Description

On 3 May 2006, an Airbus A320 (EK-32009) being operated by Armavia on a scheduled international passenger flight from Yerevan, Armenia to Sochi, Russia as RNV967 was instructed to discontinue its ILS approach at destination in night IMC due to a deterioration in reported cloud ceiling but it failed to complete the prescribed go around and was subsequently found to have crashed into the sea. The aircraft was destroyed and all 113 occupants were killed.

Investigation

An Investigation was carried out by the Interstate Aviation Committee (MAK). The FDR and CVR were recovered from the aircraft and their data were successfully downloaded. ATC recorded radar data was also available.

It was a found that the Captain, born in 1966, had begun his flying career as an An-2 First Officer, and then, in 1990 as a Yak-40 First Officer, on which type he gained his command in 1997. In 2004, he had joined Armavia and been trained as an A320 First Officer at the SAS Flight Academy in Stockholm and been promoted to A320 Captain with Armavia a year later. He had 5,458 total flying hours which included 1,436 total hours on the A320 of which 566 had been in command on the type.

The First Officer, born in 1977, had begun his flying career in 1999 as a Tu-154 First Officer, transferring to Armenian Airlines in 2002 where he continued on the Tu-154 for one year until the airline ceased operations. In 2004, he joined Armavia and qualified on the ATR-42 as a First Officer, before converting to the A320 on a course at the SAS Flight Academy in Stockholm later the same year and beginning as a First Officer on type. He had 2,185 total flying hours which included 1,022 hours on the A320.

It was established that after an initial decision to turn back to Yerevan en route when the destination weather was advised as forecast to be below landing minima, the crew had decided, once they had initiated the turn back, to check the weather at Sochi again. This time they told the controller there that they had VIPs on board, information which they knew was "not true". The Sochi controller had then replied that "The weather is around the limit, but OK so far” and the Captain decided to again proceed towards Sochi. The Investigation analysed crew conversation recorded on the CVR at this time and concluded that "the crew intentionally misinformed the controller, in order to obtain a positive weather forecast". As the aircraft continued towards Sochi, the Investigation concluded from CVR evidence that "the situation in the flight deck was getting complicated - the crew (especially the Captain) appeared to be eager to land in Sochi, and nowhere else". Subsequent conversations were found to "show that the crew did not even wish to bother the Sochi approach controller once more, so as not to get an unfavourable weather forecast from him".

An ILS approach to runway 06 was flown with the AP and A/T engaged and the CVR evidence was found to indicate, without notable consequences except being high on the ideal approach profile and initially overshooting the ILS LOC during the turn on, an absence of a full understanding of the automated flight modes on the part of the Captain who was PF. Once on the ILS LOC, the GS was intercepted at about 6nm from touchdown and descent continued on track and stabilised.

Then, passing an altitude of around 1,300 feet, the controller advised that the cloud ceiling was now 330 feet agl and that the aircraft should turn right and climb to 2,000 feet. The controller "did not give a direct instruction to the crew to go around". The published go around from a 06 approach at Sochi was noted to have been "a coupled right hand climbing turn onto heading 240º in the take-off configuration, with the roll angle at least 20 degrees and at a speed not exceeding 200 knots, with a climb to 600 metres (2,060 feet) at the maximum possible vertical speed".

The aircraft remained in landing configuration and without any increase to TOGA thrust as the climb began, it was turned in accordance with the controller's instruction with the AP and A/T remaining engaged. Further indications that the crew, and particularly the Captain, were not making optimum use of the automated flight path control modes quickly became apparent. This situation was likely to have been exacerbated by the failure to reconfigure - the landing gear and land flap remained deployed - since manoeuvring the aircraft at significant bank angles in landing configuration is not expected. Inputs to the Captain's rudder pedals began to occur - and these continued until the end of the flight. Since such inputs are not required to coordinate a turn and some were too great to normally go unnoticed and occurred with the side sticks in neutral, it was considered that these actions "may be a sign that the crew’s mental state was far from optimal" by this point.

