Pilot Error Found in Crash That Killed Russian Hockey Players

Source: The New York Times - November 2, 2011

1 MOSCOW — Russian air safety officials said Wednesday that a September plane crash that killed an elite hockey team was caused by an extraordinarily basic human error: one of the pilots accidentally pressed the brakes on the landing gear, so that the aircraft was moving too slowly when it tried to take off.

2 Aleksei Morozov, who led a team investigating the crash for Russia’s Interstate Aviation Committee, said it was not clear whether the error was committed by the pilot or co-pilot of the plane, a Russian-made, three-engine Yak-42 chartered to carry the team, Yaroslavl Lokomotiv, to a game. Investigators noted that both men had more experience flying Yak-40 aircraft than Yak-42s. The Yak-40’s pedals are laid out differently, and “a negative transfer of Yak-40 skills” may have led to the error, they said. An autopsy also found that the co-pilot had phenobarbital — a depressant that can slow reaction times — in his system.

3 “Test pilots established in a flight experiment that an erroneous pushing of the brake pedals during takeoff is possible only if the pilot’s feet are placed by mistake on the braking floor,” Mr. Morozov said in televised remarks. “Even a slight pressure on the pedals may have been overlooked by the pilot.”

4 The plane was airborne for only a few moments before crashing about 500 yards from the runway at an airport near Yaroslavl, 160 miles northeast of Moscow. Among the 43 people killed instantly were many hockey stars, including several veterans of the National Hockey League. […]

5 The commission’s findings on Wednesday placed blame squarely on the crew. […] The report describes a lack of coordination on the flight deck, citing cockpit voice recordings. After someone — presumably the commander of the flight — pushed the control stick forward, as if preparing to abort the takeoff, the co-pilot can be heard asking, “What are you doing?” The stick was then pulled back with great force, most likely by both pilots, in preparation for takeoff.

6 At that moment, the flight engineer set the engines to idle, as if to abort the takeoff. A pilot cursed and shouted “Takeoff power!” but the engines did not resume takeoff power for six seconds, and the aircraft slowed down in the meanwhile. The report also found that, as the two pilots pulled with all their strength on the control column, one of them had braced his feet on the brake pedal, meaning that the brakes were applied to the wheels at the same time that the crew was trying to reach takeoff speed. If the crew had identified the problem, they had time to abort the takeoff and save the aircraft, Mr. Morozov said.

7 The report was sharply critical of training practices at Yak-Servis, the private company operating the flight, noting that “in such an organization, scheduled preparation was practically impossible to organize.” Investigators found that the captain, co-pilot and flight engineer had never trained together in a flight simulator, and that the pilots were being trained in Yak-40s and Yak-42s at the same time, a practice discouraged in the industry.

8 Russia’s federal transport agency revoked Yak-Servis’s licenses in September and last month grounded 10 more Yak-42s being operated by other companies. […]

Ellen Barry

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© Christian Lassure - EFT
December 1st, 2012 / Le 1er décembre 2012

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