Originally posted by Gabriel
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The report is in Russian, which few of the forum members understand.
AvHerald translated the causal factors part of the report:
Not much to discuss... I highlighted some (in my opinion) key parts.
The report concludes the probable causes of the crash were:
The crash of the An-148-100B RA-61704 was caused by erroneous actions of the crew during departure in instrumental weather conditions in relation to unreliable indications of the air speed caused by the icing (ice blockage) of all three dynamic probes of the pitot system, which led to the loss of control over the parameters of the aircraft's flight resulting in a dive and collision with the ground.
The accident falls into the category loss of control in flight (LOC-I).
The investigation revealed systemic deficiencies in the assessment of risk as well as risk control, the failure of the airline's flight safety management system as well as lack of supervision of training of flight crew by aviation authorities at all levels, which led to the issuances of certificates to aviation personnel and crew, who did not fully qualify.
The most likely contributing factors were:
- Crew's rush in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" time;
- The crew's failure to turn on the heating of the pitot probes before take-off and non-compliance with/non-execution of the "BEFORE TAKEOFF" checklist, which provides for this action.
- Design features of the An-148 aircraft which restrict the duration of pitot heating while on the ground, which required to move the items pitot heating into the "BEFORE TAKEOFF" checklist rather than the "ENGINE START" checklist, which creates additional risks of missing these operations.
- Systematic failure by airline crews to comply with the principle of "dark cockpits" and the requirements of the pitot system, which contributed to the "habit" of taking off despite the presence of emergency and warning messages on the electronic indication and alarm system (KISS) and failing to identify the fact that the heating of the pitot probes is not included. Six warning messages were displayed on KISS before departure for the accident flight including three relating to the absence of pitot probes' heating.
- Design features of the An-148 aircraft which disabled removal of KISS messages related to system defects which have been deferred under MEL.
- Low safety culture within the airline which led to non-entries of inflight problems into the tech logs as well as performing flights with issues that were neither rectified nor deferred with the relevant fault messages displayed at KISS and failure to identify the KISS messages and analyse them to identify lack of pitot probe heating.
- The crew's unpreparedness when the ALARM "SPEED DISAGREE" was issued because of lack of theoretical training, lack of according simulator training and lack of according training on aircraft. This resulted in the failure to follow the proper procedures once the alarm was raised.
- Lack of supervision by the Civil Aviation Authority in certifying the flight simulator according to Russian Air Code
- Approval of the An-148 flight simulator without consideration to their ability to reproduce special cases in flight as stipulated in Russian Air Code and FAR-128.
- Lack of specific guidance on values of flight parameters that must be sustained in case of "SPEED DISAGREE" alarm respective lack of an unreliable airspeed procedure.
- Increased psycho-emotional stress by flight crew members during the final stages of flight due to the inability to understand the speed fluctuations. As result the captain suffered "tunnel view" on his speed indications for speed control rather than considering all flight parameters.
- Insufficient training of flight crew with respect to human factors, cockpit resource management, threat management and error management.
- Individual psychological characteristics by both flight crew, for the captain reduction of intellectual and behavioural flexibility, fixation on own position and inability to hear prompts from the first officer, for the first officer problems in organisation and sequencing actions) which in the stressful situation with inadequate CRM became apparent.
- Loss of psychological efficiency the captain (resulting on psychological incapacitation) which led to complete loss of spatial orientation and did not permit to respond properly to correct advice offered by the first officer or the EGPWS PULL UP warning.
- Absence of criteria to determine psychological incapaciation/loss of health which did not permit the first officer to take more efficient measures.
- Large arrear of annual leave that could have caused accumulation of fatigue and might have adversely affected the efficiency of the captain.
- System operations features not described in operations manual.
