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fully comply with the requirements of the 1987 FOM. Analyses of
flights (for example, the overshooting of an A-310 at
Domodedovo airport on 29.06.05) were simply reduced to a
statement of fact, without any detailed analysis of the flight
parameters or the actions of the crew.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
112
3.7. Analysis of the actions of the crew from the onset and in the
development of an emergency situation revealed shortcomings in the
professional training of both the airplane captain and the co-pilot,
which have led to:
• the airplane captain erroneously moving the throttle control lever
for the left engine, whose thrust reverser has been deactivated, to
forward thrust when controlling the reverse thrust of the right
engine without making the necessary check on the position of the
throttle control lever for the left engine, as required by the MEL.
Note: The Sibir A-310 FPTP does not provide for any training to
learn this skill.
• in the absence of the required monitoring by the co-pilot of the
performance of the engines and the specified flight parameters.
During the landing approach and landing run, the following deviations
from SOP were also established:
• during the non-precision approach the co-pilot did not report any
changes in FMA parameters or the overflight of any check points
while on the pre-landing descent;
• the co-pilot did not report reaching decision height, as well as the
airplane captain did not speak aloud the decision to land, and did
not give the command to set the landing course on the FCU;
• the co-pilot did not announce that right thrust reverser was
deployed and that autobrake was disengaged;
which is probably associated with the inadequate crew training on the
CRM course as well as with short experience on type of the co-pilot.
3.8. Medical aspects.
During the evaluation, analysis and interpretation by Sibir’s
psychologist of the data received as a result of the psychological
testing of the airplane captain, the test data “Comparison of
concepts” and “Sondi modified methods” were inadequately expertly
analyzed and taken into account. The details of Kettell’s test and
“Luscher’s eight-color test” were correctly analyzed but not taken
into account in the final interpretation and conclusions. Accordingly,
the psychologist’s recommendation to admit airplane captain to the
A-310 conversion training course was given without adequate
grounds .
The personality traits of the airplane captain which were identified
from the results of analyzing the psychological tests, together with
the features of his conceptual thinking, may have had a profound
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
113
effect on his behavior in a stressful situation, and, particularly, may
have caused disorganization.
3.9. The autopilot and thrust controller were switched off by the crew at a
height of 100m and could not have any effect on the landing and
landing run. The couplings linking the thrust controller to the engine
control linkage were uncoupled and were not connected to the
linkage any more. No steering commands given by the thrust
controller computer were recorded. The results of the investigation of
the electronic guidance and engine control system (FADEС) testify
to the efficiency of the system right up to when the airplane collided
with the barriers.
The airplane landed in the touchdown zone at Irkutsk airport at
22.43.40 in wheel control mode with engines running at idle. After
landing, the spoilers were automatically deployed and the automatic
braking system (ABS) was automatically switched on in LOW mode.
1.5 seconds after touchdown, the airplane captain set the reverse
thrust lever for the right engine to the reverse mode. The right engine
correctly went into reverse thrust mode. The reverse thrust lever for
the left engine was not applied.
Consequently, during the time the reverse thrust lever for the right
engine was being moved forward (to reduce the reverse thrust), the
airplane captain unintentionally and uncontrollably moved the
throttle control lever for the left engine forward (increasing forward
thrust). The reverse thrust of the right engine was reduced by the
pilot gradually up to the stowed position and remained in that
position until the time of colliding with the barriers. The throttle
control lever for the left engine was in the position corresponding to
the forward thrust setting of ~60% of its full rated takeoff thrust, and
remained in that position until the FDR stopped recording. The crew
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FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCI(61)
