Pilot Error --Russian Crash

[Kip Powick]

MOSCOW—Investigators say a Russian jet crash that killed 44 people, including an entire hockey team, was caused by pilot error.

They say the Sept. 7 crash occurred because a pilot accidentally activated the brakes during takeoff and then lifted the jet too sharply, causing it to crash.

The Yak-42 plane crashed into flames near the city of Yaroslavl in on the banks of the Volga River, 240 kilometres northeast of Moscow.

It was one of the worst aviation disasters ever in sports, shocking Russia and the world of hockey.

The dead included 36 players _ many of them former NHL players _ Canadian-born head coach Brad McCrimmon and staff of the Lokomotiv Yaroslavl hockey team.

The only player who survived the crash later died of burns and a flight engineer was the sole survivor.

[dagger]

MOSCOW—Investigators say a Russian jet crash that killed 44 people, including an entire hockey team, was caused by pilot error.

They say the Sept. 7 crash occurred because a pilot accidentally activated the brakes during takeoff and then lifted the jet too sharply, causing it to crash.

The Yak-42 plane crashed into flames near the city of Yaroslavl in on the banks of the Volga River, 240 kilometres northeast of Moscow.

It was one of the worst aviation disasters ever in sports, shocking Russia and the world of hockey.

The dead included 36 players _ many of them former NHL players _ Canadian-born head coach Brad McCrimmon and staff of the Lokomotiv Yaroslavl hockey team.

The only player who survived the crash later died of burns and a flight engineer was the sole survivor.

There's a lot more in this story. There was also blame affixed to the airline for inadequate training, and one of the pilots was taking meds that are described as "prohibited", and that that was a contributing factor as well.

http://www.theglobea...article2222233/

[Kip Powick]

There's a lot more in this story. There was also blame affixed to the airline for inadequate training, and one of the pilots was taking meds that are described as "prohibited", and that that was a contributing factor as well.

http://www.theglobea...article2222233/

Doesn't matter how, or when an aircraft goes down, there will always be those "other" contributing factors.....Same old----same old.....the pilot corp will circle the wagons and deflect the blame...it is the nature of the beast.

On the other hand if one encounters "The Hudson" and recently "LOT" then the pendulum swings the other way and these guys.... ergo their entire pilot corp.... must be exceptionally well trained etc. etc. etc.

[Guest rozar s'macco]

Enlightening, Kip. I for one prefer a finding of pilot error, for it emphasizes the pilots' primacy in the operation of an aircraft and therefore, airline.

A pilot should be appropriately experienced, trained, rested, well, and given the necessary level of authority to ensure the safe operation of the machine. If it crashes, blame him. Just don't take away his training, rest, health, and authority and expect him to accept the outcome of incidents and accidents lying down (assuming he lives to defend himself). Flame away

[conehead]

"They say the Sept. 7 crash occurred because a pilot accidentally activated the brakes during takeoff and then lifted the jet too sharply, causing it to crash."

How does one "accidently" activate the brakes?

[Kip Powick]

"They say the Sept. 7 crash occurred because a pilot accidentally activated the brakes during takeoff and then lifted the jet too sharply, causing it to crash."

How does one "accidental" activate the brakes?

Normally, on a Take-off roll the pilot has his heels resting on the floor and his toes on the rudder pedals. In case of an emergency stop he only has to slip his feet up a bit and push on the top of the rudder pedals. There are cases where one may have the feet already up on the brake portion, but not pushing on brakes, in case one feels they will need for occasional application of one brake to keep the aircraft straight....(very severe cross wind.)

Perhaps the "pilot" in this case inadvertently pushed "brake" instead of rudder????

[DEFCON]

The 'foot or feet on the brakes' finding seems a little suspect to me.

Had no one flown the type before? How could the crew miss or be unaware of what would have been, a completely obvious drag on acceleration?

