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did not notice the left engine’s increase in forward thrust.
The simultaneous congruence of the following factors contributed to
the moving of the TCL that went unnoticed by the airplane captain:
• presence of shakes and vibrations typical for runway at Irkutsk
airport;
• presence of negative acceleration during the normal run after
landing with an activated right engine reverser and automatic
wheel braking in LOW mode (until 22:44:00);
• possibly small friction force needed to move the TCL, which
makes any inadvertent movement of the throttle control lever
easier.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
114
After the throttle control lever for the left engine moved forward, in
accordance with the work logic involved, the spoilers were
automatically retracted, which led to the automatic braking being
switched off. The resultant asymmetry of thrust was countered by the
crew with the use of the rudder. At the same time, the crew fully
depressed the brake pedals and switched to the manual braking mode
for the undercarriage wheels.
The minimum indicated speed, up to which the airplane decelerated
in 20 seconds after touchdown, was approximately 165 kph. The
increased mode of the left engine resulted in the airplane’s
accelerating up to 180 kph and balancing at that speed up to the
moment when the airplane left the runway.
In these conditions, the co-pilot did not perform the necessary
monitoring of the engine performance and airplane speed, and it was
only 30 seconds after the emergency situation started to develop
when he reported an increase in engine revolutions ….“RPMs is
increasing”….
Approximately 800m remained up to the end of the concrete part of
the runway. Analysis showed that, if the necessary action had been
taken (setting the throttle control lever for the left engine to idle), the
speed could have been effectively reduced. The crew did not take this
action. The airplane captain’s order to switch off the engines, which
was given immediately prior to overshooting the runway, was not
carried out. With its engines still running, the airplane overshot the
concrete runway and ran on to the soil at a significant speed (180
kph), which predetermined its collision with the barriers at the airport
boundary.
3.10. As a result of the accident, 125 people died. According to the
conclusion of the forensic experts, the cause of death in the majority
of cases was carbon monoxide (CO) gas poisoning, in conjunction
with a lack of oxygen in the air inhaled. The emergency rescue work
carried out by the cabin crew and the ground services was in
accordance with current regulations. As a result of their work, 78
people were evacuated.
The F-OGYP airplane had no protective breathing equipment for the
flight attendants responsible for the emergency exits in the middle
part of the cabin. Smoke protection equipment for flight attendants in
the tail section of the cabin was located on the wall at the side of the
passenger cabin. This did not allow flight attendants to reach it
quickly if the need arose.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
115
The existing equipment was used for in-flight firefighting only.
There were no procedures or requirements to use it during an
emergency evacuation. The corresponding cabin crew training did
not exist. It was impossible to determine for sure the possible effect
of the lack of PBE equipment on the effectiveness of the cabin
crew’s actions or the severity of the consequences.
Conclusion
The cause of Sibir A-310 F-OGYP accident was the erroneous and
uncontrolled actions by the crew during rollout after landing in a configuration
with one engine reverser deactivated. After touchdown, the Captain, while
acting on the reverse thrust lever of the right engine, inadvertently and
uncontrollably moved the throttle lever for the left engine, whose thrust reverser
was deactivated, from the "idle" to the significant forward thrust position.
Inadequate monitoring and call-outs of airplane speed and engine parameters by
the Co-pilot made it impossible for the crew to perform the necessary actions,
either by moving the left throttle back to idle or shutting down the engines. The
crew had enough time to recognize the situation.
The airplane went off the runway at the high speed of ~180 km/h, hit the
concrete fence and buildings, crashed and caught fire.
125 people died as a result of the accident.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
116
4 Shortcomings Identified in the Course of the Investigation
　
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