Final Report Boeing 747-412F TC-MCL - SKYbrary Aviation
Final Report Boeing 747-412F TC-MCL1This document is an English translation of the Final Report on the fatal accident involving theBoeing 747-412F aircraft registered TC-MCL that occurred on January 16th, 2017 at ManasInternational Airport, Bishkek, Kyrgyz Republic.The translation was done as accurate as a translation may be to facilitate the understanding ofthe Final Report for non-Russian-speaking people. The use of this translation for any purposeother than for the prevention of future accidents could lead to erroneous interpretations.In case of any inconsistence or misunderstanding, the original text in Russian shall be used asthe work of reference.INTERSTATE AVIATION COMMITTEEAIR ACCIDENT INVESTIGATION COMMISSIONFINAL REPORTON RESULTS OF THE AIR ACCIDENT INVESTIGATIONType of occurrenceFatal accidentType of aircraftBoeing 747-412FRegistration markTC-MCLOwnerLCI Freighters One Limited (Ireland)OperatorACT AirlinesAviation AuthorityDirectorate General of Civil Aviation of Turkey(Turkish DGCA)Place of occurrenceNear Manas International Airport, Bishkek, KyrgyzRepublic, coordinates: N 43 03.248' E 074 2.271'Date and time16.01.2017, 07:17 local time (01:17 UTC),night timeINTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL21.FACTUAL INFORMATION . 101.1.1.2.1.3.1.4.1.5.1.19.HISTORY OF FLIGHT. 10INJURIES TO PERSONS . 11DAMAGE TO AIRCRAFT . 11OTHER DAMAGE . 26PERSONNEL INFORMATION . 271.5.1.Crew Members Information . 271.5.2.ATC Personnel Information . 29AIRCRAFT INFORMATION . 31METEOROLOGICAL INFORMATION . 35AIDS TO NAVIGATION, LANDING AND ATC . 41COMMUNICATION AIDS . 48AERODROME INFORMATION . 481.10.1.Aerodrome Equipment . 491.10.2.Electrical and Airfield Lighting Support Equipment . 49FLIGHT RECORDERS. 55INFORMATION ON CONDITIONS OF AIRCRAFT FRAGMENTS AND THEIR LOCATION AT THE ACCIDENT SITE . 58MEDICAL INFORMATION AND SHORT SUMMARY OF AUTOPSY EXAMINATION RESULTS . 67SURVIVAL ASPECTS . 67SEARCH AND RESCUE OPERATIONS . 68TESTS AND EXAMINATIONS . 691.16.1.Fuel samples examination . 691.16.2.FCC examinations . 691.16.3.Flight test of the ILS . 70INFORMATION ON ACCIDENT-RELATED ORGANIZATIONS AND ADMINISTRATIVE ACTIVITIES . 70ADDITIONAL INFORMATION . 711.18.1.On amendments to training programs, procedures and related documentation of ACTAirlines71NEW METHODS, USED DURING INVESTIGATION . 722.ANALYSIS . 733.CONCLUSION . 1154.SHORTCOMINGS, REVEALED DURING THE INVESTIGATION . 1175.SAFETY RECOMMENDATIONS. .16.1.17.1.18.INTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL3ABBREVIATIONSAC Advisory CircularACP Audio Control PanelAD Airworthiness DirectiveAFCS Automatic Flight Control SystemAFDS Autopilot Flight Director SystemAFM Aircraft Flight ManualAGL Above Ground LevelAIP Aeronautical Information PublicationALT AltitudeAMC Aeronautical Meteorological CentreA/P AutopilotAPU Auxiliary Power UnitAS Aerodrome ServiceARP Aerodrome Reference PointASS Aviation Security ServiceATC Air Traffic ControlATS Air Traffic ServiceCAS Calibrated AirspeedCAT CategoryCDU Control Display UnitCG Center of Gravitycd Candela (unit for measuring light intensity)cm centimeterCRM Crew Resource ManagementCVR Cockpit Voice RecorderDFCS Digital Flight Control SystemDA Decision AltitudeDA(H) Decision Altitude (Height)DFDAC Digital Flight Data Acquisition CardDFDR Digital Flight Data RecorderDGCA Directorate General of Civil Aviation (Turkey)INTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL4DH Decision heightDME Distance Measuring EquipmentDNA Desoxyribonucleic acidE Eastern longitudeEFIS Electronic Flight Instrument SystemEGPWS Enhanced Ground Proximity Warning SystemEICAS Engine Indication and Crew Alerting SystemELP English Language ProficiencyELT Emergency Locator TransmitterERFSS Emergency Rescue and Fire Protection Flight SupportServiceFAA Federal Aviation Administration, USAFAF Final Approach FixFCC Flight Control ComputerFAP Final Approach PointFAR Federal Aviation RegulationsFCT-747 (TM) Boeing 747 Flight Crew Training ManualFCOM Flight Crew Operations ManualFCTM Flight Crew Training ManualFD Flight DirectorFDR Flight Data RecorderFIR Flight Information RegionFL Flight LevelFLTA Forward looking