Date of plane crash: September 14, 2008
Time of plane crash: 05:10
Country of the plane crash: Russia
Location of the plane crash: Perm region, Perm
Aircraft make: Boeing 737-500
Aircraft registration: VPBKO
Airline company name: Aeroflot-Nord
Flight: SU821
Chronology of events:
The controller gave instructions to turn to a course of 360 degrees; and decrease to the height of the circle. The commander began negotiations with the dispatcher about whether it was possible to land without a repeat approach and did not carry out the command even after three repetitions. At this time, he intervened twice in the control; with a disproportionate movement to the right of the steering wheel, he created a roll of 17 degrees; and 50 degrees;. When the plane returned to level flight, it again began to climb while losing speed. Then the left bank began to increase, but for 25 seconds no impact on the controls was recorded, that is, in fact, no one was controlling the plane. When the left bank became critically 30 degrees, and the flight altitude was 1200 m, the co-pilot asked the commander to take control. The commander, with a sharp movement to the left of the helm, increased the roll to a critical value of 76 degrees; The co-pilot reacted to his actions with the exclamation “in the other direction, on the contrary!” and helped bring the plane out of the roll. Over the next 11 seconds, the Commander made sharp movements with the steering wheel in different directions and, in the end, sharply tilted the steering wheel to the left, almost all the way. The plane went into a tailspin, making a flip over the left wing, and went into rapid descent mode, collided with the ground at high speed on a double-track railway section within the city of Perm, (Bakharevka-Perm-2 section) with an azimuth of 60 degrees and was completely destroyed. More than 100 m of railway tracks and overhead contact network railway collapsed. The crash site was located between two large residential areas of Perm in the south of the city.
Among the passengers was Colonel General Troshev Gennady, Hero of Russia, who commanded different years a united group of Russian troops in Dagestan and Chechnya.
Information about the victims:
There were a total of 88 people on board: 6 crew members and 82 passengers. A total of 88 people died: 6 crew members, 82 passengers.
Details of the plane crash:
Flight phase: approach
Identified causes of the plane crash: crew error
Aircraft details:
Aircraft make: Boeing 737-500
Aircraft ID: VPBKO
Country in which the aircraft was registered: Bermuda
Aircraft production date: 1992
Aircraft serial number: 25792/2353
Aircraft operating hours: 44533
Aircraft operating cycles: 35104
Flight details:
Flight: SU821
Flight type: Regular passenger
Aviation company: Aeroflot-Nord
Country in which the aviation company was registered: Russia
Flew from: Moscow (Sheremetyevo)
Flew to: Perm
Starting point: Moscow (Sheremetyevo)
Final destination: Perm
Additional data:
Crew details:
Commander - Rodion Mikhailovich Medvedev
Co-pilot - Rustam Rafailevich Allaberdin
flight attendants:
Plan:
- Introduction
- 1 Circumstances of the disaster
- 2
Investigation into the causes of the disaster
- 2.1 Transcript of voice recorder recordings
- 3 Airplane
- 4 Crew
- 5 Victims
- 6 Consequences
- 6.1 Railroad damage
Notes
Introduction
Flight SU821 disaster- a major aviation accident involving a Boeing 737-500 passenger aircraft of the Russian airline Aeroflot-Nord (currently Nordavia) on September 14, 2008.
The plane was flying SU821(from Moscow to Perm) of the parent company Aeroflot under a joint transportation agreement. The plane crashed during landing. As a result of the collision with the ground, all people on board were killed. This is the first crash of a Boeing 737 aircraft in Russia.
1. Circumstances of the disaster
The plane took off from Sheremetyevo Airport at 1:12 local time (UTC+4).
When landing at Bolshoye Savino airport, the pilots acted inappropriately, not following the dispatcher’s orders: when instructed to maintain an altitude of 600 meters, the plane began to climb to 900 meters; when instructed to begin a right turn, it began to turn left, etc. When The crew denied that there were any problems on board.
The aircraft was controlled throughout the entire flight with numerous violations of existing rules.
In the last minutes of the flight, the co-pilot, unable to cope, handed over control to the commander; the plane was in a state of aborted approach. The aircraft commander, having incorrectly read instrument readings (the attitude indicator), performed a fatal roll maneuver at 5:09:14 local time (UTC+6), after which the aircraft performed a roll and entered an uncontrolled dive. At a speed of about 470 km/h, the plane crashed into the ground at 5:09:25 on the border of the Industrial and Sverdlovsk districts of the city of Perm, two hundred meters from the nearest residential building. The plane was completely destroyed and there was a fire on the ground.
2. Investigation into the causes of the disaster
The Minister of Transport of the Russian Federation Igor Levitin, who headed the commission, the head of the Federal Air Transport Agency Evgeny Bachurin, and the head of the Rosaeronavigation Alexander Neradko were sent to investigate the disaster as part of the government commission. Also sent to the crash site were the head of the Investigative Committee under the Prosecutor's Office, Alexander Bastrykin, and the presidential plenipotentiary representative in Privolzhsky federal district Grigory Rapota, chief forensic expert of the Ministry of Health and Social Development Russian Federation Vladimir Klevno.
