On 8 July 2006, an AIRBUS A-310 being operated by S7 Airlines on a scheduled domestic passenger flight from Moscow Domodedovo to Irkutsk failed to stop on the runway after a daylight touchdown at destination in normal ground visibility and after a high speed overrun eventually hit significant obstructions, caught fire and was destroyed. Of 203 occupants, 125 were killed, 41 suffered serious injury and 22 suffered minor injuries.
An Investigation was carried out by the Interstate Aviation Committee. It was found that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the Minimum Equipment List (MEL). It was noted that the previous two flights had been carried out with a deactivated right engine thrust reverser.
After a touchdown within the touchdown zone (TDZ) following a non precision approach, it was found that the aircraft commander as PF had unintentionally moved the thrust lever for the left engine into the forward thrust range whilst using reverse thrust on the right engine. The reverse thrust of the right engine was reduced to the stowed position and remained there whilst the left engine thrust lever reached a position corresponding to around 60% of its rated takeoff thrust where it remained until the Flight Data Recorder (FDR) stopped recording. It was concluded that the flight crew had not noticed the forward thrust on the left engine. The minimum speed, reached at 20 seconds after touchdown, was found to have been approximately 90 knots. Thereafter, the thrust on the left engine led to acceleration to nearly 100 knots where it remained until the aircraft left the runway. A call by the PF for engine shutdown was made as the aircraft left the runway but was not actioned.
The MEL was found to include an explicit warning that “pilots must hold the thrust lever (of an engine with a de-activated thrust reverser) in the idle position during a landing run to prevent any inadvertent movement of the thrust lever in a forward thrust direction”.
It was noted that flight crew co-operation had been poor with deficient monitoring by the First Officer who was inexperienced on the aircraft type. The Captain was found to have had no experience as a First Officer on a two crew aircraft type prior to becoming qualified on the A310
It was also noted that although the runway was reported in accordance with prevailing procedures as having ‘good braking action’, it was actually ‘covered with water’ However this fact was not considered to have materially affected the outcome.
A range of concerns relating to the evacuation of the aircraft were expressed, both in respect of the ability of the cabin crew to facilitate the evacuation and in respect of the ability of the Rescue and Fire Fighting Services to respond effectively.
A total of 57 Safety Recommendations were made as a result of the Investigation as follows:
To the Aviation Authorities of Russia:
- To carry out a comparative analysis of the specificities of operating airplanes of Russian and Western manufacturers;
- Until the necessary changes have been made by the developer of the A-310 airplane that are aimed at unifying the procedures for using the engines’ reverse thrust in various situations, to exclude the use (apart from special or emergency situations) of reverse thrust on one engine if the other is deactivated. To take into account this fact when calculating the necessary take-off and landing distances;
- In accordance with article 33 of the Air Code of the Russian Federation and article 83bis of the Convention on International Civil Aviation, to accomplish the mandatory conclusion of Agreements on continued airworthiness when allowing airlines of the Russian Federation to operate aircraft of foreign registration. To complete work on the said Agreement with the aviation authorities of France as regards the A-310 airplane being operated by Sibir;
- When allowing airlines of the Russian Federation to operate aircraft, including aircraft of foreign registration, to ensure that a check is made on their compliance with the standard construction on which the Certificate has been issued. To exclude permission to operate any aircraft that do not meet this requirement;
- To examine the question of unifying training and conversion training courses for flight crew on each type of aircraft and to put them into effect as a single basic document for all airlines operating similar airplanes, with the aim of raising the standards of training personnel and excluding any occurrences of oversimplification in this task;
- To examine the questions on creating unified training courses for flight attendants on each type of aircraft, stipulating therein the optimisation of a precise series of actions by members of the cabin crew and their use of protective, emergency and rescue equipment when carrying out an emergency evacuation of passengers in various conditions (fire, smoke etc);
