At 19:25, Boeing 737 500 (Tatarstan Airlines), operating flight No. 363 from Moscow to Kazan, exploded upon landing. According to preliminary data, during the landing approach the airliner touched the ground with its wing. As it turned out later, the crew was not ready for landing and requested permission to go around, a source in the republic’s law enforcement agencies told RIA Novosti.
Air traffic controller Kirill Kornishin (on air on the Rossiya 24 TV channel): “He (the pilot) reported to me that he was doing a go-around, and I gave him the kit - everything was according to the documents - and that’s it. And he said that he had a non-landing configuration. I gave him the kit, as it should be standard . He confirmed. And he didn’t leave. It happened literally in a few seconds.”
There were 44 passengers and six crew members on board.
Information about the dead
All 50 people on board were killed.
Among the dead are the son of the President of Tatarstan Irek Minnikhanov, the head of the FSB Directorate for Tatarstan Alexander Antonov, the wife of the famous sports commentator Roman Skvortsov.
The list of those killed includes Bull Donna Caroline, a British citizen (born February 14, 1960).
Hotlines open: 8 843 227 46 50, 8 800 775 17 17, 8 843 273 91 45.
Taxi drivers unanimously refuse to take money from relatives of the victims.
— Krasnov Sergei (@krasnov_sergei1) November 17, 2013
What is known about the plane
The crashed plane was in operation for 23 years, making its first flight in 1990. His tail number— VQ-BBN. An airplane with this number already flew last year. emergency landing in Kazan. Then the cabin depressurization sensors went off.
According to information on the website aviation-safety.net, the previous operators of the aircraft were such airlines as Bulgaria Air (since May 2008) and Romanian Blue Air (since September 1, 2005). On December 17, 2001, an air incident occurred with this aircraft, which was then in service with Rio Sul airlines, in Brazil. In total, this aircraft was operated by seven airlines, including Tatarstan.
Grigory Busarev(on air "Russia 24"): “I was flying on a day flight from Kazan (to Moscow)… The plane was landing at Domodedovo airport… It was shaking from side to side… It’s like turbulence, like when you get into air pocket. The wings were shaking from side to side, and the nose was constantly tilting down.”
Ruslan Kalimullin (on his page in " In contact with " ): " Today I flew this plane from Kazan to Moscow at 15.20, we landed at Domodedovo as if the plane’s horizon stabilization system was faulty, the pilot had difficulty leveling the ship before landing, upon contact with the ground, we skidded a little, but the pilot managed and I crossed myself. What one of the passengers said on TV was that when landing in Moscow there was a strong vibration in the body of the plane, this is observed in all old cars during takeoff, the vibration does not go through the body, but through the inner lining, this is often found on planes that have not been restored for a long time. I swore not to fly on cheap flights, which is why this time the toad strangled me to buy a ticket not for 5 for a normal Aeroflot flight, but for this one for 3. Before buying a ticket, I was not too lazy to call and find out what kind of car is operating this flight. Well, I think, since the Boeing 500, everything should be fine. And when we got in, I immediately noticed that the car was really “tired” and it became a little scary...”
Insurance
The liability of Tatarstan Airlines is insured by Ak Bars Insurance, a source in the insurance market told Prime. In accordance with the Air Code, in the event of the death of a passenger, the insurance payment is 2 million rubles plus 25 thousand for burial. SOGAZ will pay 2 million rubles to the relatives of the deceased passengers.
Investigation
According to preliminary data, the cause of the disaster could have been a crew error, a law enforcement source told RIA Novosti. The versions also include weather factors and technical malfunctions. Roshydromet reported that weather were normal for this type of aircraft.
A criminal case has been initiated into the crash under Art. 263 of the Criminal Code of the Russian Federation (violation of traffic and operation safety rules air transport resulting in the death of two or more persons through negligence). The search for "black boxes" is underway. Samples of the fuel used to fuel the plane were taken for testing.
Later, a source at Domodedovo reported that all planes at Domodedovo airport are refueled in one container.
At 22:45 Moscow time, search and rescue operations at the crash site were completed.
At Kazan airport, completed. The criminal case has been transferred to the prosecutor's office for approval of the indictment. Of the five alleged defendants, only three can be put in the dock; the pilot and co-pilot were killed. Their criminal prosecution has been completed in connection with their death. According to the law, consent to the termination of a criminal case in the event of the death of suspects can be given by relatives recognized as victims. It seems that the relatives of the pilot Rustem Salikhov and co-pilot Viktor Gutsul agreed with the preliminary conclusions of the investigation.
Let us remind you that the plane crash occurred on November 17, 2013 at 19.23. The Boeing 737-500 was landing with 44 passengers and 6 crew members on board. The plane took off from Domodedovo airport at 18.25, and at 19.30 it was supposed to land in Kazan. But the first attempt to land the aircraft was unsuccessful. The airliner went around, and then, according to IAC, due to pilot errors, the plane went into a vertical dive and crashed into the ground at the airport. Everyone on board died.
During the investigation of the criminal case under the article “Violation of traffic safety rules and operation of air transport, resulting in the death of two or more persons through negligence,” some details became clear. First of all, it was established that the very death of people and the plane was caused by the erroneous actions of the aircraft commander, Rustem Salikhov, and the co-pilot, Viktor Gutsul. It is believed that Salikhov did not have sufficient piloting skills, and the documents on the basis of which he was allowed to carry passengers were falsified.
