If you wish to contribute or participate in the discussions about articles you are invited to join SKYbrary as a registered user

 Actions

FA50 / Vehicle, Moscow Vnukovo Russia, 2014

From SKYbrary Wiki

Summary
On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.
Event Details
When October 2014
Actual or Potential
Event Type
Fire Smoke and Fumes, Ground Operations, Human Factors, Runway Incursion
Day/Night Night
Flight Conditions Not Recorded
Flight Details
Aircraft DASSAULT Falcon 50
Operator Unijet
Domicile France
Type of Flight Public Transport (Non Revenue)
Origin Moskow/Vnukovo International Airport
Intended Destination Paris/Le Bourget Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport Moskow/Vnukovo International Airport
General
Tag(s) ATC Training,
Inadequate ATC Procedures,
Ineffective Regulatory Oversight,
Inadequate Airport Procedures,
Copilot less than 500 hours on Type
FIRE
Tag(s) Post Crash Fire
HF
Tag(s) Plan Continuation Bias,
Procedural non compliance,
Violation
GND
Tag(s) Aircraft / Vehicle conflict
RI
Tag(s) ATC error,
Runway Crossing,
Intersecting Runways,
Ground Collision,
Vehicle Incursion
RE
Tag(s) Continued Take Off
Safety Net Mitigations
A-SMGCS Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Fatalities Most or all occupants (4)
Causal Factor Group(s)
Group(s) Aircraft Operation,
Air Traffic Management,
Airport Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness,
Air Traffic Management,
Airport Management
Investigation Type
Type Independent

Description

On 20 October 2014, a Dassault Falcon 50EX (F-GLSA) being operated by Unijet on an international passenger charter flight from Moscow to Paris Le Bourget as LEA074P and taking off from runway 06 collided with a snow plough at the intersection of the take-off runway with runway 01/19 and was destroyed as a consequence of the effects of the impact and a post crash fire. The four occupants of the aircraft were killed but the snow plough driver was unhurt. There was fog present at the time of the collision, but the IRVR was sufficient not to be a limiting factor in the visual acquisition by pilots of any runway obstructions ahead.

Investigation

An Investigation was carried out by the Interstate Aviation Committee (the MAK). The FDR and CVR were recovered from the aircraft and their data were successfully downloaded. ATC recorded radar data was also available.

It was noted that the Captain, a 45 year-old French national, had been employed by the Operator since 2010 and had 6,624 total flying which included 1,266 hours on type since gaining the type rating in late 2013 and 3,304 hours in command. The 28 year-old First Officer was also a French national, had been employed by the Operator since 2011 and had 1,478 total flying hours including 246 hours on type, the latter since gaining the type rating also in late 2013. For the year prior to the accident, the two pilots had been "flying as fixed crew" and both still held current type ratings on the Cessna 525 Citation. The driver of the snowplough which the aircraft collided with was noted be have been born in 1954 and to have had 10 years of experience as a civil aerodrome vehicle driver, eight of them as a qualified snowplough driver. The runway control position in the TWR was being worked by an ab-initio trainee controller supervised by an Instructor Controller.

It was established that the departure of the flight had been significantly delayed awaiting the arrival of the only passenger. Once they had boarded, the aircraft was started up and taxied to the departure runway 06. It had been decided that the First Officer would act as PF for the flight but as the aircraft only had a steering tiller at the left seat position, it was necessary for the Captain to taxi out and begin the take-off roll before a standard hand over of control to the First Officer when the airspeed reached 80 knots.

