17 Nov 2013 - VQ-BBN 737-500 Loss of control after go-around at Kazan
The Russian MAK have published their final report into the accident on 17 Nov 2013 in which Tatarstan Airlines 737-500, VQ-BBN, (24785/1882) was written off after losing control during a go-around at Kazan following an unstable approach due to a map shift. All 50 occupants died.
The aircraft (non-GPS) had developed a 2nm map shift during the flight. This was attributed partly to incorrect data entered before departure from Domodedovo and partially due to normal IRS drift. FMC position is normally a mixture of IRS position and navaid position where available.
The map shift became critical during the initial approach taking them 2nm North of waypoint MISMI. This deviation was pointed out to the crew once by ATC but was not corrected by the crew and nor did ATC offer vectors. The self positioned procedural turn left the aircraft far to the right (north) of the centreline. By the time they had intercepted the localiser they were very high on profile and at 900ft aal went around. The autopilot disconnected but this was not noticed.
The report stated that the crew was probably “not psychologically ready” for a missed approach and disconnection of the autopilot was “not recognised” due to high stress levels. The workload was further increased by an unnecessary 20sec communication by the F/O with ATC over the missed approach altitude.
The aircraft pitched up due to the thrust couple (the A/P was not engaged and nobody had control) the aircraft reached 2300ft and the IAS decayed from 150 to 117 KIAS. The crew now applied full forward pressure and entered a steep dive and impacted the ground 75 degrees ND, 45 secs after initiating the go-around and 20 seconds after reaching the maximum height.
A criminal investigation resulted in charges to various members fo Tartarstan Airlines management. Details here
*** Updated 18 Apr 2019 ***
The report raised questions about the licencing and training of both pilots and also states that both pilots were suffering from fatigue. It concludes that says that two “weak” pilots, with poor training, had been paired on the flight from Moscow – a situation which presented a “significant safety risk”.
The report also criticised the airline’s “non-functional” safety management system and an inability to eliminate weaknesses in its flight operations.
Of note is that the MAK conducted simulator tests giving pilots the accident scenario, only 58% of the pilots recognised that the autopilot had disconnected. When given the go-around / upset scenario many performed poorly.
Arrival chart overlaid with actual flight path and significant events. The crew believed that they overflew MISMI. (MAK final report)
Aerial view of the impact site next to the runway (MAK final report)
14 Nov 2019 TASS have reported that investigators have completed the inquiry into the criminal case. The press-service of the Investigative Committee told TASS. "The criminal case has been handed over to the prosecutor’s office for the endorsement of the bill of indictment," the IC said.
The investigation found that the air crash was due to mistakes made by the plane’s captain Rustem Salikhov and co-pilot Viktor Gutsul. As follows from the findings, Salikhov lacked flying skills and had been allowed to run a passenger liner on the basis of false certificates. The man who submitted Salikhov’s application containing false evidence to Tatarstan’s inter-regional board of the federal air transport agency Rosaviatsiya in 2009 was the deputy CEO of Tatarstan Airlines, Valery Portnov. The chief of Tatarstan’s interregional board of Rosaviatsiya, Shavkat Umarov, is charged with negligence for failing to check the authenticity of Salikhov’s license. As a result Salikhov was allowed to fly passenger planes although he lacked the basic knowledge, skills and experience, the IC said.
Also, Portnov and Tatarstan Airline's chief pilot Viktor Fomin did nothing to ensure Salikhov’s proper instruction, but instead upheld his request for the status of an aircraft captain. Salikhov occupied the position starting from March 2012. In flight from Moscow to Kazan on November 17, 2013 Salikhov in the process of the landing maneuver steered the plane into a precarious position. The co-pilot, Viktor Gutsul, did not intervene. In an emergency that followed Salikhov violated flying rules, thus causing the crash. The IC said the gathered evidence was based on thorough examinations by experts, including complex forensic, molecular, genetic, chemical and technical tests. More than 200 witnesses were questioned.
The criminal case against Salikhov (Captain) and Gutsul (First Officer) was closed due to their death. Portnov (Deputy CEO) and Fomin (Chief Pilot) have been charged under part 3 of article 263 of Russia’s Criminal Code (violation of air traffic and aircraft operation safety rules that resulted in the negligent death of two or more persons) and Umarov (The chief of Tatarstan’s interregional board of Rosaviatsiya), under part 3 of article 293 of the Criminal Code (negligence that resulted in the death of two or more persons).