Valery Portnov, who held the position of Deputy General Director of Tatarstan Airlines OJSC, sent documents regarding Salikhov containing false information to the Tatar Interregional Directorate of the Federal Air Transport Agency in 2009, say the Investigative Directorate of Russia. - In turn, Shavkat Umarov, being the head of the Tatar Interregional Territorial Directorate of Air Transport of the Federal Air Transport Agency, due to negligence, did not organize in September 2009 a verification of the authenticity and reliability of the commercial aviation pilot Salikhov’s certificate presented by the airline. This would have made it possible to reveal the fact that this certificate had not been issued to him, but such a check was not carried out, and, as a result, Salikhov, lacking the basic knowledge, skills and experience of a pilot, began working in passenger air transportation as an aircraft pilot.
Violations on the part of Valery Portnov and the airline's chief pilot Viktor Fomin were discovered during their work. They, as the investigation believes, did not provide Salikhov with proper training, but instead sent the untrained pilot for promotion - to obtain the status of aircraft commander. Since March 2012, Salikhov has carried out passenger air transportation as an aircraft commander.
On November 17, 2013, Salikhov, while flying on the Moscow-Kazan route, put the aircraft into a difficult spatial position when landing, while Hutsul did not take over control, the investigators concluded. - As a result, Salikhov, when an emergency situation occurred, violating piloting rules, through his actions caused the aircraft to crash.
During the investigation and consolidation of the evidence base, lengthy and numerous expert studies were required. During the preliminary investigation, large-scale and complex forensic, molecular-genetic, chemical and technical-forensic, as well as other forensic examinations were carried out, over 200 witnesses and victims, specialists were questioned, a significant amount of other investigative actions were carried out, which together confirmed the version of the investigation .
Let us remind you that criminal prosecution against Salikhov and Gutsul was terminated due to their death.
Based on the collected evidence, Portnov and Fomin were charged with committing a crime under the article “Violation of traffic safety rules and operation of air transport, resulting in the death of two or more persons through negligence”, Umarov - “Negligence, resulting in the death of two or more persons through negligence” - reported to the Russian Investigative Committee.
Among the dead were: the son of the President of Tatarstan Irek Minnikhanov, the head of the FSB of Tatarstan Alexander Antonov, orientalist scientist Diana Gadzhieva, the wife and stepdaughter of sports commentator Roman Skvortsov, chess player Gulnara Rashitova.
The Federal Air Transport Agency remained silent for two years about the fact that it considers the cause of the tragedy in November 2013 to be a design defect of the American aircraft.
The IAC's statement on the suspension of Boeing-737 aircraft certificates in Russia caused a stir in the industry the day before. But an even more sensational reason: it turns out that the Federal Air Transport Agency first signed a report on the investigation into the causes of the plane crash in Kazan, and then suddenly withdrew the signature, insisting on the version of a malfunction of the elevator. Moreover, other Boeing 737s may have the same defect. BUSINESS Online experts see the publication of these facts as revenge for Transaero, but this does not change the essence of the issue.
HOW MAC CLASHED WITH ROSAVIATION
The federal scandal began after on November 4, the Interstate Aviation Committee (IAC) announced on its website that it was suspending the certificates of all Boeing-737 family aircraft in the Russian Federation, about which letters were sent to two addresses at once - the Federal Air Transport Agency and the US Federal Aviation Administration. This is done before receiving a joint notification from the Federal Air Transport Agency and the US FAA that these aircraft are in a condition that ensures their safe operation.
Official letter from the IAC, signed by the Chairman of the Aviation Register Vladimir Bespalov, produced a sensational effect. It’s no joke, according to official statistics, in total Russian airlines operate about 300 Boeings, of which almost 200 are from the 737 family (for comparison: only 100 Tu and 21 Il aircraft). At the same time, the Boeing-737 is included in the fleets of such companies as UTair (50 copies), Orenair (16 copies), S7 (Globus, 13 copies) and Aeroflot (12 copies). Until recently, the Transaero company was considered the largest operator of this model, but, as is known, it went bankrupt. It’s not hard to imagine what awaits other companies after the official ban on the Boeing 737 is introduced. Overnight, the skies over Russia could become empty, and civil air travel could be reduced by almost half.
The reaction of the Federal Air Transport Agency was immediate. The department's press service issued a statement from which it followed that the IAC, with its decision to revoke the certificate for the Boeing-737, cannot stop the operation of this aircraft by Russian airlines. A ban on flights of a particular type of aircraft can only be imposed by a specially authorized federal executive body, which has not made such a decision. The day before, a meeting was supposed to be held with the participation of airlines operating the Boeing-737, the leadership of the International Aviation Committee and the Federal Air Transport Agency.
The Kremlin, in whose direction the eyes of all domestic air carriers involuntarily turned, also hastened to comment on the situation through the mouth of the presidential press secretary Dmitry Peskov. “Of course, a very prompt and in-depth analysis of the situation in domestic aviation will be required,” Peskov said. “And in this case, the relevant department - the Ministry of Transport, the government - will certainly do the necessary analysis, there can be no doubt about it.” Press Secretary Vladimir Putin assured that the Kremlin is closely monitoring the course of events according to media reports, but is not yet interfering.
Yesterday evening, Rosaviation announced a meeting with the participation of representatives of the Ministry of Transport of the Russian Federation, Rostransnadzor, as well as Boeing itself and the heads of airlines operating its aircraft. It is especially noted that the IAC leadership ignored the invitation to the meeting. As a result, those gathered came to the unanimous conclusion that there was no reason to stop the operation of the Boeing 737.
“A VERY STRANGE CASE” AT KAZAN AIRPORT
However, no less scandalous than the IAC’s decision was its official reason: the need for urgent improvements to the elevator control system for Boeing-737 aircraft. The day before, after the uproar, the IAC published a second statement, which directly links the decision to revoke the Boeing-737 certificates with the 2013 plane crash in Kazan.
