Flight attendant brings down Falcon 20 Jet

Events and course of the flight
The Falcon 20 took off from Moscow-Domodedovo (Russia) at around 15:50 UTC on a passenger flight to London-Luton (UK). In addition to the two pilots and a flight attendant, there were three passengers on board.
Approximately two and a half hours after take-off, at 19:19:381 , the co-pilot made radio contact with Maastricht UAC air traffic control and reported flight level (FL) 380.

At 19:21:40 hrs, the cockpit voice recorder (CVR) recorded a hissing noise lasting 4.19 seconds. The pilot in command (PIC) called out what was happening. Screams could be heard from the passenger cabin. At 19:21:50, the flight attendant called out: “Where is fire extinguisher?” The PIC asked her several times to get the fire extinguisher. Over the next three minutes, the flight attendant repeatedly asked her to help her find the fire extinguisher and to remove the extinguisher from its holder behind the copilot’s seat. At 19:21:58, the co-pilot said: “There you go, masks.” A second later, the PIC asked the copilot to give him an oxygen mask.

At 19:22:04, the controller asked the crew to enter transponder code 0772. Four seconds later, the CVR recorded the PIC’s comment: “… we have a fire on board, request emergency descent.” The co-pilot replied with “Descend” and repeated seventeen seconds later: “Let’s descend!” According to the flight data recorder, the aircraft began to descend. The PIC requested the asked the copilot again at 19:22:34: “… give the mask!” Five seconds later, the copilot said: “I have taken control, put it on.” The controller repeated his request at 19:23:09: “… squawk zero seven seven two.”

At 19:23:54 hrs, approx. 26 NM northeast of Kiel, the PIC reported: “… we have, we have a fire … emergency descent.” The flight attendant called out at 19:24:01: “I can’t stand it anymore. Open the window.” According to the flight recorder data, the aircraft was at about FL280 at this time. The controller asked at 19:24:19 and 19:25:47: “… what level would you like to descend?”
At 19:25:31 hrs the PIC asked the copilot: “…read checklist.” The flight attendant called out: “Open the window, open the window.” The co-pilot then asked the PIC at 19:25:46: “may I open?” The aircraft was passing at this time approximately FL240. At 19:26:04, the CVR recorded the flight attendant’s remark: “I didn’t want.”
At 19:26:11 hrs, the pilot replied to the controller: “… one five zero”. At 19:26:32 the controller asked the pilot’s further intentions. He replied: “We will descend one five zero and request to go nearest airport.” The pilot first suggested Hamburg Airport, and a short time later he said: “… there is an airport just below you, it’s Kiel.” After being asked to repeat the radio message, the air traffic controller said: “… there is an airport just below you with a short runway that is Kiel.” The PIC asked for a descent clearance and for the course to Kiel. After a coordination discussion with the air traffic control center in Bremen, the controller gave the instruction to descend to FL110.

At 19:28:21 hrs, when the aircraft was approximately at FL180, the controller requested the crew to change the radio frequency to Bremen-Radar. The co-pilot contacted Bremen-Radar by radio and informed them that they would perform an emergency descent to FL110. At 19:29:13 hrs the controller said: “… roger, contin- ue descent, altitude five thousand feet, QNH nine nine two.” At this time, the aircraft was one nautical mile (NM) north of Kiel Airport at FL160. The co-pilot pressed the air pressure (QNH) and the altitude of 5,000 ft. The controller asked at 19:29:43: " “…Kiel runway in use is zero eight, the length is one thousand two hundred sixty meters, is that sufficient?” The copilot replied: “Roger, sixty meters.” According to the Cockpit Voice Recorder (CVR), the PIC asked the copilot: “What are they talking about?” The copilot asked the controller: “Confirm five thousand feet?” He then repeated: “…I say again, runway length is one thousand two hundred sixty meters, is that sufficient?” According to the flight data recorder (FDR), the aircraft was below flight level FL120. The CVR recorded a high noise level on board the aircraft in this phase and the co-pilot’s response was “Affirmative”.

The PIC requested the copilot twice at 19:30:59 hrs to read the checklist. At 19:31:32, the controller issued the instruction to descend to 3,000 ft AMSL and 21 seconds later he instructed to turn right to 350°. The radar data showed that the aircraft was entering a right turn. When the copilot announced “Reading checklist” at 19:32:28 hrs, the crew received the frequency of the landing course transmitter for runway 08 from the controller by radio at 19:32:46 hrs. At 19:33:05 hrs, as the aircraft was flying in a northerly direction, the controller issued the clearance for the ILS approach to runway 08.