October 30, 2008 new head of the Federal Agency air transport(Rosaviatsiya) Gennady Kurzenkov, during the conference “Safety of the air transport complex,” stated that the causes of the disaster were “the lack of interaction between the crew and the shortcomings of the entire system of their preparation for flights.”
The immediate cause of the accident was the loss of spatial orientation by the crew, primarily the PIC [aircraft commander], who was actively piloting the aircraft during the final stage of the flight, which led to the aircraft flipping over the left wing, entering an intensive descent and colliding with the ground. Loss of spatial orientation occurred while flying at night, in the clouds, with the autopilot and autothrottle disabled. The factor that contributed to the loss of spatial orientation and the inability to restore it was the insufficient level of professional training of the crew in terms of aircraft piloting techniques, resource management (CRM) and the acquisition of skills in recovering from complex spatial positions of the aircraft with direct indication of artificial horizons installed on foreign and modern domestic aircraft. This indication differs from the indication used on types aircraft, mastered by crew members earlier (Tu-134, An 2).
The systemic cause of this accident, identified, among other things, by the results of inspections carried out by Rostransnadzor and Rosaviation after the accident, was the insufficient level of organization of flight and technical operation of Boeing 737 aircraft at the airline.
Deficiencies in the technical operation of the aircraft led to long-term flights with the “fork” in the throttle position [engine control levers] greater than the maximum allowed by the aircraft technical operation manual and failure of technical personnel to carry out the actions prescribed by the technical operation manual to eliminate this defect. The presence of a “fork” in the throttle position increased the workload on the crew during the landing approach. ...
Based on the results of a forensic medical examination performed at the State Healthcare Institution of a special type “Perm Regional Bureau of Forensic Medical Examination”, the presence of ethyl alcohol in the PIC’s body before death was established. The PIC's work and rest schedule in the period preceding the accident contributed to the accumulation of fatigue and did not comply with current regulatory documents.
Commission conclusion
A criminal case was opened on the day of the disaster under Article 263 of the Criminal Code of the Russian Federation. The investigation was closed on March 15, 2010 with the wording “due to the death of the suspect.” However, on April 26, 2010, this decision was reversed and the case was sent for additional investigation in order to verify the actions of officials involved in the disaster.
2.1. Transcript of voice recorder recordings
The flight recorders of the crashed plane were transferred to the Interstate Aviation Committee for investigation. Their tape drives suffered significant damage, but they managed to read the records of both devices. Transcription of the recordings has been completed. Despite the testimony of eyewitnesses who saw the plane allegedly “on fire,” both engines of the fallen Boeing-737 were working before the collision with the ground; there was no fire or explosion on board.
Video reconstruction of the last minutes of the aircraft - Perm - Crush on YouTube(obscene vocabulary).
Recording conversations
On September 23, an unconfirmed transcript of conversations between the dispatcher and the crew appeared in the hectop live journal.
- Dispatcher: Aeroflot 821, departure 13, approach the glide path.
- Aeroflot 821:
- Dispatcher: Aeroflot 821, approach course.
- Aeroflot 821: ...
20 seconds.
- Dispatcher: 821, according to my information, dial, ... altitude 900, confirm.
- Aeroflot 821: (pause) I confirm the set, we are descending.
- Dispatcher: Aeroflot 821, make a right turn to course 360, descend 600.
- Aeroflot 821: Aeroflot, we are making a turn 600, 821.
- Dispatcher: 821, plan for a repeat approach, vectoring to the fourth turn.
- Aeroflot 821: if you don’t mind (pause), we’ll continue our approach.
- Dispatcher: Aeroflot 821, course 360, descend 600, plan for return approach.
- Aeroflot 821: Repeated approach, descending 600, Aeroflot 821.
- Dispatcher: 821, is everything okay with your crew?
- Aeroflot 821: I confirm.
- Dispatcher: 821, I understand, then strictly follow the commands, calculate vectoring until the fourth turn, right turn to course 360.
- Aeroflot 821: 600 on course 360, Aeroflot 821. 20 seconds.
- Dispatcher: Aeroflot 821, work with approach...
P...t!!! (Scream.)
3. Airplane
The Boeing 737-500 aircraft (reg. number VP-BKO, serial number 25792) was released in September 1992, previously operated by Chinese airlines Xiamen Airlines, China Southwest Airlines, Air China. Aeroflot-Nordom was leased for the period from July 28, 2008 to March 21, 2013. Lessor - Pinewatch Limited (Ireland). The owner of the airliner at the time of the disaster was ARN 737 Limited, Bermuda.
The head of the Federal Air Transport Agency, Evgeny Bachurin, said that “ the aircraft was technically sound: the airworthiness certificate was issued on May 23, 2008 and was due to expire on May 22, 2009. Last check[technical check] was passed at the Vnukovo aircraft repair plant No. 400 on September 7 this year» .