Let us recall that a passenger Boeing-737 of Tatarstan Airlines crashed at Kazan airport on November 17, 2013, while making a routine flight from Moscow to the capital of the Republic of Tatarstan. There were 50 people on board the plane: 44 passengers and 6 crew members. Among them is the son of the President of Tatarstan Irek Minnikhanov, head of the FSB RT department Alexander Antonov, as well as the wife and daughter of a famous sports commentator Romana Skvortsova.
Within two days, the IAC reported preliminary conclusions based on the decryption of the black boxes. An emergency situation, judging by the crew's reports, arose during the landing approach. Commander Rustem Salikhov reported this to the ground and decided to go for a second circle, disabling the autopilot. The crew even retracted the landing gear, indicating that it was not about to descend sharply. But then the inexplicable happened: after the airliner began to climb with a high angle of attack, the plane at an altitude of 700 m suddenly went into an almost vertical dive and crashed into the ground at high speed. It is unknown what the pilots talked about among themselves: the IAC classified the recordings of the voice recorders.
From the first days, many aviation experts cited the jammed tail elevator as the main version of the causes of the tragedy. As Kommersant reported, in the 90s in the United States there were already several similar disasters involving Boeing-737s. The reason remained unknown for a long time, but it later became clear that when hot hydraulic fluid came into contact with the steering system, which had been cooled in flight, the servo valve that controlled the steering wheel became stuck. In the late 90s, this deficiency was eliminated on most aircraft. However, the question of whether this was done on the 1990 plane that crashed in Kazan remains shrouded in darkness.
Many people noticed that in December 2013, the Prime Minister of the Russian Federation Dmitry Medvedev during a television interview, he said that the plane crash in Kazan was “a very strange case” and demanded that the results of the investigation “be presented.”
IAC, however, from the first days, all assumptions about malfunctions were decisively rejected: already on November 22, 2013, a statement was issued that, “according to on-board objective monitoring equipment, no failures of systems, units and controls of the aircraft, including the elevator channel, were recorded.”
At the end of August 2014, developers - specialists from the American corporation Boeing, as well as experts from France, where the on-board engines were manufactured, joined in determining the causes of the accident. In September 2014, the engineering commission published brief conclusions that were almost entirely devoted to the elevator problem. It was reported that the entire history of the operation of this type of hydraulic drives and materials from the investigation of events related to abnormal operation of the elevator control system that took place in operation on Boeing-737 aircraft previously were studied. The analysis showed that the circumstances of the events that took place related to abnormal operation of the hydraulic elevator actuators differ from the circumstances of the emergency flight.
At the same time, the message listed a variety of studies with the help of which experts came to the following conclusions: here there are three-dimensional tomography, and complete disassembly of hydraulic drives, and dissection of a number of their elements, and mathematical modeling of the system’s operation, and engineering analysis of all possible options for jamming. As a result, the commission made an unequivocal conclusion: signs of failure aviation technology not present in the emergency flight.
“IT IS ALARMING THAT MORE THAN 20 MILLION PASSENGERS WERE EXPOSED TO SIGNIFICANT RISKS.”
However, yesterday's statement by the IAC turns the whole picture upside down. The agency officially stated that, in fact, from the first day of the work of the commission to investigate the causes of the plane crash in Kazan, representatives of the Federal Air Transport Agency themselves constantly insisted on the version that the cause of the incident was precisely the failure of the elevator control system.
In this regard, the studies described above were carried out, which allegedly did not confirm the version of malfunctions. After this, in April 2015, a draft final report on the results of the investigation was prepared, which was signed by all members of the commission without comments. Including representatives of the Federal Air Transport Agency. The report was also fully agreed with all states that took part in the investigation (USA, UK, Bermuda, France), the IAC emphasizes. Although the report was never published (which made the investigation almost unprecedented in duration), the conclusion was clear: since the plane was in perfect order, it means that the inexperienced crew was to blame.
However, from yesterday’s statement by the IAC it suddenly became clear that the story does not end there: it turns out that in June 2015, a representative of the Federal Air Transport Agency unexpectedly withdrew his signature on the document! The reasons are unknown - either new circumstances appeared, or my conscience tormented me... One way or another, the leadership of the Federal Air Transport Agency returned to its previous position: the cause of the incident was “failure of the steering drive of the elevator control system due to design flaws in Boeing-737 type aircraft.”
In this regard, the IAC sent a request to the US Federal Aviation Administration (the initial certification body for the Boeing-737 aircraft) to confirm the aircraft’s compliance with the requirements for safe operation. However, the IAC statement says, “the response received does not contain the conclusion that Boeing-737 aircraft are in a condition that ensures their safe operation.” This was the reason to revoke the certificate.
Now IAC directly accuses Rosaviation of inconsistency and indecision: “For a long time, while declaring serious shortcomings of Boeing-737 aircraft that directly affect flight safety, Rosaviation did not inform airlines and Russian supervisory authorities about this. If this opinion of the Federal Air Transport Agency is competent, then it is alarming that more than 20 million passengers of Boeing-737 family aircraft have been exposed to significant risks for a long time,” the committee said in a statement.
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| Tatyana Anodina |
DID ANODINA AND PLESHAKOV REVENGE FOR TRANSAERO?
The question arises: why were they silent for two years? Why was correspondence on this topic slowly carried out between interested departments, without coming to the surface? Why did they insist so much on the crew’s fault, avoiding talking about “design flaws”? Or was it only the crash of the Airbus A321 airliner, which occurred on October 31 in the Sinai desert and has already been called the largest in the history of domestic aviation, that made many people think about the safety of passenger air travel?
