Islamic Republic of IRAN

Civil Aviation Organization

Accident Final Report

State File Number: A13880431UPI6208

Type of Occurrence: Accident
Date of Occurrence: July 22th 2009
Place of Occurrence: I.R.IRAN - Mashhad Safety & Accident
Aircraft Type: IL-62M
Investigation Department
Registration: UP-I6208
Operator: Aria
 ‌

Islamic Republic Of Iran

Civil Aviation Organization
Aircraft Accident Investigation Department

Final Report
Basic Information
Type of occurrence: Accident
Date: 24.Jul.2009
Location: Mashhad International Airport/ I.R of Iran
Aircraft: Airplane
Model: IL-62M
Registration: UP-I6208
Owner: DETA Airline
Operator: ARIA Airline
Date of Issue: 05 Jun 2010

Civil Aviation Organization of I.R. of Iran

Aircraft Accident Investigation Department
Mehrabad International Airport
PBO: 13445-1795 Tehran/Iran
Fax: + 98 21 6601 8659
Tel.: + 98 21 6604 7965
E-mail: AIG@cao.ir
http://www.cao.ir

--------------------------------------------------------------------------------------------
Foreword:
Civil Aviation Organization is responsible for supervision on correct
implementation of laws and regulations and flight standards in civil Aviation industries of
the country, according to international commitments and domestic laws of the Islamic
Republic of Iran; in this respect, the accidents are investigated , in order to identify
threaten resources of safety ratio of flights, based on international regulations and
compiled guidelines of International Civil Aviation Organization, ICAO (annex 13).
After identifying main causes and contributive factors of the accident, safety
recommendations are issued in order to consider flight standards and regulations, as well
as more attention to flight safety for preventing the same accidents.
Written matters in annex 13 of ICAO and relevant appendixes emphasize on this matter
that “The sole objective of the investigation of an accident or incident shall be the
prevention of accidents and incidents. It is not the purpose of this activity to apportion
blame or liability”
The main objective of investigating accidents is to achieve main causes and roots for
preventing similar accidents in the future.
About IL-62M airplane accident, owned by DETA Airline, Kazakhstan, (leased by Aria
Airline) in July 24, 2009, at 08:05 local time (13:35 UTC) on Shahid Hasheminejad
International Airport/ Mashhad, The Accident Investigation Team was attended in the
place of accident immediately and gathered information; this team receives FDR and
CVR of the plane, in order to analyze them.
In this direction, there has been taken necessary actions for correct investigation of
technical – operational documents and study about the accident site and body of the plane
in order to identify main and contributive causes of this accident and issue safety
recommendations for preventing such same occurrences.
The accident investigation team however appreciates Interstate Aviation
Commission (IAC) for mutual cooperation in the investigation of accident involving IL-
62M with registration, UP-I6208 and preparing final report of this accident.

2
Synopsis:

Type of the aircraft Illyushin, model IL-62M

Registration mark UP-I6208
Owner DETA Airline, Kazakhstan
Operator Aria Airline
Date of accident July 24,2009
Time of accident 18:05 local time (13:35 UTC)
Place of accident End of left band of Mashhad International
Airport
Damage to airplane Destroyed
No of passengers 156 person
No of crews 17 persons& one additional crews group
No of fatal 16 persons
No of injured person 31persons
Responsible for accident Aircraft accident investigation &safety
investigation Dept. I.R of Iran
Foreign cooperator (IAC) Interstate Aviation
commission Committee/(Russia ، Kazakhstan Civil
Aviation Authority
Main cause of accident crews mistakes

3
1. Factual Information

1.1 History of the flight:

At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline

with registration, UP-I6208 and flight no. IRX.1525 of Aria Airline flight

with 169 passengers from Mehrabad International Airport/ Tehran, and it

has landed at 18:05 local time on RWY 13 L in Mashhad International

Airport; then it has run off from end of the runway, without considerable

reduction in aircraft speed and it collided with wall of the airport and it was

stopped after approximately 185 m.

The mentioned aircraft has been leased by Aria Airline as ACMI,

according to contract No. 002/IL-62M/ACMI.

Subsequently, the ground safety unit of the airport has attended in place of

occurring accident, by breaking protective fences and barbed wires of the

airport, and then they evacuated passengers and extinguished fire outside of

aircraft by carrying out necessary actions.

4
1.2 Injuries to persons:

Injured persons of this accident were carried to hospitals of Mashhad

city, after search and rescue operation, bodies of victims were transferred

to the legal medicine. The following table shows overview of body injuries

to passengers of this aircraft:

Injuries Crew Passenger Others

Fatal 11 5 0
Serious Injuries 2 1 0
Minor 0 28 0
None 7 122 0
Total 17 156 0

1.3 Damage to aircraft:

The aircraft fuselage destroyed totally due to impact to wall of the

airport and it caused destroying cockpit and nose section airframe and it
can't be reconstructed.

1.4 Other Damage:

Due to impact of aircraft landing gears with net barrier in shoulder of

RWY 13L, it has major damages on it and some damages to PAPI light in
beginning of RWY 31R.

5
1.5 Personnel Information:

1.5.1 Pilot in Command :( PF)

Birth year 1957
Kind of certificate and validity date Class one validity date
28/OCT/09
Medicine condition Without medicine limitation and
it is valid until 28/Aug/09
Total flight hours 14200
Total flight hours with IL-62 1500
Date and place of last simulator 10/Mar/09 Russia
Prior accident None
License for international flight ok
License for radio communication ok
Entrance date to Iran 19 July 2009
Date of first flight in Iran 24 July 2009
No of flight in Iran 6 flights

According to available documents, he has done Radio communication

but the level of his English conversation was not suitable.

1-5-2 Copilot:

Date of Birth 1962

Kind of certificate and validity date Class 2 validity date24/Feb/2010
Medical condition Without medical limitation and it
is valid until 24/Feb/2010
Total flight hours 8294
Total flight hours with IL-62 1319
Date and place of last simulator 10/MAY/2009 Russia

6
 Prior accident none
License for international flight ok
License for radio communication ok
Entrance date to Iran 19 July 2009
Date of first flight in Iran 24 July 2009
No of flight in Iran 6 flights

1-5-3 Flight Engineer:

Date of Birth 1957

Kind of certificate and validity date Class 1 validity
date28/OCT/09
Medical condition Without medicine limitation
and it is valid until
28/0CT/09
Total flight hours 8747
Total flight hours with IL-62airline 1697
Date and place of last simulator 10/MAY/09 Russia
Prior accident None
License for international flight ok
License for radio communication ok
Entrance date to Iran July , 17,2009
Date of first flight in Iran July , 23,2009
No of flight in Iran 6 flights

7
1.6 Aircraft Information:

The Ilyushin aircraft IL-62M with S/N: 1951525 have been

manufactured at 09.06.1989 in Ilyushin Aircraft Factory, and its owner is

DETA Air Company, Kazakhstan. It has been registered at June 16, 2008

with UP-U6208, by Civil Aviation Authority of Kazakhstan. It has also

received its last certificate of Airworthiness at Jan. 28, 2009 from this state,

which it was valid until Jan. 28, 2010.