What about the technical capability of the Russian data recorders? I have some difficulty believing the FDR in this situation would be capable of determining who was on the brakes, or even less likely; the position or force applied to any brake pedal?

[Moon The Loon]

To buy into any of the Russian explanation from my perspective might be a failure of an autobrake system say, for instance, going into full RTO mode. I can't think of any reason a pilot would take their hands off the thrust levers, reach for another lever, then go back to resume the takeoff. Unfortunately, I don't think any of the frequenters of this forum are familiar with the Russian model in question, meaning having to take the Russian report at face value.

My personal behaviour when taking off, any airplane, is to have heels on the rudder pedals, toes ready to deploy. Same on landing. It is a conscious act and I am very aware of the brakes. It is my choice to try and take advantage of the (admittedly) brief amount of time it requires to reposition heels off the floor to get toes onto the brakes.

I think this is an accident that we will never really know what happened.

[Don Hudson]

To buy into any of the Russian explanation from my perspective might be a failure of an autobrake system say, for instance, going into full RTO mode. I can't think of any reason a pilot would take their hands off the thrust levers, reach for another lever, then go back to resume the takeoff. Unfortunately, I don't think any of the frequenters of this forum are familiar with the Russian model in question, meaning having to take the Russian report at face value.

My personal behaviour when taking off, any airplane, is to have heels on the rudder pedals, toes ready to deploy. Same on landing. It is a conscious act and I am very aware of the brakes. It is my choice to try and take advantage of the (admittedly) brief amount of time it requires to reposition heels off the floor to get toes onto the brakes.

I think this is an accident that we will never really know what happened.

MtL, I always did the same, for the same reason. Autobrakes made the technique a bit redundant but pushing on the bottom section of the pedals with one's heels seemed to work in the sim for rejects as well as power losses so I kept the habit.

I think you're right about not knowing what happened. Same for the A321 accident at Islamabad, and the A330 accident at Tripoli, both countries which fall under ICAO Annex 13.

Still, the MAK, through their study of 9 loss-of-control accidents provided the initial insight into where the AF447 wreckage would be found, and they did good work on the Sochi A320 accident and the Aeroflot-Nord B737 loss of control near Perm, so they're certainly capable - but pilot competence (and therefore the regulator and the airline) are highlighted here. The Sochi and Perm accidents, not so much.

[W5]

ilot's inadvertent braking led to Yak-42 crash

Russian investigators have determined that a pilot of the Yakovlev Yak-42 which crashed on departure from Yaroslavl had inadvertently been braking during the take-off roll.

The inquiry found that the crew had accumulated extensive flight time on the smaller Yak-40 in which, said the Interstate Aviation Committee (MAK), techniques include using feet to cover the brake in case of rejected take-off.

But the pedal design on the Yak-42 is different. MAK said there had been "negative transference" of pilot skills, regarding foot position, by the crew.

The aircraft, bound for Minsk on 7 September, failed to rotate and overran, hitting an antenna before crashing in a river.

MAK has criticised "serious shortcomings" in the training of the crew, as well as the management of safety at the carrier, Yak Service. MAK said the organisation of the airline "did not allow" it to perform safe flight operations. The airline nevertheless passed regulatory compliance tests earlier this year.

Only one of the 45 occupants - including an entire high-profile ice-hockey squad - survived the accident, and investigations concentrated on a braking force which had emerged during the take-off roll.

The inquiry found that in the history of Yak-42 operations, amounting to 1.2 million flights, there had been only five cases of brake failure, and that none of these was similar to the Yaroslavl accident.

MAK said the parking brake was off, and added that the chances that a technical failure could lock the main wheels spontaneously was "virtually impossible" given their design.

The aircraft had been carrying sufficient fuel for the flight, its weight and balance were within limits, and there was no evidence of failure in the engines or aircraft systems - including jamming of the elevator.

Control and stability was in line with the type's characteristics, said MAK, and the crew checked that the rudder and ailerons were responding correctly to control inputs.

