11 DELIBERATE VIOLATIONS OF REGULATORY DOCUMENTS IN AVIATION

Lecture

Among aviation events associated with the human factor, roughly half consist of events caused by deliberate violations of regulatory documents.
It would seem that by strictly observing the requirements of regulatory documents, one could
reduce the share of human-factor-related aviation events from the current
80–60% down to 40–30%. But is this problem really as simple as it may seem
at first glance? In fact, if it really were that simple, we would have
completely different figures. So what stands in the way of solving this problem? The problem, it must
be said, has many components, and within it at least five aspects can be distinguished (Evstigneev
D.A., 2010, b).
The first aspect is the policy of airline management, with whose consent rules are established that differ completely from those enshrined in regulatory documents. Two aviation events serve as vivid illustrations of this. The first is the crash of a McDonnell Douglas aircraft of "Alaska Airlines" on 31 January 2000,
the second is the accident of an Il-62 aircraft of the "Tretyakovo" airline on 22 October 2002.
The crash of the McDonnell Douglas aircraft, which was flying the route "Puerto
Vallarta (Mexico) – San Francisco (USA)," was linked to a malfunction in the movable-stabilizer control system. The crew decided to make an emergency landing at Los Angeles airport, but lost control, after which the aircraft plunged into the waters of the Pacific
Ocean. Everyone on board was killed. As was established during the crash investigation, in flight the mechanism of the movable stabilizer – a screw jack driven by an electric motor – failed. The nut,
in which the half-meter-long steel drive screw of the stabilizer rotated, disengaged from it and was found away from the drive screw. The threads on it turned out to be completely
worn away, to the point that metal shavings had formed! As a result of the investigation conducted, it was found
that a number of violations had been committed in the aircraft's maintenance procedures, which
were the cause of the accelerated thread wear, and these violations themselves were provoked by the policy of the airline, which was experiencing financial difficulties, and with the aim of saving money the management prohibited proper maintenance
of the aircraft – the airline repeatedly increased the intervals between aircraft maintenance and did not follow the recommendations of the technical personnel who had discov-

ered the malfunctions. It became known that more than a year before the crash, one of the
technicians had pointed out that the screw jack needed to be replaced, but his instructions were not
carried out. After inspecting the fleet of "Alaska Airlines" (after the crash),
it was found that six other aircraft had the very same problem with the screw jack.
The accident of the Il-62 aircraft occurred during a night landing, in simple weather conditions, at Bishkek (Manas) airport. On board were 7 crew members (the aircraft commander – the general director of "Tretyakovo," the co-pilot, the navigator, the flight engineer,
the radio operator, the systems operator, the flight attendant) and 2 specialists of the engineering-aviation service of
"Tretyakovo." During the landing the aircraft ran off the end of the artificial runway and collided with the airfield's concrete fence, after which it burned down completely. Everyone on board sustained injuries of varying severity.
The investigation established (Directive…, 2003) that:
- the aft center of gravity (38% MAC) exceeded the operational limits set by the Flight Operations Manual, resulting in the aircraft porpoising;
- the runway threshold (4,200 ´ 55 m) was crossed at a height of 30 m at
a speed of 293 km/h;
- the reverser buckets were deployed and the reversers engaged at a height significantly exceeding that recommended by the Flight Operations Manual: the reverser buckets of engines 1 and 4 were deployed at a height of 22 m (instead of the required 5–8 m), and the reversers of engines 1 and 4 were engaged at a height of 20 m. Simultaneously with the opening of the reverser buckets, the pitch angle began to increase (~7°) – and this despite the pilot deflecting the elevator to a 13° nose-down position;
- there was an incorrect decision by the aircraft commander to go around, and an attempt to carry it out with engines 2 and 3 shut down;
- unsatisfactory crew coordination during the landing.
These factors resulted mainly from the low level of professional
training of the aircraft commander Kh.A.S. (who was also the general director of the "Tretyakovo" air transport company). The only ability that Kh.A.S. possessed
was the ability to build relationships solely for personal gain, and the numerous diplomas and certificates obtained throughout his professional career confirm this. After graduating in 1974 from the Irkutsk Aviation School,
Kh.A.S. worked as an aviation technician; in 1979 he retrained on the Mi-8 helicopter at the Kremenchug
Flight School, after which he logged around 7,000 hours as a flight engineer on the Mi-8 helicopter.
After finishing his work as a helicopter flight engineer, he did not fly for about 10 years. In April
2000 he graduated from the Serpukhov Aviation Training Center and received a

private pilot certificate for the An-2 aircraft, without a class rating. After completing correspondence training at the Kaluga Aviation Flight-Technical School, Kh.A.S. received a diploma with the qualification
"pilot," without a class rating (he did not undergo flight practice at this school). His flight training credited him with flight hours as a sport pilot at the second Moscow aeroclub on the V-35 aircraft and at the Serpukhov Civil Aviation Training Center – on the An-2 aircraft. In his flight logbook
there was an entry by the chief of staff of the "Tretyakovo" air transport company assigning him
3rd class status, referencing a protocol that was not found in his flight file. When being checked out
as second pilot on the Il-18 aircraft, Kh.A.S. did not undergo airfield training. Despite this, by order of the acting general director of the "Tretyakovo" air transport company dated 28 July 2000, Kh.A.S. was cleared to perform takeoffs and
landings. The authorization from the Flight Standards Department of the Federal Air Transport Service of Russia for his checkout as second pilot on the
Il-18 is dated 4 August 2000. Before being checked out as commander of the Il-18 (taking
into account his previous flight time and aircraft class – An-2, V-35), Kh.A.S. was required to log 1,500 hours as second pilot, but his actual flight time at the start of the checkout process was only
444 hours 35 minutes.
Clearance to fly international routes was issued as commander-in-training at a time when he was flying as second pilot on the Il-18 aircraft. At the same time,
the order appointing him to the position of Il-18 aircraft commander was issued on 13 April 2001.
From 10 June 2001 to 5 August 2002, Kh.A.S. did not fly the Il-18 aircraft at all. Having had no approaches in complex weather conditions, on 5 August 2002 he obtained the right to conduct flights at the minimum "60 ´ 800 m" (the entry in the flight logbook was made by the deputy commander of the flight squadron of the "Tretyakovo" airline). According to the requirements of ROLR
GA-87 and PPLS GA-92, he could only have been assigned a minimum no better than the initial one for this
type – "80 ´ 1,000 m."
From 14 March 2002 to 20 April 2002, Kh.A.S. retrained on the Il-62 aircraft under the
aircraft-commander program. From 9 February 2002 until the moment of the accident, Kh.A.S.'s flight records contained no information about him having completed, as
commander, the quarterly approaches in complex weather conditions and approaches using non-precision systems, either on the Il-18 or on the Il-62. Pilot Kh.A.S.'s upgrade to second
class was carried out on 13 July 2001, ahead of schedule, at the request of the flight director of the "Tretyakovo" airline with the consent of the management of the State Civil Aviation Service of the Ministry of Transport of Russia. First class of line pilot was awarded to Kh.A.S. by decision of the Higher Qualification Commission of the State Civil Aviation Service of the Ministry of Transport of Russia
on 28 June 2002. At the same time, in the documents supporting his submission for the class upgrade, his total flight time was indicated to include not only flights as an aircraft pilot, but also as a helicopter flight engineer. At the time of obtaining first class