This airplane has been exploited after upgrading its navigation and

telecommunication, as well as installing its passenger oxygen system for

flight operation in Iran.

This airplane has been arrived in I.R of Iran Territory , due to

agreement No. 002/ IL-62M/ACMI, dated on Nov. 16, 2008 as "wet lease

agreement (ACMI) for aircraft IL-62M, between DETA Air, as Lesser and

Aria Airline as Lessee at Jan. 17, 2007.

State registry number UP-I6208

Manufacture number № 1951525

Owners Eugeny V. Zhigayev
Ibragim A. Paskachev

8
Operator
Date of release
State registration certificate
Airworthiness aircraft certificate
Assigned life time and service life
Overhaul life and service time
Operating time since new(TSN)
Operating time since the last overhaul(TSO)
Number of overhauls, date of the last overhaul
Overhaul life rest
Last periodic technical maintenance
Last periodic maintenance
Fuelling
Fuel type
Insurance certificate
9
ARIA airline. The aircraft owned by D.E.T.A.
AIR airline was leased under an agreement and
operated by the airline “ARIA AIR” (IR of
Iran).
09 June 1989
No.538 dated 16 June 2008
(Kazakhstan)Republic)
No.0538 dated January 28, 2009 valid till
January 28, 2010
35000 hours, 7500 landings., 20 years
(Bulletin No.1440-БЭ),
Bulletin No. 291-62M was fulfilled on January
20, 2009, so in accordance with the bulletin the
assigned service life was extended to 20 years 4
months, till September 29 2009.
10200 hours, 2700 landings (Bulletin No.1399
БЭ), 14 years
13573 hours, 3987 landings
7876 hours, 2458 flights
One overhaul, September 29, 1995
2384 hours, 242 landings
According to the logbook – March 29, 2009,
form Ф-1К with operating time 7666 hours and
2338 landings, maintenance sheet №9
Form Б 15 July 2009, maintenance sheet
51, Teheran
20 tons
Jet -A1
Kazakhinstrakh, Insurance agreement No.
17/303/08/891
 Engines installed in the aircraft:

Engine type D-30KU-2 D-30KU-2 D-30KU-2 D-30KU

Serial № 51148802221 51248802214 51219002225 0304022212226

Manufacturer JSC “Rybinskiye JSC “Rybinskiye JSC “Rybinskiye JSC “Rybinskiye

motory” motory” motory” motory”
Date of 22 November1988 26 October1988 11 March1990 30 April1982
Operating time
manufacture 7261 hours, 7425 hours, 7307 hours, 14046 hours,
since new 1836 cycles 1890 cycles 1729 cycles 3536 cycles

Place of the JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn JSC NPO Saturn
last overhaul

Date of the 30 December 1999 23 October 2001 14 May 2002 30 March 2000.
last overhaul
Operating time 3574 hours 3119 hours 1806 hours 3567 hours
since the last 928 cycles 779 cycles 438 cycles 925 cycles
overhaul
Overhaul life 3637 hours 3330 hours 3000 hours 3627 hours
time 901 cycles 767 cycles 543 cycles 898 cycles
Overhaul life 63 hours, 210 hours, 1194 hours, 60 hours,
time rest -27 cycles -12 cycles 105 cycles -27 cycles

Engines, APU TA-6A, units and assembly parts were operated in

compliance with the effective operating regulations.

All four engines had sufficient life times in operation hours to perform
flights. According to bulletins No. 1770 and No. 1844 of the engine
manufacture JSC NPO Saturn, effective dates February 08, 2002 and June
29, 2007, the first, second and fourth engines had exceeded life time in
cycles (27, 16(12), 27 correspondingly). Life times were extended by the
JSC “Aerotechservice” (Nikolayev, Ukraine) and JSC “Engine” (Perm).

10
 Engine maintenance performed:
№ APU Periodical maintenance Current maintenance
PU 1 Ф-1К – 21 April 2009 ФБ – 19 July 2009
PU 2 Ф-1К – 29 April 2009 ФБ – 16 July 2009
PU 3 Ф-1К - 29 April 2009 ФБ – 15 July 2009
PU 4 Ф-1К – 21 April 2009 ФБ – 19 July 2009

The airframe, assemblies and units has life time sufficient to perform flight
tasks except for the cycle life time for AP units 1, 2, 4. The aircraft had no
malfunctions before the accident flight on July 24, 2009.
No complaints were made on technique functioning during the flight.
According to information of the flight date recorders, engine and aircraft
system operating parameters were in compliance with the assigned modes.

1.7 Meteorological information:

According to the meteorological office report, status of the current air
(METAR), in the accident time in Mashhad International Airport (Shahid
Hasheminejad) at 24.07.2009 was according to the following table:
ICAO ID:OIMM
Time Wind Pressure
TEMP/DEW
LMT Visibility Cloud ‫دما و نقطه شبنم‬ Density
DIRECTION SPEED(KT( ‫ميزان و‬
‫زمان‬ (DEG) ‫ديد افقي‬ altitude
UTC ‫ارتفاع ابر‬ HPA INCH (feet)
‫سمت‬ ‫سرعت‬
‫محلي‬ RH
‫رطوبت نسبي‬

53/M05
11:50 02:61 60 12 CAVOK 1013 62.91 6299
7.52 %
34/M03
12:50 17:20 80 14 CAVOK 1012 29.89 6235
9.24 %

33/M04
13:50 18:20 60 14 CAVOK 1012 29.90 6124
9.06 %

11
 There were not any effective metrological factors that could affect on
operation of the aircraft.

1.8 Aids to navigation:

Mashhad international airport is equipped with aid to navigation
systems as below:
NDB 385KHZ
DVOR/DME 11400 MHZ
LLZ 109.900MHZ
ILSGP 333.800MHZ
ILS/DME CH36X
According to available documents at accident time, all navigational
systems operations were normal

1.9 Communication:
Mashhad international airport equipped to communication system as
below:

Frequency Time Notes

APP: 127.300 MHZ H24
121.500 MHZ H24 Emergency
frequency
353.800 MHZ H24 Military frequency

TWR: 118.100 MHZ H24

121.700 MHZ H24
121.900 MHZ H24
257.800 MHZ H24 Stand by For all VHF
243.000 MHZ H24 UDF, Military
Aircraft Military
Emergency
ATIS (INFO) 126.400 MHZ

Communication and conversation from the flight control units & CVR of
aircraft have shown the correct operation of these systems.

