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Flight PS752 Accident Investigation: Final Report

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https://newsmedia.tasnimnews.com/Tasnim … 244374.pdf

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The Aircraft Accident Investigation Board of the
Islamic Republic of Iran
Flight PS752 Accident Investigation
Final Report

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In the Name of God
Crash of
Ukraine International Airlines
Flight PS752
AAIB File Number: A981018URPSR
Type of Occurrence: Accident
Date of Occurrence: Jan. 08, 2020
Place of Occurrence: Near IKA Airport (OIIE) - I.R of Iran
Aircraft Type: B737-800
Registration: UR-PSR
Date of Issue: Mar. 15, 2021

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Table of Contents
Abbreviations and Definitions...................................................................................................5
Special Foreword To English Edition ........................................................................................8
Foreword....................................................................................................................................9
Summary.................................................................................................................................. 10
1. Introduction........................................................................................................................11
1.1. Accident Investigation Institution............................................................................. 11
1.2. The Objective and Scope of the Accident Investigation ............................................ 11
1.3. Investigation Methodology and Participating Parties...............................................13
1.4. Previous Reports........................................................................................................ 15
1.5. Other Investigations .................................................................................................. 15
1.6. Points to Consider in This Report .............................................................................16
2. Factual Information........................................................................................................... 18
2.1. Flight History.............................................................................................................18
2.2. Injuries to Persons:....................................................................................................21
2.3. Identification of Victims ........................................................................................... 22
2.4. Damage to Aircraft ................................................................................................... 22
2.5. Other Damage........................................................................................................... 22
2.6. Organizational and Managerial Information ........................................................... 23
2.7. Personnel Information ............................................................................................. 24
2.8. Aircraft Information ..................................................................................................25
2.9. Meteorological Information ..................................................................................... 29
2.10. Aids to Navigation .................................................................................................... 29
2.11. Communications....................................................................................................... 29
2.12. Aerodrome Information: .......................................................................................... 32
2.13. Flight Path, Impact Point and Wreckage Information............................................. 34

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2.14. Medical and Pathological Information..................................................................... 49
2.15. Fire Breakout and Extinguishing.............................................................................. 50
2.16. Search and Rescue .................................................................................................... 50
2.17. Tests and Examinations ............................................................................................ 51
2.18. Flight Recorders ........................................................................................................61
2.19. Launching Missile at the Aircraft ..............................................................................74
3. The Management of Potentially Hazardous Military Activities to Civil Aviation .............79
3.2. Background and Structure of Civil-Military Coordination in Iran............................81
3.3. Airspace Risk Management for Civil Aviation in Iran.............................................. 86
3.4. Iran Airspace Risk Assessment at the Time of the Accident .................................... 89
3.5. Risk Management in the Airline and the State of the Operators ............................104
3.6. The availability of Information and the Level of Access to Them ...........................106
4. Review of Similar Accidents ............................................................................................ 110
4.1. Korean Airlines Flight No. 007.................................................................................111
4.2. Flight No. 655 of the Islamic Republic of Iran Airlines (IranAir) ............................111
4.3. Flight No. 1812 of Siberia Airlines............................................................................111
4.4. Malaysia Airlines Flight No. 17.................................................................................111
4.5. 2020 African Express Airway accident.................................................................... 112
5. Analysis.............................................................................................................................113
5.1. Missiles Function..................................................................................................... 113
5.2. Aircraft Technical and Operational Conditions ...................................................... 114
5.3. CVR Turn-on.............................................................................................................117
5.4. Operational Conditions of the Flight Crew, and the Aircraft .................................. 118
5.5. Risk Assessment ...................................................................................................... 119
5.6. Availability of Information for Risk Assessment..................................................... 127
5.7. Effective Implementation of Standards and Measures ...........................................128

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5.8. Similar Accidents.....................................................................................................129
6. Conclusions...................................................................................................................... 134
6.1. Findings ...................................................................................................................134
6.2. Accident Causes and Contributing Factors ............................................................. 135
7. Safety Actions Taken and Safety Recommendations ...................................................... 137
7.1. Safety Actions Taken ............................................................................................... 137
7.2. Safety Recommendations ........................................................................................138
8. Table of Figures and List of Tables.................................................................................. 142
8.1. Table of Figures .......................................................................................................142
8.2. List of Tables............................................................................................................145
8.3. List of Appendixes ...................................................................................................145

