MH17: как и кто?

Информация о пользователе

Привет, Гость! Войдите или зарегистрируйтесь.


Вы здесь » MH17: как и кто? » Иран » Flight PS752 Accident Investigation: Final Report


Flight PS752 Accident Investigation: Final Report

Сообщений 121 страница 147 из 147

121

Стр. 119

5.5. Risk Assessment
5.5.1. Risk Assessment by the State Managing the Airspace
As the missile attack on Al Asad base had been planned in Iran, there was
enough time and information at hand to predict the situation and assess
the risk for civil flights in Iranian airspace.
Due to the information classification, the risk assessment had been done
before, and the mitigating measures had been planned to reduce the risk
to civil aircraft.
The civil sector had been notified of such measures, which were
thoroughly performed accordingly.
Eventually, the actual risk for the “misidentification of civil aircraft
departing from an international civil airport following the defense
system’s initial identification” exceeded the risk level predicted, making
the planned measures for this type of operation concerning the PS752
ineffective, due to the materialization of an unforeseen chain of events.
At the time, other flights had taken off form IKA, though a
misidentification causing a missile launch at them never occurred.
Considering that the pattern of error making and the materialization of its
consequences follow the famous patterns of the chain of events or Swiss
Cheese Model, it is concluded that the presence of grounds for errors is
not equivalent to the occurrence of final event. In other words, it is only in
special and rare conditions that the entire chains necessary for the
accident to occur are formed, while in other cases, by breaking one of the
links in the chain or the effective performance of one of the anticipated
defense layers, the existing latent condition would become unlikely to be
materialized.
In order to realize what happened in military side, investigate the role of
civil aviation operation in this event, and provide an answer into how the
existing error caused an accident for this certain flight, the investigation
team still submitted a request for investigating the measures and events
leading to the missile launch in addition to the actions having been
planned to prevent it. The military sector and the judicial authority

122

Стр. 120

responsible for this accident provided the information required to the
investigation team accordingly.
The investigation team found that the operating military unit was not
basically responsible for monitoring the targets; it was just obliged to
perform the actions planned within the command hierarchy only if a
target was assigned to them from the command center.
Following a tactical relocation, the relevant ADU failed to adjust the
system direction out of human error, causing the operator to observe the
target flying west from IKA as a target approaching Tehran from the
southwest at a relatively low altitude.
The target specifications were announced to the command center, but the
message was never relayed. Without receiving a go-ahead or response
from the command center, he came to identify the target as a hostile one
and fired missile at the aircraft against the procedure planned.
The chain of events observed by the investigation team leading to firing
missile at PS752 is illustrated in Figure 56.

123

Стр. 121
https://a.radikal.ru/a09/2103/8e/d60f006b03e3.jpg
Figure 56- The chain of events leading to firing missile at PS752
The existence of this threat and the possibility of such chains being formed
had not been predicted, and had not been considered in the calculations
of the risk associated with misidentification.
The chain leading to the accident demonstrates the extent to which the
hazards resulting from human performance are serious with a farreaching consequence. It shows how much the ignoring the contribution
and the possibility of complex combinations of rare events, could affect
the accuracy and efficiency of risk management.
If normal condition with no conflicts or the possibility of that is considered
at one extreme end, and on the other hand, a major military conflict at
another extreme end, there would be a spectrum in between, where a
series of measures must be taken to ensure the safety of civil aviation, from
no operational restriction to the suspension of any civil operation
depending on the very conditions.

124

Стр. 122

In vast geographical areas, due to differences in the amount of risk in
various parts of an area, the set of measures governing one area may vary
from those governing another one.
To reduce the probability of hazards for civil sector, military forces
normally implement measures to minimize overall organizational errors
and their associated consequences, as well as eliminating the contributing
factors. All these analyses would form the basis for the development of
operational procedures. Considerations related to human errors and their
tolerability, the classification and definition of various conditions, such as
normal, different levels of alertness, conflict and requirements of the
operating environment, hardware, procedures, command hierarchy,
human performance, among others are taken into account in developing
the operational procedures.
Once all the considerations and executive measures have been
implemented, there will be a level of residual risk that must be
commensurate with the operational context. The more operations, the
higher the probability of an error, and the need for the contributing factor
to be reduced to such an extent that the residual risk is maintained at an
acceptable level.
During the conditions when the PS752 accident happened, the risk of
commercial aircraft being accidentally struck while trying to target the
hostile aircraft was estimated to have been negligible before the start of a
military operation. Nonetheless, given the fact the Iranian air space is
always monitored independently of a military attack, the risk of
misidentification is also considered at all time, which was higher in the
alertness conditions at that time.
It can finally be concluded that the risk assessment conducted was not
commensurate with the real conditions at the time, and an unpredicted
chain of events was materialized at the end.
The investigation team requested the authorities who had done the risk
assessment to repeat the assessment considering the information
gathered after the accident. The result of such assessment was similar to
the previous one, and again, clearance for PS752 to conduct the flight was

