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Old 4th Mar 2014, 16:33
  #513 (permalink)  
vovachan
 
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Here is Avherald's approximate translation w slight revs

Misalignment of mechanism and locks of thrust reversers on both engines as well as inappropriate actions (not in accordance with the flight crew operating manual) by the crew during the landing run that resulted in lack of effective braking overrunning the runway and colliding with obstacles at high speed (about 190 kph/102 knots), the destruction of the aircraft and loss of life.

Contributing factors were:

- lack of documentation in what sequence the adjustments and checks of the engine control system should be performed upon replacing the engine control system as well as lack of documentation on the rigidity of the controls and thrust reverser locks. This factor only becomes relevant in a handling of the thrust reversers in violation of the flight crew operating manual.

- inconsistencies and contradictions in the maintenance manuals of the aircraft and engines.

- lack of a formal procedure for maintenance organisations engaged in replacing engine management systems (including control mechanism and thrust reverser locks) to provide feedback to the aircraft and engine manufacturer in a timely manner to eliminate defects.

- unstable approach and significant speed exceedance (45 kph/24 knots), that resulted in a prolonged flare, significantly increased landing distance (by about 950 meters), soft touchdown (+1.12G) preventing simultaneous activation of left and right gear compressed signals and thus preventing automatic extension of spoilers and air brakes.

- lack of checks by the crew for extension of spoilers and air brakes

- lack of extending the spoilers manually

- violation of the flight crew operating manual by the crew with respect to the use of reverse thrust, evidenced by the application of maximum reverse thrust in one motion without pause at low reverse thrust and without checking whether the thrust reversers had deployed, which resulted in an increase of (forward) engine thrust.

- absence of a (combined) gear compressed signal (more than 5.5 tons of weight on each main landing gear) throughout the entire landing roll and the crew's failure to extend the spoilers manually resulted in the thrust reversers remaining stowed.

- poor cockpit resource management by the commander throughout the entire flight, which in the approach phase led to lack of monitoring of flight remaining within stabilized approach criteria and the runway overrun

- unsatisfactory organisation of flight operations and non-functional safety management system at the operator, unsatisfactory formal verification of qualification of flight instructors to conduct pilot proficiency verifications, lack of proper monitoring of qualifications and flight operations [using FDR readouts] by the operator made it impossible to identify and eliminate systemic weaknesses in pilot techniques including speed control on landing and use of thrust reversers.

- absence of periodic training of flight crew in reacting to scenarios involving the malfunction of landing gear switches requiring the manual extension of spoilers and speed brakes. The techhnical possibilities at the simulators do not permit to work such scenarios.
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