Aeroflot Flight 821
The primary cause of the crash was that both pilots had lost spatial orientation due to their inexperience with the Western type of attitude indicator on the aircraft. Lack of adequate rest, poor crew resource management, and alcohol consumption by the captain also contributed to the accident.
This air disaster led to Aeroflot-Nord rebranding as Nordavia, effective on 1 December 2009, and later to Smartavia in 2019.
Accident
The Boeing 737-505, registration VP-BKO, an aircraft belonging to the Aeroflot subsidiary Aeroflot-Nord but operating as Aeroflot flight SU821, was travelling from Moscow's Sheremetyevo International Airport to Perm (Russia). The aircraft crashed into a railway line southwest of Perm at 5:10 AM local time (13 September 2008, 23:10 UTC). The area was rainy at time of the accident (unbroken clouds at 240 metres (790 ft), light rain).
According to an interview given by the air traffic controller shortly after the disaster, the crew did not respond correctly to ATC commands: after going around, it turned eastward instead of westward. However, the crew reported no emergency onboard and confirmed all commands given by ATC. At 5:10 AM, radio contact with the plane was lost as it crashed on the outskirts of Perm.
Aeroflot-Nord officially stated that: "The Boeing-737 carried 82 passengers on board – including 7 children – and 6 crew. All passengers and crew were killed. As the plane was coming in for landing, it lost communication at a height of 1,100 metres (3,600 ft) and air controllers lost its blip. The airplane was found within Perm's city limits completely destroyed and on fire." Investigator Vladimir Markin said that "there were 82 passengers plus a baby and 5 crew on board, and by preliminary information, they are all dead as the airplane fell into a ravine near the city limits." RIA Novosti however reported that "it was possible that three people who bought a ticket for the ill-fated flight 821 to Perm did not get on board."
Both flight recorders were found and successfully decoded. The airline stated, "it pledged to pay compensation on obligatory accident insurance in full, which would make up to 2 million rubles per victim." The crash damaged and shut down a section of the Trans-Siberian Railway; rail traffic was temporarily re-routed via Chusovaya station and was restored by the evening of 14 September. The aircraft was leased by Aeroflot-Nord from Dublin-based Pinewatch Limited from July 2008 to March 2013.
It was reported that its engines caught fire at an altitude of 1,000 metres (3,300 ft). Eyewitness reports stated that the plane was visibly on fire prior to crashing and hit the ground at a 30–40-degree angle. However, the low clouds (at 240 metres (790 ft)) must have prevented any witnesses from seeing the plane for more than a few seconds and the report was subsequently discounted by the accident enquiry (see below).
The final enquiry report stated that "after the base turn, approaching the landing course at 600 metres (2,000 ft) with both autopilot and autothrottle disengaged, the aircraft started climbing up to 1,300 metres (4,300 ft), rolled 360° over the left wing and collided with the ground".
Aircraft
The aircraft involved in the crash was originally ordered by Braathens, but never operated by them and was quickly sold shortly after delivery to Xiamen Airlines, who operated it from September 1992 to March 1993. The 737 was then operated by China Southwest Airlines itself until the airline merged with Air China, who operated the aircraft from 2003 until it was stored in March 2008 and was returned to Pinewatch Limited. Aeroflot-Nord then leased the aircraft and had operated the airframe from 29 May 2008 until its hull loss.
Crew
According to early claims of Aeroflot-Nord representatives, the crew was described as very experienced and one of the best in the company. Captain Rodion Mikhailovich Medvedev (Russian: Родион Михайлович Медведев; age 34) had a flight record of 3,689 hours (including 1,190 hours on the Boeing 737) while First Officer Rustem Rafailovich Allaberdin (Russian: Рустем Рафаилович Аллабердин; age 43) had 8,713 hours, though only 219 of them were on the Boeing 737. Later it was revealed that Medvedev's flight record as a captain was 452 hours along with Allaberdin's low experience of piloting the Boeing 737. For the most part of their careers, Medvedev and Allaberdin had piloted the Tupolev Tu-134 and Antonov An-2 respectively. Gennady Kurzenkov, head of the State Aviation Inspection Service, stated that the flight crew submitted falsified documents to the airline showing that they had passed preflight courses.