MAK found that the crew had not performed a correct take-off calculation, citing the V1 speed as 102kt rather than 113kt. The inquiry also said that the crew did not decide to abort the take-off despite the failure to rotate.

Source: Air Transport Intelligence news

[Moon The Loon]

ilot's inadvertent braking led to Yak-42 crash

Russian investigators have determined that a pilot of the Yakovlev Yak-42 which crashed on departure from Yaroslavl had inadvertently been braking during the take-off roll.

The inquiry found that the crew had accumulated extensive flight time on the smaller Yak-40 in which, said the Interstate Aviation Committee (MAK), techniques include using feet to cover the brake in case of rejected take-off.

But the pedal design on the Yak-42 is different. MAK said there had been "negative transference" of pilot skills, regarding foot position, by the crew.

The aircraft, bound for Minsk on 7 September, failed to rotate and overran, hitting an antenna before crashing in a river.

MAK has criticised "serious shortcomings" in the training of the crew, as well as the management of safety at the carrier, Yak Service. MAK said the organisation of the airline "did not allow" it to perform safe flight operations. The airline nevertheless passed regulatory compliance tests earlier this year.

Only one of the 45 occupants - including an entire high-profile ice-hockey squad - survived the accident, and investigations concentrated on a braking force which had emerged during the take-off roll.

The inquiry found that in the history of Yak-42 operations, amounting to 1.2 million flights, there had been only five cases of brake failure, and that none of these was similar to the Yaroslavl accident.

MAK said the parking brake was off, and added that the chances that a technical failure could lock the main wheels spontaneously was "virtually impossible" given their design.

The aircraft had been carrying sufficient fuel for the flight, its weight and balance were within limits, and there was no evidence of failure in the engines or aircraft systems - including jamming of the elevator.

Control and stability was in line with the type's characteristics, said MAK, and the crew checked that the rudder and ailerons were responding correctly to control inputs.

MAK found that the crew had not performed a correct take-off calculation, citing the V1 speed as 102kt rather than 113kt. The inquiry also said that the crew did not decide to abort the take-off despite the failure to rotate.

Source: Air Transport Intelligence news

Now THAT is interesting. Many years ago, I can't remember the light plane I flew, the brake was activated by the lower action of the rudder pedals rather than the top/toe action. Could that be the case here???

[DEFCON]

From 'Flight Safety Information', Nov 2/11

MOSCOW (AP) - A Russian jet crash that killed 44 people, including an entire professional ice hockey team, was caused by pilots inadvertently putting on the brakes during takeoff, investigators said Wednesday, blaming poor crew training and lax oversight.

The Interstate Aviation Committee said the Sept. 7 crash of the Yak-42 plane near the city of Yaroslavl in central Russia occurred because one of the pilots accidentally activated the brakes during takeoff and then pulled the plane up too sharply in a desperate attempt to take off.

It was one of the worst aviation disasters ever in sports, shocking Russia and the world of hockey, as the dead included 36 players, coaches and staff of the Lokomotiv Yaroslavl hockey team. The only player who survived the crash later died of burns. A flight engineer was the sole survivor.

Alexei Morozov, who led the investigation, said the crew still had enough time to abort the takeoff safely at the moment when they realized that it had gone wrong.

He blamed the plane's owner, Yak-Service, for failing to observe safety standards and adequately train the crew. The company was closed in September by Russia's federal aviation authority following a check that found severe violations.

"The company practically lacked a proper system of flight oversight and controls over air safety," Morozov said.

Morozov said that both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like virtually all other existing Russian and Western planes, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part.

But instead of putting their heels on the cockpit floor as regulations require, the crew left their feet resting on the pedals, inadvertently activating the brakes and slowing the plane down on takeoff. They at first didn't notice they were putting on the brakes, and then made the fatal mistake of failing to abort the takeoff, he said.

