- 10. Crew Interaction Under Poor Teamwork and Incompatibility Among

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instructed the flight engineer to go down to the compartment located directly below the cockpit and check whether the gear was extended (it could be observed through a special viewing window), but the captain forgot to turn on the exterior lighting of the aircraft, so the flight engineer
was unable to see the landing gear. At one point the autopilot disengaged (it takes only a slight nudge of the
control column to disengage it), and the aircraft began to descend. When the altitude reached 900 feet, the controller
noticed this and radioed the crew: "Eastern 401, how are things going?", to which the pilot replied: "Everything's fine, we want to turn around and come back in." At the moment the low-altitude alert sounded, the crew were so absorbed in the light-bulb problem that they did not hear

the alert. The crew of another aircraft reported to air traffic control that they had seen a flash – the
L-1011 had gone down in the swamp of Everglades National Park. After the crash, 77
people survived (99 people died). A surviving maintenance specialist who had been in the cockpit with the captain, first officer, and flight engineer told the investigation commission that right up until nearly the moment of impact the entire crew had been absorbed in solving
the light-bulb problem.
Formal, rote reading of checklists is a fairly common phenomenon.
As an example, consider the actions of the crew of an An-28 of "Vostok" airline, which led to an aviation incident on May 11, 2009. During the takeoff roll the captain noticed a slow buildup of speed and an increasing
takeoff roll distance. At the decision point the captain successfully rejected the takeoff. The aircraft stopped on the runway. The captain determined that the flaps were extended to 40° (whereas according to
the flight manual they should have been at 15°), reported this to air traffic control, taxied off the runway, and shut down the engines (Informational Bulletin..., 2009, No. 6).
During the investigation it was established that, after starting the engines, the crew began checking the systems and equipment. While checking the flight control system, the first officer extended the flaps to 40° and the captain checked the extension and retraction of the spoilers. The first officer then proceeded to check the anti-icing system, the communication and navigation radio equipment, and the flight-navigation instruments, without retracting the flaps back to 0°. During the pre-takeoff checks (while running the checklist) the first officer was distracted by setting the altimeter needles to "0" and, while reading the checklist, skipped item 2, "Flaps." The captain neither required the first officer to complete this item on flap setting to 15°, nor checked that it had been done.
Absence of conscious monitoring of whether an action has actually been performed is another
facet of a formal attitude toward the work being performed. Absence of conscious monitoring of whether an action has actually been performed, combined with the crew members' inability to identify the cause of all four engines shutting down, was the cause of the crash of an An-12 that occurred on
December 12, 1990. The crew was flying the route "Batumi – Kiev": the aircraft was carrying 12 tons of tangerines on board (Slobodyanyuk A.V., 2009). While descending through
4,150 m, approaching the upper boundary of the clouds, the first officer, trying to switch on the wing anti-icing system, mistook the engine fuel shutoff valve switches for the anti-icing system switches, as a result of which the fuel shutoff valves of all engines were
closed. The fuel shutoff valve switches and the wing anti-icing system switches are located on the right panel in close proximity to one another; they are covered by transparent
safety guards and are not safety-wired.

Engine performance changes and the crew members try to understand what is happening.
Airspeed decreases from 450 to 370 km/h, the rate of descent – 15
m/s. First the captain gives the command to feather the propeller of engine No. 1, after which the first officer mistakenly reports that three engines are running, and the captain tries to arrest the drop in engine RPM by moving the throttles forward until the fuel control lever indicator exceeds 42°,
as a result of which the propellers of three engines feather automatically. As A.V. Slobodyanyuk (2009) notes, being in continuous cloud, flying the aircraft on instruments, and suddenly finding themselves in a situation with non-functioning engines, the crew members were
unable to correctly and promptly detect and analyze the cause of the engines stopping.
In this situation the flight engineer switched to manual fuel management and turned on all the boost pumps. The crew made repeated attempts to restart the non-functioning engines – all unsuccessful. The Boryspil airport approach controller
(Ukraine, Boryspil) contacted the crew, switched them to another frequency, and
only at that point did the navigator report to him that they had reached 2,400 m (rate of descent – 20–24 m/s), instead of the assigned 3,000 m, and also reported the failure of all four engines. At an altitude of
1,800 m the flight engineer realized the cause of the engines shutting down: "The valves... the shutoff valves... that's
the problem." The crew attempted to restart engine No. 1, but due to a drop in voltage in the aircraft's electrical system, the engine did not start. The captain decided to make a landing "straight ahead": he gave the order "everyone strap in," and increased speed to
390 km/h (rate of descent – 24 m/s), since he believed the main task was to ensure
sufficient speed for maneuvering after breaking out of the clouds. The aircraft broke out of the clouds at
a height of 120 m. A field was chosen as the landing site: the aircraft's touchdown
on the ground was not hard (ny = 1.6–2.0). During the final part of the landing roll the aircraft, passing under
a power line, struck the embankment of the "Boryspil – Brovary" highway and broke into
two parts: the tail section back to the center wing box remained on one side, while the cockpit and center wing box remained on the other
side of the road. The landing roll covered 740 meters, and there was no fire. The crew members and passengers (17 people in total) survived: there were bruises and fractures of varying severity. After this incident, when briefing his crew, the captain began saying: "All conversations
are to go through the intercom only, so that anyone's foolishness is visible and the crew can work together to prevent similar flight accidents" (Slobodyanyuk A.V., 2009).
Deviation from the habitual algorithm of actions. The crew of an An-124 was preparing to
fly the route "Baikonur – Krasnoyarsk." After taxiing to the takeoff
position, the captain decided not to bother pressing the brake pedals and instead engaged
the parking brake. Having completed the pre-takeoff procedures and received takeoff clearance,

