A Boeing 747-412F cargo plane was destroyed after impacting terrain near Bishkek-Manas International Airport (FRU). All four crew members and 35 persons on the ground were killed.

Flight 6491 departed Hong Kong on a cargo service to Istanbul, carrying a load of 85618 kgs. An en route refueling and crew change stop was planned at Bishkek, Kyrgyzstan. Weather at Bishkek was poor with winds from 60°at 1 m/s and a visibility (RVR) of 400m at the beginning of the runway; 350m at the mid-point and 400m at the end of the runway. Vertical visibility was 50 m. Air temperature was -9°C, dew point -10°C, pressure (QNH) was 1023,9 hPa.

The initial descent towards Bishkek was normal. The crew contacted Approach Control at 07:06 hours and were cleared for a descent to FL060 as per TOKPA 1 STAR (Standard terminal arrival route). The aircraft overflew the TOPKA reporting point at 07:11 at FL092 while in descent. According to the approach chart, FL060 or above should be reached when overflying TOKPA.

Shortly afterwards the controller cleared the flight for an ILS approach to runway 26. At 07:12 the controller cleared the crew for further descent to altitude 3400 ft. The aircraft was meanwhile crossing FL074. The crew was busy monitoring the flight altitude and was aware they were higher than the STAR chart.

The localizer was capture at 3600 ft agl. At that time the altitude should have been 1345 ft agl (3400 ft amsl).

At 07:15:21 after the crew confirmed capturing the localizer, the flight was handed over to Tower Control.

At a distance of 1.7 nm the aircraft reached 3400 ft amsl and the ALT HOLD OPER autopilot mode was engaged longitudinally. At that point the flight was already over 400 ft above the glideslope. The glideslope mode was armed (G/S MODE ARM), but the glideslope was not captured.

At 07:15:31 while the aircraft was in level flight at 3400 ft amsl Outer Marker overflight was recorded (as per the approach chart Outer Marker overflight altitude is 2800 ft amsl).

A glideslope signal was captured at 07:15:52, at that time the aircraft was almost over VOR/DME MANAS at a distance of approximately 1.1 nm from the runway 26 threshold, at an angle of approximately 9°. However, as per the approach chart, the rated glideslope angle is 3°. The aircraft automatically initiated descent with a vertical speed of up to 1425 ft/min.

Six seconds after the glideslope capture LAND 3 autoland status annunciation was recorded. The crew called out the annunciation.

At 07:16:01 at 3300 ft amsl the aircraft crossed the Middle Marker (as per the approach chart MM overflight altitude is 2290 ft amsl). After the glideslope descent was initiated the glideslope pointer was fluctuating within - 4 to + 4 dots.

At 07:16:07, at 3150 ft amsl, AP CAUTION and FMA FAULT 2 events were recorded. These events were continuously recorded almost until the end of the flight. An FMA FAULT 2 means that the autopilot can no longer track the actual glideslope, but will track a constant 3° glide path until a valid glideslope signal is regained or until the crew intervenes by disengaging the autopilot or initiating a go-around.

As the aircraft was descending LAND 3 status degraded to LAND 2, which was confirmed by the crew callout. LAND 2 means that the autopilot flight director system redundancy is reduced to the use of only two of the three autopilots.

The EGPWS 'Glideslope' alert was then triggered 5 times.

At 07:17:04 the flight crossed the runway 26 departure end at a height of about 110 ft. Decision height was 99 ft. The FO then called "Minimums" and the captain informed that there was no visual contact and called to go-around.

At 58 ft radar altitude the TOGA switch was pushed and engine power increased. 3.5 seconds after the TOGA switch had been pushed the aircraft hit slightly upsloping terrain and obstacles. The ground speed at the time of impact was 165 kt. The maximum recorded vertical acceleration was 6 g.

Initial impact occurred at a distance of approximately 930 m from the runway 26 departure end. It collided with a concrete airport fence and rolled into a holiday village. The aircraft broke up and spilt fuel caught fire.

Probable Cause:

Conclusion:

The cause of the Boeing 747-412F TC-MCL aircraft accident was the missing control of the crew over the aircraft position in relation to the glideslope during the automatic approach, conducted at night in the weather conditions, suitable for ICAO CAT II landing, and as a result, the measures to perform a go-around, not taken in due time with the aircraft, having a significant deviation from the established approach chart, which led to the controlled flight impact with terrain (CFIT) at the distance of 930 m beyond the end of the active RWY.