12
1.10 Aerodrome information:

Mashhad international Airport of (OIMM) has aerodrome reference

point with geographical coordination 361403N 0593842E in MAG 312 Deg

with elevation of 3226 FT RWY 13L threshold.

Its direction and distance is as East and 3 Km from Mashhad, its height

from sea level is 3263 ft, and its temperature degree reference is 34.1 C.

There are permission IFR/VFR flights in this airport. Fire fighting

facilities of Mashhad INTL Airport is in CAT7. It has two Runways in

direction of 13/31 L, R with 3811 * 45 m dimension. About this accident,

there weren’t any faults in this regard.

1.11 Flight Recorders:

FDR

The aircraft was equipped with flight data recorders MSRP-64 and MSRP-
12-96. A tripartite recorder K3-63 was not installed in the aircraft. The
recorders were retrieved from the accident site by Iranian accident
investigation team. Data readout was carried out at a facility of the “PARS
Aviation Service” company. The information from the MSRP-12-96
recorder was not downloaded. The cassette KS-13 of the accumulator KBN
as well as the magnetic tape of the tape media MLP-14-5 of the onboard
recorder MSRP-64 were in satisfactory condition and had the parametric
accident flight data recorded on them. On the pictures below some readout
results are shown:

13
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:57:22 #11 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Alt.pr CCP Elev VHF keying

[m] [mm] [deg]
9800 150 15 13.8

9600 100 10 Alt.pr 9538.5

9400 50 5 CCP: Control column position 0.6
9200 0 0
4.0
Elev: Elevator position
9000 -50 -5
8800 -100 -10 -6.3
-8.6
8600 -150 -15
8400 Pitch VertAcc
8200 AOA [g]
1.23
1.17
8000 [deg] 1.2
VertAcc: Vertical acceleration 1.00 1.00
7800 12 1
7600 10 0.8 8.8 9.0
8.4
7400 8 0.6
7200 6 0.4 AOA: Angle of attack 4.4
7000 4 3.2
6800 2 Spoil.r
6600 0 Spoil.l Pitch: Pitch angle -0.6

6400 -2 [deg]
6200 30 24.0 22.1
6000 Flaps.r 20 24.2
20.9
5800 Flaps.l 10 7.1
6.8

14
Spoil.r: Spoiler (right) -0.3 -7.8
5600 [deg] 0
Spoil.l: Spoiler (left) -1.0 -0.7 30.0
5400 30 Stabzr
AFCS.Rol: AFCS roll channel ON
5200 20 [deg] 15.6
AFCS.Pit: AFCS pitch channel ON
5000 10 6
Flaps.r: Flaps (right) 0.2 Left gyro horizon failure
4800 0 4
Flaps.l: Flaps (left) 0.0 Right gyro horizon failure
4600 2
СGV malfunction
4400 0 Stabzr: Stabilizer position -1.44 -1.00
4200 -2 -2.79
-1.83
4000 -4
3833.3 -5.60
3800 Alt.radi IAS AS760: Altimeter setting 760
3600 [m] [km/h]
3388.9
3400 1100 600 571
3200 1000 550 IAS: Indicated airspeed
514 3000.0
3000 900 500
2800 800 450 479 GPWS
Alt.radi: Radio altitude 793.3 Alt.radi 793.3 664.7
2600 700 400
2400 600 350 364
Touchdown

Landing gears actuator to extend

2200 500 300 325
Alt.pr 2200.0
2000 400 250 279
276
1800 300 200 265.6

1600 200 150

87.5
1400 100 100
0.0
1200 0 50
Time UTC
13:21:00 13:22:00 13:23:00 13:24:00 13:25:00 13:26:00 13:27:00 13:28:00 13:29:00 13:30:00 13:31:00 13:32:00 13:33:00 13:34:00 13:35:00
AS760
AFCS.Rol AFCS.Pit GPWS
LG-ToExt Stab.p
GHLFai VHFkey Stab.p
GHRFai RA.Glid+
Elv.l+ RA.Locz+
СGV!

Pic.1.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:19:00 #12 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525
37.7
Alt.pr CWP Ail.r
[m] [deg] Ail.l 8.1 7.6
10400 20 [deg]
10200 10 5 CWP: Wheel position 1.9
10000 0 2.5 Ail.r: Aileron position (right)

9800 -10 0 Ail.l: Aileron position (left) 1.5

9600 -20 -2.5 Alt.pr 9538.5
-2.9
9400 -30 -5
-30.0
9200 Rudder Roll_ri
-38.3
9000 [deg] Roll_le 21.9
8800 20 Roll
8600 10 [deg]
Rudder: Rudder position 0.0
8400 0 30 24.5
8200 -10 20
8000 LatAcc 10 -17.0
Roll: Roll angle Roll_le: Roll angle (left FD) 0.0 0.0
7800 [g] 0
7600 0.6 -10 Roll_ri: Roll angle (right FD)

7400 0.4 -20

-18.4
7200 0.2 GMH 0.13
LatAcc: Lateral acceleration 0.01 -28.9 0.01
7000 0 [deg] -33.5
6800 -0.2 280
6600 LocDev 260

15
6400 [mkA] 240
6200 150 220 LocDev: Localiser deviation 114.1 115.6
6000 100 200
5800 50 180
-2.1
5600 0 160
9.6 5.8
5400 -50 140 127.1
140.0
5200 -100 120 130.0
121.4
5000 -150 100
GMH: Magnetic heading 82.9
4800 Alt.radi 80
62.9
4600 [m] 60
4400 800 40
Alt.radi: Radio altitude 793.3 Alt.radi 793.3
4200 750 20
4000 700 0 664.7
3833.3
3800 650 IAS
3600 600 [km/h]
3388.9
3400 550 600 571
3200 500 550 IAS: Indicated airspeed
514 3000.0
3000 450 500
2800 400 450 479
2600 350 400
2400 300 350 265.6
Touchdown

364
2200 250 300 325
Alt.pr 2200.0
2000 200 250 279
AFCS.Rol: AFCS roll channel ON 276
1800 150 200
1600 100 150 87.5

1400 50 100
0.0
1200 0 50
1000 -50 0 Time UTC
13:21:00 13:22:00 13:23:00 13:24:00 13:25:00 13:26:00 13:27:00 13:28:00 13:29:00 13:30:00 13:31:00 13:32:00 13:33:00 13:34:00 13:35:00