Two minutes later, while on the final approach, the controller informed the crew: “… you are presently five mi- les for touchdown. Discontinue approach, maintain three thousand feet, turn right, I put you on the localizer again.” A few seconds later, the pilot said: “… main- tain three thousand feet, turn right heading two one zero.” The pilot continued to issue course instructions several times and instructed the pilot to descend to 2,000 ft AMSL.
At 19:40:57 hrs, the controller again issued the clearance for the ILS approach to runway 08.
At 19:43:05 hrs, approx. 4 NM from the runway threshold, the copilot made radio contact with Kiel Tower and reported: “… fully established, ready to land.” About a minute later, the tower controller reported the current wind at 170°, six knots. At 19:44:19, the co-pilot reported that the runway was in sight.
At 19:44:39, the CVR recorded the synthesized voice “MINIMUMS, MINI- MUMS” and the warning “TOO LOW FLAPS” three times, each three seconds apart.

The records of the flight data recorder showed that the aircraft touched down at approx. 19:44:44 with an indicated airspeed (IAS) of approx. 140 kt. The vertical acceleration amounted to approx. 1.2 g. Within eight seconds the speed decreased by about 22 kt.
At 19:44:58 the co-pilot called out to the PIC: “Brake, Brake.” He replied: “Yes, a little.” At 19:45:15, the CVR recorded curses from both pilots.
According to the FDR, the speed decreased to about 52 kt during the roll-out. The vertical acceleration fluctuated around 1 g for about 19 seconds after touchdown. It then briefly decreased to 0 g and then increased to about 4 g before the aircraft came to a stop about 21 seconds after touchdown.
The pilots stated that the aircraft was at FL380 when there was a sudden explosive bang. They saw flames behind them and within two seconds the cabin was full of smoke. They then initiated an emergency descent. At FL120, the PIC opened the side cockpit window to allow the smoke to dissipate. During the ILS approach at an altitude of approx. 200 m, they came out of the clouds and saw the approach lights, but not the runway lights. There was still smoke in the cabin and the cockpit windows were
were sooty. They had been exactly on the glide path. Shortly before touchdown, they had steered the aircraft slightly below the glide path and the aircraft touched down at a speed of 120 KIAS. They had assumed that the runway was 2,600 m long and had therefore not activated the thrust reverser.
According to the flight attendant, the aircraft had only recently come out of maintenance. She had found the galley in an untidy state. During the flight, she had served food to the passengers and pilots and was in the process of tidying up the galley. The passengers had asked her not to close the curtain between the galley and the passenger cabin while the food was being prepared. Later she was busy tidying up, she wanted to cover the leftover food and was looking for cling film in a cupboard in the galley. She found a red cylindrical object in the cupboard. She did not notice any labeling on the object. When she tried to open the object, flames shot out of it and everything was full of smoke.
She panicked and feared that the plane would crash. Two of the passengers helped her find a fire extinguisher and tried to put out the fire. The flight attendant was in the middle of the passenger cabin when one of the passengers handed her one of the oxygen masks hanging from the cabin ceiling. She later lost consciousness. When she regained consciousness, the plane was approaching to land. She then tried to extinguish a still burning curtain when she felt a blow and fell on her back. After the aircraft had come to a standstill, the passengers and pilots helped the flight attendant lying on the ground in front of the exit and all occupants left the aircraft.
The flight attendant suffered serious injuries, the other occupants were slightly injured.
Personal details
Pilot in command
The 39-year-old pilot in command was a Russian citizen. He held a commercial pilot’s license (ATPL(A)) and was authorized to fly the Falcon 20 as pilot in command. He was in possession of a He has a total flight experience of 2,592 hours, including 949 hours on the Falcon 20. Within the last 90 days, he had completed 74 hours of flight time. Before taking up his duties, the pilot had more than 24 hours off.
Co-pilot
The 47-year-old second pilot was a Russian citizen. He held a commercial pilot’s license (ATPL(A)) and was entitled to fly the Falcon 20 as pilot-in-command. He also held type ratings for the TU-134 and Yak-40 aircraft. He had a total flight experience of 6,263 hours, including 57 hours on the Falcon 20. His flight time within the last 90 days amounted to 29 hours. He had more than 24 hours off before taking up his duties.
Flight attendant
The 22-year-old flight attendant was a Russian citizen. She had a total flight experience of approximately 36 hours, including five hours on the type. She had completed approximately three hours within the last 90 days.
About a year before the accident, she had completed a three-month flight attendant training course at a Russian school. Since then, she had worked for the aircraft owner’s company as a flight attendant on Falcon 20. According to her statement, she had learned about emergency signals during her theoretical training. However, these were smaller than the signal rocket on board the Falcon 20. However, she had never seen them in practice or practiced with them.

