Armavia Flight 967
|Date||May 3, 2006|
|Summary||Controlled flight into terrain,
Pilot error, Psycho-emotional stress
|Site||6 kilometres (3.7 mi) off Adler-Sochi International Airport over Black Sea|
|Aircraft type||Airbus A320-211|
|Flight origin||Zvartnots International Airport, Zvartnots, Armenia|
|Destination||Sochi International Airport, Sochi, Russia|
Armavia Flight 967 (U8 967/RNV 967) was a scheduled international passenger flight operated by Armavia, the largest international airline of Armenia and the flag carrier of Armenia from Zvartnots International Airport, Zvarnots in Armenia to Sochi, a Black Sea coastal resort city in Russia. On 3 May 2006, the aircraft operating the route, an Airbus A320-200, crashed into the sea while attempting to go-around following its first approach to Sochi airport, killing all 113 aboard.
The accident was the first major commercial airline crash in 2006 and the fifth highest death toll of any accident involving an Airbus A320 after Gulf Air Flight 072, Germanwings Flight 9525, Indonesia AirAsia Flight 8501 and TAM Airlines Flight 3054. It was Armavia's first and only fatal plane crash.
The plane took off from Zvartnots International Airport (EVN) at a scheduled departure time at 01:45 Armenian Daylight Time (20:45 UTC, May 2) and with a scheduled arrival time at Sochi International Airport (AER) of 02:00 Moscow Daylight Time (22:00 UTC, May 2).
In order to make their decision for departure, the crew obtained the observed weather data and the weather forecast for the takeoff, landing and alternate aerodromes all of which met the requirements for IFR flights. All the crew were correctly licensed and adequately rested to operate the flight.
The airplane took off from Zvartnots airport at 20:47. There were 113 occupants on board: 105 passengers (including 5 children and 1 infant), 2 pilots,1 aircraft engineer and 5 flight attendants. Takeoff, climb and cruise were uneventful.
The first communication between Sochi approach controller and the crew took place at 21:10. At that moment the airplane was beyond the coverage area of the Sochi radar. Up until 21:17 the approach controller and the crew discussed the observed and forecast weather, and as a result the crew decided to return to Yerevan. At 21:26, after the decision had already been made, the crew asked the controller about the latest observed weather. At 21:30 the controller informed the crew that visibility was 3,600 metres (2.2 mi) and the cloud ceiling 170 metres (600 ft). At 21:31 the crew decided to continue the flight to Sochi airport.
The next communication with the approach controller was at 22:00. At that moment the aircraft was descending to an altitude of 3,600 metres (12,000 ft) and was being tracked by the Sochi radar. The approach controller cleared the flight for a descent to 1,800 metres (6,000 ft) and reported the observed weather at Sochi, as at 22:00, for runway 06, which was above the minimums.
The crew was then handed over to the holding and tower controllers, and was cleared for descent to 600 metres (2,000 ft), before entering the turn to the final approach. Whilst performing the turn, the runway extended centreline was overshot. After eliminating the deviation, the crew started descending the aircraft along the glide slope, following the approach pattern.
At 22:10 the crew reported that the gear was down and that they were ready for landing. In response they were advised that they were 10 kilometres (6 mi) from the airport and that the weather was now 4,000 metres (2.5 mi) visibility x 190 metres (600 ft) cloud ceiling, and were cleared for landing. However, about 30 seconds later, the controller advised the crew of the observed cloud ceiling at 100 metres (300 ft) and instructed them to cease their descent, abandon the landing attempt, and carry out a right turn and climb to 600 metres (2,000 ft) and also to contact the holding controller, who gives instructions for entering the airport's holding pattern.
The last communication with the crew was at 22:12. After that the crew did not respond to any of the controller’s calls. At 22:13 the aircraft struck the water, and broke up on impact.
The aircraft involved was built in France with its first flight in June 1995. It has a MSN number of 547 with a test registration code of F-WWIU. The aircraft has been delivered in 1995 to Ansett Australia, registered in Australia as VH-HYO. It was acquired by Armavia in 2004 registered as EK-32009 with its name as Mesrop Mashtots. Armavia repainted the plane with its new livery on 31 October 2004. The plane recorded more than 10,000 hours before the crash.