Take-off clearance was given as the aircraft was lining up with the runway clear ahead and the take-off was commenced 48 seconds later. Fourteen seconds after take-off as the aircraft approached 80 knots, the Captain was recorded on the CVR as exclaiming (in French) "What’s the car crossing the road, eh". This "car" was in fact one of three snowploughs working airside on the closed intersecting runway 01/19 and was fully lit and moving from left to right at the intersection without requesting or obtaining ATC permission to enter the active runway. However, the Investigation concluded that this sighting had not been assessed as an obstruction to the continued take-off and three seconds after this the Captain had handed control to the First Officer who confirmed with "my control". After a further 4 seconds, V1 was called at 110 KCAS followed by "Rotate" at 118 KCAS. Then, as the aircraft passed 123 KCAS, approximately 210 metres before the now-stopped snowplough, the Captain was recorded as exclaiming (again in French) "Hey there’s, there’s a truck there". One second after this call, at 127 KCAS, the aircraft became airborne with approximately 145 metres to run to the snowplough. The pitch was rapidly increased by an "abrupt nose up control column deflection" which achieved an AoA of just over 17° "at the moment of the collision". It was noted that this AoA was "less than the stall AoA for the take-off aircraft configuration without ground proximity effect, which is 19.5° (with) the stall AoA with ground proximity effect having not been defined by the aircraft designer". However, during the initial rapid pull up, AoA was found to have peaked momentarily at 22-24° before the control column was pushed forward 17° within less than a second just two seconds before impact. It was considered that this final action "could have been caused by the will of the pilot to avoid exceeding the critical AoA".

With the FDR airspeed recorded at 133 KCAS and the radio altitude as less than 20 feet agl, the aircraft collided with the now stationary snowplough, its right wing hitting the cab roof and the snow expulsion outlet while its right main landing gear hit the rear of the vehicle. After the collision, the impact damage to the right wing resulted in an abrupt right bank which full left input to the control column by the crew did not counteract. The aircraft rolled and hit the ground inverted about 250 m further on. Detachment of the left wing during the collision and the impact damage to the right wing resulted in both wing tanks being breached and a fuel-fed fire rapidly engulfed the main body of the impact-damaged wreckage. The snow plough was damaged but the driver was uninjured.

The main wreckage of the aircraft (the left wing was detached at impact with the vehicle). [Reproduced from the Official Report]

The Investigation found from recorded surveillance radar data - which would have been visible to the TWR Instructor controller and the unqualified ab-initio trainee who was being supervised in position - that the snowplough had stopped moving soon after the aircraft Captain had first seen it (the "car") and had been stationary close to the centre of the runway intersection for 11 seconds prior to the collision. This data also showed that the same snowplough had crossed the active runway at the same intersection in the opposite direction some 4½ minutes earlier, again without requesting or obtaining ATC permission to enter the active runway and again without being noticed by the controllers.

The ground tracks of the aircraft (red) and conflicting snowplough (yellow) with UTC timings. [Reproduced from the Official Report

It was found that although the radar display of moving airside objects was fully functional, the associated system of runway incursion alerting, which had been installed in its current form over a year previously, had never been properly configured and, to the extent that it was active, did not function at the positions used by the TWR and GND controllers. Such configuration would have had to be done by "technical staff" and in any case, it was found that most controllers had not been adequately trained in use of the system, with ATC "corporate documentation" found not to "contain any guidance or recommendations for the controllers […] with regard to conflict detection on their displays" - not even "how different alert modes are switched on".

The Investigation attempted to establish whether it would have been possible for the crew to reject the take-off had they begun such action immediately after the Captain had spoken on the intercom of seeing a (moving) "car". It was concluded after careful analysis with the assistance of the aircraft manufacturer that, assuming that the runway had been covered with 1 mm of wet snow, if the crew had promptly rejected the take-off at the moment they first noticed the "car", "most probably, they might have been able to stop the aircraft before the snowplough" or in the worst case with low forward speed, steer around it. FDR data showed that the aircraft became airborne after a take-off roll of 845 metres and performance data suggested that the further distance required to reach 35 feet agl using normal take-off techniques would have been around 200 metres whereas recorded radar data showed that by this point, the now-stationary snowplough was only 145 metres - and two seconds - away.