- elevator control offset during reconfiguration mode with unreliable airspeed doubles elevator deflection with same control input and has the elevator deflected nose down with the control in neutral position for about 60 seconds which reduced time available to the crew to recognize the situation.Leave a comment:
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I think I actually taught Gabriel something...once...Originally posted by Evan View Post
But the concept that you could select a familiar, robust power setting and attitude and maintain desired, fat, dumb and happy horizontal and vertical speeds...and that sub-par pilots might remember that from 172 school since it amazingly ALSO applies to an A330...
...he learned that elsewhere...
Probably some CFI or textbook or something.Leave a comment:
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I'm also done try to arguing this here, except to repeat this simple and obvious truth:Originally posted by 3WE View Post
The procedures are not there to inhibit stellar pilots with perfect situational awareness; they are there to protect us all from pilots like the one who doomed AF447. But in order for that to happen, ALL pilots have to learn them, practice them and follow them.Leave a comment:
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You can’t stand it when we suggest that it’s ok for the elbow to hinge parallel to the the body- because some procedure says your elbows must hinge out and away from the body.Originally posted by Evan
In the meantime we ask why Bonin deliberately landed teeth first while he worries which way to fold toilet paper when wiping front to back and wondering why his 2-ft thick anti push suit failed.Leave a comment:
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1) You know I do.Originally posted by Gabriel View Post
2) That's gotta be a no, BECAUSE even those who have a poor understanding of the concepts and dynamics of aerodynamics and piloting may still be trained like monkeys to RELIABLY react in a certain way to a given circumstance. If, at that moment, the brain lacks a trained response, the brain will improvise, as it did on that fateful day, and many other fateful days. Again, the procedures are not there to inhibit stellar pilots with perfect situational awareness, they are there to protect us all from pilots like the one who doomed AF447. But in order for that to happen, ALL pilots have to follow them.
Here's my question to you: when someone suddenly pushes you from behind and, completely disoriented, you fall forward, do you have to think about raising your arms in front of you?
These immediate recall procedures are very simple and designed to be almost that instinctive.
Sudden decompression! Boom! Oxygen mask! Pax Oxygen ON! Now you have time to think, for CRM. And you didn't go to the QRH in a state of hypoxia.
Ground Proximity! Advance to climb thrust! Establish 20° pitch (don't stall)! Now you have time to think, for CRM. And you didn't add pitch while spacing out the thrust levers.
UAS! Level wings! Fly 5* pitch! Move the thrust levers to climb (or out of the detent and back in if you're driving the bus)! Kill the FD's! Now you have time to think, for CRM. And you didn't fall for the instinct to climb above the weather (even though it seemed viable).
If only they were taught, practiced and respected to the extent needed. What gets in the way, I think I'm finding out...Leave a comment:
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Evan, 2 yes/no questions:
1) Do you agree that we need to ensure, to the extent possible, that we have good pilot material that understands well the generalities of airmanship before teaching him specific procedures for specific circumstances in specific types?
2) Do you agree that a pilot that meets 1) and gets so confused / startled / disoriented / paralyzed / panicked to react to UAS (or to any other abnormal circumstance) at cruise by pulling a 1.5G, 7000 fpm, 2000 ft climb and when the stall warning activates, pull up again and keep pulling up all the way to the ground (or sea), may (vs will) fail to make a correct UAS diagnosis in the first place and then fail to recall or apply the UAS memory items correctly even if said procedure was taught, demonstrated and trained? (else you are proposing that the startled pilot will fail to fly the plane reasonably straight and level will not fail to recognize a specific situation and apply a specific procedure)
If you reply YES to both questions, then we have nothing else to discuss.
If you reply NO to one or more of those questions, then we have nothing else to discuss (but for totally different reasons).
In any event, we have nothing else to discuss. I am done here.Leave a comment:
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Another way to look at this is AVIATE > COMMUNICATE (CRM) > AVIATE > NAVIGATE > COMMUNICATE (RADIOS)Originally posted by Evan View Post
Where the first AVIATE stabilizes you enough to safely COMMUNICATE (CRM) so that the second AVIATE is done with the correct situational awareness.Leave a comment:
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