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Crash of a Boeing 737-505 in Perm: 88 killed

Date & Time: Sep 14, 2008 at 0510 LT
Type of aircraft:
Operator:
Registration:
VP-BKO
Survivors:
No
Schedule:
Moscow - Perm
MSN:
25792/2353
YOM:
1992
Flight number:
AUL821
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
3900
Captain / Total hours on type:
1190.00
Copilot / Total flying hours:
8900
Copilot / Total hours on type:
236
Aircraft flight hours:
44533
Aircraft flight cycles:
35104
Circumstances:
On September 13, 2008 an Aeroflot –Nord flight crew (Captain and copilot), were conducting a scheduled domestic passenger flight n°AFL821 on a B737-505 aircraft, registration VP-BKO, from Moscow (Sheremetyevo, UUEE) to Perm (Bolshoye Savino, USPP). Apart from the two-member flight crew there were 4 flight attendants and 82 passengers on board, which makes a total of 88 people, including 66 citizens of the Russian Federation, 8 citizens of Azerbaijan, 1 citizen of Byelorussia, 1 of Germany, 1 of Italy, 1 of China, 1 of Latvia, 1 of Turkey, 1 of Uzbekistan, 5 citizens of Ukraine and 2 of France. According to the load sheet, the aircraft payload (cargo and passengers) was 8079 kg. The takeoff weight was ~54000 kg (with the max TOW of 60554 kg), the CG was at 20.61 % MAC, which was within the B-737-500 FCOM limitations. The calculated landing weight was 49700 kg (with the maximum of 49895 kg), and the CG was at 21.9 % MAC, which was also within the B737-500 FCOM limitations. The pre-flight briefing was conducted in due time and in compliance with the standard procedures. All the crew members passed medical check at the medical office of Aeroflot – Russian Airlines on September 13, 2008 at 1948 hrs and got permissions to fly. On the basis of the dispatch information (aircraft condition, aeronautical information, weather information, aircraft load data and operational flight plan) the PIC at 1955 hrs made a decision to fly. The takeoff was performed at 2113 without delay. The climb and level flight at FL290, 9,100 metres were conducted without any deviations. At 2245 hrs the crew started descent from the flight level to waypoint Mendeleyevo (940 MN). After passing over Mendeleyevo, in compliance with the Perm Approach Control instruction, the aircraft flew via the outer marker (705 PX) of Runway 21 which is the initial approach fix (IAF) for Runway 21 (heading 212° magnetic). After passing over the RWY with heading 110° M, the crew, following the Controller’s instruction, turned right for back course and started maneuvering for ILS approach to Runway 21. After the base turn, approaching the landing course at 600 m with both autopilot and autothrottle disengaged, the aircraft started climbing up to 1300 m, rolled 360° over the left wing and collided with the ground. The aircraft was totally destroyed and partly burnt in the ground fire. All passengers and crew members on board died due to the ground impact. The accident occurred at 2310 hrs 12.4 km from aerodrome reference point (ARP) of Perm Airport, azimuth 60° M. Accident site elevation is 153 m.
Probable cause:
The immediate cause of the accident was spatial disorientation of the crew, especially the Captain who was the pilot flying at the final stage of the flight, which led to the left flip-over, a steep descent and the crash of the aircraft. The spatial disorientation was experienced during the night time operation in clouds, with both autopilot and autothrottle disengaged. Contributing to the development of the spatial disorientation and failure to recover from it was a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using "western"-type attitude indications that are found on foreign and modern Russian made aircraft. This type of indication differs from the one used on aircraft types previously flown by the crew (Tupolev 134, Antonov 2). The cause above was determined on the basis of flight recorders and ATC recorder data analysis, examination of the airframe and engine wreckage, results of the accident flight simulation, findings of the independent expertise conducted by test pilots from State Research Institute of Civil Aviation and Gromov Flight Research Institute as well as line pilots, and also on the basis of all the works conducted with participation of experts from Bermuda, France, Russia, UK and USA in the course of the investigation. The systemic cause of the accident was insufficient management by the airline of flight and maintenance operations of the Boeing 737 type of aircraft. These deficiencies in the aircraft maintenance also revealed through safety inspections conducted by the Russian Transport Oversight Authority and the Russian CAA after the accident. Deficiencies in the aircraft maintenance led to a situation when flights were performed for a long time with a throttle stagger that exceeded the limitations in the AMM and when the maintenance staff did not follow the AMM recommended troubleshooting procedures. The need to manage the throttle stagger during the approach increased crew workload. The forensic medical examination performed in the State Healthcare Center of Special Status “Perm Regional Forensic Expertise Bureau” confirmed the presence of ethyl alcohol in the Captain’s body before his death. The captain’s recent work schedule during the time period before the accident was conducive to fatigue and did not comply with national regulations.
Final Report:

