I am often asked for explanations of an accident as soon as the crash has occurred and of course it is seldom possible to be dfinitive; merely offer likely scenarios. In this particular case we have a lot of evidence to point to likely causes already.
The crash – I will no call it an accident fo reasons that become clear – was fatal for at least 15 of those on board including the captain. The first officer survived but died later. Over 30 passengers were hospitalised; 95 passengers plus 5 crew were on board at the time.
THE EVENT
This was the first flight of the day in snowy, icy conditions. It is imperative that before flight an aircraft that has stood outside in this kind of weather is checked for ice/frost contamination of the flying surfaces. The wings and tail plane are the most important but hinge lines, ports and any vital areas should be inspected. If hoar frost, snow or ice is detected then the aircraft must be de-iced prior to flight.
It is near certain that an aircraft outside overnight in this weather will be contaminated and so any surfaces that cannot be inspected would be assumed to require de-icing and I think we can assume that critical areas of this aircraft needed de-ice fluid applied before flight. This is especially so in the case of the Fokker 100 as it is known to be very intolerant of wing contamination and so there should be no question about de-icing before flight.
Whilst we do not have clear evidence, there is rumour that only tail surfaces were treated and pssibly none. What we do know is that after the crash, passengers using the over wing emergency exits reported that the wing was icy; this is supported by post crash photos, which show the kind of finish on the wing that you would expect with hoar frost.
The video clip of the aircraft’s take off run shows it lifting off, rolling right, then sinking back onto the runway before passing the camera; we do not see the crash at this point. However, the Russian investigators have released a transcript of the conversation on the flight deck and some of the crew actions and it is disturbing reading.
,When the aircraft sank back onto the runway the fist officer closed the thrust levers intending to reject the takeoff. The captain then said “No Need,” and advanced the thrust levers again saying “Let’s go, Let,s go.”
This appears to have been the final action that ensured the crash. The aircraft failed to gain height, veered to the right impacting a wall and finally a building, where it broke up; thankfully there was no fire. It is a puzzle why two such experienced pilots would allow this sequence of events to occur. Both pilots had thousands of hours on the Fokker 100 and over 21,000 hours in total in the case of the captain.
My view at this stage is that the neglect of contaminated wings was a major factor but there is also the possibility that wake turbulence from the preceding aircraft could have played a part but if it did tht may not have been fatal had the wings been clear; I will explain the effect that the preceding aircraft may have had.
Aircraft generate wing tip vortices as they produce lift. These vortices spread outwards and so with sufficient time they disperse. However on the day in question there was a cross wind that may have held one vortex over the runway adding to the lift and control problems. I understand that the preceding aircraft took off less than 2 minutes prior to the Fokker, which is on the limit of acceptability depending on the preceding aircraft type.
As is usually the case it is a sequence of events that lead to disaster and I would start with the de icing issue in this instance as it is a fundamental rule that no responsible pilot would ignore and so that why such experienced men as these failed to take the necessary action is the focus of our examination of this crash.
It is common for operational pressures to be brought to bear on aircrews, with schedules to meet, costs to mitigate and so forth but it is incumbent on the aircraft commander to resist them and no responsible operator should apply them to their crews but we know that it happens. This may be down to the culture in a company and whilst I am unable to asses this airline from direct experience we will see that the Kazakh authorities found them badly wanting in many areas and have withdrawn thei operators certificate.
One report from the area suggests that commonly Bek Air crews did not perform pre-flight inspections, which is truly shocking if true. I would doubt that the airline will survive given the wide range of violations discovered by the aviation authorities. This is whay I cannot classsify this as an accident it was an avoidable crash.
Of course this then raises the question of oversight. How can an airline operate for a long period without such flagrant flaws being discovered before an accident? Some questions will no doubt be asked of the regulator.
A full report will be forthcoming ultimately and it is encouraging that the authorities have released what they have done already.
What this emphasises is that the safety cuture in the airline is the most vital element in ensuring a safe operation and that is the reason for my forthcoming book on the impact of culture on safety. It is clear that this airline had a culture that I do not recognise in professionally run airlines. The certification of airlines such as this should not be permitted and it tells me, that the iternational standards that are intended to ensure your safety, fail to be met far too often.