terrain alertingFMA Flight Mode Annunciator (on PFD)FMC Flight Management ComputerFO First Officerft feetft/min feet per minuteGCU Generator Control UnitGS Glideslopeh hourINTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL5HAT Height Above Terrain, Height Above TouchdownHF High frequencyHPC High Pressure CompressorHz HertzIAC Interstate Aviation CommitteeIAS Indicated air speedICAO International Civil Aviation OrganizationIDG Integrated Drive Generatorilleg illegibleILS Instrument Landing SystemIRS Inertial Reference SystemIST Ataturk Airport, Istanbul (IATA Code)JED King Abdulaziz International Airport, Jeddah, SaudiArabia (IATA Code)КАIK Accident Investigation Board, Turkeykg kilogramkm kilometerkt knotkVA kilovolt-ampereLH Left-handLIM Localizer Inner MarkerLOC LocalizerLTD LimitedLOM Localizer Outer MarkerIATA International Air Transport AssociationICAO International Civil Aviation OrganizationIFR Instrument Flight RulesILS Instrument Landing SystemIOSA IATA Operational Safety AuditLPC Line Proficiency Check or Low Pressure Compressor (bycontext)LPT INTERSTATE AVIATION COMMITTEELow Pressure Turbine
Final Report Boeing 747-412F TC-MCL6LTBA Ataturk Airport, Istanbul (ICAO Code)m meterMAP Navigation display modeMCP Mode Control PanelMDH Minimum Decision HeightMETAR Meteorological Aerodrome ReportMFD Multifunction DisplayMHz megahertzmin minutemps meters per secondMSN Manufacturer Serial NumberN Northern latitudeN/A Not applicableND Navigation Displaynm nautical mileNOSIG No significant changesNTSB National Transportation Safety Board, USAOM Operations ManualOPC Operational Proficiency CheckOPER OperationOVI-I Level I High-Intensity Lighting SystemOVI-II Level II High-Intensity Lighting SystemPAPI Precision Approach Path IndicatorPF Pre-flightPFD Primary Flight DisplayPIC Pilot-in-CommandPLC Public Limited Liability CompanyQFE Atmospheric pressure at runway thresholdQNH Mean sea level pressureQRH Quick Reference HandbookRH Right-handRVR Runway Visual RangeINTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL7RWY RunwaySB Service BulletinSOP Standard Operating ProceduresSN Serial NumberSSFDR Solid State Flight Data RecorderSTAR Standard Arrival ChartTAF Terminal Aerodrome ForecastTCF Terrain Clearance FloorTDZ Touchdown ZoneTEM Threat and Error ManagementTM Training ManualTOGA Takeoff/Go-aroundTOW Takeoff WeightTSO Time Since OverhaulTWY TaxiwayUCFM Manas Airport, Bishkek (ICAO Code)US United StatesUSA United States of AmericaUTC Universal Time CoordinatedV voltVHF Very High FrequencyVHHH Chek Lap Kok Airport, Hong Kong (ICAO Code)VOR/DME VHF Omnidirectional Range/Distance MeasuringEquipmentWGS INTERSTATE AVIATION COMMITTEEWorld Geodetic System
Final Report Boeing 747-412F TC-MCL8SynopsisOn 16.01.2017, at 07:17 local time (01:17 UTC)1, at night time, , a fatal accident occurredto the cargo Boeing 747-412F aircraft, registration mark TC-MCL, operated by ACT Airlines,which was performing the THY6491 flight in order to transport the cargo from Chek Lap KokAirport (VHHH, Hong Kong) via Manas Airport (UCFM, Bishkek) to Ataturk Airport (LTBA,Istanbul). During the landing at Manas International Airport (Bishkek city, the Kyrgyz Republic).There were 4 crew members (all being citizens of the Republic of Turkey) and 85618 kg of cargoon board the aircraft.As a result of the accident and the post-crash ground fire, the aircraft was completelydestroyed. The 4 persons on board and 35 local residents on the ground were killed. Other 36residents on the ground received injuries of varying severity, 38 buildings were destroyed ordamaged.The information on the accident occurrence was received by the IAC at 07:00 on16.01.2017.The investigation was conducted by the Investigation team, appointed by Order No.1/814-rof the Chairman of Air Accident Investigation Commission, IAC, dated 16.01.2017.In compliance with ICAO Annex 13, the notification on the accident was sent to theNational Transportation Safety Board (NTSB), the accident investigation competent authority ofthe State of Aircraft Design and Manufacture (USA), as well as to Accident Investigation Board(KAIK), the accident investigation competent authority of the State of Registry and