In an apparent error, the stop altitude was reset to 3,200 feet before being returned to 2,100 feet as cleared; it was suspected that this happened "unintentionally […] during the process of mode activation". However, it was considered that this action had "fundamentally influenced the flight". A few seconds later, the aural "SPEED" warning which advises the crew that “the aircraft energy is decreasing to the limit, below which the engine thrust must be increased to regain a positive angle on the flight path” was annunciated. At this point, 14 seconds after the go around had begun with the aircraft at 1,150 feet, the AP was disengaged. By this time it was considered that the crew "were unable to evaluate the current situation adequately" and that it was likely that "the aircraft behaviour while manoeuvring and the activation of the Low Energy Warning were unexpected" with the AP probably being disengaged "because of doubts about whether it was functioning correctly". From now on, it was considered that "the crew was probably in a state of psycho-emotional strain" because of a combination of:

• The need to make a go around which is quite rarely encountered.
• Flight at night and the lack-of-sleep state of at least the First Officer.
• The variable weather at Sochi throughout the flight and the uncertainty as to whether it would be possible to land there.
• The unexpected aircraft behaviour during automatic flight on the segment described above.

Evidence of speech intonation on the CVR during the crew's further conversations was considered to "indicate that their stress levels were increasing".

For the next half minute, the aircraft maintained a more or less level right hand turn with the flight directors still commanding "fly up" because of the stop altitude remaining at 3,200 feet - although the maximum recorded altitude actually reached by the aircraft was 1,670 feet. This incorrect stop altitude was then reset to 2,100 feet as cleared, but as the aircraft was transferred to the radar frequency, the Captain, for reasons "that could not be determined [...] started moving the side stick forward and thereby pushed the aircraft nose down" but no contrary alerting came from the First Officer. The continued pitch down action led to an increased airspeed which triggered almost continuous overspeed warnings. Although potentially distracted by a 20 second controller response to their check-in on the Radar frequency, it was found that the crew had reacted to these warnings appropriately on two successive occasions by retracting the deployed flaps.

However, just as the long controller transmission finished, the GPWS 'PULL UP' Warning began and the First Officer called out "Level Off". He also began to operate his side stick to oppose the increasing right bank being applied by the Captain. The 'DUAL INPUT' Warning did not operate because it had a lower priority than the EGPWS Warning. The Captain had "twice moved the side stick half-way backwards, possibly reacting to the EGPWS, but at the same time the First Officer was inadvertently making nose-down inputs, which might have led the Captain to believe that the aircraft response to the control inputs in the pitch channel was not adequate". The combined inputs were summed and the extent of the pull up reduced.

The descent continued and, just under a minute after the AP had been disconnected, the aircraft hit the sea surface with the landing gear still down. It was destroyed and most of the wreckage subsequently sank in water approximately 1,600 feet deep. Only a small amount of floating wreckage was recovered from the sea surface. It was noted that simulator experiments "showed that the aircraft could have been recovered at any stage of the flight until five seconds before impact provided the crew had acted properly".

The Investigation found no evidence that the aircraft was not airworthy or that it was incorrectly loaded and sought to focus particularly on the performance of the pilots and the context for it. It was considered that "a number of psychological factors" had contributed to the development of an initially abnormal situation into the catastrophic one. The crew "had shown low mental readiness to undertake any other task apart from landing at Sochi airport" and a "conflict of motives" between the strong desire to land at Sochi and the need to carry out the controller's instruction to discontinue the approach may have led to them fulfilling the instruction given “literally” - without setting the TOGA thrust, gear up and flap retraction which are automatic actions for any go around – even the automatic one carried out in this case. It was also considered that the Captain had demonstrated "low mental readiness" to switch to manual flight path control in an unfamiliar situation. It was suggested that despite recovering the aircraft to stable flight after disconnecting the AP, "he probably still felt startled and stressed". In the final moments, the possibility that "mental torpor" had led to the inadequate action to decrease the pitch angle and ultimately to his very poor response to the EGPWS 'PULL UP' Warning was suggested. In such a state, a pilot is able to "concentrate on perception and analysis of only (some of the) flight parameters, being incapable of perceiving and evaluating the situation as a whole". In this case, such evidence as was available pointed to "the attention, perception and thoughts of the Captain and partially (that) of the First Officer being concentrated on monitoring of the flight speed".