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Abbreviations and Definitions
AAIB Aircraft Accidents Investigation Board of I.R.Iran
ACC Area Control Unit
ACCREP Accredited Representative
ADS-B Automatic Dependent Surveillance–Broadcast
ADU Air Defense Unit
AMO Approved Maintenance Organization
Annex 13 Annex 13 to the Convention on International Civil
Aviation
ANSP Air Navigation Service Provider
APP Approach Control Unit
APU Auxiliary Power Unit
ATCO Air Traffic Control Officer
BEA Bureau d’Enquête et d’Analyse pour la Sécurité de
l’Aviation Civile
CAM Cockpit Area Microphone
CAMO Continuing Airworthiness Management Organization
CAOIRI Civil Aviation Organization of the Islamic Republic of Iran
CCTV Closed-Circuit Television
CMOCC Civil- Military Operational Coordination Center
CSMU Crash-Survivable Memory Unit
CVR Cockpit Voice Recorder
EASA European Union Aviation Safety Agency

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ELT Emergency Locator Transmitter
EUROCAE European Organisation for Civil Aviation Equipment
FAA Federal Aviation Administration
FAR Federal Aviation Regulations
FCOM Flight Crew Operating Manual
FDR Flight Data Recorder
FL Flight Level
FMS Flight Management System
FOD Foreign Object Debris
FS Frequency Spacing
GND Ground Movement Control unit
IATA International Air Transport Association
ICAO International Civil Aviation Organization
IDG Integrated Drive Generator
IFR Instrument Flight Rules
IKA Imam Khomeini International Airport
LS Load Sheet
NTSB National Transportation Safety Board
PA Passenger Address system
PSR Primary Surveillance Radar
QAR Quick Access Recorder
RSL Radio Station License

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SID Standard Instrument Departure
SSCVR Solid-State Cockpit Voice Recorder
SSFDR Solid State Flight Data Recorder
SSR Secondary Surveillance Radar
STC Supplemental Type Certificate
TC Type Certificate
TI Trip Information
TMA Terminal Maneuvering Area
TWR Air Traffic Control Tower
UIA Ukraine International Airlines
WPS Words Per Second

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Special Foreword To English Edition
This is a courtesy translation by the AAIB of the Islamic Republic of Iran
of the Final Report on the PS752 accident investigation.
As accurate as the translation may be, the original text in Farsi is the work
of reference.

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Foreword
Flight PS752 departing from Imam Khomeini International Airport for
Kyiv crashed shortly after takeoff. 176 people lost their lives in this
accident and their next of kin suffered profound grief.
Two major questions following any air accident were raised: what was the
cause of the accident and how can similar accidents be prevented?
Aircraft Accident Investigation Board of I.R.Iran instituted the accident
investigation in accordance with the international regulations laid down
in Annex 13 to Convention on International Civil Aviation.
This report contains facts, analyses and conclusions as a result of the
investigation. Based on them, the recommendations which can serve to
prevent similar accidents are made to different parties.
Although the prevention of accidents cannot be 100 percent guaranteed in
aviation, there are always areas to be improved to minimize the
probability of such occurrences. The lessons learned from this accident
are used to make recommendations to related parties. It is for those
parties to decide what action to take.
The accident-related preliminaries are provided in Section 1 of this report
and the factual information is explained in Section 2. The Management of
Potentially Hazardous Activities to civil aviation in general and, in
particular, regarding this accident is elaborated on in Section 3. Section 4
reviews similar accidents and Section 5 makes an analysis of the issues
provided in the preceding Sections. Conclusions, including the Findings,
the cause of accident and other contributing cactors are stated in Section
6, and finally the Safety Actions Taken by Iran and Safety
Recommendations to the States managing airspace, to States overseeing
the airlines activities, to ICAO and to the EUROCAE are listed in Section 7

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Summary
On January 08, 2020, Ukraine International Airlines (UIA) Flight PS752
departing from Imam Khomeini International Airport for Kyiv crashed
shortly after takeoff.
Under the Islamic Republic of Iran Regulations and as per Annex 13, the
accident investigation team was formed, who collected and analyzed data,
made conclusions and safety recommendations with the aim of preventing
similar accidents.
The accident aircraft was misidentified by the air defense unit in the
suburbs of Tehran and, consequently, two missiles were launched toward
it. The operation of aircraft had not imposed any error to the air defense
unit.
The cause of the accident was the detonation of the missile.
All 176 people on board lost their lives.
The airworthy Boeing 737-800 operated by qualified crew of Ukraine
International Airlines was under control of Iranian air traffic control and
the takeoff clearance was issued after coordination with military sector.
The air defense forces were on a higher level of alertness at the time of the
accident.
According to the analyses conducted by the investigation team, safety
recommendations are made to enhance the process of distribution and
gathering information, risk assessment, and implementation of measures
when potentially hazardous military activities may put the civil aviation
safety at risk, to prevent similar accidents.