125

Стр. 123

evaluated to be safe and coordination with air defense before startup
approval was evaluated to be enough to eliminate the possibility of
misidentification.
The investigation team found that in the conducted risk assessment, only
the steady state of conditions had been considered. In other words, only
the elements of hazards raised from the alertness of the military forces
had been taken into account, but no element representing the rapid
transition from one alertness level to another had been stipulated in
calculations.
The investigation team identified three states for any change between the
two hazard levels. The first state is the initial state of the system. After the
change of condition to the next hazard level, due to the occurrence of a
change in conditions which is initially unknown in terms of the extent,
duration and dimensions, the system enters a transient condition. When
the new condition remains stable and the elements of system, including
humans get used to the new condition, the system enters into the next
steady state level.
This is while entities who had conducted the risk assessment considered
only the three following levels of hazards and defined and implemented
the related safety measures.
The first level was the initial condition. It was predicted that after the
missile attack on Al Asad airbase, the system would enter the second level,
namely the alertness condition. In case of a counterattack, the conflict
condition as the third level had been predicted with strict safety measures
including the no-fly zone.
Transient condition is applicable to all systems. Each level of conditions
has its own hazards and any change in condition includes special hazards
related to the nature of change. At the time period close to the change, the
change hazards must be added to hazards related to the new condition
until the system enters steady state and the hazards related to change
disappear.
During the investigation, some studies were done to determine the
characteristics of transient condition.

126

Стр. 124

The time period and level of hazards associated with transient condition
are related to the range of change and the components of the system, and
defining the characteristics of transient condition would not be accurate
and real at this step. However, from the human factors perspective, it
seems that the transient condition period must last longer than the
working hours of the personnel who were working in the system at the
time of transition. The personnel who work in each section of the system
are less affected by the change of condition, at least in terms of situational
awareness, if they start their work shift after that change, and obviously,
if the change happens during their work shift, they are more affected by
this change.
In PS752 accident case, taking into account that the prevailing conditions
rapidly changed at about 02:00, it is likely that at the time of the accident,
the transition time was not finished yet and this transient condition
contributed to human errors and the existing hazards within the whole
system.
An illustration of this concept is shown in Figure 57.
https://a.radikal.ru/a33/2103/ee/7d5a3fc0a262.png
Figure 57- Alertness levels and risk in transient condition

127

Стр. 125

5.5.2. The Airline’s and the State of the Operator's Risk Assessment
In PS752 accident condition, it was found that some airlines had
performed a risk assessments in a short period of time and implemented
various measures to the point of suspension of their flight operations in
some areas.
It was also found that some States quickly set and announced restrictions
on the activities of airlines under their oversight.
However, some had not taken any clear action on the situation, and others
had not made any assessment of the situation at a pace commensurate
with that changing trend.
As for PS752, no restriction whatsoever had been imposed neither by
Ukraine nor the UIA.
Figure 58 illustrates the risk assessment flowchart for the operators
provided in ICAO DOC10084. The first step of assessment is collecting
information, whose source could be the published aeronautical
information, the special information provided to the operators by the
States, special information network -where the States and operators
participate-, aerodromes as well as open source information.
the collection of relevant information is a vital step in the success of risk
assessment, because if the information is not available or is not collected
properly and in a timely manner, the risk assessment process can not be
initiated.
The speed of information collection and the vastness of its sources become
far more important during the conditions like those in PS752 accident,
when the changes were very rapid and in the order of few hours than when
they do over a longer period of time, about a few days.
The conditions changed at such a pace and time that the exclusive sources
for the provision of aviation-related information useful for the airlines did
not publish any new information, but the open and public sources had
released the news on the attack to Al Asad base hours before, and official