4. Crew
Representatives of the Aeroflot-Nord airline immediately after the disaster stated that the plane’s crew was experienced, but in fact there were problems with the crew’s readiness for a night flight. The aircraft commander, Rodion Medvedev, had a total flight time of 3,689 hours (most of the flight time was on the Tu-134), and co-pilot Rustam Allaberdin had 8,713 hours of flight time (most of the flight time was on the An-2). At the same time, Medvedev spent 452 hours as PIC, and Allaberdin’s piloting experience on a Boeing was only 219 hours. The first indicator is comparable to the annual flight time of one aircraft, and the second does not meet the European standard for obtaining a commercial pilot license, which is 300 hours. Their level of proficiency English language was insufficient to pilot an aircraft with technical documentation only in English. Analyzing the actions of the pilots, IAC concluded that they lacked basic skills in flying multi-engine aircraft with spaced apart engines.
In addition, both pilots returned from vacation on September 11 and, without having time to get into flight shape, were assigned to perform a night flight. In the three days preceding the flight, the commander completed 6 flights (3 of them at night) and was deprived of proper rest.
In addition, experts found an increased alcohol content in the muscle tissue of the aircraft commander, Rodion Medvedev, which may indicate that the pilot was drunk during the flight. The commission's report mentions an SMS sent from a plane by one of the passengers to an acquaintance in the UK; she wrote that she was very scared because the commander’s voice sounded like the voice of a “completely drunk man.”
According to the investigation, the commander constantly confused echelons, frequencies and his call sign, which was a consequence of a combination of fatigue and the presence of alcohol in the blood. The crew’s speech “was replete with obscene expressions with extremely harsh unfounded comments addressed to the flight attendants and the airport’s air traffic control service, as well as lengthy discussions not directly related to solving current problems, which did not allow them to adequately concentrate attention on solving urgent problems in controlling the aircraft.” .
5. Victims
Memorial stone at the crash site
There were 82 passengers (including 7 children) and 6 crew members on board the plane.
According to NTV television and the Ministry of Emergency Situations, citizens of 12 countries died in the disaster.
| Citizenship | Death toll |
|---|---|
| 65 people | |
| 9 people | |
| 5 people | |
| 1 person | |
| 1 person | |
| 1 person | |
| 1 person | |
| USA | 1 person |
| 1 person | |
| 1 person | |
| 1 person | |
| China | 1 person |
Five passengers who missed flight 821 were transported by airport staff to Yaroslavsky railway station and sent to Perm by rail.
Among the dead were several famous people: Advisor to the President of the Russian Federation, Hero of Russia, Colonel General Gennady Nikolaevich Troshev, First Vice-President of the All-Russian Sambo Federation of Russia Vladimir Evgenievich Pogodin, President of the Sambo Federation of Chuvashia and Deputy of the State Council of the Republic Alexander Ivanovich Trofimov.
The dead were identified through DNA analysis.
On January 18, 2011, the Perm District Court approved a settlement agreement on the claim of the relatives of one of the victims. The total amount of payments amounted to 6.5 million rubles
6. Consequences
The insurance company servicing Aeroflot will pay the families of the victims up to 2 million rubles per person. The families of the victims will receive 12 thousand rubles in compensation from the state.
Aeroflot announced that it is abandoning the practice of operating joint flights with Nord and prohibiting it from using Aeroflot’s fleet to operate its own flights. From September 15, 2008, Aeroflot-Nord will not be able to use the Aeroflot brand due to the withdrawal of its trademark by Aeroflot - Russian Airlines. At that moment, airline representatives, however, stated that they refused to comply with this decision. On December 1, 2009, the company changed its name to “Nordavia - Regional Airlines”.
In addition, Aeroflot sent a commission to check the technical condition of the aircraft of its other subsidiary, Aeroflot-Don.
6.1. Railroad damage
The plane crashed on the double-track section Bakharevka - Perm II of the Sverdlovsk Railway; as a result of the fall, about 100 meters of the upper structure of the track and about 500 meters of the contact network were destroyed. About 400 m of the main fiber-optic cable of the EMTSSS Russian Railways was damaged. Normal train service on the Trans-Siberian Railway was interrupted, and trains were diverted. Due to search work at the site of the plane crash, the restoration of the railway track was postponed. Only the fiber cable was repaired, restoring Russian Railways communications before the start of search work (in the first few hours). Train traffic was carried out in a detour, through the Chusovskaya station. By the end of the day on September 14, traffic was completely restored.