However, in response to the IAC decision to revoke the certificates of Boeing-737 aircraft, a version was immediately thrown in that this was revenge on the part of the shareholders of the bankrupt Transaero airline. The Vedomosti newspaper, in particular, writes about this, citing its sources. The fact is that the chairman of the IAC is Tatyana Anodina- mother of the largest shareholder of Transaero Alexandra Pleshakova. “A week ago, the certificate of Transaero, the largest Boeing 737 operator in Russia, was revoked. And so, in fact, the company’s shareholder decides to stop these planes - draw your own conclusion,” the newspaper quotes the opinion of its source in federal structures.
The Kommersant publication adheres to the same version, noting that the IAC decision was unexpected for market participants and relevant officials and provoked “a big commotion in the industry.” Concern about the IAC statement was also expressed abroad. The American corporation Boeing expressed its intention to “meet with Russian officials to understand what their concerns are.” The Russian representative office of the corporation (Boeing Russia CIS) has already commented that the information about the revocation of flight certificates for Boeing-737 aircraft “sounds absurd.”
IAC itself insists on its objectivity and is surprised by the media that see in its statement some kind of “revenge for Transaero.” However, even if we assume that certain selfish motives motivated the department’s officials, this does not negate the facts described above. Just an ugly story with Transaero could help them get out...
ONLY 6 BOEING-737 HAVE “RUSSIAN REGISTRATION”
Against the backdrop of the scandal and commotion caused by the IAC letter, another important news spread - about a possible ban on Russian air carriers registering aircraft abroad. It is expected that this issue, also directly related to the safety of air transportation, will be resolved in the State Duma of the Russian Federation before 2016. The authors of the initiative are Duma deputies Oksana Dmitrieva, Ivan Grachev And Natalia Petukhova. Currently, as stated in the explanatory note, 1,337 aircraft are operated in Russia. Of these, 837 units are foreign-made (578 units are registered in the Bermuda register, 142 units are in the Russian register, 116 units are in the Irish register, 1 unit is in the Swiss register); also 500 units are of domestic production (of which 499 units are registered in the register of the Russian Federation, 1 unit is in the register of Belarus). Dmitrieva and Grachev, in turn, propose obliging airlines to register aircraft in the state register of civil aircraft of the Russian Federation.
By the way, it is the lack of Russian registration for most Boeing-737 aircraft that makes them invulnerable to IAC. As stated by the head of the Air Transport Operators Association (AEVT) Vladimir Tasun, the suspension of certificates will affect only six aircraft of two Russian airlines: a subsidiary of Aeroflot called Aurora and the Gazpromavia company.
“About 200 Boeing-737 aircraft are in foreign registers; the IAC’s decision to revoke the certificate will not affect them in any way,” Tasun explained. “But there are six more aircraft of this type that are on the Russian register. We are talking about four aircraft of the Far Eastern airline Aurora and two aircraft of Gazpromavia airline. It is on these aircraft that a decision will be made at a meeting in the Federal Air Transport Agency with the participation of airline operators, representatives of IAC and Boeing. And here it is already difficult to say what decision the Federal Air Transport Agency will make. Because it is on the basis of the certificate issued by the IAC that the Federal Air Transport Agency issues a certificate of airworthiness,” concluded the head of AEVT.
“THIS IS AN ORDINARY FROLL, A CONFRONTATION BETWEEN TWO DEPARTMENTS”
Valery Postnikov - Executive Director of the Society of Independent Air Accident Investigators:
- Of course, this is a scandal! Confrontation between two departments - Rosaviation and MAK. What can you offer instead of 195 Boeing 737 aircraft? It seems to any sane person that there is no other alternative yet. Thousands of aircraft of this modification fly all over the world. And just now a “late reaction”? Not true. These are ordinary feuds to figure out who is who.
Boeing-737s occupy a significant share of the Russian aircraft fleet. Some of our airlines fly entirely on these boards. Even recently organized ones. Take the same “Victory”, 9 sides. I recently flew from Tyumen - wonderful cars.
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Alexey Sinitsky — Editor-in-Chief of the magazine "Aviation Transport Review":
— At the beginning of the year, about 190 Boeing-737s were in operation in Russia, now the number is at the level of 150. Two issues have been confused in the public consciousness—certificate and operation. The decision of the IAC does not affect the operation of the aircraft in any way; it must be made by the Federal Air Transport Agency. That's all. And since most aircraft have Bermudian or Irish registration, from the point of view of the aviation registers of these countries there are no claims against these aircraft. These countries do not revoke any certificates. Therefore, aircraft registered in Bermuda or the Netherlands can fly normally. This is a discussion about hidden games, that's all. No need to panic. They will also be used.
So far, we cannot engage in import substitution in the aviation industry. All that remains is to wait for the appearance of the MS-21 aircraft; it is located approximately in this market niche. But time is needed for operational testing and production deployment, so this is not a matter of the next few years. Production should begin in three years of this aircraft Naturally, at first the capacity will be small, dozens of aircraft per year, but hundreds are needed, there is no point in discussing this.
Regarding the “late reaction” of the IAC to the Kazan tragedy, let me say this unofficially. According to the MAC results, there is no technical factor there. But in the Federal Air Transport Agency there is a special opinion, which is that there is a technical factor for the “classics”, and they believe that this issue needs to be dealt with. The manufacturer must also participate in this. But at the same time, they do not raise questions about the suspension of the entire type.
Petr Trubaev — General Director of UVT Aero JSC:
— Our company was not affected by the IAC decision, since we operate other aircraft. I don’t think that this is a belated reaction of the IAC to the Kazan tragedy, although the question is, of course, interesting... Potential Russian Federation there is talk about the construction of a civilian fleet, but it takes time for this to happen. And it won't be very fast. According to first impressions, from five years or more.
