Seven minutes after takeoff, the crew requested a return back to Manas airport due to a "technical reason", when they saw an indication that one of the doors was not properly locked and the cabin was not pressurized as expected. The ATC asked the crew whether they are going to perform a visual approach, and the crew confirmed they are requesting a visual approach. Realizing that the speed and altitude was too high for landing, the pilot decided to execute a left 360 degree turn when they were away from the airport. While executing this turn, the pilot failed to monitor altitude and vertical speed and inadvertently descended, being unable to see the ground at night. The aircraft struck ground with its left wing and crashed. The United States Air Force sent ambulances and fire apparatus with firefighters and medical personnel from its base at the airport in response to a request for assistance. There were 90 people on board of whom 65 died. This makes it the deadliest aircraft accident to ever occur in Kyrgyzstan. A total of 25 are reported to have survived. The victims included ten members of a Bishkekhigh school sports team, Kyrgyzstan National U18 Basketball Team.
Investigation
The Interstate Aviation Committee attempted to retrieve data from the flight-data and cockpit voice-recorders, which were badly damaged in the fire which destroyed most of the aircraft. While disassembling the casing, both the mechanisms of the tape recorder and the tape media in the voice recorder were found in damaged condition, but the MAK attempted to read the data from the damaged media. The MAK has released its final report. According to the report, the forward left cabin door was not closed completely, most likely due to a jammed seal. The MAK stated that this did not contribute to the accident. It further stated that lack of pressurization did not require an urgent landing using a visual approach, and therefore pilots should have used an instrument approach. During the visual approach, the crew realized they were too fast and too high to land, and therefore decided to make a 360 degree orbit to reduce their speed and altitude before landing. The decision to make the turn was made at 3.3 nm away from the airport reference point. While executing that turn, the pilot flying descended below the minimum maneuvering altitude, failed to maintain visual contact with the runway, failed to properly monitor altitude and ignored automated warnings about terrain proximity. The aircraft was in a 10 degree left turn, with landing gear down, flaps 15 and speed 160 knots when it impacted ground.
Conclusions
The MAK concluded that, despite holding proper licenses, "the analysis of the crew’s actual actions during the approach, their explanations and enquiries suggests that the crew was not properly trained for visual approaches". The MAK also concluded that the aircraft was "reacting as expected to control inputs" and "the airframe, aircraft systems and engines as well as the avionics were operative until the impact, except the cabin not pressurizing and the ". MAK concluded that the cause of the crash was the crew allowing the altitude reduction of the aircraft at night to a height below the minimum height during a visual approach for an emergency landing at the airport of departure due to depressurization caused by a failed left front door seal, which led to the collision of the aircraft with the ground, the destruction of the aircraft structure followed by fire and death. According to the report, the combination of the following factors contributed to the accident:
Deviations from the Boeing 737-200 standard operating procedure and pilot flying / pilot monitoring task sharing principles;
Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact;
Non-adherence to the prescribed procedures after the TAWS warning was triggered.
Pilots
Captain: Yury Goncharov, 18250 hours of flying experience, 2337 hours on B737-200
First officer: Timofey Vodolagin, 4531 hours of flying experience, 881 hours on B737-200
The captain and the first officer were sentenced to 5 years 2 months and 5 years respectively in a penal colony. As of August 2011, both pilots were reported to be released.
Aircraft information
The crashed plane first flew on 16 June 1980 and was delivered on 1 July of the same year to Air New Zealand as ZK-NAS. In 1995, it was sold to Copa Airlines, and in 2003 was again sold to Phoenix Aviation. In 2005, Phoenix Aviation was rebranded as AVE.com, and in April 2006, it changed hands to Itek Air. Itek Air, along with all air carriers certified by the authorities with responsibility for regulatory oversight of Kyrgyzstan, is included in a European Unionlist of banned airlines for safety concerns and is therefore not permitted to fly over the territory of the EU. In May 2008, EX-009 passed a full technical inspection.
