The crash of a Yak-42D on May 26, 2003, can be summed up in one sentence: “Military charter hazards and the convention of nil responsibility for safety and standards.” The Spanish peacekeepers aboard the flight had survived the tour in Afghanistan, but not the flight home as a consequence.
The international commission of four participating nations has provisionally approved the investigator’s draft report covering the crash into mountainous terrain near Trabzon Airport, on the shore of the Black Sea in northeast Turkey. All 75 persons on board perished.
The aircraft was a military charter carrying 62 Spanish troops back to Zaragoza, Spain, after a four month NATO peacekeeping mission in Kabul, Afghanistan. The crash was the third of a Ukrainian-operated jet within six months. The aircraft was operated by Ukrainian-Mediterranean Airlines (UM Air) and carried two crews. Staging from Kabul, it had departed Manas Airport, Bishkek (Kyrgystan) at 2012 hours GMT and crashed at 0145 hours GMT (0445 local) near the town of Macka, 50 kilometers South of Trabzon, following a second approach attempt in fog. The Spanish defense ministry had hired the airline, which runs charter flights for Egypt, Greece, Italy, Lebanon, Spain and Turkey.
Unlandable weather
The weather for the flight’s arrival was visibility better than 10 kilometers, rain showers, and clouds scattered at 800 feet above ground level. Notably, although the visibility code was declaring visibility not to be a problem, the dewpoint and temperature were close enough together for advection fog to quickly form – the wind falling off before dawn at a coastal airfield – and this is what happened. Unfortunately, faulty planning had led to the flight to being unintentionally grounded at Bishkek during that airfield’s promulgated hours of closure (1400 hours to 2000 hours GMT).
Even though there is an instrument landing system (ILS) and high intensity approach lighting on runway 11 at Trabzon, once the fog had clamped down, visibility was nil and a successful arrival in those conditions was impossible. A later arrival time, after any fog would have burned off, would have presented much better circumstances.
Operational deficiencies
Just before impact, in a final conversation with air traffic control (ATC), it was apparent that another more senior pilot had intervened and that the aircraft had increased power in an attempt to climb above the 11,500-foot Minimum Safe Altitude. However, the investigators could not be certain, as the cockpit voice recorder (CVR) had been unserviceable. In addition, there was no data to be had from the flight data recorder (FDR), and the aircraft was not fitted with a Ground Proximity Warning System (GPWS). It is assumed from the crash position of around 30 nautical miles south of Trabzon that the crew could have been, in fact, not about to try a further futile approach but were departing for an alternate site: Ankara, or possibly T’bilisi, Georgia, or Yerevan, Armenia. There was an unexplained gap of seven minutes in communications with ATC so this could not be confirmed. However, ATC did confirm that the crew did not act as last cleared.
The possibility exists that the more senior captain may have claimed command and that there was a crew changeover under way during the seven minutes of silence with ATC, shortly after which the aircraft crashed. The Spanish member of the commission claimed that the crew would not have had the fuel they expected to have. Fuel usage records from the FDR were unavailable, but according to the report, the airplane should have had fuel to divert to an alternate airport, “because they had filled the tanks at Manas.” However, Spain alleges that, in calculating their reserve fuel, the pilots used tables not prepared for the Yak-42D, but for another Yak-42 model that reflected much lesser fuel consumption rates.
The Spanish commission member indicated in a dissent that the crew would only have had the fuel (5,000 liters) to divert if they’d not attempted the approach at all. In fact, if they had not crashed, and had attempted to divert to their planned alternate, Ankara, they could not have arrived there – or at least not with anything approaching the reserve fuel that international norms demand.
The commission also concluded that the flight crew was likely extremely fatigued. In a 2003 statement, Spanish Defense Minister Federico Trillo had claimed: “The accident crew flew into Bishkek and Trabzon, where they crashed, after having flown for 17 hours and 15 minutes.”
Investigators, however, established that the unanticipated enforced stopover at Bishkek had led to the crew having been subjected to 23 hours and 26 minutes of awake activity. The maximum crew duty time under Ukrainian regulations is 18 hours.
The report further maintains that the pilots “had not been familiarized with the airport” and that it was an especially difficult approach. This was due to the runway being situated between the sea and a mountain range and in an environment that lacked, but definitely needed, an operating approach radar. The Ukrainian representatives reassured the commission that the two pilots had made previous flights to Trabzon in a Tupolev 154, but did not tender any documentary evidence of this. UM Air, the report emphasizes, did not conduct any personal crew resource management (CRM) training nor controlled flight into terrain (CFIT) indoctrination that would have enabled to the crew to act in a coordinated manner in the critical situation that arose after their missed approach and climb to level at 6,000 feet. In addition, the crew had been stuck with an unexpected delay of five hours at their departure point of Bishkek (Manas airport), where they’d only planned an average hour-long refueling stop.
