A Russian pilot inadvertently put the wheel brakes on during takeoff, causing a crash that killed 44 people including a professional ice hockey team, investigators said Wednesday, citing lax oversight and insufficient crew training as key reasons behind the error.
The Interstate Aviation Committee said the Sept. 7 crash of the Yak-42 plane near Yaroslavl in central Russia occurred because one of the two pilots accidentally activated the brakes and then yanked a control wheel to his chest, pulling the plane up too sharply in a desperate attempt to take off.
It was one of the worst aviation disasters ever in sports, shocking Russia and the world of hockey, as the dead included 36 players, coaches and staff of the Lokomotiv Yaroslavl hockey team. The only player who survived the crash later died of burns. A flight engineer was the sole survivor.
Alexei Morozov, leader of the investigation, said the crew should have aborted the takeoff the moment they realized it was going wrong. He said one possible reason the pilot obstinately still tried to take off was a fear of reprisals from his employer.
Industry experts say 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.
"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."
Morozov blamed the plane's owner, Yak-Service, for failing to observe safety standards and adequately train the crew. The company was closed in September by Russia's federal aviation authority following a check that found severe violations.
"The company practically lacked a proper system of flight oversight and controls over air safety," Morozov said.
Morozov said both pilots had flown another type of plane with a slightly different cockpit layout and apparently had never learned the correct position for their feet on takeoff. He said in the Yak-42, like most other Russian and Western planes now, a pilot steers the aircraft by pressing the lower part of pedals and activates the brakes by pressing their upper part.
But instead of putting their heels on the cockpit floor as regulations require, one or both of the pilots left their feet resting on the pedals in line with old habits, inadvertently activating the brakes and slowing the plane down on takeoff.
At first they didn't notice the brakes were on, and then they made the fatal mistake of failing to halt the takeoff, he said.
"A properly trained pilot would have immediately aborted the takeoff when he saw the nose failing to lift," said Ruben Yesayan, a highly decorated test pilot who took part in the probe. "The plane would simply have rolled past the runway and everyone would have been safe."
Morozov said the second pilot was taking phenobarbital — a sedative used to control seizures that is prohibited for pilots — and that also contributed to the disaster. He said the pilot suffered from polyneuropathy — a neurological disorder that could affect the feet and hands and cause weakness and loss of sensation. It had passed unnoticed during an official medical certification, but investigators found that the pilot had consulted private doctors about it.
A clash of egos could also have been a factor, Morozov said, noting that the second pilot felt like the real leader.
The plane was already past half of the 3,000-meter (9,900-foot) runway when the crew tried and failed to lift it. Both pilots then threw their body weight on the steering wheels desperately trying to lift the plane and managed to apply even more pressure on the brakes while doing so.
The jet sped past the runway and ran nearly 450 meters (1,485 feet) onto the grass before finally taking off. It lifted up too sharply and immediately banked on its wing, crashing on the side of the Volga River, 150 miles (240 kilometers) northeast of Moscow.
The team had been heading to Minsk, Belarus, to play its opening game of the Kontinental Hockey League season.
Among the dead were Lokomotiv coach and National Hockey League veteran Brad McCrimmon, a Canadian; assistant coach Alexander Karpovtsev, one of the first Russians to have his name etched on the Stanley Cup as a member of the New York Rangers; and Pavol Demitra, who played for the St. Louis Blues and the Vancouver Canucks and was the Slovakian national team captain.
Other standouts killed were Czech players Josef Vasicek, Karel Rachunek and Jan Marek, Swedish goalie Stefan Liv, Latvian defenseman Karlis Skrastins and defenseman Ruslan Salei of Belarus.
The crash raised new concerns about Russia's aviation safety and prompted the president to suggest replacing all aging Soviet-era aircraft with Western-made planes.
But industry experts say recent Russian air disasters have been rooted not just in the age of the planes, but in a combination of other factors, including insufficient crew training, crumbling airports, lax government control and widespread neglect of safety in the pursuit of profits.