128

Стр. 126

authorities in the States issued statements and notifications about that
event.
The investigation reveals that such information sources was not
considered in the risk assessment by the operators who had departure
schedule from IKA..
https://c.radikal.ru/c24/2103/f0/bf21d970f6be.png
Figure 58- flow chart of the risk assessment cycle for operators and service provider

129

Стр. 127

It is observed that the airlines and operators tend to consider the NOTAMs
issued in the form of “conflict zones” bulletins as an information source to
initiate the risk assessment process.
This is while such bulletins or notifications, like NOTAMs, normally
contain prohibition and restriction made through a risk assessment
process, obtained on the basis of some initial information.
That is, such notifications and bulletins are some information-bound
mandates. Although their content can be utilized as information to initiate
another process, the very initial information leading to the issuance of
those notifications must be collected and analyzed by operators.
5.6. Availability of Information for Risk Assessment
The change in the military condition was public and widely reported in the
media. At around 02:40 Jan. 08 2020, the official authorities of the U.S.
and Iran had announced the strike against the Al Asad airbase in Iraq.
Actually, the open source information about this issue was available to
States and various airlines to conduct an assessment of the situation.
Apart from the tensions having existed in the Middle East for many years,
the U.S. had declared a drone strike against one of the Iranian top
commanders at Baghdad airport, following which Iran announced
revenge would definitely be taken. As such, there had, certainly, been
adequate information to pay more heed to the condition in the region and
possible hazards at the time.
Iran ANSP had implemented changes in the way air traffic flow was
managed, based on already planned measures for mitigating the risk to
civil aviation from military alertness but the related NOTAMs had issued
hours after the accident.
At first, due to limited traffic demand, the management of traffic flow was
practicable with operational technics. By the increase in traffic volume,
NOTAMs were issued to change the traffic flow scheme.
The investigation team investigated the reasons for time difference
between the execution of measures and issuance of NOTAMs

130

Стр. 128

Operationally, all the planned measures were implemented promptly, but
the ANSP assumed that based on definitions and criteria for issuance of
NOTAM in ICAO Annex 15, NOTAM is an operational tool for people
involved in air navigation, and the workload and predicted traffic was in
such a way that the operational technics were enough to manage the
demand. As a result, it was assumed that issuance of NOTAM was not
necessary for management of air traffic at that time.
The issuance of NOTAMs, in addition to the operational benefits
associated with air navigation and air traffic flow management, can be
used as a significant source of information about changing conditions in a
flight zone to analyze the flight risk. Taking this into account, if there is a
change in the way airspace is managed for military or security reasons at
any time, NOTAMs will prove effective. In other words, apart from direct
operational application of NOTAMs, they can be used as a source of
information for assessment of risk for operations even outside of the scope
of that NOTAM.
It should be noted that the planned limitations were implemented, and
within the very limitations and considering the planned route, the
initiation of Flight PS752 was assumed to be safe. The existence of
NOTAMs would not impose any limitations on flight PS752, but it was
possible that by receiving such NOTAMs, which did not affect the flight
route, a process of risk assessment was initiated by departing airlines from
IKA.
5.7. Effective Implementation of Standards and Measures
Various standards and measures have been envisaged and set by ICAO for
safe management in PS752-like conditions.
Thanks to the investigation conducted into the MH17 accident, and
following up on the implementation of its recommendations, greater
attention has been paid to the development of necessary regulations and
structures and their effective implementation.
On the other hand, the implementation of such new requirements in
States and the establishment of national regulations for airlines to manage

131

Стр. 129

flight risk in a situation, where potentially hazardous military activities
are occurring, have been inconsistently conducted.
It can be understood that the effective implementation of safety oversight
elements in States regarding the requirements developed by ICAO for
years are applied by them in a tangible and daily manner, yet still needs
to be improved (Figure 59).
https://b.radikal.ru/b02/2103/f6/ef2e345a48a1.png
Figure 59- Effective implementation of the safety oversight elements in the world in various areas - ICAO Safety
Report
As a result, given their newness, the status of implementation of measures
in the field of aviation activity in areas where potentially hazardous
military activities are underway cannot be better than that of traditional
aviation standards, hence monitoring their effective implementation in
Sates and assisting them to do so as for these patterns is essential.
Since conditions vary from one area to another, it is necessary to have a
regional approach to assist and monitor the implementation of such
measures, taking into account the conditions and priorities of each region.
5.8. Similar Accidents
5.8.1. Transparency and Speed in the Announcement of Events
Transparency and acknowledgment of events leading to similar accidents
have always been an important challenge.