line pilot status, his total flight time as a pilot amounted to 1,790 hours, which could not serve as grounds for the award of first class (the total flight time of a multi-engine aircraft pilot
must be at least 4,000 hours, of which 1,000 hours must be at night).
Thus, the unsatisfactory professional training of commander Kh.A.S. resulted from
the improper performance of duties by officials of the "Tretyakovo" air transport
company and the central apparatus of the State Civil Aviation Service of the Ministry of Transport of Russia.
The behavior of Kh.A.S. noted above is a fairly typical case of behavior of a whole
range of executives: the ability to negotiate and arrange one's own position is placed above
ensuring flight safety, and this behavior of executives is extremely quickly absorbed by subordinates. As M.A. Kotik and A.M. Yemelyanov (1993) rightly note, in order to strengthen motivation to comply with safety rules, it is first of all necessary
to radically change the attitude within work collectives toward safety issues:
"an attitude toward something is not taught – it is adopted." The authors emphasize that a positive attitude of operators toward the observance of safety rules can arise only
provided that managers of all ranks become imbued with an understanding of the importance of this issue: an operator will adhere to safety norms to the extent that his immediate and higher-ranking supervisors adhere to those norms.
Besides the two widely resonant aviation events illustrating the first aspect of the problem of deliberate violations of regulatory documents, let us examine one
more. The crew of a Tu-134 aircraft of "Krasnoyarsk Airlines" made a landing in weather below the established minimum at the destination airport – Khabarovsk (Informatsionny…, 2001, No. 3).
As the investigation commission noted, the license to operate flights on the route
"Krasnoyarsk – Khabarovsk" held by JSC "Krasnoyarsk Airlines" listed the Tu-154M aircraft,
which is the most optimal from a flight-safety standpoint, since it guarantees both the option of choosing a standard alternate airport for Khabarovsk (Vladivostok, Yuzhno-Sakhalinsk), and a longer holding time in the Khabarovsk airport's holding zone. Using the Tu-134 on this route is undesirable, since
the flight duration does not provide a sufficient fuel reserve for diverting to an alternate
airport in accordance with clause 5.5.11.4 of NPP GA-85.
During preflight preparation at Krasnoyarsk airport, the crew made the decision
to depart with the diversion-point calculation set for the alternate airport of Blagoveshchensk. On approaching the diversion point, the crew received information on the actual and forecast weather, which did not prevent continuing the flight to Khabarovsk.

Before the start of the descent, visibility at the airport was 1,300 m. Ten minutes after the start of the aircraft's descent, the crew received information from the controller about a deterioration in visibility to 1,000 m. The approach was made to the left runway,
where the weather minimum was "70 × 900 m" (the commander's minimum was "80 × 1,000 m"). While
on the glide path, the crew received clearance to land, and a minute later the controller transmitted: "Visibility 900 m," after which the crew went around. By this point, the fuel
remaining was enough for 40 minutes of circling flight. In the absence of information on improving visibility, a decision was made to fly the circuit and carry out a landing.
The weather conditions during the landing were as follows: visibility 800 m, vertical visibility 200 m, heavy snow, with fresh snow up to 30 mm deep on the runway. The temporary
deterioration in visibility (lasting about 11 minutes) was caused by a brief increase in the intensity of precipitation and the lifting of previously fallen snow by vortex flows generated by aircraft that had landed earlier (Informatsionny…, 2001, No. 3).
Thus, it was precisely the substitution of the Tu-154 with the Tu-134 on the "Krasnoyarsk – Khabarovsk" route, initiated by the airline's management personnel, that provoked the crew's violation of regulatory documents. This particular flight did not end tragically,
but one can only guess what might have happened had conditions that day been slightly different. As we have already repeatedly seen, sometimes one additional condition is
enough for a situation to turn from dangerous into catastrophic.
The second aspect is the groundless confidence that the deliberate
violations being committed are entirely acceptable, and that the Flight Operations Manual, NPP, and FAP are some sort of formality
(there is an underestimation of the danger of deviating from the standard operating procedures). But the myth
about the arbitrariness of these documents dissipates as soon as, through their own experience, having allowed
an aviation accident to occur, a crew learns the price of violating one or another point of
the operating procedures. It is important to note that the price of violating each point of the regulatory documents is already known – the entire history of aviation is a history of aviation events, after
each of which a new "price tag" appears. Moreover, the number of types of aviation events
is limited, and all of them can be avoided, but in order to prevent them, one needs to
study them, one needs to become imbued with the fact that each type of aviation event and the
underlying psychophysiological hazard factor has a certain weight and probability of occurrence, and this must be reckoned with – one must be ready at any moment to encounter this or
that hazardous flight factor and be able to withstand it. However sad it may be, sometimes
one has to prove obvious things – that regulatory documents are a product of flight
testing and the bitter experience of aircraft operation. To illustrate the aspect under
consideration, let us analyze several aviation events.