the captain began the takeoff roll, forgetting to release the parking brake. During the takeoff roll
the crew heard the characteristic bangs of the main landing gear tires bursting. After landing at the destination airport, nine tires
and three wheels had to be replaced on the aircraft (Tsibulkin V.A., 2008).
An example of an aviation event connected with errors in the use of navigation equipment is the event involving a Boeing 737-500 on December 1, 2008, during an approach at Domodedovo airport. After course capture by the aircraft's equipment and completion of the fourth turn, up to the start of the descent on final approach, the flight proceeded without any deviations (Informational Bulletin..., 2009, No. 1). According to the flight data readouts and the crew's written statements, after passing an erroneously created
glide-path entry point derived from the DME collocated with the ILS beacon, at a distance of 7.4 nautical
miles from the threshold of runway 14R, the crew began the descent, even though in the standard FMC database the glide-path descent point for ILS RW14R "GS-14R" is located at a distance of 5 nautical miles
from the runway threshold.
The glide-path entry point during an ILS approach is monitored on the flight instruments
(EADI, EHSI) using the glideslope scale indicator. At the moment the descent began on final
approach, the indicator was in the upper position on the glideslope scale, which indicated
that the aircraft had not yet reached the glide-path entry point and therefore glideslope capture by the aircraft's equipment had not occurred.
The crew, assuming that glideslope beacon capture had not occurred due to interference from
an aircraft flying ahead, decided to continue the approach in VOR-DME mode for runway 14R,
engaging VS mode with a vertical speed of 800 ft/min set. At this point the autopilot disconnected due to forward pressure applied on the control column, which caused the vertical speed to increase to 1,000 ft/min. Flying manually, the crew reduced the vertical speed, re-engaged the autopilot, and continued the descent in
VS mode to an altitude of 400 feet, set on the MCP by the captain when switching to the non-precision approach type,
which is an altitude above the decision height (367 feet). At
a distance of 7.4 km and an altitude of 520 feet (158 m), on the controller's instruction, the crew stopped
the descent, leveled the aircraft off, and continued flying at this altitude. After establishing visual contact with the approach lights, the crew reported to the controller that they were ready to land. At a distance of 1.8 km from the runway threshold, glideslope capture by the aircraft's equipment occurred, and the crew continued the approach and landed safely (Informational Bulletin..., 2009, No. 1).
According to the investigation commission's findings, the violations noted above resulted
from:
– non-integrated use of navigation equipment;
– exceeding the rate of descent;
– premature descent;
– failure to go around.
The aviation event involving a Boeing 737-400 of "Transaero" airline, which occurred on March 31, 2009, was connected with entering an incorrect altitude value into the autopilot. While descending from flight level 9,600 m, after flying in a holding pattern at an altitude of
25,804 feet (7,867 m), at 04:48:40 the crew received an instruction from the controller: "TSO
210, descend to 6,600 for now..." The descent was carried out using the autopilot. The crew
acknowledged receipt of this instruction, set the autopilot's target altitude to
21,696 feet (6,600 m), and continued the descent. At 04:50:12 the crew received an instruction to
continue descending to 3,900 m. At 04:50:33, at an altitude of 22,440 feet (6,841 m),
the controller issued the instruction: "TSO 210, revision, descend to 6,600 for now." The crew
acknowledged receipt of this instruction: "Descending to 6,600." However, the first officer, who was flying the aircraft, mistakenly set the autopilot's target altitude to 11,792 feet (3,600 m). The captain did not verify the correctness of the target-altitude setting and did not detect the error in the target-altitude setting in time. At 04:51:40 the crew received information from
the controller: "TSO 210, 6,600 was your instruction." This was followed by the instruction:
"TSO 210, climb to 6,600, you're below, turn right, heading 300." The crew initiated an aggressive climb and turned to heading 300°. Due to the dangerous proximity, the collision-avoidance alert activated. The minimum separation between the aircraft was 130 m at a distance of 8.6 km (Informational Bulletin...,
2009, No. 7).
Perfunctory monitoring of landing gear position after takeoff by the crew of a Tu-154, followed by ill-considered actions to correct the malfunction, led to a dangerous proximity event with a Boeing 767. This serious incident occurred
on April 24, 2009. The crew of a Tu-154M of "UTair" airline was flying the
route "Vnukovo – Samara."
In violation of the requirements of the Tu-154's flight manual, the crew members did not confirm that the
green, and subsequently the red, indicator lights signaling completion of gear retraction had gone out
after the gear legs locked in the retracted position and the doors closed. The climb
was performed with the landing gear extended, and the green indicator lights showing the gear extended
continued to burn, but the crew, despite the fact that it was nighttime, paid no attention to this.
On the flight engineer's command "lever neutral," the first officer moved the landing gear
control lever to the neutral position. The flight engineer, in violation of the flight manual requirements, after crossing
the transition altitude, did not carry out a check of the retracted landing gear position using the checklist during