Pic.1.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 21:18:24 #13 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Alt.pr Throt4 VHF keying RevShut4

121.1122.9
[m] Throt3 RevShut1
9800 Throt2 115.0113.3
86.0
9600 Throt1 N1.4 Alt.pr 9538.5 66.7
62.4
9400 [deg] N1.3 65.8 50.3
57.3 60.0 39.7
9200 40 N1.2 26.8
Throt4: Throttle position 4 23.7 41.1
9000 20 N1.1 30.6
Throt1: Throttle position 1 16.6 13.9 16.6
8800 0 [%]
8600 EGT4 100 -34.2
83.3
77.0 74.5
8400 EGT3 80
63.2 82.7
-41.8 -41.8
8200 EGT2 60 72.7 N1.4: Low pressure compressor rate 4 48.6 70.9
N1.1: Low pressure compressor rate 1 56.5 33.8
8000 EGT1 40 46.3
7800 [deg] 20 35.0 30.3
7600 650 0 13.8
605
7400 600
7200 550 VibRm4 526 570
487 497
7000 500 VibRm3 477
500
6800 450 VibRm2
EGT4: Exhausted gaz temp. 4 398 435 435
6600 400 VibRm1 420 366
6400 350 [mm/sec] EGT1: Exhausted gaz temp. 1
355 345
6200 300 20 340

6000 250 15 11.3 VibRm3: Engine rear mount vibration ratio # 3

16
5800 Cab/Atm 10 7.9 7.0 7.9
5600 [kgf/sm2] 5
5400 0.8 0 2.4 3.1
VibRm4: Engine rear mount vibration ratio # 4 1.6 0.8
5200 0.6 Ubus22A
0.61 Cab/Atm: Cabin/atmosphere pressure ratio
5000 0.4 Ubus21A 0.50
4800 0.2 [V] 0.11
4600 0 29
4400 28.5 Ubus22A: Bus 22A voltage 28.3 28.3
4200 28 28.2 28.2
Ubus21A: Bus 21A voltage
4000 27.5
3800 Alt.radi IAS
3600 [m] [km/h]
3400 1100 600 571
3200 1000 550 IAS: Indicated airspeed
514
3000 900 500
2800 800 450
Alt.radi: Radio altitude 793.3 Alt.radi 793.3 664.7
2600 700 400
2400 600 350 364
Touchdown

2200 500 300 325

Alt.pr 2200.0
2000 400 250 279
276
1800 300 200 265.6

1600 200 150

Landing gears actuator to extend 87.5
1400 100 100
0.0
1200 0 50
Time UTC
13:21:00 13:22:00 13:23:00 13:24:00 13:25:00 13:26:00 13:27:00 13:28:00 13:29:00 13:30:00 13:31:00 13:32:00 13:33:00 13:34:00 13:35:00
DVibr VHFkey LG-ToExt
CIO! LOP
RevShut1
EngFire FMmin RevShut4
BagSMK Fire
HSP< AC1+
AC2+

Pic.1.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:58:29 #31 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

CCP Elev VHF keying

[mm] [deg] 16.0
150 15 13.8

100 10
50 5 CCP: Control column position 7.8
0 0 Elev: Elevator position
-50 -5
-100 -10 -67.3 -7.0
-8.6
-150 -15
VertAcc
[g] -234.7
1.77
Pitch 1.6 17.0
AOA 1.4
1.23
[deg] 1.2
VertAcc: Vertical acceleration 1.00
12 1
10 0.8
8 0.6 6.8
AOA: Angle of attack
6 0.4
4 0.2 3.2
2 0 2.6
0
-1.7
Pitch: Pitch angle -0.6 -2.2
-2 Spoil.r
-2.2

17
-4 Spoil.l
-6 [deg]
-6.1
Stabzr 15
-7.8
[deg] 10 7.1 6.8
4 5 Spoil.l: Spoiler (left) 2.5
2 0 Spoil.r: Spoiler (right)
0
-2
-1.83
-4
Stabzr: Stabilizer position -5.60
Left gyro horizon failure
-6
Alt.radi IAS Right gyro horizon failure
[m] [km/h] IAS: Indicated airspeed
318 СGV malfunction
110 320 325
100.0
100 300
90 280
279
80 260 Alt.radi: Radio altitude 276
70 240
71.9
60 220 206
50.0

Thrshould passing
50 200 186
40 180
31.3
30 160 GPWS

Touchdown
20 140 129
End of the RWY
Ditch

10 120 111
0.0
0 100
Time UTC
13:34:45 13:34:50 13:34:55 13:35:00 13:35:05 13:35:10 13:35:15 13:35:20 13:35:25 13:35:30 13:35:35 13:35:40 13:35:45 13:35:50
GPWS
Stab.p
VHFkey
GHLFai
GHRFai Stab.p
RA.Glid+
RA.Locz+
Elv.l+
СGV!

Pic.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 23:35:05 #32 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525
37.7 37.7
CWP Ail.r
31.7
[deg] Ail.l
20 [deg] 6.9
9.4
10 5 Ail.l: Aileron position (left) 3.8 3.9
0 2.5 0.6
-10 0 Ail.r: Aileron position (right)
CWP: Wheel position 0.6
-20 -2.5 -1.0 -0.6 -1.2
-18.0
-30 -5 -3.3
-5.6 -5.2
Spoil.r Roll_ri
Spoil.l Roll_le
[deg] Roll 6.6 7.1 6.8
Spoil.l: Spoiler (left) 4.2 3.2
5 [deg]
0 10 Spoil.r: Spoiler (right)
-5 5 2.9
Roll: Roll angle Roll_le: Roll angle (left FD) 0.0
-10 0
LatAcc -5 Roll_ri: Roll angle (right FD) -3.8 -2.5
[g] -10
0.4 -15
0.2 Rudder 0.14
LatAcc: Lateral acceleration
0 [deg]
-0.2 30 21.9
LocDev 20 12.7 -0.36
19.3

18
[mkA] 10
Rudder: Rudder position
250 0
200 -10
150 -20 115.6 -16.5
-18.9
100 115.6
59.3
LocDev: Localiser deviation
50
-2.1
0
-2.1
GMH
[deg]
135
130 GMH: Magnetic heading 127.1 127.1
130.0
125
120
Alt.radi IAS
[m] [km/h]
120 350
IAS: Indicated airspeed
110 325 318
325
End of the RWY
Ditch

100 300
90 275 87.5
276 279
80 250
70 225 Alt.radi: Radio altitude
60 200 206 186