It was noted that although the weather recorded at the time of the take-off roll included "fog", the actual IRVR along runway 06 at the time was a steady 1,000 metres which was almost the same as the distance from that point to the collision - 980 metres, so it was concluded that lack of forward visibility alone had not been a causal factor in the collision.

It was subsequently found that the (unexplained) performance of the snowplough driver involved may have been affected by his consumption of alcohol whilst on duty.

Much of the remainder of the Investigation involved a very detailed examination of all aspects of the airside operational environment at Vnukovo and much evidence of a very significant number of related and apparently habitual procedural non compliances with existent procedures and an obvious absence of sufficient or adequate working practices and personnel training. Many of the findings in these areas which were not identified as directly causal to the collision were formally recorded as an inventory of 24 "Shortcomings" (see below) and the 55 Safety Recommendations made (see below) sought to address both these Shortcomings and the 16 formally documented Contributory Factors which it was considered had in combination caused the accident to occur. These were as follows:

  • a lack of guidance in pertinent documents defining the duties of aerodrome service personnel (aerodrome shift supervisor and vehicle drivers) on any loss of control over an aerodrome vehicle and/or situational awareness on the aerodrome;
  • the insufficient effectiveness of risk mitigation measures to prevent runway incursions attributable to the presence of two intersecting runways;
  • a lack of proper supervision by the aerodrome shift supervisor over airside operations with no report to ATC or request to the snowplough driver as he lost visual contact with it, with his performance potentially affected by alcohol consumption;
  • violation by the aerodrome shift supervisor of the procedure for aerodrome vehicle operations in particular their entering of runway 01/19 when it was closed for take-off and landing operations without requesting and receiving clearance from the GND controller;
  • violations by Airport medical personnel of vehicle driver medical check requirements by performing only external assessment of drivers after their duties which significantly increased the risk of drivers consuming alcohol during those duties. The measures and controls applied at Vnukovo Airport to mitigate the risk of aerodrome drivers carrying out their duties whilst under the influence of alcohol were not effective enough;
  • the lack of any opportunity for snowplough drivers engaged in airfield operations to continuously listen to the radio frequency being used for control of the active runway because of a lack of the necessary equipment in their vehicles. This does not comply with the specified 'Interaction Procedure for Aerodrome Service' with Vnukovo ATC Centre.
  • a loss of situational awareness by the snowplough driver whilst performing airfield operations that led to a runway incursion and stopping on the runway in use with his awareness potentially impaired by alcohol consumption. His failure to contact the aerodrome service shift supervisor or ATC controllers after situational awareness was lost;
  • ineffective procedures that resulted in ATC personnel being insufficiently trained in the use of the A-SMGCS airfield surveillance and control subsystem A3000 at the Vnukovo ATC Centre for air traffic management;
  • the absence of any guidance in the SOP for ATM personnel at the Vnukovo ATC Centre on how to set up the A-SMGCS including activation and deactivation of the 'Reserved Lines' function and alerts at the TWR and GND controller’s working positions which resulted in all alerts being de-activated. Also, the absence of any guidance on how to operate the system including attention allocation techniques during aircraft take-off and actions to deal with system messages and alerts;
  • the use of the A-SMGCS screen at the ATC shift supervisor position for the display of weather information which is not envisaged by the Operations Manual for the system. When weather information is selected to be displayed on this screen, the radar data and the light alerts (which were present during the accident take-off) become unavailable to the ATC shift supervisor’s working position;
  • the ATC shift supervisor’s decision to combine the working positions of GND and TWR without considering the actual level of personnel training and possibility for them to use the information of the A-SMGCS. The criteria for combining these two positions is not defined in the Job Description of ATC shift supervisor and in particular this description does not take into account the technical impossibility of changing the settings of the A-SMGCS;
  • the failure by the GND controller to comply with the SOPs, by not taking action to prevent the incursion of runway 01/19 (which was closed for take-off and landing operations) by vehicles by having radar information and alerts on the screen of the A-SMGCS system;
  • the failure by the OJT (on-the-job training) instructor controller and their trainee controller to detect two runway incursions by the snowplough onto the runway in use, both prior to and then again after the departing aircraft had been cleared to take off when there was pertinent radar information on the A-SMGCS screen and as a result the failure to inform the flight crew about an obstacle on the runway;
  • the lack of guidance in the Operator’s (Unijet) OM at the time of the accident on actions by pilots when external threats appear (e.g. foreign objects on the runway) during the takeoff;
  • the aircraft flight crew failing to take measures to reject take-off as soon as the Captain observed "the car crossing the road". The absence of a decision to reject the take-off at that point might have been caused by probable non-optimal psycho-emotional status of the crew as a result of the long wait for departure at an unfamiliar airport and their desire to fly home as soon as possible, which might have made it difficult for them to assess the actual threat level as they noticed the snowplough after they had started the take-off roll;
  • the fact that in the Falcon 50EX aircraft, the nose wheel steering can only be controlled from the left seat which results in the need to transfer aircraft control at a high workload phase of the take-off roll when the pilot in the right seat performs the take-off.

