FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT A310-324 F-OGYP

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FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT A310-324 F-OGYP

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"Approved"
Deputy Chairperson of the Interstate Aviation Committee
O. K. Ermolov
2007
INTERSTATE AVIATION COMMITTEE
FINAL REPORT
ON THE RESULTS OF THE INVESTIGATION
OF THE ACCIDENT
Type of aircraft A-310-324
State of Registry France
Registration F-OGYP
Owner Wilminton Trust Company acting as the
holder of fiduciary rights
Lessor Airbus leasing II.Inc
Operator ОАО Aviakompania Sibir
Date and time of accident 8 July 2006, 10:44 pm UTC (07.09.06,
7:44 am local time)
Place of accident At a distance of 2140 m and on a
magnetic azimuth of 296° from Irkutsk
ARP
In accordance with the standards and recommendations of the Intergovernmental Civil
Aviation Organization, this report was issued with the sole purpose of preventing accidents.
The investigation conducted for this report does not presume to establish the share of any
party's guilt or liability.
Any criminal aspects of this accident are treated in separate criminal proceedings.
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Table of Contents
Glossary.................................................................................................................... 3
Background Information........................................................................................ 8
1. Factual Information ....................................................................................... 10
1.1. History of Flight ......................................................................................................10
1.2. Injuries to Persons ..................................................................................................11
1.3. Damage to Airplane ................................................................................................11
1.4. Other Damage .........................................................................................................11
1.5. Personnel information ............................................................................................11
1.5.1. Flight Crew .......................................................................................................11
1.5.2. Cabin Crew .......................................................................................................20
1.6. Aircraft Information...............................................................................................26
1.7. Meteorological Information...................................................................................32
1.8. Air Traffic Control .................................................................................................36
1.9. Aids to Navigation...................................................................................................39
1.10. Aerodrome Information.....................................................................................39
1.11. Flight Recorders..................................................................................................44
1.12. Wreckage and Impact Information...................................................................44
1.13. Medical and Pathological Information .............................................................47
1.13.1. Medical information .........................................................................................47
1.13.2. Results of pathological and anatomical examinations......................................49
1.14. Survival Aspects..................................................................................................49
1.15. Fire .......................................................................................................................50
1.16. Tests and Research .............................................................................................54
1.16.1. Full-scale experiment........................................................................................54
1.16.2. Mathematical simulation...................................................................................54
1.16.3. Analysis of materials from previous research work to determine the friction
coefficient of a runway with various surface conditions ..................................................57
1.16.4. Assessment of forces needed to move the throttle control lever ......................57
1.16.5. Results of investigations made on engine control computers (FADEC)..........59
1.16.6. Results of examining the engine control console .............................................59
1.17. Information on Organizations and Management ............................................60
1.18. Additional information.......................................................................................62
1.18.1. Characteristics of the operation of A-310 airplane by Sibir .............................62