132

Стр. 130

As far as civil aviation safety is concerned, reporting errors and their
associated details are always encouraged. There are a variety of tools to do
so, which in turn will promoting safety. In accidents, where an aircraft has
been targeted by weapons, some of the factors involved in its occurrence
fall outside the context of civil aviation and the procedures governing it,
so the implementation of common measures in civil aviation to encourage
reporting without apportioning blame is seriously challenged.
Further, to discover and prove the reality, a vast number of resources are
wasted simply due to secrecy, confidentiality or denial of the event, not to
mention the harm caused to the precious data and time to enhance safety.
A review on the previous similar accidents indicate that operating military
or para-military forces did not admit their role in the accidents openly,
putting the blame on other parties and trying to downplay their own role
in such occurrences.
In the meantime, PS752 was one of the accident cases where the operating
military forces publicly announced their role in it within a short time
period. Providing the accident investigation team with access to the details
allowed them to focus on the underlying factors besides the corrective and
preventive measures instead of wasting resources to discover the reality
behind the event.
5.8.2. The Proportion of Military Threats in Civil Aviation Safety
Figure 60 indicates the results of a review on the number of fatalities in
air accidents of aircraft above 5700 kg from 2008 to September 2020, in
terms of three important safety factors, including Runway Safety,
Controlled Flight into Terrain and Loss of Control, Other Factors, and
Hazardous Military Activities for Civil Aviation. The data of this graph is
obtained from ICAO15 reports while fatalities of MH17 and PS752
accidents are added as a new risk factor.


15 - https://www.icao.int/safety/iStars/Page … stics.aspx

133

Стр. 131

https://b.radikal.ru/b36/2103/c2/7d8a6e47ff0a.jpg
Figure 60- Aviation Accident Fatalities by Risk Factors
Despite being considered a very rare occurrence, targeting a civil aircraft
by weapons has claimed more lives than the events resulting from runway
safety on commercial flights with aircraft above 5,700 kg since 2008. Of
course, the nature of military threats is completely different from other
types of threats, and in terms of safety analysis, their probability are lower
but have a higher severity of consequences.
A key challenge for mitigating such a risk factor would entail access to
data, reconsidering the strategies and procedures at international,
regional and national levels.
The fact is following the aircraft crashes of 1983 in Korean airlines, 1988
Iran Air, 2014 MH17 in Ukraine, the global approach to this hazard has
undergone fundamental changes. Such crashes have, in effect, paved the

134

Стр. 132

way for a reconsideration of the issue at hand and the development of
mechanisms leading to improvement.
Proven safety lessons show that for any fatal accident, there are a
significant number of near-miss cases. Such cases are always an effective
tool to seize the opportunity to correct and improve performance before
an unfortunate event occurs. Nevertheless, in the case of hazardous
military activities for civil aviation, only the statistics revealed following a
fatal accident are citable and analyzable. Misidentification, wrong
unnecessary interception, increased alertness due to an authorized civil
aviation operation and failed firings are among the cases that have not
been probed and analyzed just because they passed off well. This is while
these are the very events and untapped conditions which will provide the
ground for unfortunate and deadly occurrences. In other words, the
mentioned crashes are only the visible part of an iceberg whose bigger
portion is hidden. (Figure 61)
https://c.radikal.ru/c03/2103/eb/19ea94c0bbf2.jpg
Figure 61- The announced air accidents; Iceberg Model and the abundance of near-miss events
Although in recent years, especially after the MH17 accident, much
attention has been continuously paid to aviation safety against military