The Investigation also formally documented the following 24 "Shortcomings":

  • The ELT failed to activate during the accident. Despite examination, it was not possible to determine the cause of this. During the subject accident, the ELT failure did not affect the outcome, whereas under different circumstances it could bear significant impact on the survival aspects.
  • Personnel simulator training at the Vnukovo ATC Centre was organised and conducted in violation of the Provisions of the ATC Simulator Training Arrangement and Conduct for Personnel of the State ATM Corporation.
    • Some provisions of the arrangement and conduct of Vnukovo ATC Centre personnel simulator training procedure are not consistent with the requirements of the Provision of the ATC Simulator Training Arrangement and Conduct for Personnel of the State ATM Corporation and the Supplement to Order № 93 of the Russian Ministry of Transport dated 14.04.2010.
    • The content of the training and checks plan in Supplement A (of the Provision of ATC Simulator Training Arrangement and Conduct for Personnel of the State ATM Corporation) is not consistent with the purpose (the reason for training is substituted by the objective).
    • The content of the boxes in the Log of Simulator Training in Supplement B (of the Provision of ATC Simulator Training Arrangement and Conduct for Personnel of the State ATM Corporation) is not consistent with the purpose (the reason for training is substituted by the objective).
    • Since June 2014, the controller simulator training and check records have been kept in violation of the established procedure (numbers of training tasks were not recorded).
  • The on-the-job training of the trainee controller (in progress at the time of the accident) was conducted in violation of regulations and corporate documents.
    • In violation of Para 18, Supplement to Order № 93 of Russian Ministry of Transport, the practical training of the trainee controller (in progress at the time of the accident) was conducted without the required on-the-job training plan.
    • In violation of Para 7.1 Section 10 of the Provision on ATC Simulator Training Arrangement and Conduct for Personnel of the State ATM Corporation, only 12 hours were scheduled for simulator training and 2 hours for the simulator skill check instead of having complete simulator training to accomplish Tasks 1 to 4 (24 hours).
    • No records were made of the date and time of the OJT sessions at the TWR controller working station in the OJT log.
    • There were no task and exercise numbers in the training assignments for trainee controller simulator sessions, which violated the methodology of the trainee controller OJT training and decreased its quality and efficiency.
  • The following deficiencies were found in the individual logs of ATM personnel:
    • The records of simulator training, theoretical and practical checks did not contain information on the name of the evaluator.
    • The records in the medical examination section were not consistent with the conclusion of the medical check.
    • Boxes in the various sections of the logs were filled in with violations of the applicable requirements.
    • There are no rules for ATC personnel individual log book maintenance and no responsible persons are assigned for the maintenance of the ATM personnel individual logs.
  • In violation of FAR-216 of the Russian Ministry of Transport dated 26.11.2009, a Class 2 Air Traffic Controller (Instructor Controller) was authorised to work as an instructor of a trainee by order № 601 of Deputy Director for ATM of Moscow ATM Centre, State ATM Corporation dated 01.09.2011.
  • When maintaining radio exchanges, Controllers of the Vnukovo ATC Centre, the Moscow ATC Centre, the State ATM Corporation, aerodrome service personnel of Vnukovo Airport as well as drivers of Russia Special Flight Squadron violate the RTF rules and callsigns established by Para 11.6 of the 'Technology on Coordination of Aerodrome Service with the Vnukovo ATC Centre and Other Ground Services at Vnukovo Aerodrome' and Para 7 of the 'Temporary Instruction on Aircraft Towing at Vnukovo Aerodrome' (as introduced by Order № 146 of the General Director of Vnukovo Airport dated 15.05.2007).
  • In violation of Para 2.1, Provision of Usage of Recording Devices and Data during ATM at the Moscow ATC Centre, State ATM Corporation 24/7 background recording and video monitoring of ATM working positions was not provided.