Vladimir Gainutdinov — Head of the Department of Construction and Design aircraft, Doctor of Technical Sciences, Professor of KNRTU-KAI:
— Technology and human control can sometimes conflict with each other. And they conflict when the staff is not prepared. This is what happened in the tragedy in Kazan. There were two people at the helm who were not prepared for the extraordinary situation. It cannot even be called critical. Just look at the statistics to see how long the Boeing 737 flies! They had problems with management - they solved them. We're on this moment We don’t know all the details of what’s happening now.
By and large Russian park aircraft consists of imported ships. What to replace it with? Superjet, perhaps? 100 of them were produced, about 50 of them fly, two crashed, but the cause of the tragedies is the human factor. Have you ever wondered why out of 100 only 50 are in operation?
The Investigative Committee of Russia announced the completion of the investigation into the criminal case of the Boeing 737-500 plane crash in international airport city of Kazan in November 2013.
Airport crash
On November 17, 2013, a Boeing 737-500 (53A) airliner of Tatarstan Airlines, operating flight U9-363 on the Moscow-Kazan route, crashed while landing at Kazan airport.
As a result of the crash, everyone on board the liner died - 44 passengers and 6 crew members. Among the victims of the disaster was the son of the head of the Republic of Tatarstan Rustam Minnikhanov Irek Minnikhanov, Head of the FSB Directorate for the Republic of Tatarstan Alexander Antonov, famous orientalist Diana Gadzhieva, Ellina Skvortsova(wife of a sports TV commentator Romana Skvortsova), two-time chess champion of the Republic of Tatarstan Gulnara Rashitova.
On the same day, the investigative authorities of the Volga Region Investigation Department for Transport of the Investigative Committee of the Russian Federation opened a criminal case on the grounds of a crime under Part 3 of Art. 263 of the Criminal Code of the Russian Federation (violation of traffic safety rules and operation of air transport, resulting in the death of two or more persons through negligence).
Almost immediately, among the main versions of the disaster, the assumption of erroneous actions by the crew in difficult weather conditions began to appear. Negotiations between the pilots and the dispatcher indicated that the crew’s first approach attempt was unsuccessful. Having assessed the position of the aircraft relative to the runway as “non-landing”, the pilots began a go-around. 25 seconds after this, the Boeing began to fall.
In December 2013, the official representative of the RF IC Vladimir Markin stated: “The aircraft commander Rustem Salikho c had the specialty of an aircraft navigator, and then he allegedly received a commercial aviation pilot certificate at one of the aviation training centers licensed by the Federal Air Transport Agency. The investigation has doubts about the legality of the activities of these centers, which have now been liquidated.”
IAC conclusions: the Boeing commander did not have initial flight training
On December 23, 2015, the Interstate Aviation Committee published the final report on the results of its investigation into the Kazan disaster.
“The cause of the crash of the Boeing 737-500 VQ-BBN aircraft was systemic deficiencies in identifying hazards and controlling the level of risk, as well as the inoperability of the airline’s flight safety management system and the lack of control over the level of training of crew members on the part of aviation authorities at all levels (Tatar MTU VT , Rosaviatsia), which led to the admission of untrained crew to flights,” the document said. — During the go-around, the crew did not recognize the fact that the autopilot had been turned off and allowed the aircraft to fall into a difficult position to pitch up (“NOSE UP UPSET”). The PIC's (pilot's) lack of skills to recover the aircraft from a difficult spatial position (“UPSET RECOVERY”) led to the creation of a significant negative overload, loss of spatial orientation and the aircraft being put into a steep dive (dive pitch angle up to 75°) until it collided with earth."
According to the IAC, the accident was the result of a combination of a number of factors, including:
- absence of the PIC (aircraft commander - approx. AiF.ru) initial flight training;
— admission to retraining on Boeing 737 flight crew members who do not fully meet the qualification requirements for retraining, including English language skills;
— methodological imperfection of the retraining process, formal control over the results and quality of retraining;
— low level of organization of flight work at the airline, which led to the failure to eliminate shortcomings that had been identified for a long time in working with navigation equipment, piloting techniques and interaction between crew members, including during a go-around;
— systematic violation of the work and rest schedule of crew members and large debts for vacations, which could lead to the accumulation of fatigue and negatively affect the performance of crew members;
— increased psycho-emotional stress of crew members before go-around due to a long-term inability to determine the location of the aircraft with the accuracy necessary for landing.
Based on falsified documents
It took the investigative authorities another four years to reach final conclusions from a legal point of view.
“During the investigation, it was established that the erroneous actions of the aircraft commander Rustem Salikhov and the co-pilot led to the plane crash Victor Gutsul. According to the investigation, Salikhov did not have sufficient piloting skills and was allowed to carry out passenger transportation on the basis of falsified documents,” the RF IC said in a statement. - So, Valery Portnov, who held the position of Deputy General Director of Tatarstan Airlines OJSC, sent documents regarding Salikhov containing false information to the Tatar Interregional Directorate of the Federal Air Transport Agency in 2009. In its turn Shavkat Umarov, being the head of the Tatar Interregional Territorial Directorate of Air Transport of the Federal Air Transport Agency, due to negligence, in September 2009 he did not organize a verification of the authenticity and reliability of the commercial aviation pilot Salikhov’s certificate presented by the airline, which would have made it possible to identify the fact that this certificate had not been issued to him. As a result, Salikhov, without the basic knowledge, skills and experience of a pilot, began to carry out passenger air transportation as an aircraft pilot.”
The investigation also believes that Valery Portnov and the airline’s chief pilot Victor Fomin did not provide adequate training for Salikhov, but instead sent an untrained pilot to obtain the status of pilot-in-command. Since March 2012, Salikhov has carried out passenger air transportation as an aircraft commander.
