B1/2005L Serious incident in Kittilä on 4 January 2005

On Tuesday, 4 January 2005, a Tupolev Tu-154 commercial aircraft, registration RA85794 and callsign SYL9923, landed at its destination in Kittilä at 07:31:53 UTC. The aircraft, chartered by Yakutia Airlines, had departed from Vnukovo airport in Moscow. The aircraft landed short, touching the paved section of runway 34 thirty (30) metres before the threshold. The tail section of the fuselage was the first section to make contact with the ground and sustained major damage. None of the passengers or aircrew members were injured. On 10 January 2005, Accident Investigation Board Finland (AIB) decided to appoint an investigation commission, B 1/2005 L, for this accident. Air Accident Investigator Hannu Melaranta was named investigator-in-charge with investigators Jussi Haila and Heikki Isomaa as members of the commission. The Federal Aviation Authority of Russia designated Yury Fedyshin as their authorized representative.

Once Rovaniemi Area Control Centre (ACC) first cleared the airliner to descend to Flight Level (FL) 150 (4,575 m) and later to FL 100 (3,050 m), the airliner left its cruising altitude at the normal position. At 07:19 Rovaniemi ACC recleared the aircraft to continue its descent and a moment later cleared it to leave controlled airspace. The ACC also informed it that radar service was terminated and instructed the aircraft to contact Kittilä Aerodrome Flight Information Service (AFIS). The aircraft contacted Kittilä but the flight crew did not understand that the Air Traffic Service (ATS) in Kittilä was AFIS service. The aircraft maintained FL 100 (3,050 m), even though under the AFIS procedure it should have continued to descend on own navigation for the approach. The aircraft finally left FL 100 (3,050 m) 11.5 NM (21 km) from Kittilä runway. This distance represents approximately one third of the normal distance from where descents commence. The aircraft did not intercept the ILS precision approach as per published procedure nor in accordance with regulated company procedures at any phase of the approach. Nor did it follow and maintain the ILS glidepath at any time during the approach. Kittilä aerodrome has a published racetrack procedure and had the aircraft followed it, it could have descended and intercepted the glidepath from the position at which it was when it passed locator KIT. The subsequent descent angle was approximately three times greater than the normal 3.4° path angle, established for the approach. During final approach the engine RPMs were at idle, running at ca. 30%. As per regulations, the engines should have been running at the minimum RPM of 61% and at 75% below 200 m. All engine RPMs began to spool up 6 seconds before touchdown. The aircraft touched down at an abnormal attitude; nose high with the tail section of the fuselage touching the ground first. The Flight Data Recorder (FDR) recorded a +3.5 g vertical acceleration at touchdown.

The investigation revealed that the flight crew were unaware of how the AFIS service worked, of the temporarily changed airspace structure in Kittilä as well as of the type of ATS service provided in Kittilä at any given time. Some of the crew members had flown to Kittilä the previous week, at which time Air Traffic Control (ATC) services had been available. The crew used the Jeppesen Licensed to Russia airway manual. However, the description of AFIS procedures in Finland contained therein was both inadequate and erroneous. Regulations on Finnish AFIS procedures as well as AFIS standard phrases were published in aeronautical information circulars (AIC) disseminated in Finland.

Multi Crew Cooperation during the approach did not function as intended, nor did the crew fully comply with the regulations in the company's manuals. The crew did not have sufficient command of the English language.

The direct causal factors of the incident were:

The crew were unaware of the fact that they were flying in an AFIS environment. Nor were they familiar with the principles of AFIS procedures.

The crew commenced the descent too late at a distance which was approximately three times shorter than normal procedure.

The pilot-in-command decided to execute a straight-in approach even though the aircraft was approximately three times higher than that required at the time.

Even though the parameters for a safe landing were not fulfilled, the pilot-in-command decided to land.

Contributing causal factors were:

Finnish ATS arrangements with regard to AFIS service differ from ICAO definitions. No descriptions on Finnish AFIS service characteristics existed which could appropriately reach all airlines that fly to Finnish AFIS aerodromes. This, especially, applies to foreign airlines. When the flight crew briefed for the flight, they did not have full access to information regarding the type of ATS service that is available in Kittilä at any given time. This information is included in NOTAMs meant for pilots.

The present ATS provider practice of only publishing AFIS procedures domestically does not facilitate the dissemination of complete information to operators or flight crews. This, for its part, shows that the risks inherent in this type of air traffic service have not been analysed. Whilst AFIS service has been considered appropriate even at aerodromes where scheduled and chartered commercial aviation takes place, neither AFIS procedures nor information on them are adequately tailored to correspond to traffic volume requirements. Individual aerodromes have tried to manage air traffic volumes by instituting various temporary arrangements. However, no uniform practice among Finnish aerodromes exists.

There are no explicit requirements concerning AFIS training in international or JAR flight crew certifications.

Multi Crew Cooperation did not work as intended. The co-pilot's and the flight engineer's remarks on abnormal flight parameters did not carry sufficient weight and the pilot incommand, who was the Pilot Flying (PF), disregarded them.

The flight crew's proficiency in the English language was inadequate. Communication with air traffic control during the phases of flight preceding the approach did not fully comply with standard phraseology. The air traffic controller and the AFIS officer had little possibility of steering the operation of the flight crew in the desired direction. No international standard AFIS phraseology exists. Examples of standard AFIS phrases are published in domestic regulations; however, no one has seen to it that this information reaches operators or pilots.

The investigation commission made three recommendations:

It is recommended that the Ministry of Transport and Communications see to it that the Civil Aviation Administration and the Finnish Civil Aviation Authority ensure that that the user of air traffic services be at all times aware of the content of service provided or that the service provided comply with international standards.

The investigation commission recommends that the Federal Aviation Authority of Russia inspect the airline's operating practices and procedures as well as aircrew training in order to ensure that they are in full compliance with the requirements established for safe international aviation and the rules of the air.

The investigation commission recommends that the Ministry of Transport and Communications see to it that the appropriate authority promulgate all ICAO Annex notifications pursuant to the obligations of ICAO's contracting states.

The final draft of the investigation report was disseminated for statement and comments on 21.9.2006. Responses received by the due date are taken into consideration in the final version of the investigation report.

During the investigation, the Civil Aviation Administration has defined the documentation concerning AFIS-operations to make it more available to the international operators.

The Finnish Civil Aviation Authority has expressed its interpretation concerning the AFIS-service in Finland. This interpretation differs from the Investigation Commission's view, which is based on the ICAO:n circular 211-AN/128, paragraphs "Foreword", 5. c) and "General", 1.

The Investigation Commission also notes, that contrary to the view of the Finnish Civil Aviation Authority, the state's obligation to notify about the differences to all ICAO Annexes is unambiguous.

B1/2005L Report (pdf, 1.37 Mt)