  • In violation of Flowchart 5 of the ATC Shift Supervisor’s Job Description, the Main Aviation Meteorological Centre (MAMC) Officer was not ordered to make an unscheduled measuring of all weather elements being monitored at the time of the accident.
  • In violation of requirements of Para 2.37, Section 2 of the ATC Shift Supervisor’s Job Description, the ATC shift supervisor did not make a record in the Log of Airfield Condition when approving the times of the start and the end of airfield operations.
  • In violation of Para 4.1.2 of the Interaction Procedure of the Aerodrome Service with the Vnukovo ATC Centre, the coordination of operations between the ATC shift supervisor and the Aerodrome Service shift supervisor was done without using the internal aerodrome communications radio, telephones or intercom telephony.
  • In violation of Para 39 of Instruction 82 the Aerodrome shift supervisor did not report the problem with one of the three snowploughs prior to the accident to ATC.
  • In violation of the Supplement to Order № 93 of Russian Ministry of Transport, an ATC controller was authorised to work with a trainee as an instructor controller by Order № 921 of Moscow ATC Centre Director, State ATM Corporation with effect from 11.12.2012 without the necessary approval of the Federal Air Transport Agency.
  • In violation of Para 45 in the Supplement to Order № 93 of Russian Ministry of Transport, the duties of ATC shift supervisor in April-May and June-August 2014 were delegated to Chief Shift 3 controller who had not passed the annual check for work as an ATC shift supervisor.
  • In violation of Para 4.1.1 Section ENR 1.10 and 1.11 of the Russian AIP, Para 52.1 of the FAR "Planning of Use of Airspace in the Russian Federation" (approved by Order № 6 of the Russian Ministry of Transport on 16.01.2012) and Para 3.7.1 of FAR-293, Ground Handling Agent VIPPORT did not submit information on the delay of over 30 minutes to the unscheduled LEA074P flight from Moscow Vnukovo to Paris Le Bourget to ATC.
  • The Interaction Procedure of Aerodrome Service with Vnukovo ATC Centre did not contain the requirement to establish reference contact between the Aerodrome Service shift supervisor and ATC every 15 minutes in violation of Para 36 of Instruction 82.
  • Incomplete weather information was provided to the Falсon 50EX F-GLSA crew by the representatives of the VIPPORT Ground Handling Agent.
  • The Falcon 50EX F-GLSA crew did not have current weather forecast and actual weather for the destination, alternate and en-route aerodromes before the take-off.
  • At the emergency and rescue station № 1 observation post, located at the area of runway 01/19 departure (magnetic heading 013º) the observation of the part of this runway around the landing area is obstructed as there is a structural frame at the observation sector, so that the observer is forced to move within the post whilst on duty.
  • A report on the findings in respect of aerodrome lighting had not been drawn up.
  • In violation of Para 2.3.1 of PRAPI-98, there is no specific instruction on the actions, responsibilities and accountabilities of management personnel at the Vnukovo ATC Centre in the event of an accident that is within the area covered by the Central Regional Office of Rosaviatsiya, the Federal Air Transport Agency.
  • FAR-293 does not specify a procedure for monitoring that the runway is clear of foreign objects during the take-off run and the landing roll.
  • There is an inconsistency between the provisions of FAR-362 and Instruction № 82 in terms of fitting all aerodrome vehicles involved in airfield operations with equipment to enable their occupants to listen to the radio exchanges on the active runway control frequency.
  • The method of recording knowledge testing of aerodrome vehicle drivers used during the seasonal training for autumn 2014/winter 2015 does not comply with the Manual on the Operation and Maintenance of Aerodrome Vehicles at Airports in the Russian Federation enforced by Letter № 30/И of the Federal Air Transport Agency dated 07.04.1997.
  • There is no system in the Russian Federation for the planning and implementation of the A-SMGCS system. The implementation of A-SMGCS is conducted in the course of its operation. No aerodrome regulation contains a requirement that there shall be A-SMGCS systems deployed at aerodromes.