Casualties
Nationality | Casualties |
---|---|
Russia | 66 |
Azerbaijan | 8 |
Ukraine | 5 |
Belarus | 1 |
China | 1 |
France | 2 |
Germany | 1 |
Italy | 1 |
Latvia | 1 |
Turkey | 1 |
Uzbekistan | 1 |
Total | 88 |
Notable deaths
- Gennady Troshev, Colonel General in the Russian military, formerly the commander of the North Caucasus Military District (including Chechnya) during the Second Chechen War and adviser to the President of Russia.
Investigation
Russia's Air Accident Investigation Commission of the Interstate Aviation Committee led the investigation, with US assistance from the National Transportation Safety Board, the Federal Aviation Administration, and Boeing. As the aircraft was registered in Bermuda, that government was represented by the UK's Air Accidents Investigation Branch, with two senior inspectors sent to participate under the Memorandum of Agreement. The AAIB team had representatives from the Bermudian Department of Civil Aviation as advisors. The engines were made in France, so that state was represented by the Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA).
According to the data in flight recorders, the engines did not catch fire and continued working until the impact. The latest official reports are published in Russian on the Air Accident Investigation Commission website. An English translation of the final report is available at the United Kingdom Air Accidents Investigation Branch website; the AAIB states that it is not an official English translation.
The final investigation report stated the following reasons for the crash:
- The immediate cause of the accident was the loss of spatial orientation by the crew and chiefly by the captain, who was piloting the aircraft during the landing phase. The plane banked left, overturned and went into a rapid descent. The loss of spatial orientation occurred in the night, while flying in the clouds, with autopilot and autothrottle switched off. Poor crew resource management and insufficient training for using the Western type of attitude indicators contributed to the accident. The pilots had previously flown Tupolev Tu-134 and Antonov An-2 with a different type of attitude indicator (where the bank angle is shown by the movements of an aircraft symbol, and the indicator's background does not turn left or right).
- Inadequate practices by Aeroflot-Nord in managing and operating the Boeing 737 aircraft.
- The aircraft had been flown for a long time with a throttle problem. The pilots had a higher workload because they had to operate the throttle levers for the left and right engines independently.
- Forensic examination found alcohol in the captain's tissue, with different sample groups suggesting a blood alcohol level of either around 0.05% or around 0.11% abv. He also did not have adequate rest before the flight.
Lawsuit
On 1 October 2008, the mother of a 27-year-old female passenger who died in the accident sued Aeroflot and Moskva Insurance Company for 7.7 million rubles (approximately US$300,000) in punitive damages.
ATC communications before the crash
This section needs additional citations for verification. (September 2017) |
A recording of the conversation between ATC and Flight 821 was published online. According to the final investigation report, the captain, who was making the communications, was 'mildly intoxicated', and this can be heard in the audio.
Irek Birbov, the air traffic controller on duty at the time of the accident, said that on final approach the aircraft was too far right of the localizer. He advised the captain to change heading. Furthermore, instead of descending to land, the plane then went up.
The controller requested Flight 821 to check the altitude: "According to my data, you are climbing. Confirm current altitude 900 meters (3,000 ft)." The aircraft should have been at an altitude of 600 metres (2,000 ft) at that time to descend further 300 metres (980 ft). The pilot replied "Roger, we are descending" and initiated a climb to about 1200 m, at which point he could no longer catch the glideslope. The controller instructed the pilot to turn right and go around. The captain acknowledged but failed to comply. Instead, he turned left and asked to continue his approach. The controller asked whether everything was all right with the crew; the pilots confirmed that it was.
The controller then insisted on a go-around, instructing them to switch to another ATC frequency. The pilots, however, never contacted the other ATC and started to descend quickly. When they were at about 600 metres (2,000 ft), the controller radioed the plane to maintain 600 metres (2,000 ft). In response, the pilots' final radio transmission was "Aaa (expletive)!" A moment later the controller saw an explosion.
In popular culture
The accident was featured in the 19th season of the TV series Mayday. The episode is titled "Lethal Limits".
See also
- Adam Air Flight 574
- Aero Flight 311
- Crossair Flight 498
- Flash Airlines Flight 604
- Indonesia AirAsia Flight 8501
- Japan Air Lines Cargo Flight 1045
- Trans-Colorado Airlines Flight 2286, an accident where a captain impaired by cocaine failed to correct a first officer making multiple pilot errors.
- Flydubai Flight 981, another Boeing 737 which crashed in Russia due to spatial disorientation.