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1. Introduction
1.1.Accident Investigation Institution
Following the accident involving a Boeing 737-800, UR-PSR operated by
Ukraine International Airlines on January 08, 2020, near Tehran, Iran’s
Vice Minister of Roads and Urban Development and the president of Civil
Aviation Organization designated the investigator-in-charge for this
accident. The accident investigation team was formed afterwards.
The accident investigation was carried out to implement the Civil Aviation
Accidents and Incidents Investigation Bylaw, adopted by Iran's Cabinet of
Ministers on August 21, 2011.
This investigation was done in compliance with the provisions of Annex
13 to the Chicago Convention, whose Standards and Recommended
Practices were applied accordingly.
1.2. The Objective and Scope of the Accident Investigation
The investigation was carried out to determine the root causes of the flight
PS752 accident on January 08, 2020, so that similar events in the future
could be prevented accordingly.
The provisions of Annex 13 do not approve of conducting an accident
investigation with the aim of apportioning blame or liability and the sole
objective of this investigation is the prevention of accidents and incidents.
This prevention can only be realized through identifying the details of
events and providing recommendations to implement the necessary
improvements for eliminating the roots of such events.
As for this accident, the interference of military activity with civil aviation
operations resulted in an accident.
The team addressed three areas in their investigation: military, civil and
the area of their cooperation and interactions; however, the identification
of the root causes and the provision of recommendations are confined
solely to the civil area and its cooperation scope with the military one

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In order that the investigation team could independently identify the
events, announced by the military authorities, and compare it with other
data available and reciprocally verify them, some military operational
events, which resulted in the launching of the missiles at the aircraft, were
identified.
It was necessary to become aware of such events in the military sector so
that the impact of civil operations and practices on the military occurrence
could be investigated. The investigation scope and areas probed in civil
and military areas are illustrated in Figure 1.

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Figure 1-Scope of the investigation

After I.R. Iran General Staff of the Armed Forces publicly announced their
air defense system had targeted flight PS752 mistakenly, Iran Armed
Forces Judicial Organization commenced judicial proceedings into the
accident by order of the Iranian head of the Judiciary.
The accident investigation subject to Annex 13 and judicial proceedings
are independent of one another. Nevertheless, given the coordination
required in data gathering or recording evidence, joint cooperation was
performed in accordance with the standards contained in Annex 13. The
investigation team used the results of a simulation performed by the
judicial systems, where the required data for judicial investigation was
obtained through deploying the defense systems in similar positions and

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conducting similar flights and validated some of the findings already
gained.
1.3. Investigation Methodology and Participating Parties
The investigation into this accident can be categorized into three general
stages:
First, it was initiated upon the accident notification. Under the Air
Accident Investigation Regulations, the eleven expert groups were then
formed. However, due to the signs of fire and explosion on the aircraft
wreckage, the images and videos showing the aircraft being targeted or hit
by missile, and the observations of ATC men as well as a passing flight
pilot, another group was formed to specifically investigate the explosives.
The initial evidence confirmed that the fire had broken out in the aircraft
before crashing into the ground. The analysis convinced the investigation
team that the explosion is the probable cause of fire. Having made some
analyses, the team focused on three scenarios:
- Explosion in the aircraft due to technical issues
- Explosion in the aircraft due to the presence of ‘dangerous goods’
inside the aircraft
- Explosion due to unlawful interference from the inside of the
aircraft
- The aircraft being targeted by terrorists acts
- The aircraft being targeted by military forces
While the team was gathering facts, on January 11, 2020, i.e. 3 days after
the accident, the I.R. Iran General Staff of the Armed Forces announced
publicly that its air defense system had fired missiles at flight PS752 due
to human error.
The AAIB and the accident investigation team had been made aware of
this targeting hours before the announcement of the statement at about
18:30 on January 10, 2020.

