Air Bagan Fokker F100 crash in Myanmar city - Burma (Photos included)
Join Date: Nov 2000
Location: Dre's mum's house
Posts: 1,432
Likes: 0
Received 0 Likes
on
0 Posts
@bluepilot: that particular model was a 650-15 unlike the KLM jets that were 620-15 a la F70. The KLM jets had AHRS.
That jet had triple IRS: there is no DME / DME updating in that area. Once you leave the Mandalay VOR you are on your own:the Heho NDB is next to useless, in a valley 3600ft above MSL. If you can't do a visual approach the chance of getting in is slim.
The road that runs perpendicular to the runway axis has power lines to the south: it may be an error setting the local QNH.
@bob - there is no LIKE button on here :-)
That jet had triple IRS: there is no DME / DME updating in that area. Once you leave the Mandalay VOR you are on your own:the Heho NDB is next to useless, in a valley 3600ft above MSL. If you can't do a visual approach the chance of getting in is slim.
The road that runs perpendicular to the runway axis has power lines to the south: it may be an error setting the local QNH.
@bob - there is no LIKE button on here :-)
Join Date: Jul 2006
Location: Portugal
Posts: 10
Likes: 0
Received 0 Likes
on
0 Posts
I was under the impression that KLM had a mix of 650-15 F100's with triple FCC and triple IRS, which was the top notch config available.
Also, FMS approaches are not allowed in the Fokker 100, but if used wisely, can make NPA's, specially NDB, much, much, much safer. You don't have to be in a 3rd world country to start an approach only to find your ADF needles just frozen. Happened to me more times than i would like, but you gotta relate all the information available to the crew and don't screw with the MDA.
I flew F100's with 3 AHRS over the Atlantic to the beautiful Madeira Island, it always found us that piece of land, but we had some drift events.
With 3 IRS's, if everything is checked out and operated correctly, you have a better gun than ADF needles, even after 150NM navigating only on IRS sources.
FMS navigation, like i said before, is a good source for cross-reference, on the Fokker 100, is a supplemental means of navigation.
I am sorry for the loss of life, my condolences to the families of those who where victims of this tragic event.
Also, FMS approaches are not allowed in the Fokker 100, but if used wisely, can make NPA's, specially NDB, much, much, much safer. You don't have to be in a 3rd world country to start an approach only to find your ADF needles just frozen. Happened to me more times than i would like, but you gotta relate all the information available to the crew and don't screw with the MDA.
I flew F100's with 3 AHRS over the Atlantic to the beautiful Madeira Island, it always found us that piece of land, but we had some drift events.
With 3 IRS's, if everything is checked out and operated correctly, you have a better gun than ADF needles, even after 150NM navigating only on IRS sources.
FMS navigation, like i said before, is a good source for cross-reference, on the Fokker 100, is a supplemental means of navigation.
I am sorry for the loss of life, my condolences to the families of those who where victims of this tragic event.
Last edited by JFA; 3rd Jan 2013 at 00:05.
Join Date: Aug 2004
Location: europe
Posts: 359
Likes: 0
Received 0 Likes
on
0 Posts
Shady is correct the KLM F100s were TAY620-15 with triple AHRS, the F70s had twin IRS, KLM later aquired 5 used F100s with 650-15 engines with triple IRS. All F100s have been retired and only the F70s remain in service.
I am informed that this airframe was ex BMI so probably did have triple IRS, not that that makes a huge difference given the challenges to the crew on the day with primative NDB equipment and terrain issues.
I am informed that this airframe was ex BMI so probably did have triple IRS, not that that makes a huge difference given the challenges to the crew on the day with primative NDB equipment and terrain issues.
