Georgian Civil Aviation and Maritime Transport Accident Incident Investigation Bureau Investigation Report On the serious incident on 01.02.2014 to the Boeing 737-82R Registered TC-AAZ Operated by “Pegasus Airlines” Flight PGT-463 Tbilisi - Istanbul Tbilisi 2014
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Georgian Civil Aviation and Maritime Transport Accident
Incident Investigation Bureau
Investigation Report
On the serious incident on 01.02.2014
to the Boeing 737-82R
Registered TC-AAZ
Operated by “Pegasus Airlines”
Flight PGT-463 Tbilisi - Istanbul
Tbilisi 2014
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Aircraft Type: Boeing 737-82R
Aircraft Serial No: 40875
National Registration No: TC-AAZ
Owner: Poseidon Leasing LLC
Operator: Pegasus Airlines
Date and time of the serious incident:
01.02.2014. 02.46 (UTC)
Place of Incident: Tbilisi International Airport
(runway 31L) 413929.54N - 0445753.59 E
The sole objective of the investigation of an accident or incident is the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability. (Article 3.1 of the Annex 13 to the Chicago Convention 1944). The present document is the translation of the Georgian Investigation Report. Although efforts are made to translate it as accurate as possible, discrepancies may occur. In this case the Georgian version is authentic.
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Table of contents:
Brief Information
1. Factual information
1.1. Pre-flight history
1.2. Injuries
1.3. Damage to aircraft
1.4. Other damage
1.5. Personnel Information (Flight crew)
1.6. Aircraft Information
1.7. Meteorological information
1.8. Aids to Navigation
1.9. Communications
1.10. Aerodrome information
1.11. Flight Recorders
1.12. Wreckage and Impact Information
1.13. Medical and pathological Information
1.14. Fire
1.15. Survival Aspects
1.16. Tests and Research
1.17. Organizational and management Information
1.18. Useful or effective investigation techniques
2. Analyses
3. Conclusions
4. Safety Recommendations
Appendices
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Brief Information
On February 1, 2014 at 02:55 (UTC) Head of Civil Aviation and Maritime
Transport Accident Incident Investigation Bureau received the notification
about the aviation incident. Namely, on 01.02.2014 when performing the
flight No PGT 463 Tbilisi Istanbul the aircraft Boeing 737-82R registration
No TC-AAZ operated by Pegasus Airlines on the starting point of takeoff
run from the runway 31L, the aircraft suspended take off, during which
went out of the runway range to the right side.
As per the requirements of regulations of the air-code of Georgia, Ministry
of Economy and Sustainable Development of Georgia and Investigation
Bureau, the investigation of the aviation incident was carried out by Civil
Aviation and Maritime Transport Accident Incident Investigation Bureau.
The investigation started on 01.02.2014
The investigation was completed: 25.03.2014
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1. Factual Information
1.1. Pre-flight history
on February 1 , 2014 the aircraft Boeing 737-82R, operated by Pegasus
Airlines, registration No TC-AAZ, was performing the regular flight PGT -
463 Tbilisi - Istanbul;
At 02.45 (UTC), the aircraft TC-AAZ taxied to the airport runway 31L for
takeoff, it started takeoff run, which was rejected by the crew in a few
seconds, at the starting stage of run due to non-symmetric acceleration of
the engines, namely the parameters of the right engines fell behind the left
one. During the rejected takeoff the aircraft at the distance of 135 meters
from the threshold of runway went to the right side and stopped. Aircraft
main gear was on the right edge paved surface of the runway and nose
gear stopped on the Unpaved runway at 3.5 meter from the runway edge.
1.2. Injuries
The flight crew, cabin crew and 124 passengers received no injuries.
Injuries Crew Members Passengers Others
Fatal 0 0 0
Serious 0 0 0
Slight/None 0 0 0
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1.3. Aircraft Damage
During the rejected takeoff the aircraft received no damage, Only nose
gear wheel was soiled.
1.4. Other Damage
Rejected takeoff caused no damage to other objects.
1.5. Personnel Information
Captain
Age: 44 years
Aircraft type rating: B737-300/900
Transport pilot license : ATPL
License valid until: 31.12.2014
Medical certificate: Class I
Date for medical check, term: 08.06.2013-08.06.2014
Inspection on simulator: 01.12.2013
Flying hours on Boeing 737: 3729
First Officer
Age: 35 years
Aircraft type rating: B737-300/900
Transport pilot license : ATPL
License valid until: 03.03.2014
Medical certificate: Class I
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Date for medical check, term: 13.09.2013-13.09.2014
Inspection on simulator: 02.08.2013
Flying hours on Boeing 737: 2564 hours
1.6. Aircraft Information
Aircraft Type: Boeing 737-82R
Serial No: 40875
Year of Manufacture: 2010
Airworthiness certificate issued 14.06.2013, valid until 14.06.2014
National Registration mark: TC-AAZ Registration Certificate: 2294
Flying hours: 13992 hours /9254 cycles Last check: 27.01.2014
Engines:
Left Engine:
Type: CFM56-7B26/3
Year of Manufacture: 2010
Serial No: 804257
Last check: 27.01.2014
Operation hours: 13992 hours/9254 cycles
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Right engine
Type: CFM56-7B26/3
Year of Manufacture: 2010
Serial No: 805264
Last check: 27.01.2010
Operation hours: 13992 hours/9254 cycles
1.7. Meteorological Information
The weather conditions at Tbilisi International Airport:
e) The representative of the air company “Pegasus Airlines” in
Georgia – LTD “GASA”;
3. With the view of improving flight safety and prevention of similar
incidents in future the administration of the air company “Pegasus Airlines”
is to ensure the following:
- Organize detailed review of the final report of the serious incident in the
airline and implement of relevant preventive actions with the view of
enhancing flight safety culture.
- Organize additional theoretical trainings for flight personnel on the topic:
- Crew Resource Management’s objective in flight safety;
- Human Factor, situation awareness, timely comprehension and decision
making as per the requirements of FCOM and SOP;
Putting emphasis on the following during Crew Briefings:
- Trust Setting Management;
- Cold Weather Operations;
- Slush/standing Water Takeoff’
- Slippery Runway Takeoff;
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Appendix 1
The overall picture of the numbers of aircraft and engines parametersThe overall picture of the numbers of aircraft and engines parametersThe overall picture of the numbers of aircraft and engines parametersThe overall picture of the numbers of aircraft and engines parameters