Tatarstan Airlines Flight 363
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Tatarstan Airlines Flight 363 was a scheduled domestic passenger flight, operated by Tatarstan Airlines on behalf of Ak Bars Aero, from Moscow to Kazan, Russia. On 17 November 2013, at 19:24 local time (UTC+4), the Boeing 737-500 crashed during an aborted landing in Kazan International Airport, killing all 44 passengers and 6 crew members on board.Investigation
The Interstate Aviation Committee (IAC) launched an investigation into the crash and arrived at the site on 18 November. Both flight recorders, the flight data recorder (FDR) and the cockpit voice recorder (CVR), were recovered from the wreckage. The Tatarstan Transport Prosecution Office has opened a criminal investigation into the crash. The American National Transportation Safety Board (NTSB) dispatched a team of investigators to the crash site.
On 19 November, Aksan Giniyatullin, the director of Tatarstan Airlines, declared that although the cockpit crew was experienced, the captain of the airliner may have lacked experience performing a go-around maneuver. Moments before the crash the pilot informed the control tower that the aircraft was not properly configured for landing and initiated a go-around, before plunging into the ground as if it had stalled. Investigators said the possible causes of the accident included technical malfunction as well as pilot error. On 22 November the British Air Accidents Investigation Branch announced they had joined the investigation and had dispatched investigators to Kazan.
On 19 November, Aksan Giniyatullin, the director of Tatarstan Airlines, declared that although the cockpit crew was experienced, the captain of the airliner may have lacked experience performing a go-around maneuver. Moments before the crash the pilot informed the control tower that the aircraft was not properly configured for landing and initiated a go-around, before plunging into the ground as if it had stalled. Investigators said the possible causes of the accident included technical malfunction as well as pilot error. On 22 November the British Air Accidents Investigation Branch announced they had joined the investigation and had dispatched investigators to Kazan.
Offical report
On 19 November 2013, the Investigation Board of IAC reported the following preliminary details after recovering some information from the flight data recorder:
Tatarstan Airlines Boeing 737-500 Accident Technical Investigation Board of IAC informs about preliminary results of flight data recorder information recovery.
During the final approach the flight crew were unable to follow a standard landing pattern defined by the regulating documentation. Having considered the aircraft is not lined-up properly relative to the runway, the crew reported to the ATC and started to go-around using the TOGA (Take Off / Go Around) mode. One of the two autopilots, which was active during the final approach, has been switched off and the flight was being controlled manually.
The engines reached thrust level close to full. The crew retracted the flaps from 30 degrees to 15 degrees position.
Affected by the upturn moment generated by the engine thrust, the aircraft started to climb, reaching the pitch angle of about 25 degrees. Indicated airspeed has started to decrease. The crew retracted the landing gear. Since initiating the go-around maneuver up to this moment the crew did not perform control actions through the yoke.
After the airspeed decreased from 150 to 125 knots, the crew started control actions through the yoke, pitching nose down, which has led to stopping climb then starting descent and increase of the airspeed. Maximum angles of attack have not exceeded operational limits during the flight.
After reaching the altitude of 700 meters, the aircraft started a steep nosedive, with the pitch angle reaching −75° by the end of the flight (end of the recording). The aircraft collided with terrain at high speed (exceeding 450 km/h) and with highly negative pitch angle. About 45 seconds have passed between the moment of starting go-around maneuver and the moment the recording stopped, the descent took about 20 seconds. The propulsion systems were operating up to the collision with terrain. No single commands have been detected by the preliminary analysis, which would indicate failures of systems or units of the aircraft or engines. On 24 December 2015, the Interstate Aviation Committee released their final report stating that the crash was caused by an under-qualified crew who lacked the skills to recover from an excessive nose up attitude during a go-around procedure. The go-around was necessitated by a positional error in the navigation system, a map drift. The pilots’ deficiencies were caused by lack of airline safety management and lack of regulators’ oversight.
According to the final report, during the final approach the crew initiated a go-around, but being under high workload, which possibly caused a "tunnel vision effect", they did not perceive warning messages related to auto-pilot disconnection. When the plane climbed to 700 m, its pitch angle reached 25 degrees and the airspeed dropped to 230 km/h. At that moment the captain, who never performed a go-around before, apart from the training, moved the yoke, pitching nose down, which led to stopping climb and started descent and increase of the aircraft's airspeed. After reaching the altitude of 700 m, the aircraft started a steep nosedive, with the pitch angle reaching −75° when the aircraft impacted the ground. The plane crashed on the airport's runway with a speed exceeding 450 km/h. The time from the start of the go-around maneuver until the impact was about 45 seconds, including 20 seconds of aircraft descent.
After reaching the altitude of 700 meters, the aircraft started a steep nosedive, with the pitch angle reaching −75° by the end of the flight (end of the recording). The aircraft collided with terrain at high speed (exceeding 450 km/h) and with highly negative pitch angle. About 45 seconds have passed between the moment of starting go-around maneuver and the moment the recording stopped, the descent took about 20 seconds. The propulsion systems were operating up to the collision with terrain. No single commands have been detected by the preliminary analysis, which would indicate failures of systems or units of the aircraft or engines. On 24 December 2015, the Interstate Aviation Committee released their final report stating that the crash was caused by an under-qualified crew who lacked the skills to recover from an excessive nose up attitude during a go-around procedure. The go-around was necessitated by a positional error in the navigation system, a map drift. The pilots’ deficiencies were caused by lack of airline safety management and lack of regulators’ oversight.
According to the final report, during the final approach the crew initiated a go-around, but being under high workload, which possibly caused a "tunnel vision effect", they did not perceive warning messages related to auto-pilot disconnection. When the plane climbed to 700 m, its pitch angle reached 25 degrees and the airspeed dropped to 230 km/h. At that moment the captain, who never performed a go-around before, apart from the training, moved the yoke, pitching nose down, which led to stopping climb and started descent and increase of the aircraft's airspeed. After reaching the altitude of 700 m, the aircraft started a steep nosedive, with the pitch angle reaching −75° when the aircraft impacted the ground. The plane crashed on the airport's runway with a speed exceeding 450 km/h. The time from the start of the go-around maneuver until the impact was about 45 seconds, including 20 seconds of aircraft descent.
| Incident summary | |
|---|---|
| Date | 17 November 2013 |
| Summary | Pilot error on landing |
| Site | Kazan International Airport, Kazan, Tatarstan, Russia |
| Passengers | 44/td> |
| Crew | 6/td> |
| Fatalities | 50td> |
| Survivors | 0 |
| Aircraft type | Boeing 737-53A |
| Operator | Tatarstan Airlines |
| Registration | VQ-BBN |
| Flight origin | Domodedovo International Airport, Moscow Oblast |
| Destination | Kazan International Airport, Kazan, Tatarstan, Russia |
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