Incident Overview

Description
A British Aerospace BAe-125-800B executive jet, registered RA-02807, was destroyed when it crashed in a forest while on approach to Minsk-2 International Airport (MSQ), Belarus. The airplane operated on S-Air flight RLS9607 from Moskva-Vnukovo Airport (VKO), Russia to Minsk. The en route and descent part of the flight were uneventful. The crew were vectored for an approach and landing on runway 31 in instrument conditions. In preparation for an ILS approach the crew tuned in to the wrong ILS frequency. The captain thought the flight director was causing problems. Descent was continued until the TAWS gave an aural warning “Pull up” at 21:19. The captain decided to initiate a go around. The minimum altitude reached was 110 m agl. The crew then positioned the plane for another ILS approach to runway 31. At 21:30, at an altitude of about 550 m, the copilot questioned the ILS frequency. It was concluded that the wrong frequency had been set. The flight now continued using the correct frequency. The airplane descended below the glide slope until the TAWS again gave aural warnings “Caution terrain, Caution terrain.. ..Terrain, Terrain”. Then the “Pull up” warning sounded for 35 seconds until the airplane began colliding with trees at an altitude of about 30 m. It crashed into a forest and broke up. CONCLUSION The cause of the crash of BAe-125-800B RA-02807 during the ILS approach procedure at night, in weather conditions that met ICAO CAT I, was the failure to take timely action by the crew to carry out a missed approach, or divert to an alternate, when the ground could not be seen while descending below decision height during a transition to visual flight, and the lack of a proper response and action required when the TAWS alarm repeatedly sounded, which led to the collision of the aircraft with obstacles (forest) and land in a controlled flight (CFIT), its destruction and death of people on board. Contributing factors were: – Deficiencies in the type of retraining and training of the flight crew, especially in the use of automatic flight modes, and flight director; – Erroneous actions of the captain, which led to an execution of the approach with the wrong ILS frequency set on the left set; – Lack of preparation of the commander of the plane for an approach in weather conditions that meet CAT I ICAO. Values of meteorological conditions in the flight log were in most cases were falsified; – Poor communication and crew resource management (CRM) of the flightcrew; – Poor control of the level of training of the crew by the airline’s management and lack of organization in the airline’s flight operations; – Psychological characteristics of the pilots, unrecorded in the formation of the crew and, possibly, reduced efficiency of the captain in a stressful situation because of chronic ischemic heart disease with coronary artery problems, which was not detected when passing aviation medical checks.
Primary Cause
Failure to adequately respond to the critical situation and to take timely action when the TAWS alarm repeatedly sounded, leading to a collision with obstacles and a loss of control.Failure to adequately respond to the critical situation and to take timely action when the TAWS alarm repeatedly sounded, leading to a collision with obstacles and a loss of control.Share on: