Throttle Trouble Inadvertent Thrust Increase Caused a Fatal Overrun
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ONRecorD Throttle Trouble Inadvertent thrust increase caused a fatal overrun. BY MARK LACAGNINA The following information provides an aware- captain nor the copilot had received crew ness of problems in the hope that they can be resource management training on two-pilot avoided in the future. The information is based operations. The pilots had conducted 12 previ- on final reports by official investigative authori- ous A310 flights together. ties on aircraft accidents and incidents. The flight crew that had conducted the previous flight in the accident airplane had JETS reported a malfunction of the thrust reverser on the left engine, and it had been deactivated ‘The Crew Failed to Perceive the Cause’ by maintenance personnel in accordance with Airbus A310. Destroyed. 125 fatalities, 41 serious injuries. the A310’s minimum equipment list before the he A310 overran the runway while land- airplane departed from Moscow. ing at Irkutsk, Russia, the morning of July The flight to Irkutsk was uneventful. The T8, 2006. The airplane struck the reinforced report noted, however, that the copilot used an concrete airport perimeter fence and several incorrect radio frequency to report to air traffic brick garages before stopping, said the report control (ATC) that they were beginning descent. by the Russian Interstate Aviation Committee. After correcting the error, the copilot told the Both pilots, three cabin crewmembers and 120 captain, “I didn’t switch it over. … It’s night, and passengers were killed. Three cabin crewmem- we’re not getting enough sleep.” bers and 38 passengers were seriously injured. The Irkutsk airport was reporting surface Twenty-two passengers sustained minor injuries, winds from 270 degrees at 4 m/second (8 kt), and 15 escaped injury. The A310 was destroyed 3,600 m (2 1/4 mi) visibility with weak rain by the impact and fire. showers and an overcast ceiling at 190 m (623 The airplane was on a scheduled flight from ft). The runway was wet, and braking action was Moscow. The captain, 45, had 10,611 flight reported as good. hours, including 1,056 flight hours in type. He The crew disengaged the autopilot and had flown Antonov An-24s, Boeing 757s and autothrottles while conducting a nondirec- Tupolev Tu-154s before transitioning to A310s tional beacon (NDB) approach to Runway 30. in May 2005. The copilot, 48, had 9,771 flight After the airplane touched down in the runway hours, including 158 flight hours in type. He touchdown zone — about 200–300 m (656–984 had flown An-26s as a captain and Tu-154s ft) from the threshold, the spoilers deployed and as a copilot before transitioning to A310s two the autobrakes activated in the “LOW” mode. months before the accident. The report noted “The captain moved the right engine (no. 2) that while transitioning from the three-pilot thrust reverser [lever] forward,” the report said. Tu-154 to the two-pilot A310, neither the “However, simultaneously with the subsequent WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2008 | 57 ONRecorD reduction of the reverse mode of engine no. Maximum wheel braking was applied, but 2, engine no. 1 started to speed up (forward “because of the significant forward thrust of the thrust), which led to an increase in airplane left engine … the braking force came to equal speed and the onset of torque that pulled the the total thrust of the engines, [and] speed airplane to the right. The crew failed to perceive stabilized [at] about 180 km/hour [97 kt],” the the cause of what was happening.” report said. In accordance with the engine manufac- Aircraft rescue and fire fighting (ARFF) ve- turer’s recommendation, the captain had not hicles arrived about one minute after the airplane moved the lever for the deactivated left thrust came to a stop. The report said that 67 occupants reverser. Postaccident experiments indicated were evacuated by flight attendants and 11 were that he might have inadvertently moved the rescued by ARFF and municipal fire and rescue left throttle lever forward with the palm of his personnel before rescue efforts were halted six hand when he used his fingers to move the minutes later because of intense flames inside the right thrust reverser lever aft. The report said cabin. The fire was extinguished about 2.5 hours that shaking and vibration of the airplane from later. Of the 120 fatalities, 119 were caused by contact with the rough runway likely contrib- acute carbon monoxide poisoning, and one was uted to the unintended movement of the left caused by severe trauma and burns. throttle lever, which caused engine power to increase to 60 percent of maximum takeoff Engine Separates During Departure thrust. The airplane’s groundspeed, which had Boeing 747-100. Substantial damage. No injuries. decreased to 165 km/hour (89 kt), began to ighttime visual