Moscow-Domodedovo

The accident was the consequence of erroneous actions on part of the crew while climbing in instrument meteorological conditions at unreliable readings of instrument speed caused by icing (blockage with ice) of all three Pitot tubes. This caused the aircraft to become uncontrollable, enter a dive and eventually collide with the ground. The accident was then considered as a loss of control in flight (LOC-I). The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements. The following contributing factors were reported:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time,
- Skipping by the crew of the operation to switch on the Pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action,
- Design features of the An-148 aircraft in terms of the restrictions on the duration of Pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of Pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START",
- Systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the Pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of Pitot tube heating,
- Design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects,
- Low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS,
- Failure to take necessary measures in case of detection of previous facts of untimely activation of Pitot tube heating by crews based on the results of express analysis of flight information,
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm,
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation,
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128,
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases,
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters,
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources,
- Individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system,
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures,
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain,
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.

The accident with A320-231 EY-623 aircraft was caused by the aircraft collision with snow parapet during landing on unprepared RWY that was cleared to 22 m in width (45 m RWY total width), and with 50-95 cm snow parapets along the cleared part that resulted in front gear leg destruction and engines flameout followed by aircraft runway overrun to the right. The accident was caused by the consequence of the following factors combination:
- flight operation officer decision for aircraft clearance on unprepared RWY,
- having unprepared RWY by the time of the aircraft arrival the aerodrome service didn't put temporary restrictions, didn't make the appropriate note in the "Aerodrome airworthiness log", didn't take any measures to prevent the aircraft landing on unprepared RWY.

Systemic weaknesses in identifying and controlling the levels of risk, non-functional safety management system in the airline and lack of control over the level of crew training by aviation authorities at all levels (Tatarstan Civil Aviation Authority, Russian Civil Aviation Authority), that resulted in an unqualified crew being assigned to the flight.
During the go-around the crew did not recognize that the autopilot had disconnected resulting in the aircraft impacting ground in a complex spatial position (nose up upset). The captain, pilot flying, lacked the skills to recover the aircraft from the complex spatial upset (lack of Upset Recovery), that led to significant negative G-forces, loss of spatial orientation sending the aircraft into a steep drive (75 degrees nose down) until impact with ground.
The go around was required because the aircraft on its final approach arrived in a position from which landing was impossible as result of a map shift by about 4000 meters (aircraft systems determining the position of the aircraft in error), the inability of the crew in those circumstances to combine aircraft control and navigation with needed precision, and the lack of active support by air traffic control during prolonged observation of significant deviation from the approach procedure.
The following factors were considered as contributory:
The captain not having had primary flight training,
The flight crew members being allowed to upgrade to Boeing 737 without satisfying the required qualifications including the English language,
Methodical shortcomings in retraining as well as verification of results and quality of training,
Insufficient level of organisation of flight operations at the airline, which resulted in failure to detect and correct shortcomings in working with the navigation equipment, pilot technique and crew interaction, including missed approaches,
Systematic violation of crew work and rest hours, a large debt of holidays, which could have resulted in accumulation of fatigue adversely affecting crew performance, Simulator training that lacked a missed approach with intermediate height and all engines operating,
Increased emotional stress to the flight crew before deciding to go around because they could not establish the position of their aircraft with the necessary precision to accomplish a successful landing,
Violation of the principle "Aviate, Navigate, Communicate" by both flight crew and air traffic control, which resulted in the flight crew not following standard operating procedures at the time of initiating the go around because the pilot monitoring was diverted from his duties for a prolonged period and did not monitor the flight parameters,
The fact that the crew did not recognize the autopilot had disconnected and delayed intervention by the crew, that resulted in the aircraft entering a complex spatial position (nose up upset),
Imperfection of simulator training programs for Upset Recovery Procedures as well as lack of criteria for assessing the quality of training, which resulted in the crew being unable to recover the aircraft from the upset,
The possible impact of somatogravic illusions,
The non-addressing of prior accident investigation recommendations, geared towards elimination of risks and establishing risk level management, had prevented the prevention of this accident,
Lack of proper supervision of issuance of pilot certificates in accordance with achieving specified requirements and qualifications,
Failure of safety management system (SMS) in the airline, lack of guidelines for SMS development and approval, lack of a formal approach to approve/agree on SMS and pilot training by the related authorities,
Deficiencies in aviation training centers' performance and absence of verification of training quality,
Lack of requirements for flight crew to be proficient in English Language for retraining on foreign aircraft types and lack of formal approach to verify language proficiency,
lack of formal approach to conduct periodic verification of flight crew qualification,
systematic violation of crew work and rest times,
lack of training of flight crew on go around from intermediate heights in manual control potentially leading to complex spatial position (e.g. nose high upset),
The map shifts in aircraft without GPS without training of crew to operate in such conditions,
Lack of active assistance by air traffic control when the approach procedure was deviated from over a prolonged period of time,
Breach of principle "Aviate, Navigate, Communicate".
Translation via www.avherald.com