Threshould passing
50 175
50.0

Touchdown
40 150
31.3
30 125
20 100 111
10 75
0.0 Time UTC
0 50
13:34:45 13:34:50 13:34:55 13:35:00 13:35:05 13:35:10 13:35:15 13:35:20 13:35:25 13:35:30 13:35:35 13:35:40 13:35:45 13:35:50

Pic.3.2. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 INTERSTATE AVIATION COMITTEE Printed: 02.08.2009 22:04:50 #33 User: Zayko (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Throt4 RevShut4 128.7

121.1 122.9
Throt3 RevShut1
121.4
Throt2 115.0 91.6 113.3

Throt1 N1.4
61.1
[deg] N1.3
40 N1.2 26.8
Throt4: Throttle position 4
20 N1.1 4.2
Throt3: Throttle position 3 2.0
16.6
0 [%]
EGT4 120 -34.2
EGT3 100
-41.8 83.3 -41.8
EGT2 80
82.7
EGT1 60
[deg] 40 N1.4: Low pressure compressor rate 4 33.8

650 20 N1.1: Low pressure compressor rate 1 30.3

600 0 11.4
602 6.0
550 VibRm4 570
497
500 VibRm3 EGT4: Exhausted gaz temp. 4
450 VibRm2
400 VibRm1 EGT2: Exhausted gaz temp. 2 435
366 359
350 [mm/sec]
345 339
300 25
18.8 249
250 20
238

19
15
10
Engine rear mount vibration ratio # 2 5.0
Ubus22A 5 1.8
Ubus21A 0 Engine rear mount vibration ratio # 4 2.0
-0.8
[V]
32
30
Bus 22A voltage 28.2 28.1
28
Bus 21A voltage 28.2
26
24 24.7
Alt.radi IAS
[m] [km/h] IAS: Indicated airspeed VHF keying
318
110 320 325
Low oil pressure in any engine
100 300
90 280 87.5
Hydraulic system oil pressure is low
279
80 260 276
Alt.radi: Radio altitude
70 240
60 220 206
50 200 186
50.0

Threshould passing
40 180
31.3

Touchdown
30 160
139
20 140
Ditch

End of the RWY

10 120 3.1 111

0.0
0 100
Time UTC
13:34:45 13:34:50 13:34:55 13:35:00 13:35:05 13:35:10 13:35:15 13:35:20 13:35:25 13:35:30 13:35:35 13:35:40 13:35:45 13:35:50
VHFkey
LOP
RevShut1
RevShut4
Fire
BagSMK
HSP<
AC1+
AC2+

Pic.3.3. Aircraft IL-62M UP-I6208 24.07.2009 at Mahrabad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 Printed: 03.09.2009 14:57:41 #44 User: Зайко (#3) A/C type:IL-62M Reg.No.:UP-I6208 Date:24.07.09 Flight:1525

Throt4 RevShut4
Throt3 RevShut1 128.7
121.1 122.9
Throt2
121.4
Throt1 115.0 91.6 113.3
[deg] N1.4
61.1
60 N1.3
40 N1.2 26.8
Throt4: Throttle position 4 23.1
20 N1.1 11.1
Throt3: Throttle position 3 16.6
0 [%]
120 -34.2
EGT4 100
83.3
-41.8 -41.8
EGT3 80
82.7
EGT2 60
N1.4: Low pressure compressor rate 4 33.8
EGT1 40
[deg] 20 N1.1: Low pressure compressor rate 1 30.3
650 0 11.4 6.0
600
602
550 570
497
500 EGT4: Exhausted gaz temp. 4
450
400 EGT2: Exhausted gaz temp. 2 435
366 359
350
345 339

20
300
249
250
200 238

Alt.radi IAS
[m] [km/h]
100 500
95 480
90 460 87.5
85 440

GPWS: Pull up.

NAV: 30

Crew: Switching on.

Crew: (Reverse)(?)
80 420
75 400

NAV: Kilometer
РИ: Minimum, minimum.
NAV: 15 FE: ... eversed.
NAV: 12
NAV: 10
NAV: 8
NAV: 6
NAV: 5
NAV: 4
NAV: landing, speed 26… 270.
FO: Did you turn on the reverse?
NAV: Speed is increasing, speed is increasing!
NAV: Turn to the left. To the left!

GPWS: Pull up.

Crew: Is the idle on?
NAV: 40 meters
NAV: 20
NAV: 260
NAV: 270 speed.
NAV: Speed is increasing!
Pax: Berast, bersat (Pers.)
Pax: Right, right, right.
FO: What's up? Why reverse don't switch?
FE: Because there was no thrust reversal displacement.
NAV: Turn to the left.

NAV: 25
NAV: 3
NAV: 2
NAV: 1
NAV: about 0.5 meter
NAV: ...270
Crew: Turned on.
FE: Thrust reversal ...
Pax: Berast, bersat (Pers.)
FO: Go around, let's go around!
NAV: Emergent breaking!
КВС: Emergent.

70 380
65 360
60 340 IAS: Indicated airspeed
318
55 320 325 Low oil pressure in any engine
50 300
50.0
45 280 VHF keying
Hydraulic system oil pressure is low
279
40 260 276
35 240 31.3
30 220 206
25 200 186
20 180

RWY threshould
Toushdown
15 160
139
10 140
Impact with a wall.

121
Ditch

3.1
Noize at the cabine.

5 120
End of the RWY

0.0
0 100
-5 80 Time Relative
13:34:45 13:34:50 13:34:55 13:35:00 13:35:05 13:35:10 13:35:15 13:35:20 13:35:25 13:35:30 13:35:35 13:35:40 13:35:45 13:35:50

Pic.3.3.1. Aircraft IL-62M UP-I6208 24.07.2009 at Mashhad accident FDR (MSRP-64) flight parameters. (Preliminary)
 WinArm32 Тип:IL-62M Борт:UP-I6208 Дата:24.07.09 Рейс:1525 User: Зайко d:\up-i6208.Ил-62М.Иран.2009\map\up-i6208_1b.tra

10nm
13:28:00.0

13:29:00.0 8nm

13:32:00.0

13:31:00.0
6nm

13:30:00.0 13:33:00.0

4nm

2nm

21
13:34:00.0

13:35:00.0

2nm

4nm

6nm

8nm

Pic. 5b. Aircraft IL-62M UP-I6208 on 24.07.2009 at Mashhad airport flight path (FDR data). (Preliminary)
CVR:

The aircraft IL-62M was equipped with a CVR MARS-BM with a

total record time of 30 minutes. The recorder was retrieved from the
accident place by Iranian accident investigation team. The information
readout was performed at a facility of “PARS-Aviation Service Company”.
The magnetic tape of the recorder was in a satisfactory condition so the
accident flight data was recorded. Preliminary download of the cockpit
conversation and voice identification was also conducted by representatives
of Kazakhstan Civil Aviation Committee and D.E.T.A. AIR airline. The
final transcript of cockpit radio communication with time synchronization
was made by the Air Accident Investigation Scientific and Technical
Support Commission of the IAC.