Crash of an Antonov AN-12BP in Chelyabinsk: 9 killed

Date & Time: May 26, 2008 at 2011 LT
Type of aircraft:
Operator:
Registration:
RA-12957
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Chelyabinsk - Perm
MSN:
8 3 455 08
YOM:
1968
Flight number:
GIA9675
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Aircraft flight hours:
42817
Aircraft flight cycles:
14828
Circumstances:
Following an uneventful cargo flight from Moscow to Chelyabinsk where a load of 9 tons of various goods was deplaned, the aircraft was ferried to Perm. One minute after takeoff from Chelyabinsk Airport runway 09, while climbing in marginal weather conditions, the crew declared an emergency and reported smoke in the cockpit. After being cleared to return, the crew completed a circuit. During a third turn to the left, while in a left bank of 15° and at a speed of 335 km/h, both left engines failed and their propellers autofeathered. About 40 seconds later, the aircraft entered a right turn then descended to the ground and crashed in an open field located 11 km from Chelyabinsk Airport, bursting into flames. The accident occurred 8 minutes after takeoff. The aircraft was totally destroyed and all 9 occupants were killed.
Probable cause:
The accident was the result of a loss of controllability due to the destruction of the aileron control cables while carrying out an emergency approach to Chelyabinsk Airport after smoke spread in the cabin and the cockpit. The destruction of aileron wiring occurred, presumably, in the area of the 23-25 web frames of the cargo hold. The reason for the destruction of the wiring installation has most likely been a significant heating of a control rod located in this zone, made of alloy D16-T, and its subsequent break under tension-load operation. Heating of the control rod could be a consequence of fire of the aircraft's electricity network, in immediate proximity of the control rod. This led smoke to spread in the cargo hold, unexpected triggering of alarm systems, aircraft equipment failures, and the auto-shutdown of two engines. Electrical bunch-conductors, distributors, blocks and aggregates of the aeronautical equipment, located in the 15-25 frames zone (ceiling of the cargo compartment) came under intense attack by fire, resulting in a collision collision with the ground, as a result of which it was impossible to accurately determine the primary origin and reason of the fire.

Crash of an Ilyushin II-76TD in Irkutsk

Date & Time: Jul 26, 1999 at 1346 LT
Type of aircraft:
Operator:
Registration:
RA-76819
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tianjin – Irkutsk – Perm – Moscow
MSN:
10134 09274
YOM:
1991
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2882
Aircraft flight cycles:
1177
Circumstances:
The aircraft departed Tianjin on a cargo flight to Moscow with intermediate stops in Irkutsk and Perm, carrying a load of 49,750 kilos of various goods and seven crew members. At Irkutsk-Intl Airport, 38 tons of fuel were uplifted and the crew calculated 30,040 kilos for the cargo, giving a total weight of 170 tons, about 4 tons below the MTOW. During the takeoff roll, after a course of 2,000 metres, at a speed of 225 km/h, the captain started the rotation. The aircraft lifted up and flew for about 4 seconds when the captain requested gear up. At a speed of 250 km/h, the aircraft passed the runway end and adopted a 16° angle of attack. Then the aircraft' speed decreased when the flight engineer reduced the power on all four engines and activated the thrust reverser systems on both left engines n°1 and 2. The aircraft rolled to the left, collided with a building containing an electrical transformer and came to rest 1,476 metres past the runway end, bursting into flames. All seven occupants were injured, two seriously. The aircraft was destroyed.
Probable cause:
It was determined that the total weight of the aircraft at the time of the accident was 198-200 tons which means 24-26 tons above MTOW. The cargo manifest showed a total weight of 49,750 kilos of various goods upon departure from Tianjin Airport but only 30,040 kilos upon departure from Irkutsk Airport while no cargo was unloaded. The following contributing factors were identified:
- A miscalculation of the mass and balance,
- Poor flight planning,
- Poor crew coordination.

Crash of an Antonov AN-24B in Sovetskiy: 32 killed

Date & Time: Nov 21, 1989 at 1728 LT
Type of aircraft:
Operator:
Registration:
CCCP-46335
Survivors:
Yes
Schedule:
Perm - Sovetskiy
MSN:
97305602
YOM:
1979
Flight number:
SU37577
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
32
Aircraft flight hours:
36861
Aircraft flight cycles:
31763
Circumstances:
Following an uneventful flight from Perm, the crew started the descent to Sovetskiy Airport and was informed about the weather conditions at destination with ceiling down to 80 meters and an horizontal visibility estimated to 2 kilometers, which was below minimums. Despite this situation, the crew decided to continue the approach and deliberately passed below the minimum descent altitude probably to establish a visual contact with the ground. On short final, the aircraft struck tree tops (25 meters high), banked right and crashed in a wooded area located 700 meters short of runway 30, about 250 meters to the right of its extended centerline, bursting into flames. Eight passengers were rescued while 32 other occupants were killed.
Probable cause:
It was determined that the accident was the consequence of a wrong approach configuration of the flying crew who decided to continue the approach in below weather minimums and passed the MDA until the aircraft contacted trees and crashed.
The following contributing factors were reported:
- Poor approach planning,
- Unsatisfactory crew interactions,
- Poor distribution of tasks among the flight crew,
- Violation of minimums,
- The crew decided to continue the approach after passing the MDA,
- The crew failed to initiate a go-around procedure.

