Date & Time: Dec 29, 2012 at 1633 LT
Type of aircraft:
Tupolev TU-204
Operator:
Registration:
RA-64047
Flight Type:
Ferry
Survivors:
Yes
Schedule:
Pardubice - Moscow
MSN:
1450744864047
YOM:
2008
Flight number:
RWZ9268
Country:
Russia
Region:
Asia
Crew on board:
8
Crew fatalities:
5
Pax on board:
0
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
5
Captain / Total flying hours:
14975
Captain / Total hours on type:
3080
Copilot / Total flying hours:
10222
Copilot / Total hours on type:
579
Aircraft flight hours:
8676
Aircraft flight cycles:
2484
Circumstances:
Crew was performing a ferry flight from Pardubice to Moscow-Vnukovo Airport. After landing on runway 19 in marginal weather conditions, aircraft did not stop on the remaining runway, overrun at high speed and collided with an embankment separating the airport with the M3 Highway. Aircraft broke in three parts and four crew were killed (captain, copilot, engineer and one stewardess). Four other flight attendants were seriously injured. At the time of the accident, wind was gusting to 29 knots and the ceiling was 2,400 feet. A day later, one of the stewardess died from her injuries. According to MAK, aircraft landed 900-1000 meters past the runway threshold. Despite the fact that crew applied brake, aircraft did not decelerate as expected. It overrun 32 seconds after touch down at a speed of 215 km/h before hitting an embankment located 320 meters further on at a speed of 190 km/h. The AOC of Red Wings has been suspended few days later and on 18JUN2013, Rosaviatsia renewed the AOC, so the company was again authorized to operate commercial flights.
Probable cause:
Misalignment of mechanism and locks of thrust reversers on both engines as well as inappropriate actions (inappropriate provisions in 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 of 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 verification, lack of proper monitoring of qualifications and flight operations by objective criteria 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 technical possibilities at the simulators do not permit to work such scenarios.
Source: AvHerald
Final Report: