Learning from the recent past. Armavia flight 967 departed Yerevan (EVN) at 00:47 on a scheduled flight to Sochi (AER). Weather at Sochi was poor with rain and poor visibility. During final approach, the weather deteriorated quickly and the controller instructed the flight crew to abort the approach and to make a climbing right hand turn to an altitude of 600 m. The aircraft was flying at 300 m and performed a climbing turn to 450 m. Simultaneously the groundspeed dropped and the Airbus descended until it contacted the water and broke up. Wreckage sank to a depth of 700 m.Organizational deficiencies, lack of adequate training, fatigue, and spatial disorientation were identified as contributing factors to the accident.
In the Flydubai accident Interim Report, the investigation team recommended, among other things:
– To repeatedly study and analyze the applicability of recommendations to prevent accidents and incidents during go-around, developed by the BEA based on the safety study related to Aeroplane state awareness during go-round (ASAGA) (Already published in this blog on March, 20th, 2016 Going around with all engines operating)
– To repeatedly study and analyze the implementation of safety recommendations issued by investigation teams of the accident involving the Boeing 737-500 aircraft registered VQ-BBN on 17.11.2013 at Kazan Airport (Already published on this blog on April, 9th, 2016 Tatarstan B735 crash during go-around at night. Learning from the recent past).
-To repeatedly study and analyze the implementation of safety recommendations issued by investigation teams of the accident involving the A320 aircraft registered EK 32009 on 3.05.2006 near Sochi Airport (Here it is !!).
Photo © ErwynS
Межгосударственный авиационный комитет (МАК) – Interstate Aviation Committee Air Accident Investigation Commission (IAC) final report.
Aircraft type: A320
Registration No:. ЕК-32009
Serial Number: 547
State of Registry: Armenia
Owner: Funnel, George Town, Cayman Islands
Operator: Armavia Airlines
Aviation Oversight Authority: Civil Aviation Administration of Republic of Armenia
Date and time of the accident: 2 May 2006 at 22.13 UTC (3 May 2006 at 02h13 local time)
Accident site: In the Black Sea near Sochi airport,
History of Flight
On 2 May 2006 the Armavia A320, registered EK-32009, was undertaking passenger flight RNV 967 from Zvartnots (Yerevan, Armenia) to Adler (Sochi, Russia).
Preliminary preparation of the crew was conducted on 23-24 May 2006 under the guidance of the airline’s Flight Director, in accordance with the requirements of ROLRGA RA-2000, Section 7.2.1.
Pre-flight briefing of the crew was conducted on the day of departure, under the guidance of the Captain, in accordance with the requirements of ROLRGA RA-2000, Section 8.2.1
On 2 May 2006 at 19.30 the crew passed the pre-flight medical examination.
The crew’s pre-flight rest period exceeded 24 hours. In accordance with ROLRGA RA-2000 and Work-Rest Norms for civil aircraft crews from the Republic of Armenia, each crew member is individually responsible for adherence to the pre-flight rest regime. It should be noted that it was difficult for the crew to take adequate rest during the day before the night flight, due to impairment of bio-rhythms. That is most likely why, in their cockpit conversations the crew members mentioned that they had not got enough sleep.
In order to make their decision for departure, the crew obtained the observed weather data and the weather forecast for the takeoff, landing and alternate aerodromes that met the requirements for IFR flights.
According to the documents submitted, the airplane takeoff weight and the center of gravity were 62,712 kg and 29.9% mean aerodynamic chord, i.e. within the A320 FCOM limitations.
There were 113 occupants on board: 105 passengers (including 5 children and 1 baby), 2 pilots, 5 flight attendants and 1 engineer.
The airplane took off from Zvartnots airport at 20:47. Takeoff, climb and cruise were uneventful. The first communication between the Sochi approach controller and the crew took place at 21:10:20. At that moment, the airplane was beyond the coverage area of Sochi aerodrome radar. Up until 21:17 the approach controller and the crew discussed the observed and forecast weather, and as a result, the crew decided to return to Yerevan. At 21:26:37, after the decision had already been made, the crew asked the controller about the latest observed weather. At 21:30:49 the controller informed the crew that visibility was 3,600 m and the cloud ceiling 170 m. At 21.31.14, the crew decided to continue the flight to Sochi airport.
The next communication with the approach controller was at 22:00:45. At that moment the airplane was descending to an altitude of 3,600 m heading to GUKIN point and was being tracked by the Sochi radar. The approach controller cleared the airplane for descent to 1,800 m and reported the observed weather at Sochi, as at 22:00, for runway 06, which was above the aerodrome minimum. Then the crew was handed over to the holding and tower controllers and was cleared for descent to 600 m, as per aerodrome pressure QNH 1016 hPa, before entering the turn to final. While performing the turn to final, the runway extended centerline was overshot.
Having eliminated the deviation, the airplane started descending along the glide slope, following the approach pattern.
At 22:10:45 the crew reported extension of the landing gear and their readiness for landing. In response, they were advised of the distance of 10 km and weather 4000 x 190, and were cleared for landing. However, about 30 seconds later, the controller advised the crew of the observed cloud ceiling at 100 m and instructed them to stop their descent and carry out a right turn and climb up to 600 m and also to get in touch with the holding controller.
The last communication with the crew was at 22:12:35. After that, the crew did not respond to any of the controller’s calls.
At 22:13:03 the airplane struck the water, was destroyed and sank.
Photo (C) gettyimages.com
(Note: Findings 1 to 7 were omitted on purpose, by Living Safely with Human Error)
8. Armavia does not exercise operational supervision of the A320 aircraft crews’ flights by using flight recorder information, which made it impossible to fully evaluate the professional skill level of the flight crew members.
9. According to the data presented, the pre-flight rest of the crew prior to the departure to the Sochi airport consisted of over 24 hours at home. However, the crew’s cockpit conversations indicated their fatigue, which could have influenced the outcome of the flight. The flight was performed at night when the probability of mistakes is especially high.
10. The meteorological and air navigation support for the flight met the requirements of the existing regulatory documents. Air traffic control service personnel, including personnel from the areas of responsibility in Sochi, Yerevan, Tbilisi, and Rostov, had valid licenses as civil aviation specialists with the required ratings.
11. At the time of the accident the meteorological conditions were complicated and did not correspond to the meteorological minima of the runway 06 of the Sochi airport due to the «cloud ceiling» parameter. In the time before the accident, the weather conditions at Sochi airport were unstable. The crew was informed of the weather changes by the air traffic controller in a timely manner. Inaccuracies committed by the air traffic controller while reporting the weather were not directly connected with the cause of the aircraft accident, but they influenced the initial decision of the crew to return to the departure aerodrome .
12. The emotional reaction of the crew to the air traffic controller’s information about the actual weather changes below the established meteorological minima was negative and could have led to an increase in the psycho-emotional strain of the crew members during the final stage of flight.
13. The approach for a landing on runway 06 was made with the use of ILS in an automatic mode. There was no deviation of the aircraft from the established glide slope profile. All the radio navigation aids at Sochi airport were fully serviceable.
14. The tower controller’s instruction to abort the descent and perform a right hand climbing turn to 600 m that was given to the crew after the cloud ceiling decreased below the established minima for RW 06, did not fully comply with the provisions of the controller’s operational manual, though it did not directly influence the outcome of the flight. According to the AIP of Russia, the controller had a right to refuse the landing. It should be noted that a number of AIP items contradict each other and are ambiguous.
15. According to the Armavia Operations Manual, the crew must initiate the go-around maneuver on receiving weather information below the minimums, even if the reliable visual contact is established with the runway or with landmarks.
16. At the beginning of the aborted approach maneuver, the crew did not comply with the standard go-around procedure stipulated by the FCOM, regarding applying takeoff thrust, retracting flaps by one step and retracting the landing gear. The climb in the OPEN CLIMB mode and the right-hand turn in the HDG mode were carried out under autopilot control in the landing configuration with the auto-thrust working in the speed hold mode. The landing gear was extended until the end of the flight. The mode in question is not described in the A320 AFM.
17. During flight under autopilot control, the LOW ENERGY WARNING signal was activated. The crew had properly reacted to this warning by setting the thrust levers in the takeoff position in full compliance with the AFM. It must be noted that the crew actions on activation of this warning are specified in the ABNORMAL PROCEDURE section of the A320 QRH.
18. Simultaneously with an increase in engine power, the crew (the Captain) switched off the autopilot in the normal manner using the take-over pushbutton on the side stick.
Most probably, the cause of the autopilot disengagement was the fact that the aircraft dynamics and attitude during this maneuver were unexpected by the Captain: pitch angle +21º, roll angle +25º, decrease in speed, the activated «SPEED SPEED SPEED», warning as well as the fact that he could not predict further changes in these parameters. Throughout the rest of the flight, the airplane was controlled manually, with the both FDs switched on.
19. After disengagement of the autopilot, the Captain was pilot flying. His actions, originally, led to the plane making a stabilized turn to the right with a roll of about 20 degrees, climbing at a rate of 2-3 m/s and accelerating. The stabilized turn proceeded until the magnetic heading attained the value differing from the runway heading by 90 degrees. Subsequently, the Captain controlled the plane to descend with a pitch angle up to 12 degrees pitch down and a roll angle up to 40 degrees to the right, which at maximum continuous power resulted in a substantial increase in IAS and the vertical rate of descent, as well as in activation of EGPWS and CRC warnings (excessive speed in flight with high-lift devices extended). The actual reason for such actions by the Captain could not be determined. Probably, such inadequate piloting was caused by the lack of monitoring of such flight parameters as pitch, altitude, and roll, at night in difficult weather conditions with a background of fatigue and psycho-emotional stress.
20. After the activation of the EGPWS warning, both pilots made control inputs simultaneously. The take-over button was not pressed by either of the pilots. The control inputs by the Captain and the co-pilot, both in roll and pitch were not coordinated and made in opposite directions. The DUAL INPUT warning was not activated because of its lower priority compared to the EGPWS warning. Before the airplane collided with the water the crew had almost completed retraction of the wing high-lift devices in several steps (the slats were still moving).
Neither of the pilots was monitoring the aircraft descent parameters or fulfilled the FCOM requirements for crew actions after EGPWS warning activation, which are stated in the “EMERGENCY PROCEDURE” Section of the A320 QRH.
The crew’s attention might have been distracted by a long 20-second controller’s message regarding a change in the approach procedure, which was recorded by the CVR along with the EGPWS and CRC warnings that were sounding in the background. The controller issued the message in accordance with the controller’s operational manual after the crew contacted him.
21. Experiments on the simulators showed:
– Provided that the standard «GO AROUND» and «MISSED APP» procedures prescribed by the FCOM are followed, the aircraft performs the go-around maneuver with no difficulties, in both the automatic and director modes.
– In the case where the autopilot remains engaged, while the aircraft is performing a maneuver similar to that in the accident flight, the autopilot normally completes the go-around procedure, with a maximum pitch angle not exceeding 21.5º, the short-time decrease of speed not exceeding 10-12 kt, with activation of the «SPEED SPEED SPEED» warning, and without activation of the α – FLOOR function.
– If after activation of the «PULL UP» warning the FCOM recommendations are implemented, for the parameters similar to those in the accident flight (indicated airspeed 270…280 kt, pitch angle -5.5º…-6.5º, roll angle about zero and the wing high-lift devices in the 18º/0º position), the decrease in altitude during aircraft recovery from descent is about 200…230 ft.
Photo (C) www.gettyimages.com
The fatal crash of the “Armavia” A-320 EK-32009 was a CFIT accident that happened due to collision with the water while carrying out a climbing maneuver after an aborted approach to Sochi airport at night with weather conditions below the established minima for runway 06.
While performing the climb with the autopilot disengaged, the Captain, being in a psycho-emotional stress condition, made nose-down control inputs due to the loss of pitch and roll awareness. This started the abnormal situation.
Subsequently, the Captain’s inputs in the pitch channel were insufficient to prevent the development of the abnormal situation into the catastrophic one.
Along with the inadequate control inputs of the Captain, the contributing factors to development of the abnormal situation into the catastrophic one were also the lack of necessary monitoring of the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot and the absence of proper reaction by the crew to the EGPWS warning.
