Status: | Accident investigation report completed and information captured |
Date: | Tuesday 11 April 2006 |
Time: | 15:05 |
Type: | Antonov An-2R |
Operator: | Kapoly Air |
Registration: | LZ-1178 |
MSN: | 1 174(473)17 |
First flight: | 1962 |
Total airframe hrs: | 9798 |
Cycles: | 49726 |
Engines: | 1 Shvetsov ASh-62IR |
Crew: | Fatalities: 1 / Occupants: 1 |
Passengers: | Fatalities: 1 / Occupants: 2 |
Total: | Fatalities: 2 / Occupants: 3 |
Aircraft damage: | Damaged beyond repair |
Location: | near Kozlovets ( Bulgaria)
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Phase: | Maneuvering (MNV) |
Nature: | Agricultural |
Departure airport: | Kozlovets, Bulgaria |
Destination airport: | Kozlovets, Bulgaria |
Narrative:The pilot was performing the 12th flight of the day spraying crops. Before the 12th takeoff the pilot allowed to two unauthorized persons to go on board, an 11-year old boy, who occupied a right seat, and a 22-year old man, who was standing behind the seats. Takeoff was performed at 14:51. During the left turn at a speed of 140-150 km/h the An-2 descended from altitude of 5-10 m, struck the ground, left lower wing first, crashed and was destroyed by fire. Both adult men were killed while the boy suffered the serious injures.
Probable Cause:
MAIN CAUSE:
Demonstrated self-sufficiency and lack of self-discipline by the aircraft commander, lead to violation of the flight rules during AW, defined in Aerial Works Instruction, due to which the complicated flight conditions became dangerous and in the specific circumstances the situation created developed to a catastrophic one.
IMMEDIATE CAUSE:
Collision with the terrain.
The commission considered that for the occurrence contributed the following contributory factors:
1. Negligence of the requirements for available regular flying staff by Air Operator for the established by AOM flight conditions for minimum crew during AW.
2. Degraded level of control by Air Operator on the activities, character and quality of the aerial work performed.
3. Lack of in-depth analysis of the personal and professional abilities of the flight personnel of the Air Operator and passivity displayed in cases directly influencing the safe performing of the flights.
During the process of the cause about the accident the commission disclosed also the following deficiencies:
1. Formal attitude of the inspector during the fulfillment of the control list of the aircraft commander for the flight proficiency and navigation check.
2. Lack of record in the aircraft engine technical book for installation of a plug No 105975 into the altitude corrector during the technical measures for PSSE.
3. The reason for replacement of the cylinder No 1, 4 and 9 wasnt registered in the technical documentation.
Accident investigation:
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Investigating agency: | AAIU Bulgaria |
Status: | Investigation completed |
Duration: | 131 days (4 months) | Download report: | Final report
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Classification:
Non-adherence to procedures
Loss of control
Sources:
» Ministry of Transport, Aircraft Accident Investigation Unit Accident Report
» Translation: Dmitriy Yertsov
Follow-up / safety actions
AAIU Bulgaria issued 4 Safety Recommendations
Issued: -- | To: CAA Bulgaria | LZ-1178(1) |
CAA should organize working meeting with the flight crews of the AW air operators to discuss the flight safety level and the readiness of the crews for work in spring and summer conditions. |
Issued: -- | To: CAA Bulgaria | LZ-1178(2) |
CAA should perform an inspection of the staffing of AW air operators crews. |
Issued: -- | To: CAA Bulgaria | LZ-1178(3) |
During the active season of AW, CAA should perform an extra inspection of the planning, performing, account and control of the flight and production activities of AW air operators. |
Issued: -- | To: Kapoly Air | LZ-1178(4) |
AO on the grounds of the Final Report of the commission and in accordance with p.18of Flight Operation Manual should prepare and submit in CAA a written analysis about the human factor influence on the AW flight safety and about the planned activities of the airline management for improvement of the safety level during organisation, planning and execution of flight and production activities. |
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This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.