Aeroflot - Russian International Airlines

The following findings were reported:
- Weather conditions were marginal,
- At the time of the accident, the runway length was 2,350 metres instead of 3,300 metres due to work in progress,
- The ILS CAT III system was inoperative during work in progress,
- The pilots were warned that the crew of an aircraft that landed on the same runway 36 about 11 minutes earlier established a visual contact with the runway at an altitude of 200 feet only,
- The crew continued the approach below MDA without establishing visual contact with the runway,
- Poor crew coordination,
- Poor approach planning,
- The crew failed to follow the approach checklist,
- The crew did not divide up the tasks in a correct manner,
- The crew did not prepare for a possible go-around procedure,
- The decision of the captain to initiate a go-around procedure was taken too late,
- The crew encountered engine trouble after the power levers were suddenly moved,
- The relative low experience of the captain on this type of aircraft.

Engine failure during climb out for unknown reasons.

The right main gear could not be lowered because of a breakage of the filling connection of the hydraulic tank due to metal fatigue while the aircraft was taxiing at Moscow-Sheremetyevo Airport. The fitting was blown out under pressure and damaged hydraulic lines, causing a hydraulic fluid leak and the oil pressure to drop.

The accident was caused by a stall, spin and impact with the ground resulting from a combination of the following factors:
1. The decision by the PIC to allow an unqualified and unauthorized outsider (his son) to occupy his duty station and intervene in the flying of the aeroplane.
2. The execution of demonstration manoeuvres that were not anticipated in the flight plan or flight situation, with the PIC operating the autopilot while not at his duty station.
3. Application by the outsider and the co-pilot of control forces that interfered with the functioning of the roll channel of the autopilot (and are not recommended in the A310 flight manual), thus overriding the autopilot and disconnecting it from the aileron control linkage.
4. The copilot and PIC failed to detect the fact that the autopilot had become disconnected from the aileron control linkage, probably because:
- The A310 instrumentation has no declutch warning. The provision of signals in accordance with the requirements of Airworthiness Standard NLGS-3, para. 8.2.7.3., and international recommended practices, could have enabled the crew to detect the disengaged autopilot in a timely manner.
- The copilot and PIC may have been unaware of the peculiarities of the declutching function and the actions to be taken in such a situation because of a lack of appropriate information in the flight manual and crew training programme;
- It was difficult for the co-pilot to detect the disengagement of the autopilot by feel, either because of the small forces on his control column or because he took changing forces to be the result of Eldar's actions;
- The PIC was away from his position and distracted by the conversation with his daughter.
5. A slight, unintentional further turn of the control wheel(s) following disengagement of the autopilot caused a right roll to develop.
6. The PIC and copilot failed to detect the excessive right bank angle, which exceeded operating limits, and were late in re-entering the aircraft control loop because their attention was focussed on determining why the aircraft had banked to the right, a manoeuvre they interpreted as entry into a holding area with either no course line or with a new (false) course line generated on the navigational display.
A strong signal indicating that the aeroplane had exceeded the allowable operating bank angle, taking account of the delay in recognizing and assessing the situation and making a decision, could in this situation have attracted the crew's attention and enabled them to detect the bank at an earlier stage.
7. The aeroplane was subjected to buffeting and high angles of attack because the autopilot continued to perform its height-keeping function even after the actuator declutched and as the right roll developed, until the pilot disconnected it by overriding its longitudinal channel.
8. Inappropriate and ineffective action on the part of the copilot, who failed to disconnect the autopilot and to push the control column forward when the buffeting occurred and the aeroplane entered an unusual attitude (high angles of attack and pitch). These actions, which caused the aeroplane to stall and spin, could have resulted from:
- the presence of an outsider in the left-hand pilot's seat and the resulting delay before the PIC re-entered the aeroplane control loop;
- the less-than-optimum working posture of the copilot, whose seat was pushed back to its rearmost position;
- the occurrence, 2 seconds following the onset of buffeting, of an unintentional pitching up of the aeroplane, which sharply increased the angle of attack and reduced lateral controllability;
- unpreparedness of the crew to act in this situation because of lack of appropriate drills in the training programme;
- temporary loss of spatial orientation in night conditions.

Loss of control after rotation due to application of wrong rudder by trainee pilot during engine failure exercice. The instructor did not guard/block the rudder control and give clear commands as instructor so as to obviate the application of wrong rudder control by the trainee pilot.

Engine failure for unknown reasons.

It was determined that the aircraft was not properly aligned with the runway centerline upon landing after the crew mistook the runway edge lights with the runway centerline lights.