During the takeoff of an An-10 aircraft at night on 24 December 1968, in complex weather conditions (horizontal visibility 1,500 m, vertical visibility 50–70 m, haze), because the flaps were retracted
too early, the aircraft descended and struck an approach-lighting pole. As a result of the
collision, the navigator's cabin was destroyed, the flight controls on the left were severed, and the engine control levers on the right were torn out. On the commander's order, the co-pilot, with the flight engineer's help, brought the aircraft to level flight at a height of 900 m. According to the commander, the crew was lucky – at this altitude there was a significant break in the cloud cover, and so they were able to immediately restore spatial orientation. The aircraft then climbed to
1,200 m and a speed of 350–360 km/h was established. The crew set a course south, reported the emergency
situation and the decision to proceed to Krasnodar airfield – "toward better weather." The crew flew the aircraft under horrific conditions: the crew was doused in AMG-10 fluid from a damaged right hydraulic system, the navigator had both legs broken, the navigation and flight instruments had failed, it was cold in the cabin and there was a roar created by the oncoming airflow. The crew, in a state of affective stress, worked clearly and in a coordinated manner. The landing
of the aircraft with 106 passengers on board was masterfully carried out by the co-pilot (Antonov O.K.,
2009, b).
Another illustration of the second aspect of the problem of deliberate violations is
the circumstances preceding the incident that occurred on 2 February 2008 with an
Il-76TD aircraft in Iraq. A crew of the "Volga-Dnepr" airline was flying the route
"Kuwait – Iraq (Al-Sahra)."
20 minutes before approaching Al-Sahra airfield, visibility was 8,000 m. At a distance of 16 km from the runway threshold, the air traffic controller cleared a visual approach to runway 32L and informed the crew of the actual weather conditions at the airfield: wind – 2 m/s, visibility 3,200
m, haze, cloudless, temperature +2°C. The crew reported that they had the runway in sight and were ready for
landing. At a distance of 6.2 km from the threshold of runway 32L (altitude 500 m), the air traffic controller issued an instruction to approach runway 14R instead (Informatsionny…, 2008, No. 4).
At a distance of 6 km from the threshold, the runway was in sight, and the crew continued the visual approach, for which the minimum at Al-Sahra airfield was "280 × 3,000 m."
The approach was flown into the sun. At a height of 130–100 m, visibility began to
deteriorate, and at a height of 60 m visual contact with the runway was lost. In violation of the requirements of NPP GA-85 and the Il-76TD Flight Operations Manual, the crew did not go around.
The runway's landing threshold was crossed at a height of 9 m and 50 m to the left of the runway centerline! At a height of
10–20 m the crew saw the runway to the right, after which they began a maneuver with a right bank (maximum value 18°) to correct the leftward lateral deviation, as a result of which they crossed
the centerline and ended up 40 m to the right of the runway! To correct the now right-hand lateral devi-

ation, the crew undertook a maneuver with a left bank (maximum value 21°). The aircraft's
touchdown occurred at 5:25:29 (UTC) at a speed of 222 km/h, at a distance of
1,720 m from the threshold, with a 10° right bank and a load factor of 1.54 (according to flight data recorder data). At the moment of touchdown the aircraft's right wingtip struck the runway surface. Data on the actual weather at the airfield, obtained from the Aviation Digital Data Service (ADDS) website after the aircraft landed, were as follows. At 4:55, visibility was
8,000 m (cloudless, haze), and at 5:14 it was 800 m (cloudless,
fog).
It should be said that the problem of uncoordinated corrections toward the runway, noted
in the incident described above, has a rather long history. As is well known, all
aircraft turns must be performed in a coordinated manner (setting bank angles, in accordance with airspeed, at which the centrifugal and centripetal forces are
balanced). If there is no such balance, the aircraft slides on its wing. In
real (not training) flight operations, pilots deliberately violate the rules for executing
turns. Thus, if an approach is being made without direct visibility of the ground, and after breaking out of the clouds the pilot discovers that the aircraft has ended up off to the side of
the runway centerline, then often correcting the aircraft's heading by the book (with the required bank angle) into the runway centerline turns out to be simply impossible, and the pilot has to go around. Experienced [though it is debatable whether they can be called that] pilots in such situations go on to violate this rule – they correct the aircraft into
the runway centerline in an uncoordinated manner, performing a sideslip while turning toward the runway centerline, after which they carry out the landing. As M.A. Kotik and A.M. Yemelyanov (1993) note,
management usually treats this kind of violation with understanding [though this too is
debatable]. To find out exactly how pilots perform coordinated and
uncoordinated turns, M.A. Kotik (1978) asked 15 experienced pilots, among
whom were instructors, to describe the sequence of control actions when
performing uncoordinated corrections through an angle of 5–7°. While each of them could easily
describe the sequence for executing a coordinated turn, no one was able to reproduce the sequence of actions for an uncoordinated turn. Paradoxically, experienced pilot-instructors, who had performed the forbidden uncoordinated turns more than once, could not describe how they actually carried them out. After this preparatory stage of the experiment, they moved on to the next stage – a control-surface-position recorder and a film camera were installed on the aircraft, which was used to record
the readings of the flight instruments. The experiment was carried out according to the following scheme. In straight and level flight on a multi-engine passenger aircraft,

