Investigation Summary
The flight was operating under Instrument Flight Rules (IFR) with a destination weather report indicating visibility of 6,000 meters and a cloud base at 470 meters. The standard approach procedure for Palana required the crew to fly to the Non-Directional Beacon (NDB) at a minimum safe altitude of 2,150 meters before entering a holding pattern for descent. Instead, the crew initiated a premature descent while still 22 kilometers away from the beacon, despite reporting to air traffic control that they were already overhead. The aircraft struck trees at an elevation of 320 meters above sea level. Post-accident toxicological tests revealed alcohol in the blood of both the captain and the first officer. The investigation also highlighted a lack of discipline within the airline and the absence of a Ground Proximity Warning System (GPWS) on the aircraft, which might have alerted the crew to the impending terrain impact. The Interstate Aviation Committee (MAK) released its final report on the accident in February 2013.
Final Conclusions
The Interstate Aviation Committee (MAK) concluded that the primary cause was the crew's violation of established approach procedures, specifically descending below the minimum safe altitude in mountainous terrain under weather conditions that precluded visual contact with the ground. The presence of alcohol in both crew members' blood was a critical factor. Contributing factors included poor flight discipline, unsatisfactory pre-flight preparation oversight by the airline, and the crew's failure to react to the altimeter alarm when reaching a dangerous altitude.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Alcohol discovered in blood during post-mortem.
First Officer
Alcohol discovered in blood during post-mortem.
Systems & Failure Modes
Ground Proximity Warning System (GPWS)
The aircraft lacked this system, which provides automated alerts to flight crews if the aircraft is in immediate danger of flying into the ground or an obstacle.
Non-Directional Beacon (NDB)
A radio transmitter at a known location used as an aviation navigation aid; the crew failed to follow the published procedure for the Palana NDB.
Interesting Facts
- 01Both pilots were found to have alcohol in their blood during post-mortem examinations.
- 02The aircraft was flying 22 km away from its reported position when it began its final descent.
- 03The crash site was located on Mount Pyatibratka at an elevation of 320 meters.
- 04The minimum safe altitude for the approach area was 2,150 meters.
- 05The aircraft was not equipped with a Ground Proximity Warning System (GPWS).
Safety Actions & Advisories
GPWS Implementation Review
The investigation noted that installing GPWS on An-28 aircraft could prevent similar CFIT accidents.
Operational Discipline Oversight
Recommendations were made to improve pre-flight preparation controls and monitoring of crew discipline at Petropavlovsk-Kamchatsky Air Enterprise.