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At this point, the Accident Investigation Team revised their approach.
Given that a significant amount of information was made available from
official military and judicial sources, they shifted their focus on identifying
other findings and comparing them with the information received from
the military sector, to simply ensure that the only cause of the crash had
been the defense system’s missile launch and identifying the underlying
factors.
Once the facts on the missile firing were collected and confirmed, the
collection for risk assessment, analysis and preparing safety
recommendations was performed.
The following States participated in the investigation by appointing and
introducing their accredited representative(s):
- Ukraine (as the State of Registry and State of the Operator)
- The U.S. ( as the State of Design and State of Manufacture of
aircraft)
- France (as the State of Design and Manufacture of the aircraft
engines as well as State providing information and assistance for
readout of flight recorders)
There were passengers of different nationalities, and some with multiple
nationalities registered while purchasing tickets, reception, boarding and
crossing the border. Hence, Canada, the United Kingdom, Sweden,
Germany and Afghanistan as the States having special interest in the
accident by virtue of fatalities to their citizens, were invited to introduce
their experts to enjoy their entitlement according to Standard 5-27 to
Annex 13, all of which did so but Afghanistan.
The Canadian and Ukrainian representatives visited the accident site. One
day following the crash, a full delegation from Ukraine was authorized to
access the crash.
Given the nature of the accident and the need for full coordination of the
interested States, the ICAO was also invited to appoint a team of advisors
to observe the process and lend their support, where necessary. The ICAO
was accordingly kept abreast of the investigation via their representative.

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In accordance with paragraph 6.3 of Annex 13, the AAIB sent the draft
final report to the accredited representatives of the states participating in
the investigation, inviting their significant and substantiated comments.
In addition, the draft final report were sent to ICAO representative to
receive their advisory comments and UK expert to receive their comments
about sections related to information provided by UK.
1.4. Previous Reports
After the accident occurred, the first Preliminary Report containing the
initial information related to the accident was published on Jan. 08, 2020.
The second Preliminary Report was published on Jan. 20, 2020, when
some supplementary information, such as the recorded radio
communication and radar data had been obtained.
A Factual Report was released in June 2020, setting out the details on the
missile launch by the air defense unit.
Having read out the flight recorders, the relevant report was also released
in July 2020, considering the expectations of the victims’ families to
become aware of the content obtained in the flight recorders read-out.
Given that the Final Accident Investigation Report had not been released
on the first anniversary of the flight PS752 accident, the investigation team
published an Interim Statement pursuant to Section 6.6 of Annex 13 to the
Convention on International Civil Aviation, providing a brief overview of
the progress of the investigation.
1.5. Other Investigations
Under Article 172 of the Constitution of the Islamic Republic of Iran,
military courts are established to investigate offenses germane to the
military or disciplinary duties of members of the armed forces.
After I.R. Iran General Staff of the Armed Forces publicly announced the
air defense unit had fired missiles at PS752 because of human error, the
head of Iran's Judiciary assigned the Armed Forces Judicial Organization
of I.R.Iran to institute judicial proceedings into the accident.

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This type of investigation is carried out within the framework of the
Judicial Law of the Armed Forces of the Islamic Republic of Iran,
approved by the Parliament of I.R.Iran on May 12, 1985, and the
associated regulations, and investigation on errors and violations in
military sections fall under their authority.
Coordination between the investigator-in-charge and judicial authorities
was conducted pursuant to the standard 5-10 of Annex 13.
1.6. Points to Consider in This Report
The objective of the investigation of an accident subject to Annex 13 to the
Chicago Convention shall be the identification of the root causes and
prevention of similar incidents and accidents by determining the
corrective measures required and implementing them accordingly. This
type of investigation is not conducted with the aim of apportioning blame
or liability. Such issues are obviously important and will be addressed by
other authorities through their investigations, in an accident investigation
conducted with the aim of improving safety, but if the process is diverted
to simply apportioning blame or liability, safety goals will be put at risk
for two major reasons:
First, individuals involved in an accident would naturally be led to
defending themselves, hence reducing their cooperation in identifying the
factors having contributed to it. Even worse, some would consider
concealing issues concerning their responsibilities in case of occurrence of
an error leading to an accident, so that they can escape blame or avoid
liability, and, resort to hiding such sensitive issues rather than reporting
voluntarily and cooperating to eliminate the areas of concern.
Second, if the factors contributing to an accident are not well determined
and eliminated, the identification of the liable individuals and eliminating
them from the system in place will not entail the prevention of similar
occurrences. On the contrary, the very factors leading such liable
individuals to commit the error, causing the accident, will still be lurking
for others; hence, similar accidents will take place through others'
negligence in the same area.