the pilot was given the command to correct the aircraft's heading in an uncoordinated manner by a specific angle (for example, 5°). Six pilots took part in the experiment: five pilots with extensive
experience and one novice young pilot. It turned out that the different experienced pilots
performed such a correction in roughly the same way, in 5–6 s (whereas a coordinated
correction of the aircraft through the same angle at the same speed would have taken about 11 s), while the young pilot
took more than 11 s to correct the aircraft by 5°, that is, even longer than if the same correction had been performed in a coordinated manner.
Thus, pilots develop, in the course of their work, a roughly uniform skill for performing actions of which they were previously unaware. They were unaware of them because these actions were forbidden, and there was accordingly no need to analyze them in order to
subsequently teach these actions to novice pilots (Kotik M.A., 1978). The author even raised
the question of whether it might be easier to legalize uncoordinated corrections (Kotik M.A., Yemelyanov
A.M., 1993), to which he received a well-founded answer – introducing such a rule could do
more harm than good.
An illustration of just how dangerous actions forbidden by procedure really are on the glide slope
is the analysis, presented by R. Yesayan (2005), of the hard landing of a Tu-154M
aircraft at Kittilä airport in Finland on 4 January 2005. This aviation event greatly
interested R. Yesayan (2005) – during the landing, the aircraft first struck the ground with the tail
section of the fuselage (30 m before the runway), and 5 m further on it touched down on its landing gear. This was the first case in the operating history of the Tu-154 in which the aircraft struck the ground with its tail
section. Until then it had been considered that, given this aerodynamic configuration, such an event was impossible (during the testing of this aircraft type, the takeoff (liftoff) procedure at minimum speed had been worked out right up to the point of the tail section touching
the runway). Since the tail section of the Tu-154's fuselage is much shorter than
that of other aircraft types, achieving such contact is practically impossible – in this regime the aircraft reaches angles of attack at which a stall occurs. Theoretically, tail-section contact is possible at pitch angles of about 18° (if the wing installation angle of 3° is added, that becomes 21°, which is already a stall). As R. Yesayan (2005) notes, after
analyzing the "black box" recordings, it was concluded that the aircraft's landing indeed occurred on the verge of a stall.
In the course of a detailed analysis of the circumstances of the occurrence, R. Yesayan (2005) came to
the conclusion that the crew did not understand what was happening to the aircraft, and that if the vigorous flare maneuver undertaken by the commander had occurred not at a height of 15 m, but a little
higher, the aircraft would have entered a stall regime. Thus, at a distance of 23 km and an altitude of 3,000 m
the crew was genuinely aware that the landing was unsafe, since the aircraft was

above the glide slope, but nevertheless stubbornly continued to descend in gross violation of the Flight Operations Manual for
the Tu-154. The high rate of descent and exceeding the permissible speed for deploying the wing high-lift devices indicate that
the crew, forgetting about safety, was determined to land at all costs. According to the Flight Operations Manual, if the ground-proximity warning system activates, the crew is obliged to go around. Also according to the Flight Operations Manual, if at a
height of 60 m the rate of descent exceeds the calculated value by more than 1 m/s, the crew must, below a height
of 60 m, go around immediately. The crew ignored the Flight Operations Manual, and the aircraft continued to descend, since there was a speed margin and the crew was trying
to "catch up" to the glide slope, which is categorically forbidden. As R. Yesayan (2005) notes, back in 1990,
following the Tu-154 crashes at Krasnovodsk (18 January 1988) and Aleppo (Syria, 24 September 1988), a test program was carried out – "Flight on steep glide slopes simulating crew errors on the Tu-154 aircraft" – in which R.
Yesayan himself directly took part. Following this, a decision was made to increase the glide slope angle to 5°. Despite this,
while catching up to the glide slope from above at Kittilä airport, with abrupt elevator movements and the creation of high load factors, the aircraft began to sink noticeably (down to an altitude of 45 m!). In this
regard, the Flight Operations Manual states that if at a height of 60 m the aircraft is not balanced (that is, the horizontal and vertical speeds and the engine power setting are not properly matched), the
aircraft must go around immediately. Despite this, down to a height of 45 m the crew, exceeding the permissible rate of descent of 5 m/s (actually 10 m/s), stubbornly
tried to catch up to the glide slope. The deployed spoilers made the flight even more difficult (it is impermissible to fly an approach with the spoilers deployed, since the approach
speed must exceed the stall speed by 30%). At a height of 45 m it finally
caught up with ("pierced") the glide slope and began rapidly closing with the ground. Now the crew began to approach the glide slope again, but this time from below, all the while having no idea what was happening
with the aircraft (high vertical speed, horizontal speed of 283 km/h (versus a calculated 265 km/h)). At a height of 15 m, with a vertical speed of 7.6 m/s (1.5 times the calculated value), the aircraft commander vigorously pulled the control column toward himself,
attempting to reduce the rate of descent. At that moment the "angle-of-attack limit" warning activated
(apparently, the commander had not been watching it up to that point, since
within one second the commander performed two completely opposite actions: pulling the control column
"toward himself" and then immediately pushing it "away from himself"). All this led to the crew placing itself in a hopeless position: it was not possible to pull the control column back, since the aircraft would enter the limiting angle of
attack, nor was it possible to push the control column forward, since the rate of descent was very high, and the
ground was already close. The load factor experienced by the passengers and crew was 3.43.