Passengers and crews
- Citizenship of the passengers and crew
The Captain of Flight 967 was Captain G.S Grigoryan. Born in 1966, he had completed his primary training in Krasnokutsk Civil Flight School. He graduated in 1986 and also graduated from Moscow Institute of Civil Aviation Engineers. He joined Balaklavsky United as a co-pilot in 1986. He then joined Ararat Airlines in 1997 as a Captain of a Yakovlev Yak-40. He then joined Armavia as a co-pilot of an Airbus A320 in 2004 and subsequently promoted to a Captain in 2005. He had passed a test for an Airbus A320 Captain in SAS Flight Academy in Stockholm, Sweden with a safisfying results. Captain Grigoryan had a total flight hours of 5.458 hours.
The First Officer (Co-pilot) of Flight 967 was First Officer A.D Davtyan. He was born in 1977 and had completed his primary training in Ulyanovsk Civil Flying School and graduated in 1999. He then joined Chernomor-Avia in December 2001 as a co-pilot of a Tupolev Tu-154. He joined Armavia in 2002, joined Armenian Airlines in 2004, and then joined Armavia again in the same year. First Officer Davtyan had passed a training course for an Airbus A320 in SAS Flight Academy in Stockholm, Sweden with a safisfying results. He had a total flying hours of 2.185 hours.
Flight 967 disappeared from Sochi's radar at 02:13 local time. Chief of Flight Operation N.G Savelyev alerted all the search and rescue services in the area and deployed an Mi-8 helicopter. At 02:19, the disappearance of Flight 967 was informed to Russia's Minister of Emergencies. A search helicopter was ready for take off to find the missing flight, but was not allowed by Sochi due to the deteriorating weather. The search and rescue operation was then suspended. At 04:08, the Ministry of Emergency's boat Valery Zamarayez found the probable crash area. Rescuers then went to the search area. From 07:30 to 12:30, search and rescue team recovered 9 body parts from the crash site.
Search and rescue personnel only managed to recover some of the flight's debris. They recovered the Airbus' nose, landing gear, fin, elevator, and several other fragments. Wiring and electronic units were also found. A total of 52 body fragments were found by the search and rescue team as well. The BEA noted that, at the time when Flight 967 impacted the sea, the landing gear was extended. The lower part of the rudder was severely damaged due to the impact forces. Several parts of the aircraft elevator was also damaged. Some of the aircraft parts recovered from the sea were severely deformed.
The weather at the time was considered to be fine. Low pressure was present near Sochi at the time. A cold front was also detected and was forming in the Caucasian Edge and further to the east of Turkey at the time. Rain was also present in Adler (Sochi). In the spring transition period, low clouds often occurred in the Caucasian Edge, which, could have limited visibility for the pilots. This proved to be dangerous, as most Controlled Flight Into Terrain (CFIT) occurs due to this kind of cloud (which obscures the pilots visual reference).
Prior to take off from Yerevan, the crew was briefed on the weather conditions in Sochi. At the time, the weather in Sochi was fine. After the take off of Flight 967, the pilots were given another weather briefing. It was still in good condition, with considerable clouds, mist, and light rain. The weather at the time would not have allowed for a vortex (i.e storm, tornado, downdraft). In the following hours, the probability that a vortex might occur was reduced to zero. By the time Flight 967 entered Sochi, the weather conditions had deteriorated. A cold front wave occurred in Sochi, producing Cumulonimbus cloud. The rain intensified, and the visibility was reduced to 1.500 meter. For several minutes, the weather became better for landing. The controllers instructed Flight 967 to abort their descent and conduct a go-around immediately, as low clouds were present in Sochi Airport. Shortly afterwards, Flight 967 disappeared from Sochi Radar.
Shortly after Flight 967 impacted water, the radio beacon signals, known as the Emergency Locator Transmitter (ELT), started to sound. French BEA retrieved the submerged Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) from the Black Sea and found that there were only minor damages in both recorders. BEA later examined both the CVR and the FDR.