- TAROM Flight 371, another accident involving asymmetrical thrust as well as a pilot becoming confused with a Western style ADI.
- Manx2 Flight 7100, another accident where pilots mishandled an engine power imbalance, leading to a roll.
References
- ^ "Russia: Aeroflot plane crash kills 88". Associated Press. 14 September 2008. Retrieved 21 October 2019 – via The Guardian.
- ^ "Westerners among 88 killed in Russian air disaster". The Telegraph. 14 September 2008. Retrieved 21 October 2019.
- ^ "88 killed: Engine failure cited in deadly Russian plane crash". Die Welt. 15 September 2008. Retrieved 21 October 2019 – via www.welt.de.
- ^ Ranter, Harro. "ASN Aircraft accident Boeing 737-505 VP-BKO Perm Airport (PEE)". aviation-safety.net. Aviation Safety Network. Archived from the original on 17 September 2008. Retrieved 13 June 2019.
- ^ "A Boeing-737 belonging to Aeroflot-Nord crashed today at the airport of Perm" (Press release). Aeroflot. 14 September 2008. Archived from the original on 18 September 2008. Retrieved 14 September 2008.
- ^ "Final report B 737-505 VP-BKO (full text)" (PDF). Interstate Aviation Committee. Archived from the original (PDF) on 4 November 2014. Retrieved 5 September 2018 – via Air Accidents Investigation Branch.
- ^ "Passenger plane crashes in Russia". BBC News. BBC. 14 September 2008. Archived from the original on 14 September 2008. Retrieved 14 September 2008.
- ^ 88 человек погибли при крушении "Боинга-737" под Пермью [88 people died in the crash of the Boeing 737 near Perm] (in Russian). Lenta.Ru. 14 September 2008. Archived from the original on 15 September 2008. Retrieved 14 September 2008.
- ^ Самолет в Перми упал недалеко от жилых домов [The plane in Perm fell near residential buildings] (in Russian). 14 September 2008. Archived from the original on 14 September 2008. Retrieved 14 September 2008.
- ^ При падении Boeing 737 повреждена Транссибирская магистраль [Falling Boeing 737 damaged Trans-Siberian Railway] (in Russian). Gazeta.ru. 14 September 2008. Archived from the original on 14 September 2008. Retrieved 14 September 2008.
- ^ "Crash: Aeroflot-Nord B735 at Perm on Sep 14th 2008, impacted ground while on approach to Perm". Aviation Herald. Retrieved 14 September 2008.
- ^ Диспетчер: экипаж Boeing вел себя неадекватно – Газета.Ru: Хроника дня [Dispatcher: Boeing crew behaved inadequately – Gazeta.Ru: Chronicle of the day] (in Russian). Gazeta.ru. Archived from the original on 16 September 2008. Retrieved 15 September 2008.
- ^ "88 die in Russian jet crash". Toronto Star. Associated Press. 15 September 2008. p. 26.
- ^ "88 including 21 foreigners killed in airplane crash in Russia's Urals". Agence France-Presse. Archived from the original on 18 September 2008.
- ^ "Plane crash kills all on board". ukpress. Archived from the original on 18 September 2008.
- ^ "Russian Aeroflot plane crashes, 88 people killed". 14 September 2008.
- ^ "Foreign Reports". GOV.UK. Air Accidents Investigation Branch. 7 October 2012. Archived from the original on 22 July 2013. Retrieved 2 February 2013.
- ^ "VP-BKO Boeing 737 MSN 25792 Planesregister.com". planesregister.com. 17 September 2008. Archived from the original on 15 July 2011. Retrieved 18 September 2008.
- ^ "Aeroflot-Nord VP-BKO (Boeing 737 – MSN 25792) (Ex B-2591 LN-BRW)". www.airfleets.net. Airfleets aviation. Archived from the original on 2 June 2008. Retrieved 31 October 2019.
- ^ Уточняющая информация [Clarifying information] (Press release) (in Russian). Aeroflot-Nord. 14 September 2008. Archived from the original on 17 September 2008.
- ^ Perm Crash Pilots Used Fake Papers Moscow Times 31 October 2008 (archived 21 November 2008).
- ^ "Все нормально в экипаже? – Первым заподозрил неладное диспетчер аэропорта Большое Савино [Everything is normal in the crew? – The first one was suspected that the dispatcher of the Bolshoe Savino Airport was wrong] Archived 7 December 2008 at the Wayback Machine" Novaya Gazeta (in Russian).