1.18.2. Flight assessment based on the results of studies conducted during the
investigation.....................................................................................................................67
1.18.3. Information about previous incidents ...............................................................72
1.18.4. Expert conclusion reached by clinical psychologists based on records of the
psychological examinations of the airplane captain of the A-310 F-OGYP that was
involved in the accident on July 9, 2006 at Irkutsk airport...............................................77
1.18.5. Expert conclusion reached by aviation doctors based on records of the medical
examinations of the airplane captain of the A-310 F-OGYP that was involved in the
accident on July 9, 2006 at Irkutsk airport........................................................................80
2. Analysis............................................................................................................ 87
3. Findings and Conclusion ............................................................................. 109
4 Shortcomings Identified in the Course of the Investigation..................... 116
5 Safety Recommendations............................................................................. 119
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Glossary
ACAFA - Aktyubinsk Civil Aviation Flight Academy
ACT - airport control tower
AeMS - aeronautical meteorological station (civilian)
AMS - aviation meteorological station
ANO - autonomous noncommercial organization
A & AE - aviation and avionics equipment
AS - airport service
CRT - crash and rescue team
CRTr - crash and rescue training
CRW - crash and rescue work
CRS - crash and rescue station
AMC - aviation maintenance center
АMB - aircraft maintenance base
AS - air squadron
FS - flight safety
MM - middle marker
SSN - spring-summer navigation
SSP - spring-summer period
PEB - physical evaluation board
AQC - advanced qualifications commission
DFB - departmental fire brigade
ASCC - auxiliary start control center
APU - auxiliary power unit
AT - air transport
CA - civil aviation
HV - horizontal visibility
PAS - public address system
SSRICA - State Scientific and Research Institute of Civil Aviation
GPT - glide-path transmitter
ArCC - area control center
AppCC - approach control center
TCC - taxi control center
OM - outer marker
US - unified system
ZAO - closed joint-stock company
ASDC - air squadron deputy commander
AES - aviation engineering service
ICAO - International Civil Aviation Organization
ILS - instrument landing system
MP - maintenance personnel
ASC - air squadron commander
ATC - air traffic control
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PIC - pilot in command
SW - short waves
KCAFA - Kirovograd Civil Aviation Flight Academy
ADD - aircraft division director
PRC - People's Republic of China
LB - localizer beacon
ARP - airport reference point
FRI - flight research institute
FS - flight section
IAC - Interstate Aviation Committee
MH - magnetic heading
МLH - magnetic landing heading
MT - main taxiway
PA - parking area
MU - medical unit
MES - Ministry for Emergency Situations
AAERC IAC - Air Accident Engineering and Research Commission of the
International Aviation Committee
AOS - Airport Operating Standards
AAS - Aircraft Airworthiness Standards
CAMM - civil aviation meteorological manual
NOTAM - notes to airmen (changes in aeronautical information)
CAFOM - civil aviation flight operations manual
CAMRM - 93 - Civilian Aircraft Maintenance and Repair Manual – 1993
NSM - navigation service manual
ОАО - open joint-stock company
UAE - United Arab Emirates
TOC - departure control
ATS - air traffic service
HIL - high-intensity lights
VHF - very high frequency
ООО - limited-liability company
MOP - main observation point
SLB - separate locator beacon
ATM - air traffic management
LSE - landing system equipment
OCS - operations control service
ACS - approach controller station
CRP - compulsory reporting point
FPTC - flight personnel training course
RIAAI-98 - 1998 Rules for Investigating Air Accidents and Incidents
PM - periodic maintenance
TORA - takeoff run available
ASDA - accelerate-stop distance available
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RF - radar facility
FM - flight manual
FOM - flight organization manual
FOO - flight operations officer
AFOD - airport flight operations director
CAFSRM - civil aviation flight search and rescue manual
LDA - landing distance available
FOM - flight operations manual
RSRB - regional search-and-rescue base
PMP - periodic maintenance procedure
AMG - airplane maintenance guide
TCL - throttle control lever
RTL - reverse thrust lever
RF - Russian Federation
RC - regional center
RF CAOG - RF Civilian Airport Operations Guideline
ICC - integrated control center
FME - forensic medical examination
TTSN - total time since new
TMS - transport management service
FSRS - flight search and rescue service
USA - United States of America
CMEA - Council for Mutual Economic Assistance
M&R - maintenance and repair
ATC - air traffic control
