Date: 02 May, 2006
Type of error: Pilot Error, ATC Error
Time of accident occur: 22:13, Standard Time (02:13 UTC)
Location of accident: Black Sea close to Sochi Airport (Russia)
Aircrraft Operator: Armavia Airlines
Aircraft Type: Airbus A320
Aircraft Registration: EK-32009
Passengers on board: 105 Passengers
Crew: 8 (2Pilots + 5 Flight Attendants + 1 Engineer)
Fatalities: 113 ( 105 Passengers + 8 Crew)
Flight Origin: Zvartnos (Yerevan, Armenia)
Destination: Adler (Sochi, Russia)
On the 2nd of May 2006, at about 2047 local time, an Armavia A320 flight EK-32009, a Republic of Armenia registered aircraft crashed into the black sea close to Sochi Airport. EK-32009 departed from Zvartnos with 2 pilots, 1 engineer, 5 flight attendants and 105 passengers. Ek-32009 operated regularly between the departure and destination aerodrome, as it was a common route for international passengers.
EK-32009 made initial contact with ATC controllers from Sochi at 21:17 and spend a good 9 minutes discussing the weather amongst each other. Shortly, after making a decision to return to their departure aerodrome with the air traffic controllers, EK-32009 requested the weather at Sochi. The Air Traffic Controllers responded by informing that the visibility was 3600m with a cloud ceiling of 170m. At that point, EK-32009 decided to continue their flight as planned.
The next radio call with Air Traffic Controllers was their clearance to descend to 3600m while tracking to a reporting point known as GUKIN. The air traffic controllers further cleared there descend to 1800m. The air traffic controllers than reported the latest weathers, which were above minima’s for Runway 06 and handed EK-32009 to the Control Tower. Sochi Control Tower cleared them to descend to 600m before a turn onto finals.
The first signs of trouble were noticed, when the aircraft overshot the extended centerline when turning onto finals however the aircraft was descending according to the glideslope and was following the approach pattern as well. At 22:10, the flight crew indicated their preparation to land by reporting the extension of the landing gear. The ATC replied advised with “ the distance of 10km and weather 4000 by 190” followed by the clearance to land. Approximately 30 seconds later, ATC asked EK-32009 to cancel their descent and commence a right turn and climb to 600m due to the lowering cloud base to approximately 100m and asked them to contact the controller in charge of holds. The crew reported in accordance at 22:12 and that was the last time any form of communications was established. At 22:13, the aircraft struck the water, and was completely destroyed killing all on board.
Background Information of Pilot
The Captain completed his primary training in 1986 as a pilot and graduated as an engineer in 1997 from the Moscow Institute of Civil Aviation Engineers. The pilot had been a co-pilot for the Armenian Civil Aviation Department from 1988 to 1997, from which, he was promoted to a Captain of Aarat Airline. In 2004, he joined the Armavia Airline and was a co-pilot for a year. He became a captain of the A320 in 2005 and had accumulated a total of 5,458 hours.
The Captain had a class 1 medical and in training for the Airbus A320, had scored between 85% to 94% and receiving an average rating of Satisfactory and Good.
In his last skills check, the captain had received a rating of excellent and had clocked a weather minimum of 60x550 and a takeoff of 200m. Within the previous month, the Captain had clocked 47 hours and had received more than 24 hours of rest time at home.
The Co-Pilot completed his basic flying in 1999, and worked as a co-pilot for Chernomor-Avia Airlines from 1999 to 2003 after which he joined Armenian Airlines in 2004 flying an ATR. Eight months later in 2004, the Co-Pilot joined Armavia airline as a co-pilot for the Airbus A320. The Co-Pilot accumulated a total of 2185 hours and completed 77 hours in the previous month. Hi
With all this background information, it was seen that the Captain was a sound pilot with a experience background in Aviation. Like the Captain, the co-pilot achieved Satisfactory and Very Good Grades ranging from 85% to 100% and received an Excellent grade in his last pilot skills check. Prior to the flight, the co-pilot had more than 24hours of rest at home.
Both Pilot & Co-Pilot were considered good aviators with no prior knowledge of any difficulties in their training. With the flight experience accounted for, this flight was considered another routine flight for the crew.
