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The Civil Aviation Organization of Islamic Republic of Iran investigating the crash of Iran Aseman ATR 72-212 has released an interim report on the causes of the fatal accident, which took the lives of 60 passengers as well as 6 crew members on 18 February 2018.
According to the document, many causes contributed to the crash, however, among the primary reasons that lead an aircraft impacting the mountainous terrain in Iran is “human error”, or to be more precise “Cockpit Crew action which has caused dangerous conditions for the flight“.
The captain (62, ATPL, 17,926 hours total, 12,519 hours on type) was also training pilot of the company and CAO examiner, he had flown to Yasouj twice in the last three months. The captain was pilot monitoring. The first officer (36, CPL, 1,880 hours total, 197 hours on type) was pilot flying.
The report says that depending on all evidence collected, the following cockpit crew errors were found:
- continuing to the Yasouj airport for landing against Operation manual of the Company, due to low altitude ceiling of the cloud and related cloud mass; they should divert to alternate airport;
- descending to unauthorized altitude below minimum of the route and MSA;
- lack of enough CRM during flight;
- failure to complete the stall recovery (flap setting, max RPM);
- inappropriate use of Autopilot after Stall condition;
- inadequate anticipation for bad weather based on OM (Clouds, Turbulence, and Icing …);
- quick action to switch off anti-ice system and AOA;
- failure to follow the Check lists and standard call out by both pilots.
Among the contributing factors appeared (but are not only limited to) the following:
- the airline was not capable to detect systematic defectives about:
- effectiveness of crew training about Meteorology, OM, SOP, …
- enough operational supervision on pilot behaviors;
- the lack of SIGMET about Mountain Wave or Severe Mountain wave;
- unclear procedure for stall recovery in FCOM;
- lack of warning in aircraft manuals by manufacturer for flight crew awareness about mountain wave;
- lack of APM System to alert crew about performance degradation.