the established climb, citing the fact that he "sensed that something of ours had not
retracted." According to his account, he repeatedly informed the other crew members of this and tried to determine what the problem was. According to the crew's written statements and interviews,
it was only at an altitude of about 4,000–4,500 m that their attention was drawn to an unusual noise, not characteristic
of a standard flight. The flight engineer suggested that the source of the unusual
noise might be the flaps, since work had been done on the aircraft before departure to replace monorail No. 4 of the right flap (Informational Bulletin..., 2009, No. 8).
At 18:06:13 the crew of the Tu-154 established contact with the "Moscow Approach-7" sector controllers, reporting that they were proceeding to the Cherusti NDB while climbing through flight level 3,900 m. The controller cleared the crew to continue climbing to 4,500 m. At 18:07:29 the crew reported reaching 4,500 m. At 18:08:10 the crew was cleared to climb to 5,100
m. According to the crew's report, 5,100 m was reached at 18:09:47. At 18:10:13 the radar controller instructed the crew to climb to 8,100 m, which was acknowledged at 18:10:19.
At 18:12:31 a Boeing 767-300, which had departed Domodedovo on the route "Moscow – Vladivostok," entered the "Moscow Approach-7" sector at an altitude of 3,900 m. At 18:12:37
the crew of this aircraft was cleared to climb to 6,300 m. The vertical separation between the Tu-154 and the Boeing 767, which were following the same departure corridor, was about 2,400 m (with a longitudinal separation of 6 km).
At 18:15:11 the radar controller cleared the Tu-154 to climb to
9,100 m. The crew carried out the climb to this altitude and the subsequent flight on instruments, with the autopilot engaged in the speed-stabilization and bank-stabilization channels. Thus, on the radar controller's instructions, the Tu-154 and the Boeing 767 were climbing to 9,100 and 7,500 m respectively (on parallel tracks, with the altitude gap between them gradually narrowing from 2,400 to 600 m). At 18:12:
31, as the Tu-154 crossed 6,040 m, the vertical separation between the aircraft was 2,400 m, and at 18:15:28 – 1,370 m.
After passing through 6,000 m, the Boeing 767 began to "catch up" with the Tu-154 due to the
increasing difference in ground speeds. However, the controllers did not inform
the crews of the presence of traffic on a parallel track. After the Boeing 767 crew reported
reaching flight level 6,300 m, the controller, at 18:15:51, instructed them to climb to 7,500 m. At
this time the Tu-154 was passing through 7,350 m (the average vertical "closure" rate
was 5.4 m/s). By 18:17:28 the vertical separation between the aircraft had narrowed to
730 m and continued to decrease. According to the radar controller's account during questioning, he had not anticipated the Boeing 767 "catching up" with the Tu-154 in terms of vertical speed and did not apply speed-management methods as required by his operating procedures. In the controller's

view, there was no need to assign the crews specific ground speeds and vertical speeds,
since the available altitude buffer and the possibility of continuous monitoring allowed him to
change the flight conditions given to the crews at any moment. The controller judged there to be no need to provide traffic information or apply speed-management methods, since he did not know (and could not have known) about the landing-gear situation on the Tu-154 and the fact that it could lead to an uncontrolled descent of the aircraft (Informational Bulletin..., 2009, No. 8).
According to the Tu-154 crew's account, during the climb the flight engineer left the cockpit twice
to try to locate the source of the noise. Upon returning to the cockpit after the second time out (at an altitude of ~7,000 m), he heard noise coming from the pilots' side of the cockpit and suspected that the source
might be the nose landing gear or its doors. On entering the cockpit he confirmed his suspicion – the green indicator lights for the extended position of all landing gear legs were illuminated. The flight altitude was about 7,600 m and the speed was 495 km/h. The flight engineer reported that the gear had failed to
retract to the captain, who, having confirmed the flight engineer's conclusion, decided to
reduce the flight speed. The captain justified this action on the grounds that, according to the flight manual
for the Tu-154M, "The maximum flight speed during extension and retraction of the landing gear under
normal conditions is 400 km/h." The flight engineer reported the need to retract the gear and proposed doing so by disabling the interlock. Because of the crew's insufficient knowledge,
determining the procedure for retracting the gear, which took place in the cockpit, distracted the captain's attention from
the intended actions to reduce speed. At 18:16:58 the captain independently
reduced power on all three running engines, forgetting to disengage the ABSU speed-stabilization
mode.
According to ground-based flight data recorder information, at 18:17:04 the Tu-154 reached an altitude of 7,710 m while the controller's radar display continued to show the climb symbol until
18:17:20; the aircraft then flew level until 18:17:28, after
which it entered a descent that was not controlled by the crew. At 18:17:39 an indication of the aircraft's descent appeared on the controller's radar display, along with a blinking letter "V" ("D"), signaling that
the aircraft had stopped climbing without reaching the assigned altitude of 9,100 m entered into the controller's flight progress strip, and had entered a descent.
At 18:17:44 (according to analysis of the Boeing 767's flight data and the pilots' written statements), the Boeing 767 crew, monitoring the developing situation on TCAS and visually, despite the absence of any information from the controller about a parallel-track aircraft or a possible conflict, upon seeing a descent indication for the parallel-track aircraft on the display,
reduced their rate of climb. The TCAS system did not issue "TA" (traffic advisory) or "RA" (resolution advisory) alerts.

At 18:17:47 the controller instructed the Boeing 767 crew to stop the climb to the assigned flight level of 7,500 m: "TSO 123, hold at 7,200." This instruction was issued before a violation of
the established vertical separation minima occurred, at a point when the vertical separation between the aircraft shown on the controller's radar display was 370 m and the aircraft continued to converge. As the investigation showed, the controller began responding to the emerging conflict situation
45 seconds before the collision-avoidance warning system activated, 8 seconds after the descent indication appeared on the radar display (Informational Bulletin..., 2009, No. 8).
At 18:17:50 the altitude difference between the Tu-154 and the Boeing 767 was
250 m, which is less than the established vertical separation minimum (with a longitudinal separation of about 4
km). The collision-avoidance warning system (SPOS) did not activate on the controller's radar display. At 18:17:53 the controller repeated: "TSO 123, turn right to heading 110° and stop at 7,200." This instruction was received and acknowledged by the Boeing 767 crew. The Boeing 767 crew, however, was not informed by the controller of the reason for the recommended
maneuver, which does not comply with the Federal Aviation Regulations "Conducting Radio Communications in the Airspace of the Russian Federation." The Boeing 767 crew leveled off the aircraft and turned right to a magnetic heading of 110° with a bank of up to 22.5°. During the development of this critical situation, TCAS did not activate on the Boeing 767 – neither in "TA" mode nor in "RA" mode.
At 18:18:05 the altitude difference between the Tu-154 and the Boeing 767 was 70 m
with a lateral separation of about 4 km, which meets the definition of a dangerous proximity event, yet neither the radar controller's SPOS nor the Boeing 767's TCAS activated. The TCAS selector on the Tu-154 was set to "AC" transponder mode for this flight and
was operating with altitude-reporting only (according to a technical log entry, the aircraft was
permitted to fly over the territory of Russia with an inoperative TCAS until May 1, 2009, because the last digit of the four-digit flight number code could not be entered on the TCAS control panel).
The Tu-154 crew tried to sort out the situation without monitoring the flight's dynamics. At 18:18:10 the aircraft were at the same altitude, 7,280 m. The Tu-154 crew, not
responding to the controller's calls (since at that time they had discovered the aircraft was descending at a rate of up to 17.5 m/s), increased engine power and began pulling the aircraft out of the descent, losing more than 50 km/h of speed over 35 seconds. The aircraft then continued for
25 seconds on diverging headings with an altitude difference of 30–60 m and a separation of about
4 km, without SPOS or TCAS activating.
To clarify the situation aboard the Tu-154, at 18:18:16 the controller told
the crew: "UTA 437, your transponder shows 7,200 m," and, to confirm the accuracy of the altitude
readout given by the transponder, asked the crew for their actual flight altitude.

