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down the engines" given at 22:44:33 (7 seconds before the collision), the
engines were not shut down. At the moment of collision with the barriers, the
left engine was working at higher rpm than the right engine.
The Captain who was the pilot flying the airplane should have shut down
the engines himself or given more precise instructions to the co-pilot. It is
probable that, having been under stress because of insufficient training on type,
both pilots experienced the transferring of habits from a previous airplane type
(Tu-154) where the flight engineer is the crew member who controls the
throttles. That is, although the Captain gave the command but did not address it
to any particular person, he assumed that it would be carried out by the flight
engineer, while the co-pilot also failed to perceive that this command was
addressed to him.
Thus, the analysis conducted showed that the development of the
abnormal situation and its escalation into a catastrophic situation happened
because of the crew's lack of teamwork as well as the co-pilot's inadequate
degree of professional training in terms of monitoring the working parameters
of the engines and the airplane's speed while on the landing run, which did
not facilitate a timely and complete diagnosis of the situation or prevent the
accident. The crew had enough time and information for the timely
recognition of the situation. The aural and visual warnings were unexpected
to the crew in relation to their intention of carrying out a complete landing
and may have hampered their recognition of the situation. On the other hand,
one of the necessary conditions for the functioning of this warning is the
position of the TCL of any engine at a position higher than 22 degrees TLA,
which could have served as a clue to the crew.
Simulation results showed that, if the crew had moved the TCL of the left
engine from idle and again applied the thrust reverser after the co-pilot reported
that "RPMs are increasing" (in this case the spoilers would also have been
released automatically), then the overrun speed would have been around 70 kph.
If the above-mentioned actions had been accomplished before 22:44:16 the
airplane would have stopped before the end of the runway, that is, the crew had
more then 25 seconds to perceive the irregular situation (from the moment the
throttle control lever of the left engine started to move).
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
106
Analysis of incidents with a similar scenario involving the onset of an
abnormal situation (section 1.18.3) showed that crews on average took 30-35
seconds from the time the TCL started to move forward to recognize the
situation. After recognizing the situation, in all cases, what followed was the
retarding of the TCLs for both engines to idle. This prevented the airplane from
overrunning the runway at high speed.
Analyzing the possible reasons that, in conjunction with the co-pilot's lack
of adequate experience, could have prevented the crew in this instance from
switching the TCL to idle (or deactivating the engine), after recognizing that the
speed was increasing (at 22:44:19, the co-pilot reported: "Speed increasing"), we
should turn to the results of the airplane captain's psychological tests that were
carried out from 2003 to 2005 (sections 1.18.4 and 1.18.5). Thus, given the
adequately high degree of development and functioning of his cognitive
functions, a high degree of sensitivity to the effects of the environment and
instability of emotional reactions was revealed. The personality features of the
Captain that was highlighted by the results of psychological tests, in
combination with elements of his conceptual thinking, could have had a
significant effect on his behavior in a stressful situation. In particular, they could
have caused disorganization. An emergency situation that suddenly appeared
could have caused the Captain to have a rapid vegetative and psychoemotional
reaction, under which only simple and highly automatic skills and actions could
have been performed. Intellectual activity under such conditions is extremely
difficult, behavior disorganized and chaotic, is not mediated by intellect, but
resembles an inconsistent, disjointed and haphazard set of actions.
The FDR and CVR data confirm the conclusions of the psychologists.
The highly automatic skills in maintaining the direction of an airplane's
movement along the center line of the runway and the forcible braking of the
wheels were carried out by the captain normally, whereas the actions to
recognize and prevent the development of an abnormal situation (moving
engines to idle or switching them off) were not taken.
　
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