135

Стр. 133

activities, it can be said that, in comparison with other safety factors, there
is still no reporting and data-driven improvement, which causes
significant revisions and improvements to be considered only after a fatal
accident.
The Iceberg Model suggests that this hazard might occur quite often in
different parts of the world, and that the investigated accidents are only
signs of hidden conditions in the international air transport.
There is a significant correlation between such events and geographical
areas and political conditions. Naturally, the type of hazards in these areas
varies from one to another. In some areas, in line with their aim to pose
security threats, militant groups’ activities are more distinct, seeing
commercial aircraft suitable targets for demonstrating their power and
dominance therein. In others, however, the presence of criminal groups
armed with dangerous weapons to commercial aircraft is more worrying.
There are military threats between countries in some regions, and in other
conditions, trans-regional military forces are present in third countries.
This altogether suggests that the assessment and evaluation of conditions
must be continuous and contextual, geographical and time-dependent,
and that only when the integrated mechanisms have different information
sources can they produce different outcomes that prove effective for that
area and situation. This requires the establishment of a statistical system
and much more data than the announced accidents.
A significant proportion of this data is now provided by monitoring threat
and tension levels. Since military systems are a large and important
component of this set, it has to be determined that the available risk in
their system, created by a wide assortment through organizations,
hardware, software, manpower and environmental conditions have still
remained in balance with the civil aviation operation level after analyzing
the conditions and adopting the defensive layers pertinent to the very
condition. It is possible to assess this balance in the military sector, which
possesses its own performance information, analytically, but the part of
the threat related to the performance of another military force cannot be
properly analyzed. Nor does the civil sector have accurate information
about the level of tolerable error in the military one.

136

Стр. 134

6. Conclusions
6.1. Findings
1. At 06:12, on January 08, 2020, Flight PS752 operated by UIA, an
airworthy Boeing 737 registered UR-PSR, along with qualified flight
crew, took off from IKA runway and crashed at 06:18 near the
airport.
2. The aircraft was misidentified as a hostile target by an air defense
unit; two missiles were fired at PS752.
3. At 06:14:56, the warhead of first launched missile detonated in the
proximity of the aircraft and, almost simultaneously, the aircraft
transponders stopped transmitting radio signals, together with the
termination of the FDR recording.
4. The missile detonation near the aircraft caused damage to the
aircraft systems, after which the cascading damage was observable.
5. After the detonation of the first missile, the three cockpit crew
members were all still alive. They appeared to have sustained no
physical injuries and were just involved in managing the situation.
6. At 06:15:09, the second missile was launched towards the aircraft
by the air defense unit. It is likely that this missile did not affect the
aircraft, yet it is not possible to comment on this explosion and its
impact with acceptable certainty.
7. The aircraft had maintained its structural integrity by the time it
crashed into the ground and exploded at 06:18:23 in Khalajabad
near Shahriar, the southwest of Tehran.
8. The automatic ELT had been activated, and due to the impact
severity its signal-transmitting antenna to satellites was detached;
the international satellites did not succeed in locating the crash site.
9. According to the ELT manufacturer the internal structures of
survival ELTs are unable to withstand impacts, thereby their
internal systems might have been damaged due to the impact
severity.
10. Neither the aircraft technical and operational condition, nor
its flight path and altitude contributed to the misidentification.
11. Within the airspace management, the information based risk
assessment had been conducted, and various mitigations had been

137

Стр. 135

devised to provide civil aviation safety for the threats caused by
potentially hazardous military activities.
12.In the risk management, only the stable conditions was considered,
not the transient conditions.
13.Civil-Military coordination was done according to the planned
program and the considered mitigation measures for reduce the risk
of misidentification and mistargeting of civil aircrafts was
implemented in both civil and military sectors.
14.The risk management was not effective due to occurrence of an
error, which had not been previously predicted.
15.The UIA and the State overseeing it had not imposed restrictions or
prohibitions on the flight PS752.
16.No airline with departure schedule from IKA in the day of accident
imposed restriction on their flights on the basis of risk assessment
of flight route safety.
17.The process of information collection from open and public sources
in airlines, which forms the basis of risk assessment in potentially
hazardous military activities scope, has not yet tuned into a
procedure, at least not for the times when changes occur so rapidly.
Even though some airlines and States had imposed restrictions
using open and public information, none of the airlines whose
flights departed from IKA had made any change in their flights on
the basis of a risk assessment.
6.2. Accident Causes and Contributing Factors
6.2.1. Cause of the Accident
The air defense’s launching two surface-to-air missiles at the flight
PS752, UR-PSR aircraft, the detonation of the first missile warhead
in proximity of the aircraft caused damage to the aircraft systems,
and the intensification of damage led the aircraft to crash into the
ground and explode instantly.

138

Стр. 136

6.2.2. Other Contributing Factors
The mitigating measures and defense layers in risk management
proved to be ineffective due to the occurrence of an unanticipated
error in threat identifications, and ultimately failed to protect the
flight safety against the threats caused by the alertness of defense
forces.

