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17 Nov 2013 - VP-BBN 737-500 Loss of control after go-around

The Russian MAK have just published their final report into the accident on 17 Nov 2013 in which Tatarstan Airlines 737-500, VP-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.

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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.

The full report in Russian is available here

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)

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