Pilots of an executive jet failed to set their altimeter
to the correct pressure level before the aircraft descended low enough to
collide with trees, investigators in Russia have determined.
The
crew allowed the BAe 125-800 to continue descending despite automated warnings
and the aircraft suffered substantial damage from the collision – some 18km
from the airport – before the pilots aborted the approach.
Russia's
Interstate Aviation Committee says the jet had departed Tyumen bound for
Neryungri Chulman airport on 5 June 2016. It had been conducting the approach
at night and had been following the RUGIL2 pattern, which involved flying
south-east before turning left onto the 083° heading for runway 08.
The
crew initially had difficulty contacting the local Chulman air traffic centre
on 129.7MHz and instead reached the regional Neryungri centre on 121.7MHz.
This
centre, upon the crew's request, cleared the flight to descend to flight level
90 (2,750m) before transferring the aircraft to Chulman tower control.
The
tower confirmed the transition level as 2,450m and the airfield pressure (QFE)
as 685mmHg, and allowed the aircraft to descend to 500m ahead of its turn
towards the runway approach heading.
As
the jet descended the tower asked the crew to confirm the QFE setting. While
the crew replied with the correct number, 685, they needed to convert this to
millibars – which would have resulted in a QFE of 913mb.
Instead
the crew asked for confirmation of the sea-level pressure (QNH) to which the
tower gave the figure of 1012mb.
The
crew "did not recalculate" the airfield pressure of 685mmHg to give a
QFE figure in millibars, says the inquiry, and instead set the altimeter to the
QNH while continuing to descend.
This
effectively meant that the altimeter was falsely showing the aircraft to be
more than 800m above its actual height. Upon reaching the cleared height of
500m the aircraft would have still been indicating a height of more than
1,300m.
The
enhanced ground-proximity warning system began to issue sink-rate and terrain
alerts and, within a few seconds, ordered the crew to "pull up".
But
the inquiry says the crew "did not follow the requirements of the flight
manual" and instead continued with the descent. By the time the crew
responded to the height warnings, the aircraft was flying so low that it
collided with trees.
It
climbed away despite sustaining damage to the leading edge of the wings,
ailerons, horizontal stabiliser, and the engine inlets and fan blades. The
collision partly jammed the elevator and the jet's left-hand winglet was torn
off, says the inquiry, causing "considerable difficulty" for the crew
as they tried to control the aircraft.
Inspection
of the Aerolimousine aircraft (RA-02773), which managed to land without further
incident, found that it had suffered impact damage to several other structures
and system including its air brakes, radio altimeter antenna, and
angle-of-attack sensor.
Investigators
state that the crew's "delayed response" to the ground-proximity
warning led to the collision with the trees. But it adds that there was
"carelessness" in the treatment of the altimeter settings and that
the crew had demonstrated that they had received "insufficient"
training to carry out the flight.
Five
passengers and a crew of three had been on board the jet, none of whom was
injured.
(Evangle Luo of TTFLY shared with you)
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