Final Report Boeing 747-412F TC-MCL
2
1.
FACTUAL INFORMATION ..................................................................................................................... 10
1.1. 1.2. 1.3. 1.4. 1.5.
1.19.
HISTORY OF FLIGHT.................................................................................................................................... 10 INJURIES TO PERSONS ................................................................................................................................. 11 DAMAGE TO AIRCRAFT ............................................................................................................................... 11 OTHER DAMAGE ......................................................................................................................................... 26 PERSONNEL INFORMATION ......................................................................................................................... 27 1.5.1. Crew Members Information ....................................................................................................... 27 1.5.2. ATC Personnel Information ....................................................................................................... 29 AIRCRAFT INFORMATION ............................................................................................................................ 31 METEOROLOGICAL INFORMATION .............................................................................................................. 35 AIDS TO NAVIGATION, LANDING AND ATC ................................................................................................ 41 COMMUNICATION AIDS .............................................................................................................................. 48 AERODROME INFORMATION ....................................................................................................................... 48 1.10.1. Aerodrome Equipment ............................................................................................................... 49 1.10.2. Electrical and Airfield Lighting Support Equipment ................................................................. 49 FLIGHT RECORDERS.................................................................................................................................... 55 INFORMATION ON CONDITIONS OF AIRCRAFT FRAGMENTS AND THEIR LOCATION AT THE ACCIDENT SITE ... 58 MEDICAL INFORMATION AND SHORT SUMMARY OF AUTOPSY EXAMINATION RESULTS ............................... 67 SURVIVAL ASPECTS .................................................................................................................................... 67 SEARCH AND RESCUE OPERATIONS ............................................................................................................ 68 TESTS AND EXAMINATIONS ......................................................................................................................... 69 1.16.1. Fuel samples examination ......................................................................................................... 69 1.16.2. FCC examinations ..................................................................................................................... 69 1.16.3. Flight test of the ILS .................................................................................................................. 70 INFORMATION ON ACCIDENT-RELATED ORGANIZATIONS AND ADMINISTRATIVE ACTIVITIES ...................... 70 ADDITIONAL INFORMATION ........................................................................................................................ 71 1.18.1. On amendments to training programs, procedures and related documentation of ACT Airlines 71 NEW METHODS, USED DURING INVESTIGATION ........................................................................................... 72
2.
ANALYSIS ................................................................................................................................................... 73
3.
CONCLUSION .......................................................................................................................................... 115
4.
SHORTCOMINGS, REVEALED DURING THE INVESTIGATION ................................................ 117
5.
SAFETY RECOMMENDATIONS.......................................................................................................... 118
1.6. 1.7. 1.8. 1.9. 1.10.
1.11. 1.12. 1.13. 1.14. 1.15. 1.16.
1.17. 1.18.
INTERSTATE AVIATION COMMITTEE
