The plane crash that devastated Yaroslavl's Lokomotiv hockey team in September was caused by multiple pilot errors, including sedatives in a pilot's blood, inadequate training and a crucial instrument mix-up, investigators said in their final report Wednesday.
In a two-hour news conference, lead crash investigator Alexei Morozov and others from the Interstate Aviation Commission led journalists on a harrowing, moment-by-moment replay of Lokomotiv's last moments, beginning with pre-flight chit-chat in the cockpit and ending with the pilot's last word, a frantic "f---."
Forty-four people were killed — everyone on board the plane but its mechanic — in the Sept. 7 crash, which sent shockwaves through the hockey world and sparked a new round of soul-searching and finger-pointing in what has been a disastrous year for Russian air travel.
The crash was caused less by a string of errors than by one crucial mistake, investigators said: At least one of the two pilots had his feet on the brakes as the chartered Yak-42 rolled down the runway. As a result, the plane failed to gather sufficient speed, lurching off the ground only to crash back down on the banks of the Tunoshonka River half a kilometer away.
Having excluded mechanical failure early on, investigators strained to explain how two pilots — both with more than 600 hours experience flying Yak-42s — could have made such a rudimentary mistake and then failed to notice and correct it.
Captain Andrei Solomentsev and co-pilot Igor Zhevelov were trained on the older Yak-40 and had spent significantly more time on that aircraft, which uses a different pedal configuration than the Yak-42, investigators said. The place where a pilot rests his foot during takeoff on the Yak-40 is a brake on the Yak-42.
For technical reasons, it is not clear which pilot was pressing the brakes.
Investigators blamed Yak-Service, the plane's operator, for botching a retraining program that was supposed to prepare the pilots for flying the Yak-42. The program was ineffective because it took place piecemeal over a long period of time, with long breaks, and the pilots continued to fly Yak-40s while they were being trained on the Yak-42s, investigators said.
Investigators also said Yak-Service "didn't have the organization structure, the business model or the financing arrangement to ensure safe travel," according to a report published on the web site of the Interstate Aviation Commission, which handles crash investigations.
The company, whose fleet numbered five planes before the crash, lost its license in mid-September. The government has also announced a crackdown on airlines with less than 10 planes in operation. Eight fatal crashes this year have killed 120, according to Aviation-safety.net, a fact that didn't stop commission chairwoman Tatyana Anodina from reminding the audience that air travel was still the safest mode of transportation.
One of the revelations in Wednesday's report was that a barbiturate called phenobarbital was found in the co-pilot's blood. It was unclear why he was taking the drug, which is typically used to treat seizures and whose sedative effect may have deadened his sensitivity and reaction time in the crucial seconds when the takeoff could have been aborted.
There has been speculation that the plane was rushed into takeoff because the airport was crowded with jets arriving for a global political forum in Yaroslavl that day. But investigators denied this, and a tape from a flight recorder played Wednesday, complete with conversation between ground control and pilots, contained nothing that confirmed this version.
The recording also provided little insight into why the crew decided not to abort the flight, a option the pilots never discussed. Earlier, observers had speculated that the pilots were afraid of damaging the plane or delaying Lokomotiv's regular season opener in Minsk.
The final report into the crash may have given some closure to the accident, but it was of little comfort to Lokomotiv fans.
"Many of us don't believe the results," said Yekaterina Sulayeva, a Lokomotiv fan. She said speculation that the plane was hurried into taking off remain widespread among fans and victims' families.
But for at least one aviation expert, the case is closed. "The committee specialists are highly qualified. There's never been a reason not to trust them," said Roman Gusarov, editor-in-chief of industry web site Avia.ru.