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Turkish Airlines Flight 6491: Difference between revisions

Coordinates: 43°03′26″N 74°26′14″E / 43.05722°N 74.43722°E / 43.05722; 74.43722
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→‎Investigation: Clean up some language around the final IAC report
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The preliminary investigation report found that the aircraft descended late and captured a false glideslope.<ref name="prelim">{{cite web|last=|first=|date=|title=Preliminary Report Boeing 747-412F TC-MCL|url=http://mak-iac.org/upload/iblock/7f7/Preliminary%20Report%20Boeing%20747-412F%20TC-MCL.pdf|accessdate=27 March 2017|website=|publisher=[[Interstate Aviation Committee]]}}</ref>{{rp|10}} On capturing the false glide slope, the 3 auto pilots then initiated the descent of the plane<ref name="prelim" />{{rp|10}} in low visibility conditions.<ref name="prelim" />{{rp|19}} Initially all three auto pilots were engaged (LAND 3) the false glideslope was lost 15 seconds after it was acquired and AP CAUTION and FMA FAULT 2 events were recorded meaning that the auto pilots would continue to descend the aircraft on a 3 degree slope using inertial guidance.<ref name="prelim" />{{rp|27}} One autopilot disengaged (LAND 2) and the remaining auto pilots flew down to the decision height. The crew did not acquire the required visual reference at the decision height (99&nbsp;ft) and initiated a go-around 1/2 second later at 58&nbsp;ft radar altitude by pressing the [[Takeoff/go-around switch|TOGA switches]].<ref name="prelim" />{{rp|11}} Given the slightly up-sloping terrain after the end of the runway, the aircraft did not have sufficient height at that point to climb out safely.
The preliminary investigation report found that the aircraft descended late and captured a false glideslope.<ref name="prelim">{{cite web|last=|first=|date=|title=Preliminary Report Boeing 747-412F TC-MCL|url=http://mak-iac.org/upload/iblock/7f7/Preliminary%20Report%20Boeing%20747-412F%20TC-MCL.pdf|accessdate=27 March 2017|website=|publisher=[[Interstate Aviation Committee]]}}</ref>{{rp|10}} On capturing the false glide slope, the 3 auto pilots then initiated the descent of the plane<ref name="prelim" />{{rp|10}} in low visibility conditions.<ref name="prelim" />{{rp|19}} Initially all three auto pilots were engaged (LAND 3) the false glideslope was lost 15 seconds after it was acquired and AP CAUTION and FMA FAULT 2 events were recorded meaning that the auto pilots would continue to descend the aircraft on a 3 degree slope using inertial guidance.<ref name="prelim" />{{rp|27}} One autopilot disengaged (LAND 2) and the remaining auto pilots flew down to the decision height. The crew did not acquire the required visual reference at the decision height (99&nbsp;ft) and initiated a go-around 1/2 second later at 58&nbsp;ft radar altitude by pressing the [[Takeoff/go-around switch|TOGA switches]].<ref name="prelim" />{{rp|11}} Given the slightly up-sloping terrain after the end of the runway, the aircraft did not have sufficient height at that point to climb out safely.


On 4 March 2020 the [[Interstate Aviation Committee|IAC]] released is final report on the accident, stated that the cause of the incident was the lack of control by the crew over the aircraft position relative to the glide path during night landing with [[Instrument landing system|Istrument Landing Systeme (ILS)]] and the failure to execute a [[Go-around]] in time when there were significant deviations from the established landing path which leading to the crash, also, according to the final report, the instructions and actions of the flight controllers were sufficient to follow the established operational procedure.<ref name="final" />
On 4 March 2020 the [[Interstate Aviation Committee|IAC]] released is final report on the accident, stating that the cause of the incident was the flight crew's loss of [[situational awareness]] (specifically, of the aircraft's location relative to the glideslope) during an instrument approach with no visual ground reference, and the crew's failure to execute a [[go-around]] promptly when a safe landing could no longer be achieved due to the aircraft's excessive altitude on [[final approach]].<ref name="final" />


Other contributing factors of the incident were:
Other contributing factors of the incident were:


