Accident | |
---|---|
Date | 25 December 2012 |
Summary | Controlled flight into terrain due to pilot error |
Site | Heho Airport, Heho, Myanmar 20°43′30″N096°47′31″E / 20.72500°N 96.79194°E |
Total fatalities | 2 |
Total injuries | 10 |
Aircraft | |
Aircraft type | Fokker 100 |
Operator | Air Bagan |
IATA flight No. | W9011 |
ICAO flight No. | JAB011 |
Call sign | AIR BAGAN 011 |
Registration | XY-AGC |
Flight origin | Yangon International Airport, Yangon, Myanmar |
Stopover | Mandalay International Airport, Mandalay, Myanmar |
Destination | Heho Airport, Heho, Myanmar |
Occupants | 71 |
Passengers | 65 |
Crew | 6 |
Fatalities | 1 |
Injuries | 9 |
Survivors | 70 |
Ground casualties | |
Ground fatalities | 1 |
Ground injuries | 1 |
Air Bagan Flight 011 was a scheduled domestic passenger flight of a Fokker 100 twinjet from Yangon to Heho, Myanmar. On 25 December 2012, the aircraft crash-landed short of the runway at Heho Airport in fog, coming to a stop in a paddy field and bursting into flames. One of the 71 people on board and a motorcyclist on the ground were killed and more than 10 people were injured. [1] [2] [3]
The Myanmar Accident Investigation Bureau (MAIB) concluded that the pilots had not followed the proper procedure for an approach to Heho. During their landing attempt, the crew decided to continue their descent below the minimum decision altitude (MDA) even though they had not obtained visual contact with the runway. The pilots' high workload and the decision to assign the First Officer as pilot flying (PF) without sufficient judgement further contributed to the crash. [4]
The aircraft was a 21-year-old Fokker 100, [5] manufactured in 1991 as PH-CFE. Before being owned by Air Bagan, the aircraft had been operated by multiple European airliners including Air Europe, Air Littoral, and British Midland Airways. The aircraft was initially owned by Air Bagan from 2005 - 2008 and was later sold to Myanmar Airways International for a year. [6] The aircraft was later delivered to Air Bagan again in 2009. [7] The aircraft had accrued a total flight cycles of 32,584 cycles. [4]
Despite its old age, the aircraft had passed the latest major maintenance check in November. The last line check had been conducted just two days before the accident flight. [4]
There were 65 passengers and 5 crew members on board the aircraft. Majority of the passengers were foreigners, but the exact number was not known. According to reports, those onboard included nationals from Australia, France, Germany, Korea, Switzerland, Taiwan, United Kingdom and United States. [8] [9] [10] The rest were Burmese. [11]
The identities of the captain and the first officer were not revealed by authorities. However, according to the investigation report, the captain was an experienced 49-year-old pilot with a total flying experience of 5,937 hours and had been the captain of the Fokker 100 for 6 years with a total flying experience on the Fokker 100 of 2,547 hours. The first officer had only accrued a total flying experience of 849 hours, of which 486 were on the type. [4]
Flight 011 was a flight from Myanmar's largest city of Yangon to Heho with a stopover in Mandalay. The route was popular among tourists as Heho was the main gateway to Inle Lake, a major tourist attraction in the country. [12] The Fokker 100 had departed Yangon International Airport in the morning on its first leg to Mandalay International Airport. In Mandalay, a total of 60 passengers disembarked and 40 passengers boarded the aircraft. With a total of 71 people on board, the aircraft departed Mandalay at 08:26 local time to Heho. The first officer was designated as the pilot flying for the leg while the captain was assigned for the radio communication. [4]
On approaching Heho, air traffic control reported local weather conditions to the crew as wind calm, visibility 3000 m and "distinct fog." As it was foggy, the crew decided to conduct a non-precision approach. At about 08:47 local time, the crew initiated a non-precision NDB approach procedure to Heho's runway 36. Approximately 10 nautical miles from the airport, the crew reported that they had obtained visual contact with the runway. The aircraft was then configured for a landing at Heho. [4]
As the aircraft was aligned with runway 36, the crew decided to descent further. However, the aircraft later entered some clouds and the crew eventually lost visual contact with the runway. The captain exclaimed "Not okay" and instructed the First Officer to push the altitude hold button so that the autopilot would maintain the aircraft's altitude. The captain then pushed the altitude knob and tried to disconnect the autopilot. At the same time, the EGPWS warned the crew on the decreasing altitude. [4]
At 08:53 local time, about 1.3 km (0.7 nmi) from the runway threshold, the aircraft struck power lines and trees. During the impact with the trees, the left wing separated, rupturing the fuel lines. The debris and the aircraft's fuel then struck a passing motorcycle that was carrying two people. The aircraft eventually struck telephone cables and fences before colliding with terrain across a road. It then immediately burst into flames. The first officer then declared "Mayday" and an emergency evacuation was carried out. Of the 8 emergency exits, two were not used as both were located over the right wing, which was on fire. [4]
