Aerosvit Flight 241

Aerosvit Flight 241

UR-42334 in service with Tiger Air in the mid-1990s
Accident summary
Date	17 December 1997
Summary	Controlled flight into terrain due to pilot error, cockpit confusion
Site	Pierian Mountains, Thessaloniki, Greece 40°13′38″N 22°14′29″E / 40.227271°N 22.241433°E / 40.227271; 22.241433Coordinates: 40°13′38″N 22°14′29″E / 40.227271°N 22.241433°E / 40.227271; 22.241433
Passengers	62
Crew	8
Fatalities	70 (all)
Injuries (non-fatal)	0
Survivors	0
Aircraft type	Yakovlev Yak-42
Operator	Aerosvit – Ukrainian Airlines
Registration	UR-42334
Flight origin	Boryspil International Airport, Kiev, Ukraine
Stopover	Odessa International Airport, Odessa, Ukraine
Destination	Thessaloniki International Airport, Thessaloniki, Greece

Aerosvit Flight 241 (VV241/EW241) was a scheduled international passenger flight from Kiev's Boryspil International Airport in Ukraine to Thessaloniki International Airport in Thessaloniki, Greece with a stopover Odessa. On 17 December 1997, the Yakovlev Yak-42 operating the flight registered as UR-42334 flew into a mountainside during a missed approach into Thessaloniki in Greece. All 70 people aboard the aircraft were killed.

The crash was the third deadliest plane crash in Greece's history, behind Olympic Airways Flight 954 and Helios Airways Flight 522 and was the fifth deadliest plane crash involving a Yakovlev Yak-42. It was the 14th loss of a Yakovlev Yak-42.

Investigation carried out by the Greek Air Accident Investigation and Aviation Safety Board (AAIASB) concluded that the cause of the crash was due to pilot error. The crew lost their situational awareness while carrying a missed approach in Thessaloniki. As a result, the plane flew onto terrain. Detailed information on the report blamed the crew for not issuing an emergency call despite the plane's recurring warnings and the lack of discipline and the lack of structural and organized environment in the cockpit.

Flight

Aerosvit Flight 241 was originally scheduled to be operated by a Boeing 737. The first sector of the flight from Kiev-Odessa was operated by the Boeing 737 but due to engine issues the aircraft was swapped to a Yakovlev Yak-42. The flight continued onwards towards Thessaloniki, Greece, flying through Ukrainian and Bulgarian airspace . According to the Greek investigation team, this was the first time the crew flew to Thessaloniki. The weather was snowing at the time.

Accident

Flight 241 contacted Thessaloniki Tower. At the time, Thessaloniki Tower was communicating with an Olympic Airways flight. Thessaloniki Tower was asking an Olympic Airways flight to descent. The crew of Flight 241, however, misinterpreted this and thought that the descent was meant for them. Thessaloniki Tower then clarified that the order was meant for Olympic Airways. Flight 241 later cleared to decrease its altitude to FL100.

After its clearance to FL100, Flight 241 was ordered to approach waypoint LAMBI. Everything was normal in the cockpit until Flight 241 arrived at point LAMBI. In the following minutes, confusion started to prevail in the cockpit and the crew management began to break. The flight did not follow the "arc" of LAMBI arrival as instructed by the ATC. Instead, they followed another direction, towards THS/NDB. The Ground Proximity Warning System then sounded twice. However, the crew didn't react and ignored the warnings.

Flight 241 then missed the localizer course twice, in trying to establish on the localizer course. The crew didn't realize that they had overshot the airport. By not following the published procedure for transitioning to and engaging the localizer (utilizing the "arc") and with the rapid descent required, the flight crew was unable to establish a stabilized approach.

Thessaloniki Tower reported to the crew of Flight 241 that they had overshot the airport. Confusion occurred on the cockpit as they didn't know the heading for an approach. They later asked for a heading, however their request was not heard by the controller and they immediately handed over to Thessaloniki Approach.