Based on the examination, the flight was uneventful until the approach. However, during the cruise stage of the flight, First Officer Davtyan stated: "**** it.. who operates such flights with the jitter and not enough sleep". This may indicate that he didn't has adequate sleeping hours, meaning he was fatigued at the time. The BEA also noted that neither pilots understand on how the autopilot of an Airbus A320 works. Analysis of the internal communications at this stage of the flight shows that Captain Grigoryan was annoyed by the fact that in DESCENT mode (MANAGED MODE) the descent rate was not as high as he expected. BEA noted that in this mode, the descent rate is calculated automatically, depending on a number of parameters describing the descent, e.g. the aircraft attitude in relation to the preset profile and so on. This fact shows that either the Captain did not fully understand the autopilot work algorithm in the DESCENT mode, or was in a state of high psycho-emotional strain with an imperative to land at Sochi as soon as possible.
Flight 967 then instructed by Sochi Tower to pass waypoint GUKIN and TABAN. It then passed both waypoints. While banking to turn to final, the rain started. First Officer Davtyan then overreacted by saying exclamation words, possibly due to emotional stress. Sochi controller then told the crews of Flight 967 that the weather in Sochi had deteriorated, and instructed the crews of Flight 967 to abort their descent. The crews overreacted with this report and started to say some negative words and expletives to the controller. The crew had been discussing the issue for three minutes, swearing about the controller's actions even between the items of the check list. Such behaviour by the crew inevitably must have resulted in an increase of their psycho-emotional stress.
The aircraft then went up and started to bank. The flaps were extended to 18. At this point, Captain Grigoryan was heard in the CVR saying: "**** him" to Sochi controller. The crews then contacted Sochi's holding controller and final controller. They then selected the "glideslope capture" descent mode, which is an automatic descent. The aircraft was descending with two engaged autopilots and engaged autothrust. The speed was controlled by the autothrust. The target speed that of 137 knots was equal to the actual speed. Thus, the aircraft was stabilized on the glide-slope, in the landing configuration and was perfectly, completely ready for landing. The crews then proceed to the landing check list.
Suddenly, Sochi Tower instructed them to abort their descent and conduct a go-around, as low clouds formed near the airport. The plane then went up, the thrust levers were moved to climb position, the flaps and slats were fully extended, and the landing gear was fully extended. Few minutes later, the "Speed Speed Speed" (LOW ENERGY) warning sounded. This warning advises the crew that "the aircraft energy is decreasing to the limit, below which the engine thrust must be increased to regain a positive angle of the flight path". At the moment when the aural warning sounded, the aircraft altitude was at 1.150 ft (350 m). The correct crew response to this warning would be to increase the engine thrust. the crew then pushed the TO/GA button.
BEA stated that none of the crew actions were important and necessary for a go-around procedure, such as extending the flaps and the landing gear. This proved that at that time, both flight crews' condition were not at its optimum level. BEA also suspected that the LOW ENERGY warning wasn't detected or noticed by the crew.
The autopilot then disengaged by the crew, as they cast doubts on the autopilot (on the cruise stage of the flight, First Officer Davtyan joked about the autopilots that Captain Grigoryan's autopilot was better than him, this indicate that they cast doubts on the autopilot and suspect that the autopilot wasn't functioning properly.) Captain Grigoryan then banked the aircraft to the right.
Then, both crew members became more physically and emotionally stress, as further conversations among them revealed that their intonations became higher and higher. The aircraft then decreased its pitch up attitude and banking to the right. Then, one of the crew stepped the rudder pedals, causing the rudder to deflect. This was not necessary. The BEA suspect that Captain Grigoryan stepped the pedals, while under psycho-emotional stress. Due to the emotional stress he suffer at the time, he didn't notice that he had stepped the pedals.
