In September 2011, a Yak Service Yak-42, carrying a professional ice hockey team, crashed on takeoff from Yaroslavl-Tunoshna Airport in Russia, killing 44 of the 45 occupants. The world was shocked and saddened by the news. Obviously something had gone terribly wrong. This week, crash investigators made public their findings. The reason: Pilot error.

Surprising?  No.  Preventable?  Yes.   The pilots clearly made errors.  But the sad truth is that the crash was preventable.  How?  To answer that we must dig deeper and go beyond the “who” is to blame and turn our focus to the “why.”  That is how we’ll uncover the underlying problems – the real reasons for the crash – and determining a way to solve them.

If the goal is to reduce accidents, then “why” an event occurs is a far more important question to answer.

If focus remains on “who” made the error, the solution will point to remedial training, or more extreme, to suspension or dismissal of the pilots.  Is the solution effective?  In the case of this accident, it doesn’t apply since the pilots didn’t survive.  If the pilots’ are at fault, and perished in the accident, should we be comfortable that the problem is solved and won’t happen again?  That is wishful thinking.

If the goal is to reduce accidents, then “why” an event occurs is a far more important question to answer.  A broader look at the facts makes it possible to gain an understanding of the organizational problems that set events in motion, long before the crew reports for duty.

Let’s take a closer look.

According to Alexei Morozov, chief of the investigative commission: “the immediate cause of the Yak-42 plane crash was the plane crew’s erroneous actions, namely the pilot stepping on the brake pedals before raising the nose wheel because of the wrong position of the feet on the brake platforms during takeoff.”

The investigation technical data indicated, that during the takeoff, the crew was preparing for an abort.  Something changed and the aircraft continued with the takeoff.  If the crew had identified a problem, why didn’t they abort?  Was there time to abort the takeoff and save the aircraft?

Identified in the accident report as causal factors:

  1. Pilot training
  2. Absence of control over the crew
  3. Inadequate preparation for flight
  4. Failure to follow standard operating procedures
  5. Poor crew coordination

So what happened?

It is difficult to state specifically what happened, even with the flight recorder data but, let’s review a few facts and data points that shed some light on the aviation situation that existed before the crew started their day:

  1. Industry experts have reported that when Russian crews abort takeoffs, make second runs or divert their planes to other airports, they can risk losing their bonuses or face other sanctions as carriers focus on cutting costs.
  2. “Many pilots say that those who cause delays in flight schedules … run into various problems at many carriers,” Morozov told a news conference. “Company management doesn’t like it.”
  3. Morozov blamed the plane’s owner, Yak-Service, for failing to observe safety standards and adequately train the crew.
  4. The company was closed in September by Russia’s federal aviation authority following a check that found severe violations.
  5. “The company practically lacked a proper system of flight oversight and controls over air safety,” Morozov said.
  6. Investigators noted that both pilots had more experience flying Yak-40 aircraft than Yak-42s. The Yak-40’s pedals are laid out differently, and “a negative transfer of Yak-40 skills” may have led to the error, they said.
  7. The report was sharply critical of training practices at Yak-Servis, noting that “in such an organization, scheduled preparation was practically impossible to organize.”
  8. One of the pilots was taking Phenobarbital for a neurological disorder that resulted in weaker reflexes in his legs and hands.

Back to the question, did the problem go away with the loss of the crew?  Hardly.  Are there actions this organization can take to prevent an occurrence of a similar event?  Most definitely.

What can you do?

It is important for all organizations to take a look their safety culture.  Is your organization doing everything it can to eliminate preventable events?  Do you identify operational hazards?  Do you analyze and mitigate associated risks?  Are managers sending messages that inspire a positive safety culture?  Are frontline personnel participating in a positive safety culture by providing hazard and safety information?

For more information about safety management systems, visit AirSafetyGroup.com or contact Jeff Whitman.