1.12 Wreckage and Impact information:

Accident site inspection revealed that the aircraft position had coordinates
N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away
from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad
airport with the azimuth of 125º (true).
Power line along the road was destroyed by the right aircraft wing. Wing
fuel tanks of the right wing were damaged evidenced by fuel leaking. Main
and emergency exits were open. An inflatable slide was dropped down from
the port side. No evidences of fire on board and at the accident site were
found.
First tracks of intensive braking (black tire tracks) were found at the
concrete at a distance of 550 m from the departure threshold of RWY31R.
The track of the main gear wheels was going along the RWY in its left part,
and diverging further to the right beyond the departure threshold. At about
100m away from the threshold at the end portion of the braking way, a net
barrier was found (textile aerodrome emergency braking unit).

22
 The aircraft ran over the RWY when moving along the right side of the
stop way, 300m long. Beyond the end of the RWY landing gear wheels track
could be clearly seen passing over a rough partly grassed surface, and
crossing a dirt road. At a distance of 100m from the RWY end, where the
right gear crossed the road, a destroyed tire tube was found, which
presumably belonged to the right gear front wheel.
At a distance of 160m from the RWY end smashed approach lights were
found, and after that point the gear wheel track started to diverge to the left
from the RWY centerline. The front gear wheel track further merged with
the left gear wheel track and extended joining the forward airframe track. At
a distance of 320 m from the RWY end another line of broken approach
lights were found. Airframe structures were found before the approach lights
(along the aircraft way). From that point small aircraft structure pieces were
found along the whole aircraft path. 40m past the destroyed approach lights
line a ditch of 0,5…1m in depth was found (with an underground pipeline)
which was crossing this area from the south to the north.
The south-eastern part of the aerodrome was fenced with a brick wall of
2,5m high and 0,4m thick with a concrete strip foundation. It went along the
RWY there. The aircraft collided with the fence at a distance of 820m from
the departure threshold (520m past the stop way end) with a heading of 105
degrees. The fence was destroyed throughout 70m.
Debris of the nose part of the airframe, cockpit, passenger seats, aircraft
cabin parts were found behind the fence. Earlier aerodrome employees,
police and medical services found at the site and evacuated crew bodies, as
well as killed and injured passengers. After the collision with the fence the
aircraft kept moving for 160 m with a heading of 105 degrees and came to a
stop at the road.

Layout of accident site:

23
Detailed description of aircraft, systems and engines damage

24
 After landing at the RWY13 the aircraft ran over the RWY at a high
speed. The aircraft passed the RWY end with breaking the protective net
barrier. Further the aircraft moved along the stop way deviating to the right
and then to the left at a soil road. There were tracks of aircraft movement at
the soil road after running over the RWY. The tracks looked like tracks from
the front, left and right landing gear wheels.

Photo 1. Tracks of aircraft movement over the dirt road after running over the RWY

Photo 2. Tracks of aircraft movement over the dirt road after running over the RWY

25
Due to emergency braking after running over the RWY the front right wheel
of the right main gear was destroyed. The aircraft ran over the RWY at a
speed of about 200 km per hour.
The aircraft moved to the right and broke several approach lights at a
concrete footing. When moving over a rough terrain due to a high speed,
the aircraft front gear was broken. At a distance of 350m from the
runway , there was a ditch 2m wide and 1m in depth. As the aircraft got
into the ditch at a speed of about 185 km per hour the front gear was
completely broken. Further the left main gear got into the ditch followed
by aircraft turning to the left. As the front gear was broken the aircraft
moved on sliding on the airframe nose. Further the aircraft hit the brick
wall concrete base 2,5 m high at a speed of 120 km per hour. This
resulted in destruction of the cockpit and the airframe up to frame 22 (6 th
seat row). The distance from the RWY end to the place of the collision
with the fence was 880m. Then the aircraft moved 160m more and came
to stop. There was no fire on board.
Wires of the power line passing outside the aerodrome were ruptured by
airframe structure elements.

The aircraft leaned on the tail part of the airframe with a little bank to the port
side. The flaps were fully extended, spoilers retracted, reverse flaps open; the
stabilizer was set 1,8 degrees pitch up.

26
 Photo 3. Aircraft post-accident overall view

During the accident the aircraft got sever damage as follows:

- The cockpit and the cabin up to the frame 22 (the 6th seat row) were
totally wrecked.
- The nose part and lower wing panels were heavily damaged.
- The right flaps (inner and outer) were sheared off.
- The left flap had got substantial damage.
- The front gear was torn out from the attachment points, between main
gears, between frames 58 and 62.
- The right main gear flap was sheared off.
- Main gears had major damage and the right gear front right wheel was
wrecked.
- Lower flaps of power units 1 and 4 and flap control elements had
significant damage.
- Control linkage was totally destroyed up to the airframe nose destruction

line; beyond this no damage found.

27
Photo 4. Airframe nose (destroyed up to frame 22)

Photo 5. Left wing structures damage

28
Photo 6. Right wing structures damage

Photo 7. Right (outer) flap’s damage

29
Photo 8. Front right gear (torn out of attachment points), destroyed right inner flap

Photo 9. Right main gear flap sheared off

30
Photo 10. Right main gear destroyed wheel

Photo 11. Power unit 1 reverse flaps

31
 Photo 12. Power unit 4 reverse flaps

Photo 13. Power unit 4 front power lever

32
 Photo 14. Power unit 4 rudder shackle of padlock

As the cockpit was completely destroyed it appeared not possible to

determine throttle positions, instrument data and switches positions.

All structure damages occurred once after the aircraft had run over the RWY,
when it was moving over terrain, and resulted from the collision with
obstacles (the ditch, lights concrete footing and brick wall). There were no
tracks of destruction resulting from fatigue.

No evidences of ailerons, rudders and elevator jamming were found. Spoilers

were in the retracted position. The flaps were fully extended.

The aft fuselage had no visible damage. The stabilizer setting was
changed by the crew during the landing run from 5,6 degrees pitch up to
1,8 degrees pitch up (according to the MSRP–64). The rudders were not
fixed. There was no stabilizer position indication on the fin.

33
 Photo 15. Stabilizer position – 1,8 degrees

1.13 Medical and pathological information:

Crew of this flight has valid medical license from Kazakhstan civil

Aviation Authority and they had not medical problem for the flight.