* Insufficient pre-flight briefing of crew on approach schedules for landing at [[Manas International Airport]],
* Insufficient pre-flight briefing of crew on approach procedures for landing at [[Manas International Airport]]
* The crew did not take effective measures to reduce the altitude of the aircraft and the only point of reference were the approach charts, despite the crew being aware that the height of the aircraft was too high compared to that required on the approach charts.
* The crew's failure to correct the aircraft's consistently high altitude on approach relative to the altitudes specified on the approach charts
* Lack of tower controllers who followed the aircraft position deviations and took the necessary actions, the necessary technical equipment was available and working at that moment.
* The Tower controllers were not required to watch for deviations from a published approach and warn pilots of such
* Excessive stress on the crew, caused by the complex approach
* Incapacity of the crew due to excessive psycho-emotional stress due to the too complex approach conditions (night flight, CAT II landing, extended flight), and deviations from the landing path for a long period of time.
* The crew's failure to monitor the aircraft's crossing the established navigational reference points
* The crew's failure to notice that the autopilot had captured a false glideslope
* The aircraft's autopilot's issuance of a "Caution" rather than a more urgent "Warning" when it detected problems with the glideslope
* The crew's failure to monitor the aircraft's position using available instruments
* The crew's failure to initiate the go-around at the [[decision height]] of {{convert|99|ft|m}} when visual reference to the runway was not established; it was instead initiated at {{convert|58|ft|m}}


== Aftermath ==
== Aftermath ==

Revision as of 14:23, 15 October 2023

Turkish Airlines Flight 6491
The crash site of Flight 6491
Accident
Date16 January 2017 (2017-01-16)
SummaryControlled flight into terrain during go-around in fog
SiteManas International Airport, Bishkek, Kyrgyzstan
43°03′26″N 74°26′14″E / 43.05722°N 74.43722°E / 43.05722; 74.43722
Total fatalities39
Total injuries14
Aircraft
Aircraft typeBoeing 747-412F/SCD
OperatorACT Airlines on behalf of Turkish Airlines
IATA flight No.TK6491
ICAO flight No.THY6491
Call signTURKISH 6491
RegistrationTC-MCL
Flight originHong Kong International Airport, Hong Kong, China
StopoverManas International Airport, Bishkek, Kyrgyzstan
DestinationIstanbul Atatürk Airport, Istanbul, Turkey
Occupants4
Passengers0
Crew4
Fatalities4 (initially 3)
Survivors0 (initially 1)
Ground casualties
Ground fatalities35
Ground injuries14

Turkish Airlines Flight 6491 was a scheduled international cargo flight operated by ACT Airlines on behalf of Turkish Cargo, from Hong Kong to Istanbul via Bishkek, Kyrgyzstan. On 16 January 2017, the Boeing 747-400F flying the route crashed in a residential area while attempting to land in thick fog at Manas International Airport, Bishkek. A total of 39 people – all four crew members on board and 35 residents on the ground – were killed.[1]

The subsequent investigation found that the aircraft failed to properly acquire the instrument landing system's signal, remaining significantly higher than the correct approach path while overflying the entire length of the runway; it then collided with houses seconds after initiating a go-around.[2]

Accident

At 07:19 local time (01:19 UTC) on 16 January 2017, the aircraft crashed nearly 1 km (3,300 ft) beyond the end of runway 26 at Manas International Airport,[3]: 11  in thick fog.[4] According to initial reports, the aircraft failed to gain enough altitude while attempting a go-around. It crashed into terrain and destroyed several houses.[5] Kyrgyz authorities later stated that the crew were making a determined attempt to land the aircraft instead of aborting the landing.[6]

A total of 39 people were killed in the crash: all four crew members and 35 residents of Dacha-SU (Kyrgyz: Дача-СУ), a residential area located approximately 2 kilometres (1.2 mi; 1.1 nmi) to the west of the airport.[7][8][9][4][10] Among the dead were 17 children.[8]

Witnesses and rescuers reported that they found the pilot still conscious strapped into his seat, from which he had to be cut free. He later died while en route to a hospital.[11][12]

Fourteen people on the ground were injured, including a number of children.[3]: 7, 11 [13][14][10] Nineteen houses were destroyed at the crash site, and a further seven were damaged.[3]: 12 [9] Manas International Airport was closed, with all flights cancelled, following the accident.[15]

Aircraft and crew

9V-SFL, the Boeing 747-412F involved in the crash when the plane was still operating for Singapore Airlines Cargo
The aircraft involved, seen at Maastricht Aachen Airport, 5 days before the accident.

