Scheduled Revenue Flight

Primary Causes:
- Involuntary runway excursion due to an intentional high-speed approach and landing by the pilot-in-command (PM).
- Failure to adhere to SOP's.
- Lack of situational awareness and anticipation resulting in inadequate decision making.
Contributing Factors:
- Lack of assertiveness by the pilot-in-command (PM).
- Inadequate application of Crew Resources Management (CRM).

The pilot’s failure to maintain adequate airspeed while maneuvering during an attempted go around, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall at low altitude. Contributing to the accident, was the pilot’s decision to perform an approach to a short runway at an excessive airspeed and his late decision to perform a go-around, which resulted in a slow climb at a reduced safe margin above stall airspeed.

The runway excursion occurred because of combination of:
- Disconnection of auto pilot at an altitude 118' RA with the nose up trim bias without adequate compensation.
- Disconnection of auto throttle at 118' RA at a higher thrust setting for that phase of flight.
- Late touchdown of the aircraft on the runway.
- Reduced visual cues due to heavy rain impacting depth perception and ascertaining of actual touchdown position.
- Tailwind conditions at the time of landing resulting In increasing the distance covered during the extended flare (float).
- Approach with lower flaps (30) than recommended (40).

The accident occurred during landing with one engine inoperative as a result of a longitudinal-lateral rollout beyond the runway and subsequent collision with a building outside the aerodrome, resulting in damage to the aircraft structure and a fire. The landing was performed on a runway with an available landing distance of 1,503 metres that was significantly less than the distance required of 2,160 metres for the actual conditions.
Most likely, the accident was the result of the combination of the following factors:
- The decision by the pilot-in-command (pilot flying) to land without calculating the required landing distance;
- The incorrect choice by the pilot-in-command of the type and trajectory of the approach, which made it impossible to reduce the flight speed in time. Instead of visual maneuvering ('circle-to-land' maneuver) provided for in the approach pattern and agreed upon by the crew with the air traffic controller, the crew performed a visual approach;
- The absence in the airline's flight manual and the aircraft's flight manual of procedures for performing a visual approach maneuver ('circle-to-land' maneuver);
- Failure of the crew to take measures to go around for a second approach despite a significant discrepancy between the actual flight parameters and the criteria for a stabilized approach specified in the airline's flight procedures;
- Lack of crew coordination and cross-checking;
- Failure to follow a number of standard operating procedures in terms of informing the PIC (pilot in command) by other crew members about significant deviations of actual flight parameters from the published values;
- Insufficient crew resource management;
- Landing at a significant high speed (275 km/h instead of the recommended 220 km/h), which led the aircraft to land 530 metres pas the runway threshold;
- Incorrect use of the main landing gear wheel braking system by the crew, resulting in premature compression of the brake pedals (in the air), which, upon repeated contact, led to landing on the braked wheels of the right main landing gear with destruction of the tires and, subsequently, to the aircraft rolling sideways;
- Increased psychological and emotional stress on the part of the captain, compounded by his particular mental characteristics, contributed to the adoption of unreasonable decisions in the situation that had arisen.
- The left engine failed in flight due to abnormal operation of the fuel control system, probably the ADT-24. Due to the high degree of destruction of the system due to fire, it was not possible to definitively determine which unit failed and the cause of the failure. The abnormal adjustments of the left engine and deviations in the operation of its fuel control system manifested themselves long before the day of the accident and could have been detected by both flight and engineering personnel.

The pilot’s inadequate compensation for a quartering tailwind during a water landing, which resulted in a loss of control and subsequent nose-over. Contributing to the accident was the company’s inadequate operational control of the flight release process, which resulted in assignment of an inexperienced pilot to a commuter seaplane flight.

While the aircraft was unstabilized on approach, the pilot did not execute a go-around.