USW - ultra short waves
FIA - flight inspection authority
RFPL - required fire protection level
TC - training center
FAR - federal aviation rules
FCAMCR - federal civil aviation medical certification regulations
FSUE - federal state unitary enterprise
FTOA - Federal Transportation Oversight Authority
CPEB - Central Physical Evaluation Board
CIL - central indicator light
EIF - electrical illumination for flights
A/C - aircraft
AFS - automatic flight system
ATIS - automatic terminal information system
BEA - Bureau d'Enquêtes et d'Analyses (French accident
investigation authority)
BFU - Bundesstelle für Flugunfalluntersuchung (German accident
investigation authority)
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CBT - computer-based training
CRM - crew resources management
CVR - cockpit voice recorder
DFDR - digital flight data recorder
DGAC - Direction Générale de l'Aviation Civile (French civil
aviation authority)
EASA - European Aviation Safety Agency
ECAM - electronic centralized aircraft monitoring
EGT - exhaust gas temperature
EPR - engine pressure ratio (determines thrust)
FADEC - full authority digital electronics control
FC - flight cycles
FCOM - flight crew operating manual
FCU
- flight control unit
FDR - flight data recorder
FFS - full flight simulator
FH - flight hours
Flare - (caption on flight mode annunciator)
FMA - flight mode annunciator (on primary flight display)
FWC - flight warning computer
GE - General Electric
GLB - ground log book
IATA - International Air Transport Association
Reverse Idle - reverse idle mode
ILS - instrument landing system
IOSA - IATA operational safety audit
LOW - automatic braking mode
Max Rev - maximum reverse thrust
MEL - minimum equipment list
MMEL - master minimum equipment list
N1 - low rotor rotation speed
N2 - high rotor rotation speed
NOTAM - notices to airmen
NTSB - US National Transportation Safety Board
PFD
- primary flight display
P&W - Pratt & Whitney
Retard - engine shift to idle (caption on flight mode annunciator)
Rollout - (caption on flight mode annunciator)
SIGMET - significant meteorological information
SOP - standard operating procedure
STC - supplement type certificate
TLB - technical log book
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UTC - coordinated universal time
VOR-DME
- VHF omni-directional radio range/distance-measuring
equipment
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Background Information
On July 8, 2006 at 22:44 UTC1 (7:44 local time on July 9, 2006), as it was
landing at Irkutsk airport, an А-310 airplane, registration F-OGYP, operated by
ОАО Aviakompania Sibir [Sibir airlines], ran down the runway, overran the
runway threshold and, at a distance of 2140 m and on a magnetic azimuth of
296° from the aerodrome reference point, collided with barriers, broke apart and
burst into flames. As a result of the accident 125 individuals died, including both
pilots and 3 of the cabin crew; 60 passengers and 3 cabin crew suffered physical
injuries of varying degrees of severity.
The investigation of the accident was conducted by a commission
appointed by Order no. 13/379-R dated July 8, 2006 of the Deputy Chairman of
the Interstate Aviation Committee (IAC), as amended by Order no. 33 dated July
18, 2006 of the IAC Chairman:
Commission chairman A.N. Morozov, Chairman of the Accident
Investigation Commission of the Interstate
Aviation Committee
Deputies of the commission
chairman:
V.V. Chernyaev, Deputy Chairman of the
Accident Investigation Commission of the
Interstate Aviation Committee
Yu.V. Zhuravlyov, Director of the East
Siberian Administration of Gosavianadzor
(Federal Transport Oversight Authority) of the
Ministry of Transportation of Russia
Commission members: V.A. Trusov, Chairman of the Commission for
the Scientific and Technical Support of Air
Accident Investigation of the IAC;
S.A. Maryshev, branch consultant of the
Inspection board for flight safety and the
investigation of accidents of the Federal
Transport Oversight Authority
(Rostransnadzor);
V.I. Volobuyev, director of the Department of
Aerodromes and Airports of the Airport
Operations Administration of the Federal Air
Transportation Agency (Rosaviatsia);
1 Hereinafter, unless otherwise specified, UTC is used. Sunrise at Irkutsk was at 20:50 UTC.
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A.P. Dovzhik, chief maintenance engineer of
the aviation maintenance center ОАО
"Aeroflot - Rossiskiye avialinii";
R.A. Teimurazov, IAC technical director for
safety issues;
A.G. Kruglov, advisor to the Chairman of the
IAC;
V.V. Biriukov, class 1 test pilot of the federal
state unitary enterprise "М.М. Gromov Flight
Research Institute"
Specialists from FTOA, Rosaviatsia, Rosaeronavigatsia, Irkutsk airport,
the airlines Aeroflot - Rossiskiye avialinii and Sibir, as well as the accredited
representative of BEA, who represented the State (France) of the airplane
Design, Manufacture and Registry, and of NTSB, which represented the State
(USA) of the engine developer and manufacturer, as well as their advisors from
Airbus and P&W, participated in the investigation.
