Investigation Summary
The investigation focused on the ergonomics of the Airbus A310 throttle quadrant and the crew's reaction to a 'split' thrust condition. The aircraft was operating with the left thrust reverser deactivated due to a previous maintenance deferral. During the landing rollout, as Captain Shibanov manipulated the right reverse lever, his palm inadvertently pushed the left throttle lever forward to a significant power setting. Because the left engine was producing forward thrust, the flight computers automatically retracted the ground spoilers, which are critical for aerodynamic braking and keeping weight on the wheels for effective wheel braking. The crew, focused on the right engine's reverse thrust and the aircraft's failure to slow down, did not notice the left engine's high power setting until it was too late to stop.
Final Conclusions
The Interstate Aviation Committee (MAK) concluded the crash was caused by the accidental movement of the left engine throttle lever past the 'idle' position during the deployment of the right engine's reverse thrust. This led to a significant increase in forward thrust on the left side, the retraction of spoilers, and a reduction in braking efficiency. The crew failed to monitor engine parameters during the rollout and did not recognize that the left engine was fighting their braking efforts until the aircraft had already exited the runway at high speed.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Thrust Reverser
A system that redirects engine exhaust forward to help slow the aircraft; the left unit was inoperative on this flight.
Ground Spoilers
Panels on the wing that dump lift upon landing; they retracted automatically when the left throttle was moved forward.
Autobrakes
A system that applies wheel brakes automatically after touchdown; its effectiveness was compromised by the forward thrust and loss of spoilers.
Interesting Facts
- 01The aircraft was 19 years old and had previously been operated by Pan Am, Delta, and Aeroflot.
- 02The left thrust reverser was deactivated and pinned shut due to a maintenance deferral.
- 03The runway was wet at the time of landing, which reduced braking friction.
- 04The captain had expressed fatigue during the flight, noting they were not getting enough sleep.
- 05The aircraft struck a storage cooperative consisting of concrete garages, which caused severe structural damage and fuel ignition.
Safety Actions & Advisories
Throttle Quadrant Design Review
Recommendations were made to review the design of throttle and reverse levers to prevent accidental movement of one lever while manipulating the other.
CRM and Monitoring Training
S7 Airlines and Russian aviation authorities emphasized the need for pilots to monitor engine instruments during the entire landing roll, even when using only one reverser.