Sudan Aviation Authority Civil - السودان - الهيئة العامة للطيران المدنى

Central Directorate Of Air Accident Investigation الإدارة المركزية للتحقيق في حوادث الطائرات

(ACCID)

Tel: +249155775152 00249155775152تلفون : Fax: +249155775150 00249155775150فاكس :

Date: - 12.01.2009 URef:-CAA/ACC/ST-ARN, AN-12

Aircraft Accident Final Report

1. Aircraft Operator: 2. Aircraft Manufacturer: 3. Aircraft Model:

Juba air cargo co. LTD Antonov Bureau AN12-BK

4. Nationality and Registration mark: Sudanese – ST-ARN

5. Place and date of the accident:

North of Malakal N 09 31 52.5 E 031 26 42.9 Date 27.06.2008

Synopsis:-

The accident was notified to the AAICD by Juba air cargo and Phalouge airport authorities.

Investigations conducted by a board formed by the Minister of the Presidency of the Republic Authority releasing the report: the Minister of the Presidency of the Republic.

1- Factual Information:- 1.1 History of the flight:

The aircraft arrived from Sharja on 19.6.2008, after it had been overhauled in Volga Dnepr Company according to the approved maintenance schedule.

The aircraft ST-ARN AN12, flight number JUC-500, cargo flight, departed Khartoum airport at time 0255 UTC on the 27.06.2008 destination Juba airport, fuel endurance 0530 HRS. First intended flight level was 190, modified by the pilot to flight level 170 as final level, total persons on board 08. En route weather forecast obtained by the company. The aircraft took off from runway 18, after one hour ten minutes from take off time the aircraft crashed 25 NM north of Malakal, location - : N 09 31 52.5 E 031 26 42.9

1.2 Injuries to Persons: Crew Passengers Others

Fatal 7 Nil Nil

Serious Nil Nil Nil

Minor One Nil Nil

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1.3 Damage to aircraft: The aircraft totally damaged due to impact with the trees and friction with the ground, many parts detached and the rest caught fire.

1.4 Other damages: Nothing sustained damages other than the aircraft. 1.5 Personnel information:

PIC F/O F/E Name Oleksandr Miroshnyk Sayed Kamil Oleksandr prystupa Licence type and No. ATPL No: 001451 ATPL. No:0431 F/E lic No: 001599 Total flight experience 13 300 HRS 11 535 HRS 15 400 HRS Total hrs on type 5000 HRS 3300 HRS 5191 HRS Total last 3 months 95 HRS. 10 min 144 HRS 55 min 114 HRS Total hrs last 28 days 17 HRS. 50 min 07 HRS 10 min 17 HRS 10 min Total hrs last 7 days 07 HRS 10 min 07 HRS 10 min 07 HRS 10 min Last route check 15.02.2008 19.06.2008 15.03.2008 Date of Medical 07.06.2008 09.04.2008 07.06.2008 I/R validation 11.08.2008 31.10.2008 11.08.2008

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1.6 Aircraft information: The aircraft ST-ARN is airworthy and maintained according to the approved

maintenance schedule, having the flowing information:- Type& Registration of A/C AN12 , ST-ARN Date of Manufacture & Serial .No 30.11.1968-8346010 Total flying hours since new 14597.36 HRS-6924c Total hours since last check 6274.36 HRS-1892c Number & type of engine 4-AN-20M Date of manufacture of engine 1) 23.6.1969 2)9.12.1968 3) 31.10.1970

4)22.8.1968 No. and type of propellers 4- AB-68N cep.04 Propellers serial number 1)H108240527 2)H012280020 3) H012280022

4) H124430234 Total flying hours 1) 12149.00 HRS 2) 2971.00 HRS

3) 4604.00 HRS 4) 4542.00 HRS Date of manufacture 1) 31.10.1978 2) 5.7.2006 3) 26.1.1982 4)

31.12.1994 Location of ACCID 25.NM north of Malakal Phase of flight Cruise

1.6.1 Airframe Type of a/c AN-12 Manufacture serial number 8346010 Date of Manufacture 30.11.68 Date Of The Last Repair 26.09.95 Number Of Repairs 4 Assigned Service Lift 16750h/8000c/till 01.08.08 Time Between Overhaul (TBO) 7500h/2500c/till 01.08.08 Time Since New (TSN) 14597.36h/6924c Time Since Overhaul (TSO) 6274.36h/1892c Remaining Hours (Service Life) (TSN) 2152.24h/1076c Remaining Hours (Service Life) (TBO) 1225.24h/608c Monthly Flight Operation 510h/2c Last Airframe/Engine/ APU Report Received On