The aircraft involved was a Boeing 747-412F,[note 1] registered as TC-MCL and with manufacturer's serial number 32897.[16] The plane entered service with Singapore Airlines Cargo in 2003, with the registration 9V-SFL.[17] After multiple periods of storage, the aircraft was acquired by LCI Aviation in 2015. It was leased it to Istanbul-based cargo company ACT Airlines, which then began operating it on behalf of Qatar Airways Cargo, followed by Turkish Airlines Cargo from 2017.[16][18][19] The aircraft had flown a total of over 45,000 hours and 8,000 cycles as of June 2016. Its last C-check maintenance check had been completed on 6 November 2015.[19]

The crew consisted of Captain Ibrahim Diranci, First Officer Kazim Ondul (both aged 59), loadmaster Ihsan Koca, and cargo handler Melih Aslan.[20]

Immediate response

Deputy Prime Minister Mukhammedkalyi Abulgaziyev reported that, by late morning, more than 1,000 rescue workers were at the scene.[18] Minister of Health Talantbek Batyraliyev reported that by 11:46 a.m. local time, around 56 doctors and psychologists and 14 ambulance crews had been dispatched to the scene.[21]

A number of heads of state expressed condolences, including the presidents of the other members of the Commonwealth of Independent States and the Prime Minister of Turkey.[22][23]

The following day was declared a day of national mourning in Kyrgyzstan.[24]

Investigation

The location of the crash (red square) past the end of runway 26 at Manas Airport

The cause of the crash was not immediately clear.[25] Kyrgyzstan's Emergency Situations Minister, Kubatbek Boronov, stated that it was foggy at Manas at the time of the crash, but that weather conditions were not critical. By the afternoon of 16 January, one of the two flight recorders had been found,[26] and the other was located later in the recovery process.[27] Both the flight data recorder (FDR) and cockpit voice recorder (CVR) were damaged in the crash, but investigators were still able to retrieve data from both recorders.[27]

Deputy Prime Minister Abulgaziyev suggested that the cause may have been pilot error, noting that eleven aircraft had landed safely, despite the same weather conditions, on the previous day. He added that the aircraft had attempted to land twice and had damaged the runway lights at one stage.[21] This statement was at odds with another official statement that the aircraft crashed during its first landing attempt.[6]

The Interstate Aviation Committee (IAC or MAK) of the Commonwealth of Independent States opened a technical investigation.[28]

The Turkish Transportation Ministry said it had sent two experts from its accident investigation board to Bishkek to assist Kyrgyz authorities.[18]

A Boeing technical team travelled to the accident site to provide assistance at the request and under the direction of the American accident investigation body, the National Transportation Safety Board.[29]

Many initial press responses stated that a Turkish Airlines aircraft was involved in the accident. In response, Turkish Airlines released a statement saying that neither the aircraft nor the crew were part of the airline, calling it an "ACT Airlines accident".[30] Journalists were threatened by Turkish lawyers claiming reputational damage.[31] Nevertheless, the flight was operated under a Turkish Airlines flight number.

The crash site of TC-MCL almost six months after the crash

The preliminary investigation report found that the aircraft descended late and captured a false glideslope.[3]: 10  On capturing the false glide slope, the 3 auto pilots then initiated the descent of the plane[3]: 10  in low visibility conditions.[3]: 19  Initially all three auto pilots were engaged (LAND 3) the false glideslope was lost 15 seconds after it was acquired and AP CAUTION and FMA FAULT 2 events were recorded meaning that the auto pilots would continue to descend the aircraft on a 3 degree slope using inertial guidance.[3]: 27  One autopilot disengaged (LAND 2) and the remaining auto pilots flew down to the decision height. The crew did not acquire the required visual reference at the decision height (99 ft) and initiated a go-around 1/2 second later at 58 ft radar altitude by pressing the TOGA switches.[3]: 11  Given the slightly up-sloping terrain after the end of the runway, the aircraft did not have sufficient height at that point to climb out safely.