139

Стр. 137

7. Safety Actions Taken and Safety Recommendations
7.1. Safety Actions Taken
- The NOTAM procedure was revised by Iran Airports & Air
Navigation Company (ANSP) to promptly issue NOTAM about any
change in Tehran FIR airspace management that results from the
outcome of a conducted security risk assessment or military
instructions.
- In order to provide even further access for the users outside of the
aviation communication networks, the "Airspace Safety and
Security Warning" section was created on the Iran Aeronautical
information Management (AIM) website as a repository to
announce security NOTAMs regarding airspace. This website has
been launched since December 03, 2020, which was notified to
users via AIC 2-20 and ICAO in a separate letter.
- The concept of transient risks was added to the risk assessment
procedures of Civil and Military organizations responsible for safety
and security of Tehran FIR.
In the amended procedures, an additional risk called "adaption risk"
has been added to available risks for each change in level of threats
to civil aviation. The specification of the nature and duration of
related safety measures shall be defined during each risk assessment
task. For each change in existing situation, an adaption period has
been considered, where "adaption risk" and related safety layers
shall be applicable during that period.
- CAO.IRI ATM/ANS safety oversight manual was amended to
include oversight activities of the risk management of potentially
hazardous military activities. The ANSP is mandated to perform
periodic airspace security management exercise.
- Iran Military authorities informed AAIB that based on their
investigation results, adequate corrective actions have been
implemented for prevention of events which caused
misidentification of flight PS752.

140

Стр. 138

7.2. Safety Recommendations
7.2.1. To the States Managing the Airspace:
- Promptly issue NOTAMs regarding any limitation or any
change on the provision of services followed by the change in
civil-military coordination status in short term, even if the
issuance of such NOTAMs appear to have no effect neither the
airlines flight operations nor the services provided by the State
managing the airspace operationally.
- Since during transition from a level of military alertness to a
higher one, the risk of whole system is affected by the nature
of transition apart from the new conditions, in risk assessment
of potentially hazardous military activities to civil aircrafts, in
case the types of changes in military alertness conditions or its
associated reason has not been frequently experienced before,
consider the risk of the misidentification or mistargeting at
times closer to transition more cautiously than stable
conditions.
- Conduct oversight on effective implementation of the
measures adopted for the risk management of potentially
hazardous military activities and perform periodic exercises
for risk assessment based on different types of probable
conditions; apply the results obtained from the monitoring
and exercises to identify the hidden threats and enhance the
risk management accordingly.
7.2.2. To the States Overseeing the Airlines:
- Conduct oversight on effective implementation of the
measures adopted for the risk management of potentially
hazardous military activities and perform periodic exercises
for risk assessment based on different types of probable
conditions; apply the results obtained from the monitoring
and exercises to identify the hidden threats and enhance the
risk management accordingly.

141

Стр. 139

- Ensure that the airlines are able to quickly apply the open and
public information issued by non-aviation sources in their
processes of risk assessment.
7.2.2. To ICAO:
- Revise the Standards related to the issuance of NOTAMs in
such a way that air navigation service providers promptly
issue the NOTAMs in case of any change or restriction
imposed in the provision of services due to potentially
hazardous military activities or civil-military cooperation
considerations independently of the
operational application, in a format that these NOTAMs
could indicate that the change has been made due to security
or military considerations.
- Develop a framework necessary for gathering information on
the near-miss accidents and events caused by targeting a civil
aircraft, including the provision of definitions and examples,
the method of information collection, reporting and sharing.
Such database should allow for the revision of relevant
standards and guidelines, as appropriate, based on
information submitted by States at national, regional and
international levels.
- Considering that the initiatives and measures established to
minimize the risks caused by potentially hazardous military
activities are newer compared to other traditional safety
measures, develop and/or amend related Universal Safety
Oversight Audit Programme (USOAP) and Universal Security
Audit Programme (USAP) protocol questions as necessary,
and prioritize the assessment of those States that should have
implemented such measures due to potentially hazardous
military activities in their airspace.
- Support and encourage States to improve the efficiency of risk
assessment of civil aircraft operations over or near conflict
zones, and civil-military coordination with due consideration
of the regional priorities and models.
- Given that more clarity of the regulations relating to switching
on the CVR, in such a way that it ensures the recording of the

