Vnukovo Airlines Flight 2801
The wreckage at Operafjellet
|Date||29 August 1996|
|Summary||Controlled flight into terrain due to pilot error and loss of Situation awareness|
|Site||Operafjellet, Svalbard, Norway |
|Aircraft type||Tupolev Tu-154M|
|Flight origin||Vnukovo International Airport, Moscow, Russia|
|Destination||Svalbard Airport, Longyear, Longyearbyen, Norway|
Vnukovo Airlines Flight 2801 was an international charter flight that, on 29 August 1996, at 10:22:23 Central European Summer Time, crashed in Operafjellet, Svalbard, Norway during the approach to Svalbard Airport, Longyear. All 141 people aboard the Tupolev Tu-154M were killed, making it the deadliest aviation accident ever in Norway. The accident was the result of a series of small navigational errors causing the aircraft to be 3.7 kilometres (2.3 mi) from the approach centerline at the time of impact. The accident was investigated by the Accident Investigation Board Norway with assistance from the Interstate Aviation Committee and became known as the Operafjell Accident (Norwegian: Operafjell-ulykken).
The Vnukovo Airlines aircraft, registration number RA-85621, was chartered by Arktikugol, a Russian state owned coal mining company, to fly Russian and Ukrainian workers from Vnukovo International Airport in Moscow, Russia to Svalbard Airport, Longyear in Longyearbyen, Norway. The passengers all belonged to the Russian communities of Barentsburg and Pyramiden. The fatalities included 11 crew members and 130 passengers, of which 3 were children. The accident was a contributing cause for Arktikugol's closure of Pyramiden two years later. After the accident, there were a series of lawsuits to determine the compensations to the victims' families.
Flight 2801 was a chartered flight flown by Vnukovo Airlines on behalf of Arktikugol, which operated mines at the two company towns of Barentsburg and Pyramiden in Svalbard. The aircraft was a Tupolev Tu-154M, with registration RA-85621, serial number 86A 742 and date of manufacture 14 January 1987. The flight consisted of a crew of eleven, including a cockpit crew of four (two aircraft pilots, one engineer and one navigator), a cabin crew of five and two technicians. The pilot in command (PiC) had previously landed at Svalbard Airport; the first officer had not and was the piloting pilot.
On board were 130 passengers, of whom 3 were children, consisting of Arktikugol employees and their families. Waiting at the airport for the return flight were 120 other employees and their families. The aircraft left Vnukovo Airport at 04:44 Coordinated Universal Time (UTC) or 08:44 Moscow Summer Time. Estimated flight time was 3 hours and 30 minutes, and alternative airports were Murmansk Airport and Severomorsk-3, both in Murmansk Oblast, Russia. The flight proceeded normally until descent, following the routing W 29 from Moscow to Padun (west of Murmansk), before crossing to Bodø Flight Information Region over the Barents Sea cruising at FL 350 at an average airspeed of 500 kilometres per hour (310 mph). It then proceeded over Bjørnøya non-directional beacon (NDB), Isfjord NDB and Advent NDB.
The weather at the accident area was dominated by a low pressure trough, giving rain showers and wind from 15 to 30 knots (28 to 56 km/h; 17 to 35 mph) at 240–270°. Visibility exceeded 10 kilometres (6 mi). Between 08:00 and 09:00, a weak trough passed, reducing visibility to 6 kilometres (4 mi) and a cloud base at 400 to 450 metres (1,300 to 1,500 ft).
Svalbard Airport, Longyear, is the main airport serving the Svalbard archipelago. It is located on the south shore of Isfjord, with high terrain to the south, southeast and east. It has a single, 10/28 runway (roughly east–west) which is 2,140 metres (7,020 ft) long. The airport has an elevation of 28 metres (92 ft) above mean sea level (MSL), and has an aerodrome flight information service (AFIS), which is subordinate Bodø Air Traffic Control Center (Bodø ATCC). The airport is regarded as uncontrolled and does not provide approach service. On that day, all aircraft had used Runway 28, due to favorable wind conditions, climb-up conditions and short distance from the terminal.
At 07:55 UTC (09:55 local Central European Summer Time, CEST), the crew requested clearance to start descent. Because of lack of communication with Bodø ATCC, this was not obtained. At 07:56, information from Longyear AFIS was given that there was no conflicting traffic, allowing a descent to 1,800 metres (6,000 ft) MSL. The crew tried to request use of Runway 10, but this was, due to language problems, not understood as such by AFIS. Instead, Longyear communicated the actual weather and informed that Runway 28 was in use. An additional request for use of Runway 10 was again not understood, because of the misunderstanding of the term "runway in use". Because of this, the crew decided to instead use Runway 28.