Thus, violation of regulatory documents (in particular, flying off the glide slope) is linked to the crew members' confidence that the violations they commit will not lead to
serious consequences. But what feeds this confidence? Primarily the fact that
the crew has a certain amount of experience with violations of regulatory documents: a favorable flight outcome, in such cases, is attributed not to a fortunate combination of all the factors
at play in a difficult situation, but to their own ability to fly the aircraft
beyond the limits set by the operating procedures. In this connection, let us examine an aviation event involving an An-124 aircraft.
The crew of an An-124 aircraft was flying to the mountain airfield of Xichang (China). As the
aircraft approached the airfield, the controller cleared the crew to descend and make an approach according to the established scheme, providing for descent over the NDB (non-directional beacon) in two circuits followed by transition to the final approach segment (Tsibulkin V.A., 2008). Instead of two circuits, the crew flew only one and brought the aircraft to the initial pre-landing
position at an altitude of 2,515 m – instead of the established 1,155 m. On approaching the glide-slope intercept point, the excess altitude amounted to 984 m. In this situation, the simplest solution would have been to fly a descending
orbit, as cleared by the controller, and fit into the pattern without crossing the glide-slope intercept point (Tsibulkin V.A., 2008). Instead, the commander, displaying excessive overconfidence, decided to "catch up" to the glide slope
from above and land no matter what. The other crew members remained silent, which, unfortunately, has already become the standard pattern of behavior in such situations. The landing was
carried out safely, which only reinforces, as we have already noted, the confidence in the possibility of violating operating procedures, and in the possibility of creating one's own procedures.
Equally dangerous were the actions on the glide slope of the crew of an Il-76TD aircraft during
an attempt to land at Kabul airport on 30 December 2004. The aircraft was operated by "Airline Transport Incorporation" (Moldova). The crew was flying a charter flight on the route "Billund (Denmark) – Baku (Azerbaijan) – Kabul (Afghanistan)" under
a United Nations program (Informatsiya…, 2005). The flight to
Baku airport proceeded without any particular incident. After a rest period and refueling, the crew
conducted preflight preparation for the leg to Kabul. The crew commander made the decision to proceed from Baku to Kabul, having at his disposal information that weather conditions at the time of approach to Kabul did not meet the airfield minimum (the airfield
minimum was assessed as "450 × 5,000 m," while the weather forecast that the crew had received
was different: visibility 3,000 m, deteriorating between 00:00 and 06:00 to 1,200 m).
As the aircraft entered the Kabul airfield zone, the crew received information from ATC on the actual weather conditions: "480 × 2,000 m." At that time, the tower controller

was told by the crew of another aircraft: "Low cloud layers are moving in from the north, they will be over the airfield in approximately 5–10 minutes." Indeed, ten minutes later low cloud reached the airfield, resulting in fog forming at the airfield with visibility of
500 m. The commander made the decision to divert to an alternate airfield. Subsequently, the commander received information from the crew of an aircraft carrying out an approach, about
an improvement in visibility to 2,000 m, after which he decided to land at Kabul, expecting that visibility would improve by the time of arrival.
The crew began the descent for the approach on a heading of 285°. The aircraft's descent
was carried out in a left turn with a 25° bank, along an orbit with a radius of about 7,000 m. From the record of conversations it follows that the crew observed the airfield from an altitude of ~4,000 m. During
the approach, the wing high-lift devices were deployed and the landing gear extended. To
reduce indicated airspeed, the spoilers were deployed, which should have been retracted by the flight engineer, on the commander's order, at the transition altitude, but this was not done. During the approach, the RI-65 voice annunciator repeatedly announced: "speed exceeded." At a distance of 4,230 m from the runway threshold, with a right lateral deviation of 365 m, the flight altitude was 310 m. Descending at a high vertical speed
triggered the ground-proximity warning system, which continued sounding down to a height of 150 m. The "Before entering the glide slope" checklist was not completed by the crew. The aircraft continued to descend along a steep trajectory and dropped below the
glide slope. The remainder of the flight took place below the glide slope.
At a distance of 910 m from the runway threshold, at a geometric altitude of 13 m and an indicated airspeed of 230 km/h, the aircraft collided with an obstacle located 45 m to the left of the runway
centerline. The throttles were advanced to takeoff power 7 seconds after the
collision.
The aircraft went around in order to make a pass over the runway so that air traffic controllers could assess the aircraft's damage. After inspecting the aircraft, the controller informed the crew: "922, from the ground it looks like your right gear leg is hanging, and the left one is gone."
The crew set course for the alternate airfield of Termez (Uzbekistan), but it turned out to be closed due to
weather (fog), so a decision was made to proceed to
Dushanbe airfield (Tajikistan). A landing on unprepared ground was made with the nose gear and the right main gear extended. After landing, the crew evacuated on their own; there was no fire.
According to statements from crew members, at a height of about 80 m the aircraft was affected by wind shear, which was not confirmed by an analysis of flight data recorder data and the prevailing weather
conditions.

In the course of investigating this aviation event, a whole series of violations was identified, relating both to the aircraft's maintenance and its conformity with airworthiness standards, and to the documentation the crew relied on during flight
preparation. Engines 1 and 4 had exceeded the established overhaul
life of 310 hours, while engines 2 and 3 had been operated beyond the established overhaul
calendar service life of 2 years 3 months and 4 years 7 months respectively. The crew
used the "JEPPESEN" chart binder dated 13 February 2004, according to which the transition altitude corresponded to FL 110 (3,350 m), whereas as of 30 December 2004 information dated 24 August 2004 was in effect, according to which the transition altitude was FL 120
(3,630 m).
In outlining the second aspect of the problem of deliberate violations of regulatory documents,
we noted that crew members underestimate the danger of deviating from standard operating procedures. As an illustration of this, let us present the circumstances preceding
the crash of an An-2 aircraft in the Moscow region on 27 June 2008.
The flight was planned to carry out aerial-photography work (two pilots and three duty passengers were on board). Owing to a lack of fuel for the
flight, the crew was forced to wait for 6 hours. Without waiting for the arrival of the fuel truck, the aircraft commander and the aircraft's owner (a private individual) decided to refuel the aircraft with fuel from a plastic container of B91/115 gasoline located at the site, belonging to the owner of the aircraft. The investigation commission
was unable to establish when or from where this container had been delivered (Informatsionny…, 2008, No. 8).
On the commander's instruction, the aviation technician took a fuel sample through the upper neck
of the container. A visual inspection of the sample raised no objections. Since draining fuel
through the upper neck was inconvenient, the commander and the owner of the aircraft gave instructions to move the container to one side and dig a pit under the lower tap – to make it easier to fill 20-liter canisters. After this, the refueling process proceeded according to the following scheme:
a canister was filled through the lower tap (using a hose through a fine-mesh funnel), and then the gasoline from the canister was poured into the aircraft's tanks through another funnel with an even finer mesh.
The investigation commission specifically noted that the "Instructions on the Use and Quality Control of Fuels, Lubricants, and Special Fluids in Civil Aviation" prohibit the transport and storage of
aviation gasoline in polymer, galvanized, and painted containers. The sequence of actions is noteworthy. The fuel sample for quality assessment was taken from the upper

