S7 Airlines Flight 778

S7 Airlines Flight 778

File:Airbus A310-324(ET), Aeroflot AN0369461.jpg The accident aircraft while operating as Aeroflot, pictured at Charles de Gaulle Airport on 2003.
Accident summary
Date	9 July 2006
Summary	Landing accident, pilot error
Site	Irkutsk International Airport, Irkutsk Oblast, Russia
Passengers	195
Crew	8
Injuries (non-fatal)	63
Fatalities	125
Survivors	78
Aircraft type	Airbus A310-324
Operator	S7 Airlines
Registration	F-OGYP
Flight origin	Domodedovo International Airport, Moscow, Russia
Destination	Irkutsk International Airport, Irkutsk, Russia

S7 Airlines Flight 778 (RU778/SBI778) was an Airbus A310-300 scheduled domestic passenger flight, serving the route from Moscow Domodedovo to Irkutsk when it crashed upon landing at Irkutsk International Airport at 07:44 local time on 9 July 2006 (8 July, 22:44 UTC). The plane overshot the runway, sliding over several hundred metres of wet runway and grass. It crashed through a concrete barricade, hit a group of private garages and burst into flames. Television pictures showed smoking ruins of the Airbus with only the tail section intact. It took two hours for local firefighters from five different fire stations to extinguish the blaze.

A total of 125 people were killed in the accident. It was the deadliest plane crash in Irkutsk since Vladivostok Air Flight 352 in 2001. It was also the company's deadliest plane crash. Currently, it held as the 4th deadliest plane crash in Russia and the third deadliest involving an Airbus A310, after Kenya Airways Flight 431 and Yemenia Flight 626.

In the wake of the crash, most media outlets reported that a brake failure occurred in Flight 778. However, the final report, concluded by the Russian Interstate Aviation Committee (MAK), stated that the cause of the crash was due to pilot error.

Flight

File:Irkutsk airport international terminal.jpg

Irkutsk Airport, the location of the accident

Flight 778 departed Moscow Domodedovo International Airport at 17:17. The plane then went airborne with no incident and started their descent to Irkutsk at 22:17. At the time, the weather at Irkutsk was quite affected by a cyclone near Ulaanbaatar. It was affected by its rear part of the cyclone. Observers stated that the weather in Irkutsk was raining with light precipitation and cumulonimbus clouds were spotted over the airport. If landing in Irkutsk couldn't be performed, the flight would be diverted to Bratsk Airport. The plane contacted the runway and land perfectly lined up with the runway.

After the touchdown, the aircraft's spoilers section were armed and the autobrake was deployed to low mode. The pilot then deployed the right engine no.2 thrust reverser. However,simultaneously with the subsequent reduction of the reverse mode of engine no. 2, engine no. 1 started to speed up (forward thrust), which led to an increase in airplane speed and the onset of torque that pulled the airplane to the right.

The cockpit crews quickly became confused of the current situation. As the aircraft speed increased, flight crews tried their best to stop the plane and prevent it from an imminent disaster. In spite of their best effort, it didn't pay off. The aircraft used the entire length of the runway and overshot its end at a speed of about 180 kph. The aircraft then smashed into a concrete barrier. The nose collapsed and a fire ignite. The fire then 'exploded' after the left wing detached from the plane. The plane then plowed into a total of 20 private garages. This causing the aircraft to be severely damaged. The fuel tank then burst and ignited, causing a fuel-fed fire. The fire then penetrated the cabin and destroyed the aircraft.

Rescue operations

ATC in Irkutsk were watching Flight 778 landing progress and saw the crash. They noticed that the plane overran the taxiway at high speed and not slowing down. It then smashed into a concrete barrier and burst into flames. An alarm signal was issued at 22:45. The flight operation director then ordered the controller in the airport control tower to send out the initial report of the accident, and ordered the weather observer at the main observation point to compile an observation of the weather. At 22:46, the aircraft was closed by the Aerodome Flight Operation Director and not a single aircraft could take off or land in the airport.

The surviving flight attendants in the aircraft then tried to evacuate the remaining passengers on the plane. A flight attendant was suspended by her seatbelts as the floor beneath her was destroyed. She then unfasten her seatbelts, fell to the ground, and received burn injuries. The forward entry door was destroyed shortly after the fire. The left central door couldn't be opened as an intense fire occurred right beneath it. At this point, another flight attendant, died. The right rear door and a flight attendant, who was sitting near it, ended up being blocked by metal food containers that had fallen as a result of the airplane's collision with the barriers. The flight attendant who opened the left rear door released the emergency inflatable escape chute, thus ensuring a route for evacuating passengers. The inflatable chute opened but was damaged by sharp metal objects on the ground and lost its load-bearing capacity. Another flight attendant, after freeing herself from the metal containers, helped in the evacuation of passengers through the left rear door. Another flight attendant, while helping passengers inside the cabin, died from acute carbon monoxide poisoning. Some passengers from business class and the first compartment of the economy class evacuated through gaps that formed along the sidewall of the fuselage.

