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Report: weather, workload, poor CRM cited in Tupolev 204 CFIT accident near Moscow
20 September 2010

The Tu-204 cut a swath through the forest near Domodedovo Airport (Photo: MAK)

The Russian MAK Interstate Aviation Committee (IAC) issued their final report of the investigation into the cause of a CFIT accident involving a Tupolev 204 in March 2010, citing amongst others workload and poor crm.

The Tupolev 204-100 passenger jet, registered RA-64011, was destroyed when it crash-landed in a forest on March 22, 2010 while on approach to Moskva-Domodedovo Airport (DME), Russia. The airplane operated Aviastar-TU flight flight TUP1906 on a ferry service from Hurghada Airport (HRG), Egypt. All eight crew members survived the accident.
On approach to Moscow the flight was cleared for a runway 14L ILS-approach. Weather was reported to the crew as: visibility at the beginning of runway 1300m, mid-600m, at the end of 550 m, vertical visibility 60 m, wind 170 degrees, at 2m/sec. The airplane descended until it struck trees, cutting a swath trough the forest. It came to rest 1450m short of the runway threshold and 150m further to the right of the runway.

Investigators concluded that the flight crew conducted an approach to the airport in below-minima weather conditions for an airplane with a defective flight control computer system. They failed to execute a go-around when failing to obtain visual contact with the ground.
Contributing factors were:
– Insufficient training of the crew to perform approaches at or near weather minima;
– Lack of control over the activities of the crew, which led to poor resource management (CRM) of the captain;
– Failure of the flight control computer system, which led to an increase in the allowed weather minima of the aircraft;
– Failure of captain to divert to another airport;
– Failure of captain to decide about a missed approach when there was visual contact with the approach lights;
– Failure of the co-pilot to call for a missed approach;
– Unsatisfactory interaction in the crew, resulting in a descent below safe altitude.
Failure of the flight control computer system in flight (most likely due to unstable radio altimeters at altitudes exceeding their operating range) and the impossibility of “removal” of failure on this plane because of the lack of buttons to simulate the compression of the undercarriage, and inadequate crew training, and possibly fatigue, led to a significant increase of mental and emotional stress in which it it is not possible to make the best decision for the successful completion of the flight.