Landing (descent or approach)

The accident with Тu-204-100В RA-64047 aircraft was caused by actuator maladjustment and reverse locking of both engines and incorrect crew actions (not complying with FOM provisions) performing landing run during spoilers and thrust reverse control that resulted in lack of efficient aircraft breaking action, RWY overrun, collision with obstacles at a high speed (~190 km/h), aircraft destruction and fatalities. (In accordance with the ICAO Accident and Incident Investigation Manual (DOC 9756 AN/965), causes and factors are in logical order, without the priority assessment).
Contributing factors to the fatal accident were:
- Actual structure stiffness of reverse control and locking mechanism unaccounted in operational documentation determining the engine control system inspection and adjustment procedure during its service replacement. This factor can emerge only in case of the crew thrust reverse control with violation of FOM provisions;
- Incoordination and conflicts in aircraft and engine operational and technical documentation and long-term formalism towards inspections of the engine control system adjustment (including reverse control and locking mechanism) by organisations performing engines replacement that didn't allow to ensure feedback with aircraft and engine designers and timely eliminate identified deficiencies;
- Unstabilized approach and significant (up to 45 km/h) rated overspeed during glide slope phase by the crew that resulted in long holding before landing, significant landing distance extension and aircraft overshoot landing (~950 m);
- Non-extension of spoilers and speed breaks in automatic mode due to the lack of the signal of simultaneous left and right struts compression caused by aircraft anticipatory "soft" landing (plunge acceleration 1.12g) at left main gear at right cross wind saturation (~11.5 м/с);
- Lack of crew monitoring for automatic extension of spoilers and speed brakes after landing and manual non-extension of spoilers;
- Violation of thrust reverse landing procedure be crew specified by FOM resulted in application of maximum thrust reverse by "one motion" without throttle intermediate stop setting (low reverse) and without reverse buckets position (stowage) monitoring that under deficiencies of the reverse control and locking mechanism resulted in immediate thrust increase;
- Lack of simultaneous main landing gear compression during the RWY motion due to design features of limit switches (no failures of limit switches were identified) of main landing gears compressed position (~5.5 tonnes leg load is required for switch actuation) and non compliance with the FOM on spoilers extension in manual mode that resulted in reverser buckets non-stowage into reversal thrust mode;
- Inadequate cockpit resource management by the PIC during flight that resulted in lack of monitoring for stabilized approach at the approach phase and in "fixation" at reverser deployment operation at the lack of monitoring for other systems operation;
- Untimely preventive measures during the investigation of the serious incident with Tu-204-100V RA-64049 aircraft operated by "Red Wings" Airlines occurred in Tolmachevo airport on December 20, 2012;
- Inadequate level of flight operation management and nonoperation of flight safety control system in the airline and formal attitude of the pilot-instructor towards proficiency check of the PIC and the lack of the appropriate supervision over proficiency checks and flight operations using flight recorders that didn't allow to timely identify and eliminate regular deficiencies in PIC's piloting technique regarding increased speed holding during glide-slope flight and the procedure of using reverse thrust application at landing run operation as well. Supervision over proficiency checks specified by FAR-128 (clause 5.7) wasn't held;
- Lack of actions training in situations connected with failure of main landing gears limit switches in line proficiency check programs of crew members followed by non-extension of spoilers and speed breaks in manual mode. Technical abilities of the available simulators don't allow to train this situation.

Primary Cause:
- During the final approach, the aircraft descended below the MDA and the crew did not follow the operator SOP's.
- The pilots had no corrective action against to change VMC to IMC during bad weather condition and insufficient time for effective respond to last moment.
Secondary Cause:
- Captain of the aircraft had insufficient assessment on the risk that assigned the FO as PF.
- There may be under pressure by the following aircrafts as the first plane on that day to Heho.

The pilot's inadequate preflight planning, which resulted in fuel exhaustion and a subsequent total loss of power in both engines during cruise flight. Contributing to the accident was the pilot’s use of prescription and illicit drugs, which likely impaired his judgment.