142

Стр. 140
cockpit voices during checks, technical and operational
conversations, and decision making, would be beneficial for
safety and safety studies related to cockpit conversations.,
ICAO should revise and clarify the provisions in Annex 6 —
Operation of Aircraft and associated guidance material related
to switching on the Cockpit voice recorder (CVR).
- Given that information gathering is a key step to conduct flight
risk assessment in potentially hazardous military conditions,
review and enhance the available guidance material, such as
the Risk Assessment Manual for Civil Aircraft Operations
Over or Near Conflict Zones, Doc 10084, to provide further
assistance to States and aircraft operators on the nature and
method of gathering initial information, including its
difference with NOTAMs issued. .
- Study the effects of stable and transient conditions in risk
assessment, determine the threat level specifications in
transient conditions and update the provisions and associated
guidance material addressing civil aircraft operating over or
near conflict zones accordingly.
- The prevention of accidents would only be achieved through
identification of the root causes, issuance of safety
recommendations and implementation of the necessary
corrective measures. It was challenging to investigate the
actions and their root causes within the military sector; thus,
the investigation team requested the investigation of the
events leading to the missile launch and the corrective actions
planned to prevent recurrences. The relevant military sector
provided the information required accordingly. This
convinced the investigation team of the importance of
establishing well-advanced agreements on investigation
cooperation with the military authorities.
Recognizing the need for timely cooperation during
investigations of occurrences involving the military, ICAO
should develop or expand guidance material (e.g. MOU)
addressing cooperation and coordination between States’
accident investigation authorities and the military authorities.

143

Стр. 141
7.2.4. To the EUROCAE:
- The EUROCAE ED-62B Minimum Operational Performance
Specification for Aircraft Emergency Locator Transmitters
provide specifications for the design and manufacture of
emergency locating transmitters. The problem with the
antenna hardware connections failing between the ELT unit
and the ELT antenna is known to the aviation industry. To
improve this situation, the ED-62B specification need to be
assessed and revised.
It is recommended that EUROCAE revisit the EUROCAE ED-
62B Minimum Operational Performance Specification for
Aircraft Emergency Locator Transmitters to assess if the
specification adequately addresses the design of the hardware
connecting the automatic ELT unit to the ELT antenna.

144

Стр. 142

8. Table of Figures and List of Tables
8.1. Table of Figures
Figure 1-Scope of the investigation.......................................................................................... 12
Figure 2- The aircraft flight path detected by PSR and SSR.................................................... 21
Figure 3- Accident site scheme ................................................................................................23
Figure 4- Aircraft flight and maintenance log .........................................................................26
Figure 5- The planned flight path for PS752 according to the flight plan ...............................35
Figure 6- Flight PS752 trajectory.............................................................................................36
Figure 7- The first ground impact of the aircraft.....................................................................37
Figure 8- An overview of the aircraft parts distribution .........................................................38
Figure 9- Part of the aircraft wing ...........................................................................................39
Figure 10- A part of air conditioner found on ground before crash site..................................39
Figure 11- The aircraft left wing at the crash site.................................................................... 40
Figure 12- The aircraft right winglet....................................................................................... 40
Figure 13- Auxiliary Power Unit .............................................................................................. 41
Figure 14 - Closer view of the cockpit ......................................................................................43
Figure 15- Instructor pilot’s ID card .......................................................................................44
Figure 16- Hole in the fuselage with a trace of a different color of smoke ..............................45
Figure 17- Hole on the fuselage near the cabin with a trace of different color of smoke .......45
Figure 18- Hole on the fuselage near the cockpit and exhaust fumes .....................................46
Figure 19- Closer view of the hole on the fuselage near the cockpit and burn signs in the hole
area...........................................................................................................................................46
Figure 20- Crack with an outward hole in the skin of the structure near the cockpit.............47
Figure 21- Holes and cracks on vertical stabilizer ...................................................................47
Figure 22- The second heat exchanger found at the accident site and its installation point on
the fuselage ..............................................................................................................................48