At 18:18:25 the Tu-154 crew replied: "That's correct, 7,200 m, we have a small problem
here." At 18:18:28 the controller instructed the Tu-154 crew to turn left to heading
50°, and also informed them: "Traffic on your right, behind you." 7 seconds after the Tu-154 crew reported turning to heading 50°, the Boeing 767 crew reported turning to heading 110° and maintaining an altitude of 7,200 m.
According to flight data recorder information, the SPOS activation occurred only
36 seconds after the violation of the vertical separation minimum began. At the radar
controller's workstation, the SPOS activation was not displayed. As the Tu-154 crew carried out the climb and established a safe separation between the conflicting aircraft, at 18:18:56 the SPOS activation ceased. At 18:19:17 the aircraft
regained the established lateral separation, and subsequently vertical separation as well. Throughout the entire period of resolving the conflict, the Tu-154 was flying with
the landing gear extended. The gear was retracted at an altitude of 7,600 m at a speed of 445 km/h.
After landing at Kurumoch airport, the Tu-154 crew made no entries in the aircraft log regarding any technical issues, made no voluntary report of what had happened during the flight, and gave the flight squadron commander false and incomplete information about the events of this flight!
As the investigation commission notes, the aviation incident, expressed in a
dangerous proximity event between the Tu-154 and Boeing 767, was made possible by a combination of
the following factors (Informational Bulletin..., 2009, No. 8):
– gaps in the Tu-154 crew members' knowledge of the provisions of the "Instructions on Crew Interaction and Operating Procedures
for the Tu-154M Crew" and the Tu-154M flight manual regarding matters connected with performing
takeoff and gear retraction;
– ill-considered actions by the Tu-154 crew in attempting to correct violations
committed during takeoff;
– unintentional and uncontrolled descent of the Tu-154;
– the Tu-154 captain's failure to promptly report to air traffic control that an
abnormal situation had arisen aboard the aircraft.
Errors in the use of navigation equipment, combined with disregard for data communicated to the crew by air traffic controllers, led to a Yak-40 deviating from
its route while flying "Khabarovsk – Nikolaevsk-on-Amur" on January 4, 2001. The maximum deviation from the route centerline was 33 km, and from the boundary of the airway –
23 km.
Prior to passing the mandatory reporting point (MRP) Tambo, the flight proceeded strictly along the route with
a magnetic heading of 46°. After passing MRP Tambo the crew mistakenly applied an additional

