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Sabiha Gökçen Havalimanı 'nda 5 Şubat tarihinde pistten çıkarak 3 kişinin ölümüne 180 kişinin de yaralanmasına neden olan kaza ya ilişkin yürütülen soruşturma kapsamında 6 kişilik bilirkişi heyeti tarafından hazırlanan rapor soruşturma dosyasına girdi.
Raporda, soruşturmada şüpheli olarak yer alan kaptan pilot Mahmut Aslan asli ve ikinci pilot Ferdinant Pondaag tali kusurlu bulunurken, soruşturmada şüpheli olmayan, Sabiha Gökçen ve Yeşilköy kulelerinde görevli iki kişi de kusurlu bulundu. Pistin bir bölümünde lastik temizleme çalışması yapılmadığı gerekçesi ile HEAŞ da asli kusurlu bulundu. Raporda kaptan pilot Mahmut Aslan'ın, stabil yaklaşma kriterlerine uymadan piste yaklaştığı, indikten sonra 6 saniye boyuncu frenleme yapmadan ilerlediği, rüzgarın şiddetli ve pistin ıslak oluşunu dikkate almadığı belirtildi. Raporda, Sabiha Gökçen Kule Kontrolörü Serhat Kara'yı uçağın pistten çıkabileceği yönünde uyaran kule görevlisi Ela Akar kusursuz bulundu.
Sabiha Gökçen Havalimanı'nda meydana gelen kazaya ilişkin soruşturmayı yürüten İstanbul Anadolu Cumhuriyet Başsavcılığı tarafından 6 kişilik heyetten istenen rapor soruşturma dosyasına girdi.
BİLİRKİŞİLER 4 KİŞİ VE BİR KURUMU KAZANIN OLUŞUMUNDA SORUMLU TUTTU Bilirkişi, dosya şüphelileri kaptan pilot Mahmut Aslan ve yardımcı pilot Ferdinant Pondaag 'ın dışında Sabiha Gökçen ve Yeşilköy kule görevlilerinden iki kişi de kaza nın oluşumunda gerekli uyarıları yapmadıkları, uçuş trafiğini durdurmadıkları gerekçesi ile kusurlu bulundu. Ayrıca HEAŞ da (Havaalanı İşletme ve Havacılık Endüstrileri A.Ş.) kurum olarak kusurlu bulundu.
"YILDIRIM'IN ÇARPMASI KAPTAN PİLOTU STRESE SOKTU" Bilirkişi raporunda Kaptan Pilot Mahmut Aslan , bilirkişi raporuna muhalefet şerhi koyan üye dahil 6 kişilik heyetin oybirliği ile aldığı kararla asli kusurlu bulundu. Aslan'ın olay günü rüzgarın kuyruk hızını, pistin ıslak oluşunu hesaba katarak uçağın pistten çıkma ihtimalini göz önüne alması gerektiği belirtilen raporda, "Yalova dolaylarında uçağa yıldırım isabet etmesinin verdiği stres ile yolcuların mevcut meteorolojik koşullardan olumsuz etkilenmelerinin önüne geçmek amacıyla bir an önce uçağı güvenli şekilde indirmeye odaklanması sebebiyle bunu yapamadığı tespit edilmiştir" denildi.
Kaptan Pilot Aslan'ın piste stabil yaklaşma kriterlerindeki hıza da uymadan yaklaştığı savunulan raporda, "Bu nedenle Sink Rate (alçalma hızı) uyarısı aldığı, uçağı indirdikten sonra pist içinde durabilecek seviyede yavaşladığını düşünerek Autobrake (Otomatik fren) ve Speedbrak'ı (Hız freni) kapatmıştır. Uçak 6 saniye boyunca pist üzerinde yavaşlamadan ilerlemiş ve pilotlar tarafından yavaşlamak amacıyla manuel olarak maksimum frenleme yapılmıştır. Sürati düşmeye başlamış olan uçak yerde kuvvetli kuyruk rüzgarı etkisiyle yavaşlayamamış ve söz konusu kaza meydana gelmiştir" denildi.
Raporda, "Yaklaşma esnasında maruz kaldıkları yıldırım sebebiyle inişe fazla odaklanıp inişe devam eden kaptan pilot Mahmut Aslan'ın meydana gelen kazada asli kusurlu olduğu kanaatine varılmıştır" denildi.
"KONTROLÜ ALIP UÇAĞI PAS GEÇMESİ GEREKİYORDU" Raporda ikinci pilot Ferdinant Pondaag 'ın bir yıldan kısa süredir Pegasus'ta görev yaptığı belirtilerek, "400 saatlik az bir tecrübesi olduğundan yaklaşma boyunca süratinin üstüne çıkıldığı zaman ve alçalma hattının üstüne/altına hareket edilirken uyarılarıyla kaptan pilotu desteklemesi gerekirken bunları yapmamıştır. Herhangi bir düzeltme kaptan pilot tarafından yapılmıyorsa sesli ikaz, hala tepki gelmiyorsa kontrolleri alıp uçağı pas geçirmesi gerekiyordu. Ancak hem şirketteki hem de uçak tipindeki düşük tecrübesinin de etkisiyle bu görevleri tam olarak yerine getirmediği tespit edilmiştir. Bu sebeplerden dolayı yardımcı pilot Ferdinant Pondaag'ın meydana gelen kazada tali kusurlu olduğu kanaatine varılmıştır" denildi.