The contributing factors were, most probably, the following:

- the insufficient pre-flight briefing of the flight crew members for the flight to Manas aerodrome (Bishkek), regarding the approach charts, as well as the non-optimal decisions taken by the crew when choosing the aircraft descent parameters, which led to the arrival at the established approach chart reference point at a considerably higher flight altitude;

- the lack of the crew's effective measures to decrease the aircraft vertical position and its arrival at the established approach chart reference point while the crew members were aware of the actual aircraft position being higher than required by the established chart;

- the lack of the requirements in the Tower controllers' job instructions to monitor for considerable aircraft position deviations from the established charts while the pertinent technical equipment for such monitoring was available;

- the excessive psycho-emotional stress of the crew members caused by the complicated approach conditions (night time, CAT II landing, long-lasting working hours) and their failure to eliminate the flight altitude deviations during a long time period. Additionally, the stress level could have been increased due to the crew's (especially the PIC's) highly emotional discussion of the ATC controllers' instructions and actions. Moreover, the ATC controllers' instructions and actions were in compliance with the established operational procedures and charts;

- the lack of the crew members' monitoring for crossing the established navigational reference points (the glideslope capture point, the LOM and LIM reporting points);

- the crew's failure to conduct the standard operational procedure which calls for altitude verification at the FAF/FAP, which is stated in the FCOM and the airline's OM. On the other hand, the Jeppesen Route Manual, used by the crew, contains no FAF/FAP in the RWY 26 approach chart;

- the onboard systems' "capture" of the false glideslope beam with the angle of 9°;

- the design features of the Boeing 747-400 aircraft type regarding the continuation of the aircraft approach descent in the automatic mode with the constant descent angle of 3° (the inertial path) with the maintained green indication of the armed automatic landing mode (regardless of the actual aircraft position in relation to the RWY) while the aircraft systems detected that the glideslope signal was missing (after the glideslope signal "capture"). With that, the crew received the designed annunciation, including the aural and visual caution alerts;

- the absence of the red warning alert for the flight crew in case of a "false" glideslope capture and the transition to the inertial mode trajectory, which would require immediate control actions from the part of the crew;

- the lack of monitoring from the part of the crew over the aircraft position in regard to the approach chart, including the monitoring by means of the Navigation Display (ND), engaged in the MAP mode;

- the crew's failure to conduct the Airline's Standard Operational Procedures (SOPs), regarding the performance of the go-around procedure in case the "AUTOPILOT" (the AP switching to the inertial mode) and "GLIDESLOPE" (the EGPWS annunciation of the significant glideslope deviation) alerts during the automatic CAT II landing at true heights below 1000 ft (with no visual reference established with either the runway environment or with the lighting system);

- the delayed actions for initiating the go-around procedure with no visual reference established with the runway environment at the decision height (DH). In fact, the actions were initiated at the true height of 58 ft with the established minimum of 99 ft.

Accident investigation:

Investigating agency: MAK Status: Investigation completed Duration: 3 years and 2 months Accident number: Final report Download report: Final report

Classification:

Sources:

METAR Weather report:

UCFM 160100Z VRB01MPS 0050 R26/0300N FZFG VV001 M09/M10 Q1023 R26/19//60 NOSIG

01:00 UTC / 07:00 local time:

UCFM 160130Z VRB01MPS 0150 R26/0550 FZFG VV001 M09/M10 Q1024 R26/19//60 NOSIG

01:30 UTC / 07:30 local time:

