Scheduled Revenue Flight

Controlled flight into terrain.

Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.

The airplane crashed after loss of control by the crew as a result of spatial disorientation (non recognized or subtle type transitioning to recognized spatial disorientation), after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night. Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the AP, have also contributed to cause this situation.

The probable Cause has been determined as an over-center Torque Link condition that culminated in a single cycle failure of the cylinder. The over center torque links condition occur as a result of the over extension of the shock strut.
Possible Contributory factors to the over extension of the shock strut includes:
Possible Cause for Loss of Damping
• The failure to install the dampening ring when the landing gear was assembled.
• Improper servicing of the landing gear shock strut with Mil-H-5606 hydraulic fluid plus nitrogen during initial assembly.
• Improper servicing of landing gear shock strut during line maintenance and inadequate post servicing follow up per AMM Chapter 12. See attached report Appendix A-30 From Bombardier
• Under-serviced shock strut (low oil volume)
• A broken damper ring
• No damper ring
• Disengaged damper ring.

The decision of the crew to continue the descent below MDA in below minimums weather conditions until the aircraft impacted ground and crashed.
The following contributing factors were identified:
- Organizational, technical and procedural deficiencies in the work and interactions between the met office and ATC services as well as from the crew,
- Deficiencies in the standards and technical documentation of the Samara Airport that made it impossible for ATC to inform the crew on a timely manner about the readings from the KRAMS-4 weather station that indicated a deterioration of the weather conditions below airport minimums,
- At decision height, in the absence of reliable visual contact with the approach lights and airport environment, the flight crew failed to initiate a go-around procedure,
- ATC failure to use the full capability of the radar equipment because of contradictions in the relevant standards and procedures documents,
- Poor crew coordination and their delay in executing a missed approach procedure,
- Lack of unified federal regulations covering flight operations, ATC, met and other services, taking into account both domestic and international experience in flight safety.