During the course of the investigation the Commission requested
information about the cabin reconfiguration carried out by Lufthansa Technik
(Germany). In accordance with Annex 13 to the ICAO Convention, this
information was provided via BFU, which also appointed an accredited
representative.
Start of investigation - July 9, 2006
End - 2007
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1. Factual Information
1.1. History of Flight
On July 8, 2006 an А-310 airplane with state registration number FOGYP
(France), leased by ОАО Aviakompania Sibir, and with a flight crew
consisting of the Captain and the co-pilot, was flying scheduled passenger flight
С7 778 from Domodedovo to Irkutsk.
Apart from the two cockpit personnel, there were 6 flight attendants and
195 passengers on board (of these, 2 worked for the company), which included
181 nationals of Russia, 3 of Germany, 3 of the PRC, 2 of Poland, 3 of Belarus,
2 of Moldova and 1 of Azerbaijan.
The airplane's payload according to the flight manifest was 19,800 kg
(which included about 80 kg of hazardous freight - perfume), its take-off weight
140414 kg (maximum permissible – 150,000 kg), and center-of-gravity position
25.5% (the range of permissible center-of-gravity positions for take-off is 18% -
32%).
Upon completion of the pre-flight preparation, the crew took off from
Domodedovo airport at 17:17 (17:15 – as per schedule) and after climbing set a
course for its destination airport of Irkutsk (alternate airport Bratsk). The flight
proceeded without incident and at 22:17 the crew initiated descent for an
approach and landing at Irkutsk airport. At 22:43:40 the airplane landed without
misalignment on runway 30 at Irkutsk airport.
Note: Before the flight, in accordance with Sibir’s MEL, the maintenance
personnel deactivated the thrust reverser on the airplane's left engine after
hearing the crew's observation about this thrust reverser's malfunction during a
previous flight.
After touchdown all spoiler sections prepared ("armed") by the crew for
utilization were deployed and the autobrake in Low mode, previously selected
by the crew, was activated. The pilot moved the right engine (no. 2) thrust
reverser forward. However, simultaneously with the subsequent reduction of the
reverse mode of engine no. 2, engine no. 1 started to speed up (forward thrust),
which led to an increase in airplane speed and the onset of torque that pulled the
airplane to the right.
The crew failed to perceive the cause of what was happening. In spite of
intense wheel-braking efforts, the airplane used up the entire length of the
runway and overshot its end at a speed of about 180 kph. The airplane then
continued to travel on wet soil. At a distance of about 300 m from the departure
threshold of the runway, the airplane collided with a concrete barrier of the
aerodrome and then with some garages located directly behind the barrier, after
which the airplane, now seriously damaged, stopped. As a result of the
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destruction of the fuel tanks the fuel ignited and fire penetrated the airplane's
interior.
As a result of the accident, 125 individuals died, including the two pilots
and three of the flight attendants. The airplane was practically completely
destroyed by the fire.
1.2. Injuries to Persons
fatal serious minor n/a
passengers 120 38 22 15
crew 2/3 0/3 - -
1.3. Damage to Airplane
As the airplane was overshooting the runway, it collided with a concrete
barrier of the aerodrome and with some garages behind it. As a result of the
break-up of the airplane's structure and the subsequent fire, the airplane was
practically completely destroyed.
1.4. Other Damage
As the airplane was overshooting the runway, its left engine cowling and
air intake damaged six first-row elements and one second-row element of the
localizer antenna array. The shock struts of the landing gear then broke the
aerodrome's concrete barrier, after which the airplane collided with the garage
structures behind the barrier, resulting in the destruction of 20 garages.