number 1AJ006-25.[2]
Accident
An Antonov An-28 passenger plane operated by Petropavlovsk-Kamchatsky Air Enterprise, was destroyed in an accident near Palana Airport, Kamchatka peninsula, Russia.
Flight 251 was operating on an instrument flight rules (IFR) flight plan. Weather at the destination airport Palana included a visibility of 6000 m and a cloud base at 470 m, within limits for an approach and landing at Palana. The crew were cleared for an approach to runway 11. The approach to Palana consists of a flight to the NDB beacon above the minimum safe altitude of 2150 m, followed by entering a holding pattern, and a descent for the approach. The crew did not fly to the NDB. The flight was 22km from the NDB when the crew reported being overhead.
Descent was initiated until the airplane struck trees at 320 m above sea level on the wooded slope of Mount Pyatibratka.[3]
Investigation
The Interstate Aviation Committee (MAK) have released their final report on February 2013 concluding the probable causes of the crash were:
non-compliance of the crew with the published approach procedure, descending below minimum height prematurely while flying in mountainous terrain in weather conditions that prevented consistent visual contact with the ground. This led to a controlled flight into the slopes of a mountain, the destruction of the aircraft and fatalities amongst the crew and passengers.[4]
Contributing factors were:
Low level of discipline of staff and inadequate supervision of pre-flight preparation and implementation of approaches by the airline
Lack of alertness by the crew when the radio altimeter reached a dangerous height
The presence of a GPWS could possibly have averted the accident[4]
Following deficiencies were identified leading to the crash:
The blood of both flight crew contained alcohol in violation of Russian regulations
During pre-flight checks both flight crew were permitted to conduct the flight despite their intoxication in violation of Russian regulations.
In violation of Airline regulations the captain did not ensure a pre-flight examination was conducted.
According to tape recordings the decision to depart was made by the first officer of another crew, which is in violation of Russian and Airline regulations.
The flight crew did not track along the planned trajectory and entered the approach procedure not at the published entry point.
The flight crew provided air traffic control with wrong position reports.
Nearing the Palana Airport the crew performed a premature descent and flew an arbitrary trajectory in violation of the approach procedure.
Near the Palana Airport the flight crew again provided a false position report to ATC.
ATC cleared the aircraft to intercept the turn to final at an altitude, which violated the instrument approach procedure.
The "uncertainty phase" was not declared by the aerodrome preventing taking measurements of weather data.
The operations manuals at Palana Airport do not provide limiting values in altitude and bearings to air traffic controllers vectoring aircraft in the terminal area.[4]