Country
code

Republic of Tatarstan

Crash of a Let L-410UVP-E3 in Menzelinsk: 16 killed

Date & Time: Oct 10, 2021 at 0911 LT
Type of aircraft:
Operator:
Registration:
RF-94591
Flight Phase:
Survivors:
Yes
Schedule:
Menzelinsk - Menzelinsk
MSN:
87 18 26
YOM:
1987
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
The twin engine aircraft departed Menzelinsk for a local skydiving mission, carrying 20 skydivers and two pilots. During initial climb, the crew reported technical problems with the left engine and elected to return for an emergency landing. The aircraft lost height and eventually struck a concrete wall before coming to rest on a wood piles. Six passengers were rescued while 14 other occupants were killed.

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

Date & Time: Apr 3, 2016 at 0732 LT
Type of aircraft:
Operator:
Registration:
RA-54828
Flight Phase:
Survivors:
Yes
Schedule:
Aksarino - Aksarino
MSN:
1G184-35
YOM:
16
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6095
Aircraft flight hours:
6782
Circumstances:
The pilot, sole on board, was engaged in a crop spraying mission over plantation located near Aksarino, Republic of Tatarstan, and the aircraft was carrying a load of 1,200 kilos of fertilizers. Shortly after takeoff, while climbing, the engine encountered technical problems. The pilot elected to make an emergency landing when the aircraft crash landed in a field and came to rest. The aircraft was damaged beyond repair and the pilot was uninjured.
Probable cause:
Most probably the accident with An-2 RA-54828 aircraft after its takeoff in order to perform crop dusting was caused by inadvertent engine cut-off due to water ingestion into fuel flow system. Most probably water ingestion into engine fuel flow system was due to violation of refueling procedure by the crew. The aircraft sustained significant damage during the emergency landing on slush soft surface.
Final Report:

Crash of a Boeing 737-53A in Kazan: 50 killed

Date & Time: Nov 17, 2013 at 1924 LT
Type of aircraft:
Operator:
Registration:
VQ-BBN
Survivors:
No
Schedule:
Moscow - Kazan
MSN:
24785/1882
YOM:
1990
Flight number:
TAK363
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
50
Captain / Total flying hours:
2783
Captain / Total hours on type:
2509.00
Copilot / Total flying hours:
2093
Copilot / Total hours on type:
1943
Aircraft flight hours:
51547
Aircraft flight cycles:
36596
Circumstances:
On final approach to Kazan from Domodedovo in marginal weather conditions, crew was forced to make a go around as the aircraft was not correctly aligned with the runway centerline. While climbing to a height of 700 meters, the aircraft went out of control, nosed down and hit the ground. The aircraft disintegrated on impact and all 50 occupants were killed. MAK reported in a first statement that the crew did not follow the standard approach profile and the approach was unstable. TOGA mode was selected, autopilot deactivated and flaps raised from 30 to 15 degrees. As gear were retracted, the aircraft pitched up to about 25 degrees nose up and the indicated airspeed decreased from 150 to 125 knots. Crew countered the nose up by control inputs and the climb was stopped. Aircraft reached a maximum height of 2,300 feet and began to rapidly descend until it impacted the ground with a near vertical angle of 75 degrees at a speed of 242 knots, some 20 seconds after reaching the height of 2,300 feet. The crash was no survivable.
Probable cause:
Systemic weaknesses in identifying and controlling the levels of risk, non-functional safety management system in the airline and lack of control over the level of crew training by aviation authorities at all levels (Tatarstan Civil Aviation Authority, Russian Civil Aviation Authority), that resulted in an unqualified crew being assigned to the flight.
During the go-around the crew did not recognize that the autopilot had disconnected resulting in the aircraft impacting ground in a complex spatial position (nose up upset). The captain, pilot flying, lacked the skills to recover the aircraft from the complex spatial upset (lack of Upset Recovery), that led to significant negative G-forces, loss of spatial orientation sending the aircraft into a steep drive (75 degrees nose down) until impact with ground.
The go around was required because the aircraft on its final approach arrived in a position from which landing was impossible as result of a map shift by about 4000 meters (aircraft systems determining the position of the aircraft in error), the inability of the crew in those circumstances to combine aircraft control and navigation with needed precision, and the lack of active support by air traffic control during prolonged observation of significant deviation from the approach procedure.
The following factors were considered as contributory:
The captain not having had primary flight training,
The flight crew members being allowed to upgrade to Boeing 737 without satisfying the required qualifications including the English language,
Methodical shortcomings in retraining as well as verification of results and quality of training,
Insufficient level of organisation of flight operations at the airline, which resulted in failure to detect and correct shortcomings in working with the navigation equipment, pilot technique and crew interaction, including missed approaches,
Systematic violation of crew work and rest hours, a large debt of holidays, which could have resulted in accumulation of fatigue adversely affecting crew performance, Simulator training that lacked a missed approach with intermediate height and all engines operating,
Increased emotional stress to the flight crew before deciding to go around because they could not establish the position of their aircraft with the necessary precision to accomplish a successful landing,
Violation of the principle "Aviate, Navigate, Communicate" by both flight crew and air traffic control, which resulted in the flight crew not following standard operating procedures at the time of initiating the go around because the pilot monitoring was diverted from his duties for a prolonged period and did not monitor the flight parameters,
The fact that the crew did not recognize the autopilot had disconnected and delayed intervention by the crew, that resulted in the aircraft entering a complex spatial position (nose up upset),
Imperfection of simulator training programs for Upset Recovery Procedures as well as lack of criteria for assessing the quality of training, which resulted in the crew being unable to recover the aircraft from the upset,
The possible impact of somatogravic illusions,
The non-addressing of prior accident investigation recommendations, geared towards elimination of risks and establishing risk level management, had prevented the prevention of this accident,
Lack of proper supervision of issuance of pilot certificates in accordance with achieving specified requirements and qualifications,
Failure of safety management system (SMS) in the airline, lack of guidelines for SMS development and approval, lack of a formal approach to approve/agree on SMS and pilot training by the related authorities,
Deficiencies in aviation training centers' performance and absence of verification of training quality,
Lack of requirements for flight crew to be proficient in English Language for retraining on foreign aircraft types and lack of formal approach to verify language proficiency,
lack of formal approach to conduct periodic verification of flight crew qualification,
systematic violation of crew work and rest times,
lack of training of flight crew on go around from intermediate heights in manual control potentially leading to complex spatial position (e.g. nose high upset),
The map shifts in aircraft without GPS without training of crew to operate in such conditions,
Lack of active assistance by air traffic control when the approach procedure was deviated from over a prolonged period of time,
Breach of principle "Aviate, Navigate, Communicate".
Translation via www.avherald.com
Final Report:

Crash of a PZL-Mielec AN-2R in Kholodnyy Klyuch

Date & Time: Jun 21, 1994
Type of aircraft:
Operator:
Registration:
RA-40788
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kholodnyy Klyuch - Kholodnyy Klyuch
MSN:
1G173-15
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Sole on board, the copilot decided to make an illegal survey flight for crop spraying operations in the region of Kholodnyy Klyuch. En route, he encountered low patches of fog and suffered a spatial disorientation. Control was lost and the aircraft crashed on the ground. The pilot was slightly injured and the aircraft was damaged beyond repair.
Probable cause:
Loss of control after the pilot suffered spatial disorientation while flying in foggy conditions.

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

Date & Time: Apr 14, 1992
Type of aircraft:
Operator:
Registration:
CCCP-70451
Flight Phase:
Survivors:
Yes
Schedule:
Sukharevo - Sukharevo
MSN:
1G143-30
YOM:
1973
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a crop-spraying flight in Sukharevo, about 23 km southwest of Nizhnekamsk. While cruising at low altitude, the engine lost power due carburetor icing. The crew attempted an emergency landing when the aircraft collided with a high voltage power line and crashed. Both pilots were injured and the aircraft was destroyed.
Probable cause:
Engine failure after carburetor iced up.