Pilot error
Consequently, after the second frustrated landing approach, “their compelling desire to land because of their fatigue,” argues the report, produced in the pilots a disorientation or “loss of direction.” This took them toward the 10,000-foot mountains instead of away from them via the missed approach procedure. A scant few seconds before crashing, the radio altimeter warned them of the proximity of the ground, the report adds.
However, the crew did not respond to that, as they were convinced that they were flying over the adjacent sea. The investigators recognized that they had only been able to make suppositions on what had happened in those final moments inside the cockpit. This was because of the fact that only 30 seconds of their final radio responses were recorded by ATC, since the CVR was not working.
The report states that the departure of the airplane with a “damaged” CVR “was prohibited” by Ukrainian regulations and yet it was found that the CVR had been unserviceable for at least 45 days. This was confirmed because the last recording clearly corresponded to a flight on April 11, 2003. The commission concluded that the Yak-42 should never have taken off and also that the crew did not make the required pre-flight check of the CVR, although it was mandatory.
Misidentification
Due to the munitions that were being carried, there were protracted explosions following the crash. Consequently, there was no rescue attempt possible and identification of the bodies had to rely heavily upon DNA. Three top Spanish generals were replaced after it was discovered that at least 22 bodies (and likely more) had been sent to the wrong families. In some cases, exhumations disclosed that remains from more than one soldier ended up in some caskets. It was finally officially admitted that only 17 soldiers had in fact been correctly identified.
Of the “misidentified,” 14 had already been cremated. Additionally, families had been told by their sons that the aircraft they were being ferried on was in very poor condition. Spain’s center-right newspaper, El Mundo, reported that Commander Jose Antonio Fernandez complained about the state of the plane to his wife in a telephone conversation minutes before climbing aboard. The Spanish troops had complained that cargo had not been secured, that the pilots couldn’t speak proper English, and that tires on the plane’s landing gear were excessively worn. They also complained of loose panels and loss of oil from the aircraft. It was clear that the Ukrainian aircraft was among the cheapest on offer in an increasingly competitive market that competes for UN and NATO charter roles.
NATO officials in Spain insisted that it was not up to them to oversee or inspect the safety of the aircraft, that this was up to the Ukrainian authority. Inquiries quickly subsided after it was determined that any scandal might cause inquiries into the lucrative NATO contracting procedures. Senior NATO officials regard these “available” aircraft as the real “workhorses” for peacekeepers in the region. NATO is preparing to sign a $1 billion contract for the charters through to 2010, i.e., until the European Airbus A400M enters the picture. However, quite incongruously, three Spanish C-130’s arrived at Trabzon to retrieve the 62 bodies, and Spain has quietly decided not to make further use of former Soviet bloc aircraft charters.
Other nations safety concerns
Up until July 18, 2003, it remained uncertain which, if any, company would be responsible for insurance claims. It was revealed that safety concerns had existed among many European nations that had used the UM Air aircraft. Investigators discovered that the Finnish Armed Forces had cancelled a similar contract the previous February. Lt. Col. Kimmo Salomaa said that, “they used this type of plane, but the contract was terminated because of mounting concerns over poor maintenance.” Norwegian Armed Forces spokesman Brigadier Finn Hannestad said that they had also stopped using the planes because they failed to meet international safety standards.
A Norwegian explosives expert who’d made the trip to Kabul in September 2002 said, “To travel in that aircraft was more dangerous than deactivating mines.” In December 2002, an AN-140 had crashed in Iran, killing 44, mostly Ukrainians. On May 9, 2002, 160 unrestrained people spilled out the back of an IL76MD after a cargo door accidentally opened in flight. That aircraft was chartered from Ukrainian Cargo Airways via the Ukrainian Ministry of Defense. On Jan. 31, 2003, a UN-chartered IL76TD had been destroyed in a CFIT at Bucau, East Timor, in very similar circumstances to the accident in Turkey.
Six agencies involved in NATO’s hiring of crashed Yak-42
On May 25, 2005, the Spanish minister of defense reported: “Six different agencies had been involved in the hiring of a UM Air Yakovlev 42 plane to transport Spanish peacekeeping forces back home from Afghanistan.” He argued that this was a factor in the accident, in addition to the preliminary conclusions drawn by the international accident investigation committee. Reportedly poor CRM, improper inflight planning and crew fatigue were responsible for the May 2003 accident near Trabzon, Turkey.”
The legacy of the continuing failure to assume responsibility for monitoring military charter aircraft serviceability and airworthiness has yet to play out in the Spanish Courts. The final 70-page detailed report (in English) is expected to be published shortly.