Heho firefighting services eventually arrived at the crash site within 10 minutes, though with some difficulties due to the location of the crash. At least 9 local firefighting vehicles were deployed to assist with the rescue effort. Local police and citizens also participated in the evacuation of the aircraft's occupants. A total of 10 people were seriously injured by the crash, consisting of two crews, seven passengers and one person on the ground. Of those, 8 were transported to Yangon and 2 others were transported to Bangkok for further treatment. [4] [8] Other injured occupants were transported to Shan State's capital of Taunggyi for examination. [13] A total of 61 people were listed as mildly injured or unhurt. Due to the crash, two people were killed; a passenger and one of the occupants of the passing motorcycle. [4]
In response to the crash, survivors of foreign nationalities were provided with accommodation in Yangon's Kandawgyi Palace Hotel, USD$2,000 and another 300,000 Burmese kyat for buying clothes and other essentials. Air Bagan stated that they would pay for the accommodation and medical bills. [14] The owner of the airline, Htoo Foundation, donated USD$5,000 to the families of the deceased. The airline initially had offered 'reasonable compensation' to the survivors, however subsequent problems with the payment eventually caused survivors to file lawsuits. A significant amount of settlement was later agreed. Survivors of Burmese origins however reported that they had only received a little amount of compensation from Air Bagan. [15]
On 26 December, Burmese authorities formed the Myanmar Accident Investigation Bureau. The team was headed by the Deputy Director General of the department, U Win Swe Tun, and consisted of four other members. On the same day, investigators managed to retrieve the aircraft's flight recorders from the wreckage. [16] The team initially had planned to send the flight recorders to Singapore for analysis, [17] however it was deemed impossible due to the poor condition of both recorders. The flight recorders were later sent to Australian Transport Safety Bureau for analysis. [18]
Initial statements by the authorities suggested that the pilots mistook a road for the airport's runway in low visibility. [19] [20] Managing director of Air Bagan U Thet Htoo Htwe stated that the aircraft was airworthy and that both pilots had followed the standard operating procedures. [11]
During the approach to Heho, the crew elected to conduct a non-directional beacon (NDB) approach to Heho. As it was an NDB approach, the crew were required to pass the Heho NDB first and later turned towards the right with a heading of 220. The crew later had to turn left to heading 010 so that the aircraft would have been aligned with the runway. The flight recorder, however, showed that the crew had turned prior to Heho's NDB and later had to correct their heading again due to the premature turn. [4]
Flight 011 later entered clouds, obstructing their previously established visual contact with the runway. The standard operating procedures from Air Bagan stated that a flight officer was not allowed to conduct a landing in inclement weather condition and should be assigned as the PNF to monitor the aircraft's instruments. As the visibility at the time was less than 3000 ft, the captain should have been at the control instead of the first officer. [4]
As Flight 011 reached the airport's minimum decision altitude (MDA) of 530 ft, which was the lowest altitude where the pilots had to obtain visual of the runway before they were allowed to land, the GPWS alert sounded. The warning was ignored as the crew were trying to locate the runway. The aircraft kept descending and the crew were still not able to obtain visual contact with the runway as the presence of fog had deteriorated the visibility. The captain exclaimed "Not okay, altitude hold" and then asked the first officer to press the altitude hold button so that the autopilot would maintain the aircraft's altitude. [4]
Air Bagan's standard operating procedures (SOP) clearly stated that if an aircraft had passed the airport's minimum decision altitude in inclement weather condition, an approach should have been aborted and the crew should have conducted a go-around. The crew, however, decided to press the altitude hold button, even though they were just about 100 ft from the ground. As the aircraft was already too low for a missed approach, it crashed onto the trees, causing the separation of the left wing and severing the aircraft's ability to fly. [4]
The crew's situational awareness had deteriorated due to their high workload. Their lack of situational awareness probably had also been affected by their landing order. The presence of other aircraft behind Flight 011 led to the increase of the crew's workload. As the crew were pre-occupied with the landing, the Captain couldn't address the flight officer on problems regarding the aircraft's position and rate of descent. [4]
The final report concluded that the primary cause of the accident was the crew's decision to descend below the approach procedure's minimum descent altitude of 160 metres (530 ft) without having the runway in sight. At that point, the airline's standard operating procedure would have called for an aborted landing to be immediately initiated. The report cited as contributory factors the captain's inadequate risk assessment in designating the first officer as pilot flying for the approach in the given weather conditions, and an increased pressure on the flight crew to complete the landing due to the presence of other aircraft on approach to Heho at the time. Three safety recommendations were made. [4] [21]
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