Aerosvit Flight 241

On 17 December 1997, the Yakovlev Yak-42 operating the flight registered as UR-42334 flew into a mountainside during a missed approach into Thessaloniki in Greece.

[1] Investigation by the Greek Aircraft Accidents Inquiry Council concluded that the crash was caused by the flight crew's navigational error.

[2] In light of the investigation, both the Ukrainian and Hellenic authorities were urged to create a compulsory CFIT training for all pilots in both countries.

The Ukrainian State Department of Aviation Transport was urged to include compulsory cockpit resource management (CRM) training to all flight crews and the Hellenic Civil Aviation Authority was asked to provide radar facility for Thessaloniki Airport.

The first sector of the flight from Lviv-Odesa was operated by a Boeing 737 but due to engine issues the aircraft was replaced with a Yakovlev Yak-42.

At the time, the air traffic controller was instructing an Olympic Airways flight near the area to descend to 3,500 ft (1,100 m).

[2] During the flight crew's attempt to approach the airport for the second time, the controller repeatedly asked about their position for confirmation.

The controller was relieved with the answer and then asked the crew to adhere with the ILS approach and report back when they were established on the localizer.

After obtaining the radar data from the Hellenic Air Force, it was subsequently revealed that the aircraft was actually flown towards the west and later to the southwest of the airport.

The search for the wreckage was also rendered difficult due to the fact that the Yak-42 was not equipped with an Emergency Locator Transmitter (ELT).

[6] On 20 December, three days after the initial accident, a Hellenic Navy helicopter spotted signs of treetops that had been cut.

The wreckage was found at an elevation of 1,100 m, located in a gorge and was buried in heavy snow with debris strewn over a large area.

According to the President of Aerosvit Airlines, Leonid Pogrebnyak, at least 34 passengers were Greeks, 24 were Ukrainians, 2 were from Poland, and 1 was from Germany.

Meanwhile, his co-pilot and the instructor pilot were busy concentrating on the ADF, a basic navigation instrument which would have pointed the crew towards the airport's beacon.

The instructor pilot then took the opportunity to "stretch the system" and give the crew some training, including the heading, the track, and the radio navigation equipment.

[2] The crew never achieved situational awareness during the entire flight and were pre-occupied with the settings of the radio-navigation aid and data interpretation from the navigational instruments.

There was technically no commander in the cockpit and as a result during the last 30 minutes of the flight, the crew didn't conduct any checklist.

[2][15] The decreased situational awareness of the crew further contributed to their lack of response to the GPWS warning that had sounded for at least 4 times.

The flight crew finally realized the danger that they were facing when the fourth alarm sounded, at 19:12:32, during which the red "ground proximity" warning was illuminated.

The problem was also aggravated with both the controllers and the flight crew's insufficient proficiency in English, the universal language medium for aviation.

Both the controller and the flight crew could not go beyond said exchange to actually understand the rapidly changing critical situation at hand.

The failure of the flight crew to properly utilize the Makedonia airport radio-navigational aids and aircraft radio equipment I instruments and to interpret the information that was presented.

The failure of the flight crew to declare an emergency when they lost their orientation following the missed approach, despite numerous cues alerting them for the aforementioned situation.

The lack of command presence, cockpit discipline and resource management which resulted in a disorganized, confused and ultimately dysfunctional flight crew.

Hellenic Civil Aviation Authority was also urged to develop a mandatory CFIT training program and to provide radar to Thessaloniki airport.

[2] A member of the inquiry committee, Major Spiros Georgopoulos from the Hellenic Air Force, disagreed with the contributing factors of the crash.

He opined that the air traffic controller in Thessaloniki had directly caused the crash rather than one of the contributing factors, adding that he felt that the controller didn't prevent the crash by not helping the crew for radar assistance even though it was apparent that the crew had lost their orientation.

[2] In 1998, the Ukrainian government sent a letter of protest to the Greek Foreign Ministry following the grounding of an Aerosvit Boeing 737-200 aircraft in Thessaloniki.

Ukrainian authorities stated that the grounding was not in accordance with international norm and requested an official explanation on the incident.

[17] In year 2000, following lawsuits that had been filed by 29 families of the victims, two of the air traffic controllers were convicted of manslaughter by Greek court.

For an approach to Runway 16, the crew were required to make an approach from the north of the airport