On the 1st October, 2008 in night time, during landing at aerodrome Kaliningrad (Khrabrovo) , JSC KD Avia flight KNI794 was involved in an accident: The flight was operated with a Boeing B-737-300 registered EI-DON operated by JSC KD AVIA airline of North-Western Air Transport (AT) ITA of Russian CAA.
As a result the aircraft got damage to the fuselage and engines.
None of the crew or passengers was injured.
A commission for the investigation of the accident was appointed by Order No. 35/454-P, issued on October 02, 2008 by the Vice-Chairman of the Interstate Aviation Committee (IAC).
In compliance with ICAO Annex 13, notifications about the accident were sent to the National Transportation Safety Board (NTSB), USA as a representative body of the State of Design and Manufacture and to the Air Accident Investigation Unit, Ireland as the representative body of the State of Registry.
The NTSB and the AAIU assigned their Accredited Representatives to participate in the investigation.
Experts from JSC KD Avia flight KNI794 ( Transaero airline ), as well as the Boeing Company were involved in the investigation.
The Prosecutor General’s office of the North-Western Region has not conducted a preliminary investigation of the accident.
Start of investigation – October 02, 2008, end of investigation – August 24, 2009.
The cause of the JSC KD Avia flight KNI794 accident was a belly landing, which lead to aircraft structure’s and engine’s damage and was a result of the following negative factors:
erroneous cutout by the JSC KD Avia flight KNI794 ‘s co-pilot of the Landing Gear Warning Horn of the GPWS system, which was a result of the incorrect fulfillment of QRH recommendations regarding flap warning cutout in case of flap asymmetry.
- the use of the QRH which was on board the Boeing 737-300 EI-DON and which contains recommendations in its Additional Deferred Item, Chapter Trailing Edge Flap Asymmetry that were not customized to the particular aircraft layout.;
- violation of the Boeing-737-300 FCOM and a failure to comply with requirements of QRH (section LANDING CHECKLIST) by the crew, which resulted in the crew forgetting to extend the landing gear and check its position
- The crew having a negative stereotype about the Landing Gear Warning Horn activation when approaching, which caused the crew to deactivate it more than once without checking landing gear position;
- An unsatisfactory CRM, which resulted in the absence of cross-checks when following the FCOM and QRH requirements, when an abnormal situation emerged and developed.