The air accident to the RRJ-95B RA-89098 aircraft was caused by the uncoordinated control inputs by the PIC at the flare, landing and through the several repeated bounces of the aircraft off the RWY (the porpoising), having manifested in the several disproportionate alternating sidestick inputs in pitch with keeping the sidestick retained against each stop. The indicated control inputs had resulted in three hard touchdowns of the aircraft, as a consequence at the second and third touchdowns the absorbed energy significantly exceeded the maximum values, for which the structural integrity had been evaluated at the aircraft type certification, which led to the destruction of the airframe structural elements, the fuel tanks with the fuel spillage and the fire onset.
The contributing factors to the accident were:
- The ineffectiveness of the RRJ-95 flight personnel approved training programs as for the actions into the major failure condition//abnormal situation at the FBWCS reversion to DIRECT MODE and, consequently, the insufficient knowledge and skills at the flight crew members to operate the airplane in this mode. The training programs met the minimum requirements, determined by FAR, but did not account for the specific nature of a particular emergency;
- The ineffectiveness of the airline SMS in terms of the monitoring of the piloting sustainable skills development at the pilots, which prevented the identification and elimination of the PIC’s common systematic errors at the sidestick pitch control at the stage of landing, including these, associated with its forward inputs beyond neutral (to nose down) into the flare;
- The failure to identify the biases (hazards) in the airline flight crews’ piloting technique as far the previous events of the FBWCS reversion to DIRECT MODE are concerned and thus the failure to implement preventive measures;
- The aircraft operational documentation unclear wording in terms of the piloting peculiarities at flare and the correction of the deviations at the landing (counteracting the consecutive aircraft separations off the RWY);
- The failure of the crew to comply to the FAR and OM requirements at the flight preparation and performance at the actual and forecast thunderstorm activity, as well as at the availability to observe these zones on the weather radar display, which had resulted in the aircraft encounter the atmospheric electricity, the EIUs reboot and the FBWCS reversion to DIRECT MODE. As per the certification results the FBWCS reversion to DIRECT MODE had been assessed as «the major failure condition», the in-flight onset of «the major failure condition» at the lightning or static electricity exposure does not contradict the applicable certification requirements;
- The dramatic increase of the psycho emotional stress at the PIC because of the aircraft exposure to atmospheric electricity and the failure within a long time to ensure the acceptable piloting precision at the FBWCS in DIRECT MODE, which led to the psychological dominant mindset formation to perform immediate landing together with the lack of readiness to initiate go around (not go-around minded);
- Psychological personality traits of the flight crew members that determine their behavior in the stress environment, as well as the PIC’s insufficient training in human factor/performance and threat and error management approach, which prevented the objective assessment of his psycho emotional condition and the ability to control the airplane, to choose the optimal strategy to proceed the flight, as well as to establish the required interaction and CRM;
- The failure of the PIC to ensure the aircraft pitch trim under the manual control, including at the glideslope descent;
- The incorrect assessment of the situation by the crew at the Predictive Windshear warning (GO AROUND WINDSHEAR AHEAD) trigger at the flight on glideslope and, consequently, the non-initiation of a go-around maneuver, that resulted in the aircraft encounter the wind microburst at the early flare and affected the aircraft flight path. The documentation by the aircraft designer and the airline allows the crew to ignore the subject warning activation, if it made sure there is «no windshear threat», still the operational documentation and the OM do not integrate the respective clear criteria of «no threat»;
- The purposeful ducking under the glideslope by the PIC at the final approach (after passing DH);
- The difference between the airline OM provisions as for the crew actions at the glideslope warning activation (the excessive deviation off the glideslope equisignal zone) and the similar provisions in the aircraft designer documentation. Subject to the provisions of the aircraft designer documentation the crew should have performed go-around;
- The unjustified extension by the airline of the approach «stabilized condition» criteria as for the acceptable deviations range off the target speed, which at the actual IAS of 15 kt higher against the target one and the FBWCS in DIRECT MODE resulted in the unexpected for the PIC increased aircraft response to the sidestick input in pitch;
- The failure by the crew to carry out the SOP on the manual speed brakes deployment at the aircraft touchdown. The operational documentation unclear wording and the monitoring algorithms of the landing configuration, used at the aircraft that require to arm the speedbrakes for the automatic deployment, including at FBWCS in DIRECT MODE, in which the automatic deployment is disabled, degrade the crew’s situational awareness as for this aspect.
- The TR actuation after the first bounce off the RWY, which had made the subsequent go-around impossible. As per the results of the forensic medical examination the death of 40 out of 41 fatally injured people had been caused by the exposure to open flame, accompanied with the burns of the upper respiratory tract through the inhalation of hot air. The fire erupted after the aircraft third touchdown due to the disintegration of the wing fuel tanks and the fuel spillage. The fuel spillage occurred as due to the destruction at the landing gear retraction/extension actuating cylinders attachment points, as well as due to the destruction of the other wing parts. The landing gear structure had been damaged at the second touchdown that is at the third touchdown functioned beyond the expected operational conditions and had not been able to bear the applied landing loads as designed. The operation (destruction) of the landing gear fuse pins («weak links») at the second touchdown had been consistent with the design integrated logic. With that the loads, actually accomplished, had been less of those in use to demonstrate compliance to AR-25 item 25.721 at the aircraft type certification, which prevented the MLG legs to completely separate off the airplane structure (it is only the Attachment A fuse pins that had been destructed). No correlation between the certification requirements for the structure, including MLG legs structure, and the conditions for demonstrating their safe separation off results in actual significant risks of the fuel tanks disintegration and the fuel spillage even in case of compliance demonstration to every single of these requirements. At its very onset the fire by its nature had been the deflagration flash, which had been accompanied with an intense smoke release with the onset of a steady burning in two seconds. By the point of the evacuation initiation the fire had been propagated inside the cabin through a row of cabin windows at the rear fuselage along the right and left sides, with that the airworthiness standards do not set up the requirements for the cabin windows as to the external fire protection. That situation had been beyond the expected operational conditions as there had been no time margin (90 sec), at which the crew and passengers’ emergency evacuation is demonstrated at the type certification.
Most probably the following factors had contributed to the increase in the severity of the consequences:
- The running engines of the aircraft, having been not timely shut down by the crew;
- Large amount of fuel, spilling out of both wing panels, which penetrated the area of the exhaust-mixing nozzles, exposed directly to their jet streams;
- The inability to evacuate through both of the rear emergency exits;
- The manifestation of the flashover effect at the rear passenger cabin;
- The crush and panic among the passengers;
- The efforts by a number of passengers to pick up their carry-on luggage at the evacuation;
- The CFA’s error in operating the PACIS, and consequently the decline in the passengers’ situational awareness as for the evacuation procedure.