The pyrotechnic object was an emergency signal (handheld flare). Powered by a solid propellant rocket motor, it is designed to reach a height of approx. 300 m after firing and release a red flare on a parachute for at least 40 seconds. The object was intended for outdoor use for signaling purposes, e.g. in emergencies. According to the manufacturer, the activated pyrotechnic object could be extinguished with water. According to the manufacturer, this object had to be transported in accordance with the regulations for dangerous goods and was not allowed to be carried on passenger aircraft.
According to the flight attendant, the inflatable boat and the emergency signals were normally stowed in a container at the rear of the passenger cabin under the sofa. In contrast, the two pilots stated that the distress signals were stored in a compartment opposite the door.

Evaluation
General information
The triggering of the pyrotechnic object resulted in the rocket motor being activated first. The CVR recordings show a period of 4.19 seconds during which the hissing noise was recorded. According to the manufacturer, the burning time of the red flare was at least 40 seconds. The traces of heat and soot clearly visible in the cabin of the aircraft in the area of the galley and the front left passenger seat on the cabin ceiling over an area of approx. 2 m2 showed that the pyrotechnic object had burned in this area of the cabin.
At the same time, from the BFU’s point of view, the traces show that the fire did not fully ignite the interior of the aircraft. The main reason for this is the relatively short burning time of the pyrotechnic signal (rocket motor and flare) of a maximum of one minute in total. The entire passenger cabin as well as the cockpit showed clear traces of soot. This means that the entire fuselage must have been filled with smoke. The flight attendant’s statement indicates that at least the curtain had not yet been completely extinguished during the aircraft’s landing approach.
The flight data show that the aircraft touched down at a speed of 140 KIAS and had covered a taxi distance of 1,080 m before coming to a standstill.

This shows that the aircraft touched down about 100 m behind the runway threshold of runway 08.
When rolling over the end of the runway, the aircraft still had a speed of about 55 kt and about 50 kt when leaving the asphalt strip. The drop in vertical acceleration to zero shows that the aircraft was then moving over the sloping terrain on a ballistic trajectory before it hit the ground hard at approx. 4 g.
Operational aspects
Flight attendant
From the flight attendant’s statement, it appears that when she was looking for a roll of cling film in the galley, she found the pyrotechnic device, unscrewed it and inadvertently activated it.
The flight attendant suffered injuries during the activation of the signal rocket and the attempts to extinguish it. It is likely that the flight attendant’s ability to act was already impaired at the beginning of the emergency due to the burn injuries she sustained. The CVR records show that she had great difficulty finding a fire extinguisher. She had become increasingly panicked. The flight attendant kept shouting to the pilots to open the cockpit window. The last statement of the flight attendant recorded 4:24 minutes after the activation of the signal rocket: “I didn’t want”, shows that she had still not put on an oxygen mask at this point.

According to her statement, the passengers had then given her one of the oxygen masks hanging from the cabin ceiling. It can be assumed that she lost consciousness shortly afterwards. It was not possible to determine with sufficient certainty how long she was unconscious and thus incapacitated. The available statements show that she was temporarily unconscious during the descent. According to her statements, she regained consciousness during the landing approach and fell while trying to extinguish the curtain due to a heavy blow. It is probable that she did not fall during the relatively soft touchdown of the aircraft with an acceleration value of 1.2 g, but during the impact on the slope, where 4 g were reached.

Flight crew
The pilot in command had initiated an emergency descent about 40 seconds after the rocket was triggered. The co-pilot had put on the oxygen mask within 18 seconds and the PIC within 59 seconds after the signal rocket was triggered.
The fact that the PIC’s remark: " …we have a fire on board, request emergency descent" at 19:22:08 was recorded by the CVR, but not by the air traffic control, can be explained by the fact that the pilot did not press the transmit button. When he repeated his information 1:46 minutes later, it reached the controller.
During this phase, the co-pilot was busy communicating and supporting the flight attendant in the search for the fire extinguishers. The PIC was very busy controlling the aircraft. The CVR recording shows that he had to ask the co-pilot several times to hand him an oxygen mask.

