Plane Crash

 

What Happened?

A Russian passenger plane crashed, killing all 71 people on board.  Prior to take-off, the pilot failed to turn on the heating unit for the plane’s pressure measurement equipment.  The result of this caused the equipment to report incorrect data (zero speed) during flight to the pilot, in turn causing the pilot  to make wrong decisions.  Eventually, the pilot mistakenly put the plane in a 30-35 degree dive, crashing into a field and killing everyone on board.

Contributing Factors

Overall plane design may be a contributing factor - measurement system reporting incorrect readings has been linked to several other crashes or near miss events in the past.

What Can We Learn?

Tools

Using the appropriate Procedures for pre-flight instrument checks could have helped to ensure the heating system was turned on.

A Second Check from the co-pilot could have provided an opportunity to catch the error and completely avoided the crash.

Traps

The pilot had over 5000 hours of flight experience, 2800 hours flying this plane – Overconfidence could have been an issue.

Physical Environment of freezing temperatures caused the instruments to freeze and report incorrectly.

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?