By considering to collision the airplane with the wall, flight crew and

front passengers have been injured by hitting it, and they have been dead,

because of this collision. After transferring bodies to the forensic medicine

of Mashhad, necessary pathological test were carry out ,and samplings

from the flight crew was done, and it was determined that they don't have

an especial deficiencies about using drugs and alcohol.

34
1.14 Fire:

After this accident, the ground safety of Mashhad Airport sent fire

extinguish vehicles to the site of this accident immediately, but they only

extinguished a small fire in plants and thorns of around the airplane caused

by friction, because there wasn't observed a considerable fire in the airplane.

As wreckage of the airplane has been located near the flammable gas line,

these vehicles have remained in this site until carrying out it to a safe place,

in order to prevent fire and explosion of the pipe.

1.15 Survival aspects:

After this accident, ground security and research & rescue units of

Shahid Hashemijejad Airport (Mashhad) began their efforts, in order to

allocate place of accident, to rescue passengers and crew. By considering to

condition of the region and location of the airplane outside of the airport,

there were taken necessary actions by cooperating ground safety and

extinguish staffs, and other research and rescue organs; the passengers were

evacuated from aircraft wreckage, and injured persons were transferred to

hospitals of Mashhad.

35
1.16 Test and Research:
None
1.17 Organizational and management information:

According to contents ATC records of Shahid Hashemijejad Airport

(Mashhad), after this accident, the control tower in Mashhad Airport has

reported this accident to the relevant authorizations, which there have been

taken necessary actions, in order to initiate search and rescue operation.

There have been carried out all actions about search and rescue,

transferring bodies to the forensic medicine of Mashhad and identify their

identity, flight crew and passengers.

1.19 Useful or effective investigation Techniques:

The standard and normal techniques were applied.

36
 2. ANALYSIS:
After joining landing course the flight altitude was 7000 ft, distance from
the RWY end 22 km. The aircraft was preceded by another aircraft
approaching to land, which had been cleared to land earlier. Being instructed
by a controller to reduce speed due to the proceeding traffic, approaching to
land, the captain decided to make left orbit and informed the crew about that.
Upon a navigator’s request the controller cleared to perform left orbit
maintaining 7000 ft.
No evidences of task sharing regarding flying the aircraft before
descending from the FL to approach to land were recorded. By some
navigator’s words one can judge that it was the captain who was the flying
pilot: Kolya, 7000, climb, climb Kolya!.
The aircraft landing weight was 93.7 tons. Data on the landing weight,
landing approach speed, approach chosen, and alternate aerodrome were not
voiced during the pre-landing preparation (not proceeding check list). After
joining landing course the controller cleared to descend to 6000 ft, at a
distance of 13 km from the RWY end. As the aircraft approached to the
RWY the navigator reported the distance: Distance 6, distance 5, flying
above. After crossing the 5 km distance the navigator without a captain’s
command read out the checklist: landing gear down, brakes, spoilers, altitude
selector. No answers to the voiced checklist points were recorded.
Further the navigator goes on counting distance: distance 2 km,
distance 1, altitude 40m. When passed distance 1 km, the co-pilot gave a
command (which was supposed to be given by the PIC) to set idle: “Idle”.
The flight engineer confirmed: “Idle”, but according to the MSRP-64 data
idle was set before the command. Flight speed along the glide path was 325
km/h, which was 50 km/h more than the assigned speed for a landing weight
of 93 tons. The rate of descent was 10 m/sec. During the descent the GPWS

37
warning activated several times. The RWY end was crossed at a height of 31
m and at a speed of 310 km/h.
At a height of 22m the flight engineer shifted trust reverses to a reverse
thrust position without a captain’s command. No report “Lever latched
lights on” about the shift was made. The landing was performed (according
to the calculation made) at a distance of 1000 m from the RWY threshold at
a speed of 275 km/h (instrument speed).
According to the MSRP record before landing the flight engineer
shifted engine’s 1 and 4 trust reversers to the forward thrust. After landing
and extending the front gear down, the co-pilot (it is a captain who should
give command) gave the command “Reverse”, without any monitoring by
either of them of engine trust reversers position indication at the instrument
panel. The flight engineer without checking out the thrust reverse lever
position and trust reversers position indication and reading back (“roger,
reverse on”) set throttles of engines 1 and 4 at the maximum trust.

Note: It should be noted that as for that aircraft type, if the reverse lever is
in the “Reverse” position, throttles cannot, due to their design, be set at a
position over the “Nominal” mode (80…90 degrees according to thrust
mode indicator).

The actual record of the MSRP-64 contained record of the flight mode
implied on engines 1 and 4, which is possible only in case reverse thrust
lever is set at the “forward thrust” mode. There was no reporting “reverse
engaged”.

38
 No command was given to activate spoilers, which were not extended
upon landing. The co-pilot set the stabilizer from 5, 6 degrees pitch up to 1, 8
degrees pitch up.
Just at the same time upon landing (2 seconds later) inner engines were
shut down by the flight engineer. Nevertheless the aircraft did not brake as
the trust reversers were shifted to forward thrust. The mode was maintained
for 12 seconds. According to navigator’s reports, which were consistent with
the MSRP record, the speed began to increase. The navigator informed the
crew about increase of speed. According to the MSRP a speed of 280
km/hour was reached. After the navigator informed about increase of the
speed, the flight engineer shut down engines no. 1 and 4.
The MARS-BM record contains crew members’ voices record: Co-pilot
– “Leaving”, Navigator – “Brakes”, Co-pilot – “Why isn’t reverse
functioning?” the PIC – “because flaps are not shifted”, Navigator –
“Emergency braking”.
MSRP-64 record contains multiple change of throttle position of
engines 2-3 and 1-4 before the flight mode, as well as shifting trust reversers,
but it was done with engines disengaged. Crew’s actions, engine parameters,
flaps position are consistent with the readout chart.
It should be noted that crew’s actions when landing did not comply with
the Crew Interaction and Procedure Instruction for the case of landing with
reverse engaged, under the Operating Manual of the IL-62 type (Tab 4.1).
Wheel Braking, including emergency braking, was not effective. The
aircraft ran over the RWY at a speed of 200 km/hour, deviated to the right
after the front right wheel tire of the front right gear blew out. Further on, it
broke some approach lights, with a concrete base, crossed the net barrier had
its front gear broken and then at a speed of 185 km/hour got into the ditch,
up to 1 m in depth and 2m in width, which traversed the aircraft’s path at an
angle, had its front gear broken down. Then due to its left gear getting into

39
the ditch as well, turned to the left facing the brick wall with a concrete
foundation. As the front gear was broken, the aircraft moved on its forward
fuselage and at a speed of 120 km/hour collided with the concrete foundation
of the brick wall 2,5 m high. As a result of the front impact the cockpit and
airframe up to frame 22 (6th seat row) were totally ruined. The crew and
some passengers, who were in the first cabin, were killed.
The aircraft moved on over the dirt for 160m, broke the power line and
came to a stop. There was no fire on the aircraft after the stop.
It should be noted that several accidents with aircraft IL62M took
place before, which occurred due to the lack of accurate interaction
between captain and crew during landing with thrust reverse involved.
In most cases these accidents were a result of non-authorized flight
engineer’s actions to shift engine trust reversers at heights more than these
recommended in the FM, followed by their shifting to forward thrust and
setting engines 1 and 4 at the flight mode. Another cause was an
unmonitored thrust lever position (not latched) and position of engine trust
reversers indication before setting engines at the maximum braking mode,
which resulted in running over the RWY.