17.02.08

Date Of Last Scheduled Maintenance Φ-15+25k+season job form 19.02.08 till 02.06.08 (6274h/1892c)

Hours Since Last Scheduled Maintenance -h/-c

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1.6.2 Engines 1 2 3 4 Type AN-20M AN-20M AN-20M AN-20M Manufacture serial number

H2926174 H2846131 H2046052 H2836075

Date Of Manufacture 23.06.69 09.12.68 31.10.70 22.08.68 Installation Date 04.12.95 26.10.92 10.10.04 05.12.96 Date Of The Last Repair 12.11.93 25.09.92 30.11.89 15.11.93 Number Of Repairs 3 2 4 2 Assigned Service Lift 20000h 20000h 20000h 20000h Time Between Overhaul (TBO)

5315h till 12.11.08

4000h till 25.09.08

4000h Till 30.11.08

5176h Till 15.11.08

Time Since New (TSN) 10975.43h 8559.13h 16967.27h 109221.41h

Time Since Last Overhaul (TSO)

4998.47h 3707.03h 3470.59h 4859.41h

Remaining Hours 316.13h 292.57h 529.01h 316.19h Monthly Flying 5.14h/2c 5.14h/2c 5.14h/2c 5.14h/2c

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1.6.3 APU

Type TT-16M

Manufacture serial number OM 41902053

Date of Manufacture 23.03.90

Installation Date 27.12.05

Date Of The Last Repair 22.10.03

Number Of Repairs 1

Assigned Service Lift 15300c 1560hrs

Time Between Overhaul (TBO) 5100c/250hrs till 22.10.13

Time Since New (TSN) 311.52hrs/1890c

Time Since Last Overhaul (TSO) 55.181h/305c

Remaining Hours 194.42h

Monthly Flying 02h/2c

1.6.4 Propellers 1 2 3 4 Type AB-68N

cep.04 AB-68N cep.04

AB-68N cep.04

AB-68N cep.04

Manufacture Serial No. H108240527 H012280020 H012280022 H124430234 Date Of Manufacture 31.10.78 05.07.06 26.01.82 31.12.94 Installation Date 24.07.06 08.10.07 13.04.04 13.04.04 Date Of The Last Repair 13.03.06 05.07.06 19.08.94 - Number Of Repairs 1 No Repair 1 - Assigned Service Lift 15000h 15000h 15000h 15000h Time Between Overhaul (TBO) 3000h

Till 31.10.08 3000h Till 05.07.15

4000h Till 09.12.08

6000h Till 09.06.09

Time Since New (TSN) 12149.00h 2971.00h 4604.00h 4542.00h Time Since Last Overhaul (TSO)

375.00h 21.00h 3817.00h -

Remaining Hours 2625.00h 2979.00h 183.00h 1458.00h Monthly Flying 5.14h 5.14h 5.14h 5.14h

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1.7 Meteorological Information: Natural light at the time of accident was sunlight.

Forecasted enroute weather:- wind direction at 18000 ft easterly, ranging between (15-25 knots). Average temperature-6°c. Area between latitude (1° - 9° N) and longitude (°23 - °36 E) covered with low clouds, thunder storms and rain. Cumulonimbus clouds at altitude between (15000-47000 ft). Freezing level at 15000 ft (MAP attached).

1.8 Aids to Navigation: Irrelevant 1.9 Communication: Clearances issued by the Tower on frequency 119.2 MHZ:

TWR : Khartoum control clears JUC-500 Khartoum Juba via flight plan route to climb and maintain flight level 190 JUC-500: JUC-500 cleared to climb FL 190 total on board (07) fuel endurance 0530 TWR to approach: JUC airborne 55 Clearances issued by the approach on frequency 124.7 MHZ:

Approach: 170 final level JUC 500: 1 confirm Approach: Roger maintain level 170 final level and call Khartoum 127.3 JUC 500 127.3 good bye.