Notes
- 1 2 The Boeing crash in Perm claimed the lives of 88 people, of which 21 were foreigners - www.rian.ru/incidents/20080914/151253739.html
- The Boeing 737 plane crashed - www.aviaport.ru/digest/2008/09/14/157323.html
- The Boeing 737 plane crash in Perm killed 88 people - pda.avia.ru/news/?id=1221396776
- “Dispatcher: the Boeing crew behaved inappropriately” - www.gazeta.ru/news/lenta/2008/09/14/n_1270291.shtml. Article on Gazeta.ru
- 1 2 MAK - Final report on the results of the investigation of the aircraft accident - Boeing 737-500 VP-BKO (full text) - www.mak.ru/russian/investigations/2008/vp-bko_report.pdf
- A Boeing 737 passenger plane flying from Moscow to Perm crashed - www.aviaport.ru/digest/2008/09/15/157372.html
- Malfunction or terrorist attack - www.aviaport.ru/digest/2008/09/15/157415.html
- http://www.prime-tass.ru/news/show.asp?id=832852&ct=news - www.prime-tass.ru/news/show.asp?id=832852&ct=news
- NR2.Ru::: The Perm plane crash was attributed to the pilots / 10.30.08 / New Region - Scandals and incidents - www.nr2.ru/incidents/203832.html
- The term “fork” refers to different adjustments of the right and left engines, when, with the same position of the engine control levers, different thrust is realized, and vice versa, with the same thrust, the position of the engine control levers is different.
- The case of the plane crash in Perm was closed due to the death of the suspect - www.rian.ru/general_jurisdiction/20100315/214384901.html. RIA Novosti (03/15/2010).
- The resolution to terminate the criminal case regarding the 2008 crash of the Boeing 737 505 near Perm was canceled - www.sledcomproc.ru/news/18701/, Investigative Committee under the Prosecutor's Office of the Russian Federation.
- Relatives of the victims of the Boeing crash in Perm are waiting for an assessment of the actions of officials - www.rian.ru/society/20100426/226827229.html. RIA Novosti (04/26/2010).
- MAK has completed work on deciphering the black boxes of the Boeing 737 plane that crashed in Perm - pda.avia.ru/news/?id=1222346411
- http://www.aviacompromat.ru/rus/content/download/3281/17691/file/821.mp3 - www.aviacompromat.ru/rus/content/download/3281/17691/file/821.mp3 Recording of negotiations in MP3
- The “black box” of the fallen Boeing was discovered - pda.lenta.ru/news/2008/09/14/perm1/
- MAK official website. Boeing-737-500 VP-BKO 09/14/2008 - www.mak.ru/russian/investigations/2008/boeing-737-500.html
- http://hectop.livejournal.com/677467.html - hectop.livejournal.com/677467.html
- VIEW / The system is to blame for the Boeing crash - www.vz.ru/society/2008/9/24/211454.html
- 1 2 3 Novaya Gazeta | No. 71 of September 24, 2008 | “Is everything okay in the crew?” - www.novayagazeta.ru/data/2008/71/10.html
- Boeing 737 - MSN 25792 - www.airfleets.net/ficheapp/plane-b737-25792.htm
- Updated information on the accident from the official website of Aeroflot-Nord - www.aeroflot-nord.ru/news/actual/?file=5000171409200829
- The Boeing that crashed in Perm was previously operated in China - www.rian.ru/incidents/20080914/151247204.html RIA Novosti
- I. Levitin reported that no signs of a terrorist attack were found. The dispatcher said that the pilot showed inadequacy before the crash - www.aviaport.ru/digest/2008/09/15/157374.html
- Interfax. Who ruined Boeing - www.interfax-russia.ru/r/B/eventday/490.html?menu=1&id_issue=12146894
- 1 2 3 4 5 6 7 MAK report - www.mak.ru/russian/investigations/2008/vp-bko_report.pdf
- Plane crash near Perm: was the pilot drunk? - www.avia.ru/press/13804/
- Alcohol was found in the tissues of the commander of the Boeing 737-500 plane that crashed in Perm - www.avia.ru/news/?id=1233561507. From February 2, 2009
- The “black box” of the fallen Boeing was discovered - lenta.ru/news/2008/09/14/perm1/index.htm Lenta.ru
- Plane crash of Boeing 737 on flight No. 821 Moscow - Perm - mchs.gov.ru/portal_news/detail.php?ID=9645 Portal of the Russian Ministry of Emergency Situations
- The Perm region allocated 7.7 million rubles to speed up DNA testing - Boeing, disaster - Rosbalt - www.rosbalt.ru/2008/09/16/524174.html
- Passengers who were late for flight No. 821 were sent by airport employees to Yaroslavsky Station - www.aviaport.ru/digest/2008/09/14/157346.html
- Mourning will be declared in the Perm region on Monday - www.rian.ru/society/20080914/151249835.html
- Blood sampling begins from relatives of those killed in the plane crash // AviaPort. Digest - www.aviaport.ru/digest/2008/09/15/157390.html
- 4.5 million rubles - compensation for the death of the mother - TV Company VETTA - vetta.tv/news/society/14180/
- Aeroflot stopped cooperation with Aeroflot-Nord due to the disaster in Perm - prm.ru/global/2008-09-14/22981
- Aeroflot broke off relations with the owner of the fallen Boeing - www.lenta.ru/news/2008/09/14/aeroflot/
- Aeroflot-Nord does not intend to change its name | Newspaper. Ru: Chronicle of the day - www.gazeta.ru/news/lenta/2008/09/15/n_1270479.shtml
- Aeroflot is inspecting the aircraft fleet of its subsidiary Aeroflot-Don - www.aviaport.ru/digest/2008/09/14/157363.html
- Due to a plane crash near Perm, traffic on the Trans-Siberian Railway was stopped - www.tatar-inform.ru/news/2008/09/14/132284/ “TatarInform”
- Trains on the Trans-Siberian Railway were launched to bypass the Boeing crash site - www.vesti.ru/doc.html?id=208954 Vesti.ru
- Traffic along the damaged section of the Trans-Siberian Railway has been completely restored - rian.ru/society/20080914/151259483.html RIA Novosti
On September 14, 2008, during a re-approach to Perm, a Boeing 737-500 passenger plane of Aeroflot-Nord Airlines (currently Nordavia), operating flight SU821 on the Moscow-Perm route, crashed.