- To develop and implement a universal course for improving the qualifications of flight crew specializing in crew resources management (CRM) on airplanes with two-man crews. To ensure that crews undertake it obligatorily at conversion from aircraft with three or more crew members. To cease the practice of immediately having the Captain of an aircraft with a crew of three or more members conversion to captain of an aircraft with a two-man crew without gaining any experience of operational flights as a co-pilot of an aircraft with a two-man crew;
- To amend the procedure of confirming the airlines’ MEL, excluding the possibility of confirming any “softer” variations than the developer’s MASTER MEL;
- To cease the practice of granting permits to carry out flights with a prolonged period for correcting faults without a detailed analysis of each specific occurrence;
- Together with the Federal customs service, to examine the question of accelerating the customs formalities for importing spare parts for aircraft of foreign manufacture;
- To carry out a one-time check of all aircraft for the actual availability of emergency and rescue equipment provided by type design, as well as for the availability of layout diagrams of the external emergency and rescue markings;
- To develop and incorporate the new edition of the section on the psychological and physiological selection of candidates for conversion to new aircraft and promotion to the aircraft Captain position into the “Guide to ensuring the psychological selection, training and professional activity of civil aviation flight crew and air traffic control staff in the Russian Federation” 2001 edition. During the period of developing the new edition of the section to prolong the effectiveness of the previous rules of selection, as confirmed by the Minister of Civil Aviation in the “Guide to professional, psychological and physiological selection in civil aviation” (1986);
- When selecting candidates for conversion to a new aircraft type, to oblige physical evaluation board and airline psychologists to pay particular attention to any candidates’ personal qualities affecting the processes of emotional reaction and behaviour in non-standard conditions (increased tension and stress), and, when identifying any unfavourable signs, to approach more severely the resolution of any question of their suitability for conversion training and/or the need for an individual approach in conversion training;
- To ensure the high-quality and thorough investigation of air incidents according to ICAO Annex 13 and the development of specific recommendations on preventing similar occurrences in the future;
- To equip at least two devices at Irkutsk airport with modern units for measuring, processing and recording the results of measuring the friction coefficient to replace the visual recording equipment being used. To check the availability and, if need be, to re-equip other airports, a list of which is given in Order no. NA-30-r of the Ministry of Transport of the Russian Federation dated 24.01.01, with the appropriate measuring equipment;
- Together with the scientific research organisations, to develop a method of objective, multiple and quantitative assessment of the state of the runway in accordance with any parameters affecting the take-off and landing characteristics of aircraft of all types, as well as the introduction of the corresponding forms of information of crew members. In order to improve the braking characteristics of civil aircraft on a runway covered in precipitation, to carry out investigations of possibilities to perfect runway surfaces (surface cleaning, corrugation etc);
- To develop and implement regulations to exclude the possibility of civil airports accepting any aircraft of a category higher than the level of fire protection of the airport (UTPZ);
- To develop and implement changes to the List of Flight Search and Rescue (SPASOP) equipment for airports and regional search and rescue bases (RPSB) in the section dealing with the obligatory provision of special helmets that can be rapidly donned for firefighters and rescue workers equipped with devices for radio communication and the protection of the respiratory organs;
- To develop and implement requirements for an increase in at least one UTPZ category of any airports where take-offs and landings are carried out above structures (buildings and erections), with a guaranteed time for the arrival of the first airport fire engine of no longer than two minutes, and a guaranteed range of delivering fire extinguishing compound at medium and high frequency of at least 70 metres;
- Together with the scientific research organizations, to conduct investigations and prepare recommendations on extinguishing combined fires on aircraft;
- To consider the possibility of developing and providing special clothing for rescue workers when working close to centre of open fire;
- To complete the number of departmental search and rescue fire brigades in accordance with the prescribed standards.
