Investigation Summary
The accident was rooted in a series of operational failures starting before takeoff. The flight was originally scheduled to be operated by a Boeing 737, but an aircraft change to the Yakovlev Yak-42 occurred at Odessa due to engine problems on the Boeing. The aircraft was dispatched from Odessa with its primary VOR receiver inoperative, a violation of the Minimum Equipment List (MEL). Upon arrival at Thessaloniki, the crew failed to perform the required DME arc for the LAMBI arrival, instead flying directly to the airport beacon. This resulted in an unstable approach at excessive altitude, forcing a go-around. During the missed approach, the crew requested radar vectors from a non-radar facility and became confused by their instruments, which displayed distances in kilometers while the charts used miles. The presence of a marginally qualified instructor pilot in the cockpit further disrupted crew coordination. Despite a GPWS warning 30 seconds before impact, the captain failed to execute a maximum performance climb, and the aircraft struck Mount Pente Pigadia at 3,300 feet.
Final Conclusions
The Greek Aircraft Accidents Inquiry Council concluded the primary cause was the crew's failure to plan and execute the approach and missed approach procedures correctly. Contributing factors included the lack of cockpit discipline (CRM), the dispatch of an unairworthy aircraft with inoperative navigation equipment, and the crew's loss of situational awareness. The investigation also noted that the Jeppesen charts contained a symbol suggesting radar was available when it was not, and that air traffic controllers failed to recognize the crew's distress and offer proactive assistance.
Video Analysis
The Flight that Got Lost in the Mountains | Aerosvit Flight 241 — A detailed look at the navigational errors and cockpit confusion that led a Yakovlev Yak-42 to crash into the Greek mountains in 1997.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Aleksii Vcherashnyii; Russian nationality
First Officer
Russian nationality
Instructor Pilot
Russian nationality
Systems & Failure Modes
VHF/NAV Receiver
The primary navigation unit was inoperative, leading to the loss of localizer guidance during the approach.
GPWS
The Ground Proximity Warning System alerted the crew 30 seconds before impact, but the captain did not initiate a maximum climb.
DME
Distance Measuring Equipment; the crew struggled to convert the kilometer readings on their instruments to the nautical miles required by the charts.
Interesting Facts
- 01The aircraft was a wet-lease from Lviv Airlines to Aerosvit.
- 02The No. 1 VHF/NAV receiver was inoperative, which prevented the crew from obtaining a localizer signal on the captain's side.
- 03The crew confused kilometers (displayed on their Soviet-designed instruments) with miles (used on the approach charts).
- 04A Greek Air Force C-130 search aircraft crashed on Mt Pastra while positioning to pick up soldiers for the search mission, killing all five on board.
- 05Two Greek air traffic controllers were later convicted of manslaughter and sentenced to prison.
Safety Actions & Advisories
CFIT Training Mandate
The Ukrainian Department State of Aviation Transport was asked to develop a compulsory CFIT training program and make CFIT assessment imperative for flight crews.
Radar Installation
The Hellenic Civil Aviation Authority was urged to provide radar equipment to Thessaloniki Airport to assist in monitoring aircraft orientation.
CRM and LOFT Implementation
Cockpit Resource Management (CRM) and Line-oriented flight training (LOFT) were requested to be included in the national flight safety programs of both Greece and Ukraine.
Known Controversies & Unanswered Questions
Controller Liability
Reference ↗While the official report focused on pilot error, a member of the inquiry committee and subsequent Greek court rulings placed significant blame on the air traffic controllers for failing to recognize the crew's disorientation and provide assistance.