Shortcomings found during investigation
1. During descent and approach, the crew constantly had irrelevant conversations that had nothing to do with the crew operations manual and therefore violated the requirements of ROLRGA RA-2000, Section 8.3.4.
2. The A320 FCTM, which was approved by the Civil Aviation Administration of the Republic of Armenia and according to which Captain G.S. Grigoryan passed his training before starting solo flights with the airline, does not contain the requirement for passing the Upgrade to Captain program. Captain G.S. Grigoryan did not pass this training. This training program was made mandatory in the next revision of the FCTM.
3. The Flight Operations Department of Armavia does not comply with the provisions of ROLRGA RA Section 11.2 and ICAO Annex 6 Part 1 Chapter 3, which require airlines to analyze fight operations with the use of the FDR and CVR recordings for aircraft with the certified MTOW exceeding 27 000 kg.
4. In violation of ROLRGA RA-2000 Sections 4.5.33 and 6.1.5, Armavia airline does not keep records on the approaches and landings in complicated weather conditions performed by their Captains.
5. The following deficiencies were identified in air traffic management:
– At 21:16 the approach controller of the Sochi aerodrome advised the crew of the trend weather forecast for landing as 150 by 1500 and did not identify the trend as “AT TIMES”. This inaccuracy committed by the controller while reporting the weather to the crew was not directly connected with the cause of the aircraft accident, but it influenced the initial decision of the crew to return to the departure aerodrome.
– At 22:01:37 the approach controller advised the crew of the observed weather at Sochi aerodrome as at 22:00 and by mistake said the cloud ceiling was “considerable 1800”, instead of 180 m, however, this did not influence the Captain’s decision.
– At 22:03:29 the crew did not report, and the holding controller did not request the crew to report the selected system and mode of approach, which does not meet the requirements of the Holding Controller’s Operation Manual, Section 4, item 4.2.1, of Sochi aerodrome.
– At 22:11:38 the final controller at Sochi aerodrome was informed by the weather observer on the actual weather at Sochi aerodrome with the cloud ceiling at 100 m, which was below the established minima (cloud ceiling 170 m, visibility 2500 m). Based on this information, the final controller instructed the crew: “Abort descent, clouds at 100 m, right-hand climbing turn to 600 meters”. The controller’s actions did not comply with the requirements of the Civil Flight Operations Guidance 85 Section 6.5.16 and the Final Controller’s Operation Manual, items 4.3 and 4.3.1. However, according to the AIP of Russia the controller had a right to forbid the landing. It should be noted that a number of AIP items contradict each other and are ambiguous.
6. Meteorological support:
– The weather forecast for the Sochi aerodrome for the period from 18:00 to 03:00 was not verified with regard to visibility in the “At times” group;
– In violation of the Guidance for Meteorological Support in Civil Aviation 95, Sections 4.3.1 and 4.4.1 d) and the Instruction for meteorological support at Sochi aerodrome, the observer did not complete the special weather report at 22:11, when the cloud ceiling descended to 100 m, i.e. to a value stipulated in Annex 8 of the Criteria For Issuance of a Special Weather Report;
– The recommendation for ATIS broadcast content stipulated in the joint Order No. 62/41 “On approval and implementation of Instruction for ATIS broadcast content in English and Russian languages” of 20.03.2000 issued by the Federal Air Transport Administration and Hydrometeorology and Environment Monitoring Service was not entirely fulfilled.
7. A320 aircraft:
– In course of reading out the FDR data, a number of discrepancies were found in the documentation describing the logic of binary signal recordings;
– While performing maneuvers in the landing configuration with the auto pilot and auto thrust engaged, the LOW ENERGY WARNING may sound, which Airbus considers as an abnormal situation.
Photo © Michael Nikel
1. To aviation administrations of the CIS countries:
– To conduct briefings with the flight crews, controllers and technical and engineering personnel to review the circumstances and the causes of the accident.
– To ensure fulfillment of the requirements of ICAO Annex 6 Part 1 Chapter 3 for mandatory analysis of performed flight operations based on the CVR and FDR recordings for the aircraft with a certified MTOW exceeding 27000 kg.