Crash of a PZL-Mielec AN-2R in Perm

Date & Time: Mar 16, 1989
Type of aircraft:
Operator:
Registration:
CCCP-41383
Flight Phase:
Survivors:
Yes
MSN:
1G67-01
YOM:
1966
Location:
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed following an engine failure. There were no casualties.
Probable cause:
Engine failure for unknown reasons.

Crash of an Antonov AN-24B near Petukhovo: 39 killed

Date & Time: Jan 21, 1973 at 2356 LT
Type of aircraft:
Operator:
Registration:
CCCP-46276
Flight Phase:
Survivors:
No
Schedule:
Krasnodar – Volgograd – Saratov – Kazan – Perm
MSN:
77303609
YOM:
1967
Flight number:
SU6263
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
39
Aircraft flight hours:
10623
Aircraft flight cycles:
11419
Circumstances:
At 2354LT, while cruising at an altitude of 5,700 meters in good weather conditions, the crew was cleared to descend to 4,500 meters and confirmed his ETA in Perm in 15 minutes. Less than two minutes later, the airplane went out of control and entered a dive and reached the speed of 1,000 km/h. At 2,700 meters, the captain was able to regain control for few seconds when the airplane made an upward looping and started to lose parts due to excessive g loads. Out of control, it went down and eventually crashed at a speed of 250 km/h in a field covered by 70 cm of snow and located near Petukhovo, about 90 km north of Perm. The wreckage was found at 1400LT on January 22 and all 39 occupants have been killed. It was later reported that four passengers survived the crash but died due to extreme low temperature (-41° C) before the rescuers arrived on site.
Probable cause:
The exact cause of the accident could not be determined with certainty. It is believed that traces of explosives were found on several debris but this was not proven and the Soviet Authorities confirmed there were no military activities in the area at the time of the accident.

Crash of a Lisunov LI-2 in Molotov: 3 killed

Date & Time: Jun 4, 1943
Type of aircraft:
Operator:
Registration:
CCCP-L344
Flight Phase:
Flight Type:
Survivors:
Yes
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Just after rotation from Molotov Airport, the aircraft stalled and crashed. It veered off runway, hit a parked Lisunov LI-2 registered CCCP-L3962 and came to rest in a wooded hangar. All three crew members were killed while all seven passengers were seriously injured.
Probable cause:
The pilot attempted to take off from a wrong runway and the rotation was completed after a take-off roll of 340 meters only. Due to an insufficient speed, the aircraft stalled shortly after take off.

Crash of a GVF PS-84 in Perm: 1 killed

Date & Time: May 11, 1943 at 1130 LT
Type of aircraft:
Operator:
Registration:
CCCP-L3931
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Perm - Perm
MSN:
184 14 01
YOM:
22
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew was engaged in a test flight after one of the engine was changed. Shortly after takeoff, while in initial climb, both engines flamed out simultaneously. The captain decided to return for an emergency landing but the aircraft lost height, hit the roofs of two wooded houses and crashed few km from the airport. A crew member was killed while four other occupants were seriously injured. The aircraft was destroyed.
Probable cause:
It appears that the flight mechanic made a mistake in handling the fuel management system after liftoff, causing both engines to stop.

Crash of a GVF PS-84 in Ustinovo

Date & Time: Jan 25, 1942 at 1815 LT
Type of aircraft:
Operator:
Registration:
CCCP-L3479
Survivors:
Yes
Schedule:
Krymskaya – Kuybychev – Molotov
MSN:
184 09 01
YOM:
1941
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
766
Circumstances:
The airplane was performing a special flight from Krymskaya to Molotov (now Perm) with an intermediate stop in Kuybyshev (now Samara). The goal of the mission was to pick up spare parts for deliver in Krymskaya. While descending to Molotov Airport at dusk, the crew encountered poor weather conditions with snow falls. As the pilot was unable to locate the airport and was forced several time to abandon the approach and to go around, he eventually attempted to land in a snow covered field located near Ustinovo, about 3,5 km southwest of the airfield. The aircraft crash landed and was damaged beyond repair. All nine occupants were injured.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The captain decided to continue the flight despite poor weather conditions and limited visibility due to snow falls,
- The crew was cleared for takeoff by airport authorities in Kuybyshev despite poor weather conditions,
- The weather briefing was not reflecting the true conditions.