meteorological condi- increase. The left throttle lever movement also tions (VMC) prevailed when the airplane caused the spoilers to retract and the auto- Ndeparted from Chicago for a cargo flight brakes to disengage. to New York on Oct. 20, 2004. The 747 was The left throttle The pilots received aural and visual warn- climbing through 15,000 ft over Lake Michigan ings that the airplane was not configured prop- when the flight crew heard a loud bang, detected lever movement also erly for takeoff. Because the warnings were not a left yaw and observed indications that the no. related to landing and were not expected by 1 — left outboard — engine had failed, said caused the spoilers the pilots, they might have contributed to their the report by the U.S. National Transportation to retract and the inability to recognize the developing situation. Safety Board (NTSB). “The unusual behavior of the airplane, espe- “A visual inspection by the crew of the no. autobrakes to cially the strong turn to the right, increased 1 engine to check for damage revealed that the mental and physiological load on the pilots the [mounting] pylon was still in place but the disengage. and facilitated the distraction of attention from engine was missing,” the report said. The crew control over the engine rpm and speed,” the diverted to Detroit and landed without further report said. incident. The copilot did not comply with a require- Most of the no. 1 engine was recovered from ment to continuously monitor engine parameters the lake bottom, about 270 ft (82 m) below the and airspeed during the landing. The airplane surface, during the summer of 2005. Examina- was about 850 m (2,789 ft) from the end of the tion of the engine showed that an uncontained 2,425-m (7,956-ft) runway when the captain separation of about half of the second-stage said, “What’s wrong?” The copilot replied, “Speed turbine disk rim had occurred in flight, creat- increasing.” The captain told the copilot, “Reverse ing a severe imbalance that caused the turbine once again.” The copilot moved the right thrust exhaust case to break up and release the engine. reverser lever, but, because of the position of the The report said that an anti-seize compound left throttle lever, the thrust reverser doors on the that is not authorized for use because it causes right engine did not unlock. corrosion had been used on second-stage 58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2008 ONRecorD turbine bolts during maintenance of the engine blocked by a windshield post. The pilots heard and no preservation procedures had been a “graunching” sound but felt no impact when performed before the engine subsequently was the bottom of the right engine nacelle struck the placed in storage for five years. Only a visual rear of the tractor and pushed it out of the way. inspection of the high-pressure turbine and They observed no abnormal indications but The right engine turbine exhaust case had been performed before decided to have the aircraft inspected after they the components were installed on the no. 1 en- were clear of the narrow portion of the taxiway. nacelle struck the gine of the accident airplane 94 operating hours “Just as the commander was about to transmit a rear of the tractor before the separation occurred. request for ATC to dispatch a vehicle to inspect the aircraft, he heard a transmission [by the and pushed it out ‘All Clear’ Signal Given Prematurely tractor driver] advising ATC to stop an aircraft Airbus A320-200. Substantial damage. No injuries. as it had hit a tractor,” the report said. “Realizing of the way. ight rain was falling, but visibility was good that they were the aircraft involved, the crew when the aircraft was pushed back from its stopped the aircraft and applied the parking Lstand onto a taxiway at London Heathrow brake. At the same time, ATC advised them to Airport the afternoon of June 26, 2006, for a stop the aircraft.” scheduled flight to Munich, Germany. The A320 The right engine was shut down, and ARFF was given a long pushback to a relatively narrow personnel observed substantial damage but no part of the taxiway, to allow another aircraft to be fuel leaks. The pilots then taxied the aircraft on taxied to the stand, said the report by the U.K. Air one engine to a stand, and the 83 passengers Accidents Investigation Branch (AAIB). disembarked. The pushback was conducted by a marshaller and the driver of a towbarless tractor. After the Taxiway Mistaken for Takeoff Runway pushback was completed, the tractor was discon- Cessna Citation CJ1. No damage. No injuries. nected and parked near the A320’s right engine. he pilot had been on duty nearly 13 hours The marshaller did not signal the tractor driver to when he was cleared to take off on Runway reposition the vehicle outside the aircraft move- T36L at Memphis (Tennessee, U.S.) Inter- ment area before disconnecting his headset and national Airport the night of Oct.