– To draw the attention of A320 crews to the necessity of the immediate response to activation of the EGPWS warning (even if other warnings are on at the same time) in the case of instrument flight, or flight in difficult weather conditions, or flight in the mountains. To introduce the relevant exercises in the simulator training programs to practice these actions.
– To consider the advisability of extending these recommendations to other aircraft types.
– To review the necessity of enhancing crew simulator training in the section on flying in Flight Director mode, especially during approach and go-around.
– To bring the content of the AIP, as well as the ATC controllers’ job descriptions and operations manuals, into compliance with the standards and practices recommended by ICAO, with regard to clearance for approach and landing.
2. To aviation administrations of CIS countries jointly with the industrial and scientific and research organizations:
– To organize and conduct research into the conditions under which a crew may lose spatial orientation and/or upset aircraft attitude may develop, and to issue practical recommendations to enhance flight safety, in particular, to evaluate the effect of in-flight acceleration illusions. Based on the research, to develop and introduce a specialized course for recurrent training of crews that should contain both classroom and flying training.
3. To the Civil Aviation Administration of the Republic of Armenia and Armavia airline administration:
– To include in the A320 FCTM the mandatory requirement for trainee Captains to pass the Upgrade to Captain program.
– To keep records on approaches performed in difficult weather conditions by A320 crews, in accordance with the regulatory documents relating to the organization of flight operations in civil aviation of the Republic of Armenia.
– To organize FDR and CVR readouts for analysis of A320 flight operations, in order to reveal any errors and deficiencies in crews’ piloting technique, and to develop measures for their prevention.
– To point out to aircraft crews that, irrelevant conversations in the cockpit, especially during the climb and descent phases, are prohibited.
– To consider the necessity of enhanced simulator training for A320 crews.
– To develop a procedure for storage of A320 operational documentation that would regulate the conditions of keeping the originals and copies of the documents by both Sabena Technics and Armavia airline.
4. To the Federal Air Navigation Service of the Russian Federation:
– To review the possibility of updating of AIP of the RF and other regulatory documents for the purpose of unification of ATC procedures for issuing instructions for go-arounds to aircraft operated by domestic and foreign airlines, and to incorporate the relevant amendments into the Rules and Phraseology for In-flight Radio Communications and ATC.
– To review the possibility of incorporation of the Air Traffic Service procedures in the aerodrome services provided in accordance with ICAO recommendations (Document 4444, Attachment 11) and the Order No. 103/DV-116 of 26.10.95 issued by Department of Air Transport.
5. To the Federal Service for Hydrometeorology and Environmental Monitoring:
– To review the possibility of purchasing and installing of a new Doppler weather radar at the civil aviation meteorological station in Sochi.
– To undertake measures to eliminate the shortcomings in the meteorological support to civil flight operations at Sochi aerodrome brought to light in the course of the investigation.
6. To the federal state unitary enterprise “State Corporation for Air Traffic Management»:
– To restore complete ATIS broadcasting for Sochi aerodrome, including weather data.
– To clarify to controllers of the Sochi Air Traffic Support of the groups of BECMG and TEMPO changes in the weather forecasts for the aerodrome and of the two-hour “trend” weather forecasts.
7. To Airbus:
– To eliminate the discrepancies in the documentation describing the logic of the binary signals recorded by the FDR.
– To introduce in the A320 FCOM information clarifying specific features of activation of the OPEN CLIMB mode in various flight conditions.
– To introduce in the A320 FCOM a warning about possible activation of the LOW ENERGY WARNING, when the aircraft performs maneuvers in the landing configuration with considerable changes in pitch and roll angles.
– To review the expediency of alteration of the type and/or priority of the EGPWS warning to ensure more reliable pilots’ response to its activation.
8. To eliminate the shortcomings revealed during the investigation of the aviation accident.
- Flydubai accident Interim Report
- The Head-Up Illusion: do you remember it?
- Tatarstan B735 crash during go-around at night. Learning from the recent past
- Going around with all engines operating
- Speaking of going around
- Loss of flight crew airplane state awareness
By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@dralaurita. Human Factors information almost every day