Morozov added that a medical condition of the second pilot, and the prohibited medicine he had taken contributed to the disaster. He said the pilot's illness had passed unnoticed during an official medical certification, but had been diagnosed by private doctors whom the pilot had consulted on his own initiative.

The plane was already past half of the long, 3,000-meter (9,900 feet) runway, when the crew tried and failed to lift it. They then weighed on the steering wheel trying to lift the plane and at the same time applied even more pressure on the brakes.

The jet sped past the runway and ran 400 meters (1,320 feet) onto the grass before finally taking off. It went up so sharply that it banked on its wing and crashed on the side of the Volga River, 150 miles (240 kilometers) northeast of Moscow.

The team had been heading to Minsk, Belarus, to play its opening game of the Kontinental Hockey League season.

Among the dead were Lokomotiv coach and National Hockey League veteran Brad McCrimmon, a Canadian; assistant coach Alexander Karpovtsev, one of the first Russians to have his name etched on the Stanley Cup as a member of the New York Rangers; and Pavol Demitra, who played for the St. Louis Blues and the Vancouver Canucks and was the Slovakian national team captain.

Other standouts killed were Czech players Josef Vasicek, Karel Rachunek and Jan Marek, Swedish goalie Stefan Liv, Latvian defenseman Karlis Skrastins and defenseman Ruslan Salei of Belarus.

The crash raised new concerns about Russia's aviation safety and prompted the president to suggest replacing all aging Soviet-era aircraft with Western-made planes.

But industry experts say that recent air disasters have been rooted not simply in planes' age, but in a combination of other factors, including insufficient crew training, crumbling airports, lax government control and widespread neglect of safety in the pursuit of profits.

[Moon The Loon]

Now THAT is interesting. Many years ago, I can't remember the light plane I flew, the brake was activated by the lower action of the rudder pedals rather than the top/toe action. Could that be the case here???

Two interesting lines from the above article:

"Morozov said that both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like virtually all other existing Russian and Western planes, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part.

"But instead of putting their heels on the cockpit floor as regulations require, the crew left their feet resting on the pedals, inadvertently activating the brakes and slowing the plane down on takeoff. They at first didn't notice they were putting on the brakes, and then made the fatal mistake of failing to abort the takeoff, he said."

The first answers my query; the second - "...as regulations require..."???????????

[boestar]

Many a Super Cub has been lost by pilots transitioning from a 150 or 172 to the Super Cub to get tail Dragger experience. The Cessna has toe brakes and the Super Cub has heel brakes. Brampton Flying Club has had theirs damaged a few times by this difference.

[Miles]

RE: Strong Crosswind take-offs

I've dealt with very strong gusty crosswind conditions, and never at any time in my career did I EVER consider using brake to keep the centerline! Proper crosswind technique quite adequately handles 99% of the take-offs, and when the going gets really bad, a slight thrust differential is all it takes on a multi-engine.

RE: Rejects and foot position.

Maybe because I have size 14 feet, I would never put my heels on the brakes just because all it would take is a sneeze to accidentally apply brake pressure. I'll also add that there is a reaction time built into the RTO numbers that's more than adequate to allow a pilot to slide his feet up and apply brakes. AND, I'll also add that most modern aircraft have a RTO function that's instant.

IMO having your heels on the pedals is just asking for trouble.

[Don Hudson]

RE: Strong Crosswind take-offs

. . . .

. . . I would never put my heels on the brakes

??

As has already been suggested by Moon regarding 'heel brakes vice toe brakes', foot position on the pedals depends upon how they are mounted, (where the pivot point is for braking). It also depends upon how high the pedals are off the floor.

The heel-on-pedal technique worked well for the DC9, DC8, B727, L1011, B767, A320, A330, A340 because the pivot points are at the bottom of the pedal. The heel is placed at the lower part of the pedal, opposite the pivot point with the toes resting lightly or even slightly away from the rest of the pedal. The technique worked nicely in crosswinds as it did in normal takeoffs/landings and it was easy to keep the toes from pressing forward, accidentally applying brakes.

