In a blog I wrote here on September 8 entitled
"Some random thoughts on Hockey's darkest day ever ..." I noted that
September 7, 2011 would for all time no doubt be sadly remembered as the darkest day of all in hockey with the tragic loss of an entire team ...
Lokomotiv Yaroslavl (Локомотив Яросла́вль) of the
KHL ... in a horrendous airplane takeoff accident of a
Як-42Д that crashed into the
Volga River about a mile from
Yaroslavl-Tunoshna Airport (Аэропорт Туношнаon Яросла́вль) on a flight to
Minsk to open the club's 2011-12 season.
Among the
43 lives it took (only the flight engineer survived) were those of former NHL players
Pavol Demitra, Karel Rachůnek, Ruslan Salei, Josef Vašíček, Karlis Skrastins, Alexander Vasyunov, Alexander Karpovtsev and
Igor Korolev as well as that club's new head coach, 52-year old
Brad McCrimmon, one of the steadiest blueliners in NHL history during his 18-year playing career before spending the last thirteen seasons as an NHL assistant coach with the
Islanders, Flames, Thrashers, and
Red Wings.
In my blog then I also opined that I suspected that this accident would most likely eventually be found to
"have been 100% preventable" and that its
"probable cause" would be determined to be a product of the dismal safety standards practiced by many civil aviation carriers in Russia (and tolerated by their regulators) such as Moscow based
"Yak-Service" (Як Сервис), the operator of the Як-42Д (Registration: RA-42434, c/n 17-05) tri-jet accident aircraft it flew under the name of
"Proton Airlines" (Протон Авиалинии) that made this terrible loss even more devastatingly tragic.
Proton Airlines (Протон Авиалинии)
Operator: Yak-Service (Як Сервис)
Type: Yakovlev-42D (Як-42Д)
Reg: RA-42434
On Wednesday, November 2, the Russian
Interstate Accident Investigation Commission (MAK) released their final report on the cause of this tragic crash and as I suspected it was indeed
100% preventable. In its report the MAK concluded that the
probable causes of the crash were:
"Erroneous actions by the aircrew, especially by applying brake pedal pressure just before rotation as result of a wrong foot position on the pedal during the takeoff run. This resulted in 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 from reaching a proper pitch angle to become airborne.
"The aircraft overran of the 3,000 meter (9,850 foot) runway at high speed with the elevator fully deflected for nose up rotation thus 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 in the grass about 450 meters (1,475 feet) beyond the end of the runway and rotated up to a supercritical angle of attack causing the aircraft to stall at low altitude (20-30 feet), impact a localizer antenna tower, break up and catch fire, and killing all but one occupants.
"Had the crew rejected takeoff even above V1, with about 1,000 meters (3,280 feet) of runway remaining available after the failed first attempt to rotate the aircraft, the 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 to the accident 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 also made the following additional findings:
- 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, were insufficient to provide safe operation;
- Organization 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 organizations named in the report;
- The re-training of the captain as well as the first officer was conducted in violation of current regulations and 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 pilots with the authority of the first officer being higher than the captain's;
- The first officer was unfit to fly due to influence of Phenobarbital, a drug that had an inhibiting effect on the central nervous system;
- The first officer failed to conduct a number of important procedures and computations in preparation for takeoff;
- The captain, conducting a balanced takeoff, took the incompetent decision to begin the takeoff roll from a point not at the beginning of the runway;
- No crew activity could be heard/observed during the takeoff run;
- During the takeoff run, just prior to attempting 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 V(r);
- 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 abort the takeoff but instead 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.
MAK's lead investigator
Alexei Morozov said the aircrew should have aborted the takeoff the moment they realized it was going wrong and gave as the possible reason they failed to do so was a fear of reprisals from their employer. Many aviation industry experts say Russian crews who
abort takeoffs, make missed approaches, or divert to other airports risk losing their bonuses or face other sanctions
as carriers focus on cutting costs.
“Many pilots say that those who cause delays in flight schedules run into various problems at many carriers,” Morozov told a news conference. “Company managements don’t like it.”
Morozov blamed the
YaK-42D's operator,
Yak-Service, for failing to observe safety standards and adequately train the aircrew. The
company's certificate was pulled in September by Russia’s federal aviation authority following a check that found
severe violations.
“The company utterly lacked a proper system of flight oversight and controls over air safety,” Morozov said.
* * *
The bottom line here for hockey is, as I opined two months ago, any player or coach considering the KHL should do so with great pause unless and until that league can assure them that is has a support structure adequate to make that a safe decision. No professional hockey team in North America at
any level would have ever been permitted to travel with such a charter carrier as the KHL appears to use routinely.
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