The crew used Jeppesen charts dated 21 January 1994. According to procedures, both horizontal situation indicators (HSI) were set to 283°, but the magnetic localizer course of 300° was not set. A global positioning system (GPS) was used as a back-up. No requests were made for VHF direction finding. From 3,000 metres (10,000 ft) MSL until impact, the flight was carried out in instrument meteorological conditions (IMC) and the flight controlled by automatic stabilization mode, with lateral navigation controlled by the navigator.
At 08:10 UTC, the aircraft reached 1,524 metres (5,000 ft) MSL, which is the minimum altitude to Advent and the initial approach altitude. At 08:15:32 UTC, it reached Advent and entered a base turn, reaching a magnetic heading of 160° at 08:16:28 UTC. While the crew had adjusted for the wind drift, they did not attempt to intercept the magnetic course 155° outbound from Advent. During this turn, there was a malfunction in the electric trimming mechanism, which caused the piloting pilot to deactivate the aircraft flight control systems' servogear in the pitch channel at 08:15:58. This was again activated at 08:16:42 UTC.
At 08:17:08 UTC, the crew started the turn to bring the aircraft to 300° magnetic inbound, however, the lateral deviation from the outbound magnetic course was 155°, or 3.7 kilometres (2.3 mi) to the left. At 08:17:57 UTC, the navigator said "Ah, abeam eight miles 2801 inbound", to which AFIS replied two seconds later "Correct". This was the last radio communication between the crew and Longyear. At 08:18:30 UTC, the piloting pilot turned off the autopilot pitch channel. For the rest of the flight, the plane continued with autopilot only in roll.
Following the aircraft passing through the localizer centerline and having rolled out on 290°, there was a discussion among the crew if the turn had been made at the right time. The initial comment about this was made by the first officer at 08:19:06 UTC. This resulted in a roll out of the turn to final approach and corrective turn to magnetic heading 306°. At this time, the aircraft was 27.4 nautical miles (50.7 km; 31.5 mi) from the airport and 2.8 kilometres (1.7 mi) right of the centerline at 1,520 metres (5,000 ft) MSL with an airspeed of 330 kilometres per hour (210 mph). Instead of intercepting the centerline, the crew continued to track on the right side, nearly paralleling the localizer course.
At 08:20:17 UTC, the pilot in command ordered the aircraft turned to 291°, which adjusted for drift resulted in a course close to 300°. At this time, the aircraft had a lateral deviation from the approach centerline of 3.7 kilometres (2.3 mi). The aircraft started descending at 08:20:24 UTC. A corrective turn was made at 08:21:13 UTC and completed 11 seconds later at magnetic heading 300°. At the time, the aircraft was descending 5 to 7 metres per second (16 to 23 ft/s). The aircraft started turning left at 08:22:05 UTC, and immediately entered an area of turbulence created by the surrounding mountains.
During initial approach, the radio altimeter warning had been activated several times, which indicated less than 750 metres (2,460 ft) from the aircraft to the terrain. During final approach, the ground proximity warning system was activated nine seconds before impact, which lasted until impact. Six seconds before impact, the radio altimeter warning was activated. At 08:22:23 UTC (10:22:23 local CEST) the aircraft collided with the top of Operafjellet at 907 metres (2,976 ft) elevation, located 14.2 kilometres (8.8 mi) from Svalbard Airport and 3.7 kilometres (2.3 mi) right of the approach centerline. The aircraft was destroyed and all occupants perished instantly. It is the single deadliest plane crash to have occurred on Norwegian soil.
The Joint Rescue Coordination Centre of Northern Norway received a message about the crash at 10:30 CEST (8:30 UTC) and the search and rescue service was immediately deployed. This included seven Norwegian aircraft that were in the area. The area had bad weather with a low cloud height, resulting in difficult searching conditions. The aircraft was found at 12:06 CEST at Operafjellet, 14 kilometres (8.7 mi) east of Svalbard Airport. Most of the aircraft was located on the mountain's plateau, although some debris had slid down a vertical cliff and was scattered along the valley and partially covered by an avalanche. Rescue workers and medics from Longyearbyen Hospital arrived at 12:36, and quickly established that there were no survivors.
The responsibility of the recovery was transferred to the Governor of Svalbard on 30 August, since there were no survivors. In addition, police personnel from the mainland were transferred to Svalbard to work with the investigation and recovery. The work was supplemented by local volunteers. Because of the bad weather, which included fog and snow, it was often impossible to transport workers to the plateau, and work therefore started in the valley.