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This report never blames the entities who are named in this report and
has no adversarial position with them. The investigation team did all its
efforts to use neutral wording, information, analysis and conclusions to
conduct the investigation and preparing the report. No biased or
misleading interpretation of this report will be valid.
The dates written in the English version are according to the Gregorian
Calendar, and the times according to Tehran Local Time (UTC+3:30),
unless specified otherwise.
Considering the different information sources, the key event times,
particularly those related to the missile launch and activation had minor
differences. The investigation team calibrated the times using available
information and techniques; however, the tolerance of direction and
distance measurements and the update rate of information resulted in a
2-second uncertainty for the reported time values. Values related to the
direction of ADU have a tolerance of ±2 degrees. Even so, these tolerances
and uncertainties did not affect the conclusions and results.
The details of an accident could be painful and poignant to the victims'
families. Stating the contributing factors could also be interpreted as
justifying or downplaying them, or making them look inevitable simply.
However, it should certainly be borne in mind that elaborating on the
causes of an accident is not supposed to mean it was inevitable. More
importantly, no analysis and elaboration on such issues will be in any way
worthy of comparison neither to the accident victims' lost lives nor to their
families' hurt feelings.
The PS752 accident investigation team would hereby genuinely like to
extend their heartfelt condolences and sympathies to those having
suffered distress and loss as a result of the accident and show great respect
for their deep feelings and emotions.

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2. Factual Information
2.1. Flight History
On Wednesday, January 08, 2020, at 00:53, the inbound flight No. 751 of
Ukraine International, Boeing 737-800, UR-PSR, en route to Tehran
Imam Khomeini INTL. Airport from Kyiv Boryspyl INTL. Airport was
cleared for landing, and after four minutes landed on the IKA runway.
After disembarking 58 passengers and refueling, the flight crew went on
to check into the hotel located at IKA.
From 01:16 to 01:38, the aircraft was refueled with 9510 kg (11800 liters)
of fuel. Once the total weight of the cargo received from passengers (310
packages weighing 6794 kg) was determined, in order to comply with the
maximum takeoff weight allowed for aircraft, 82 packages in 2094 kg in
weight, were separated by Airport Service Company, that is, they were not
loaded. Initially, 78 packages of the passengers’ luggage were not loaded
first, then due to the large volume of passengers' hand luggage, the flight
attendants passed some of them on to the Airport Service Company
personnel to be placed in the aircraft cargo. After that, 4 packages
belonging to the passengers were removed from the aft cargo door, where
the hand luggage was placed.
At 04:35, the flight crew embarked on the aircraft. After checking the
aircraft and cabin, boarding was announced at 04:45, and passengers
started to board the plane.
Based on the available documents, 167 passengers proceeded to the
Airport Services Co. counter at the airport terminal, all of whom went on
board. Only one of the passengers who received the boarding pass online
the night before the flight, due to the delay in arriving in Tehran from
another city did not go to the airport in person, and therefore had been
removed from the list of passengers provided by the UIA.
At 05:13, the pilot made his first radio contact with the IKA’s control tower
ground unit and requested the initial clearance for flying, which was
issued by the controller subsequently.

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At 05:48, all the aircraft documents required to start the flight operations
were filled out, and all the doors were then closed at 05:49.
The flight was initially scheduled for 05:15, and based on the flight
coordinator's report form, the reason given for its delay was the aircraft
being overweight and the decision not to load the passengers’ luggage for
reducing the aircraft weight.
At 05:51 the pilot notified his position at the airport parking, declared his
readiness to exit the parking and start up the aircraft. The IKA tower asked
him to wait for receiving the clearance since they wanted to make the
coordination required with other relevant units.
At 05:52, the IKA tower made the necessary coordination with the
Mehrabad approach unit, who contacted Tehran ACC asking for
clearance. Accordingly, the controller in ACC made coordination on
Ukrainian flight clearance with the CMOCC. The clearance was issued by
the CMOCC.
At 05:54, the Mehrabad approach unit, received the FL260 clearance for
the flight AUI752 from ACC, and forwarded it to IKA via the
telecommunication system.
Flight no. 752 was detached from the A1 Jet Bridge and at about 05:55
started to leave its parking position, NO 116 on the right, by a pushback
truck.
Following that, at 05:55 the ground controller cleared the AUI752 flight
for startup and exiting the parking, which was read back by the pilot.
At 06:12, the aircraft took off from the Runway 29 Right of IKA and was
delivered to the Mehrabad approach unit. The pilot contacted the
approach unit, and announced the IKA 1A radar procedure as SID
procedure. Next, the Mehrabad approach identified and cleared the flight
to climb to FL260. The controller instructed the pilot to turn to the right
after 6,000 feet, and continue straight to PAROT.