When the PIC asked the copilot to read out the checklist at 19:25:31, he was distracted by the flight attendant, who asked for the cockpit window to be opened because she was having difficulty breathing as a result of the heavy smoke. The co-pilot then asked the PIC if the window could be opened, but the checklist was not read. The CVR recordings and the available statements did not indicate whether the pilots noticed that the flight attendant had lost consciousness a short time later.
About six and a half minutes after the rocket was released, the frequency changed to Bremen Radar and then the radar controller gave descent instructions and information about Kiel Airport. With the question “…Kiel runway in use is zero eight, the length is one thousand two hundred sixty meters, is that sufficient?”, the controller wanted information about the runway length and confirmation as to whether this length was sufficient for the aircraft. The co-pilot’s answer: “Roger, sixty meters.”, as well as the PIC’s question: “What are they talking about?”, shows that neither of them had understood the information. This is also demonstrated by the co-pilot’s subsequent question to the radar controller: “Confirm five thousand feet?” Even when the controller repeated his question: “…I say again, runway length is one thousand two hundred sixty meters, is that sufficient?”, the information did not reach the pilots.

due to the open side window. From the copilot’s reply: “Affirmative”, the controller deduced that the pilots considered the runway length to be sufficient.
The PIC’s further requests at 19:30:59 hrs and the copilot’s announcement at 19:32:28 hrs to read the checklist were also interrupted by radio messages from the controller. Furthermore, there was no approach briefing during the entire descent to landing.
As the aircraft was well north of the approach baseline, the controller instructed the approach to be aborted and the pilots were then given vectors for the second approach.
According to the pilots’ statements, they had seen the approach lights from an altitude of approx. 200 m during the ILS approach. The pilots’ statements indicate that the cabin was still filled with smoke at this time and visibility through the cockpit windows was impaired due to the soot build-up.
At 140 KIAS, the speed at touchdown was significantly higher than indicated by the pilots and was also above the speed value set on the airspeed indicator of the pilot in command.
The pilots, assuming a runway length of 2,600 m, had not used the thrust reverser and had not applied maximum braking with the wheel brakes.

Specific conditions
In the opinion of the BFU, the flight attendant’s statement that the signal rocket was lying loose in the galley area is credible. The unsecured storage only made it possible to handle the pyrotechnic object improperly. In the opinion of the BFU, the fact that it was dark at the time of the incident also contributed to the flight attendant being able to confuse the signal rocket.
The pyrotechnic object complied with the specifications in ICAO Annex 2 for the emergency equipment of aircraft. While the operational regulations (JAR OPS) required medical emergency equipment to be kept “dust-tight, moisture-proof and protected from unauthorized access … and, if possible, in the cockpit …”, no provisions were made in this regard for pyrotechnic signalling devices as part of the survival equipment.

The different statements of the pilots and the flight attendant regarding the storage location of the distress signals indicate that this was not clearly regulated in the airline. These statements also indicate deficiencies in the training regarding the storage and handling of pyrotechnic signaling devices in the airline.
On board the aircraft, the situation for the passengers after the activation of the pyrotechnic object suddenly looked like a fire in the aircraft due to the massive smoke development, the flames and the red glow. For the pilots and passengers, as well as for the flight attendant, the situation could not be clearly and comprehensively grasped at this time. Within seconds, the aircraft cabin was filled with smoke and visibility and breathing were severely impaired for the occupants.
From the BFU’s point of view, the pilots’ voice pitch and speaking speed documented on the CVR, the failure to complete checklists and the excessive speed at which the aircraft touched down can be explained by the fact that the pilots were under a high level of stress.

The pilot in command was experienced both in terms of his overall flying experience and on the type. The co-pilot was eleven years older, had considerably more overall flight experience, but had completed few flight hours on the type.
The flight attendant’s overall experience as well as on the type must be rated as low.
The darkness and the fact that the aircraft was only 600 ft (200 m) below the clouds made the approach more difficult. In addition, the two pilots were unfamiliar with Kiel Airport and did not have the appropriate approach charts.
According to the data in the AFM, the aircraft would have required a landing distance of 811 meters. Although the LDA of 1,100 m would theoretically have been sufficient for the landing, it was significantly below the runway length value of 1,387 m, which would have included reserves.

Conclusions
The aircraft accident can be attributed to the following causes: Immediate causes
 Unintentional ignition of a pyrotechnic emergency signal in the passenger cabin
 Emergency situation due to fire and smoke development
 Misunderstandings in communication
 Non-use of the thrust reverser or brake chute and inadequate use of the wheel brakes
Systemic causes
 Improper storage of the pyrotechnic signaling device on board
 Inadequate training of crew members in the airline with regard to emergency equipment