It was accepted that the conditions for the Captain to be influenced by somatogravic illusions, "in particular the illusion of pitching up experienced by the pilot flying, with a lack of monitoring of the flight indicators and longitudinal acceleration of the aircraft, at night, with no visible references" were present. It was considered that this interpretation "is substantiated by the inadequate actions of the Captain that were recorded at the moment when the aircraft deviation from the runway heading was more than 90 degrees" which would have meant that intermittent sight of lights on the ground through breaks in the cloud may have occurred whilst the acceleration of the aircraft continued. Counter to this, though, "is evidence that shows that the Captain monitored the PFD and read it correctly, at least in respect of the speed and the Flight Mode Annunciator indication".

The Investigation noted the similarities between the final stages of this event and those of the A320 accident at Bahrain in 2000 in respect of both the "inadequate actions by the Captain, who moved the side stick forward and held it there, despite the EGPWS warning sounding for a long time" and "the crew response to the overspeed warning that was sounding at the same time (flap retraction)".

The Conclusion of the Investigation as to Cause was as follows:

This was a CFIT accident that happened due to collision with the water while carrying out a climbing manoeuvre after an aborted approach to Sochi airport at night with weather conditions below the established minima for runway 06. While performing the climb with the autopilot disengaged, the Captain, being in a psycho-emotional stress condition, made nose down control inputs due to the loss of pitch and roll awareness. This created an abnormal situation. Subsequently the Captain's inputs in the pitch channel were insufficient to prevent development of the abnormal situation into a catastrophic one. Along with the inadequate control inputs of the Captain, two Contributory Factors to the development of an abnormal situation into a catastrophic one were:

• the lack of necessary monitoring of the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot
• the absence of proper reaction by the crew to the EGPWS warning.

A number of "Shortcomings" were identified during the Investigation as follows:

• During descent and approach, the crew constantly had irrelevant conversations that had nothing to do with the crew operations manual, and therefore violated the requirements of Armenian Republic Regulations.
• The A320 FCTM, which was approved by the Civil Aviation Administration of the Republic of Armenia and on the basis of which the Captain passed his command upgrade training with the airline, does not contain any requirement for passing an 'Upgrade to Captain' programme and the Captain did not pass such training. It is noted that after the accident, such a training programme was made mandatory in the next revision of the FCTM.
• The Flight Operations Department of Armavia does not comply with the provisions of Armenian Republic Regulations and ICAO Annex 6 Part 1 Chapter 3, which require airlines to monitor fight operations standards for aircraft with the certified MTOW exceeding 27,000 kg using FDR and CVR recordings.
• In violation of Armenian Republic Regulations, Armavia does not keep records on the approaches and landings in complicated weather conditions performed by their Captains.
• The following deficiencies were identified in air traffic management:
  • During the en route part of the flight, the Sochi Approach Controller advised the crew that the Trend weather forecast for landing was '150 by 1500' but did not identify that Trend as “AT TIMES”. This inaccuracy was not directly connected with the cause of the aircraft accident, but it influenced the initial decision of the crew to return to Yerevan.
  • As the aircraft was in descent towards Sochi, the approach controller advised the crew of the latest observed weather at Sochi and by mistake said the cloud ceiling was “considerable 1800”, instead of 180 metres, however this did not influence the Captain’s subsequent actions.
  • Soon afterwards, the crew did not report, and the Holding Controller did not request the crew to report the selected system and mode of approach, which does not meet the requirements of the Sochi Aerodrome Holding Controller’s Operation Manual, Section 4, item 4.2.1.
  • With the aircraft at approximately 5½ nm final, the Final Controller was informed by the Sochi weather observer that the cloud ceiling had reduced to 100 metres which was below the established approach minima (cloud ceiling 170 metres, visibility 2500 metres). Based on this information, the Final controller instructed the crew to discontinue the approach due to “clouds at 100 metres" and make a right-hand climbing turn to 600 metres (2000 feet). The controller’s actions did not comply with the requirements of the Civil Flight Operations Guidance 85 Section 6.5.16 and the Final Controller’s Operation Manual, items 4.3 and 4.3.1. However, according to the Russian AIP, the Controller had the right to forbid the landing but it should be noted that a number of AIP items contradict each other and are ambiguous.
• In respect of Meteorological Support at Sochi Aerodrome,
  • The weather forecast for the aerodrome for the period from 18:00 to 03:00 was not verified with regard to visibility in the “At times” group;
  • In violation of the Guidance for Meteorological Support in Civil Aviation 95, Sections 4.3.1 and 4.4.1 (d) and the Instruction for meteorological support at Sochi aerodrome, the observer did not complete a Special Weather Report when the cloud ceiling dropped to 100 metres, i.e. in the form stipulated in Annex 8 of the Criteria For Issuance of a Special Weather Report;
  • The recommendation for ATIS broadcast content stipulated in the joint Order No. 62/41 “On approval and implementation of Instruction for ATIS broadcast content in English and Russian languages” dated 20 March 2000 issued by the Federal Air Transport Administration and the Hydrometeorology and Environment Monitoring Service was not entirely fulfilled.
• With regard to the A320 aircraft:
  • In course of reading out the FDR data, a number of discrepancies were found in the documentation describing the logic of binary signal recordings;
  • While performing manoeuvres in the landing configuration with the autopilot and autothrust engaged, the LOW ENERGY WARNING may sound, which Airbus considers as an abnormal situation.

