Incident Overview

Date: Sunday 11 February 2018
Aircraft Type: Antonov An-148-100B
Owner/operator: Saratov Airlines
Registration Number: RA-61704
Location: near Stepanovskoye, Ramenskoye district – ÿ Russia
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 71 / Occupants: 71
Component Affected: An-148 Aircraft ? Specifically, the pitot tube heating system, airspeed indicators, autopilot, and the aircraft’s flight control systems.An-148 Aircraft ? Specifically, the pitot tube heating system, airspeed indicators, autopilot, and the aircraft’s flight control systems.
Investigating Agency: MAKMAK
Category: Accident
On October 14, 2023, an Antonov An-148 aircraft, carrying six crew members and 6 passengers, crashed near Stepanovskoye, Russia, following an incident involving improper actions during a climb. The aircraft experienced a rapid descent, culminating in a catastrophic impact with a snowy field. The flight crew, led by Captain [Unknown Name] and Flight Officer [Unknown Name], had been operating under challenging conditions ? limited visibility, a cold temperature (-5øC), and an overcast sky. The aircraft’s autopilot was switched on, and the aircraft ascended to approximately 1300 meters (4265 feet) at an airspeed of 465-470 km/h. During this climb, discrepancies emerged between the captain’s and standby airspeed readings, prompting a rapid adjustment of the aircraft’s parameters. The aircraft then entered a steep descent, increasing airspeed to 0 km/h, and subsequently experienced a loss of control, leading to a significant impact. The incident was attributed to a confluence of factors, including a delay in heating the pitot tubes, an incorrect switch to the standby airspeed indicator, inadequate checks of the flight safety management system, and a failure to adhere to critical flight safety procedures, particularly concerning the ‘dark cockpit’ principle and the monitoring of airspeed data. The crew?s actions, including the failure to properly control the airspeed and the lack of adequate training on the ‘dark cockpit’ principle, contributed significantly to the accident. The incident highlighted systemic weaknesses in aviation safety management and training, ultimately resulting in certification lapses and a lack of accountability.On October 14, 2023, an Antonov An-148 aircraft, carrying six crew members and 6 passengers, crashed near Stepanovskoye, Russia, following an incident involving improper actions during a climb. The aircraft experienced a rapid descent, culminating in a catastrophic impact with a snowy field. The flight crew, led by Captain [Unknown Name] and Flight Officer [Unknown Name], had been operating under challenging conditions ? limited visibility, a cold temperature (-5øC), and an overcast sky. The aircraft’s autopilot was switched on, and the aircraft ascended to approximately 1300 meters (4265 feet) at an airspeed of 465-470 km/h. During this climb, discrepancies emerged between the captain’s and standby airspeed readings, prompting a rapid adjustment of the aircraft’s parameters. The aircraft then entered a steep descent, increasing airspeed to 0 km/h, and subsequently experienced a loss of control, leading to a significant impact. The incident was attributed to a confluence of factors, including a delay in heating the pitot tubes, an incorrect switch to the standby airspeed indicator, inadequate checks of the flight safety management system, and a failure to adhere to critical flight safety procedures, particularly concerning the ‘dark cockpit’ principle and the monitoring of airspeed data. The crew?s actions, including the failure to properly control the airspeed and the lack of adequate training on the ‘dark cockpit’ principle, contributed significantly to the accident. The incident highlighted systemic weaknesses in aviation safety management and training, ultimately resulting in certification lapses and a lack of accountability.

Description

Saratov Airlines flight 703, an Antonov An-148, was destroyed after impacting terrain near Stepanovskoye, Russia. All 65 passengers and 6 crew members were killed. The aircraft took off from runway 14R at Moscow’s Domodedovo Airport at 14:21 hours local time (11:21 UTC). Weather about the time of departure at Domodedovo Airport included limited visibility (2100m) during light snowfall. Temperature was -5øC, overcast cloud deck at 2600 feet AGL. The Interstate Aviation Committee stated that, prior to departure, the heating of the three pitot tubes had not been turned on. After takeoff, at an altitude of 130-150 m (425-490 ft) above ground level, the autopilot was switched on. Flaps were raised as the aircraft climbed through an altitude of 550 m (1800 feet). About 2 minutes 30 seconds after the takeoff, at an altitude of about 1300 meters (4265 feet) and an instrument speed of 465-470 km/h, there were discrepancies between the air speed readings on the captain’s side compared to the standby airspeed indicator. The airspeed on the copilot’s side is unknown as this parameter was not registered by the flight data recorder. There were no significant difference in the altitude indications. After another 25 seconds, the discrepancies reached about 30 km/h with the speed on the captain’s side being greater. After about 50 seconds, at an altitude of about 2000 meters (6560 ft), the airspeed on the standby airspeed indicator was higher and continued to increase while the airspeed on the captains ASI continued to decrease. The flight crew then disconnected the autopilot. The airspeed on the captain’s side continued to decrease, while the standby ASI showed 540-560 km/h. About 50 seconds after the autopilot was turned off, the flight passed an altitude of 1700-1900 m (5580-6230 ft) with vertical loads ranging from 1.5 to 0.5 g. Subsequently the aircraft entered a steep descent with the ASI on the captain’s side showing 0 km/h, and the standby ASI showing 200 km/h. The pitch angle decreased to -30/-35 degrees with a vertical load factor of 0 g. The aircraft impacted a snowy field around 14:27:05 and disintegrated. Before the collision with the ground, the standby ASI had increased to 800 km/h with the captain’s ASI still displaying 0 km/h. The captain of the An-148 had 2168 hours on type, of which 58 as captain. The first officer had 672 hours on type. The AN-148-100V RA-61704 crash occurred due to erroneous actions of the crew at the stage of climbing in instrument weather conditions at unreliable readings of instrument speed caused by icing (blockage of ice) of all three pitot tubes, which led to the loss of control over the parameters of the aircraft, its transfer to dive and collision with the ground. The accident was classified as a loss of control in flight (LOC-I). The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline’s flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements. The most likely contributing factors were: – Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to “catch up” with the time; – Skipping by the crew of the operation to switch on the pitot tube heating before takeoff and failing to comply with the section of the check list “BEFORE TAKE-OFF”, which provides for the control of this action; – design features of the An-148 aircraft in terms of the restrictions on the duration of pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of pitot tube heating and compliance with the principle of “dark cockpit” in a separate section of the “BEFORE THE FLIGHT” check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section “ON THE RUNWAY START”; – systematic failure of the airline’s crews to comply with the “dark cockpit” principle and the requirements of the radar, which contributed to “getting used” to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of pitot tube heating; – design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects; – low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS; – Failure to take necessary measures in case of detection of previous facts of untimely activation of pitot tube heating by crews based on the results of express analysis of flight information; – Unreadiness of the crew to take actions in case of triggering the alarm “Speed of Emergency” due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm; – Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation; – Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128; – Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft’s flight ma

Source of Information

https://www.rt.com/news/418466-passenger-jet-missing-russia/, https://www.flightradar24.com/data/flights/6w703#106596d0https://www.rt.com/news/418466-passenger-jet-missing-russia/, https://www.flightradar24.com/data/flights/6w703#106596d0

Primary Cause

Systemic failures in aviation safety management, including inadequate hazard identification, operational procedures, training, and system oversight, leading to a failure to adequately address the risks associated with critical flight parameters and the potential for human error.Systemic failures in aviation safety management, including inadequate hazard identification, operational procedures, training, and system oversight, leading to a failure to adequately address the risks associated with critical flight parameters and the potential for human error.

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