Here is some additional information about the tragic crash of ACT Airlines Turkish Cargo flight 6491.
Safety recommendations (from the final report)
For the top management of airline companies
- To draw the attention of the flight crews to the necessity of fulfillment of the requirements, established in the approach charts, of the criteria for the stabilized approach and landing and of monitoring distance and altitude during the crossing of the reference points (FAF, LOM, LIM) when conducting ILS approaches, especially ICAO CAT II and CAT III approaches.
- To provide the flight crew training, during which to clarify additionally that in case of absence of the visual reference with the runway environment, the go-around procedure must be initiated no lower than the established decision height/altitude.
- To conduct additional training on the CRM and the interaction in case of one pilot’s “fear” of the impossibility to continue the approach (or other stage of flight) and the absence of the other crew member’s due reaction to this as well as the additional training on the actions required when the “minimums” message comes on.
- To conduct the theoretical and practical (if required) training for the flight crews, operating the aircraft, manufactured by the Boeing Company (all models) for the recognition, order and specific features of conducting the flights in case of the autopilot switching to the inertial mode during the descent along the glideslope. To consider the applicability of this recommendation to the aircraft, manufactured by other companies.
For the ATC service personnel
- In case of the pertinent equipment availability, to inform flight crews on significant altitude deviations from value, established by the approach charts, especially for ICAO CAT II and CAT III approaches and in case of conditions, requiring actions in compliance with the Low Visibility Procedures, and for this purpose, to consider the issue of making the corresponding amendments to the job instructions of air traffic controllers.
- To finish the provision of the metreport to the crews before the aircraft reaches the LIM. The repetitive provision of the already-provided metreport should be avoided, especially if the flight crew is in the process of conducting the ICAO CAT II and CAT III approach and landing.
- To consider the practicability of including additional requirement into the ATC specialists’ job instructions, in case of flights in low visibility conditions, to request the flight crew for confirm capturing both the localizer signal and the glideslope signal (“fully established” status) after crossing the FAP.
For the Boeing Company and the FAA
- To consider the practicability of improving the algorithm of glideslope capture and of the implementation of the warning type alert in case of the “false” glideslope capture.
- To consider the practicability of changing the A/P logic in order to prevent occurrences of continuous inertial glideslope descent (in LAND 3 or LAND 2 modes) in cases when approach path does not allow landing in the appropriate zone of the runway.
For the Boeing Company
- To consider the practicability of amending the operational documentation (FCOM, FCTM) in order to provide more detailed description of the inertial path flight mode.
- To consider the practicability of amending the operational documentation (FCTM and the B-747 TM) in order to eliminate the discrepancies in the provided actions recommended for the crew in case of “AUTOPILOT CAUTION” annunciation triggering.
For the Aviation Administrations and the Aerodromes’ Administrations
- To analyze the acceptability of constructions in the immediate vicinity of aerodromes and, in case of findings, take appropriate decisions in cooperation with pertinent authorities.
For the Aviation Administration of the Kyrgyz Republic
- To consider the practicability of amending the provided aeronautical information regarding the publishing of the note on the possibility of increasing the safe altitude following the associated instruction from the ATS unit.