Comprehensive Report on the Itek Air B737-200 Crash, Tehran 2008

The report analyzes the 2008 Itek Air B737-200 crash near Tehran, Iran, which resulted in the loss of many lives. The investigation revealed multiple contributing factors, including a non-secured forward left cabin door, pilot errors (such as failure to maintain visual contact and ignoring warnings), and deviations from standard operating procedures. The report highlights the roles of the Interstate Aviation Committee (IAC) and the impact of the crash on the airline, families, and aviation safety. It also discusses the concept of a 'just culture' in aviation, contrasting it with a blame culture, and its potential impact on the prosecution of aviation professionals. The author opines on the verdict, suggesting a ban on the 737 series and prosecution of cabin crew, and emphasizes the importance of a just culture for encouraging reporting and learning from mistakes. The crash led to significant financial losses for the airline, increased insurance premiums, and legal action from victims' families, thereby affecting the risk profiles of international airlines. The report also touches upon the potential negative effects of criminalization on aviation safety professionals.

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Itek Air B737-200, Tehran Iran 2008
Name
Affiliation

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Itek Air B737-200 was a registered charter flight operated under the name of the Iran
Aseman Airlines. It crashed on 24th August 2008 near the Manas International Airport of
Kyrgyzstan while it was trying to land at its airport of origin i.e. at the Imam Khomeini
International Airport in Tehran, Iran while facing technical difficulties. Out of the eighty-three
passengers only twenty-one survived.
MAK or the Interstate Aviation Authority attempted to retrieve the data from the voice
recorders in the cockpit but they were badly damaged by the fire, which destroyed most of the
aircraft. When the MAK professionals tried to disassemble the casing of the tape recorder and
the voice recorder, they found those damaged however MAK still attempted to read the data
from the damaged media.
MAK has concluded that the crash came out as a result of the forward left cabin door not
being closed properly by an engineer who was not listed under the Cabin Attendant Manual nor
was he supposed to close the door. The aircraft lost cabin pressure because of this error however
this was just one of the many contributing factors to the crash.
The Itek Air along with all its listed carriers is banned by the EU and isn’t allowed to fly
over the territory of the European Union.
Both the captain and the co-pilot were prosecuted and received five years and two months
sentences each against penal code for the crash. Their punishable mistakes involved trying to
land with increased pressure in the cockpit and failure to maintain visual contact with the
runaway, failure to monitor altitude and ignorance of automated warnings about terrain
proximity.
Other contributing factors to the accident include;
 Deviating from the Boeing 737-200 SOP as well as the PF/PM task sharing principle.

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 Not following prescribed procedures once visual contact was lost with the runaway and
ground references.
 Incorrect identification by the PIC of the aircraft’s position in comparison with the
required descent flight path as the PIC had decided on the straight in approach instead.
 Not following or adhering to the prescribed procedures when the TAWS warning signs
were triggered.
The IAC or the Interstate Aviation Committee is the supervising body which oversees the
use and management of civil aviation. The IAC was formed in 1991 and the Air Accident
Investigative Committee of the IAC works with the Federal Air Transport Agency where
investigations of the accidents and incidents in aviation are concerned.
In my opinion the verdict was partially incomplete as the aviation authorities should have
banned the 737 series from flying ever again. Not only this but they should have also prosecuted
and heavily penalized the cabin crew as well for not checking whether the forward left cabin
door was closed completely or not as it is their responsibility as well. Considering how many
accidents had taken place on the 737 series it is hard to understand how these aircrafts were
allowed to fly in the first place. Not only that the Boeing Company that has produced this series
should have also been prosecuted if not for this case but for others that happened before it.
There were fifty-nine foreign nationals aboard the plane out of which three were from
Kyrgyzstan, fifty two were Iranian, two Canadian, 1 Chinese and 1 Turkish. Also on board were
the seven crew members and a youth volleyball team. Out of the ninety passengers on board only
twenty two survived including all the crew members’, pilot and co-pilot. Three of the survivors
were in resuscitation while the rest of the survivors received minor injuries.

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This aviation disaster has led to the all the carriers facing annual losses exceeding some
$2 billion including insurance liability as well as hull losses amounting to several hundred
millions. However, apart from the monetary impact such accidents have already started
damaging the risk profiles of these international airlines which has led them to suffer increased
premiums from the insurance companies. Not only this but the families of the dead and surviving
victims have started suing these airline companies for the trauma that they have faced as well as
the loss of income.
The aviation professionals have found themselves in jeopardy especially from the system
safety standpoint. Prosecution of the aviation professionals for their crimes or negligence
involves evidence and sources of evidence against them can come from accident’s technical
investigations and protected and sensitive data. The prosecuting courts rely heavily on such data
and in some cases the courts give them verdict based on the entire findings of these reports if
other evidence isn’t bought forward. However, an important point to note here is that
criminalization will have no effect either positive or negative on safety as the ATCO and the
pilots are already under great pressure to maintain high levels of safety and productivity and this
additional fear of criminalization and prosecution will lead to increased judgmental errors and
also high stress which will in turn have a negative effect on the concentration, decision making
and performance of all aviation professionals.
Just culture is defined as a culture that supports a leaning organization where a uniform
and systematic approach is taken to interpreting a situation and providing solutions for all issues
whether they are large or small. A just culture will allow the pilots to provide feedback without
fear of any punishment. In a just culture, individuals are not punished for normal errors and
omissions during a person’s daily day to day business as long as the person who has committed

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an error fesses up and gives him and the others an opportunity to learn from his mistakes.
Discipline is only used when a person deliberately and thoughtlessly creates a challenge.
In my opinion, if the just culture was followed in the Tehran crash then the captain and
co-pilot wouldn’t have been prosecuted for up to five years and two months. They would have
received a much lesser sentence and retraining and would have been let off the hook quite easily
instead of eventually. However, a just culture for an aviation industry is a positive step as this
will bring forward a lot of issues that the aviation professionals do not talk about or bring up for
the fear of being prosecuted. A blame culture is counter-productive as having a just culture
allows for mistakes to be picked up and learned from.