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commander to state the reasons for these deviations.
The practice of collecting signatures of the flight crew signaling their
familiarity with the results of the debriefing, including any entries containing no
useful information for them, attests to the perfunctory attitude towards postflight
debriefings (the most important remedial measure ensuring flight safety).
It should be noted that FTOA does not send airlines investigation
materials on accidents according to type of airplane for debriefing purposes. The
materials, for example, on the accident on March 29, 2006 at Domodedovo
airport involving an Il-62 of Libavia airlines (Libya) were submitted to the
FTOA. However, this event was not discussed during post-flight debriefings of
the airline's flight divisions in spite of its connection to the airplane's rolling off
the runway because of the error committed by the crew in the use of the thrust
reverser.
Special characteristics of the technical operation of А-310 airplane
The intensification of passenger traffic at Sibir also affected the
maintenance support for A-310 airplane. A comparison of requests for
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
66
consumable items, including spare parts, to rectify defects that have been
discovered with their actual availability at airline warehouses has shown that
warehouse stocks met requests at percentages of 25% - 30%. In June 2006, for
example, 4273 consumable items and 469 spare parts were requested and
warehouses actually had 757 and 55 items available, respectively.
These circumstances, as well as the difficulties of customs clearance
when importing spare parts from abroad in cases when defects have to be
repaired urgently (within 10 days), have led to the ubiquitous use in flight
practice of so-called "deferred defects".
The А-310 F-OGYP, for instance, flew on July 6, 2006 from
Domodedovo to Irkutsk with an inoperative reverser on the right engine. Upon
landing at Irkutsk airport the reverser on the left engine was not operative. So
the airplane was on its landing run when the reverser mechanisms of both
engines failed. The Captain’s crew made the corresponding entry in the flight
log. It should be noted that in compliance with 1998 RIAAI this event was
classified as an incident.
During maintenance done on July 7, 2006 the defect on the right engine
was fixed using parts taken from the left engine (with the failed reverser) and
the left engine ended up under the category of a "deferred" defect. Then the
airplane was released for flight on July 8, 2006 (the last trip of this airplane on
the Domodedovo-Irkutsk route no. 778) with the deactivated (inoperative)
reverser on the left engine.
This procedure was covered by current regulations and was mentioned
in the Sibir MEL publication, which meets the recommendations of the airplane
manufacturer. However, the dynamics of application of the MEL was not
efficiently monitored. Moreover, the practice of allowing flights with extended
"deferred" defects without any form of control procedure exercised by Russian
aviation authorities in each specific instance took root at Sibir with the
agreement of the Airworthiness Support Administration of the FTOA (RF
Rostransnadzor).
So for the first six months of 2006 there were 86 extended deferred
defects recorded on A-310 airplane. No steady downward trend in the frequency
of these negative factors was observed.
The appropriate training to support flights using MEL was absent from
the airline crew training system.
It is perfectly obvious that this practice was instigated by the growth of
traffic volumes at Sibir but this cannot justify ignoring the requirements of flight
safety.
This state of affairs, in conjunction with insufficient remedial work to
prevent repeated defects, determined the low degree of reliability of aviation
equipment (1 failure every 23 hours of flight for the A-310).
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
67
1.18.2. Flight assessment based on the results of studies
conducted during the investigation5
A test pilot carried out a flight assessment in terms of the appearance and
development of abnormal situations as part of the investigation of the accident in
order to determine the most likely scenario for the sequence of events.
Based on the results of all experiments carried out, the test pilot made
the following assessments:
1 Effect of the position of the pilot's hand on the possibility of the
unintentional movement of the TCL forward while disengaging the
thrust reverser
The experiments carried out show that pilots have different ways of
　
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