The airport fire brigade then gave an alarm on 22:44, after seeing the collision of the aircraft with the barrier and the outbreak of the fire. Fire trucks headed to the crash site. After receiving the alarm command, the chief of crash and rescue work shift director of operational control of Irkutsk airport, decided and gave the command to deploy airport crash and rescue details to the site of the accident. 72 freelance CRT rescuers and 24 special-purpose vehicles were deployed. Airport CRT details arrived at the scene of the accident at 22:47.

The rescuers then reached the crash site and saw most of the planes had been engulfed by flames. Firefighters tried to extinguish the flames. Firefighters then pry open the right rear door (which was, initially, blocked by food container) and reached the interior of the plane that fully engulfed with thick, black smoke. They managed to save a total of 11 other people. The flames quickly engulfed the cabin, thus, forcing them to stop their rescue operation,

A total of 125 people were killed. The Captain and the First Officer died in the accident, while 3 flight attendants out of 6 were killed. 119 passengers and crews were killed due to a high intake of carbon monoxide in their body. One flight attendant was found with a total of 85% of carboxyhemoglobin concentration inside her blood, along with her colleagues. One female passenger was killed due to severe trauma, combined with burns on her body.

Passengers and crew

People on board by nationality

Nationality	Passengers
Russia	176
Poland	2
People's Republic of China	7
United States of America	7
Belarus	3
Indonesia	3
Japan	3
Germany	2
Moldova	2
South Korea	2
Total	203

There were 195 passengers and 8 crew members aboard. 75 passengers and 3 flight attendants survived the crash, leaving 125 dead. Nearly 60 people were taken to a hospital, some with critical injuries, but others managed to escape with few injuries and 15 were able to continue their journeys. Some survivors said they owed their lives to a flight attendant who managed to open the emergency exit in the rear of the aircraft.

The ITAR-Tass news agency in Russia reported that many children were among the passengers who were flying to a holiday on Lake Baikal, near Irkutsk, about 4,200 kilometres (2,600 mi) east of Moscow. Besides Russian citizens, who were the majority of passengers, there were also 2 Polish tourists traveling to Mongolia via Irkutsk. Having been in the tail section, they managed to escape the plane unassisted, one injuring a leg. There were 27 other non-Russians on board, 7 each from China and USA, 3 each from Belarus, Indonesia and Japan and 2 each from Germany, Moldavia, and South Korea. Among the dead were Sergey Koryakov, regional head of the Federal Security Service of the Russian Federation (FSB), and Mariya Rasputina, daughter of writer Valentin Rasputin.

Aircraft

Airbus said the aircraft involved in the accident was registered as F-OGYP, previously N812PA and MSN (Manufacturer Serial Number) 442. It was delivered new in June 1987 to Pan Am and later to Delta Air Lines after Pan Am's bankruptcy in 1991. Prior to service in S7, Airbus Industrie and Aeroflot had flown the aircraft. It had accumulated more than 52,000 flight hours in more than 10,000 flights. It was powered by Pratt & Whitney PW4152 engines.

Investigation

A spokeswoman for the ITAR-Tass news agency in Russia, Irina Andrianova said "The aircraft veered off the runway on landing. It was travelling at a terrific speed."

File:Hydroplaning.jpg

An illustration of aquaplaning, where a loss of traction that prevents the vehicle from responding to control inputs, occurred after a layer of water builds between the wheels of the vehicle and the road surface

News agencies reported Russian Transport Minister Igor Levitin as saying the pilots advised air traffic controllers they had landed successfully, but that radio contact then broke off suddenly. Speaking before flying from Moscow to Irkutsk, Levitin was also quoted as saying the runway was wet after rain.

According to Airbus, the aircraft was properly maintained. The most recent A Check, or maintenance check, on the aircraft was on 1 June 2006, Sibir said. A C Check, which involves a more thorough overhaul, was carried out 12 July 2005 in Frankfurt. According to the final results of the investigation, the accident was not caused by the left engine thrust reverser's non-deployment due to a Minimum Equipment List (MEL) authorized reverser deactivation – The thrust reverser in question was inoperative in line with MEL requirements prior to the accident.