A total of 23 Safety Recommendations were made:

• that the Aviation Administrations of the CIS countries should conduct briefings with the flight crews, controllers and technical and engineering personnel to review the circumstances and the causes of the accident.
• that the Aviation Administrations of the CIS countries should ensure fulfilment of the requirements of ICAO Annex 6 Part 1 Chapter 3 for mandatory analysis of performed flight operations based on the CVR and FDR recordings for aircraft with a certified MTOW exceeding 27000 kg.
• that the Aviation Administrations of the CIS countries should draw the attention of A320 crews to the necessity of immediate response to activation of EGPWS warnings (even if other warnings are on at the same time) in the case of instrument flight, or flight in difficult weather conditions, or flight in the mountains. Relevant exercises should be introduced into simulator training programmes to practice these actions and the advisability of extending these recommendations to other aircraft types should be considered.
• that the Aviation Administrations of the CIS countries should review the necessity of enhancing crew simulator training in the section on flying in Flight

Director mode, especially during approach and go-around.

• that the Aviation Administrations of the CIS countries should bring the content of the AIP, as well as the ATC controllers’ job descriptions and operations manuals, into compliance with the standards and practices recommended by ICAO, with regard to clearance for approach and landing.
• that the Aviation Administrations of the CIS countries jointly with the industrial and scientific and research organisations should organise and conduct research into the conditions under which a crew may lose spatial orientation and/or upset aircraft attitude may develop and issue practical recommendations to enhance flight safety. In particular, they should evaluate the effect of in-flight acceleration illusions and based on the research, they should develop and introduce a specialised course for recurrent training of crews that should contain both classroom and flying training.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should include in the A320 FCTM a mandatory requirement for trainee Captains to pass the Upgrade to Captain programme.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should keep records on approaches performed in difficult weather conditions by A320 crews, in accordance with the regulatory documents relating to the organisation of civil flight operations under the control of the Republic of Armenia.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should organise FDR and CVR readouts for analysis of A320 flight operations, in order to identify any errors or deficiencies in crews’ piloting technique and use the findings to develop measures for their prevention.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should point out to aircraft crews that irrelevant conversations in the flight deck, especially during the climb and descent phases, are prohibited.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should consider the necessity of enhanced simulator training for A320 crews.
• that the Civil Aviation Administration of the Republic of Armenia and Armavia should develop a procedure for the storage of A320 operational documentation that would require the retention of originals and copies of such documents by both Sabena Technics and Armavia.
• that the Federal Air Navigation Service of the Russian Federation should review the possibility of updating of the Russian AIP and other regulatory documents for the purpose of unifying ATC procedures for issuing go-around instructions to aircraft operated by domestic and foreign airlines and incorporate the relevant amendments into the Rules and Phraseology for In-flight Radio Communications and ATC.
• that the Federal Air Navigation Service of the Russian Federation should review the possibility of incorporating Air Traffic Service procedures in aerodrome services which are in accordance with ICAO recommendations (Document 4444, Attachment 11) and the Order No. 103/DV-116 dated 26.10.95 and issued by Department of Air Transport.