wind correction and continued on heading 57°, drifting to the northeast. On
approaching MRP Erben the crew requested their position from the Komsomolsk-on-Amur area radar controller, received a correction to turn left, and then changed heading
first to 42°, and then to 34°, without calculating a correction to regain the assigned track,
relying solely on the controller's information that the aircraft was on the right edge of the airway. After being handed off to the Nikolaevsk-on-Amur area control center controller, the crew received information from him about their position (bearing =
204°, distance = 180 km), without determining their position through integrated use of the onboard
radio navigation equipment. In doing so, no instruction was given to apply a left correction to regain the route, although a report that this had been done followed. After the controller's message "...you are 10 km to the right of the route,"
the crew replied: "...according to our equipment we're right on track, on your beacon..." Subsequently
the crew took no active measures to regain the assigned track and made only a passive approach
to the outer marker beacon of Nikolaevsk-on-Amur airport. One cannot help but be struck
by the fact that after completing the flight, the captain conducted a crew debrief
without a full analysis, did not note the aircraft's deviation beyond the boundaries of
the airway, and did not report the deviation to the flight unit's management. The violation was
identified on January 9, 2001, when the flight squadron commander analyzed the flight data recorder data. The incident occurred due to non-integrated use of radio navigation
equipment, errors by the crew in calculating magnetic heading, and unwarranted distrust by the crew of the air traffic controllers.
What stands out is the crew members' overconfidence and complete lack of any self-criticism regarding their own actions. Note that in some cases distrust of air traffic controllers is instilled by instructor pilots who, while training
cadet pilots, allow themselves remarks such as: "Go on and show those controllers," thereby
"driving a wedge" between pilots and controllers and fostering an unspoken rivalry between them. The only comforting thing in this regard is that such instructors are few and far between.
Clear gaps in crew members' professional training, combined with a conviction to the contrary, have led to more than one aviation event. As an illustration, one can cite the crash of a Boeing 737-200 near Manas airport on 24
August 2008. The aircraft's crew was flying the route "Bishkek – Tehran." After
climbing to about 3,000 m, the crew reported to air traffic control problems with cabin pressurization and decided to return to the departure airport. During a maneuver to
descend for a visual approach, the aircraft struck the ground, broke apart, and caught fire
(26 people were seriously injured (5 crew members and 21 passengers), and 64
passengers died).
As the investigation commission established (Informational Bulletin..., 2009, No. 6), the crash
was made possible by a combination of a number of unfavorable factors:
– the crew's failure to comply with the requirements of the Instructions on Crew Interaction and Operating Procedures in flight;
– the crew's failure to follow the rules for a visual approach regarding maintaining constant visual contact with the runway and its landmarks, and the required actions
if visual contact with the runway is lost;
– the crew's loss of altitude control while performing a maneuver for a repeat
approach (which was undertaken because of the captain's incorrect assessment of the aircraft's position relative to the calculated descent path when deciding to fly a straight-in visual approach);
– the crew's failure to carry out the prescribed actions when the terrain awareness and warning system (TAWS) activated.
A second example of an aviation event in which gaps in professional training can be seen is the incident with a Boeing 737-500 of "Aeroflot-Don" airline at Tel Aviv airport. During a straight-in ILS approach
at Tel Aviv in automatic mode, after full capture of the localizer and glideslope beacons and receiving landing clearance, while descending on the glideslope (at an altitude of 2,200 feet and
a distance of 10 miles from the DME), according to the captain, the flight directors disappeared from both pilots' flight instruments, as did the ILS indication on the standby attitude indicator.
The crew reported that visual contact with the runway had been established and
the approach was continued, but due to the blinding effect of the rising sun the crew allowed a premature descent to an altitude of 1,400 feet at a distance of 8 miles from the DME (Informational Bulletin..., 2009, No. 7).
On the tower controller's instruction, the crew executed a go-around. According to the crew's statement, during the repeat approach the readings of all the flight instruments
returned to normal. The landing was completed safely.
On the parking stand, the crew was questioned by a Tel Aviv airport inspector, who noted the following in his report:
– the crew could not explain the cause of the altitude deviation and/or the reason for the loss
of the ILS indications;
– the crew demonstrated a lack of knowledge of DME readings as part of the "ILS – DME" procedure (no
altitude/distance checks had been performed);
– the ILS system was checked and it was concluded that the ILS was operating without any
malfunctions.
The approach was flown during the day in normal weather conditions using the ILS system
in automatic mode under instrument flight rules. As the analysis of flight data recorder information shows,
58 seconds after the aircraft's onboard equipment fully captured the localizer and glideslope signals from the ground-based landing system, the signals
of the ground ILS localizer/glideslope system dropped out. 2 seconds later the crew switched to combined
manual control of bank and pitch. Over 1 min 11 s (from 15:47 to 16:58) the aircraft descended from
3,488 feet to 1,144 feet (heading during this varied from 119.9 to 138.2° and back); the rate
of descent was 33 ft/s. The aircraft descended below the equal-signal zone of the glideslope
(Informational Bulletin..., 2009, No. 7).
The investigation commission suggested that during this period, because of the blinding
effect of the rising sun, the crew lost the visual contact with the runway they had previously established, which, combined with the loss of the ILS signals, led to
inadequate crew actions. Nevertheless, after re-establishing visual contact with the runway, the crew continued the approach. Subsequently, on the controller's instruction, the crew discontinued
the approach and went around. During the go-around and the subsequent repeat
approach in automatic mode, there were no deviations in the operation of the flight instruments. The ground ILS localizer/glideslope system was operating normally.
The aircraft's distance readings from the distance measuring equipment (DME) were
consistent, according to the readout of the analog "DME distance" parameter.
The malfunction in the ground ILS localizer/glideslope system at Tel Aviv airport most
likely occurred due to a brief loss of electrical power. The crew did not switch to flying using the backup VOR/DME approach system.
According to the investigation commission's findings (Informational Bulletin..., 2009, No. 7), the cause of the incident was an impermissible altitude deviation of the aircraft from the assigned descent path during the approach, caused by such factors as:
– the crew's failure to comply with the requirements of clause 7.6.15 of NPP GA-85 regarding the mandatory discontinuation of the descent and a go-around when the aircraft's spatial position relative to the glideslope does not ensure a safe completion of the flight;
– the captain's failure to observe flight procedures required by clauses 2.1.1 and
2.12 of Table 1, "Flight Quality Assessment Standards," of Appendix 1 to the PPLS Boeing 737-
300/400/500, regarding untimely actions that affected the execution of flight procedures,
and lack of monitoring of the first officer's actions, which required his intervention in
control of the aircraft;
– incorrect execution of the procedure, which resulted in a prohibition on continuing the
approach (item 2 of Table 1, "Flight Quality Assessment Standards," of Appendix 1 to the PPLS Boeing 737-300/400/500);
– deviation beyond the scale of the flight-navigation display system during manual (control-wheel) flying in the localizer/glideslope zone, descending below the boundary of the equal-signal zone of the ILS glideslope beacon without use of the flight-navigation display system (item 3, "Assessment of Piloting Technique," Table 2,
item 1.6.2.3);
– the crew's violation of clause 5.2.4 of NPP GA-85 regarding the transition from instrument flight rules to visual flight rules without coordination with air traffic control;
– the crew's lack of knowledge of DME readings as part of the "ILS – DME" procedure (no
altitude-versus-distance check was performed);
– the captain's failure to comply with the requirements of clause 5.2.6 of NPP GA-85 regarding maintaining the
approach procedure, the assigned flight path, and flight parameters.
A third example of an aviation event connected with gaps in professional
training is the crash of an Il-76TD of "Azov-Avia" airline (Ukraine),
which occurred near Baku (Bina) airport during the day on March 4, 2004. The aircraft's crew
included a captain, first officer, navigator, flight engineer, radio operator, and load master. Also on board the aircraft was an aviation engineering service (AES) specialist
– needed to service the aircraft at the landing airports. The crew was flying a cargo flight on the route "Boryspil (Ukraine) – Ankara (Turkey) – Baku (Azerbaijan) – Kabul (Afghanistan)." The crew did not carry out preliminary preparation for the route at Boryspil
airport (Information..., 2004).
On the flight from Boryspil to Ankara there was no cargo on board the aircraft. At Ankara 39,980 kg were loaded onboard (for delivery to Kabul). At Baku airport the aircraft
was refueled with 47 tons of fuel. The actual takeoff weight before departure was 189 tons, and the center of gravity was 29.3%, which did not exceed operational limits. During
the layover at Baku airport (8 hours), the crew decided to rest on the aircraft rather than at a
hotel. By the time of departure the crew's duty time was 17 hours. The crew members did not undergo a medical check before departure. During flight preparation the RI-65 voice annunciator was not switched off, and the AES specialist was in the navigator's station.
During taxiing the radio operator read out the item "wing high-lift devices," which is not called for in the checklist. The flight engineer responded, "Extending, 14/30,"
after which the phrase "Additional" is heard on the CVR at 61 minutes. At the pre-takeoff checklist stage, the item
for checking the wing high-lift devices was not read out. According to the explanations