All 88 people on board (82 passengers and 6 crew members) were killed. Among the dead were seven citizens of Azerbaijan, six of Ukraine, one each of France, Italy, Germany, Uzbekistan, Turkey, China and Belarus. On board the plane was also the former commander of the North Caucasus Military District, Hero of Russia, Colonel General Gennady Troshev. Also, as a result of the plane crash, Deputy of the State Council of Chuvashia, President of the Republican Sambo Federation Alexander Trofimov, who was flying with General Gennady Troshev and the First Vice-President of the All-Russian Sambo Federation of the Russian Federation Vladimir Pogodin to the Perm Territory to participate in the Sambo tournament in memory of Vasily Shvai, died as a result of the plane crash.
An aviation technical forensic examination found that before takeoff, the Boeing had two malfunctions: the engine thrust control system was not functioning, the onboard collision avoidance system was also faulty, which was not a reason to terminate flights, and the decision on takeoff was authorized to be made by the aircraft crew commander .
The weather conditions made it possible to land the plane safely, and by the time of the tragedy the aircraft commander had repeatedly carried out similar flights and landings without violations. A minor lack of qualifications permitted by the requirements of the pilot training program, according to investigators, also could not be considered a violation.
In March 2010, the case of the plane crash in Perm was closed due to the death of the suspect, but on September 14, 2010 it was resumed on the initiative of relatives dead passengers aircraft, after which it was reopened and closed several times. Additional investigative actions were carried out, including interrogation of members of the regional qualification commission of the Arkhangelsk UGAN and pilots who had previously piloted the aircraft. Another two years of investigation made it possible to once again establish that there were no perpetrators of the tragedy other than the commander of the ship himself. November 11, 2012 criminal case regarding the Boeing crash
The technical commission completed the investigation of the disaster An Aeroflot-Nord Boeing 737 crashed in September 2008, killing all 88 people on board. Several reasons contributed to the fall, in particular, incorrect actions of the dispatcher, a technical malfunction of the airliner and its design features, as well as crew errors and the “painful” condition of the commander, in whose tissues alcohol was found.
On September 14 last year, an Aeroflot-Nord Boeing 737 aircraft, flying from Moscow to Perm, crashed during a re-entry in difficult weather conditions at Perm Bolshoye Savino airport. All 88 people on board were killed. Last week, the Interstate Aviation Committee announced that the work of the technical commission to investigate the crash had been completed. However, its results were not made public, since they had not yet been approved by the state commission. The Kommersant newspaper managed to find out from the participants in the investigation what conclusions the experts came to.
Manager error
The first prerequisite for the approaching disaster was the actions of the Perm airport dispatcher, who did not allow the crew of the Russian airliner to land on the first attempt, despite difficult weather conditions. The controller not only sent the plane to re-land, but also changed the landing course. This meant that the crew would need to completely change the memory of the on-board computer geographical coordinates four new checkpoints, which is 24 eight-digit numbers. Due to lack of time, the crew did not do this and was forced to land the plane using manual controls.
The controller has the right to change landing conditions only in emergency situation. But, as experts found out, then the Perm dispatcher did not allow the Russian airliner to land the first time only because the German pilot of the departing Lufthansa Airbus asked to take off first in order to do it against the wind. The controller violated the unwritten rule that a pilot in the air has priority over his colleagues waiting on the ground to take off. If the controller had let the Russian plane through first, it would have cost the German airliner seven minutes to wait. The re-landing of the Russian airliner cost the lives of all passengers on board.