Crash of an Antonov AN-24RV in Bugulma: 41 killed

Date & Time: Nov 26, 1991 at 0502 LT
Type of aircraft:
Operator:
Registration:
CCCP-47823
Survivors:
No
Schedule:
Nizhnevartovsk - Bugulma
MSN:
17307204
YOM:
1971
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
41
Circumstances:
The aircraft departed Nizhnevartovsk on a charter flight to Bugulma, carrying four crew members and 37 employees from an oil company. Weather conditions in Bugulma were poor with clouds down to 80 metres, icing conditions and a visibility of 800 metres. At an altitude of 1,100 metres on approach, the crew encountered icing conditions but did not consider it necessary to activate the deicing systems. Still descending to the altitude of 900 metres, the icing alarm sounded in the cockpit but the captain decided to continue the approach in such configuration. After the crew selected the flaps down to an angle of 30°, he was cleared to land when the aircraft became unstable and departed the approach path to the right. After the aircraft crossed the permissible deviation limit, the crew was instructed by ATC to initiate a go-around procedure. The captain increased engine power and initiated a go-around maneuver when the aircraft adopted a high angle of attack then stalled and pitched down to an angle of 75-80°. At a speed of 260 km/h, the aircraft struck the ground 802 metres short of runway and was destroyed upon impact. The wreckage was found 598 metres to the right of the extended runway centerline and all 41 occupants were killed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Icing conditions and poor weather conditions that were underestimated and misevaluated by the flight crew,
- An excessive accumulation of frost on the stabilizers (up to 15 millimetres),
- Failure of the crew to activate the deicing systems prior to enter the clouds,
- The decision of the captain to continue the approach after the icing alarm sounded,
- The crew selected flaps down to an angle of 30° without inspecting the wings and stabs surfaces, (in icing conditions, flaps should be deployed in 15° max),
- The flaps were not retracted when the crew initiated the go-around procedure, which caused the aircraft to adopt a high angle of attack,
- Poor crew interactions,
- Lack of crew supervision and mutual monitoring and checks.

Crash of a PZL-Mielec AN-2R in the Kuybyshev Reservoir: 3 killed

Date & Time: Jun 2, 1991
Type of aircraft:
Operator:
Registration:
CCCP-05704
Flight Phase:
Flight Type:
Survivors:
No
MSN:
1G153-17
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Based at Tenki after being dispatched for a local spraying mission, the single engine aircraft was stolen by the copilot who was intoxicated. He took off in the afternoon with two other unauthorized people and later, the aircraft crashed in unknown circumstances in the Kuybyshev Reservoir. The wreckage was not recovered. Two dead bodies were later found in the Kama River. The third occupant was never found.

Crash of a Let L-410UVP in Muslyumovo

Date & Time: Feb 17, 1991
Type of aircraft:
Operator:
Registration:
CCCP-67145
Flight Phase:
Survivors:
Yes
MSN:
80 04 11
YOM:
1980
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on a snow covered runway, the crew lost control of the airplane that veered off runway and came to rest in a ravine. All 17 occupants escaped uninjured while the aircraft was damaged beyond repair.

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

Date & Time: Jan 16, 1990
Type of aircraft:
Operator:
Registration:
CCCP-05703
Survivors:
Yes
MSN:
1G153-16
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While approaching Kurkachi Airport, the engine failed. The crew attempted an emergency landing when the aircraft collided with the mast of a high-voltage powerline and crashed. All 13 occupants were injured and the aircraft was destroyed.
Probable cause:
Engine failure on approach after a newspaper had blocked the air intake.

Crash of an Antonov AN-24B in Bugulma: 38 killed

Date & Time: Mar 2, 1986 at 0304 LT
Type of aircraft:
Operator:
Registration:
CCCP-46423
Survivors:
No
Schedule:
Moscow - Cheboksary - Bugulma
MSN:
0 73 041 08
YOM:
1970
Flight number:
SU77F
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
34
Pax fatalities:
Other fatalities:
Total fatalities:
38
Aircraft flight hours:
31570
Aircraft flight cycles:
23765
Circumstances:
On approach to Bugulma Airport by night, the left propeller autofeathered. The aircraft speed dropped and the aircraft started to veer to the left. The crew elected to maintain directional control but the speed continued to drop. At a speed of 140 km/h, the aircraft banked left to an angle of 110° then stalled and crashed in a field located 8 km from the runway threshold and 500 meters from its extended centerline. The aircraft was totally destroyed and all 38 occupants were killed.
Probable cause:
The left propeller autofeathered one second after the flaps were deployed in an angle of 38° because an electrical switch connected to the automatic feathering system failed. This situation affected the aircraft stability and controllability and the crew was unable to correct abnormal yaw and roll following several errors.