The case against the dead pilots has been closed. Their bosses are indicted
“On November 17, 2013, Salikhov, while performing a flight on the Moscow-Kazan route, during landing, brought the aircraft into a difficult spatial position, while Hutsul did not take over control. As a result, when an emergency situation occurred, Salikhov, violating piloting rules, caused the aircraft to crash through his actions,” the report says. “Long and numerous expert studies were required to obtain and consolidate the evidence base. During the preliminary investigation, large-scale and complex forensic, molecular genetic, chemical and technical-forensic, as well as other forensic examinations were carried out, over 200 witnesses and victims, specialists were questioned, a significant amount of other investigative actions were carried out, which together confirmed the version of the investigation "
Criminal prosecution against the aircraft commander Rustem Salikhov and co-pilot Viktor Gutsul was terminated due to their death.
Portnov and Fomin were charged with committing a crime under Part 3 of Art. 263 of the Criminal Code of the Russian Federation (violation of traffic safety rules and operation of air transport, resulting in the death of two or more persons through negligence), Shavkta Umarov - under Part 3 of Art. 293 of the Criminal Code of the Russian Federation (negligence resulting by negligence in the death of two or more persons).
The criminal case has been sent to the prosecutor for approval of the indictment.
© Photo by the press service of the Ministry of Emergency Situations of Russia
© Photo by the press service of the Ministry of Emergency Situations of Russia
© Photo by the press service of the Ministry of Emergency Situations of Russia
© Photo by the press service of the Ministry of Emergency Situations of Russia
© Photo by the press service of the Ministry of Emergency Situations of Russia
© Photo by the press service of the Ministry of Emergency Situations of Russia
| Event date | 17.11.2013 |
| Aircraft registration number | VQ-BBN |
| Aircraft departure location | |
| Departure airport | |
| Planned destination | |
| Planned arrival airport | |
| Event location | territory international airfield Kazan |
| Latitude | 55°36.5291" |
| Longitude | 49°16.6111" |
| Sun | Boeing 737 |
| Serial number | |
| Aircraft operator | OJSC "Airline "Tatarstan" |
| Aircraft owner | AWAS (Bermuda) Limited |
| Date of completion of the investigation (report) | 23.12.2015 |
| Death toll | 50 |
| Data Accuracy | |
| Degree of aircraft destruction | Aircraft destroyed |
| Report | |
| Type of aviation | a commercial |
| Type of work | |
| Note | |
| Investigation status | Investigation completed |
November 18, 2013
According to information received, on November 17, 2013 at 7 p.m. 23 minutes Moscow time at the Kazan airport during landing, a Boeing 737-500 plane of the TATARSTAN airline of the Tatar MTU VT FAVT crashed.
Six crew members and forty-four passengers on board the aircraft were killed. The plane is destroyed.
Based on Russian legislation and in accordance with the “Rules for the investigation of aircraft accidents and incidents with civil aircraft in the Russian Federation”, approved by Decree of the Government of the Russian Federation of June 18, 1998 No. 609, as well as taking into account the requirements of Appendix 13 to the Convention on International civil aviation, the investigation is being conducted by a commission of the Interstate Aviation Committee with the participation of specialists from the Federal Air Transport Agency and other interested departments.
The commission began work on the spot aviation accident.
November 18, 2013
The technical commission of the Interstate Aviation Committee for the investigation of the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a parametric information flight recorder container was found at the scene of the accident.
The recorder container has significant mechanical damage.
November 18, 2013
The technical commission of the Interstate Aviation Committee to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a container for a flight voice data recorder was found at the scene of the accident.
The recorder container has significant damage.
November 18, 2013
The technical commission of the Interstate Aviation Committee (IAC) to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that the containers of on-board means of objective monitoring of parametric and speech information (the so-called black boxes) found at the scene of the accident were delivered to the Interstate aviation committee.
Opening of containers, reading of information recorded on on-board media and its decryption will be carried out at the scientific and technical center of the Committee.
November 19, 2013
The technical commission of the Interstate Aviation Committee (IAC) for the investigation of an accident with a Boeing 737-500 aircraft of Tatarstan Airlines informs about the preliminary results of decoding the information from the flight parametric recorder.
During the landing approach, the crew failed to perform a standard approach in accordance with the procedure established by regulatory documentation. Having assessed the aircraft’s position relative to the runway as “non-landing”, the crew reported to the controller and began a missed approach in TOGA mode (Take Off / Go Around. Takeoff / Missed approach). At the same time, one of the two autopilots involved in the landing process was turned off and the further flight was carried out in manual mode.
The engines reached a mode close to takeoff. The crew retracted the flaps from the 30° position to the 15° position.
Under the influence of the pitching moment from the engine thrust, the plane began to climb and reached a pitch angle of about 25°. The indicated speed began to decrease. The crew cleared the landing gear. From the moment the go-around began until this time, the crew did not take active steps to control the aircraft.
After reducing the speed from 150 to 125 kts, the crew began control actions with the helm column to put the aircraft into a dive, which led to the cessation of the climb, the beginning of the aircraft's descent and an increase in the indicated speed. The maximum angles of attack during flight did not exceed operational limits.
The plane, having reached an altitude of 700 m, began an intense dive with a pitch angle that reached -75° by the end of the flight (end of recording).
The plane collided with the ground at high speed (more than 450 km/h) and a large negative pitch angle.
About 45 seconds passed from the start of the missed approach to the end of the recording; the descent took about 20 seconds.
Power plants worked until the plane collided with the ground. Based on the results of the preliminary analysis, no single commands characterizing failures of systems and components of the aircraft and engines were identified.
The analysis and decoding of parametric information continues.
The Commission notes that when the voice recorder container was opened, the secure container with the tape drive mechanism was missing. The commission continues to search for the device.