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Clearances issued by the center (south sector) on frequency 127.3 MHZ:

Center: JUC 500 good morning go ahead JUC 500: FL 170 Rabak 0335 Malakal 0434 ETA 0530 Center: confirm arrival Juba 0530 JUC 500: I confirm 1.10 Aerodrome Information: Irrelevant 1.11 Flight Recorders:

1.11.1 CVR: 1) Main CVR: Type: 1 Q 015 Serial number : 313325 Power : 27 v DC

2) Reserve CVR: Type: 1 Q 015 Serial number: 631557 Power: 27 v DC Their condition on recovery was satisfactory. No information recorded about the accident on both CVRs

3) K3- 63 Was not recovered.

1.11.2 FDR: Type: MCRP-12-96 Serial number: 30721 Power : 27 v DC Its condition on recovery was good

Results of decoding and analysis concerning the FDR:

The presented tape contains aircraft ascent, descent and level flight duration in a total of 1 hour & 26 minutes. Upon 1 hour 12 minutes from beginning of recording at an altitude of 5000 meters there was registered increase of vertical acceleration difference from 0.2 to 1.7m/sec (flight in the area of turbulence). Upon 1 hour 17 minutes from the beginning of recording there was registered decrease of RPM and failure of engine No.1, after 1minute failure of engine NO.3 and after 40 seconds failure of engine No. 4. After failure of engine No. 1 there was a descent from altitude 5000m to 800m in 3 minutes & 40 seconds (vertical descent-17.5 m/sec).

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Then further descent to 200m vertical speed was not higher than 3 m/sec. The crew attempted to run the failed engine (No. 3). Finally, after 1 hour 25 minutes from beginning of recording engine No.3 started, and failed immediately after it collided with the ground ( recording aborted). During impact engine No. 2 only was in operation. The FDR read out (attached).

1.12 Wreckage and impact information:

1. Referring to the first impacted tree :- - The aircraft touched it at a height of 8m above the ground (no trace

of tyres on the ground). - 58m the left horizontal stabilizer dismantled from the aircraft - 64m the aircraft touched the ground.

2. Referring to the first touch with the ground :- - 12m there was a cable on the aircraft track. - 25m the aircraft crawled on the ground leaving a path and debris

(no trace of fire). - 35m the left wing collided with a tree and part of it was dismantled. - 58m there was so much debris and traces of fire (from here fire

burst). - 94m there was a propeller and a gearbox, propeller blades were

tilted backwards. - 160m there was a propeller . - 164m there was a propeller at the left side of the aircraft track. - 179m there was engine No.1 without a propeller . - 188m there was the remains of the left wing and engine No.2

without a propeller . - 197m there was the right wing with two engines (No.3&NO.4)

.No.4 without propeller. - Aircraft stopped 200m.

3. Wreckage width 50m. (diagram attached).

1.13 Medical and Pathological Information:

1. Autopsy was carried out to the recovered 5 corpses, the cause of death was :- a) Burns ranges from 90 -100% b) Multiple injuries and sever fragmentations

2. The corpses of the pilot, first officer & flight engineer were identified. 3. The other two corpses were missing.

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1.14 Fire: After 58 m from the first touch with the ground fire began and all aircraft set on fire.

1.15 Survival Aspect:

The search was initiated at the time, Zain mobile company located the coordinates of the crashed aircraft by the assistance of the survivor’s mobile. The search and rescue executed by four aircraft, three helicopters and one AN 74. At the crash scene, three corpses found at the right side of the crashed aircraft and the rest at the aircraft wreckage, the two bodies at the right side identified to be the pilot and the first officer, the third was the flight engineer who was found under the right wing. All corpses were extensively burnt. 5 victims bodies were recovered, two missing and the only one survivor rescued. 1.16 Tests and research: No tests or research took place. 1.17 Organization and management information: Juba air cargo company LTD. has a valid AOC, and a qualified crew according to the laid down standards issued by the CAA. Juba air cargo has a contract with Volga Dnepr company (maintenance organization) for all checks according to maintenance schedule. The search & rescue concluded by the assistance of three helicopters and AN-74 under the supervision of the Search and Rescue department.