• that the Federal Service for Hydrometeorology and Environmental Monitoring should review the possibility of purchasing and installing of a new Doppler weather radar at the civil aviation meteorological station in Sochi.
• that the Federal Service for Hydrometeorology and Environmental Monitoring should undertake measures to eliminate the shortcomings in the meteorological support to civil flight operations at Sochi aerodrome brought to light in the course of the investigation.
• that the Federal State Unitary Enterprise, the 'Corporation for Air Traffic Management' should restore complete ATIS broadcasting for Sochi aerodrome, including weather data.
• that the Federal State Unitary Enterprise, the 'Corporation for Air Traffic Management' should clarify to controllers of the Sochi Air Traffic Support of the interpretation of the 'BECMG' and 'TEMPO' codes used in weather forecasts for the aerodrome and of the interpretation of the two-hour 'TREND' weather forecasts.
• that Airbus should eliminate the discrepancies in the documentation describing the logic of the binary signals recorded by the FDR.
• that Airbus should add information clarifying specific features of activation of the OPEN CLIMB mode in various flight conditions to the A320 FCOM.
• that Airbus should add a warning to the A320 FCOM about the possible activation of the 'LOW ENERGY WARNING' which occurs when the aircraft performs manoeuvres in the landing configuration with considerable changes in pitch and roll angles.
• that Airbus should review the expediency of altering the type and/or priority of EGPWS warnings to ensure more reliable pilot response to its activation.
• that the Aviation Administrations of the CIS countries should eliminate the shortcomings revealed during investigation of this accident (not already addressed in other Safety Recommendations).

The undated Final Report in available in an English language translation upon which this summary is based subject to language clarity and use corrections.

This Report includes separately and in full a series of comments made by the BEA France after they had received a final draft of the Report since the final published version of the Report was not altered in respect of them. The comments were on various matters of detail and preceded by the caveat that "the BEA agrees overall with the facts and conclusions in the Draft Report" and noting that the comments presented were made "with the aim of improving aviation safety, focus on the flight crew’s work during the flight, on the airline’s conditions for technical operations and the application of oversight by the Authority, as well as on some aspects of air traffic control".

Amongst other matters, it was felt that "the report should underline the absence, during that part of the flight that it was possible to reconstitute, of the application of Standard Operating Procedures (Standard Operating Procedures (SOPs)), as described in the Operator’s FCOM documentation, as well as on the critical inadequacies in Crew Resource Management (CRM)" and that "this failure to follow Standard Operating Procedures and teamwork led to the pilots losing situational awareness and made it impossible for them to regain control of the airplane in time". It was also considered that "the dysfunctions noted in the crew’s performance are too significant for them to be merely circumstantial" and that "in relation to the national oversight authority, reference to the requirements and procedures for approving foreign training centres that carry out training for those possessing Armenian Pilots’ licenses could usefully be added". It was also noted that "the controller treated the flight as if it had been a domestic Russian flight, for which he could intervene in the Captain’s decision to continue or reject an approach whereas this flight was an international flight governed by different regulations, which specifically allow the Captain to descend to the minima before deciding on a go-around".

Related Articles

• Controlled Flight Into Terrain (CFIT)
• Missed Approach
• Operational Use of Flight Path Management Systems
• Crew Resource Management
• Somatogravic and Somatogyral Illusions
• Stress
• Response to a "PULL UP" Warning
• Cross-checking Process
• Fatigue
• A320, vicinity Bahrain Airport, Kingdom of Bahrain, 2000