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At this moment the psychological factor called the "phenomenon of
mistrust", when the pilot does not trust the functioning of the emergency signal
because of the improbability, in the pilot's opinion, of its functioning under the
given flight conditions or because of its improper functioning, could have
appeared and played a significant role. It is probable that this phenomenon of
13 The fact that the report to the controller was done at the third attempt and "any old way" may also testify that
the co-pilot was subject to the premature mental demobilization conditions described above.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
104
mistrust was the reason for the inadequate reaction of the crew to the "wrong
take-off configuration" signal. Instead of clarifying the reason for the
functioning of the signal, the crew made long enough inputs to clear the ECAM
screen by depressing the CLR and RCL buttons. This was confirmed by the
disappearance and repeated reappearance on the FDR of the on-off command
"Non-takeoff configuration". The crew’s actions could have also distracted them
from monitoring the instrument indicators for the engine and the airplane speed
and, consequently, could have affected the time needed to diagnose the irregular
situation.
Only after the report to the controller about the landing, when the airplane
was at the 5th taxiway (850-800 m before the end of the concrete portion of the
runway), the co-pilot, in response to the captain's "What's wrong?", answered
"RPMs increasing", whereupon the "Reverse once again" command was given.
At 22:44:21 the crew (most probably the co-pilot) tried once again to
deploy the thrust reverser on the right engine, for which he moved the RTL of
the engine over to maximum reverse thrust but, per design, the location of the
TCL for the left engine in a mode higher than 22° TLA (more than 55° on the
FDR) prevented the operation, and the thrust reverser doors failed to unlock.
The right engine remained at idle forward thrust.
The crew failed to determine the reason for the lack of braking
effectiveness on the landing run after attempts to re-activate the thrust reverser
on the right engine. This is confirmed by conversations of the crew immediately
before the airplane overran the runway: "Why?" - "I don't know".
After this attempt to deploy the thrust reverser, the airplane started to
swerve to the left. The crew depressed the right pedal to the 15° angle, which
reduced the left lateral depression, and the airplane started to drift to the right.
Full depression of the left pedal did not prevent the airplane from swerving to
the right. The right main bogie exited the runway at a speed of 182 kph (98
knots), and the nose landing gear and the left main bogie moved along the
reinforced concrete portion of the runway. The nose landing gear and the left
main bogie exited on to the ground at the end of the reinforced concrete runway
at 22:44:36.
Afterwards, until the airplane collided with the concrete barrier and the
garages, it traveled over clay soil with a grassy cover. At a distance of 210 m
from the threshold of runway 12, the left engine destroyed part of the antenna
and the wooden fence of the localizer beacon system. At a distance of 250 m
from the threshold of runway 12, the airplane crossed an asphalt bypass road.
The tracks made by the airplane's landing gear on the ground attest to its
virtually straight trajectory until the collision with the artificial barriers. There is
a difference between the airplane's travel vector and its construction line, which
was approximately 6° - 9°.
The airplane stopped at 22:44:40 after colliding with a reinforced concrete
airport perimeter fence and with brick structures (garages) behind it. The
reinforced concrete fence was 2.8 m high. The place where the airplane stopped
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
105
(52° 16’ 29.35 north, 104° 21’ 59.71 east) was located at a distance of 310 m
from the threshold of runway 12 and 30 m north of the heading line of runway
12. The magnetic heading of the construction line of the airplane was 270°. The
airplane broke apart during the collision and burst into flames. The parts of the
airplane's structure that remained intact after the fire were the left and right wing
surfaces, the rear part of the fuselage and the tail unit. The airplane wreckage
was not scattered.
Results of a study of FADEC engine control computers and the nature of
the engines show that, in spite of the command by the airplane captain: "Shut
　
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