The crew were told to head north and hold for a second attempt. The crew failed to do the published missed ILS approach procedure. Instead of flying to the north as instructed by the ATC, Flight 241 headed west-southwest, flying into the side of Mount Pieria at 3,300 feet (1,006 m). Shortly afterwards, Flight 241 went missing.^[1]

Search and rescue

A search party was formed when the flight went missing. The Greek Air Force helped out in the search for the wreckage. Locals also joined the search. Greek military officials stated that the search area was concentrated around Mount Olympus. Local villagers claimed that they saw bright flash of light and heard a sound of an explosion near the area.^[2]

The search continued until 18 December, where the wreckage of the aircraft is yet to be found. The search and rescue operation was hampered by bad weather condition. According to Aerosvit's Managing Director, Leonid Pogrebnyak, the search area was moved and the wreckage of Flight 241 had not been located by rescuers.^[3]

The Greek navy joined the search and rescue operation. On 19 December, the Greek army deployed 5,000 people to participate in the search and rescue operation. 29 helicopters and 500 vehicles were also deployed to join the opeartion. However, bad weather still hampered the search and rescue effort. Greek officials stated that the search area was concentrated near Katerini. The search was later suspended.^[4][5]

On 20 December, the wreckage was found, three days after the initial accident. It was located at an elevation of 1,100 m. Rescuers could not locate the wreckage for days due to fog and harsh weather condition in the area. Debris strewn over a large area. The wreckage was located in a gorge and was buried in heavy snow. No survivors were found on the crash site. All 70 passengers and crews aboard Flight 241 were perished.^[6] In a coincidence, a Lockheed C-130 Hercules operated by the Greek Air Force, participating in the search for Flight 241, crashed near Athens, Greece, killing all five crew members.^[7]

Aircraft

The flight was operated by a Yakovlev Yak-42, registration UR-42334. The aircraft first flew in 1986 and was delivered to Aeroflot in June 1986 as CCCP-42334. The aircraft was later delivered to Air Ukraine with a registration of UR-42334. On November 1997 it returned from a seven-month lease period to Tiger Air, a Yugoslavia-based charter company. The accident flight was operated under wet-lease agreement with Aerosvit. The aircraft had accumulated 12,008 flight hours and 6,836 cycles and was also equipped with three-shaft engine manufactured in 1984.^[8]

Passengers and crews

Victims' nationalities^[9]

Nationality	Passengers	Crew	Total
Greece	34	0	34
Russia	0	3	3
Ukraine	25	5	30
Poland	2	0	2
Germany	1	0	1
Total	62	8	70

Flight 241 was carrying 62 passengers and 8 crew members. Of those, 34 of them were Greeks and 25 were Ukrainians. 23 passengers were workers of the Salonica State Construction Company. The aircraft was carrying 6 children, 16 women and 40 men. Most of the passengers were travelling for Christmas holiday. Others came from Poland and Germany. The instructor pilot, Captain and the co-pilot were Russian, while the Flight Engineer and the rest of the crew were Ukrainian.

The instructor pilot had a total flying hours of 16,210 hours. According to the Greek investigation agency, he had accumulated 5.350 total flying hours on the Yakovlev Yak-42. The Captain of the flight had a total flying hours of 9,850 hours with 2,300 total flying time on the Yak-42. The co-pilot had accumulated a total flying hours of 6,700 in which 3,000 of them were on the Yak-42. According to Leonid Pogrebnyak, the Managing Director of Aeroswift, the commander of the flight was identified as Aleksii Vcherashnyi.

Investigation

Initially, faulty compass was blamed for the crash. Initial report suggested that Flight 241 suffered a failure on their compass while approaching Thessaloniki Airport. This claim was initially reported by the ATC worker of Thessaloniki. The claim stated that the compass of the plane was in 230 degrees.^[10]

However, according to Serhii Lukianov, assistant director of the State Aviation Department of Ukraine, he stated that every Ukrainian aircraft that had departed from Ukraine was airworthy, as he stated that all Ukrainian aircraft must meet stringent maintenance requirements and certifications in response to the complaints and critics on Ukrainian-operated aircraft, which led to a ban of Air Ukraine by John F Kennedy International Airport in 1998.^[11]

An unconfirmed report by the Associated Press suggested that the flight crew of Flight 241 may have become confused while communicating with air traffic controllers due to their poor English.^[11]

Investigators then shifted their attention to other factors, such as bad weather condition and pilot error. Weather condition around Thessaloniki was reportedly in bad condition. Investigators knew that this was the first time the crew flew to Thessaloniki, which could be a potential challenge for the crew. According to a flight transcript, the crew thought that they were flying over the sea while in fact they were flying over the mountain. In addition, Thessaloniki Airport doesn't have any radar, which could have helped the approach. Greek Air Force General Athanasios Tzoganis said that pilot error might have played a part in the crash of Flight 241.^[4]

