Background
AeroSvit Airlines Flight 241 was a scheduled service from Kiev, Ukraine to Thessaloniki, Greece, with an en route stop at Odessa, Ukraine. The first leg was operated by a Boeing 737, but due to engine problems, an aircraft change occurred at Odessa. The final leg was flown with a Yakovlev 42 (registration UR-42334) chartered from Lvovskie Avialinii. The flight crew had no previous experience flying to Thessaloniki.
Flight Details
The aircraft was dispatched from Odessa with the No 1 VHF/NAV receiver inoperative, contrary to the minimum equipment list (MEL), and took off at 17:23 UTC. Weather conditions at Thessaloniki Airport were above required minima, but darkness and an overcast cloud layer obscured awareness of mountainous terrain.
The approach controller instructed the flight to follow the LAMBI1F standard arrival and cleared them for a VOR-DME-ILS approach to runway 16. The aircraft did not follow the required "19 DME arc" but proceeded directly to the THS NDB. It overshot the localizer course at least twice, and the flight crew could not establish a stabilized approach. Cockpit voice recorder (CVR) conversations revealed confusion and uncertainty regarding navigation aids and presented information. Standard callouts for glide slope, outer marker, or minima were not made.
At 18:54 UTC, the Thessaloniki Tower controller reported that the aircraft had passed the airport. The flight crew was unaware they had overflown the runway until informed by the controller. They initiated a go-around but did not follow the published missed approach procedure nor ATC instructions. Although instructed to proceed to and enter the south holding pattern, the flight continued west. The crew remained confused, disorganized, and disoriented during the missed approach, losing situational and terrain awareness. They requested "route vectors" and "heading" twice, though Thessaloniki Airport was a non-radar facility. The crew occasionally misread distances on DME equipment (miles versus kilometers) as their instruments displayed kilometers. They frequently switched focus between VOR/DME and ADF information, which, combined with the VHF/NAV receiver malfunction, contributed greatly to cockpit confusion and loss of orientation.
At 19:12 UTC, the GPWS sounded for 4 seconds. The approach controller radioed: "AEW number one, continue VOR-DME/ILS approach minima, continue and report approaching the outer marker." The crew replied indicating they would report the outer marker. Shortly after, the controller asked if they had the field in sight as the GPWS sounded again. The aircraft then impacted the side of Mount Pente Pigadia at 3300 feet.
Investigation and Aftermath
Wreckage was found at 10:30 UTC on December 20. On the same date, a Greek Air Force Lockheed Hercules used in the search crashed, killing all 5 on board. On October 6, 2000, a trial began with two air traffic controllers accused of multiple counts of manslaughter and violating transportation regulations; they were initially sentenced to five years imprisonment. In December 2002, a Thessaloniki appeals court reduced their sentences to four years and four months each.
Probable Cause
The official investigation listed the following causes: failure of the flight crew to adequately plan and execute the approach and missed approach; failure to properly utilize radio navigational aids and interpret information; failure to declare an emergency after losing orientation; captain's failure to achieve maximum climb in response to GPWS; lack of command presence and resource management; and company's inadequate oversight resulting in scheduling an unprepared crew and an aircraft not complying with regulations. Contributing factors included inadequate training, dispatch with inoperative equipment, assignment of a marginally qualified instructor pilot, incorrect chart symbol for radar service, and insufficient evaluation by approach control.