Table 4.1. Il-62M crew interaction checklist to be fulfilled at landing

with thrust reverse engaged
Flight At the command of captain “Idle”, read it back and reduce
engineer engine power to idle.
PIC By the end of flaring at the idle mode give the command: “Shift
flaps” (with a glide path angle under 3 degrees 30 min. At a
height of no more than 5 m give the command “Shift flaps”
(with a glide path angle no more than 3 degrees 30 min)
Flight At the captain’s command “Shift flaps” read it back. Shift the
engineer reverse control lever of engines 1-2 from the position

40
 “REVERSE OFF” to the position “REVERSE ON”. Check by
the indication display whether the reverse flaps are shifted and
report “Lever latched lights on”.
PIC At a height of 1-2m, if necessary, give the command
“Reverse”. By the end of flaring prevent increase of pitch angle
and touch down the RWY by the main wheels. Upon landing
manipulating the rudder, match the aircraft axis with the RWY
centre line, put down at the RWY the front gear (in 2-3
seconds), give the command “Reverse” (if reverse was not
engaged earlier) and activate the front gear control. Fix the
control column in the “Push” position; give the command
“Spoilers”.
Flight On the captain’s command “Reverse” read it back, set engines
engineer 1 and 4 throttles at the maximum reverse thrust mode (to the
“Reverse” stop) and report: ”Reverse engaged”.
Upon the captain’s command “Spoilers” read it back, extend
spoilers to the maximum angle and report: “Spoilers extended”.
Make sure that the engines 1 and 4 parameters are consistent
with the reverse thrust mode.

41
THROTTLES AND THRUST REVERSE LEVER CONTROL
SYSTEM

Thrust reverse
lever

Nominal mode
stops

42
 Middle thrust
reverse lever
position latch

43
3. CONCLUSIONS:
3-1 Findings:

 The crew was not trained &acquainted with flight conditions in

the Iran territory with an Iranian instructor pilot and the operation
unit of Aria Airline has acted so weak regarding those mentioned
subjects.

 The approach speed of aircraft was higher than recommended

available airport charts & aircraft weight, however it was
controllable if the crew could proceed to land correctively.

 The crew had not done correct procedure according to the aircraft
Standard Operation Procedure (SOP) to use related check lists.
(Descend-Approach-Landing)

 There was lack of precise coordination between flight crew on

their self responsibility during the approach and landing.

 The flight crew did not pay attention to EGPWS warning, and did
not take corrective action.

 The crew did not use engine reverser and spoiler systems correctly
to reduce aircraft speed during the landing and consequently it
caused to loose long Runway distance.

 The flight crew had not good English language proficiency. And
they were poor in England language conversation.

 The Capitan of the aircraft as the pilot in command had not

sufficient force and efficient management in the cockpit.( lack of
Cockpit Resource Management).

 There were unauthorized actions of flight engineer for shifting

engine reversers as well as lack of mutual oversight by crew
members in checklist accomplishment during approach and landing.
 The crew has had disagreement about “Go around” due to
unsuitable landing situations.

 Presence of General Director of airline in the cockpit had adverse

psychological effect on crew efficiency behaviors.

44
  The DETA airline did not use correct procedure to extend engines
No; 1-2-4 life time from Ukrainian company (Aerotechservice
co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

3-2 Main Cause :

Considering those items in factual information and analysis, the main cause
of this accident is “weak Cockpit management between the crew” to use
correct landing techniques same as releasing Engine trust reversers –
Engine shut down in unsuitable time - ….

3-3 Contributive Factors :

Some of contributive factors for this accident occurrence are noted as:

 The copilot and the flight engineer had self activity& decision without
the (PIC) coordination.

 The cockpit crew was careless and not paying proper attention toward
EGPWS warning.

 Psychological adverse effect on cockpit crew because of presence of

General Director of Aria airline

3-4 Violation &other deficiencies:

The accident investigation team encountered some violations and

deficiencies with ICAO Standards and Iran Local Authority regulation
(CAO) which are descript as:
 Poor and in-sufficient supervision controlled of operation &technical
manger of Aria Airline.

 The DETA airline has not used proper procedure to receive life time
extension of engine and has not passed necessary information to
Iranian and Kazakhstan Authorities.

 It has not been designed a headset for flight engineer to make more
coordination between the crew, by the aircraft design bureau.

 The crew was not familiar with Iranian AIP completely.

 The total on board persons was not according to written load sheet.

45
4- SAFETY RECOMMENDATIONS:

In order to prevent the similar events, the Aircraft Accident Instigation

&Safety of IRI CAO recommends:

 .A special working group (Board) between Iranian airlines which used

Russian leased aircraft and Russian airlines, be established and study
how to obtain life extensions and modifications from Russian
authorities as a state of design & manufacture.

 Those Iranian airliners that are willing to have foreign pilots shall
provide training courses, such as Iran routs and necessary
arrangements for crew members just before beginning of their flights.

 All foreign pilots should be checked by a related instructor pilot or a

CAO designee pilot.

 The IL-62 cockpit should be equipped with flight engineer headset by

the ILYUSHIN Design Bureau.

 The ILYUSHIN Design Bureau should study and investigate why

ELT has not activated by the sever impact.

 Presence and entering passengers or any other persons than crew

should really be forbidden during landing and take off by airlines.

 The Interstate Aviation Committee (MAK) and Aircraft Accident

Investigation Department of IRI CAO should deliver notified findings
of this accident to related airlines.

 It is recommended that a correct procedure of foreign pilot operation

in the Iran territory should be defined by operation department of IRI
CAO with cooperation of airlines.

 All airlines that are willing to use leased aircrafts should have

sufficient supervision just before to start operation, should check and

accomplish the written MOU between authorities and also consider
those items in "Art 83 Bis ".

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