Follow-up / safety actions

MAK issued 19 Safety Recommendations

Issued: 24-MAR-2017 To: TC-MCL (1) It is recommended that the crews pay attention to following approach charts, monitoring distance and altitude during reference points (FAF, LOM, LMM) overflight when conducting ILS approaches, especially ICAO CAT II and CAT III approaches. Issued: 24-MAR-2017 To: TC-MCL (2) It is recommended that flight crews be informed that in case ground references are not visible, go-around shall be initiated not lower than the established decision height. Issued: 24-MAR-2017 To: TC-MCL (3) It is recommended that air traffic controllers, in case they have pertinent equipment available, inform flight crews on significant altitude deviations from that established by the approach charts, especially for ICAO CAT II and CAT III approaches and Low Visibility Procedures, therefore, introducing respective amendments to the procedures and job description of air traffic control personnel should be considered. Issued: 24-MAR-2017 To: TC-MCL (4) It is recommended that top management of airlines operating Boeing aircraft (all models) arrange theoretical and practical (if needed) training to cover awareness, procedures and aspects of flight operations when A/P switches to inertial mode during glideslope descent. Consider the applicability of this recommendation to aircraft of other manufacturers. Issued: 24-MAR-2017 To: FAA TC-MCL (5) It is recommended that the FAA in cooperation with the Boeing Company consider the practicability of changing the A/P logic to prevent occurrences of following inertial glideslope descent (in LAND 3 or LAND 2 mode) in cases when approach path does not allow landing in the appropriate area on the runway. It is recommended that other certification authorities and aircraft manufacturers consider the applicability of this recommendation taking into account actual A/P algorithms. Issued: 24-MAR-2017 To: TC-MCL (6) It is recommended that airport administrations analyze the acceptability of constructions in immediate vicinity of airdromes and, in case findings are raised, take appropriate decisions in cooperation with pertinent authorities. Issued: 02-MAR-2020 To: top management of airline companies TC-MCL(10) To conduct the theoretical and practical (if required) training for the flight crews, operating the aircraft, manufactured by the Boeing Company (all models) for the recognition, order and specific features of conducting the flights in case of the autopilot switching to the inertial mode during the descent along the glideslope. To consider the applicability of this recommendation to the aircraft, manufactured by other companies. Issued: 02-MAR-2020 To: ATC service personnel TC-MCL(11) In case of the pertinent equipment availability, to inform flight crews on significant altitude deviations from value, established by the approach charts, especially for ICAO CAT II and CAT III approaches and in case of conditions, requiring actions in compliance with the Low Visibility Procedures, and for this purpose, to consider the issue of making the corresponding amendments to the job instructions of air traffic controllers. Issued: 02-MAR-2020 To: ATC service personnel TC-MCL(12) To finish the provision of the metreport to the crews before the aircraft reaches the LIM. The repetitive provision of the already-provided metreport should be avoided, especially if the flight crew is in the process of conducting the ICAO CAT II and CAT III approach and landing. Issued: 02-MAR-2020 To: ATC service personnel TC-MCL(13) To consider the practicability of including additional requirement into the ATC specialists\' job instructions, in case of flights in low visibility conditions, to request the flight crew for confirm capturing both the localizer signal and the glideslope signal ("fully established" status) after crossing the FAP. Issued: 02-MAR-2020 To: Boeing Company and the FAA TC-MCL(14) To consider the practicability of improving the algorithm of glideslope capture and of the implementation of the warning type alert in case of the "false" glideslope capture. Issued: 02-MAR-2020 To: Boeing Company and the FAA TC-MCL(15) To consider the practicability of changing the A/P logic in order to prevent occurrences of continuous inertial glideslope descent (in LAND 3 or LAND 2 modes) in cases when approach path does not allow landing in the appropriate zone of the runway. Issued: 02-MAR-2020 To: Boeing Company TC-MCL(16) To consider the practicability of amending the operational documentation (FCOM, FCTM) in order to provide more detailed description of the inertial path flight mode. Issued: 02-MAR-2020 To: Boeing Company TC-MCL(17) To consider the practicability of amending the operational documentation (FCTM and the B-747 TM) in order to eliminate the discrepancies in the provided actions recommended for the crew in case of "AUTOPILOT CAUTION" annunciation triggering. Issued: 02-MAR-2020 To: Aviation Administrations and the Aerodromes' Administrations TC-MCL(18) To analyze the acceptability of constructions in the immediate vicinity of aerodromes and, in case of findings, take appropriate decisions in cooperation with pertinent authorities. Issued: 02-MAR-2020 To: Aviation Administration of the Kyrgyz Republic TC-MCL(19) To consider the practicability of amending the provided aeronautical information regarding the publishing of the note on the possibility of increasing the safe altitude following the associated instruction from the ATS unit. Issued: 02-MAR-2020 To: top management of airline companies TC-MCL(7) To draw the attention of the flight crews to the necessity of fulfillment of the requirements, established in the approach charts, of the criteria for the stabilized approach and landing and of monitoring distance and altitude during the crossing of the reference points (FAF, LOM, LIM) when conducting ILS approaches, especially ICAO CAT II and CAT III approaches. Issued: 02-MAR-2020 To: top management of airline companies TC-MCL(8) To provide the flight crew training, during which to clarify additionally that in case of absence of the visual reference with the runway environment, the go-around procedure must be initiated no lower than the established decision height/altitude. Issued: 02-MAR-2020 To: top management of airline companies TC-MCL(9) To conduct additional training on the CRM and the interaction in case of one pilot\'s "fear" of the impossibility to continue the approach (or other stage of flight) and the absence of the other crew member\'s due reaction to this as well as the additional training on the actions required when the "minimums" message comes on. Show all... MAK issued 19 Safety Recommendations

Photos



accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL

accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL

accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL

accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL





TC-MCL TC-MCL

TC-MCL TC-MCL

accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL

accident date:

type: Boeing 747-412F

registration: TC-MCL accident date:type: Boeing 747-412Fregistration: TC-MCL

accident date:

type: Boeing 747-412F

registration: 9V-SFL accident date:type: Boeing 747-412Fregistration: 9V-SFL

accident date:

type: Boeing 747-412F

registration: 9V-SFL accident date:type: Boeing 747-412Fregistration: 9V-SFL

Aircraft history

date registration operator remarks 13 Jan. 2003 N5022E Boeing first flight 27 Feb. 2003 9V-SFL Singapore Airlines Cargo delivered 2 Dec. 2011 9V-SFL Singapore Airlines Cargo veered off runway at Singapore Changi Airport when trying to vacate rapid exit taxiway 5 Dec. 2015 TC-MCL MyCargo Airlines delivered 1 Jan. 2016 TC-MCL MyCargo Airlines operated for Qatar Airways Cargo 11 Jan. 2017 TC-MCL MyCargo Airlines operated for Turkish Airlines

Map

not display the exact flight path.

Distance from Hong Kong-Chek Lap Kok International Airport to Bishkek-Manas International Airport as the crow flies is 4269 km (2668 miles).

Accident location: Approximate; accuracy within a few kilometers. This map shows the airport of departure and the intended destination of the flight. The line between the airports doesdisplay the exact flight path.Distance from Hong Kong-Chek Lap Kok International Airport to Bishkek-Manas International Airport as the crow flies is 4269 km (2668 miles).Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Networks opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.