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problematic at these speeds). As a result of the decrease in the degree of nervous
and emotional tension and its discrepancy with the requirements of a flight
situation that was becoming complicated, the crew was unable to act in a timely
and adequate manner even after they discovered the disparity of the flight
parameters (engine rpm, speed) at this stage of the flight (22:44:17.8).
The psychological factor of the phenomenon of mistrust, when the pilot
does not trust the operation of the emergency signal because of the
improbability of the signal appearing, in the opinion of the pilot under these
flight conditions, or because of its incorrect operation, played a role in the
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
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development of the abnormal situation and its shift to a catastrophic
situation. It is probable that this phenomenon of mistrust was the reason for
the inadequate reaction of the crew to the "wrong take-off configuration"
signal. Apparently neither of the pilots was able to assume that the
operation of this signal was possible during the landing run. Instead of
clarifying the reason for the signal, the co-pilot made sufficiently long
inputs to clear the ECAM screen by depressing the CLEAR and RECALL
buttons.
It is probable that at the final stage (after 22:44:20) the sudden deterioration
of the situation also quickly brought the crew to an extremely high degree of
nervous and emotional tension - stress. Under conditions of stress the
performance of an individual decreases sharply, mental activity is made
difficult, errors in perception and omissions of specific operations appear, the
distribution and shifting of attention become difficult, distraction appears, the
field of vision and attention narrow, memory fails, movements become
impulsive or, on the contrary, restraint and lethargy set in. In analyzing the
situation, one can discover signs that the pilots were under stress: distracted
crew (crew: "We're rolling off the runway", co-pilot: "Why?", airplane captain:
"I don't know", co-pilot: "Oh my"), omissions of specific actions (failure to
switch off the engines although the command was given), irregularities in the
distribution and shifting of attention, as well as difficulties in mental activity (in
spite of the discovery of the increase in engine rpm, the crew failed to control
the position of the TCL), narrowing of the field of attention (attention focused
only on maintaining the direction at the end of the run), etc. On the whole, the
stress condition made it impossible for the pilots to act effectively in a situation
that was becoming more and more complicated.
Consequently, the following conclusions can be reached6:
1. The involuntary forward shifting by the airplane captain of the left
engine TCL while deactivating the reverser on the right engine most probably
occurred as his right hand was occupying a specific position on the TCL.
2. The simultaneous coincidence of the following factors contributed to
the moving of the TCL that went unnoticed by the airplane captain:
• the presence of shaking and vibrations that were typical for the runway
at Irkutsk airport;
• the possibly small friction force needed to move the TCL;
• the presence of negative acceleration during the normal run after
landing with an activated right engine reverser and automatic wheel
braking in LOW mode (before 22:44:00).
6 These conclusions are the opinion of the person who performed this assessment and may differ from the
findings and conclusion of the whole report.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
72
3. The time taken to recognize the reasons for the development of the
abnormal situation from the time the "wrong configuration" signal was actuated
until the time the crew started to act (provided they recognized the reasons for
the development of the abnormal situation) to prevent the situation from
developing into a catastrophe was 10 - 13 seconds.
4. The development of the abnormal situation and its escalation into a
catastrophic situation happened because of the crew's lack of the required
teamwork as the airplane was on its landing run, as well as the co-pilot's
inadequate degree of professional training in terms of controlling the work
parameters of the engines and the airplane's speed while on its landing run and,
consequently, the late report to the airplane captain about the increase in engine
rpm. The audio and light emergency warning signal (incorrect take-off
configuration), which is not related to this stage of the flight, was unexpected for
the crew and could have made recognition of the developing situation difficult.
　
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