Governor Ann-Kristin Olsen traveled to Barentsburg on 30 August to inform the communities about the accident, and distributed ample written information in Russian about the then-known details about the crash. Later in the day, a Russian aircraft arrived with Deputy Minister Aleksandr Petrovich of the Ministry of Emergency Situations along with a team of 11 rescue workers, and representatives from the Interstate Aviation Committee (IAC), the Embassy of Ukraine in Moscow, the Federal Air Transport Agency and Vnukovo Airlines. In a meeting that evening, the Governor accepted Russia assistance, while it was confirmed by international agreement that the investigation would be led by the authorities in the country where the accident occurred, Norway. On 31 August, Minister of Justice Grete Faremo visited the Russian settlements as a representative from the Government of Norway.
The accident had a large impact on the community, with only 1,600 people living in the two Russian settlements. The population in the communities do not speak Norwegian, and do not have a road connection to Longyearbyen. This made it difficult for the Governor to give accurate and detailed information. Issues were further complicated by erroneous reports in Russian media that there were five survivors. The Governor's cabin in Barentsburg was manned during the aftermath, and bulletins were distributed with updated information in Russian. The accident was one of the triggers causing Arktikugol to abandon Pyramiden in 1998.
Agreements between Norwegian and Russian authorities were made on 31 August, where Norway resumed full responsibility for the recovery and investigation, but Russian help was accepted. To allow the Russian workers access from the morning of 1 September, the crew was allowed to fly in and establish a base camp, but no work was to be done until Norwegian supervisors arrived in the morning. However, two people were observed at the wreck at about 20:00 CEST, who were brought to the Governor's offices for questioning. As they were both members of the Russian team, it was decided that the base would be disbanded.
There was still fog on the plateau on 1 September, but by 15:00 CEST it was possible to fly a team there by helicopter. Because the fog stayed, the team retained work until 03:00 CEST in the night. In the following days, the fog lifted, making work and transport easier. By 5 September, all bodies had been recovered and the work at the plateau could be terminated. The recovery in the valley was completed two days later. The accident resulted in about 40 journalists staying in Svalbard to cover the story. The Norwegian authority's costs related to the investigation and other activities related to the accident were estimated at 30 million Norwegian krone (NOK).
All identification of people was performed in Tromsø, as a cooperation between Troms Police District, National Criminal Investigation Service and the University Hospital of North Norway. By 18 September, all people had been identified, and the bodies were transported to Russia and Ukraine on 20 September after a short memorial in Tromsøhallen. An autopsy was performed on all crew members, without finding any abnormalities.
The official responsibility for investigating the incident lay with the Air Accident Investigation Board/Norway (AAIB/N), although the investigation and report was a close cooperation with the Interstate Aviation Committee and to a lesser extent, the Federal Air Transport Agency. AAIB/N had the primary responsibility for investigations at the crash site, cooperation with the Norwegian police and the Norwegian Civil Aviation Administration, and writing the report. IAC was responsible for handling the investigations in Russia, the reading of the cockpit voice recorder, the flight data recorder, the relationship with Vnukovo Airlines and a test flight. Both agencies agreed that English was to be the language of the final report; English is one of the ICAO languages.
The official investigation concluded that the flight, regarded as a controlled flight into terrain, was caused by pilot errors and that there was no fault with the aircraft. Contributing factors causing the accident were lack of a procedure for offset localizer approach for setting approach course on the HSIs. Thus, both HSIs were set incorrectly, which along with the course deviation indicator hinted that the plane was being blown to the left and needed to adjust course to the right. Because he was in a stressed situation, the navigator set the GPS in the wrong mode. He also did not have sufficient time to recheck his work, allowing mistakes to happen, and his work was not monitored by the pilots. As the navigator was overworked, it was inappropriate for the first officer to transfer the responsibility of lateral control to him.
The AFIS air controller has a different role in Norway than in Russia, and the crew were not aware that they were being given information and advice, rather than orders. Communication with AFIS was left with the navigator, which is a breach of norms. Communication between air control and the crew was problematic, since the crew lacked sufficient English skills. The pilot in command had insufficient crew resource management. After the crew decided to carry out the approach to Runway 28, a new approach briefing was not accomplished. The aircraft overshot the approach centerline when turning inbound, because they did not try to intercept the outbound track from Advent. The crew showed a lack of situational awareness following their uncertainty of the aircraft position in relation to LLZ 28, caused by indications on the HSIs.
Situational awareness was also reduced because the pilots did not have a chart in front of them at all times. The crew was not aware that they could check the aircraft location in relation to the centerline with a VDF (VHF direction finder). The crew probably put too much emphasis on the indications displayed by the GPS. The aircraft descended into mountainous terrain without control over the lateral navigation. Despite uncertainty and disagreement in the group, the approach was not abandoned, as the aircraft should have climbed to a safe altitude while the problem was solved.