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After it was read back by the pilot, the controller again instructed the pilot
to continue to PAROT point once passing the 6000-foot altitude, which
was read back by the pilot.
From 06:17 onwards, upon the disappearance of the PS752 information
from the radarscope, the controller called the captain repeatedly, but
received no response.
According to the data extracted from the surveillance systems and FDR,
the aircraft climbed to an altitude of 8,100 feet; thereafter, the label
including the call sign and altitude of aircraft disappeared from the
radarscope, yet no radio contact indicating unusual conditions was
received from the pilot. FDR recording terminated at 06:14:56. This time
corresponds to the termination of Secondary Surveillance Radar (SSR)
and ADS-B information.
After the mentioned time, the aircraft was still being detected by the
Primary Surveillance Radar (PSR), according to which the aircraft veered
right and after approximately three minutes of flying, it disappeared from
the PSR at 06:18 too.
The aircraft was conducting the flight under the Instrument Flight Rules
(IFR) and the accident occurred around half an hour before the sunset.
The aircraft flight path detected by PSR and SSR is illustrated in Figure 2.

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https://b.radikal.ru/b18/2103/8c/90f107008c25.jpg

Figure 2- The aircraft flight path detected by PSR and SSR

2.2. Injuries to Persons:
All 176 persons on board this flight lost their lives1 as shown in Table 1.

Table 1- The number and type of injuries to persons

Injuries

Crew

Passenger

Others

Total

Fatal

9

167

0

176

Serious

0

0

0

0

Minor / None

0

0

0

0

Total

9

167

0

176


1 - One of the passengers on board this aircraft had been pregnant, whose fetus is reported to have been
7 months old. Under the Laws in Iran, the dead fetus is regarded a person; therefore, in judicial
investigations, the number of the victims is reported as 177 people.
Two of the passengers who had purchased tickets did not go to the airport, so they were not onboard
this aircraft.

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2.3. Identification of Victims
At the AAIB's official request, the following was put on the agenda:
 Identification of the victims
 Tests on flight crew bodies
 The cause of deaths
 The analysis of burning and discovery of metal objects in
passengers' bodies
Initially, the Iranian Legal Medicine Organization (Forensic Medicine
Organization), in cooperation with domestic entities and coordination
made with the involved international authorities, created a DNA data
bank for the passengers. By judicial authorities’ decision, bodies were
handed over to the victims’ families for burial and afterwards following
their DNA sample confirmation. At the request of some States and victims’
families, some of the passengers’ bodies were transferred to foreign
countries for delivery to their families and burial at their desired location.
2.4. Damage to Aircraft
The aircraft was completely destroyed due to crash and ground impact.
2.5. Other Damage
Apart from the damage to the aircraft, the accident caused further damage
to public properties, such as a park and playground, and also private
gardens and estates.
After losing altitude and passing by a residential area, called Khalajabad,
the aircraft initial impact point was with a gazebo in a recreational park,
called Lale. The aircraft fuselage, subsequently, impacted the ground,
disintegrating completely after passing a football pitch, which in turn
damaged the surrounding agricultural farms and gardens. Following the
initial impact, other impacts were observed along the track at the accident
site, wrecking the fuselage and spreading across the entire track. (Figure
3)

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https://d.radikal.ru/d04/2103/2b/9c3ccd30100a.jpg
Figure 3- Accident site scheme
2.6. Organizational and Managerial Information
Ukraine International Airlines was the aircraft operator.
The company was established in 1992 and is headquartered in Kyiv,
Ukraine. Its main station is Boryspyl International Airport.
The company is coded AUI in ICAO and PS in IATA. At the time of the
accident, the company owned 45 aircraft, conducting flights to
approximately 88 destinations.
The price of the ticket, as well as the flight network of this company, was
such that it was considered an economic choice by travelers who flew to
or from Tehran to travel to third countries. For example, the crashed flight
had only two passengers of Ukrainian nationality, and most of the
passengers also intended to travel to other countries.
At the time of the accident, UIA had a valid operating license No. UK 021
issued by the State Aviation Administration of Ukraine (valid from
10/14/2019 to 10/13/2021).
The airline had a valid CAMO approval certificate from State Aviation
Administration of Ukraine.