Findings as to causes and contributing factors:
1. The lack of required flight documents, such as instrument approach charts, compromised thoroughness and placed pressure on the captain to find a workaround solution during flight planning. It also negatively affected the crew’s situational awareness during the approaches at CYSK (Sanikiluaq).
2. Weather conditions below published landing minima for the approach at the alternate airport CYGW (Kuujjuarapik) and insufficient fuel to make CYGL (La Grande Rivière) eliminated any favourable diversion options. The possibility of a successful landing at CYGW was considered unlikely and put pressure on the crew to land at CYSK (Sanikiluaq).
3. Frustration, fatigue, and an increase in workload and stress during the instrument approaches resulted in crew attentional narrowing and a shift away from welllearned, highly practised procedures.
4. Due to the lack of an instrument approach for the into-wind runway and the unsuccessful attempts at circling, the crew chose the option of landing with a tailwind, resulting in a steep, unstable approach.
5. The final descent was initiated beyond the missed approach point and, combined with the 14-knot tailwind, resulted in the aircraft remaining above the desired 3- degree descent path.
6. Neither pilot heard the ground proximity warning system warnings; both were focused on landing the aircraft to the exclusion of other indicators that warranted alternative action.
7. During the final approach, the aircraft was unstable in several parameters. This instability contributed to the aircraft being half-way down the runway with excessive speed and altitude.
8. The aircraft was not in a position to land and stop within the confines of the runway, and a go-around was initiated from a low-energy landing regime.
9. The captain possibly eased off on the control column in the climb due to the low airspeed. This, in combination with the configuration change at a critical phase of flight, as called for in the company procedures, may have contributed to the aircraft’s poor climb performance.
10. A rate of climb sufficient to ensure clearance from obstacles was not established, and the aircraft collided with terrain.
11. The infant passenger was not restrained in a child restraint system, nor was one required by regulations. The infant was ejected from the mother’s arms during the impact sequence, and contact with the interior surfaces of the aircraft contributed to the fatal injuries.
Findings as to risk:
1. If instrument approaches are conducted without reference to an approach chart, there is a risk of weakened situational awareness and of error in following required procedures, possibly resulting in the loss of obstacle clearance and an accident.
2. If additional contingency fuel is not accounted for in the aircraft weight, there is a risk that the aircraft may not be operated in accordance with its certificate of airworthiness or may not meet the certified performance criteria.
3. If Transport Canada crew resource management (CRM) training requirements do not reflect advances in CRM training, such as threat and error management and assertiveness training, there is an increased risk that crews will not effectively employ CRM to assess conditions and make appropriate decisions in critical situations.
4. If a person assisting another is seated next to an emergency exit, there is an increased risk that the use of the exit will be hindered during an evacuation.
5. If a person holding an infant is seated in a row with no seatback in front of them, there is an increased risk of injury to the infant as no recommended brace position is available.
6. If young children are not adequately restrained, there is a risk that injuries sustained will be more severe.
7. If a lap-held infant is ejected from its guardian’s arms, there is an increased risk the infant may be injured, or cause injury or death to other occupants.
8. If more complete data on the number of infants and children travelling by air are not available, there is a risk that their exposure to injury or death in the event of turbulence or a survivable accident will not be adequately assessed and mitigated.
9. If temperature corrections are not applied to all altitudes on the approach chart, there is an increased risk of controlled flight into terrain due to a reduction of obstacle clearance.
10. If the missed approach point on non-precision instrument approaches is located beyond the 3-degree descent path, there is an increased risk that a landing attempt will result in a steep, unstable descent, and possible approach-and-landing accident.
11. If there is not sufficient guidance in the standard operating procedures, there is a risk that crews will not react and perform the required actions in the event that ground proximity warning system warnings are generated.
12. If standard operating procedures, the Airplane Flight Manual and training are not aligned with respect to low-energy go-arounds, there is a risk that crews may perform inappropriate actions at a critical phase of flight.
13. If non-compliant practices are not identified, reported, and dealt with by a company’s safety management system, there is a risk that they will not be addressed in a timely manner.
14. If Transport Canada’s oversight is dependent on the effectiveness of a company’s safety management system’s reporting of safety issues, there is a risk that important issues will be missed.
Other findings:
1. The quick response of the people on the ground reduced the exposure of passengers and crew to the elements.

The flight crew's decision to fly close behind a heavy airplane, which did not ensure there was adequate distance and time in order to avoid a wake turbulence encounter with the preceding heavy airplane's wake vortex, which resulted in a loss of airplane control during final approach.

The noncertificated pilot’s failure to maintain clearance from terrain while maneuvering to land in dark night conditions likely due to his geographic disorientation (lost). Contributing to the accident was the pilot’s improper decision to fly at night with a known visual limitation.

The pilot's failure to maintain airplane control while maneuvering in night instrument meteorological conditions due to spatial disorientation.

The pilot's improper decision to continue a cross-country flight as a primary control (aileron) system anomaly progressively worsened. Contributing to the accident was an aileron control system anomaly, the reason for which could not be determined because the aileron control system could not be tested due to impact damage, and the pilot’s inability to compensate for crosswind conditions encountered during the approach due to the aileron problem.