On 20 September, the surviving relatives of each decedent received 2 million Russian rubles (about US$40,000) for each person who died in the accident. Ukrainian relatives stated to Norwegian media that they had not received information about the cause and other issues surrounding the accident. At the time, Ukraine was experiencing very high unemployment, and Arktikugol offered wages many times what was then offered in mainland Ukraine. Many miners not only had to support their immediate family, but also relatives. Vnukovo Airlines stated on Ukrainian television that the relatives would receive US$20,000 per deceased person. About a year after the accident, all relatives had been offered US$20,000, but about two-thirds of them chose not to accept the amount, and instead started a process to sue the insurance company. Their lawyer, Gunnar Nerdrum, stated that according to both Norwegian and Russian law, they could demand at least US$140,000.
In February 1998, the Norwegian Ministry of Justice stated that the relatives did not have a right to occupational injury compensation from the Norwegian National Insurance. Because of the Svalbard Treaty, the archipelago is an economic free zone and Arktikugol is exempt from paying social insurance, so its employees did not have a right to Norwegian benefits. Had this been the case, widows would have received about NOK 600,000 per worker. By 1998, a few of the relatives had accepted the US$20,000 compensation, while the rest of them were planning to sue both the airline's insurance company and Arktikugol. Among the issues in the case, which took place at Nord-Troms District Court, was whether the accident was to be considered a working accident, and thus result in injury compensation from the mining company. In November, it was decided that the Ukrainians needed to make a guarantee for NOK 2.5 million to run the case, which they could not afford. They therefore had no alternative than to accept the proposal from the insurance company. In June 1999, the parties agreed on a settlement, where the compensation was not disclosed to the public. It was later disclosed that the settlement was about three times the initial offer from the insurance company. In 1999, the Norwegian Ministry of Foreign Affairs established a scholarship to help children who lost a parent in the accident to take senior secondary and tertiary education.
- Faremo, Grete (26 September 1996). "Flyulykken på Svalbard" (in Norwegian). Government.no. Retrieved 26 August 2010.
- Accident Investigation Board Norway (1999): 15
- Accident Investigation Board Norway (1999): 7–8
- Accident Investigation Board Norway (1999): 7
- "Russian jet crash kills more than 140". The Intelligencer Record. Associated Press. 30 August 1996. p. C5. Retrieved 26 August 2010.
- Accident Investigation Board Norway (1999): 8
- Accident Investigation Board Norway (1999): 18
- Accident Investigation Board Norway (1999): 24
- Accident Investigation Board Norway (1999): 25
- Accident Investigation Board Norway (1999): 9
- Accident Investigation Board Norway (1999): 10
- "29 Aug 1996". Aviation Safety Network. Retrieved 26 August 2010.
- Steffensen, Marianne (28 September 2005). "En moderne spøkelsesby". Dagbladet (in Norwegian). Archived from the original on 4 June 2011. Retrieved 26 August 2010.
- Accident Investigation Board Norway (1999): 36
- Accident Investigation Board Norway (1999): 4
- Accident Investigation Board Norway (1999): 80
- Accident Investigation Board Norway (1999): 83
- Accident Investigation Board Norway (1999): 84
- Strøm, Ole Kristian; Nielsen, Bengt; Mortensen, Terje (21 September 1996). "Avskjed". Verdens Gang (in Norwegian). p. 3.
- "Svalbard-ylykken: Tøff økonomisk framtid for etterlatte" (in Norwegian). Norwegian News Agency. 22 September 1996.
- Tonstad, Per Lars (29 August 1997). "Et år etter Svalbard-ulykken: Pårørende lever i nød". Dagbladet (in Norwegian). p. 12.
- Rapp, Ole Magnus (1 March 1998). "Gruve-enkene nektes erstatning". Aftenposten (in Norwegian). p. 2.
- Mogård, Lars Egil (15 April 1998). "Utsatt rettssak om Svalbard". Nordlys (in Norwegian). p. 5.
- Mogård, Lars Egil (5 November 1998). "Etterlatte fra Ukrania fikk". Nordlys (in Norwegian). p. 5.
- Gjerde, Robert (2 June 1999). "Forlik om Svalbard-erstatning". Aftenposten (in Norwegian). p. 5.
- Tonstad, Per Lars (26 August 2006). "Her døde 141 mennesker". Dagbladet (in Norwegian). p. 16.
- Idås, Bård (21 April 1999). "Norsk håndslag til Svalbard-etterlatte". Aftenposten (in Norwegian). p. 3.
- Accident Investigation Board Norway (2 November 1999). "Report on the Accident to Vnukovo Airline's Tupolev Tu-154M RA 85621 Near Svalbard Airport Longyear, Norway on 29 August 1996". Archived from the original on 11 May 2012. Retrieved 26 August 2010.CS1 maint: BOT: original-url status unknown (link)