Accident Investigation Outline
Due to weather conditions, and the severity of the fatal crash, investigators had their work cut out for themselves. They were unable to use the wreckage as evidence. However, they were able to interview the Air Traffic Controllers, and use Data recorded on the Cockpit Voice Recorder. Also, the analysis of the meteorological weather conditions and the data analysis of the aircraft maneuvers during approach and the “go around” was to be assessed in an attempt to determine the cause of the accident.
Investigation – Possible Human Factors
1) Decision Making of the Crew
- The decision-making capability of the crew came into question. While the crew had all related information regarding to make an informed decision regarding the weather, they wavered on their decision. Another indication of poor decision-making was when the crew initially made a decision to turn back to the departure aerodrome and than turn back to Sochi.
It can be said that the crew did not follow the guidelines to making a decision, which is to Detect, Estimate, Choose, Identify, Do and Evaluate. Also due to eternal factors like the stress from the operators to land the aircraft could be the reason why the crew decided to continue with their flight. Also, attitudes like Optimism Bias or Confirmation Bias are other attitudes that may have attributed to the crew changing their initial actions.
2) Pilot Interaction, within the cockpit and ATC,
- While establishing contact with Sochi Air Traffic Controllers, the flight crew had requested the latest weather. While determining the decision to carry on flight or to turn back, the air traffic controllers overheard expletives being used in the cockpit. These are signs of a poor working relationship between the Captain & Co-Pilot, which adversely affect the Decision making of the crew. Also, it might also indicate a Hazardous Attitude, Macho, displayed by the captain in an attempt to show how good they are. This attitude is commonly displayed by males and occurs when people are out to prove something to one another. It was also noted that the pilots used expletives when communicating with the ATC.
3) Air Traffic Controller Standard Operating Procedures
- It was reported in the initial investigation that the there were discrepancies and differences in weather reports when the pilots switched between Air Traffic controllers. Also, it was noted that the Air Traffic Controllers deviated from Standard Operating Procedures when making radio calls and this resulted in omissions of information from weather reports.
Standard Operating Procedures (SOP) is a strict guideline for a flight crew (ATC) to carry out a safe and effective operations. SOP are made to improve the transition and improve the communication between pilots and air traffic controllers for example. However, the Air Traffic Controllers did deviate from the SOP’s and one possible reason is Individualism. People wish to influence their character on a certain procedure to offer a greater insight, lack of boredom and to differentiate them. However, when not followed, they are bring about confusion which results in the omission of important information like the weather brief for the Air Traffic Controllers.
Meteorological Information Chart
On the date of the accident, there was a secondary low formed through a depression along the eastern edge of the Black sea. Also, a cold front was formed along the east of Turkey, and this resulted in continuous precipitation and rain in Adler.
Images of Damages in Aircraft
Video footage(via Youtube)
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Conclusion – Final Findings
- Crew had valid pilot licences and medical certificates
- Crew had passed training
- Aircrafts Weight & Balance was within the limits
- Omission of Weather forecast at 21:00 which could have assisted the Pilot in making an early informed decision
- Sochi Approach controller reported the weather forecast for Sochi Aerodrome however a trend was not given
- Inaccuracies by the controller, with the exclusion of terms like “At Times”
- During Approach, when commencing missed approach, there was confusion in the cockpit and communication between the captain and the crew was complicated. The crew did not get a weather report closer to landing, afraid of receiving a unfavorable Weather forecast.
- The pilots were not sure of what approach was being used in the aircraft.
- The Cockpit voice recorder managed to record “ it, who operates such flights with jitters and not enough sleep” which was a clear indication of Crew Fatigue
- Crew did not comply with standard go around procedures regarding applying take-off thrusts
The accident resulted from the activities, which occurred within the cockpit. While, there were mistakes made from the Air Traffic Controllers, they were not vital ones. Poor Decision Making, Poor Interaction, Possible Hazardous attitudes, Fatigue, and the lack of mental preparedness for alternative actions are the probable cause and together have accumulated to cause this accident.
First and foremost, should the pilot have followed set guidelines to tackle issues like weather, and missed approach procedures, this accident would not have occurred.
INTERSTATE AVIATION COMMITTEE AIR ACCIDENT INVESTIGATION COMMISSION. (2006). Final Report on Investigation into the accident involving Armavia A320. http://www.skybrary.aero/bookshelf/books/551.pdf
1001 Crash - Aircraft Accident Armavia EK-32009. http://www.1001crash.com/index-page-description-accident-armavia_A320-lg-2-crash-33.html