The technical commission continues to work at the scene of the accident. The airline's flight documentation and crew training are being studied, including with the involvement of highly professional line pilots who have extensive experience in operating this type of aircraft in leading Russian airlines. The airline's technical documentation is being studied, including aircraft maintenance and maintaining their airworthiness in accordance with international rules. Information from ground-based objective monitoring equipment, weather conditions and air traffic services data are analyzed.
The IAC Technical Commission will regularly inform you about the progress of the investigation.
November 20, 2013
The technical commission of the Interstate Aviation Committee (IAC) to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a voice data carrier unit of the flight recorder was found at the scene of the accident.
The found block will be delivered to the IAC for the necessary work to be carried out at the scientific and technical center of the Committee.
The scientific and technical center continues to carry out a large amount of work on further decoding and analysis of parametric recorder information, including the Kazan-Domodedovo flight that preceded the emergency, and other flights.
Work is planned to synchronize and jointly process records of ground-based and airborne objective monitoring equipment.
The technical commission continues its work at the scene of the accident.
November 22, 2013
In connection with the funds that have appeared mass media With questions about the causes and versions of the crash of the Boeing 737-500 of Tatarstan Airlines, the Technical Commission of the Interstate Aviation Committee (IAC) informs:
According to on-board objective monitoring equipment, no failures of aircraft systems, components and controls, including the elevator channel, were recorded. The plane's engines were running until it hit the ground.
The IAC has repeatedly explained that ICAO standards for so-called “old” and “new” aircraft do not exist. The main thing for safety is the airworthiness of the aircraft, not its age. There is no direct relationship between aircraft crashes and their age. Over the past five years, the number of accidents in the world, including Russia, with aircraft with a passenger capacity of more than 50 seats is the same for aircraft under 5 years old and over 30 years old. According to available information, the average age of Boeing 737-500 aircraft operated in the United States is 20.4 years. In Europe – 20.3 years. More than 7,600 Boeing aircraft are in operation around the world. Their total flight time is 257.6 million flight hours. The crash rate of Boeing 737 aircraft per 100 thousand flight hours is less than 0.05.
The Interstate Aviation Committee asks to refrain from “PR” and populism against the backdrop of a serious tragedy. This traumatizes the relatives and friends of the victims and disrupts the work of the aviation transport industry.
The IAC Technical Commission continues its professional work to establish the circumstances and causes of the disaster in accordance with ICAO standards.
November 22, 2013
At the IAC Scientific and Technical Center, work continues to decipher the information recorded on the in-flight voice recorder of the TATARSTAN Airlines Boeing 737-500 aircraft that crashed on November 17, 2013 at the Kazan airport. There remains a significant amount of work to recognize and identify the voices of flight crew members, and subsequent synchronization of recorded information from ground-based and on-board objective monitoring equipment.
The IAC Technical Commission continues its work.
November 28, 2013
At the Scientific and Technical Center of the Interstate Aviation Committee, with the participation of representatives of the flight crew of Tatarstan Airlines, who know the voices of the crew members well, work was carried out to identify voices in the cockpit of the aircraft recorded on the recording of the flight voice recorder. These specialists signed a preliminary protocol of negotiations between crew members. At this stage, there were no signs of strangers in the pilot's cabin. Work on decoding and identifying voices continues.
November 29, 2013
The Technical Commission of the Interstate Aviation Committee for the investigation of the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that, based on a preliminary analysis of data from objective control means and other available information, in accordance with the provisions of the Rules for the Investigation of Aviation Accidents and Incidents with Civil Aircraft in the Russian Federation (PRAPI), the commission considers it appropriate to implement the following operational recommendations to improve flight safety:
1. Consider the feasibility of conducting additional classes and training with flight personnel:
on practicing actions during a go-around in director mode, paying special attention to the procedure for leaving an intermediate altitude when the altitude value that needs to be gained during the go-around is close to the current value, as well as the procedure for conducting radio communications;
on recognizing a difficult spatial position of an aircraft (Upset) and practicing actions to recover an aircraft from a difficult spatial position (Upset recovery);
on the order and features of the operation of aircraft systems (autopilot, flight director) during approach and missed approach, depending on specific conditions;
to study the features of the aircraft navigation system (section FCOM: FMC Navigation Check and Navigation Position).
2. Consider the need to refine the work technologies of ATS specialists in terms of providing (in case of significant deviations from the route) more active assistance to aircraft crews if technical capabilities are available, for example, by submitting a request to the crew to perform vectoring to put the aircraft on a landing course.
3. Hold a flight technical conference to exchange experience in operating Boeing 737 family aircraft.
The specified recommendations in the form of a Subsequent Report on an Aviation Accident in accordance with the PRAPI were communicated to the Federal Air Transport Agency.
The flight documentation of Tatarstan Airlines is being checked for initial training, as well as for retraining on the Boeing 737 and undergoing periodic training and inspections by flight crew members.
September 16, 2014
The technical commission of the Interstate Aviation Committee for the investigation of an accident with a Boeing 737-500 aircraft of Tatarstan Airlines informs that the work of the engineering and technical subcommittee has been completed to study and analyze the performance of aircraft equipment, including the elevator control system, in an emergency flight.
To assess the performance of the elevator control system, a number of studies were carried out:
three-dimensional tomography of the hydraulic drives of the left and right halves of the elevator;
complete disassembly and assessment of the condition of hydraulic drives;
bench testing of main switchgears (spool valves) of hydraulic drives;
preparation (cutting) of a number of hydraulic drive elements to assess the condition of internal surfaces;
mathematical modeling of aircraft movement and operation of the elevator control system using records of objective control equipment.
An engineering analysis of the operation of the system of two hydraulic elevator drives was also carried out, simulating all possible jamming scenarios of the main switchgears.