The following 55 Safety Recommendations were made:

  • that the Russian Aviation Authorities communicate information on the accident to civil flight operations personnel, ATM personnel and aerodrome service personnel.
  • that the Russian Aviation Authorities consider the practicability of developing additional measures to prevent runway incursions taking into account ICAO Doc 9870 AN/463 "Manual on the Prevention of Runway Incursions".
  • that the Russian Aviation Authorities consider the practicability of developing additional action plans to monitor that the runway is clear of foreign objects during the take-off run and landing roll.
  • that the Russian Aviation Authorities consider amending the aviation regulations to add a requirement of mandatory monitoring of ATC objects with the help of background recording and video monitoring of ATC working positions.
  • that the Russian Aviation Authorities consider mandating the check of aerodrome vehicle drivers performing airfield operations for alcohol influence during the medical check before and after the duty shift and introduce a standardised form of the medical check log for drivers of aerodrome vehicles.
  • that the Russian Aviation Authorities conduct a re-assessment of ATC personnel working stations paying special attention to the field of view and mutual positioning of the screens providing necessary information to carry out air traffic control.
  • that the Russian Aviation Authorities eliminate the contradiction between the provision of Para 1, Article 53 of the Air Code of the Russian Federation and Para 18, Section III of Order № 93 of the Russian Ministry of Transport dated 14.04.2010 in terms of the possibility of air traffic control being provided by trainee controllers not holding aviation personnel licences.
  • that the Russian Aviation Authorities consider the practicability of introducing additions to FAR-262 in terms of mandating the marking of runway holding points at runway/runway intersections.
  • that the Russian Aviation Authorities bring the provisions of Instruction № 82 into compliance with those of FAR-362 with regard to all vehicles which perform works on the runway being permanently equipped with a means of continuous monitoring of radio communications on the frequency being used for active runway control.
  • that the Russian Aviation Authorities should clarify (improve) the training and authorisation procedure for accredited instructors to be authorised to work as an instructor of trainee controllers.
  • that the Russian Aviation Authorities should develop unified rules for the maintenance of the individual log books of ATC personnel.
  • that the Russian Aviation Authorities should, due to a large number of hazards identified in the Vnukovo Airport and Vnukovo ATC Centre Aerodrome Service operations, consider conducting a re-assessment of pertinent risks and taking risk mitigation actions.
  • that the Russian Aviation Authorities should develop technical specifications and operation procedures for Advanced Surface Movement, Guidance and Control Systems (A-SMGCS).
  • that the Russian Aviation Authorities should introduce requirements for the A-SMGCS system similar to those in Section 9.8 of ICAO Annex 14 Aerodromes, Volume I, ICAO Doc 9476 and ICAO Doc 9830 into the national aviation regulations on certification and operation of aerodromes.
  • that the Russian Aviation Authorities should ensure that an Airport SMS includes both documentation and implementation of a procedure to conduct medical checks (pre-duty and post-duty) as well as oversight during shifts to mitigate the risk of drivers carrying out their duties when under the influence of alcohol.
  • that the Russian Aviation Authorities should consider the practicability of amending the applicable regulations to include a requirement to fit an airfield surveillance and control system (if installed)) with MLAT/ADS-B functions.
  • that the State ATM Corporation, in cooperation with the management of the Vnukovo ATC Centre should arrange training for their personnel on the use of the A3000 A-SMGCS system and improve Working Instructions to include provisions on the recommended settings of the A3000 system depending on the working position as well as guidance on attention allocation while operating the system and reaction to various types of alerts. The applicability of this recommendation to other ATC Centres where the same or similar system is used should be considered.
  • that the State ATM Corporation should consider revoking authorisations for work as instructors of trainees held by ATC controllers which have been issued in violation of the Supplement to Order № 93 of the Russian Ministry of Transport dated 14.04.2010.