Join Date: Sep 2006
Location: UK
Age: 78
Posts: 389
Likes: 0
Received 0 Likes
on
0 Posts
F100 SYSTEMS
I second the above comments on flyability and updating
NDBs were very easy as groundspeed and track were clearly displayed, what else do you want. On an ILS you did not get DME if the wrong runway was entered, not sure how this would be presented on a non ILS runway
There was a problem that the systems were designed for european operation and so if out of dme range for some time perculiar effects could be seen. The system seemed to assume that any errors were due to system drift and allow for it in future but if the percieved drift was due to poor dme quality the system could correct for non existing drift and induce an error
NDBs were very easy as groundspeed and track were clearly displayed, what else do you want. On an ILS you did not get DME if the wrong runway was entered, not sure how this would be presented on a non ILS runway
There was a problem that the systems were designed for european operation and so if out of dme range for some time perculiar effects could be seen. The system seemed to assume that any errors were due to system drift and allow for it in future but if the percieved drift was due to poor dme quality the system could correct for non existing drift and induce an error
Join Date: Mar 2013
Location: east midlands
Age: 72
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
A bit of history
As befits my age, I have only just become aware of the crash (thanks to Airliner World) Something jogged my memory about 11327 and sure enough, it was an aircraft that I worked on at EMA, when it flew for British Midland. (I still cannot call it bmi). Its always sad to hear bad news of an old friend.
My most stressful flight ever was on a F100 as we lost our Nav dsiplays during a dirty dive into Sofia during the Yugoslavian conflict.
A cheap system which would drop out if you lost the two DMEs that it calculated it's position from. Did the same if the two were were on the same axis as the aircraft (gva).
So you had to dive into your briefcase, find the chart, tune the nav aids.....
Similarly the all talking autothrottle didn't work in open descent - we had two stall warnings flying into Nice during visual approaches before it was realised that it didn't do what it was supposed to do.
The first the crews knew that the autothrottle wasn't working was the shakers.
Then it had a useless undercarriage - I grounded an aircraft once to be told by the guy who was responsible for the original acceptance that he had refused the aircraft...SR modified it and Marichetti? Built a new one which failed with the press on board.
Wrong aircraft for a flag carrier.
A cheap system which would drop out if you lost the two DMEs that it calculated it's position from. Did the same if the two were were on the same axis as the aircraft (gva).
So you had to dive into your briefcase, find the chart, tune the nav aids.....
Similarly the all talking autothrottle didn't work in open descent - we had two stall warnings flying into Nice during visual approaches before it was realised that it didn't do what it was supposed to do.
The first the crews knew that the autothrottle wasn't working was the shakers.
Then it had a useless undercarriage - I grounded an aircraft once to be told by the guy who was responsible for the original acceptance that he had refused the aircraft...SR modified it and Marichetti? Built a new one which failed with the press on board.
Wrong aircraft for a flag carrier.
Join Date: Jun 2002
Location: Wor Yerm
Age: 68
Posts: 4
Likes: 0
Received 0 Likes
on
0 Posts
...nobody seems to have mentioned the bloody big hole in the side of the nacelle..
There also appears to be some rather high expectations of an investigation. Analysing CVR and FDR data requires a great deal of expertise - if they were working. And then who will be doing the investigation? I'll suggest that there is not a great deal of experience in this country. Unfortunately, normal procedure in this part of the world is to find the captain and blame him.
However, if you consider these questions:
Was there a DME?
Was the runway lit (are lights installed)?
Was there an official approach?
What were the minima for that approach?
What are the restrictions if the NDB was U/S?
When was the NDB last tested?
What was the weather on the day?
What were the planning minima?
What do the airline's procedures say about operating at Heho?
How much fuel was carried?
What was the technical status of the aircraft?
What was the background of the pilots?
etc...
Unless each of these has a reasonably positive answer, this will just be another "Third World Jungle Crash", of which we will see more of as this part of the world gets richer.
Top Tip: Don't fly "Third World" if you want first world safety.
Flight Data Recorders were sent to Singapore, but got refused, then sent to Australia for read out and analyses.
In answer to your questions:
Was there a DME?
- there is no DME at Heho.
Was the runway lit (are lights installed)?
- the runwa is not lighted.
Was there an official approach?
- there are NDB approaches (with high minima) to both runways
What were the minima for that approach?
- between 4500 and 5700 ft altitude depending on the charts
What are the restrictions if the NDB was U/S?
- no IFR approach possible
When was the NDB last tested?
- good question, let's say the indication is stable 3 NM inbound
What was the weather on the day?
- fog in the morning, otherwise clear
What were the planning minima?
- see approach minima
What do the airline's procedures say about operating at Heho?
- not much I reckon!