BEA then found out that the crew might have suffer a somatogravic illusion in flight. Somatogravic illusion, in aviation, is a type of optical illusion which cause the crew to think that they are pitching up, while in reality, they don't. This could happen during night-time flying (which causing the crew to lose its visual reference, as it was dark) accompanied by the lack of monitoring of the flight's indicator. Somatogravic illusion was responsible for the crash of Tatarstan Airlines Flight 363 in Russia. However, the BEA also suspected another thing, which was the specific features of speed indication on the PFD, especially speed limitations for the Airbus A320 configuration that are shown as the red bars at the top of the speed indication strip. One of the crews may imagine the influence of the reflex acquired in training, for example, in response to a TCAS warning when the pilot is anxious to avoid the displayed red part of the instrument scale, which may result in the instinctive forward movement of the side stick, especially when the pilot is in a state of psycho-emotional strain. This version is substantiated by the fact that the pilot was monitoring the flight speed and its limitations (VFE) that depended on the Airbus A320 configuration and retracted the flaps and slats in a timely manner, and the control inputs on the side stick coincided with the moments when the current speed was getting close to the limit value. However, neither of these probable causes have enough evidence.
Flight crews of Flight 967 then communicated with Sochi Tower. The words were not completed; "Sochi Radar, Armavia 967...". This was the last communication from Flight 967, as Captain Grigoryan ordered First Officer Davtyan to fully extend the flaps.
After First Officer Davtyan extended the flaps to full, few seconds later, the master warning sounded. The warning sounded until the end of the recording. The speed at the time was too fast, which could tear the flaps apart and could cause the plane to crash, similar to Austral Lineas Aereas Flight 2553. The plane was banking to the right. Flight 967 then made a nose down and the flaps then retracted to 18°. Captain Grigoryan then made an 11° nose down input. This, causing the plane to descend even further.
Captain Grigoryan aggravating the condition by making a right bank input, causing the plane to severely bank to the right, with a roll angle of 39°. The Ground Proximity Warning System then sounded. First Officer Davtyan then ordered Captain Grigoryan to level off. At this moment, First Officer Davtyan intervened and moved the stick to the left position (20° to the left) to counter the increasing right bank, while Captain Grigoryan still making his control inputs to increase the right bank. Apparently, First Officer Davtyan was trying to counter the bank only, as he also made a nose down input, causing the plane to went down even further.
While intervening, First Officer Davtyan had not pressed the take-over push button, therefore, both pilots' control inputs were added and prohibited. This was called as dual input. Such dual piloting is prohibited. The dual input warning should have sounded at the time, however, because its priority is basically lower than the Ground Proximity Warning, it didn't sound, and so neither crews knew that they were making dual input on the Airbus A320.
The crews attention might have been distracted by the controller's direction. The controller was sending the crew a 20-second long message, which was too long. While the plane was crashing down, one of the crews suddenly moved the thrust levers way back, into its idle position, and then moved the thrust lever forward, causing the autothrottle to disengaged. The crews then desperately tried to lift the plane up, but the plane then impacted water at a speed of 285 knots, killing all on board instantly.
Primary Conclusions of the Final Accident Report
The crash of Armavia Flight 967 was a controlled flight into terrain (CFIT), specifically water, while conducting a climbing maneuver after an aborted approach to Sochi airport at night with weather conditions below landing minimums for runway 06.
While performing the climb with the autopilot disengaged, the captain, being in a psychoemotional stress condition, made nose down control inputs due to the loss of pitch and roll awareness. This started the abnormal situation. The captain's insufficient pitch control inputs led to a failure to recover the aircraft and caused it to crash.
Along with the inadequate control inputs from the captain, the contributing factors of the crash were also the lack of monitoring the aircraft's pitch attitude, altitude and vertical speed by the first officer and no proper reaction by the crew to GPWS warnings.