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The aircraft airworthiness was managed by UIA CAMO and the last
aircraft maintenance service was performed by the contractor MAU
technic.
2.7. Personnel Information
2.7.1 Pilots
The flight was being operated by three pilots, comprising a flight
instructor, captain and first officer together with six flight attendants.
According to the report provided by the UIA, the pilots' information is as
follows:
Captain, aged 50, had experience of 11590 hours total flight time,
including 4462 hrs on B737 NG and 3966 hrs on B737 CL with 4 takeoffs
and 5 landings in IKA.
Copilot, aged 48, had experience of 7633 hrs total flight time, including
266 hrs on B737 CL, 2002 hrs on B737 NG and 1374 hrs of B737
experience before joining UIA with 6 takeoffs and 7 landings in IKA.
2.7.2 Flight instructor, aged 42 , had experience of 12052 (9820 B737) hrs total
flight time, including 3240 hrs on B737 NG, 6580 hrs on B737 CL and 1075
hrs on Embraer 190 with 13 takeoffs and 14 landings in IKA.
Each of the three flight crewmembers had both valid personal licenses
relevant to their duties, and related medical certificates.
Mehrabad Approach Radar Controller’s Background
At the time of the accident, the aircraft was being controlled by the
Mehrabad approach controller, a forty-one-year-old man with valid air
traffic control tower ratings, and Mehrabad Radar Approach with License
No. 1073. He holds an English Proficiency Level 4 and medical
certification valid up to July 20, 2020.
2.7.3 Flight Attendants
There were two male cabin crew members and four females on the flight.
To date, the UIA has not provided information on training, medical

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certificate validity, approval for flight security. However, it was revealed
that such issues were not relevant to this accident and investigation.
2.8. Aircraft Information
2.8.1 Introduction to the Aircraft
The Boeing B737-8K (WL), serial No. 38124 with manufacture date of
June 21, 2016 was operated by Ukraine International Airlines.
The aircraft’s type has been certified by the U.S. Federal Aviation
Administration (FAA) with TC number A16WE subject to Federal
Aviation Regulations (FAR).
The maximum takeoff weight is 72,500 kg (159,835 pounds), and the
maximum capacity seating is 189 passengers.
The aircraft was equipped with two CFM56 7B24E, which are certified by
Type Certificate Data Sheet no. E000056EN by FAA and E004 by
European Aviation Safety Agency (EASA).
The Boeing 737-800 aircraft had a TL 0001 type certificate, the CFM-
56 7B24E engine installed on this aircraft had a TD 0038 (TD 0038) type
certificate issued by the Ukrainian Civil Aviation Authority.
2.8.2 Aircraft Technical Information
According to the list and documents provided by the State of Registry,
the aircraft technical information shows that the aircraft had a valid
Airworthiness Certificate. The Airworthiness Review Certificate was
valid until Feb. 07,2020.
The UIA had CAMO and the accident aircraft was included in the scope of
CAMO approval.
There were no changes in the aircraft that would make it subject to STC.
According to the Aircraft Flight and Maintenance Log page No.068845,
Figure 4, on the flight before the accident, the aircraft departed at 21:41
from Kyiv, Ukraine to IKA, and after flight landing and preparations, no
technical defect was reported by the pilot requiring a technical action.

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https://a.radikal.ru/a28/2103/11/ab7cde00e123.jpg
Figure 4- Aircraft flight and maintenance log
The ground handling Co. handled the flight preparations, boarding and
loading according to the Trip Information it received from the pilot,
including the amount of residual fuel, the maximum takeoff weight
(MTOW), the maximum landing weight (MLW), the amount of fuel
required to conduct the flight, the flight time and other information on the
aircraft defined in the Load Sheet.
According to the aircraft Load Sheet, the maximum allowable weight had
been calculated at 72500 kg. Due to the limit on maximum allowable
takeoff weight, the ground handling Company did not load 82 pieces of
baggage equal to 2094 kg. Ultimately, the aircraft takeoff weight was
calculated 72468 kg, which was 32 kg lower than the maximum allowable
takeoff weight. After boarding and loading, the pilot finally approved the
Load Sheet.
According to the report provided by the ground handling Co., each male
passenger’s weight was considered 88 and a female 70 kg taking their
hand luggage into account, and the excessive packages inside the cabin

