Status: | Accident investigation report completed and information captured |
Date: | Tuesday 25 December 2012 |
Time: | 08:53 |
Type: | Fokker 100 |
Operator: | Air Bagan |
Registration: | XY-AGC |
MSN: | 11327 |
First flight: | 1991-02-22 (21 years 10 months) |
Total airframe hrs: | 27378 |
Cycles: | 32584 |
Engines: | 2 Rolls-Royce Tay 650-15 |
Crew: | Fatalities: 0 / Occupants: 6 |
Passengers: | Fatalities: 1 / Occupants: 65 |
Total: | Fatalities: 1 / Occupants: 71 |
Ground casualties: | Fatalities: 1 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | ca 1 km S of Heho Airport (HEH) ( Myanmar)
|
Phase: | Approach (APR) |
Nature: | Domestic Scheduled Passenger |
Departure airport: | Mandalay International Airport (MDL/VYMD), Myanmar |
Destination airport: | Heho Airport (HEH/VYHH), Myanmar |
Flightnumber: | W9011 |
Narrative:An Air Bagan Fokker 100 aircraft registered XY-AGC departed Yangon International Airport, Myanmar on a domestic scheduled passenger flight to Mandalay International Airport with the captain as pilot flying. The aircraft was refueled at Mandalay after 60 passengers disembarked and 46 passengers boarded. The captain made the briefing and completed the aircraft checks. At 08:26 local time, the flight departed Mandalay to Heho Airport. The first officer was designated as the Pilot Flying for the flight.
The aircraft climbed to FL130 and the captain contacted Heho ATC at 50 NM from Heho. Heho ATC provided the present weather condition (wind calm, visibility 3000 m, distinct fog, temperature 17°C, QNH 1018 mb, runway 36 in use). At about 08:36 local time, the first officer started the crew briefing. The aircraft started descend to 9000 ft and continued to overhead the Heho NDB. At about 08:47 local time, while heading 220 degrees and descending to 6000 ft the flight commenced a non-precision Non Directional Beacon (NDB) approach to runway 36.
During the final inbound track at about 2.5 NM to the runway at 08:52, the EGPWS aural warning called out "500". The captain initiated "Alt hold" at about 08:53, just before the EGPWS alert "100" "50" 40" "30" and the aircraft struck 66 KV power lines, trees, telephone cables, a fence and collided with terrain short of the runway, coming to rest approximately 0.7 NM from the threshold. During the ground collision, both wings separated and a fire commenced almost immediately. An emergency evacuation was initiated by the cabin crews. One aircraft occupant and one motorcyclist on the ground were fatally injured, 70 of the occupants and one motorcyclist survived and the aircraft was destroyed by fire.
Probable Cause:
Primary Cause:
- During the final approach, the aircraft descended below the MDA and the crew did not follow the operator SOP's.
- The pilots had no corrective action against to change VMC to IMC during bad weather condition and insufficient time for effective respond to last moment.
Secondary Cause:
- Captain of the aircraft had insufficient assessment on the risk that assigned the FO as PF.
- There may be under pressure by the following aircrafts as the first plane on that day to Heho.
Accident investigation:
|
Investigating agency: | MAIB Myanmar |
Status: | Investigation completed |
Accident number: | Final report | Download report: | Final report
|
|
Classification:
VFR flight in IMC
Collision with pole or wires
Controlled Flight Into Terrain (CFIT) - Ground
Sources:
» Two confirmed dead in Shan State plane crash (Mizzima, 25-12-2012)
»
Air Bagan» Burmese authorities promise investigation into fatal plane crash (Mizzima, 26-12-2012)
» Myanmar Accident Investigation Bureau (MAIB) Final Report
Follow-up / safety actions
MAIB issued 3 Safety Recommendations
Issued: -- | To: DCA Myanmar | XY-AGC (1) |
Department of Civil Aviation ensure the Air Operator\'s implementation of FDR analyses Programmes. |
Issued: -- | To: Air Bagan | XY-AGC (2) |
Air Bagan operation ensure the qualitative requirements of operational personal with non-precision NDB approach training with IMC, awareness of MDA, and EGPWS alert. |
Issued: -- | To: Air Bagan | XY-AGC (3) |
Air Bagan operation ensure to access multi-crew operation of CRM training, supervision of captain and the risk FO to perform the PF. |
Show all...
Photos
accident date:
25-12-2012type: Fokker 100
registration: XY-AGC
accident date:
25-12-2012type: Fokker 100
registration: G-BXWE
Video, social media
Aircraft history
22 FEB 1991 |
PH-EZL |
Fokker Aircraft BV |
first flight
|
25 JUN 1991 |
PH-CFE |
Fokker Aircraft BV |
registered
|
1991 |
(G-FIOX) |
(Air Europe) |
destined for Air Europe, but the airline went bankrupt in 1991
|
29 OCT 1993 |
F-GJAO |
Air Littoral |
registered
|
30 NOV 1995 |
PH-CFE |
Fokker Aircraft BV |
registered
|
13 MAY 1996 |
PH-CFE |
British Midland Airways |
|
06 JUL 1998 |
G-BXWE |
British Midland Airways |
registered
|
29 OCT 2003 |
G-BXWE |
British Midland Airways |
incident: returned to landed following drop in cabin pressure (AAIB)
|
14 AUG 2004 |
G-BXWE |
British Midland Airways |
incident: landed at London-Heathrow with nose landing gear unsafe indication (AAIB)
|
01 JUL 2005 |
XY-AGC |
Air Bagan |
registered |
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Mandalay International Airport to Heho Airport as the crow flies is 135 km (84 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.