Incident Overview

Date: Saturday 4 December 2010
Aircraft Type: Tupolev Tu-154M
Owner/operator: Dagestan Airlines
Registration Number: RA-85744
Location: Moskva-Domodedovo Airport (DME) – ÿ Russia
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 171
Component Affected: Aircraft Engines (specifically, the three engines experiencing failure)Aircraft Engines (specifically, the three engines experiencing failure)
Investigating Agency: MAKMAK
Category: Accident
A Tupolev 154M passenger jet, registration RA-85744, experienced a catastrophic landing accident at Moscow’s Domodedovo Airport (DME) on November 16, 2010. The aircraft sustained significant damage beyond repair, resulting in the deaths of 163 passengers and eight crew members. The flight, commencing from Vnukovo Airport (VKO) at 14:08, involved a domestic flight to Makhachkala Airport (MCX). The plane’s engines were started during a fuel transfer operation, leading to a rapid and unstable fuel supply situation. Approximately 14:16, three engines failed, followed by a period of instability, ultimately causing the aircraft to land hard to the right of the runway. The crew initiated an emergency landing, diverting to Domodedovo Airport. The landing was challenging, with the aircraft splitting into three parts due to the impact. The incident was triggered by a combination of factors including an unintentional shutdown of supply tank booster pumps during the flight engineer’s manual fuel transfer, leading to oscillations in fuel flow, engine shutdown, and power supply problems. The crew’s failure to comply with crucial sections of the flight manual, particularly regarding emergency procedures, further exacerbated the situation.A Tupolev 154M passenger jet, registration RA-85744, experienced a catastrophic landing accident at Moscow’s Domodedovo Airport (DME) on November 16, 2010. The aircraft sustained significant damage beyond repair, resulting in the deaths of 163 passengers and eight crew members. The flight, commencing from Vnukovo Airport (VKO) at 14:08, involved a domestic flight to Makhachkala Airport (MCX). The plane’s engines were started during a fuel transfer operation, leading to a rapid and unstable fuel supply situation. Approximately 14:16, three engines failed, followed by a period of instability, ultimately causing the aircraft to land hard to the right of the runway. The crew initiated an emergency landing, diverting to Domodedovo Airport. The landing was challenging, with the aircraft splitting into three parts due to the impact. The incident was triggered by a combination of factors including an unintentional shutdown of supply tank booster pumps during the flight engineer’s manual fuel transfer, leading to oscillations in fuel flow, engine shutdown, and power supply problems. The crew’s failure to comply with crucial sections of the flight manual, particularly regarding emergency procedures, further exacerbated the situation.

Description

A Tupolev 154M passenger jet, registration RA-85744, was damaged beyond repair in a landing accident at Moscow’s Domodedovo Airport (DME), Russia. There were 163 passengers and eight crew members on board. Two passengers were killed. Six crew members and 33 passengers were seriously injured. The airplane’s engines were started during the period from 14:00 to 14:02, in preparation for a domestic flight from Moscow’s Vnukovo Airport (VKO) to Makhachkala Airport (MCX). On board were approximately 19.5 tons of fuel. The Tu-154 departed Vnukovo at 14:08. At an altitude of about 5000 m the flight engineer made manual selections to transferring fuel from one tank to another. About 14:16, while climbing through an altitude of 6500 m, there were fluctuations in the supply of fuel for all three engines. About 14:22, at a distance of about 80 km from Moskva-Domodedovo Airport and at an altitude of 9000 m engines no. 1 and 3 flamed out. The crew decided to divert to Domodedovo Airport for an emergency landing. After a period of instability, power on the no. 2 engine was restored and continued to operate until landing. Air traffic control radioed position reports but visual contact with the ground could not be obtained until breaking through the overcast at about 500 feet. The TU-154 landed hard to the right of runway 32R with forces of 3.5g and 5g on a second touchdown. It continued until it struck a small earthen mound beyond the end of the runway, causing it to split into three parts. This was the same aircraft (RA-85744) that was used to transport the Belgium national football team from Brussels to Voronezh on November 16, 2010 for their match against Russia. Probable causes (translated from Russian): The accident with the aircraft Tu-154M RA-85744 was due to erroneous actions of the crew during the flight and while landing with one engine running, which resulted in the emergency landing in instrumental meteorological conditions and the airplane exiting the runway until it struck an earth mount which caused significant destruction of the aircraft, killing and injuring people. The incident was made possible by a combination of the following factors: – unintentional shutdown of supply tank booster pumps when the flight engineer carried out manual fuel transfer procedures during climb, leading to instantaneous oscillation of fuel flow to the engines and their speed, a shut down of the outer engines and power supply problems in the aircraft for 2 minutes 23 seconds due to the failure of three generators; – failure to use all the possibilities by the crew to restore engine power; – failure to comply with the recommendations of Section 5 of the crew “Actions in difficult situations”, subsections 5.13 “Flight of two engines inoperative” and 5.14 “Approach and landing with two engines inoperative” of the Tu-154M Airplane Flight Manual; – lack of leadership and responsibility on the part of the pilot in command, the lack of training of in crew resource management (CRM); – difficult wind conditions at heights, and the difficulties experienced by the crew when piloting on redundant devices, further contributed to the deviation of the aircraft from landing course; – lack of training of the crew as a whole and of each of its members individually to act in emergency situations, according to the Tu-154 M flight manual;

Source of Information

http://www.interfax.ru/society/txt.asp?id=167748, http://www.mak.ru/russian/investigations/2010/tu-154_ra-85744.htmlhttp://www.interfax.ru/society/txt.asp?id=167748, http://www.mak.ru/russian/investigations/2010/tu-154_ra-85744.html

Primary Cause

Unintentional shutdown of supply tank booster pumps during manual fuel transfer, resulting in oscillations of fuel flow and subsequent engine shutdown.Unintentional shutdown of supply tank booster pumps during manual fuel transfer, resulting in oscillations of fuel flow and subsequent engine shutdown.

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