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2- Analysis:-

On the day of accident, en-route weather conditions were very bad (Thunderstorms, rain, hail, icing and turbulence) (MET forecast attached). There was a huge thunderstorm to the right of track with small paths in between the CB clouds to the far left and right. Aircraft weather radar was not operating at that time, because according to the survivor report the pilot made a right turn which led him direct in the centre of an embedded CB. Embedded thunderstorms are obscured by other clouds and it is impossible for a pilot to visually detour around them, they present a particular hazard to IFR flights. Another thing that the radar normally detects CB (200km-250km) if it was operating at that time the pilot might have detected the CB early enough and avoid it, when he entered the thunder storm he encountered heavy turbulence, icing, hail and up and down draft which led to the failure of three engines No 1,3 and 4 except engine No. 2 (refer to the FDR readings). The aircraft was flying at 5000m, when it entered the situation above its nose dropped down with 17.5 m/sec and indicated air speed of (650-690 km) which is equivalent to 0.78 mach. The aircraft lost 4200 m and after wards lost another 600 m and it decreased the angle of descent. According to the aircraft performance, if the aircraft gains speed it will pickup its nose and whenever the aircraft fly close to the ground the air is dense, so the speed reached 0.78 mach and the aircraft tried to level itself, More over according to the FDR readings and analysis the crew tried to start engine No 3 and made so many trials and were able to start it, but unfortunately the ground upfront was forest and the aircraft at a height of 8 M collided with a tree by the right wing tip. The left wing was intact and due to collision with the ground trees the aircraft parts were distributed within the aircraft track on ground. Fire bursts approximately 58 m from the touch down with the ground and all the rest of the aircraft heaped approximately 200 m from the first impact. The anti-icing system protects the aircraft from ice accretion at ambient temperatures down to- 20°C. Anti -icing is by hot air bled from engine tens stage compressors and by electric heaters element fed by 28.5V DC. Hot air is fed to wing and empennage leading edges, compressor inlet guide vanes, engine inlet, oil cooler intake, generator cooler inlets, the air –to –air cooler inlet, flight deck and navigator officer’s station windows, and main landing gear wells . Electric heater element protect propeller blades and spinner flight – deck and navigator officer’s station windscreen, static and dynamic pressure parts and DUA (detector heating system) {Ref. flight manual 6.6 page 1-6} According to the above mentioned procedures concerning operation of aircraft in cloudy weather and (Temperature +5°c& below) the deicing system should be switched on before entering the clouds. For this Captain, he entered into the embedded CB without seeing it, so it is positive that the deicing was not on, because he does not know that there was an embedded CB right of track, second

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according to the FDR readings there was no increase of torque to compensate for the air take from engines which will lead to decrease of speed and consequently challenge of deicing efficiency. Engine No.1 stopped, one minute later engine NO.3 stopped and in 40 seconds engine No.4 stopped due to ice accumulation in the air intake which closed the air flow and leading to failure of the above mentioned engines. No 2 engine was operating up to the moment of crash. This is due to every engine is operating in a totally different situation as due to its position efficiency, angle in which it is flying , air sucking by compressor and rate of accumulation of ice.

3- Conclusion:-

3.1 Findings:

- The crew was rated and entitled to fly the aircraft. - The aircraft was insured and maintained according to the approved

maintenance scheduled. - En route weather forecast information obtained by the company. - Nature of the goods on board, clothes food stuff, chairs and households

furniture no dangerous goods. 3.2 Causes

- The three engines failure constitutes the main cause. - Contributory factors:-

o En-route bad weather and pilot visual entry into an embedded thunder storm.

o Un-serviceability or sudden failure of weather Radar.

o Accumulation of ice led to the blockage of the engines air intake

assembly (IGVA).

o The nature of the impact area was forest, this caused the detachment of the aircraft parts. The running engine (No.2) caused the fire.

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4- Safety Recommendation:- - All operators and flying crew should pay attention to the preflight inspection

specially for the weather radar and deicing systems. - All flying crew should visit the airport briefing office for detailed

information about the route and intended destinations.

- All flying crew should stick to the standards check list of the aircraft type.

- CAA recommended to provide the Search &Rescue Department with the necessary means of reliable communication and transportation facilities.

- CAA should issue and implement a check list for all eastern aircraft.

- Airworthiness operation directorate recommended to carry a thorough

inspection to all aircraft.

- All operators should pay special attention to rewinding the CVR tape and it should be considered as a compulsory item.

Abdel Muhsin Ibn Idris Investigator in charge

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