Loss of control of the airplane in flight, during a left turn, due to the failure of the right engine (n°2) during takeoff, caused by a fuel exhaustion.
The following contributing factors were identified:
- Failure of the pilot to comply with the pre takeoff checklist,
- Failure of the pilot to check the fuel selector switch and the fuel quantity prior to start the engines,
- Failure of the pilot to feather the propeller of the right engine (n°2) during an emergency situation,
- Failure of the pilot to bring the flaps to the neutral position during an emergency situation,
- Decrease of the speed and altitude of the airplane,
- Increase bank of the wing during a left turn.

Repetitive and uncommanded airplane-nose-down inputs from the MCAS due to erroneous AOA input, and its unrecoverable activation system which made the airplane dive with the rate of -33,000 feet per minute close to the ground was the most probable cause of the accident.
The following contributing factors were identified:
1. The MCAS design relied on a single AOA sensor, making it vulnerable to erroneous input from the sensor;
2. During the design process, Boeing failed to consider the potential for uncommanded activation of MCAS, but assumed that pilots would recognize and address it through normal use of the control column, manual electric trim, and the existing Runaway Stabilizer NNC. The OMB and Emergency AD issued after the Lion Air accident included additional guidance but did not have the intended effect of preventing another MCAS-related accident;
3. While Boeing considered the possibility of uncommanded MCAS activation as part of its FHA, it did not evaluate all the potential alerts and indications that could accompany a failure leading to an uncommanded MCAS;
4. The MCAS contribution to cumulative AOA effects was not assessed;
5. The combined effect of alerts and indications that impacted pilot’s recognition and procedure prioritization were not evaluated by the Manufacturer;
6. Absence of AOA DISAGREE warning flag on the flight display panels (PFD);
7. The B737 MAX Crew difference CBT training prepared by Boeing and delivered to Pilots did not cover the MCAS system;
8. Failure by the manufacturer to design simulator training for pilots with regards to safety critical systems like MCAS with catastrophic consequences during undesired activation.
9. The manufacturer failed to provide procedures regarding MCAS operation to the crew during training or in the FCOM;
10. Failure by the manufacturer to address the safety critical questions raised by the airline which would have cleared out crew confusion and task prioritization;