On 4 March 2020 the IAC released is final report on the accident, stating that the cause of the incident was the flight crew's loss of situational awareness (specifically, of the aircraft's location relative to the glideslope) during an instrument approach with no visual ground reference, and the crew's failure to execute a go-around promptly when a safe landing could no longer be achieved due to the aircraft's excessive altitude on final approach.[2]

Other contributing factors of the incident were:

  • Insufficient pre-flight briefing of crew on approach procedures for landing at Manas International Airport
  • The crew's failure to correct the aircraft's consistently high altitude on approach relative to the altitudes specified on the approach charts
  • The Tower controllers were not required to watch for deviations from a published approach and warn pilots of such
  • Excessive stress on the crew, caused by the complex approach
  • The crew's failure to monitor the aircraft's crossing the established navigational reference points
  • The crew's failure to notice that the autopilot had captured a false glideslope
  • The aircraft's autopilot's issuance of a "Caution" rather than a more urgent "Warning" when it detected problems with the glideslope
  • The crew's failure to monitor the aircraft's position using available instruments
  • The crew's failure to initiate the go-around at the decision height of 99 feet (30 m) when visual reference to the runway was not established; it was instead initiated at 58 feet (18 m)

Aftermath

On 17 January 2017, the Kyrgyz press reported that ACT Airlines had declared the intent to pay the victims compensation for all material and immaterial losses, citing a press release on the ACT Airlines web site.[32] The press release itself, however, stated only that losses were covered by insurance.[33]

Notes

  1. ^ The aircraft was a Boeing 747-400F model; the "F" denoting that the aircraft was the freighter variant of the 747-400. Boeing assigns a unique code for each company that buys one of its aircraft, which is applied as a suffix to the model number at the time the aircraft is built, hence "747-412F".