The risk in placing the heels on the floor (ball-of-foot/toes on pedals) which pivot from the bottom is that the upper part of the foot is above the pivot point and can do exactly what you're trying to prevent - apply the brakes (on a rough runway, in a crosswind, especially with 'size 14'! ;-)

If the pivot point is higher up, placing the feet on the floor makes sense because the ball-of-the-foot/toes is then where the pivot point is and so is probably a better position. If the pedals are high enough off the floor, the toes can be placed opposite the pivot point and then technique becomes a matter of personal preference.

Don

[Kip Powick]

The Russian Interstate Accident Investigation Commission (MAK) have released their final report in Russian (Attachments) concluding the probable causes of the crash were:

erroneous actions by the crew, especially by applying brake pedal pressure just before rotation as result of a wrong foot position on the pedal during the takeoff run. This led to braking forces on the main gear requiring additional time for acceleration, a nose down moment preventing the crew to establish a proper rotation and preventing the aircraft to reach a proper pitch angle for becoming airborne, overrun of the runway at high speed with the elevator fully deflected for nose up rotation (producing more than double the elevator forces required to achieve normal takeoff rotation). The aircraft finally achieved a high rate of nose up rotation, became airborne 450 meters past the runway end and rotated up to a supercritical angle of attack still at a large rate of pitch up causing the aircraft to stall at low altitude, to impact obstacles and ground, break up and catch fire killing all but one occupants.

Had the crew rejected takeoff even above V1, with about 1000 meters of runway remaining available after the failed first attempt to rotate the aircraft, an accident would have been averted.

Forensic examination revealed the presence of a psychoactive drug (phenobarbital) in the first officer's body causing an inhibiting effect on the central nervous system. Performing duties as a crew member under the influence of this drug is prohibited by Russian Law.

Contributing factors were:

- serious shortcomings in the re-training of the crew members with regards to the Yak-42, which did not take place in full, was spread out over a long period of time and took place while the crew remained in full operation on another aircraft type (Yak-40), which led to a negative transfer of skills, especially a wrong position of the foot on the brake pedal on the Yak-42.

- Lack of supervision of the re-training

- errors and missed procedures by the crew in preparation and execution of the takeoff

- inconsistent, uncoordinated actions by the crew in the final stages of the takeoff

The MAK released the following findings as to the reason:

- The aircraft and all its systems were working properly upon departure from Yaroslavl. No failures of any system including brakes could be identified. There was no fire, explosion or destruction of the aircraft before impact with obstacles.

- The length and condition of the runway as well as weather conditions permitted a safe takeoff.

- The operational as well as business model of Yak Service, with respect to its operational and financial scheme, did not allow to provide safe operation.

- Organisation of flight activities as well as supervision of flight safety was absent in the company

- In 2011 there were significant shortcomings within the airline although it passed the compliance testing certification carried out by two organisations (named in the report)

- The re-training of the captain as well as the first officer was conducted in violation of current regulations, stretched over time to be combined with the development of flight operations on other types than the Yak-40

- Supervision over re-training procedures and further flight operations was insufficient

- Crew rostering had been done without consideration of important professional aspects, for example the crew consisted of two leaders with the authority of the first officer being higher than the captain's

- The first officer was unfit to fly due to influence of medicine (Phenobarbital). The drug had an inhibiting effect on the central nervous system

- The first officer did not conduct a number of important procedures and computation in preparation for takeoff

- The captain, conducting a balanced takeoff, took the incompetent decision to begin the takeoff roll not from the beginning of the runway

- No crew activity could be heard/observed during the takeoff run

- During the takeoff run, just prior to begin rotation, an incorrect leg position produced brake pedal pressure causing a retarding moment on the main landing wheels and a nose down moment counteracting rotation preventing rotation at Vr.