point of the container, while the bulk of the gasoline for refueling was taken from the lower point – the drain
tap of the container. After the container was moved to its new location, a fuel sample was not taken again, despite the fact that the container had been subjected to mechanical disturbance and the liquid inside it had been agitated.
As a result of an examination of fuel samples taken from this container, a significantly elevated concentration of "actual gum," organic
impurities, and water was found in the fuel. Organic impurities and gums are not caught by the fine metal
mesh, and water partially passes through it as well (Informatsionny…, 2008, No. 8).
According to the aviation technician's testimony, the commander was present during the draining of the fuel sump and confirmed that it met specifications. However, the results of the analysis of the samples taken raise
doubt about this claim. It is most likely that the fuel sump was not drained at all, or that
the time interval necessary for the fuel to settle was not observed.
After takeoff (3 minutes later) the commander reported unstable engine operation, and
then its failure, along with the decision made to carry out a forced landing. Landing "straight ahead" was not possible, since the flight was proceeding over broken terrain with forested areas and power lines. The flight altitude at that time was about 100–150 m, and the commander presumably decided to land on
the water surface of a river. The flaps were deployed to 40°. Given the rapid development of the
situation, the commander presumably did not have time to switch the propeller to fine (high) pitch. The investigation commission specifically noted that, according to the "Practical Aerodynamics of the An-2 Aircraft,"
the drag of a propeller left at high pitch amounts to 40–50% of the drag
at fine pitch. Thus, in order to achieve greater gliding range after an in-flight engine failure, it is necessary for the blades to be set to high pitch. During
a turn while losing altitude, the aircraft struck power lines, after which it lost forward speed and became uncontrollable. From a height of 50–70 m, falling vertically, the
aircraft crashed to the ground.
The final illustration of the second aspect of the problem of deliberate violations of regulatory documents is the aviation event that occurred on 21 June 1990 with
an An-12 aircraft at Tiksi airport. After delivering a commercial cargo to Batagay, the destination airport refused to provide refueling: the crew was informed of the lack of fuel before departure from the intermediate airport (Terskiy V.I., 2009). The commander
decided to fly on to the next airfield according to the flight plan – Tiksi.
He received clearance from the controller for the flight based on there being 5

tons of fuel on board the aircraft. Having boarded the aircraft and learned that there were only 4 tons of fuel on board, the commander
nevertheless decided to proceed with the flight. Problems arose in starting the engines, which the crew attempted to restart several times. As a result, at the moment of takeoff the fuel gauge
showed a value of 3,100 kg. At 14–16 minutes into the flight, a warning activated indicating
a fuel remainder of 1,550 kg. Thirty minutes into the flight, the red critical fuel-remainder warning light (15 minutes) illuminated
in the left wing.
As V.I. Terskiy (2009) notes, the crew continued to worsen the situation – they did not inform air traffic controllers throughout the entire flight of the growing danger, thereby depriving themselves of assistance from them. For example, to the right of the flight track there was an alternate airfield,
Kular, of whose existence the crew was unaware. In the final part of the flight, with the critical fuel-remainder warning light illuminated, the crew acted properly – they did not lose their composure. Before beginning the descent from an altitude of 6,000 m, on the commander's order, in order to
save fuel, the flight engineer shut down engine No. 1, and 2 minutes 46 seconds later – engine No. 3.
In order to reach Tiksi airfield, the crew, having received clearance, took a shortcut on the route. At an altitude of 1,200 m, the flight engineer shut down engine No. 2 owing to its unstable operation. At an altitude of 700 m and a distance of 12 km, the last operating engine was shut down. One hour 5 minutes
after takeoff, the aircraft made a landing with the landing gear retracted on the unpaved right-side safety strip of Tiksi airfield, sustaining significant damage in the process. The touchdown occurred at a distance of 1,150 m from the runway threshold.
The third aspect is the pursuit of one benefit or another that a deliberate
violation of operating procedures promises. This is expressed most acutely in the deliberate overloading of aircraft. The question arises as to what makes a crew deliberately go along with violations and exceed the established load limits. This problem has many components (Evstigneev D.A., Kopysov V.Kh., 2007):
- the desire to make extra money (crew members themselves comment on this as follows: "I have overloaded and will keep overloading – one dollar per kilogram of overload"; "I have a family, and money
is tight");
- the desire to transport as much cargo as possible with minimal economic loss;
- the policy of a number of airlines ("You must do everything to ensure that the client works
only with you, on any terms");
- the inability of less experienced crew members to object to an overload
committed by more "experienced" colleagues;
- the crew's lack of complete information about the actual load (often it is only at
the taxi stage (based on how the aircraft accelerates at the given power settings) that the commander learns of the overload);