given by the captain and first officer, they did not monitor the actual position of the slats and
flaps and did not notice the warning lights indicating the position of the wing high-lift devices before takeoff!
The takeoff was performed with the wing high-lift devices retracted and the stabilizer set to the takeoff position of –4° (corresponding to the actual takeoff
weight, center of gravity, and flaps extended to 30°). Elevator deflection to raise the nose gear began at a speed of 210 km/h. By the time the speed reached 265 km/h (the rotation speed for this aircraft at a takeoff weight of 190 tons, with flaps and slats extended
to 30 and 14° respectively) the pitch angle had reached 8°, the angle of attack – 9°, yet the aircraft did not lift off the runway. At a speed of 290 km/h, under the moment produced by the stabilizer set to the takeoff position, unbalanced by the retracted flaps, the aircraft's angle of attack reached 14.5°, triggering the critical angle-of-attack alert. At a distance of 1,750 m from the start of the takeoff roll, at a pitch angle of 19.4°,
the aircraft, moving on its main landing gear, began periodically striking the tail section of
the fuselage against the runway. At a distance of 1,820 m, a speed of 300 km/h, and an angle of attack of 19.4°, the aircraft lifted off the runway and began to stall, rolling to the left. The controller, noticing the unusually raised nose of the aircraft, sparks from the fuselage striking the concrete runway surface, and the aircraft's bank, instructed the crew to abort the takeoff, to which there was no response. At a distance of 1,950 m from the start of the takeoff, the aircraft began striking the runway surface with its left
wingtip. At a distance of 2,200 m the flight data recorder registered extension of the
flaps and slats. Apparently, extension of the high-lift devices was initiated by the flight engineer, who (having noticed his own mistake) decided to correct the situation without informing the captain
(at the crash site it was established that the flaps and slats were extended to 16 and
20° respectively). At a distance of 2,500 m from the start of the takeoff, the throttles of all four engines were set to idle, and 3 seconds later – to the "engine shutdown" position. The actions of
moving the throttles to idle, followed by moving them to the "engine
shutdown" position, could likewise have been performed by the flight engineer without a command or without informing the captain of the decision made. At the same time the captain called "Takeoff power!" three times, but the engines had already been shut down. The flight data recorder subsequently registered full nose-up deflection of the elevator
and movement of all throttles to the takeoff position. The full elevator deflection caused the aircraft to lift off the ground. The aircraft, after flying 490 meters, struck
the ground. The navigator and the AES specialist who was in the navigator's station were killed instantly, and the flight engineer died of his injuries while being taken to the hospital. The others sustained injuries
of varying severity.

As can be seen from the description, the entire crew had serious gaps in their professional training. The first officer had the least experience flying the Il-76: flight time on the Il-76 – 402
h, total flight time – 609 h. The airline's flight service management took a superficial approach to
reviewing the documents characterizing the crew members' professional training.
The first officer graduated from the Kirovohrad State Flight Academy of Ukraine in 2001 and obtained a rating to fly the An-24 and An-26 aircraft. For some time he
flew these types. The academy does not provide initial training of cadets on the Il-76 aircraft. During the cadets' academy training, as part of their military training course they were introduced to the
Il-76 military transport aircraft, but this program does not correspond to the program for
retraining flight personnel on the Il-76 and cannot be counted as such retraining.
No certificate of retraining and clearance for line training on the
Il-76 is issued upon graduation from the academy. Familiarization with the Il-76 during military training exercises is not grounds
for completing the advanced training courses required of flight personnel operating
this type of aircraft. This unlawful completion of the courses allowed the first officer, without
having proper training, to pass the flight retraining program and line training as first officer on the Il-76 (Information..., 2004).
In Chapter 5 we discussed the fact that in critical situations, identifying the causes of what is happening requires the use of decision-tree tables that must already be present in the mind before such situations develop. The aircraft's captain had no such mental constructs – he was unable to understand the cause of the slow acceleration, whereas
if he had been familiar with similar situations and the characteristic behavior of the aircraft
in them, the situation described above would not have posed any difficulty for him. There is no shortage of literature dealing with aircraft behavior with the flaps retracted. In particular, this problem was addressed by D. Mikhailov in a 1972 paper. The author notes that when the flaps are
retracted and the pilot takes off using the technique specified for takeoff with flaps extended,
the nose wheel lifts off at a lower than required speed, requiring greater control forces and increased elevator deflection. The pilot may fail to give this due
attention, believing that the increased forces and control deflections are caused by incorrect trim settings on the elevator or by a forward center of gravity. Speed continues to increase,
however, and when it reaches the rotation speed recommended for the aircraft with flaps extended,
the aircraft does not lift off. The pilot pulls the control column toward himself and forces the aircraft to lift off
the runway. For the lift force to become equal to the aircraft's weight, the pilot brings the aircraft to angles of attack close to critical. When the control column is pulled back the aircraft
readily moves to these angles of attack, but its drag increases sharply and may become
equal to the thrust of the engines. The airspeed practically stops increasing. If at this