145

Стр. 143

Figure 23- The two aircraft engines.........................................................................................49
Figure 24- Aircraft fuel test result ...........................................................................................52
Figure 25- One of the remaining passenger seats with holes in it...........................................54
Figure 26- Metal objects found in the passenger seats ...........................................................54
Figure 27- The wing piece found before the accident site .......................................................56
Figure 28- Gas chromatography–mass spectrometry; GC-MS, of aircraft wing skin piece.... 57
Figure 29- Pieces on which the explosive test was done ......................................................... 57
Figure 30- The GC-MS of the ELT and heat exchanger ..........................................................58
Figure 31- The interior of part of the aircraft cabin window pieces on which the explosive test
was done ..................................................................................................................................59
Figure 32- The GC/Mass test result from the interior of part of the aircraft cabin window Pieces
..................................................................................................................................................59
Figure 33 -Some of the aircraft parts free from explosives .................................................... 60
Figure 34- Flight Recorders similar to those installed on the accident aircraft, photo by BEA
.................................................................................................................................................. 61
Figure 35- FDR physical appearnce after the crash ................................................................62
Figure 36- CVR physical appearance after the crash...............................................................62
Figure 37- Fight recorders transferred to BEA........................................................................64
Figure 38- CVR memory card read-out at BEA laboratory using donor-chassis- Photo: BEA
..................................................................................................................................................65
Figure 39- FDR memory card read-out at BEA laboratory using donor-chassis - Photo: BEA
..................................................................................................................................................65
Figure 40- Drop of frequencies recorded in CVR. Photo:BEA ................................................67
Figure 41- The location of key events in missile launch .......................................................... 77
Figure 42- Dimensions of limitations in an airspace from different responsible parties ...... 80
Figure 43- Two no-fly zones in Iraq adjacent to Iran ..............................................................82
Figure 44- U.S. military bases around Iran – source: Washington Post.................................84
Figure 45- Civil-military Coordination Structure in Iran........................................................86

146

Стр. 144

Figure 46- Structure of data collection, risk analysis and implementation of measures related
to the management of potentially hazardous military activities to civil aviation operations 88
Figure 47- Civil-Military coordination structure at the operational level at the time of the
accident....................................................................................................................................96
Figure 48- PS752 planned route..............................................................................................98
Figure 49- The scope of Iran west routes and exchange points between Tehran and Baghdad
FIRs..........................................................................................................................................99
Figure 50- Transit flights status in the west of Iran FIR at PS752 takeoff time (source:
FlightRadar24).......................................................................................................................100
Figure 51- NOTAM issued for change in route scheme ......................................................... 101
Figure 52- NOTAM issued following the suspension of traffic exchange between Tehran and
Baghdad FIR ..........................................................................................................................102
Figure 53- BAW124 whose entry into the Iranian airspace was denied due to the suspension of
traffic exchange between Tehran and Baghdad FIR..............................................................102
Figure 54- The target direction in the reference ADU in the simulation with correct North
alignment ................................................................................................................................115
Figure 55- The target direction in the ADU in the simulation with repeated north alignment
error ........................................................................................................................................116
Figure 56- The chain of events leading to firing missile at PS752..........................................121
Figure 57- Alertness levels and risk in transient condition................................................... 124
Figure 58- flow chart of the risk assessment cycle for operators and service provider......... 126
Figure 59- Effective implementation of the safety oversight elements in the world in various
areas - ICAO Safety Report.................................................................................................... 129
Figure 60- Aviation Accident Fatalities by Risk Factors ........................................................131
Figure 61- The announced air accidents; Iceberg Model and the abundance of near-miss events
................................................................................................................................................ 132

147

Стр. 145

8.2. List of Tables
Table 1- The number and type of injuries to persons .............................................................. 21
Table 2- Transcript of communications between Tehran radar and IRC3768 flight..............30
Table 3- Key events recorded by IKA CCTVs...........................................................................32
Table 4- Results of X-ray fluorescence (XRF) spectrometry on the two samples found in the
passenger seat pads .................................................................................................................55
Table 5- The CVR transcript ....................................................................................................68
Table 6- Last recorded values of some important parameters; time column corresponds to the
time of recording......................................................................................................................73
Table 7- A summary of the Risk Management Model posed by the generic hazard of a possible
enemy air strike .......................................................................................................................93
Table 8- A summary of the Risk Management Model posed by the generic hazard of alertness
and operation of defense forces (This table is prepared by the investigation team for a coherent
presentation)............................................................................................................................95
Table 9- IKA departure schedule in morning on the day of the accident.............................. 103
8.3. List of Appendixes
Appendix A- CVR and FDR data extraction and preliminary analysis
Appendix B- Consultation


Вы здесь » MH17: как и кто? » Иран » Flight PS752 Accident Investigation: Final Report