Incident Overview

Date: Sunday 24 August 2008
Aircraft Type: Boeing 737-219
Owner/operator: Itek Air, opf Iran Aseman Airlines
Registration Number: EX-009
Location: 7,8 km WNW of Bishkek-Manas International Airport (FRU) – ÿ Kyrgyzstan
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 65 / Occupants: 90
Component Affected: Aircraft Systems (Cabin Pressure, Altitude Control, Descent Control, Navigation)Aircraft Systems (Cabin Pressure, Altitude Control, Descent Control, Navigation)
Investigating Agency: MAKMAK
Category: Accident
On August 24, 2023, an Itek Air Boeing 737-200 aircraft, operated by Iran Aseman Airlines, experienced a catastrophic accident during a flight from Bishkek to Tehran due to a combination of factors leading to a rapid descent and subsequent crash. The flight began at 16:30 local time, following a thunderstorm that affected visibility and wind conditions. The aircraft was cleared for a DW-1 departure, which involved a left turn to RENAT and then a straight-in approach to the Chaldovar NDB. The flight experienced a rapid descent, including a loss of altitude, a significant deceleration, and a failure to properly configure the aircraft for landing. The crew’s actions, including a left-hand orbit and a descent to a lower altitude, contributed to the accident. The cabin pressure alarm horn triggered due to cabin pressure issues, prompting the crew to return to Bishkek and initiate a visual approach. The aircraft subsequently struck terrain, resulting in fatalities. The incident highlights a failure to adhere to established procedures and a deviation from standard operating procedures, particularly regarding visual approach and altitude control.On August 24, 2023, an Itek Air Boeing 737-200 aircraft, operated by Iran Aseman Airlines, experienced a catastrophic accident during a flight from Bishkek to Tehran due to a combination of factors leading to a rapid descent and subsequent crash. The flight began at 16:30 local time, following a thunderstorm that affected visibility and wind conditions. The aircraft was cleared for a DW-1 departure, which involved a left turn to RENAT and then a straight-in approach to the Chaldovar NDB. The flight experienced a rapid descent, including a loss of altitude, a significant deceleration, and a failure to properly configure the aircraft for landing. The crew’s actions, including a left-hand orbit and a descent to a lower altitude, contributed to the accident. The cabin pressure alarm horn triggered due to cabin pressure issues, prompting the crew to return to Bishkek and initiate a visual approach. The aircraft subsequently struck terrain, resulting in fatalities. The incident highlights a failure to adhere to established procedures and a deviation from standard operating procedures, particularly regarding visual approach and altitude control.

Description

Iran Aseman Airlines Flight 6895 from Bishkek (FRU), Kyrgyzstan to Tehran (IKA), Iran was carried out by Itek Air. The Kyrgyz airline operated one of their Boeing 737-200 aircraft on the flight. In the afternoon of August 24, from 16:30 to 20:00 local time, a thunderstorm with associated rain passed over Bishkek. Over that period the wind shifted from 220 degrees to 100 degrees at 20:30. Wind was blowing at about 6 kts, with wind variable at 23 knots. The temperature had dropped from 31 to 27 degrees C. The weather then improved and at the time of departure visibility was more than 10 km with 6/8 clouds at an altitude of 5000 m (ca 16400 ft). The Boeing 737 was cleared to taxy to runway 08 for departure. Take off was commenced at 20:30. The flight was cleared for a DW-1 departure, which entailed a left turn after takeoff to a heading of 240 degrees towards the RENAT beacon. From there it was to continue to the Chaldovar NDB, which should be crossed at or above FL158. At 20:36:40, the airplane was climbing through an altitude of 3000 m (almost 10.000 feet). At that moment the cabin altitude alert horn probably sounded, because the crew reported problems with the cabin pressure. The crew decided to return to Bishkek and requested a visual approach to runway 08. This was approved and the airplane made a right hand turn, for a straight-in approach to runway 08. At 20:41:40 the crew reported the runway in sight. About 20:42:30 the flight was 12 km from the runway, flying at 400 m above airfield elevation at an airspeed of 460 km/h (250 kts). At a distance of 5 km from landing, the airplane had decelerated to 340 km/h (185 kts), but it was not properly configured for landing. The flight crew then obtained permission to carry out a left-hand orbit in order to configure the plane for landing. A left hand turn was flown with a 30-degree bank. In the process of the turn the aircraft descended further with the airspeed decreasing to 290 km/h (155 kts). The airplane struck terrain some 7.5 km from the runway. At the time of impact the landing gear was down and flaps were selected down at 15 degrees. The cause of the Itek Air B737-200 EX-009 accident during the air-turn back due to the cabin not pressurizing (probably caused by the jamming of the left forward door seal) was that the crew allowed the aircraft to descend at night to a lower than the minimum descent altitude for visual approach which resulted in the crash with damage to the aircraft followed by the fire and fatalities. The combination of the following factors contributed to the accident: – Deviations from the Boeing 737-200 SOP and PF/PM task sharing principles; – Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact; – Loss of altitude control during the missed approach (which was performed because the PIC incorrectly evaluated the aircraft position in comparison with the required descent flight path when he decided to perform visual straight-in approach); – Non-adherence to the prescribed procedures after the TAWS warning was triggered.

Primary Cause

Deviation from Boeing 737-200 SOP and PF/PM task sharing principles, non-adherence to visual approach rules, loss of altitude control during the missed approach, and non-adherence to prescribed procedures after the TAWS warning.Deviation from Boeing 737-200 SOP and PF/PM task sharing principles, non-adherence to visual approach rules, loss of altitude control during the missed approach, and non-adherence to prescribed procedures after the TAWS warning.

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