Investigation Summary
The approach was conducted in challenging meteorological conditions, including heavy rain and turbulence from nearby cumulonimbus clouds. Approximately 4 km from the threshold, the aircraft was carried above the ILS glide path by turbulence. The crew attempted to correct this by reducing power and applying down elevator. However, a combination of dusk, heavy rain, and water on the runway created a 'refraction' optical illusion, leading the pilots to believe they were higher and closer to the runway than they actually were. This resulted in a late, aggressive descent. The aircraft hit the runway at 260 km/h with a vertical load of 4g, causing the right landing gear strut to fail and the right wing to break off. The aircraft inverted and slid 700 meters, coming to rest upside down. The subsequent fire and smoke, combined with jammed doors and blocked emergency windows, prevented a successful evacuation.
Final Conclusions
The investigation concluded that the primary cause was a heavy landing resulting from an unstabilized approach and false perceptions (illusions) regarding the aircraft's position. The structural failure of the right wing upon impact led to the inversion and fire. The high fatality rate was attributed to the inability of passengers to evacuate due to fuselage distortion jamming the doors and the right wing stub blocking emergency exits, leading to mass carbon monoxide poisoning before the fire fully consumed the cabin.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Miloš Markićević
First Officer
Stevan Mandić
Flight Engineer
Ivan Čavajda
Trainee
Viktor Tomić
Systems & Failure Modes
Landing Gear
The right main gear strut and shock absorber failed under a 4g vertical and 1.5g horizontal load.
Emergency Exits
Four emergency windows were unusable: two due to external fire and two because they were blocked by the detached right wing.
Passenger Doors
Both the left passenger and right service doors were jammed by fuselage distortion; the passenger door may have been accidentally locked by a panicked attendant.
Interesting Facts
- 01The aircraft was nearly brand new, with only 111 airframe hours and 47 cycles at the time of the accident.
- 0272 of the 76 passengers were British tourists on a holiday charter.
- 03There were five survivors in total: one passenger who escaped through a rear opening and the four flight crew members who escaped through a cockpit window.
- 04Post-crash investigation found 30% of passengers still fastened in their seats upside-down.
- 05The pilot-in-command was not found legally responsible and later returned to flying in business aviation.
Safety Actions & Advisories
Optical Illusion Training
The commission recommended that pilots study and be trained on the specific optical illusions encountered during landings in heavy rain and dusk conditions.