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20. After the activation of the EGPWS warning, both pilots made control inputs
simultaneously. The take-over button was not pressed by either of the pilots. The control inputs
by the Captain and the co-pilot, both in roll and pitch were not coordinated and made in opposite
directions. The DUAL INPUT warning was not activated because of its lower priority compared
to the EGPWS warning. Before the airplane collided with the water the crew had almost
completed retraction of the wing high-lift devices in several steps (the slats were still moving).
Neither of the pilots was monitoring the aircraft descent parameters or fulfilled the FCOM
requirements for crew actions after EGPWS warning activation, which are stated in the
"EMERGENCY PROCEDURE” Section of the A320 QRH.
The crew’s attention might have been distracted by a long 20-second controller’s message
regarding a change in the approach procedure, which was recorded by the CVR along with the
EGPWS and CRC warnings that were sounding in the background. The controller issued the
message in accordance with the controller’s operational manual, after the crew contacted him.
21. Experiments on the simulators showed:
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- Provided that the standard «GO AROUND» and «MISSED APP» procedures prescribed by the
FCOM are followed, the aircraft performs the go-around manoeuvre with no difficulties, in both
the automatic and director modes.
- In the case where the autopilot remains engaged, while the aircraft is performing a manoeuvre
similar to that in the accident flight, the autopilot normally completes the go-around procedure,
with a maximum pitch angle not exceeding 21.5º, the short-time decrease of speed not exceeding
10-12 kt, with activation of the «SPEED SPEED SPEED» warning, and without activation of the
α – FLOOR function.
- If after activation of the «PULL UP» warning the FCOM recommendations are implemented,
for the parameters similar to those in the accident flight (indicated airspeed 270…280 kt, pitch
angle -5.5º…-6.5º, roll angle about zero and the wing high-lift devices in the 18º/0º position), the
decrease in altitude during aircraft recovery from descent is about 200…230 ft.
3. Conclusion
The fatal crash of the “Armavia” A-320 EK-32009 was a CFIT accident that happened due to
collision with the water while carrying-out a climbing manoeuvre after an aborted approach to
Sochi airport at night with weather conditions below the established minima for runway 06.
While performing the climb with the autopilot disengaged, the Captain, being in a psychoemotional
stress condition, made nose down control inputs due to the loss of pitch and roll
awareness. This started the abnormal situation.
Subsequently the Captain's inputs in the pitch channel were insufficient to prevent development
of the abnormal situation into the catastrophic one.
Along with the inadequate control inputs of the Captain, the contributing factors to development
of the abnormal situation into the catastrophic one were also the lack of necessary monitoring of
the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot and the
absence of proper reaction by the crew to the EGPWS warning.
4. Shortcomings found during investigation
4.1. During descent and approach the crew constantly had irrelevant conversations that
had nothing to do with the crew operations manual, and therefore violated the requirements of
ROLRGA RA-2000, Section 8.3.4.
4.2. The A320 FCTM, which was approved by the Civil Aviation Administration of the
Republic of Armenia and according to which Captain G.S. Grigoryan passed his training before
starting solo flights with the airline, does not contain the requirement for passing the Upgrade to
Captain programme. Captain G.S. Grigoryan did not pass this training. This training programme
was made mandatory in the next revision of the FCTM.
4.3. The Flight Operations Department of Armavia does not comply with the provisions of
ROLRGA RA Section 11.2 and ICAO Annex 6 Part 1 Chapter 3, which require airlines to analyze
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fight operations with the use of the FDR and CVR recordings for aircraft with the certified
MTOW exceeding 27 000 kg.
4.4. In violation of ROLRGA RA-2000 Sections 4.5.33 and 6.1.5, Armavia airline does not keep
records on the approaches and landings in complicated weather conditions performed by their
Captains.
4.5. The following deficiencies were identified in air traffic management:
- At 21:16 the approach controller of the Sochi aerodrome advised the crew of the trend weather
forecast for landing as 150 by 1500 and did not identify the trend as “AT TIMES”. This
　
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