Operator (theRepublic of Turkey)2. The USA and Turkey appointed their Accredited Representatives toparticipate in the investigation.The NTSB, US Federal Aviation Administration (FAA), aircraft design and manufacturingcompany (the Boeing Company, USA), KAIK, DGCA and ACT Airlines representativesparticipated in the investigation.The investigation was launched on 16.01.2017.The investigation was completed on February 17.02.2020Initial actions at the accident site (securing the accident site, clearing the debris, evacuatingthe killed and injured) were performed by the Ministry of Internal Affairs and the Ministry ofEmergency Response of the Kyrgyz Republic.1Hereinafter, the UTC is used, the local time is UTC 6 h.On 10.01.2019, KAIK was reorganized into the Transport Safety Investigation Board, UEIM.INTERSTATE AVIATION COMMITTEE2
Final Report Boeing 747-412F TC-MCL9When completing the Final Report, the investigation team took into account informationprovided by the Ministry of Internal Affairs and Ministry of Emergency Response of the KyrgyzRepublic.The aircraft fragments were removed from the accident site and were handed over forcustody to the administration of Manas Airport.Preliminary judicial investigation was conducted by the Ministry of Internal Affairs of theKyrgyz Republic.INTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL1.Factual Information1.1.History of Flight10On 16.01.2017, the crew of the Boeing 747-412F TC-MCL aircraft was performing aTHY6491 flight from Hong Kong via Bishkek (Manas Airport) to Istanbul (Ataturk Airport) inorder to transport the commercial cargo (public consumer goods) of 85 618 kg. The cargo wasplanned to be offloaded in Istanbul (Ataturk Airport). Manas Airport was planned as a transitairport for crew change and refueling.From 12.01.2017 to 15.01.2017, the crew had a rest period of 69 h in a hotel in Hong Kong.The aircraft takeoff from the Hong Kong Airport was performed at 19:12 on 15.01.2017,with the delay of 2 h 02 min in respect to the planned takeoff time. During the takeoff, the climband the on-route cruise flight, the aircraft systems operated normally.At 00:41, on 16.01.2017, the aircraft entered the Bishkek ATC Area Control Center overthe reference point of KAMUD at flight level of 10 400 m (according to the separation system,established in the People's Republic of China). At 00:51, the crew requested a descent and reachedthe FL 220 (according to the separation system, established in the Kyrgyz Republic). At 00:59, thecrew received the weather information for Manas Airport: "the RVR at the RWY threshold 400 m,the RWY midpoint and RWY end 300 m, the vertical visibility 130 ft"3. At 01:01, the crew receivedthe specified data: " in the center of the runway RVR three zero zero meters, vertical visibility onefive zero feet."At 01:03, the crew requested a descent, the controller cleared for the descent not belowFL 180. At 01:05, the crew was handed over to the Approach Control. At 01:06, the crew wascleared for the descent to FL 60, TOKPA 1 ILS approach chart, RWY 26. At 01:10, the controllerreported the weather: wind calm, visibility 50 m, RVR 300 m, freezing fog, vertical visibility160 ft, and requested the crew if they would continue the approach. The crew reported that theywould continue the approach.The crew conducted the approach to RWY 26 in accordance with the standard approachchart. At 01:11, the controller informed the crew: " transition level six zero" and cleared themfor the ILS approach to RWY 26.At 01:15, the crew contacted the Tower controller. The Tower controller cleared them forlanding on RWY 26 and reported the weather: " wind calm RVR in the beginning of the runwayfour hundred meters, in the middle point three hundred two five meters and at the end of the runwayfour hundred meters and vertical visibility one six zero. feet".3Hereinafter, if not indicated otherwise, the original author's edition is preserved in the quoted documents.INTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL11The aircraft approached the RWY 26 threshold at the height significantly higher than theplanned height. Continuing to descend, the aircraft flew over the entire length of the RWY andtouched the