References

  1. ^ "Kyrgyzstan plane crash: Dozens die as Turkish cargo jet hits homes". BBC News. 16 January 2017. Retrieved 31 July 2018.
  2. ^ a b "Final Report Boeing 747-412F TC-MCL" (PDF). Interstate Aviation Committee. 2020-02-17. Retrieved 2020-03-05.
  3. ^ a b c d e f g h "Preliminary Report Boeing 747-412F TC-MCL" (PDF). Interstate Aviation Committee. Retrieved 27 March 2017.
  4. ^ a b "ASN Aircraft accident Boeing 747-412F TC-MCL Bishkek-Manas International Airport (FRU)". Aviation Safety Network. 16 January 2017. Retrieved 16 January 2017.
  5. ^ Hradecky, Simon (16 January 2017). "Crash: MyCargo B744 at Bishkek on Jan 16th 2017, impacted terrain on go around". The Aviation Herald. Retrieved 16 January 2017.
  6. ^ a b "Разбившийся Боинг-747 не кружил в полосе ожидания, экипаж сразу решил совершить посадку, - замглавы "Кыргызаэронавигации"" [Deputy Head of Kyrgyzaeronagizatsiya: Crashed Boeing 747 Did Not Make a Go-Round, the Crew Decided to Land Right Away] (in Russian). AKIpress. 17 January 2017. Retrieved 17 January 2017.
  7. ^ "The authorities of Kyrgyzstan: in the crash of Boeing killed 38 people". 24-my.info. Archived from the original on 2017-01-18. Retrieved 17 January 2017.
  8. ^ a b "Kyrgyzstan Mourns Victims Of Plane Crash That Devastated Village". Radio Free Europe/Radio Liberty. RFE/RL's Kyrgyz Service. 17 January 2017. Retrieved 17 January 2017.
  9. ^ a b "Belarus' First Deputy Foreign Minister signs Book of Condolences at Kyrgyzstan's embassy". Belarusin Telegraph Agency. 17 January 2017. Retrieved 17 January 2017.
  10. ^ a b "Крушение "Боинга-747". Скончался один из госпитализированных" [Boeing 747 Crash: One of the hospitalized has died]. 24.kg (in Russian). 22 January 2017. Retrieved 23 January 2017.
  11. ^ "Witnesses of Kyrgyzstan crash speak of loss, finding pilot". Yahoo! News. 17 January 2017. Archived from the original on 21 December 2018. Retrieved 18 January 2017.
  12. ^ "Crash: MyCargo B744 at Bishkek on Jan 16th 2017, impacted terrain on go around". avherald.com. Retrieved 2020-03-06.
  13. ^ "Kyrgyzstan Ministry Says Cargo Plane Crash Kills 37". The New York Times. Associated Press. Archived from the original on 16 January 2017. Retrieved 16 January 2017.
  14. ^ "Крушение грузового Boeing в Киргизии" [The crash of the cargo Boeing cargo plane in Kyrgyzstan]. РБК (in Russian). 16 January 2017. Retrieved 16 January 2017.
  15. ^ "Turkish cargo Boeing 747 crashes in Kyrgyzstan". www.aljazeera.com. Retrieved 2017-01-16.
  16. ^ a b "MyCargo Airlines TC-MCL (Boeing 747 - MSN 32897) (Ex 9V-SFL)". Airfleets Aviation. 16 January 2017. Retrieved 16 January 2017.
  17. ^ "MyCargo Airlines TC-MCL (Boeing 747 - MSN 32897) (Ex 9V-SFL ) | Airfleets aviation". www.airfleets.net. Retrieved 2017-03-24.
  18. ^ a b c "Turkish cargo jet crash kills at least 37 in Kyrgyzstan village". The Daily Telegraph. 16 January 2017. Retrieved 16 January 2017.
  19. ^ a b "Turkish cargo Boeing 747 crashes near Bishkek - Russian aviation news". Russian Aviation Insider. 16 January 2017. Retrieved 16 January 2017.
  20. ^ "Matter over Mind: The crash of Turkish Airlines flight 6491". 23 August 2020.
  21. ^ a b "Kyrgyzstan Cargo Plane Crash: Turkish Airplane Crash Kills Dozens Near Bishkek". ibtimes.com. 16 January 2017. Retrieved 16 January 2017.
  22. ^ ""Разделяем боль и горе". Лидеры СНГ соболезнуют Кыргызстану - СМИ" ["We share pain and suffering": CIS leaders express condolences to Kyrgyzstan]. Mir 24 (in Russian). 16 January 2017. Retrieved 17 January 2017.
  23. ^ "Эрдоган соболезнует Атамбаеву в связи с авиакатастрофой - СМИ" [Erdoǧan expresses condolences to Atambaev regarding the air catastrophe, according to media]. Vestnik Kavkaza (in Russian). 16 January 2017. Retrieved 17 January 2017.
  24. ^ Podolskaya, Darya (16 January 2017). "January 17 declared day of mourning". 24.kg. Archived from the original on 17 January 2017. Retrieved 17 January 2017.
  25. ^ Eurasianet.org (May 11, 2022)Kyrgyzstan: Public commission created to investigate deadly 2017 plane crash
  26. ^ "Turkish cargo jet crash kills at least 37 in Kyrgyzstan village". The Telegraph. Our Foreign Staff. 16 January 2017. Retrieved 16 January 2017.
  27. ^ a b "Crashed 747's flight recorders badly damaged". Flightglobal. 21 January 2017. Retrieved 23 January 2017.
  28. ^ "Boeing 747-412F TC-MCL 16.01.2017". mak-iac.org. Interstate Aviation Committee. Retrieved February 5, 2017.
  29. ^ "News Releases/Statements". boeing.mediaroom.com. Retrieved 17 January 2017.
  30. ^ @TurkishAirlines (2017-01-16). "Regarding the ACT Airlines accident in Kyrgyzstan:" (Tweet) – via Twitter.
  31. ^ "In eigener Sache: Turkish Airlines will nach Absturz von Frachter Bericht zensurieren" [On our own behalf: Turkish Airlines wants to censor report after freighter crash]. Austrian Wings (in Austrian German). 16 January 2017. Retrieved 2020-03-06.
  32. ^ Li, Natalya (17 January 2017). "АСТ Airlines выплатит компенсации всем пострадавшим в крушении Боинга" [ACT Airlines will pay a compensation to all victims of the Boeing crash] (in Russian). Vecherniy Bishkek. Retrieved 17 January 2017.
  33. ^ "Press Release" (Press release). ACT Airlines Inc. 16 January 2017. Retrieved 17 January 2017.

External links

Wikimedia Commons has media related to Turkish Airlines Flight 6491.
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