point an attempt is made to put the aircraft into a climb, it will lose speed and may
stall.
Excessive workload on one of the crew members increases the
likelihood of them making mistakes. In non-standard flight situations, full responsibility
falls on the captain. This is entirely logical and justified. In such situations the captain
becomes overloaded, and as a result it is in some cases necessary for the captain to
hand over control of the aircraft to the first officer, while retaining the decision-making function
himself. This approach also has another purpose: in stressful situations crew members show a greater dependence on the captain and a tendency toward greater obedience, so that the captain's transfer of control to the first officer heightens vigilance and
responsibility among the crew members and makes their thinking more critical. It should be noted, however, that
this increased critical thinking on the part of the other crew members should not, in turn, degenerate into an uncontrolled dispute in which there is no clear division of roles and which
may result in a spontaneous, unjustified decision.
Let us examine the next cause of poor teamwork – crew members' attention being outside the cockpit. The circumstances of the An-2 accident described below
illustrate the phenomenon of crew members' attention being outside the cockpit – on this day two flights had been scheduled, and in the pilots' minds these had to be completed. In their pursuit of
completing the plan held in their minds for the entire working day, they
found themselves outside real time – everything was geared toward managing to complete the flights planned for the day. In the process, emotional tension arises, caused by haste and the resulting departure from standard operating procedures.
So, an accident without loss of life involving an An-2 occurred on 6
November 2002 (Informational Bulletin..., 2002, No. 12). On board the aircraft were an instructor pilot, a trainee captain, and 13 passengers. Immediately before departure the crew's work
took place under severe time pressure. Departure was originally planned for 4:30
but was postponed twice because passengers had not arrived at Sovetsky airport. Postponing the departure a third time, as stated in the instructor pilot's written explanation, was extremely undesirable because of the need to complete two flights during the daylight hours of that day: at the customer's request – the route "Sovetsky – Svetly – Sovetsky," and then – "Sovetsky – Serov"
for a crew change.
When the crew members took their seats in the cockpit at 5:06, the instructor pilot drew the trainee captain's attention to the time pressure. Starting and warming up the engine took the crew about 6–7 minutes. Under time pressure the crew decided not to

perform the engine run-up check at the parking stand, as called for by the "Instructions
on Crew Interaction and Operating Procedures for the An-2," and instead to perform this operation just before takeoff, at the takeoff position. The crew's remaining time reserve
for taxiing and takeoff within the permitted window (up to 5:30) at this stage was about 13 minutes. At 5:16 the crew began taxiing to the holding point.
During taxiing the crew encountered difficulties because the
surface of the aircraft parking area and taxiways had sections with a low friction coefficient due to snow and ice on them. The instructor pilot had to leave
his seat and get out of the aircraft several times to help with turns. This took about 8 minutes, as a result of which the time reserve remaining for taking off within the permitted window was, at the holding point, less than 5 minutes. At 5:25 the crew reported to the ground movement controller: "Partner, 70140 at the holding point, request takeoff clearance."
Clearance was given, and at 5:25 the crew reported: "140, entering the runway."
According to the pilots' written statements, after entering the runway the trainee captain
began the engine run-up check. However, as the engine was brought up from
"idle" to rated power, the aircraft began to skid sideways on the runway. To stop the aircraft's movement, the trainee captain set the throttle to "idle."
The trainee captain then, by moving the throttle, set the engine RPM to 2,000
and checked the operation of the magnetos and spark plugs. He then checked
the propeller pitch control mechanism, for which he set the engine RPM to 1,900
and, without changing the throttle position, used the propeller control lever to move the propeller from fine to coarse pitch. At the moment when the RPM dropped to 1,500 (that is,
the propeller had gone to coarse pitch), the aircraft skidded sideways on the
runway a second time. To stop the aircraft's skid, the trainee captain moved the throttle to "idle," and once the skidding stopped he moved the propeller control lever forward. However, neither
the instructor pilot nor the trainee captain checked the engine RPM or
manifold pressure after these operations. The crew decided against continuing the engine run-up check and decided to proceed with the takeoff (Informational Bulletin..., 2002, No. 12).
The crew chose to take off without flaps, using takeoff power and with the carburetor air intake heating switched on. This choice, according to the
pilots, was due to the presence of a 4 m/s crosswind, the sufficient length of the runway
in the direction of the takeoff roll (about 1,200 m), and the actual outside air temperature.
At 5:27 the crew reported to the ground movement controller: "Partner, 70140 ready for takeoff." Thus,
about a minute and a half elapsed from the moment of entering the runway to the moment takeoff clearance was requested, which allows one to say that the required operations

that the crew was supposed to carry out at the holding point, as well as the additional operations connected with the engine run-up check, were carried out under time pressure, which
is also confirmed by the pilots' written statements.
Having received takeoff clearance at 5:27, the trainee captain released the brakes and, as the aircraft began
moving, advanced the throttle fully forward. Right at the start of the takeoff roll the aircraft began to turn spontaneously to the left (into the wind), which forced the trainee captain and the instructor pilot to concentrate on countering the turning of the aircraft and distracted their attention from
monitoring the engine parameters. The instructor pilot, according to his written statement, also
switched all his attention to the aircraft's takeoff roll and remained ready to assist the trainee captain if the latter failed to handle the crosswind. As a result, in
violation of the requirements of the "Instructions on Crew Interaction and Operating Procedures for the
An-2," he did not monitor the engine parameters (Informational Bulletin..., 2002, No. 12).
During the takeoff roll, both the trainee captain and the instructor pilot noticed a very
weak buildup of speed. However, the pilots interpreted this feature of the takeoff roll as a consequence of taking off at maximum takeoff weight. Because of the unusually long takeoff roll, the
instructor pilot, according to his own account, felt an urge to abort the takeoff, but at that moment
the tailwheel lifted off. Having assessed that the remaining runway length was sufficient
to complete the takeoff, the instructor pilot decided not to abort. Some time later the aircraft became airborne, after which the trainee captain leveled off, and then began climbing.
The aircraft's takeoff was observed from the control tower by the tower controller and the flight operations supervisor.
According to their written statements, during the takeoff roll the aircraft covered a distance of about 800 m, and after liftoff climbed to a height of 3–5 m and continued flying without any further climb. During the flight, unusual aircraft motions were observed – noticeable oscillations about the
longitudinal and lateral axes. After passing the runway threshold (at a distance of 200–300 m), the aircraft sank, accompanied by a left bank. During the sinking, the aircraft descended nearly to the ground, as evidenced by the swirl of snow raised during the sinking. At the moment the aircraft sank, the tower controller sounded the "Alert" signal.
During the sinking the instructor pilot took over control, informing
the trainee captain of this. He did not, however, monitor the instrument readings, since he attributed the aircraft's sinking to possible erroneous actions by the trainee captain. To maintain speed, the instructor pilot pushed the control column forward and put
the aircraft into level flight. While holding level flight the instructor pilot had to turn left several times to avoid colliding with individual tall trees. As the aircraft approached a wooded area, the instructor pilot put the aircraft into a climb.