  • that the State ATM Corporation should consider introducing standardised OJT logs for all ATC personnel for use during on-the-job probationary training.
  • that the State ATM Corporation should maintain records of annual practical checks of instructor training for instructor controllers, both staff and trainee ones, in personal ATC controller log books.
  • that the Moscow ATM Centre of the ATM State Corporation should take measures to prevent falsification of records in personnel documents. With regard to the previous recommendation, it should consider conducting an internal investigation into the falsification of records in individual log books and the Log of Simulator Training in the case of the training of the TWR instructor controller on duty at the time of the accident.
  • that the Moscow ATM Centre of the ATM State Corporation should consider revoking authorisations to work as instructors of ATC controllers authorised as trainee instructor controllers by orders № 601 by Moscow ATM Centre of the State ATM Corporation dated 01.09.2011, № 921 dated 11.12.2012 and № 4.1.1-08801 dated 17.08.2011.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should improve its SMS taking into account the results of this Investigation paying special attention to the functioning of the voluntary reporting system.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should develop a procedure for and accomplish the setting of Reserved Lines on the A3000 A-SMGCS in the area of the runway intersection and assess the necessity of having and/or correcting Reserved Lines in other locations.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should consider changing the format and duration of the sound alarm when various alert modes are activated to ensure a better attention-getting effect.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should arrange regular checks of ATC controllers in terms of efficiency of their operation of the A3000 A-SMGCS system using readouts of the system’s recorder.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should determine criteria to be used by the ATC shift supervisor when deciding to combine ATC sectors.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should ensure that radio exchange and reference radio communication by TWR/GND ATC units complies with the Coordination Procedure of Aerodrome Service with Vnukovo ATC Centre and Other Ground Support Services at Vnukovo Aerodrome.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should ensure that background recording and video monitoring of ATM working positions at the Moscow ATM Centre of the State ATM Corporation complies with the Provision of Usage of Recording Devices and Data during ATM at Moscow ATC Centre of the State ATM Corporation.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should ensure that ATM personnel simulator training complies with Order № 182 of the State ATM Corporation dated 16.04.2014.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should, in cooperation with the Main Aviation Meteorological Centre (MAMC), ensure automatic notification of the meteorologist at the main observation post upon the Emergency Landing (Alarm) signal.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should ensure that terminology used in the Job Description of ATC Shift Supervisor at the Vnukovo ATC Centre complies with the pertinent regulations.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should conduct training for ATM personnel on the use of Terma Scanter 2001 Airfield Surveillance Radar and the A3000 A-SMGCS.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should consider clarifying the contents of exercises in Task 2 of the Arrangement and Conduct of Vnukovo ATC Centre Personnel Simulator Training Procedure to specify exercises to train personnel actions during runway and taxiway incursions.
  • that the Vnukovo ATC Centre of the Moscow ATM Centre, ATM State Corporation should develop and enforce an 'Instruction on Management Personnel Actions, Responsibilities and Accountabilities in Case of Accidents' and have it accepted by the Central Territorial Office of the Federal Air Transport Agency (Rosaviatsiya) in compliance with Para 2.3 of PRAPI-98.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should improve its SMS in the light of the findings of the Investigation and take efficient measures to prevent runway incursions taking into account any intersecting runways.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should ensure that, if required, a check that proper aerodrome signage and marking prescribed by the applicable regulations is in place.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should ensure that medical checks of aerodrome vehicle drivers at Vnukovo AP are conducted in compliance with the requirements of the Instruction on Aerodrome Vehicle Traffic Management at Vnukovo Airdrome before and after each duty shift.