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were transferred to the aircraft aft cargo, where some were removed.
Ultimately, 82 packages were not loaded.
Based on the information obtained from the ground handling Company,
it was found that the flight crew brought delivered some luggage onboard
to the handling Co. The ground handling personnel were then unloaded
some of the passengers’ luggage and cargo from the cargo section to
comply with the maximum allowable weight.
The pilot had chosen the Odessa airport (ICAO CODE: UKOO) as the
alternate airport and made fuel-related calculations accordingly.
2.8.3. Aircraft Systems
A large number of systems have been installed on aircraft, the analysis of
each is based on the recorded data parameters.
According to the information obtained out of the FDR read-out, no system
failure was recorded till 06:14:56, after which no conclusion can be made
on them due to termination of the recording.
Navigation Systems:
The accident aircraft navigation systems include the following:
1. The Flight Management System (FMS) which includes:
- Flight Management Computer System (FMCS)
- Autopilot/Flight Director System (AFDS)
- Auto throttle (A/T)
- Inertial Reference System (IRS); 2 independent systems
- Global Positioning System (GPS); 2 receivers
2. Two VOR- Receivers
3. Two ILS Receivers
4. Two Marker Beacon Indications
5. Two ADF Receivers
6. Two DME Transceiverswere transferred to the aircraft aft cargo, where some were removed.
Ultimately, 82 packages were not loaded.
Based on the information obtained from the ground handling Company,
it was found that the flight crew brought delivered some luggage onboard
to the handling Co. The ground handling personnel were then unloaded
some of the passengers’ luggage and cargo from the cargo section to
comply with the maximum allowable weight.
The pilot had chosen the Odessa airport (ICAO CODE: UKOO) as the
alternate airport and made fuel-related calculations accordingly.
Aircraft Systems
A large number of systems have been installed on aircraft, the analysis of
each is based on the recorded data parameters.
According to the information obtained out of the FDR read-out, no system
failure was recorded till 06:14:56, after which no conclusion can be made
on them due to termination of the recording.
Navigation Systems:
The accident aircraft navigation systems include the following:
1. The Flight Management System (FMS) which includes:
- Flight Management Computer System (FMCS)
- Autopilot/Flight Director System (AFDS)
- Auto throttle (A/T)
- Inertial Reference System (IRS); 2 independent systems
- Global Positioning System (GPS); 2 receivers
2. Two VOR- Receivers
3. Two ILS Receivers
4. Two Marker Beacon Indications
5. Two ADF Receivers
6. Two DME Transceivers

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In addition to the above items, the aircraft is equipped with two ATC
transponder devices, one of which can only be active at one time while the
other can be used as a backup.
On the flight resulting in the accident, according to the data found from
the SSR radar, no defect could be observed in receiving signals from ATC
transponder, from the beginning to the moment the flight reached the
altitude of 8100 feet. Nevertheless, from 06:14:56, when the aircraft had
been climbing at an altitude of 8,100 feet and the ground speed of 276 Kt
(according to the FDR), ATC transponder signal was interrupted, and this
situation continued until the aircraft crashed to the ground. (At 06:18:23)
Communication Systems:
According to its Radio Station License, the aircraft had three VHF
communication systems, manufactured by Honeywell Co., functioning in
the frequency band 118-136.992 with a Frequency Spacing of 8.33 kHz.
The pilots made their last communication with Mehrabad Approach Unit
at 06:13:23. The CVR read-out indicates that up until the end of recording
at 06:15:15, the flight crew had not been attempting to establish
communication; therefore, no comment can be given on the performance
of communication system after last recorded communication.
Other Systems
The flight recorders read-out and analysis revealed that until 06:14:56,
when the recording was continuing, all the systems had normal
performance. After the mentioned time, given the end of the FDR
recording and transponder messages stopped being received, the warning
sound as well as the unusual condition in the cabin, it is highly probable
that several electrical buses failed. Considering the objective evidence
indicating the fire outbreak and its intensification in the aircraft, the
cascading damage to other systems is likely (refer to sections 2.13 and
2.15).


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