China

- In violation of the airline's flight operation manual the captain attempted the approach to Yichun below required visibility. The airport reported 2800 meters of visibility while the manual required 3600 meters of visibility to begin the approach
- In violation of regulations by the Civil Aviation Authority the crew descended below minimum descent altitude although the aircraft was operating in fog and visual contact with the runway had not been established
- Despite the aural height announcements and despite not seeing the runway the crew continued the landing in the blind without initiating a go-around resulting in impact with terrain
Contributing factors were:
- The airline's safety management is insufficient:
* part of the flight crew arbitrarily implement the company's operations manual as the company does not follow up outstanding problems. Records suggest frequent deviations from approach profiles, i.e. deviation above or below glide slopes, excessive rates of descents and unstable approaches
* crew rostering and crew cooperation: Each of the crew was flying into Yichun for the first time despite the known safety risks at the airport, the communication and cooperation within the crew was insufficient, the crew members did not monitor each other in order to reduce human errors
* the airline's emergency training did not meet requirements, in particular the cabin crew training did not provide for hands on training on E190 cabin doors and overwing exits. Alternate means by the airline did prove ineffective and did not provide the quality China's Civil Aviation Authority requires thus leaving cabin crew unprepared to meet required cabin crew emergency response capabilities
- Parent company's Shenzhen Airlines oversight insufficient
* Shenzhen Airlines, after having taken over Henan Airlines in 2006, did not provide sufficient funding and technical support affecting the stability and safety of staff and quality management
* Air China, holding stock into Shenzhen Airlines, installed a safety supervisor but failed to address the safety management issues with Shenzhen and Henan Airlines
- No supervision by China's Civil Aviation Authority
* the license to operate the flight from Harbin to Yichun was granted without route validation and without safety management in violation of regulations
* to solve the lack of cabin crew flight attendants were certified although not meeting the relevant requirements for air transport operations
* the regional office of the Civil Aviation Authority did not communicate to their superiors that they had approved the domestic operation of the route from Harbin to Yichun permitting non-standard procedures
- China's Civil Aviation Authority safety management loopholes.

The crew did not properly operate the thrust levers so that the engines did not reach take off thrust. The aircraft had not reached Vr at the end of the runway and could not get airborne. According to the design criteria of the MD11 the crew needs to push at least two thrust levers to beyond 60 degrees, which will trigger autothrust to leave "CLAMP" mode and adjust the thrust to reach the target setting for takeoff, the servo motors would push the thrust levers forward in that case. During the accident departure the pilot in the left seat did not advance the thrust levers to more than 60 degrees, hence the server motors did not work although autothrust was engaged but remained in CLAMP mode and thus did not adjust the thrust to reach takeoff settings. The crew members perceived something was wrong. Audibly the engine sound was weak, visibibly the speed of the aircraft was low, tactically the pressure on the back of the seat was weaker than normal. Somebody within the crew, possibly on the observer seats, suggested the aircraft may be a bit heavy. The T/O THRUST page never appeared (it appears if autothrust is engaged and changes from CLAMP to Thrust Limit setting. Under normal circumstances with autothrust being engaged a click sound will occur as soon as the thrust levers reach the takeoff thrust position. A hand held on the thrust levers will feel the lever moving forward, however, the crew entirely lost situational awareness. None of the anomalies described in this paragraph prompted the crews members' attention. When the aircraft approached the end of the runway several options were available: reject takeoff and close the throttles, continue takeoff and push the throttle to the forward mechanical stop, continue takeoff and immediately rotate. The observer called "rotate", the captain rotated the aircraft. This shows the crew recognized the abnormal situation but did not identify the error (thrust levers not in takeoff position) in a hurry but reacted instinctively only. As the aircraft had not yet reached Vr, the aircraft could not get airborne when rotated. As verified in simulator verification the decision to rotate was the wrong decision. The simulator verification showed, that had the crew pushed the thrust levers into maximum thrust when they recognized the abnormal situation, they would have safely taken the aircraft airborne 670 meters before the end of the runway. The verification also proved, that had the crew rejected takeoff at that point, the aircraft would have stopped before the end of the runway. The crew did not follow standard operating procedures for managing thrust on takeoff. The crew operations manual stipulates that the left seat pilot advances the thrust levers to EPR 1.1 or 70% N1 (depending on engine type), informs the right seat pilot to connect autothrust. The pilot flying subsequently pushes the thrust levers forward and verifies they are moving forward on servos, the pilot monitoring verifies autothrust is working as expected and reaches takeoff thrust settings. In this case the left seat pilot not only did not continue to push the thrust levers forward, but also called out "thrust set" without reason as he did not verify the takeoff thrust setting had been achieved. It is not possible to subdivide the various violations of procedures and regulations. The crew had worked 16 hours during the previous sector. In addition, one crew member needed to travel for 11 hours from Europe to reach the point of departure of the previous sector (Nairobi Kenya), two crew members need to travel for 19 hours from America to the point of departure of the previous sector. These factors caused fatigue to all crew members. The co-pilot was 61 years of age, pathological examination showed he was suffering from hypertension and cardiovascular atherosclerosis. His physical strength and basic health may have affected the tolerance towards fatigue. All crew members underwent changes across multiple time zones in three days. Although being in the period of awakeness in their biological rhythm cycle, the cycle was already in a trough period causing increased fatigue. The captain had flown the Airbus A340 for 300 hours in the last 6 months, which has an entirely different autothrust handling, e.g. the thrust levers do not move with power changes in automatic thrust, which may have caused the captain to ignore the MD-11 thrust levers. The co-pilot in the right hand seat had been MD-11 captain for about 7 years but had not flown the MD-11 for a year. Both were operating their first flight for the occurrence company. The two pilots on the observer seats had both 0 flight hours in the last 6 months. The co-pilot (right hand seat) was pilot flying for the accident sector. The captain thus was responsible for the thrust management and thrust lever movement according to company manual. A surviving observer told the investigation in post accident interviews that the captain was filling out forms and failed to monitor the aircraft and first officer's actions during this critical phase of flight. There are significant design weaknesses in the MD-11 throttle, the self checks for errors as well as degree of automation is not high.
Source: Aviation Herald/Simon Hradecky

Loss of lift and subsequent stall after takeoff due to an excessive accumulation of ice and frost on wings, tail and fuselage. It was determined that the aircraft remained parked outside, on the ramp, all preceding night by negative temperature and that the crew failed to deice the airplane prior to takeoff.