KULE GÖREVLİLERİ DE KUSURLU BULUNDU Dosya şüphelisi olmayan Sabiha Gökçen Havalimanı Hava Trafik Kontrolörü Serhat Kara da raporda kusurlu bulundu. Raporda, Kara'nın, inmenin riskli olabileceği yönünde kendisinde kanaat oluşmasına rağmen uçağın inmesine izin verdiği savunularak, "Pas geçme ile ilgili uyarı, tavsiyede bulunmadığı, hatta yaklaşmakta olan adı geçen trafiğin bu meteorolojik koşullarda nasıl olsa pas geçeceği düşüncesiyle trafiğin güvenliğini sağlamak için gereken önlemleri almadığı" savunuldu.
KULE GÖREVLİSİ ŞEFİNİ UÇAĞIN PİSTTEN ÇIKABİLECEĞİ YÖNÜNDE UYARMIŞ Raporda, Sabiha Gökçen Havalimanı kule görevlisi Ela Kara'nın ekip şefi olan Serhat Kara'yı uçağın pistten çıkabileceği konusunda uyardığı, Kara'nın Yeşilköy yaklaşma kontrolörü ile iletişime geçtiği ancak koordinasyonun tam sağlanamaması nedeni ile uçağın inişe yaptığı belirtildi. Raporda, "Serhat Kara meydana gelen kaza olayında asli kusurlu olduğu kanaatine varılmıştır" denildi.
ŞEFİNİ UYARAN KULE GÖREVLİSİ KUSURSUZ BULUNDU Raporda, şefi Serhat Kara'yı uçağın pistten çıkabileceği yönünde uyaran Ela Akar'ın kusurlu olmadığı ifade edildi. Atatürk Havalimanı Hava Trafik Kontrolörü Nesrin Bala da asli kusurlu bulundu. Raporda, Serhat Kara'nın Nesrin Bala'dan tüm gelişleri bekletmesini istediği ancak Nesrin Bala'nın bunu yapmadığı belirtildi.
RİSK ANALİZİ RAPORUNA UYULMAMIŞ Raporda, Sabiha Gökçen Havalimanı 'nın 2016 yılından önce yapıldığı için pist sonu emniyet sahasının bulunmadığı, havalimanı yönetiminin bu konuda Hollandalı bir firmaya risk analizi yaptırdığı belirtildi.
Bu firmanın da kaza nın meydana geldiği 06 pistinin rüzgarlı havalarda riskli olduğu yönünde rapor düzenlediği belirtilen bilirkişi raporunda, risk analizi yapan firmanın 06 pistinin, kuru pistte 5 knot, ıslak pistte ise 0 knot kuyruk rüzgarı durumunda kullanılması gerektiği yönünde görüş bildirdiği belirtildi. Bunun üstündeki kuyruk rüzgarlarında inişlerin azaltılması yönünde tavsiyede bulunduğu belirtilen raporda, ancak bu tavsiyeye uyulmadığı gibi daha yüksek rüzgarlarda da operasyona devam edildiği kaydedildi.
PİST SONU EMNİYETİ BULUNAN PİST YÜZDE 35 PİST SONU EMNİYETİ BULUNMAYAN PİST İSE YÜZDE 65 KULLANILIYOR Hollandalı firmanın düzenlediği risk analizi raporundaki tavsiyelere uyulmadığı kaydedilen bilirkişi raporunda, "Ancak bu tavsiyeye uyulmadığı gibi havalimanı otoritesi kaza günü kendi koyduğu daha yüksek olan pist arka rüzgar limitlerine de uymamıştır. Yüksek arka rüzgarın olduğu bu durumda pist değiştirmekte geç kalınmış ve yüksek rüzgarda uçakları 06 pistine yönlendirmeye devam etmiştir. Trafik yoğunluğu olarak yüzde 35 oranında kullanılan 24 pistinin sonunda RESA (pist sonu emniyet alanı) bulunmasına karşın yüzde 65 oranında kullanılan 06 pistinin sonunda RESA bulunmamaktadır" denildi.
DHMİ ACİL DURUM MÜDAHALE YOLLARININ UYGUN OLMADIĞI RAPORU DÜZENLEMİŞ Devlet Hava Meydanları İşletmesi'nin (DHMİ) 2017-2018-2019 yıllarında bu bölgede acil durum müdahale yollarının uygun olmadığı yönünde raporlarının bulunduğu belirtilen bilirkişi raporunda, "Bu kazada uygunsuzluk; 18:19'da gerçekleşen kazadan 24 dakika sonra acil müdahale açarlarının uçak başına ulaşabilmesine neden olmuştur" denildi.
HEAŞ ASLİ KUSURLU BULUNDU Pistin bir bölümünde lastik izi çalışmasının yapılmaması, acil durum müdahale yolunun uygun olmaması nedeni ile acil durum müdahale yollarının uygun olmaması nedeni ile HEAŞ da (Havaalanı İşletme ve Havacılık Endüstrileri A.Ş.) asli kusurlu bulundu.
KARARLAR OY ÇOKLUĞU İLE ALINDI Bilirkişi heyeti içinde hukukçu sıfatı ile bulunan Necmi Demir, kaza ya ilişkin Kaza Kırım Raporu'nun düzenlenmesinden sonra bu raporun yazılması gerektiğini savundu. Demir, var olan bilgi ve belgeler doğrultusunda hazırlanan bu rapordaki bazı kararlara muhalefet etti. Demir, yardımcı pilot Ferdinant Pondaag 'ın da asli kusurlu, Nesrin Bala'nın kusursuz, Ela Akar'ın ise tali kusurlu olması gerektiği yönünde görüş bildirdi. Diğer kararlarda çoğunluk ile hareket eden Demir, DHMİ'nin gerekli denetim görevini yapmadığı için tali kusurlu olduğunu savundu.