The second reason
Forced to land the plane manually, the crew encountered a technical malfunction of the engines. As experts found out, the right engine developed more power and pushed the car harder than the left one, that is, initially the Boeing turbines had different thrust, which the crew could not know about. During the flight, the machine compensated for this defect. But with manual control, this led to the fact that when the co-pilot, Rustem Allaberdin, who was controlling the landing, tried to increase the thrust of the throttles (the so-called engine control levers), the airliner sharply turned to the left. However, an experienced pilot could easily cope with such a situation by moving the throttles separately, which is what the crew intended to do.
However, from the transcripts of the pilots' conversations, experts learned that the crew members began to argue about which particular bank they were in (to the right or to the left). As a result, the incorrect version that the airliner was going to the right won out, and the pilot added a left bank, as a result of which the plane fell into an uncontrollable tailspin.
The initial stage of a tailspin (stall) looks like that:
the roll increases and the hood goes down, and if the pilot at the first moment does not understand what is happening and begins to correct the roll by tilting the stick in the opposite direction and towards himself, trying to eliminate the lowering of the nose of the aircraft, then all the conditions will be created for the aircraft to vigorously go into a tailspin. Signs of the beginning of a stall are: an increase in roll and a lowering of the nose of the aircraft, the impression that you are being spun into a whirlpool ().
After going into a tailspin, the plane crashed to the ground.
Technical features of the aircraft
The crew's fatal error could also have been contributed to by the Boeing aircraft's instrument display features, experts say. The point is that on foreign airliners the device that shows pilots the plane's fuselage relative to the horizon and lateral roll (the so-called attitude indicator) works differently than in Russian airliners. On Russian instruments, the tick airplane swings relative to a stationary horizon line. On foreign artificial horizons, on the contrary, the horizon itself rotates, simulating the real view through the windshield. In addition, there are not one, but two “airplanes” located on the Boeing attitude indicator. One is leading, the position of which is set by the computer itself, and the second simulates the position of a real liner. The pilot at the helm needs to combine “his” with the leading “aircraft”.
Of course, Aeroflot-Nord pilots knew about such features of Boeing attitude indicators. But still, for them they were not too familiar - the crew had much more experience flying on Russian airliners than on the Boeing 737. Crew commander Rodion Medvedev spent almost all of his flight hours as a second pilot of the TU-134. Since graduating from Boeing 737 pilot training in Denver, USA, in 2006, he has logged 1,165 hours of flight time, with only 452 hours as a crew chief. His partner Rustem Allaberdin had impressive flight experience on the An-24, while he had flown only 220 hours on the Boeing 737.
The commander's illness
Participants in the investigation found alcohol in the muscle tissue of crew commander Rodion Medvedev. However, as experts stipulate, this does not mean that the commander was drunk during the flight. Firstly, all crew members underwent pre-flight medical control; everyone’s blood pressure and pulse were normal, and no one smelled of alcohol. Secondly, what is important here is not the fact of the presence of alcohol, but the content of ethyl alcohol (ppm) per unit of body weight, but it is not possible to determine such data. The presence of alcohol in tissues may be a residual phenomenon after long-term use of alcohol or alcohol-containing medications.
As a result, most experts agreed that Rodion Medvedev was in some kind of “painful” state. This is confirmed by the deciphered words of the commander at the most crucial moment, when the controller in difficult weather conditions sent the plane to the second circle and when it was necessary to land the plane “manually.” “You can see for yourself that I can’t,” said the crew commander and handed the helm to his partner.
The plane was performing a scheduled flight SU821 on the route Moscow - Perm for the parent airline Aeroflot under a joint transportation agreement and crashed during landing, approximately 11 kilometers short of the runway of Perm Bolshoye Savino Airport. As a result of the collision of the plane with the surface of the earth and ground objects, all 88 people on board were killed.
This is the first crash of a Boeing 737 aircraft in Russia.
Circumstances of the disaster
Flight SU821 took off from Sheremetyevo Airport on Sunday, September 14, at 01:12 local time (UTC+4).
When landing at Bolshoye Savino airport, the pilots acted inappropriately, not following the dispatcher’s orders: when instructed to maintain an altitude of 600 meters, the plane began to climb to 900 meters; when instructed to start performing a right turn, he began a left turn, etc. At the same time, the crew denied the presence of problems on board.
The aircraft was controlled throughout the entire flight with numerous violations of existing rules.
In the last minutes of the flight, the co-pilot, unable to cope, handed over control to the commander; the plane was in a state of aborted approach. The crew commander, having incorrectly read the instrument readings (the attitude indicator), at 05:09:14 local time (UTC+6) made a fatal roll maneuver, after which the plane performed a roll and entered an uncontrolled dive. At 05:09:25, at a speed of about 470 km/h, the airliner crashed into the ground on the border of the Industrial and Sverdlovsk districts of the city of Perm, near the end of Sovetskaya Armiya Street, opposite its intersection with Karpinsky Street, two hundred meters from the nearest residential building. The impact completely destroyed the plane and the wreckage caught fire. The fire severely damaged what was left of the plane. All 88 people on board the plane (82 passengers and 6 crew members) were killed.