- a failure to understand that, by allowing the aircraft to be overloaded, crew members provoke
structural wear, and that an entirely different crew may pay with their lives for their
mistake;
- criminal collusion with airport services that agreed to allow cargo not accounted for in the flight plan into the airport zone.
As for situations in which the crew does not know the true information about the aircraft's load, this happens, as described by V.A. Tsibulkin (2008), as follows. An incident occurred with an An-124 aircraft, whose maximum load had been exceeded. Before
loading began, the shipper's agent verbally informed the load master of information about the
nature and quantity of the cargo, without presenting any documents. The load master, trusting the
information received, determined that the total weight of the cargo was 115,200 kg, and authorized the loading. After it was completed, the shipper's agent handed the crew documents for the
cargo, in which the total cargo weight indicated was 146,699 kg. The commander and the load master demanded that the agent explain the discrepancy between the declared weight and the weight indicated in the documents,
to which the agent replied that this was a mistake by the person who had prepared the documents. Taking the
cargo waybill, the agent left, ostensibly to correct the mistake in it. On his return, he handed the crew the waybill, in which the cargo weight had been corrected by hand to 116,699 kg, without
a certifying stamp and without indicating the position or surname of the person who had made the correction. The crew did not doubt the correction and calculated the takeoff weight based on a commercial load of 116,699 kg. Only during the takeoff and subsequent flight did the crew
fully realize what had happened.
Let us now dwell on what every crew member should know about overload and all the dangers that it conceals. For this, we will turn to the opinion of the chief
designer of the Il-76 aircraft, R.P. Papkovskiy (Aralov G., 2001, v). The designer notes
that overload is dangerous because it violates the very standards according to which the aircraft was designed; under extreme conditions the aircraft may simply break apart. Overload occurs not only in commercial load, but the maximum permissible takeoff weight of the aircraft is also exceeded (for the Il-76 –
up to 220–230 tons), that is, 30–40 tons more than the maximum takeoff weight of 190
tons. Even the Il-76T (rated for a takeoff weight of no more than 170 tons) has been overloaded up to 210 tons. Given an unfortunate combination of circumstances, such an aircraft may suffer a crash also due to increased handling difficulty. The situation is made worse by the fact that pilots sometimes do not know the exact weight of the cargo and the aircraft's takeoff weight, which subsequently causes
difficulty in determining flight regimes. In the event of a hard landing of an overloaded airliner, the landing gear can be broken and the fuselage damaged. There have been cases where, after a hard landing, waves appeared on the fuselage skin. Another danger is the shifting of unsecured cargo during turbu-

lence or a hard landing. Under overload, additional loads act on the airframe structure, and after such loading, an inspection of the structure is required. All of this leads to a reduction in the aircraft's service life.
Let us try to understand the psychological state a crew is in when they take on board unregistered passengers or extra cargo. The first thing to note is that from the moment the decision is made to take on extra cargo, all crew members become "co-conspirators" (Evstigneev D.A., Kopysov V.Kh., 2007). This entails that, united by a single goal and focused on concealing the overload, during the flight the crew members cease to perceive the situation adequately and become less critical of themselves and others.
1. In the event that the in-flight situation becomes more difficult and it becomes necessary to divert to an alternate airfield, the pilots nevertheless decide to land, ignoring all standards, because they
have an arrangement with the destination airfield – and only with it. Landing at another airfield risks an investigation and subsequent penalties. And under such conditions (going beyond
all norms, including the weather minimum), the crew carries out a landing at the destination airfield!
2. Being in an altered psychological state, obsessed with achieving the intended
goal, the pilots do not take into account all the characteristics of the aircraft and the airfield (most often temperature, the runway friction coefficient, its length, the aircraft's center of gravity)
and make mistakes.
3. Pilots flying an overloaded aircraft often do not know all the possible ways the aircraft may behave – especially in special cases (icing, wind shear, engine failure).
4. A crew of an overloaded aircraft heading in to land at the destination airfield, in the event that warnings activate indicating failures or deviations from set parameters, often does not respond to them – the crew is entirely in the grip of the goal they have set for themselves.
Emotional strain (the experience of negative emotions) is determined not
only by anxiety over keeping the overload committed a secret and fear of punishment,
it is also determined by the fact that crew members, if they do become aware of the full danger
of flying an overloaded aircraft, anxiously monitor the parameters of all the aircraft's systems, especially the engines, the failure of which would leave almost no chance of a safe outcome to the flight. A few such flights – and one can develop a neurosis (primarily neurasthenia – owing to the exhaustion of the nervous system as a result of prolonged experience of negative emotions).

Overloading of aircraft with the crew's consent serves as a reliable test of a pilot's maturity, of his readiness to observe norms and rules, and of his attitude toward flight safety in
general. Below is a series of events in which crew members failed this test.
During a control weighing of cargo carried by an An-12 aircraft on 22 November 2000
at Norilsk (Alykel) airport, an excess of the declared load by approximately 7,000 kg was found. The actual takeoff weight was 67,859 kg, thereby exceeding the limits set by the Flight Operations Manual (61,000 kg). The landing weight was 60,769 kg and did not exceed the Flight Operations Manual limits. The cargo at Krasnoyarsk (Yemelyanovo) airport
was documented against the requests of three shippers, and the total cargo weight according to the documents was 13,800 kg. During the loading of the aircraft, the crew (with the exception of the systems operator) was in the airport's navigator's room. After the aircraft's loading was completed, an employee of the cargo-handling service entered a total cargo weight of 14,044 kg on the shipper's request form and submitted the documents for processing. Upon receiving word that loading had been completed, the commander arrived at the commercial cargo terminal,
made a change to the maximum-load figure, raising it to 14,100 kg, and signed the mail-and-cargo and summary manifests.
According to the investigation conducted, the incident resulted from the unauthorized transport into the airport's controlled zone, and loading onto the aircraft, of cargo
exceeding by 7,000 kg the weight declared in the shipping documentation. In the process of forming, documenting, and dispatching the flight, there was collusion involving a representative of the shipper, employees of the cargo-handling service at Yemelyanovo airport, and the aircraft commander.
The next example illustrating this group of occurrences is a serious aviation incident involving a Tu-154 aircraft, which occurred at night in simple
weather conditions on 1 August 2003 at Faro airport in Portugal. At Faro airport, the aircraft
was refueled with an additional 23,000 kg of fuel. The total amount of fuel loaded, according to
the record in the flight plan, was 31,000 kg, while according to flight data recorder data it was 33,000 kg (Zaklyuchenie…, 2004).
The traffic-handling service registered 151 passengers and 3,311 kg of baggage. In the flight plan, in the summary load sheet, and in the balance chart, the crew indicated: 151 passengers, 2,311 kg of baggage, and a takeoff weight of 99,814 kg. Taking into account
the 1,000 kg of baggage not accounted for by the crew in the calculations, at takeoff at Faro airport the weight of the aircraft was 100,814 kg, which exceeds the Tu-154M Flight Operations Manual's recommended maximum takeoff weight (100 tons). According to calculations made by the investigation commission, the aircraft's takeoff weight was 101,789 kg; the takeoff parameters
corresponded to this weight.