To S7 Airlines:
- To include questions on the use of the MEL in conversion training courses and periodic training courses and to stipulate specific actions by the flight crew. To ensure that the crew’s operating procedure is in compliance with the manufacturer’s recommendations while flying with defects deferred as per the MEL;
- To cease the practice of Training Captains of aircraft of Western manufacture with two-man crews without passing through co-pilot training courses and gaining experience on operational flights in this capacity;
- To devise a course for the initial training of airline instructors;
- To ensure the constant monitoring of the use of the MEL. In the event of the ambiguous interpretation of any provisions, to ask for relevant explanations from the aircraft developer;
- When selecting candidates for conversion to new aircraft, to oblige airline psychologists to pay particular attention to any candidates’ personal qualities affecting the processes of emotional reaction and behaviour in non-standard conditions (increased tension and stress), and, when identifying any unfavourable signs, to approach more severely the resolution of any question of their suitability for conversion training;
- To develop and implement remedial measures targeted at maintaining a high level of flight safety in conditions of intensified air traffic during familiarization with new aircraft types;
- To develop and implement the emergency layout diagram of the A-310 aircraft type for the airport emergency and rescue services;
- To exclude a perfunctory approach in debriefing flight crews in relation to the results of analysis of the circumstances of accidents and incidents, as well as any other events that have affected or may affect the level of flight safety;
- To issue tickets for all the crew members flying as passengers without adding them to the flight task list;
- To correct any other faults that have been revealed in the course of this investigation as well as during the audit conducted by Airbus in April 2006.
- Together with the engine developers, to investigate the possibility of having and developing a unified procedure for engaging reverse thrust, irrespective of the engine type or the presence of a deactivated thrust reverser;
- To investigate the possibility of changing the algorithm for the activation of the “wrong take-off configuration” warning in order to prevent its activation during any irrelevant stages of a flight or to insert the relevant caution in the FCOM about the possibility of activation of this warning during a landing run, as well as the appropriate crew actions in this situation;
- To reword the caution in the TR 02-78 A-310 MMEL chapter in order to remove any incorrect or ambiguous information to ensure precise understanding of the caution.
To EASA and other Certifying Authorities together with the Manufacturers of Large Transport Aircraft
- To review the human factors issues associated with the dispatch conditions and the operational procedures in case of one thrust reverser being inoperative, in order to avoid inadvertent forward thrust application;
- To review the design and maintenance requirements for all FADEC controlled airplanes to ensure that throttle lever breakout forces remain at the acceptable lever and that they are checked on a periodic basis;
- To evaluate the usefulness of cabin crew smoke hood devices in assisting the evacuation of airplanes; to evaluate the possibility of equipping large transport airplanes with devices for passengers and/or flight attendants to be used in case of an emergency evacuation without suffering from the effects of smoke and toxic fumes.
- The investigation showed that other events occurred on different types of aircraft, involving inadequate monitoring and erroneous activations of the reverse thrust levers during a landing run in a configuration with one engine reverser deactivated. The Interstate Aviation Committee recommends drawing the attention of operators
to the risks of erroneous movement of the thrust levers in these conditions and their non-detection.
To Moscow Domodedovo Airport:
- To the staff engaged in the registration of passengers, to enter on air tickets the actual weight of hold luggage and hand luggage, and to enter all required details in the registration information;
- To require loading and centre-of-gravity supervisors to enter information carefully and in good time and to make corrections to the airplane’s centre-of-gravity diagram and loading chart in accordance with the actual information available;
- To require loading agents to strictly comply with the rules for completing carriage documentation, including whenever inserting any corrections in air cargo manifests for the carriage of hazardous cargoes.
To the International Civil Aviation Organisation (ICAO):
- To examine the question of urgently introducing the video recording of any situation in the cockpit as an ICAO standard at least for aircraft with a maximum take-off weight of more than 27,000 kg.