Investigation into the causes of the disaster
The Minister of Transport of the Russian Federation Igor Levitin, who headed the commission, the head of the Federal Air Transport Agency Evgeny Bachurin, and the head of the Rosaeronavigation Alexander Neradko were sent to investigate the disaster as part of the government commission. Also sent to the crash site were the head of the Investigative Committee under the Prosecutor's Office Alexander Bastrykin, the Presidential Plenipotentiary Representative in the Volga Federal District Grigory Rapota, and the chief forensic expert of the Ministry of Health and Social Development of the Russian Federation Vladimir Klevno.
On October 30, 2008, the new head of the Federal Air Transport Agency (Rosaviatsiya) Gennady Kurzenkov, during the conference “Safety of the Air Transport Complex”, said that the causes of the disaster were “the lack of interaction between the crew and the shortcomings of the entire system of their preparation for flights.”
The immediate cause of the accident was the loss of spatial orientation by the crew, primarily the PIC [aircraft commander], who was actively piloting the aircraft during the final stage of the flight, which led to the aircraft flipping over the left wing, entering an intensive descent and colliding with the ground. Loss of spatial orientation occurred while flying at night, in the clouds, with the autopilot and autothrottle disabled. The factor that contributed to the loss of spatial orientation and the inability to restore it was the insufficient level of professional training of the crew in terms of aircraft piloting techniques, resource management (CRM) and the acquisition of skills in recovering from complex spatial positions of the aircraft with direct indication of artificial horizons installed on foreign and modern domestic aircraft. This indication differs from the indication used on types of aircraft previously mastered by crew members (Tu-134, An-2).
The systemic cause of this accident, identified, among other things, by the results of inspections carried out by Rostransnadzor and Rosaviation after the accident, was the insufficient level of organization of flight and technical operation of Boeing 737 aircraft at the airline.
Deficiencies in the technical operation of the aircraft led to flights for a long time with the “fork” in the throttle position [engine control levers] greater than the maximum allowed by the aircraft technical operation manual and failure of the technical personnel to carry out the actions prescribed by the technical operation manual to eliminate this defect. The presence of a “fork” in the throttle position increased the workload on the crew during the landing approach. ...
Based on the results of a forensic medical examination performed at the State Healthcare Institution of a special type “Perm Regional Bureau of Forensic Medical Examination”, the presence of ethyl alcohol in the PIC’s body before death was established. The PIC's work and rest schedule in the period preceding the accident contributed to the accumulation of fatigue and did not comply with current regulatory documents.
Commission conclusion
A criminal case was opened on the day of the disaster under Article 263 of the Criminal Code of the Russian Federation. The investigation was closed on March 15, 2010 with the wording “due to the death of the suspect.” However, on April 26, 2010, this decision was reversed and the case was sent for additional investigation in order to verify the actions of officials involved in the disaster. In July 2012, the criminal case was again discontinued due to the death of the person subject to criminal liability.
Transcript of voice recorder recordings
The flight recorders of the crashed plane were transferred to the Interstate Aviation Committee for investigation. Their tape drives suffered significant damage, but they managed to read the records of both devices. Despite the testimony of eyewitnesses who saw the plane allegedly “on fire,” both engines of the fallen Boeing-737 were working before the collision with the ground: there was no fire or explosion on board.
Aircraft information
Boeing 737-505 ( registration number VP-BKO, factory 25792, serial 2353) was released on September 8, 1992. The owner of the aircraft was ARN 737 Limited (Bermuda). Powered by two General Electric CFM56-3C-1 turbojet engines. Exploited Norwegian airline Braathens (from 8 to 24 September 1992, flight LN-BRW) and Chinese airlines Xiamen Airlines (from 24 September 1992 to 12 March 1993), China Southwest Airlines (from 12 March 1993 to 1 March 2003) and Air China (from March 1, 2003 to May 29, 2008, in all of them flew under the permanent license plate B-2591). On May 29, 2008 it was leased Russian airline Aeroflot-Nord for the period from July 28, 2008 to March 21, 2013. The lessor was Pinewatch Limited (Ireland). On the day of the disaster, he performed 35,104 takeoff-landing cycles and flew 44,533 hours.
The head of the Federal Air Transport Agency, Evgeny Bachurin, said that “ the aircraft was technically sound: the airworthiness certificate was issued on May 23, 2008 and was due to expire on May 22, 2009. Last check[technical check] was passed at the Vnukovo aircraft repair plant No. 400 on September 7 this year».
Crew information
- The aircraft commander (PIC) is 34-year-old Rodion Mikhailovich Medvedev. A very experienced pilot, worked for Aeroflot-Nord airline for 2 years. He flew An-2 (at school) and Tu-134 (co-pilot). On June 23, 2008, he became the commander of a Boeing 737. He flew 3,900 hours, 1,190 of them on a Boeing 737 (477 as PIC).