Exceeding the maximum takeoff weight became possible owing to the following
circumstances. The Tu-154 crew found itself facing a choice:
- either offload some passengers with their baggage;
- or drain the excess fuel and change the flight plan, scheduling a landing at an
intermediate airfield for refueling, which would have involved serious difficulties and a delayed departure;
- or carry out the flight in violation of operating procedures.
It was precisely the third option that the crew chose. As is well known, violating certain points of operating procedure entails the violation of other points as well: – takeoff was carried out without
stopping the aircraft at the takeoff-hold position (crew members claimed otherwise!); – the required takeoff power setting was not achieved, owing to a rise in exhaust
gas temperature to values close to the maximum permissible (the maximum power setting achieved lay somewhere between takeoff and rated power). According to the calculations performed, the total thrust deficit at the power setting actually achieved amounted to about 3,560 kg. Thrust was reduced by
a further 1,000 kg when, on reaching an indicated airspeed of 172 km/h, the power setting of engine No. 2
was reduced by 4% owing to the exhaust gas temperature reaching its maximum permissible value (625°C). All this resulted in an increase in the takeoff-roll distance of ≈700 m. The aircraft lifted off the runway 30 m from the end of the runway. The increase in angle of attack to 13.6°, which triggered the activation of the AUASP warning system (angle-of-attack and load-factor warning system), proved insufficient, and the aircraft, 180 meters beyond the threshold,
struck the tops of trees, resulting in damage to the fuselage, wing, and its
high-lift devices. The crew continued the flight and made a landing at the destination airfield (Domodedovo).
As the next example illustrating the nature of deliberate violations of regulatory documents in general and the problem of aircraft overloading in particular, let us examine
the circumstances preceding the crash of a Ts-150L aircraft, which occurred on 15 June
2009 in Bashkortostan (near the settlement of Urmantau).
This crash vividly demonstrates that, in violating the established operating procedures, it never even occurred to the pilot that he might fail to maintain control of an overloaded aircraft – and confirmation of this lies in the fact that his wife and
granddaughter were on board the aircraft (among pilots, the measure of professionalism is often gauged by whether a pilot is willing to entrust another pilot with flying his relatives: if he trusts him to, that means he is considered a professional)! After all, there is no flight manual for an overloaded aircraft, and if that's the case,
then it is impossible to speak of the ability to fly such an aircraft! The pilot's wife died at the

scene of the crash, and his granddaughter died on the way to the hospital. The pilot himself was taken to the hospital in serious condition.
In Yoshkar-Ola, on 12 June 2009, the pilot underwent a preflight medical examination, received weather information, and obtained clearance from ATC to fly the route "Yoshkar-Ola – Menzelinsk – Urmantau." The flight application stated that it was a training flight, whereas
in fact it was a transport flight carried out for the purpose of visiting relatives (!) living in the settlement of Urmantau (Informatsionny…, 2009, No. 8). The landing was made on a site selected from the air – in a field near the settlement of Urmantau, which contradicts the aircraft's technical operating manual,
according to which takeoffs and landings must be conducted at airfields with prepared
unpaved or paved runways. After landing, the pilot continued to
taxi the aircraft on the ground and moved it into the village on its own power. According to the outbound flight application filed on 14 June 2009, the pilot planned to depart on 15 June
at 06:00 UTC (12:00 local time). At 06:15, the shift flight-operations manager
received information from the local flight-control point (LFCP) controller that the pilot
of the Ts-150L aircraft had not reported taking off and was not responding on the radio. Until 06:35 attempts
were made to reach the pilot through the crews of aircraft that were airborne. At 06:37
the information was passed to the Aerospace Search-and-Rescue Center (ASRC), and at 06:46 the alarm was raised. In response to the alarm, at 07:20 a search
An-2 aircraft, with an on-duty rescue team aboard, took off from Ufa airfield. The crew of the An-2 aircraft made a landing
on a site selected from the air not far from the site of the crash.
The pilot had made two takeoffs. The first was made in order to establish
contact with the ATC service at Ufa airport. According to the testimony of the LFCP controller, the pilot made contact
after 05:00 to confirm the weather forecast and confirm departure at 06:00. On the first flight, a boy who wanted to go for a flight was on board. The takeoff weight
(734 kg) did not exceed the aircraft's Flight Operations Manual limit (737 kg), but it did exceed the limit set by the Flight Operations Manual for the Cessna-150L (726 kg): the ULA Ts-150L is a modified example of the production Cessna-150L aircraft
(Informatsionny…, 2009, No. 8). The first flight lasted no more than 15 minutes.
The aircraft's takeoff weight on the second flight was 830 kg (the pilot's wife, his granddaughter, and cargo were on board), which exceeded the maximum permissible takeoff weight specified in the Flight Operations Manual by 93 kg, and the maximum permissible takeoff weight set by the manufacturer by 104 kg (almost 15%).
Takeoff was carried out toward an obstacle – a hill 120–150 m high, located
at a distance of 1,800–2,000 m. The aircraft's takeoff roll was 325–335 m, significantly exceeding

the figure specified in the Flight Operations Manual (224 m) and in the manufacturer's technical documentation (253 m). This
confirms that the aircraft was indeed overloaded. The aircraft left the ground
at a ground speed of about 90 km/h (the Flight Operations Manual specifies a liftoff speed of 113 km/h for this aircraft).
During the climb to 25 m, a drop in speed to 84 km/h was observed. This could have occurred because of an increase in the headwind component, but it is most likely explained by insufficient engine power for the actual takeoff parameters. Confirmation of this
can be seen in the pilot's reduction of the rate of climb at this altitude, at the expense of
which the ground speed increased.
Less than 1,000 m remained before the slope of the hill. While climbing at a vertical speed of 2.5–3 m/s, the aircraft began to lose speed, since the engine did not have enough power for this rate of climb. The pilot reduced the vertical speed to 1.5–2 m/s and, at a ground
speed of 93 km/h (true airspeed 115–117 km/h), decided to make a