Contributory factors and shortcomings
|Time||Factor or Shortcoming||Applicable Policy|
|During descent and approach the crew constantly held conversations having nothing to do with the operation of the aircraft.|
|The A320 Flight Crew Training Manual (FCTM), which was approved by the Civil Aviation Administration of the Republic of Armenia and according to which the captain passed his training before starting flights with the airline, does not contain the requirement for passing the Upgrade to Captain programme. The captain did not pass this training. This training programme was made mandatory in the next revision of the FCTM.||A320 Flight Crew Training Manual (FCTM)|
|The Flight Operations Department of Armavia does not comply with the requirement that airlines analyse flight operations with the use of the flight data recorder and cockpit voice recorder recordings for aircraft with the certified maximum takeoff weight exceeding 27,000 kilograms (60,000 lb). As such it was impossible to completely evaluate the professional skill levels of the flight crew members.||ROLRGA RA Section 11.2 and ICAO Annex 6 Part 1 Chapter 3|
|Armavia does not keep records on the approaches and landings in complicated weather conditions performed by their captains.||ROLRGA RA-2000 Sections 4.5.33 and 6.1.5|
|21:16||Sochi approach control advised the crew of the trend weather forecast for landing as 1,500 metres (1 mi) visibility x 150 metres (500 ft) cloud ceiling and did not identify the trend as “AT TIMES”. This inaccuracy while reporting the weather to the crew was not directly connected with the cause of the aircraft accident, but it influenced the initial decision of the crew to return to Zvartnots.|
|22:01||The approach controller advised the crew of the observed weather at Sochi and by mistake said the cloud ceiling was “considerable" at 1,800 metres (6,000 ft), instead of 180 metres (600 ft), however this did not influence the captain's decision.|
|22:03||The crew did not report (and the holding controller did not request them to report) the selected system and mode of instrument approach.||Holding Controller’s Operation Manual, Section 4, item 4.2.1|
|22:11||The final controller at Sochi was informed by the weather observer of the current observed weather: A cloud ceiling of 100 metres (300 ft), below the established minimums (cloud ceiling 170 metres (600 ft) and visibility 2,500 metres (1.6 mi)). Based on this information, the final controller instructed the crew: “Abort descent, clouds at 100 metres (300 ft), right-hand turn, climb to 600 metres (2,000 ft)”, instructions not compliant with regulations. However, the controller had a right to order the go-around.||Civil Flight Operations Guidance 85 Section 6.5.16 and the Final Controller’s Operation Manual, items 4.3 and 4.3.1|
|The controller had a right to order the go-around.||The AIP of Russia|
|The weather forecast for Sochi for the period from 18:00 to 03:00 was not verified with regard to visibility in the “At times” group.|
|22:11||The weather observer did not complete the special weather report when the cloud ceiling descended to 100 metres (300 ft), though to do so was required.||Guidance for Meteorological Support in Civil Aviation 95, Sections 4.3.1 and 4.4.1 d; Instruction for meteorological support at Sochi; Criteria for Issuance of a Special Weather Report, Annex 8|
|The recommendation for ATIS broadcast was not entirely fulfilled.||Federal Air Transport Administration and Hydrometeorology and Environment Monitoring Service Joint Order No. 62/41 “On approval and implementation of Instruction for ATIS broadcast content in English and Russian” of 20 March 2000|
|In the course of reading out FDR data, a number of discrepancies were found in the documentation describing the logic of binary signal recordings.|
|While performing manoeuvres in the landing configuration with the autopilot and autothrust engaged, the LOW ENERGY WARNING may sound, which Airbus considers as an abnormal situation.|
To eliminate the shortcomings revealed during investigation of this accident, the final accident report made 22 safety recommendations as follows:
|5||Aviation administrations of the CIS countries|
|1||Aviation administrations of the CIS countries jointly with industrial and scientific and research organizations|
|6||Civil Aviation Administration of the Republic of Armenia and Armavia airline administration|
|2||Federal Air Navigation Service of the Russian Federation|
|2||Federal Service for Hydrometeorology and Environmental Monitoring|
|2||Federal State Unitary Enterprise “State Corporation for Air Traffic Management"|
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- Accident description at the Aviation Safety Network
- Final accident report – Interstate Aviation Committee – English translation done by and hosted by the Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) (Archive, Alternate, Archive) – Includes comments by the BEA on the investigation, and the IAC's response to the BEA's comments
- Investigation and Report (Archive) – Interstate Aviation Committee (Russian) – The Russian version is the version of record
- Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
- "Accident near Sochi on 2 May 2006." (Archive)
- CNN Report on May 2 at night (EDT)
- Armeniapedia.org article on the crash
- BBC – Hunt for Armenia air crash bodies
- AirDisaster.com – Armenian A320 crashes into Black Sea
- ARMAVIA FLIGHT RNV 967 ACCIDENT IN SOCHI, RUSSIA – Airbus