How much fuel was carried?
- usually plenty as fuel is tankered into Heho
What was the technical status of the aircraft?
- reliable sources tell me it left of lot to be desired...
What was the background of the pilots?
- local
In answer to your questions:
Was there a DME?
- there is no DME at Heho.
Was the runway lit (are lights installed)?
- the runwa is not lighted.
Was there an official approach?
- there are NDB approaches (with high minima) to both runways
What were the minima for that approach?
- between 4500 and 5700 ft altitude depending on the charts
What are the restrictions if the NDB was U/S?
- no IFR approach possible
When was the NDB last tested?
- good question, let's say the indication is stable 3 NM inbound
What was the weather on the day?
- fog in the morning, otherwise clear
What were the planning minima?
- see approach minima
What do the airline's procedures say about operating at Heho?
- not much I reckon!
How much fuel was carried?
- usually plenty as fuel is tankered into Heho
What was the technical status of the aircraft?
- reliable sources tell me it left of lot to be desired...
What was the background of the pilots?
- local
Join Date: Apr 2008
Location: nowhere
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
Accident: Bagan F100 near Heho on Dec 25th 2012, landed on road outside airport
http://avherald.com/files/bagan_f100...nal_report.pdf
The Aviation Herald was able to obtain a copy of the final report concluding the probable causes were:
Primary Cause
- During the final approach, the aircraft descended below the MDA and the crew did not follow the operator SOP's.
- The pilots had no corrective action against to change VMC to IMC during bad weather condition and insufficient time for effective respond to last moment.
Secondary Cause
- Captain of the aircraft had insufficient assessment on the risk that assigned the FO as PF.
- There may be under pressure by the following aircrafts as the first plane on that day to Heho.
Myanmar's Directory of Civil Aviation (DCA) reported the aircraft was performing an NDB approach to Heho's runway 36, MDA at 530 feet, the first officer (29, CPL, 849 hours total, 486 hours on type) was pilot flying, the captain (49, ATPL, 5,937 hours total, 2,547 hours on type) was pilot monitoring.
The crew had properly briefed a go around.
After joining the final approach the aircraft descended with flaps at 42 degrees, there were cloud between aircraft and the runway threshold. The pilot flying therefore was looking down onto the panel flying the instruments, the pilot monitoring was watching the outside.
As the aircraft descended through 660 feet the pilot flying called "I visual".
About 2.5nm before the runway threshold the EGPWS called "500", the aircraft was descending at 700fpm at 139 KIAS. The aircraft continued to descend, at 108 feet AGL the captain called "Not OK" and pushed the ALT HLD button, the EGPWS announced "100", "50", "40", "30", sounds of impact were heard in the cockpit while the aircraft collided with a 66 kV power line, trees, telephone cables, a fence and collided with the ground coming to a stop 0.7nm before the runway threshold, aircraft debris struck motorcyclists. One passenger and one motorcyclist died in the accident, another motor cyclist and the remaining occupants of the aircraft survived, 2 crew and 7 passengers with serious injuries, 4 crew and 57 passengers with minor or no injuries. The aircraft was destroyed.
The DCA reported the captain commented "Not OK" just prior to 100 feet EGPWS call and pushed the ALT HLD button just when the EGPWS sounded "100", however, the first sounds of impact occurred at the same time.
The DCA analysed:
During the approach to Heho airport, there were foggy conditions reported in the Heho area, including low fog on the approach to runway 36. As the aircraft descended on the approach, the crew briefed for a possible go-around. However, during the final approach, the aircraft passed through the MDA and the crew continued the approach in reducing visibility conditions. Due to the low fog, it is likely that the crew were not aware of the tress, power lines and other obstacles short of the runway.
The DCA analysed:
During the approach to Heho, the crew briefed for a possible go-around, which is normally action when the aircraft reaches the MDA and the crew decide to continue, based on remaining visual with the runway or, if not visual, conduct a go-around. The MDA at Heho was 530ft.