- The second pilot is 43-year-old Rustam Rafailovich Allaberdin. Experienced pilot, worked for Aeroflot-Nord airline for 2 years. He flew An-2 (co-pilot, then PIC) and Tu-134 (co-pilot) aircraft. On March 6, 2008, he became the second pilot of a Boeing 737. He flew 8,900 hours, 236 of them on a Boeing 737.
There were four flight attendants working in the aircraft cabin:
- Anna Dmitrievna Shirokova. 22 years old, total flight time 1822 hours.
- Tamara Viktorovna Noritsyna. 23 years old, total flight time 982 hours.
- Anna Yuryevna Yakovleva. 27 years old, total flight time 653 hours.
- Olga Vasilievna Kuchma. 26 years old, total flight time 525 hours.
Representatives of the Aeroflot-Nord airline immediately after the disaster stated that the plane’s crew was experienced, but in fact there were problems with the crew’s readiness for a night flight. The first indicator for a pilot is comparable to the annual flight time of one aircraft, and the second does not satisfy the European standard for obtaining a commercial pilot license, which is 300 hours. Their level of English proficiency was insufficient to pilot an aircraft with technical documentation only in English. Analyzing the actions of the pilots, IAC concluded that they lacked basic flying skills on multi-engine aircraft with separated engines.
In addition, both pilots returned from vacation on September 11 and, without having time to get into flight shape, were assigned to perform a night flight. In the three days preceding the flight, the commander completed 6 flights (3 of them at night) and was deprived of proper rest.
In addition, experts found an increased alcohol content in the muscle tissue of the aircraft commander, Rodion Medvedev, which may indicate that the pilot was drunk during the flight. The commission's report mentions an SMS sent from the plane by one of the passengers to her friend in the UK: she wrote that she was very scared because the commander's voice sounded like the voice of a “completely drunk man.”
According to the investigation, the commander constantly confused echelons, frequencies and his call sign, which was a consequence of a combination of fatigue and the presence of alcohol in the blood. The crew’s speech “was replete with obscene expressions with extremely harsh unfounded comments addressed to the flight attendants and the airport’s air traffic control service, as well as lengthy discussions not directly related to solving current problems, which did not allow them to adequately concentrate on solving urgent problems in controlling the aircraft.” .
There were 82 passengers (including 7 children) and 6 crew members on board the plane.
According to the NTV television company and the Russian Ministry of Emergency Situations, citizens of 11 countries died in the disaster.
Five passengers who were late for flight 821 were taken by airport staff to the Yaroslavsky station and sent to Perm by rail.
Among the dead were several famous people: Advisor to the President of the Russian Federation, Hero of Russia, Colonel General Gennady Nikolaevich Troshev; First Vice-President of the All-Russian Sambo Federation of Russia Vladimir Pogodin; President of the Chuvash Sambo Federation and Deputy of the State Council of the Chuvash Republic Alexander Ivanovich Trofimov, international master of sports in cycling Sergei Izhboldin.
The dead were identified through DNA analysis.
On January 18, 2011, the Perm District Court approved a settlement agreement on the claim of the relatives of one of the victims. The total amount of payments amounted to 6.5 million rubles
Consequences of the disaster
The insurance company servicing Aeroflot paid the families of the victims up to 2,000,000 rubles per person. The families of the victims received 12,000 rubles in compensation from the state.
Aeroflot announced that it is abandoning the practice of operating joint flights with Aeroflot-Nord and prohibiting it from using Aeroflot’s fleet to operate its own flights. From September 15, 2008, Aeroflot-Nord was not supposed to use the Aeroflot brand due to the withdrawal of its trademark by Aeroflot - Russian Airlines. At the time, however, airline officials said they refused to abide by the decision. Since December 1, 2009, the company nevertheless changed its name to “Nordavia - Regional Airlines”. In fact, the operation of Aeroflot-Nord (later Nordavia) aircraft on Aeroflot flights continued until the sale of the company to Norilsk Nickel and the transition to the winter schedule of 2011/2012. Nordavia flights within the framework of code-share transportation with Aeroflot continued until 2014.
In addition, Aeroflot sent a commission to check the technical condition of the aircraft of its other subsidiary, Aeroflot-Don.
As a result of an internal investigation, Aeroflot-Nord flight director Nikolai Kholopov was dismissed from his position. None of the airline's executives were punished, since the investigation did not establish their guilt in the plane crash.
Railroad damage
The plane crashed on the double-track section Bakharevka - Perm II of the Sverdlovsk Railway, as a result of which about 100 meters of the upper structure of the track and about 500 meters of the contact network were partially destroyed. About 400 m of the main fiber-optic cable of the EMTSSS Russian Railways was damaged and normal train service on the Trans-Siberian Railway was interrupted. Due to search work at the site of the plane crash, the restoration of the railway track was postponed. Only the fiber cable was repaired, restoring Russian Railways communications before the start of search work (in the first few hours). Train traffic was carried out in a detour, through the Chusovskaya station. By the end of the day on September 14, traffic was completely restored.