- During the takeoff run the crew fell back into the habit of operating a Yak-40 rather than a Yak-42 (most important difference: the position and feel of brake pedals)

- Simulation of the flight and the flight experiment showed a further compression of brake pedals could produce a retarding force of about 8000kg (78,500N, 17,600 lbs).

- After the failed rotation the crew did not take a decision to reject takeoff, but continued the takeoff accelerating the engines to maximum takeoff thrust

- The aircraft overran the runway end at a speed of 230kph (125 knots).

- The actions of the crew in the final stages of the takeoff were uncoordinated and inconsistent.

[mo32a]

Wow, an official report less than two months after the incident, and no sugar coating, PC weasel words. Impressive.

[DEFCON]

One of the pics in Kip’s post shows, the various light posts are equipped with hinged bases. I think that’s kind of interesting considering, the bases themselves are bolted to a substantial steel structure that’s guaranteed to tear the gear right off an aircraft during an overrun.

[Kip Powick]

Perhaps that was the reason for the heavy metal.....to stop an actual "over-run" from ending up in the "drink"..shear the gear and let it slide........or perhaps "they" felt it was more cost effective to put those rails down instead of drilling through, what looks like , concrete. I think that structure is about 1100 feet from the end of the runway. In reality, only those that put it there know.

I don't think they anticipated that an aircraft would be "almost" flying when it came in contact with the light standards

[Ex 9A Guy]

A co-worker that I flew with this week and who has significant experience on the Yak42 (got his first Aeroflot command on one) has some real issues with this crash and the subsequent report. From his recollections a Yak42 with less than half a passenger load should have absolutely no issues getting airborne off a runway that length. It is basically the Soviet version of a B727 and according to him had lots of available power compared to many other Soviet aircraft of that era. It was the first Soviet built aircraft to be fitted with high bypass turbo fan engines.

The Yak40 mentioned in the report as having been flown previously by one or both crew members, although it shares a common brand name and engine config it is a very different aircraft, in western aircraft think F28 vs B727 and would definitely have required significant conversion training, hopefully including any differences in rudder and braking configurations. He had flown both and could not recollect a significant difference between the aircraft in respect to rudder/brake config. Although he did say the Yak40 was a long time ago and there may be some grey matter failure on his part.

To me it looks like an elevator issue followed by an attempt to reject by one pilot whose decision was overridden by the other and an attempt to continue the take-off. when they finally got the elevator to function all the forces exerted on the controls resulted in full elevator deflection, a rapid rotation into a low level stall and resultant crash.

[Kip Powick]

...........................................................To me it looks like an elevator issue followed by an attempt to reject by one pilot whose decision was overridden by the other and an attempt to continue the take-off. when they finally got the elevator to function all the forces exerted on the controls resulted in full elevator deflection, a rapid rotation into a low level stall and resultant crash.

A valid "theory" but one would assume that if the aircraft had a CVR in it, the investigation would have espoused your "theory" if it was valid..... and actually happened. The same can be said about the DFR. The "crib" notes above, (accident investigation dialogue), makes no mention of the recorders, if they were in the aircraft, were serviceable, did record, and the investigators used the recorded data..

If they are mandated to be in the aircraft, were functioning, and the data utilized I think we have to assume that the investigation dialogue may be quite correct.

If, on the other hand, there were no recorders and their summation of the accident was a "WAG" then your "theory" could possibly be the answer.

[Boney]

Didn't the FE survived? He/she will provide important information. Hmmmmmm

[Ex 9A Guy]

It was just a WAG on my part. We had no discussion on the requirement or functionality of CVRs or FDRs.

I did however have a number of long and interesting conversations over the last 5 days on the road with this individual who has a unique perspective and experience inside the Soviet bloc both before and after Perestroika. His opinion of the current system in most ex-Soviet republics is akin to the wild west, lots of opportunity but little or no oversight.

[W5]

There was a workable FDR, but no mention of a CVR in the earlier reports dd. 7 Sept. Apparently one parameter was missing.

http://avherald.com/h?article=4428da13/0014&opt=0