While on final approach at an altitude of 660 ft, the pilot flying called "I visual", however there was no similar call when the aircraft reached the MDA at 530 ft. At 500ft, the EGPWS aural alert sounded"500" with no response from either crew member. The approach was continued without any crew call out on the visual conditions at the time until. at 02:23:04, at eight of just above 100 ft, the PIC called "Not OK, indicated that the crew were previously satisfied that the crew likely maintained some visibility of the runway or the runway environment. However, by not calling out the standard MDA call at 530 ft, the crew missed an opportunity to ensure that the approach was still within all normal parameters at a point where they could execute a successful go-around.
In addition, the aircraft EGPWS aural alert announced callout heights of "100","50", "40", "30". These callouts are standard alerts to provide height cues to the crew during the flare and landing and are not used for terrain avoidance. Despite the EGPWS callouts, there were no further actions taken by the crew apart from activating the Alt Hold function at a height that was too low to prevent terrain collision.
...
The Air Bagan Standard Operating Procedures (SOP) for a non-precision approach were clear in their guidance in regard to calling "visual" at the MDA of and approach and that if the aircraft entered IMC after passing the MDA, the crew were to conduct a go-around.
It is apparent that from the recorded evidence that the crew did not follow the requirements of the Air Bagan SOP's and Heho NDB letdown procedure during the approach to Heho.
The report analyses critical of Air Bagan's safety management and safety overview as well as DCA's overview of the airline, however, without identifying specific points related to the accident flight.
The DCA issued following safety recommendations however:
- Department of Civil Aviation ensure the Air Operator's implementation of FDR analyses Programmes.
- Air Bagan operation ensure the qualitative requirements of operational personal with non-precision NDB approach training with IMC, awareness of MDA, and EGPWS alert.
- Air Bagan operation ensure to access multi-crew operation of CRM training, supervision of captain and the risk FO to perform the PF.
http://avherald.com/files/bagan_f100...nal_report.pdf
The Aviation Herald was able to obtain a copy of the final report concluding the probable causes were:
Primary Cause
- During the final approach, the aircraft descended below the MDA and the crew did not follow the operator SOP's.
- The pilots had no corrective action against to change VMC to IMC during bad weather condition and insufficient time for effective respond to last moment.
Secondary Cause
- Captain of the aircraft had insufficient assessment on the risk that assigned the FO as PF.
- There may be under pressure by the following aircrafts as the first plane on that day to Heho.
Myanmar's Directory of Civil Aviation (DCA) reported the aircraft was performing an NDB approach to Heho's runway 36, MDA at 530 feet, the first officer (29, CPL, 849 hours total, 486 hours on type) was pilot flying, the captain (49, ATPL, 5,937 hours total, 2,547 hours on type) was pilot monitoring.
The crew had properly briefed a go around.
After joining the final approach the aircraft descended with flaps at 42 degrees, there were cloud between aircraft and the runway threshold. The pilot flying therefore was looking down onto the panel flying the instruments, the pilot monitoring was watching the outside.
As the aircraft descended through 660 feet the pilot flying called "I visual".
About 2.5nm before the runway threshold the EGPWS called "500", the aircraft was descending at 700fpm at 139 KIAS. The aircraft continued to descend, at 108 feet AGL the captain called "Not OK" and pushed the ALT HLD button, the EGPWS announced "100", "50", "40", "30", sounds of impact were heard in the cockpit while the aircraft collided with a 66 kV power line, trees, telephone cables, a fence and collided with the ground coming to a stop 0.7nm before the runway threshold, aircraft debris struck motorcyclists. One passenger and one motorcyclist died in the accident, another motor cyclist and the remaining occupants of the aircraft survived, 2 crew and 7 passengers with serious injuries, 4 crew and 57 passengers with minor or no injuries. The aircraft was destroyed.
The DCA reported the captain commented "Not OK" just prior to 100 feet EGPWS call and pushed the ALT HLD button just when the EGPWS sounded "100", however, the first sounds of impact occurred at the same time.
The DCA analysed:
During the approach to Heho airport, there were foggy conditions reported in the Heho area, including low fog on the approach to runway 36. As the aircraft descended on the approach, the crew briefed for a possible go-around. However, during the final approach, the aircraft passed through the MDA and the crew continued the approach in reducing visibility conditions. Due to the low fog, it is likely that the crew were not aware of the tress, power lines and other obstacles short of the runway.