- ^ Aeroflot Nord pilots reported to have used false papers Aero News Net 3 November 2008.
- ^ МЧС России: На борту разбившегося в Перми самолета находилась гражданка Беларуси [EMERCOM of Russia: On board the crashed aircraft was in Perm citizen of Belarus] (in Belarusian). tut.by. 16 September 2008. Archived from the original on 18 September 2008. Retrieved 16 September 2008.
- ^ 在俄客机空难中遇难中国公民为26岁浙江籍女性 [The Chinese citizen was killed in the Russian passenger plane crash. The 26-year-old Zhejiang female] (in Chinese). Xinhua News Agency. 15 September 2008. Archived from the original on 18 September 2008. Retrieved 15 September 2008.
- ^ Russian citizen with a Latvian residence permit (see)
- ^ "Russian plane crash kills 88, faulty engine blamed – Yahoo!! News". Yahoo! News. 14 September 2008. Retrieved 15 September 2008.
- ^ "NTSB assists government of Russia in aviation accident" (Press release). US: National Transportation Safety Board. 14 September 2008. Archived from the original on 16 September 2008.
- ^ "AAIB PARTICIPATE IN RUSSIAN AVIATION ACCIDENT INVESTIGATION" (PDF) (Press release). UK: Air Accidents Investigation Branch. 16 September 2008. Archived from the original (PDF) on 17 July 2012. Retrieved 2 February 2013.
- ^ "Factual report, NTSB ID: DCA08RA097". US: National Transportation Safety Board. DCA08RA097. Archived from the original on 5 December 2008.
- ^ "Boeing-737" (in Russian). Archived from the original on 22 December 2016. Retrieved 23 January 2017.
- ^ "Боинг-737-500 VP-BKO 14.09.2008 [Boeing-737-500 VP-BKO 14.09.2008] (in Russian) "Boeing-737". Archived from the original on 22 December 2016. Retrieved 18 September 2008.." Interstate Aviation Committee. Retrieved 19 February 2009.
- ^ Бывший заместитель директора Московского Дворца молодежи приговорен к сокращению срока [Former Moscow Youth Palace deputy director has her sentence reduced]. Kommersant (in Russian). 2 October 2008. Retrieved 2 October 2008.
- ^ Диспетчер о последних минутах перед авиакатастрофой в Перми [Dispatcher on the last minutes before the crash in Perm] (Press release) (in Russian). RIA Novosti. 15 September 2008. Archived from the original on 18 September 2008. Retrieved 15 September 2008.
- ^ Mayday - Air Crash Investigation (S01-S22), retrieved 13 January 2024
Further reading
- Kaminski-Morrow, David. "Both recorders badly damaged in Aeroflot-Nord 737 crash." Flight International. 15 September 2008.
- Krainova, Natalya. "Jet Flight Recorders Damaged in Crash." The Moscow Times. 16 September 2008. Issue 3989.
External links
External videos | |
---|---|
"Did This Flight Crew Have the Training to Fly a Boeing 737?". Smithsonian Channel. 19 January 2020. |
- Interstate Aviation Committee
- Investigation
- Final accident report – Unofficial English translation – Hosted by the Air Accidents Investigation Branch (AAIB) (Archive)
- Investigation (Archive) (in Russian)
- Final report (in Russian) (Archive) – the Russian version is the report of record.
- Investigation
- Lenta.ru page listing passengers of the flight (Archive)
- Aeroflot news archive (Archive)
- Aeroflot page listing passengers of the flight (Archive)
- (in Russian) АЭРОФЛОТ-НОРД ПРИНОСИТ ГЛУБОКИЕ СОБОЛЕЗНОВАНИЯ РОДСТВЕННИКАМ ПОГИБШИХ." [AEROFLOT-NORD BRINGS DEEP CONDOLENCIES TO THE RELATIVES OF THE DEAD] Aeroflot Nord. 14 September 2008. – Aeroflot Nord press release about the accident (Archive)
- ATC recording with english subtitles on YouTube
- CVR recording with english subtitles on YouTube
- Mentour Pilot's analysis of this flight on YouTube
- Video showing the throttle problem of the aircraft involved in the accident, two days before the crash on YouTube