To the Aviation Authorities of Russia and the Countries participating in the Agreement on Civil Aviation and the Use of Airspace:
- . Along with flight crews and cabin crews (flight attendants), as well as air traffic controllers and technical engineering staff, to carry out special analyses to study the circumstances of and reasons for an accident;
- To draft national (state standard) air rules for the operation and safety of flights in accordance with international standards, using the Air Rules devised within the context of the ICAO-IAC project on Air Rules, as approved by the Council of the states participating in the Agreement and the ICAO Air Navigation Bureau;
- To determine the procedure for regulating the operation of aircraft of foreign registration in any states participating in the Agreement and to engage in work on perfecting the existing standard basis. When operating any aircraft of foreign registration in any states participating in the Agreement, to ensure the concluding of agreements in accordance with article 83bis of the Chicago Convention between the state of the operator and the state of registration, including any aircraft of non-commercial organisations registered in a “private” category, for the purposes of a clear division of responsibility for maintaining operational airworthiness;
- To amend in the national suitability standards for airports the full list of requirements for flight safety at an airport, including the requirements for:
- the physical characteristics of an airport;
- the restriction and assessment of any obstacles;
- any visual flight safety equipment;
- the radio equipment and air traffic control towers;
- the meteorological equipment;
- the electrical power supply and equipment;
- the emergency and rescue equipment;
- safety control at the airport;
- air navigation information;
- equipment and methods of measuring the friction coefficient on a runway.
- To examine the question of introducing additional restrictions on residential and other buildings in the vicinity of the airport and its surrounding territory and any structures (gas pipes, fuel distribution points etc) near the runways into the legal standards documentation. To insert amendments in the existing building standards and rules for the purposes of introducing new technical and technological decisions (modern software products) in the planning, construction and acceptance of newly built (or reconstructed) airports;
- To implement the Federal Aviation Rules accepted by the Council of States participating in the Agreement on medical flight safety in civil aviation, and to organize the execution of work on the basis of a system of working time and rest periods for civil aviation flight crew and air traffic controllers, as well as the study of death rates among aviation specialists, and the drafting of preventative measures with a view to prolonging the life expectancy of flight personnel;
- To regularly carry out an examination of and a check on executing the recommendations of commissions investigating accidents and incidents, and governmental commissions' recommended actions as well;
- To resolve top-priority tasks to improve the quality of training aviation specialists, it is necessary:
- To introduce standards, norms, courses and requirements to regulate the process of training aviation specialists and the level of professional training;
- To carry out work on drawing up standard training plans to acquire professional training, as well as standard courses for conversion and improving qualifications. Particular attention should be paid to training staff instructors;
- To carry out work on preparing training courses and the requirements for the use of simulators and technical teaching methods for a detailed draft of the actions to be taken in special flight situations;
- To incorporate modern methods of training flight crews and air traffic controllers in English into the work of training establishments and airlines;
- To cease the practice of immediately training candidates from aircraft manned by 3 or more crew members as aircraft Captains (omitting the stage of flying as a co-pilot) for class 1-3 aircraft with a 2-man crew;
- To increase the minimum level required for conversion training to large types of aircraft and to ensure control thereof by observation as a supervisory service. To ban solving the problem of a shortage of flight crew by means of the oversimplified conversion training of other members of flight crews (navigators, air engineers).
- To introduce modern information systems on incidents, accidents, breakdowns and faults in aviation equipment in use, for the purposes of taking corrective actions in good time to ensure flight safety;
- To legally determine the position on the compulsory insurance covering the liability of the carrier/owner of an aircraft towards passengers and third parties, establishing the unified level of liability for domestic and international air transportation laid down by the 1929 Warsaw Convention and the Hague Protocol. To take steps to ratify the 1999 Montreal Convention;
- To introduce the requirement for compliance with international (IOSA) quality standards for all operators by no later than 1 January 2008;
- To ensure checks are made on the serviceability and proper maintenance of emergency and rescue equipment on all civil aviation aircraft.
- To examine the question of organising joint work on maintaining the airworthiness of aircraft of foreign registration taking into account the need to build up a database and analyse the reliability of the whole fleet and, in conjunction with the manufacturer, to process any recommendations for improving reliability and the level of flight safety;
- To introduce the regular practice of holding technical flying conferences on generalizing the experience of operating aircraft of foreign registration and drafting proposals for their perfection.
The Final Report of the Investigation was issued in 2007 and an English translation made available by the French BEA.