Aeroflot Flight 821
The aircraft involved in the accident 3 months before the crash.
|Date||14 September 2008|
|Summary||Spatial disorientation caused by Pilot error, poor crew resource management and alcohol consumption level by the captain|
|Site||Perm, Russia |
|Aircraft type||Boeing 737–505|
|Flight origin||Sheremetyevo International Airport, Moscow, Russia|
|Destination||Perm International Airport, Perm, Russia|
Aeroflot Flight 821 was a scheduled passenger flight operated by Aeroflot-Nord in a service agreement with Aeroflot and as its subsidiary. On 14 September 2008, the aircraft operating the flight crashed on approach to Perm International Airport at 5:10 local time (UTC+06). All 82 passengers and 6 crew members were killed. A section of the Trans-Siberian Railway was damaged by the crash. Flight 821 is the deadliest accident involving a Boeing 737-500, surpassing the 1993 crash of Asiana Airlines Flight 733, and was the second-deadliest aviation incident in 2008, behind Spanair Flight 5022.
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.
The Boeing 737–505, registration VP-BKO, an aircraft belonging to the Aeroflot subsidiary Aeroflot-Nord but operating as Aeroflot flight SU821 from Moscow's Sheremetyevo International Airport to Perm (Russia) crashed into a railway line southwest of Perm 5:10 AM local time (or 13 September 2008, 23:10 UTC). The weather at the time of accident was rainy (unbroken clouds at 240 m, 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 turning 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; minutes later it crashed in 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 were killed. As the plane was coming in for landing, it lost communication at the 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 3 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 m) 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 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 involved in the crash was originally ordered by Braathens, but never operated by them and was quickly sold shortly after delivery to China Southwest Airlines, whose subsidiary Xiamen Airlines operated the airframe from September 1992 to March 1993. The 737 was then operated by China Southwest Airlines itself until the airline merged with Xiamen Airlines, who operated the aircraft from March 2003 until it was stored in March 2008 and sold to Pinewatch Limited. Aeroflot-Nord then leased the aircraft from Pinewatch Limited, and had operated the airframe from 29 May 2008 until its hull loss. Pinewatch was incorporated in 1995.
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 Authority, and Boeing. As the aircraft was registered in Bermuda, that government was represented by the UK's Air Accident 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 d'Enquêtes et d'Analyses pour la sécurité de l'Aviation Civile (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 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 CRM 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 an unspecified amount of alcohol in the captain's tissue. He also did not have adequate rest before the flight.
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
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A recording of the conversation between ATC and Flight 821 was published online. According to the final investigation report, the pilot was 'mildly intoxicated', and this can be heard in the audio.
Irek Birbov, the air traffic controller on duty at the time of the incident, said that on final approach the aircraft was too far right of the localizer. He advised the pilot 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." The aircraft should have been at an altitude of 600 m at that time to descend further 300 m. 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 pilot 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 m, the controller radioed the plane to maintain 600 m. In response, the pilots' final radio transmission was "Aaa (expletive)!" A moment later the controller saw an explosion.
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 Medvedev had a flight record of 3689 hours while First Officer Rustam Allaberdin had 8713. Later it was revealed that Medvedev's flight record as a captain was 452 hours and that Allaberdin's experience of Boeing 737's piloting was just 219 hours. For the most part of their careers Medvedev and Allaberdin were piloting Tu-134 and 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.
|People's Republic of China||1|
- 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.
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|Wikimedia Commons has media related to Aeroflot Flight 821.|
- Final accident report – Interstate Aviation Committee – Unofficial English translation – Hosted by the Air Accidents Investigation Branch (AAIB) (Archive)
- Investigation (Archive) – Interstate Aviation Committee (in Russian)
- Lenta.ru page listing passengers of the flight
- Aeroflot news archive
- Aeroflot page listing passengers of the flight
- (in Russian) АЭРОФЛОТ-НОРД ПРИНОСИТ ГЛУБОКИЕ СОБОЛЕЗНОВАНИЯ РОДСТВЕННИКАМ ПОГИБШИХ." Aeroflot Nord. 14 September 2008. – Aeroflot Nord press release about the accident