As soon as the aircraft came back into view of the flight operations supervisor, the "Alert" signal
was cancelled. After climbing to about 20 meters, the aircraft, banked to the left, again began to descend and disappeared from view over low scrub outside the airport boundary, after which the tower controller
sounded the "Alert" signal again.
According to the instructor pilot's account, after climbing 15–20 m the aircraft sank a second time. As the pilots testified, both instances of sinking were preceded by
vibrations of the aircraft structure. These structural vibrations were transmitted
to the flight controls and to the engine cowling parts, which the pilots mistakenly interpreted
as engine roughness. When the control column was pushed forward (as speed built up),
the vibrations stopped.
Because of the approaching tall trees, the instructor pilot decided to make a forced landing in the low scrub, informing the trainee captain of this.
The aircraft landed in an area overgrown with mixed low scrub. The crew and passengers
were not injured. The aircraft sustained substantial damage.
The results of examining the aircraft and its propeller after the accident, the assessment of the
engine's technical condition, the analysis of the written statements, an experimental check of the propeller control system's operation when the engine is shut down, and special flights performed at the base of the "Second Sverdlovsk Aviation Enterprise" allowed
the investigation commission to conclude that the aircraft's takeoff was performed with the propeller blades in a position close to coarse pitch. This blade position led
to a significant reduction in propeller thrust and, as a result, to a loss of speed and
sinking of the aircraft when it was put into a climb after takeoff. The takeoff of the aircraft with the propeller
set to an increased pitch was evidently a consequence of the haste that accompanied the crew's performance of all the operations at the holding point. Under this time pressure,
after abruptly halting the check of the propeller pitch control mechanism, caused by the aircraft's spontaneous skidding on the runway, the operation of returning the propeller control lever from the "Coarse pitch" position to the
"Fine pitch" position was probably omitted by the trainee captain (Informational Bulletin..., 2002,
No. 12).
A second example of how detrimental it can be to a flight's outcome for crew members' attention to be outside the cockpit is an accident involving a twin-engine
jet aircraft. The crew had problems with the aircraft's equipment, and the captain, acting contrary to operating procedure, tried to complete the landing no matter what
– because of an important meeting scheduled for him that was to seriously change his

life (a move to another airline). The investigation commission's report makes no mention whatsoever of this
dangerous flight factor, and consequently that commission's work was largely wasted. Aviation specialists were once again deprived of information and, as a result, of the
ability to counter dangerous flight factors.
Emotional tension caused by the unusualness of a situation is the next
cause of poor teamwork within a crew. If something unusual occurs during the execution of a given sequence of
actions, conditions arise for actions to be omitted. This is what happened to an aircraft captain during takeoff: after the nose gear lifted off the runway surface, it came back down and struck the runway, something the pilot had never encountered before and which was completely unexpected for him. After the nose gear lifted a second time and the subsequent takeoff, the captain omitted the gear-retraction operation.
As a second example, let us cite the circumstances of an accident without loss of life involving a Be-103 amphibious aircraft, which occurred on July 27, 2006, near Khabarovsk airport. The purpose of the flight was to transport the general director of "Komsomolsk-on-Amur Y.A. Gagarin Aviation Production Association" airline, which owned the aircraft, from Komsomolsk-on-Amur to Khabarovsk (and back). In total there were three people on board the aircraft: the pilot, a maintenance specialist, and a passenger. As the aircraft lifted off the runway
the cockpit entry hatch cover opened spontaneously. The pilot continued the takeoff while making attempts to close the hatch cover manually. To reach the hatch cover's handle (grip), which he could not initially reach, the pilot began
undoing his seatbelt. At this time the controls were being held by the accompanying passenger. Because the captain's attention was focused on closing the hatch cover, he
omitted the gear-retraction operation, which was to be performed at an altitude of 15 m. During
the attempts to close the hatch cover, the cover was torn off by the airstream.
Separating from the canopy, it struck the rotating propeller of the aircraft's right engine and destroyed it.
The pilot feathered the propeller of the right engine. All the other actions
required by the flight manual in the event of an engine failure during takeoff, after shutting it down,
were not carried out. The resulting asymmetry of engine thrust caused the aircraft to turn and
bank to the right. Turning to the right, the aircraft descended toward garden plots located beyond the airport boundary. As a result of colliding with trees, both wing panels separated from the fuselage. The fuselage fell onto the slope of a shallow
ravine, slid down, and struck a tree, coming to rest there. As a result of the fire
that broke out on the ground, most of the aircraft structure was destroyed (Informational Bulletin...,
2007, No. 3).

Omission of one or another action within a given sequence can occur for the
following reasons:
1) due to amnesia occurring during the period of an affective state: an unexpected event naturally triggers an affective state due to the release of a huge quantity of biologically
active substances (see Fig. 8.1);
2) due to mental activity being directed toward finding a solution to an unexpectedly
arisen question at the expense of carrying out the standard sequence of actions
(from this it naturally follows that the more unplanned, unexpected situations a pilot is prepared for (whereby a specific algorithm of actions is