The DCA analysed:
During the approach to Heho, the crew briefed for a possible go-around, which is normally action when the aircraft reaches the MDA and the crew decide to continue, based on remaining visual with the runway or, if not visual, conduct a go-around. The MDA at Heho was 530ft.
While on final approach at an altitude of 660 ft, the pilot flying called "I visual", however there was no similar call when the aircraft reached the MDA at 530 ft. At 500ft, the EGPWS aural alert sounded"500" with no response from either crew member. The approach was continued without any crew call out on the visual conditions at the time until. at 02:23:04, at eight of just above 100 ft, the PIC called "Not OK, indicated that the crew were previously satisfied that the crew likely maintained some visibility of the runway or the runway environment. However, by not calling out the standard MDA call at 530 ft, the crew missed an opportunity to ensure that the approach was still within all normal parameters at a point where they could execute a successful go-around.
In addition, the aircraft EGPWS aural alert announced callout heights of "100","50", "40", "30". These callouts are standard alerts to provide height cues to the crew during the flare and landing and are not used for terrain avoidance. Despite the EGPWS callouts, there were no further actions taken by the crew apart from activating the Alt Hold function at a height that was too low to prevent terrain collision.
...
The Air Bagan Standard Operating Procedures (SOP) for a non-precision approach were clear in their guidance in regard to calling "visual" at the MDA of and approach and that if the aircraft entered IMC after passing the MDA, the crew were to conduct a go-around.
It is apparent that from the recorded evidence that the crew did not follow the requirements of the Air Bagan SOP's and Heho NDB letdown procedure during the approach to Heho.
The report analyses critical of Air Bagan's safety management and safety overview as well as DCA's overview of the airline, however, without identifying specific points related to the accident flight.
The DCA issued following safety recommendations however:
- Department of Civil Aviation ensure the Air Operator's implementation of FDR analyses Programmes.
- Air Bagan operation ensure the qualitative requirements of operational personal with non-precision NDB approach training with IMC, awareness of MDA, and EGPWS alert.
- Air Bagan operation ensure to access multi-crew operation of CRM training, supervision of captain and the risk FO to perform the PF.
Join Date: Oct 2016
Location: Taipei
Posts: 6
Likes: 0
Received 0 Likes
on
0 Posts
Thanks JammedStab for the follow-up.
Sad.
Also typical of so many accidents...reporter says witnesses said engine was on fire.
Report says no mechanical problem, just CFIT.
Thankfully old airplanes and non-precision approaches are quickly fading away.
Unfortunately, pilot error persists.
Sad.
Also typical of so many accidents...reporter says witnesses said engine was on fire.
Report says no mechanical problem, just CFIT.
Thankfully old airplanes and non-precision approaches are quickly fading away.
Unfortunately, pilot error persists.
Join Date: Jun 2002
Location: Wor Yerm
Age: 68
Posts: 4
Likes: 0
Received 0 Likes
on
0 Posts
That was a good find JS, thanks. But I disagree with you talkinair; the "old" F100 works very well and is a good instrument flying platform. A newer aircraft would do no better unless flown down a GPS approach to CAT I limits, but I don't think this airport has drawn up such an approach.
A quick read of the report puts the following questions in my mind. Firstly, what was the purpose of the Captain pressing the Alt Hold? Secondly, no mention was made of the actual mode recorder by the FDR. Why was that? The button may have been pressed but it's one of the most rarely used buttons on the panel. When functioning, with a VS or 700' or I'd expect the mode to take about 100 feet or so to take effect. That clearly didn't happen. Thirdly, did the F/O flying really have such detrimental effect? That was a very stable approach. Lastly, I saw no analysis of their failure to go around. I wonder why?
A quick read of the report puts the following questions in my mind. Firstly, what was the purpose of the Captain pressing the Alt Hold? Secondly, no mention was made of the actual mode recorder by the FDR. Why was that? The button may have been pressed but it's one of the most rarely used buttons on the panel. When functioning, with a VS or 700' or I'd expect the mode to take about 100 feet or so to take effect. That clearly didn't happen. Thirdly, did the F/O flying really have such detrimental effect? That was a very stable approach. Lastly, I saw no analysis of their failure to go around. I wonder why?