The history of operation of this type of hydraulic drives and materials from the investigation of events related to abnormal operation of the elevator control system that occurred in operation on Boeing 737 aircraft previously were studied. The analysis showed that the circumstances of the events that took place related to abnormal operation of the hydraulic elevator actuators differ from the circumstances of the emergency flight.
Based on all the work carried out, the engineering and technical subcommittee concluded that the records of objective monitoring equipment, as well as the surviving parts, components and assemblies of the airframe, engines and systems, including the elevator control system, showed no signs of failure of the aircraft during the emergency flight.
The commission is completing work to establish all the causes and factors of the accident.
April 29, 2015
The technical commission of the Interstate Aviation Committee (IAC) has completed a set of works to investigate the crash of the Boeing 737 500 VQ-BBN aircraft of Tatarstan Airlines.
During the investigation, the entire necessary amount of work was carried out, including: the field stage of the investigation, including drawing up maps of the accident site, as well as a full-scale layout of the surviving fragments of the aircraft; decoding and analysis of recordings of ground and airborne objective monitoring equipment; special studies of hydraulic elevator drives; mathematical modeling of flight; flight evaluation of crew performance by test pilots and experienced flight pilots; simulator experiment; study of data on crew training, work and rest schedules, organization of flight work and the airline’s flight safety management system; study of medical documents and results of forensic medical research; study of data on aircraft maintenance and technical operation.
Based on the results of the work, the Technical Commission prepared a draft Final Report.
In accordance with the Standards of the International Civil Aviation Organization, after translation into English, the draft report will be sent to authorized representatives: the US National Transport Safety Bureau, the UK Aircraft Accident Investigation Agency, and the French Air Accident Investigation Bureau. These states took part in the investigation.
After receiving and considering comments from states, the Final Report will be published on the official IAC website on the Internet.
December 23, 2015
The Commission of the Interstate Aviation Committee completed the investigation of the accident involving the Boeing 737-500 VQ-BBN aircraft of Tatarstan Airlines OJSC, which occurred on November 17, 2013 at Kazan airport.
The cause of the crash of the Boeing 737-500 VQ-BBN aircraft was systemic deficiencies in identifying hazards and controlling the level of risk, as well as the inoperability of the airline’s flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels (Tatar MTU VT, Rosaviatsia), which led to the admission of untrained crew to flights.
During the go-around, the crew did not recognize the fact that the autopilot had been turned off and allowed the aircraft to fall into a difficult nose-up position. The PIC's (pilot's) lack of skills to recover the aircraft from a difficult spatial position (Upset Recovery) led to the creation of a significant negative overload, loss of spatial orientation and the aircraft being put into a steep dive (dive pitch angle up to 75°) until it collided with the ground.
The need for a missed approach was caused by the non-landing position of the aircraft when approaching the runway, which was a consequence of the “Map shift” effect (an error in determining the location of the aircraft by on-board systems) by about 4 km, the inability of the crew in these conditions to integrated aircraft navigation and navigation with the required accuracy, as well as the lack of active assistance from the ATS service during prolonged observation of significant deviations from the approach pattern.
The accident was the result of a combination of the following factors:
Lack of initial flight training by the PIC;
Admission to retraining on Boeing 737 flight crew members who do not fully meet the qualification requirements for being sent for retraining, including in English;
Methodological imperfection of the retraining process, formal control over the results and quality of retraining;
The low level of organization of flight work at the airline, which led to the failure to eliminate deficiencies identified over a long period of time in the work with navigation equipment, piloting techniques and interaction between crew members, including during a go-around;
Systematic violation of the work and rest schedule of crew members and large debts for vacations, which could lead to the accumulation of fatigue and negatively affect the performance of crew members;
The absence of an element of missed approach from an intermediate altitude with two operating engines in the simulator training programs;
Increased psycho-emotional stress of crew members before go-around due to prolonged inability to determine the location of the aircraft with the accuracy necessary for landing;
Violation of the principle “Aviate - Navigate - Communicate” by both the crew and the ATS service, which led to the crew’s failure to comply with standard operating procedures during the missed approach stage due to the second’s prolonged distraction the pilot from performing his duties and monitoring flight parameters;
Failure by the crew to recognize the fact that the autopilot was turned off and later intervention in the control of the aircraft, which led to the aircraft getting into a difficult spatial position for pitching up (Nose up Upset);
The imperfection of the applied simulator training programs for recovering an aircraft from a difficult spatial position (Upset Recovery) and the criteria for assessing its quality, which led to the inability of the crew to restore the spatial position of the aircraft;
Possible influence of somatogravitational illusions.
Lack of a proper control system over the issuance of pilot licenses, compliance of the training of crew members with the established requirements and the assignment of qualification marks;
The inoperability of flight safety management systems in airlines, the lack of methodological recommendations for their development and approval, a formal approach to the approval/coordination of flight safety management systems and flight crew training programs by the authorized body;
The imperfection of the work of the training center and the actual lack of control over the results of retraining;
Lack of knowledge requirements for flight personnel in English for retraining for foreign types of aircraft and a formal approach to testing the level of language knowledge;
A formal approach to conducting periodic and qualification inspections of flight personnel;
Systematic violation of the work and rest regime of flight personnel;
Insufficient training of flight personnel for go-around from an intermediate altitude, piloting the aircraft in the control (manual) mode and when recovering from a difficult spatial position;
The occurrence of a “map shift” effect on aircraft not equipped with GPS and insufficient preparation of crew members for flights in these conditions;
The need for active assistance to the crew from the ATS service when significant long-term deviations from established patterns are detected;
Violation of the principle “Fly the aircraft - Navigate - Communicate”,
did not prevent this accident.
Based on the results of the investigation, recommendations were developed to improve flight safety.