ground at the distance of 900 m away from the farthest end of the runway (in relationto the direction of the approach) (the RWY 08 threshold). After the touchdown and landing roll,the aircraft impacted the concrete aerodrome barrier and the buildings of the suburban settlementand started to disintegrate, the fuel spillage occurred. As a result of the impact with the groundsurface and the obstacles, the aircraft was completely disintegrated, a significant part of the aircraftstructure was destroyed by the post-crash ground fire.At 01.17 UTC, the Tower controller requested the aircraft position, but the crew did notrespond.1.2.Injuries to 00/00/0Injuries to PersonsMinor/None1.3.Damage to AircraftThe aircraft airframe disintegrated into multiple fragments, the largest of those were foundat the accident site in the last third part of the aircraft's ground movement trajectory.The ground fire bed is found in the central fuselage area on the line in-between theseparated tail section and cockpit (Figure 1).4Injured and killed persons on the ground.INTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL12Figure 1. Main fire bed (indicated by yellow dashed line)FuselageThe aircraft fuselage is torn into several fragments, the largest fragments are: the cockpit,extending from Frame 1 to Frame 5; the tail section (the fin and the horizontal stabilizer withrudder and elevator); the APU compartment.The cockpit is damaged. The pilots' and observer's seats have been torn off their standardpositions.WingThe RH wing section and the LH wing section disintegrated (Figure 2 and Figure 3).Figure 2. RH wing fragmentINTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL13Figure 3. LH wing fragmentThe structural elements, mounting the RH wing section to the fuselage, have beendestroyed by the off-design stress loads, and the LH wing mounting elements have been destroyedby the thermal impact. The central wing section has been destroyed by the fire.Fin and horizontal stabilizerThe fin and the horizontal stabilizer (Figure 4) have been found attached to the tail fuselagesection, extending from the aft pressure bulkhead to the tail cone. The leading edges of the fin andthe rudder show damage caused by the terrain impact. No traces of fire or soot have been found.Figure 4. Tail fuselage sectionINTERSTATE AVIATION COMMITTEE
Final Report Boeing 747-412F TC-MCL14The horizontal stabilizer fragment has remained in its standard position and has been foundat the accident site in the turned-over position. The center box section, connecting the two parts ofthe stabilizer, the stabilizer trim drive mechanism and the jackscrew show no outer damage. Theleft part of the stabilizer and the elevator have been damaged as a result of the impact with theobstacles, part of the assembly is missing. The right part of the stabilizer has remained in itsstandard position and shows damage.Landing gearThe main landing gear – the left wing gear, the left body gear, the right body gear and theright wing gear – separated from the airframe as a result of the impacts with the concrete aerodromebarriers and the obstacles at the area adjacent to the aerodrome.Along the aircraft movement trajectory, the following landing gear fragments have beenfound:- the right body gear has been torn off its mounting points and is found at the distance ofapproximately 100 m away from the point of the impact with the obstacles, further to the right, inthe direction of the aircraft movement trajectory. The landing gear bogie (with the axle and thetwo rear wheels) has remained in its standard position attached to the gear extension/retractioncylinder rod. The front bogie axle still houses the brakes, the tyres have disintegrated. Nearby, thedestroyed wheel tyres and the torn-off bogie fragment of the other landing gear have been found.At the various distances, to the right and to the left of it, the braking devices, the tyres and thewheels attached to the
INTERSTATE AVIATION COMMITTEE This document is an English translation of the Final Report on the fatal accident involving the Boeing 747-412F aircraft registered TC-MCL that occurred on January 16th, 2017
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