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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.
To a certain degree, the condition of premature mental demobilization,
which the crew may have felt during the landing run after the long night flight
crossing 5 time zones and normal landing at their "home" airport, could also
have affected the outcome of the accident flight. Such a mental state is
characterized by a decrease in pilot alertness (relaxation) and a decrease in the
degree of nervous and emotional tension at the moment when the principal
activity has not yet ended. The discrepancy between the degree of nervous and
emotional tension and the requirements of the activity being performed,
especially as flight conditions become more complicated, becomes the reason
for the decrease in the professional reliability of pilots. The degree of conscious
control over flight parameters and actions being performed decreases. The pilot
assumes that the main stage of the flight has already ended. It is possible that,
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
107
after the engine thrust reverser was deactivated and active deceleration started
and upon sensing the usual noise and negative acceleration that are due to the
thrust reverser and the start of deceleration, the crew fell into the above state of
premature mental demobilization. As a result of the decrease in the degree of
nervous and emotional tension and its incompatibility with the requirements of a
flight situation that was becoming complicated, the crew was unable to act in a
timely and adequate manner even after they realized the disparity of the flight
parameters (engine rpm, speed) with the stage of the flight.
As a result of the destruction of the airplane after colliding with the
barriers, a surface fire broke out. The first fire truck arrived on the scene of the
accident 75 seconds after the collision at a distance from the CRS of 1,557
meters. After 20 seconds, and in intervals of 5 seconds, 3 more trucks arrived
and started to extinguish the fire. The efficiency and effectiveness of fire
suppression was reduced because of the inability of the vehicles to approach the
accident site directly (the fence and garages obstructed the way) and because of
the insufficient power of the master stream nozzles and, consequently, the need
to unroll the hose lines to ensure the supply of the fire-extinguishing mixture.
At the time of the airplane's collision with the barriers, all flight attendants
were in their seats with their seat belts fastened. Evacuation of passengers after
the collision was initially carried out only through the right middle door and left
rear door. The inflatable chute of the left rear door was released and inflated but
was damaged by sharp metal objects on the ground and lost its load-bearing
capacity. The inflatable chute of the right middle door did not inflate since the
door handle was in the DISARMED position. The right rear door was blocked
from the inside by food containers wrenched from their places as a result of the
airplane's collision with the barriers, and was opened from the outside by
arriving rescuers. It was impossible to use the forward doors and left middle
door for evacuation because of the nature of the airplane's destruction and the
seats of fire that broke out. As a result of the emergency rescue work, 78
individuals were evacuated, including three members of the cabin crew.
Of the 3 flight attendants who died, only one was identified at the time of
completion of the investigation. Forensic medical experts concluded that she
died from acute carbon monoxide poisoning. The concentration of
carboxyhemoglobin in her blood was 85%. The three unidentified men died of
acute carbon monoxide poisoning.
Based on the results of forensic medical examinations presented to the
commission, of the 120 passengers who died, 119 died as a result of acute
carbon monoxide poisoning in conjunction with oxygen insufficiency in the
inhaled air (in one case, the poisoning was accompanied by trauma to the skull
and brain) and one female passenger died from severe trauma combined with
burns to the body.
Final Report
INTERGOVERNMENTAL AVIATION COMMITTEE
108
As already mentioned above (chapter 1.6), the airplane had no protective
breathing equipment for the flight attendants responsible for the emergency exits
in the middle part of the cabin. Smoke control equipment for flight attendants in
　
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