When the pilot slowed down the plane by using wheel braking and deploying the righthand engine thrust reverser, the lefthand engine thrust lever was inadvertently advanced, causing the plane not to decelerate as per a normal landing. The crew was unaware the thrust lever had been inadvertently advanced until late in the accident cycle. The aircraft veered off the runway and hit a concrete barricade at the speed of approximately 100 km/h (62 mph).

A preliminary report was issued by the Russian MAK the week of 25 September 2006, blaming the accident on pilot error, and finding that there was no problem with the engines or the aircraft.

The cockpit of a Siberia Airlines Airbus A310, with thrust lever visible in the center of the cockpit

The autopilot and thrust controller were switched off by the crew at a height of 100m and could not have any effect on the landing and landing run. The couplings linking the thrust controller to the engine control linkage were uncoupled and were not connected to the linkage any more. No steering commands given by the thrust controller computer were recorded. The results of the investigation of the electronic guidance and engine control system (FADEС) testify to the efficiency of the system right up to when the airplane collided with the barriers. The airplane landed in the touchdown zone at Irkutsk airport at 22.43.40 in wheel control mode with engines running at idle. After landing, the spoilers were automatically deployed and the automatic braking system (ABS) was automatically switched on in LOW mode. 1.5 seconds after touchdown, the airplane captain set the reverse thrust lever for the right engine to the reverse mode. The right engine correctly went into reverse thrust mode. The reverse thrust lever for the left engine was not applied.

Consequently, during the time the reverse thrust lever for the right engine was being moved forward (to reduce the reverse thrust), the airplane captain unintentionally and uncontrollably moved the throttle control lever for the left engine forward (increasing forward thrust). The reverse thrust of the right engine was reduced by the pilot gradually up to the stowed position and remained in that position until the time of colliding with the barriers. The throttle control lever for the left engine was in the position corresponding to the forward thrust setting of ~60% of its full rated takeoff thrust, and remained in that position until the FDR stopped recording. The crew did not notice the left engine’s increase in forward thrust.

The simultaneous congruence of the following factors contributed to the moving of the TCL that went unnoticed by the airplane captain:

• presence of shakes and vibrations typical for runway at Irkutsk

airport;

• presence of negative acceleration during the normal run after

landing with an activated right engine reverser and automatic wheel braking in LOW mode

• possibly small friction force needed to move the TCL, which

makes any inadvertent movement of the throttle control lever easier.

During the evaluation, analysis and interpretation by Sibir’s psychologist of the data received as a result of the psychological testing of the airplane captain, the test data “Comparison of concepts” and “Sondi modified methods” were inadequately expertly analyzed and taken into account. The details of Kettell’s test and “Luscher’s eight color test” were correctly analyzed but not taken into account in the final interpretation and conclusions. Accordingly, the psychologist’s recommendation to admit airplane captain to the A-310 conversion training course was given without adequate grounds. The personality traits of the airplane captain which were identified from the results of analyzing the psychological tests, together with the features of his conceptual thinking, may have had a profound effect on his behavior in a stressful situation, and, particularly, may have caused disorganization.

The English translation of the accident final report, on page 115, stated the following conclusion:

INTERSTATE AVIATION COMMITTEE
FINAL REPORT ON THE RESULTS OF THE INVESTIGATION OF THE ACCIDENT, page 115
The cause of Sibir A-310 F-OGYP accident was the erroneous and uncontrolled actions by the crew during rollout after landing in a configuration with one engine reverser deactivated. After touchdown, the Captain, while acting on the reverse thrust lever of the right engine, inadvertently and uncontrollably moved the throttle lever for the left engine, whose thrust reverser was deactivated, from the "idle" to the significant forward thrust position. Inadequate monitoring and call-outs of airplane speed and engine parameters by the Co-pilot made it impossible for the crew to perform the necessary actions, either by moving the left throttle back to idle or shutting down the engines. The crew had enough time to recognize the situation.

See also

• 2011 Lokomotiv Yaroslavl air disaster, a 2011 Russian plane crash which occurred when a brake applied too much while taking off
• TAM Airlines Flight 3054, a 2007 Brazilian plane crash which occurred due to hydroplaning and pilot error

External links

• Final accident investigation report (Archive) – Interstate Aviation Committee – English translation done by and hosted by the Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA).
• Investigation and final report – Interstate Aviation Committee (Archive) (Russian)
  • Final report (Archive) (Russian) – The Russian version is the version of record
• Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
  • "Accident in Irkutsk on 11 july 2006." (Archive)
• S7 Airlines notice about the accident
• Accident description at the Aviation Safety Network