Investigator focused on the performance of the crew. Since investigators knew that this was the crew's first flight to Thessaloniki, investigators changed their attention. Apparently, the crew had never conducted or trained by the airline to approach Thessaloniki Airport, according to investigators. Thus, the crew wasn't familiar with the environment.^[12]

The aircraft did not follow the "arc", as instructed by ATC, but proceeded instead towards THS/NOB. There is evidence, by FOR, that Flight 241 was never established on the localizer. nor did it pass over the outer Marker. The flight crew also did not give a position report as it was instructed by the ATC. After arriving at Thessaloniki, the crew was instructed to turn right and head north. The instructor pilot and the co-pilot noticed about this and told the pilot to turn right and head north. However, despite of the instructions from the ATC and his fellow flight crews, the pilot in command decided to fly Flight 241 to westerly heading. According to the CVR transcript, the co-pilot had told the Captain to turn right. The instructor pilot had also told the same to the Captain, he said : "Go ahead to the VOR, go to the VOR". The Captain decided urging in respect of the flight path: "We should (turn) to the left then", and turned the aircraft towards a westerly heading.^[12]

The ATC became confused as Flight 241 had gone astray from its route. The ATC then asked the flight crew "AEW-241 are you North 0/ TSL, confirm ?". The crew responded by saying "Yes North, TSL". The Captain became confused and decided to "re-orient themselves". They continued to respond to the controllers repeated requests about their position, their flight path and their ability to comply with depicted approach procedure. Since the ATC noticed that Flight 241 was flying in the wrong direction, he kept questioning the flight crew if they were on the right heading. They kept saying that they were on the right path, even though they didn't know the heading and even though they were flying at an opposite direction from which they supposed to take. The flight crew didn't report to the ATC that they were having difficulties with the heading. The crew was flying in a false direction for over 10 minutes.^[12]

The Captain then asked his fellow flight crew to tell the ATC about radar vectoring. The instructor pilot, as well as the co-pilot, however, were concentrating on whether the ADFs I Locators were in operation or not, and what frequency each ADF set was tuned to, instead of asking the ATC about the radar vector. After they asked Thessaloniki Approach, Thessaloniki stated that there was no radar vectoring, and later asked Flight 241 to "Comply with VOR-DME-ILS approach Rwy IG" to which Flight 241 affirmed, as well as to "Report on the LLZ".^[12]

Investigators said that Flight 241's request for radar vector in Thessaloniki Airport was rather confusing, since Thessaloniki Airport didn't have any "Radar Vectoring Area" chart. There is no radar mentioned in the AIP Greece for Thessaloniki Airport. The AlP clearly indicates that there is a Military Radar Service available in case of emergency and upon request.^[12]

The communication between the flight crew and ATC was performed in English, which was used as a universal medium for communication because the national languages of the ATC controllers and the flight crew were Hellenic and Russian respectively. Communications did not appear to be seriously out of the ordinary, during the first part of the approach flight. But as the flight continued, it became increasingly apparent that while both parties possessed English language capability, neither party appeared to have the fluency in English to move beyond routine exchange of ATC terminology to describe and assimilate the extent of the critical situation that was rapidly developing.^[12]

Immediately after this communication, confusion occurred inside the cockpit. The instructor pilot distracting the other flight crew members, with discussion of problems in navigating, operating the navigation equipment, determining what track they were on, etc. Each flight crew member individually was engaged in solving his problem, since they had lost situational and terrain awareness. The pilots shared misbeliefs and perplexity and most of the time, held different but equally incorrect understandings of the situation and the procedures.^[12]

During the confusion, the Ground Proximity Warning sounded. The crew ignored the warning. The fourth warning then sounded, and at this point the Captain realized that they were flying too close to terrain. The Captain then tried to avert the impending disaster by initiating a pull-up, but it was too late.^[12]

See also

• Air navigation
• Situation awareness
• Varig Flight 254, a crash in Brazil in which the crew flew the aircraft in an opposite direction from the route they supposed to take.

References

External links

• Aviation-Safety
• The disaster at Thessaloniki. Yak-42. Aerosvit. 1997 year.