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should determine the actions required of a person in charge of the airfield operations in the event that they lose visual contact with vehicles or in case of a vehicle failure.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should determine the actions required of a vehicle driver in the event that they lose visual contact with the airfield operations supervisor or spatial orientation on the airfield.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should provide training for vehicle drivers on relevant elements of the aerodrome lighting system.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should consider the practicability of introducing qualification requirements as to English proficiency for Airfield Operations Supervisors.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should require that reference radio communication is maintained by Aerodrome Operations supervisors in accordance with the Interaction Procedure of Aerodrome Service with Vnukovo ATC Centre.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should revise the Interaction Procedure of Aerodrome Service with Vnukovo ATC Centre to add radio call sign prefixes for each vehicle type belonging to organisations operating on the airfield.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should bring the Interaction Procedure of Aerodrome Service with Vnukovo ATC Centre into compliance with the FAR-362 provisions which require all vehicles performing works on the runway to be equipped with the devices for the permanent listening to the radio communications on the runway control frequency.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should ensure compliance of the Interaction Procedure of Aerodrome Service with Vnukovo ATC Centre with the requirements of Para 36 of Instruction № 82 in terms of maintaining a radio communications watch.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should consider revising the procedure for radio communication for vehicles operating on runways to make it compliant with Para 4.2.6 of ICAO Doc 9870.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should ensure that when on duty the observer at the departure search and rescue station at the 01 end of runway 01/19 pays special attention to complying with the requirements of Para 8 of the Instruction for Search and Rescue Station Observer dated 12.07.2012 in terms of their exact position at the observation post so that an uninterrupted visual observation of aircraft take-off and landing is possible.
  • that Vnukovo Airport (and each airport operator in the IAC/MAK Contracting States as applicable) should ensure that radio communications between the Aerodrome Service Dispatcher, Aerodrome Service Shift Supervisors and vehicle drivers conducting airfield operations are recorded.
  • that Ground Handing Agent VIPPORT should ensure timely provision of meteorological information to aircraft crews in accordance with the regulations.
  • that Ground Handing Agent VIPPORT should ensure the rectification of relevant findings raised during the Investigation including reporting to the appropriate parties in the event that a pre-notified departure time is put back.
  • that Aircraft Operator Unijet should consider the practicability of improving their SMS in terms of recommended crew actions in the event that they detect an obstacle on the runway during take-off or landing.
  • that Aircraft Operator Unijet should reassess the risks of a transfer of aircraft control during the take-off roll when the First Officer is the PF on aircraft where nose wheel steering is only possible from the Left seat and if necessary amend the Operations Manual accordingly.
  • that the EASA, the IAC Aviation Register, Rosaviatsiya and other Certification Authorities consider the practicality of requiring the mandatory installation of nose wheel steering which is operable by both pilots at their assigned seating position for newly certified airplane (as per CS-25, AR-25 or equivalent).
  • that the International Civil Aviation Organisation should consider the practicability of introducing additions to Standard 5.2.10.7 of ICAO Annex 14, Volume 1 Aerodrome Design and Operations (Edition 6, July 2013) in respect of the marking of runway holding points at the runway/runway intersection even if there are no standard taxiing routes passing through this location.

The Final Report was completed on 24 October 2016 and subsequently made available by the MAK in a Courtesy English Translation upon which this summary is based subject to language clarity and use corrections.

Related Articles