Crash of a Tupolev TU-134AK at Dolinsk-Sokol AFB

Date & Time: Mar 26, 2009
Type of aircraft:
Operator:
Registration:
RA-65981
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
63250
YOM:
1980
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On take off roll at dusk during heavy snow falls, the aircraft veered off runway to the left and collided with a snow mound (1,2 meter high). The nose gear was torn off while both main gears collapsed. All occupants escaped uninjured while the aircraft was damaged beyond repair. It was used for the Far East Command.
Probable cause:
It appears that runway was not properly cleaned from snow prior to takeoff.

Crash of a PZL-Mielec AN-2T in Volosovo

Date & Time: Mar 7, 2009
Type of aircraft:
Operator:
Registration:
RF-01206
Flight Phase:
Survivors:
Yes
Schedule:
Volosovo - Volosovo
MSN:
1G98-22
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
45 seconds after takeoff, while climbing, the aircraft stalled and crashed in a snow covered field. The pilot and all 10 skydivers escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Antonov AN-2 in Pskov

Date & Time: Feb 11, 2009 at 1030 LT
Type of aircraft:
Operator:
Registration:
10 yellow
Flight Phase:
Survivors:
Yes
Schedule:
Pskov - Pskov
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take off from Pskov Airport, while climbing to a height of about 50-70 metres, the crew encountered engine problems and elected to make an emergency landing. The aircraft lost height and crashed in a snow covered field located near the airport and came to rest. All 13 occupants escaped uninjured while the aircraft was damaged beyond repair. All passengers were skydivers (paratroopers) from the Marine Corps.
Probable cause:
Engine failure for unknown reasons.

Ground collision of two Ilyushin II-76MD in Makhachkala: 4 killed

Date & Time: Jan 15, 2009 at 2110 LT
Type of aircraft:
Operator:
Registration:
RA-76825
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Makhachkala - Nizhny Novgorod
MSN:
10034 04136
YOM:
1990
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The aircraft was dispatched to Makhachkala to deliver troops, military equipments and cargo with 7 crew members on board. Ready for the next trip to Nizhny Novgorod, the crew was cleared to taxi to the holding point of runway 14. At that time, the visibility was poor due to the night and foggy conditions. Another Ilyushin II-76MD registered RA-76827 was on approach to runway 14 with 25 passengers and a crew of six on board. On final approach, the navigator informed the crew that the headlights should be switched on but no actions was taken. In a visibility lower than 800 metres, the aircraft landed slightly to the left of the runway centerline. After touchdown, the left wing impacted the cockpit of the II-76 awaiting at the holding bay. While RA-76827 suffered only minor damaged and that no one on board was injured, all four crew members in the cockpit of RA-76825 were killed while three other occupants were injured.

Crash of a Boeing 737-3Y0 in Kaliningrad

Date & Time: Oct 1, 2008 at 2318 LT
Type of aircraft:
Operator:
Registration:
EI-DON
Survivors:
Yes
Schedule:
Barcelona - Kaliningrad
MSN:
23812/1511
YOM:
1988
Flight number:
KNI794
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5372
Captain / Total hours on type:
1258.00
Copilot / Total flying hours:
1010
Copilot / Total hours on type:
1010
Aircraft flight hours:
48514
Aircraft flight cycles:
39949
Circumstances:
The accident aircraft Boeing 737-3Y0 EI-DON, was operated by KD Avia on a flight from Kaliningrad, Russia to Barcelona, Spain and return. Flight KD793 to Barcelona was uneventful. The return flight, KD794, departed at 16:18 with 138 passengers and six crew members on board. The copilot was Pilot Flying, the captain was Pilot Monitoring. The en route part of the flight was uneventful. As the flight was descending to Kaliningrad at night in heavy rains and with gusty crosswind. During the descent flaps were first selected at 1° and thereafter to 5°. As the flaps were transitioning to this position, a flap asymmetry warning caught the attention of the crew. At 19:00 hours the captain took over control and selected flaps to 2°, the position at which there was no asymmetry warning. The crew then contacted the controller at Kaliningrad and reported that they had flap problems. As the descent was continued, the copilot performed the necessary calculations for a landing with flaps at 2°. At 19:09 the cabin crew was warned to prepare for a high-speed landing. Using the QRH to work the flap issue, the co-pilot activated the 'flap inhibit' and 'gear inhibit' switches. This "incorrect" action effectively disconnected the ground-proximity warning system (GPWS). At 19:11 it was established that the landing speed would be Vref +30, leading to a planned landing speed of 161 knots. At 19:14 the Landing Gear Warning Horn sounded due to the combination of power and flaps setting with the fact that the landing gear had not been selected down. This warning was cancelled by the crew. When the engine power was reduced to idle, the Landing Gear Warning Horn sounded again. This time the crew did not pay attention to the warning and continued to land. The airplane performed a gear up landing, sliding for 1440 m before coming to rest on the runway. The flap asymmetry issue was caused by a faulty Flap Position Transmitter. The flaps had extended to the commanded position, but the system incorrectly detected an asymmetry issue. This issue had occurred previously on EI-DON. The sensor had been replaced prior to departure from Kaliningrad that same day.
Probable cause:
The crash was caused by aircraft landing with not extended landing gear that resulted in aircraft structure and engines damage and it was caused by combination of the following adverse factors:
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
Final Report:

Crash of a Boeing 737-505 in Perm: 88 killed

Date & Time: Sep 14, 2008 at 0510 LT
Type of aircraft:
Operator:
Registration:
VP-BKO
Survivors:
No
Schedule:
Moscow - Perm
MSN:
25792/2353
YOM:
1992
Flight number:
AUL821
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
82
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
3900
Captain / Total hours on type:
1190.00
Copilot / Total flying hours:
8900
Copilot / Total hours on type:
236
Aircraft flight hours:
44533
Aircraft flight cycles:
35104
Circumstances:
On September 13, 2008 an Aeroflot –Nord flight crew (Captain and copilot), were conducting a scheduled domestic passenger flight n°AFL821 on a B737-505 aircraft, registration VP-BKO, from Moscow (Sheremetyevo, UUEE) to Perm (Bolshoye Savino, USPP). Apart from the two-member flight crew there were 4 flight attendants and 82 passengers on board, which makes a total of 88 people, including 66 citizens of the Russian Federation, 8 citizens of Azerbaijan, 1 citizen of Byelorussia, 1 of Germany, 1 of Italy, 1 of China, 1 of Latvia, 1 of Turkey, 1 of Uzbekistan, 5 citizens of Ukraine and 2 of France. According to the load sheet, the aircraft payload (cargo and passengers) was 8079 kg. The takeoff weight was ~54000 kg (with the max TOW of 60554 kg), the CG was at 20.61 % MAC, which was within the B-737-500 FCOM limitations. The calculated landing weight was 49700 kg (with the maximum of 49895 kg), and the CG was at 21.9 % MAC, which was also within the B737-500 FCOM limitations. The pre-flight briefing was conducted in due time and in compliance with the standard procedures. All the crew members passed medical check at the medical office of Aeroflot – Russian Airlines on September 13, 2008 at 1948 hrs and got permissions to fly. On the basis of the dispatch information (aircraft condition, aeronautical information, weather information, aircraft load data and operational flight plan) the PIC at 1955 hrs made a decision to fly. The takeoff was performed at 2113 without delay. The climb and level flight at FL290, 9,100 metres were conducted without any deviations. At 2245 hrs the crew started descent from the flight level to waypoint Mendeleyevo (940 MN). After passing over Mendeleyevo, in compliance with the Perm Approach Control instruction, the aircraft flew via the outer marker (705 PX) of Runway 21 which is the initial approach fix (IAF) for Runway 21 (heading 212° magnetic). After passing over the RWY with heading 110° M, the crew, following the Controller’s instruction, turned right for back course and started maneuvering for ILS approach to Runway 21. 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 was totally destroyed and partly burnt in the ground fire. All passengers and crew members on board died due to the ground impact. The accident occurred at 2310 hrs 12.4 km from aerodrome reference point (ARP) of Perm Airport, azimuth 60° M. Accident site elevation is 153 m.
Probable cause:
The immediate cause of the accident was spatial disorientation of the crew, especially the Captain who was the pilot flying at the final stage of the flight, which led to the left flip-over, a steep descent and the crash of the aircraft. The spatial disorientation was experienced during the night time operation in clouds, with both autopilot and autothrottle disengaged. Contributing to the development of the spatial disorientation and failure to recover from it was a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using "western"-type attitude indications that are found on foreign and modern Russian made aircraft. This type of indication differs from the one used on aircraft types previously flown by the crew (Tupolev 134, Antonov 2). The cause above was determined on the basis of flight recorders and ATC recorder data analysis, examination of the airframe and engine wreckage, results of the accident flight simulation, findings of the independent expertise conducted by test pilots from State Research Institute of Civil Aviation and Gromov Flight Research Institute as well as line pilots, and also on the basis of all the works conducted with participation of experts from Bermuda, France, Russia, UK and USA in the course of the investigation. The systemic cause of the accident was insufficient management by the airline of flight and maintenance operations of the Boeing 737 type of aircraft. These deficiencies in the aircraft maintenance also revealed through safety inspections conducted by the Russian Transport Oversight Authority and the Russian CAA after the accident. Deficiencies in the aircraft maintenance led to a situation when flights were performed for a long time with a throttle stagger that exceeded the limitations in the AMM and when the maintenance staff did not follow the AMM recommended troubleshooting procedures. The need to manage the throttle stagger during the approach increased crew workload. The forensic medical examination performed in the State Healthcare Center of Special Status “Perm Regional Forensic Expertise Bureau” confirmed the presence of ethyl alcohol in the Captain’s body before his death. The captain’s recent work schedule during the time period before the accident was conducive to fatigue and did not comply with national regulations.
Final Report:

Crash of a PZL-Mielec AN-2R near Osinovy Mys

Date & Time: Aug 29, 2008
Type of aircraft:
Operator:
Registration:
RA-68126
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G195-31
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While performing an aerial photography mission, the engine failed. The crew attempted an emergency landing and reduced his altitude when the aircraft collided with trees and crashed in a field, coming to rest upside down. The wreckage was found a day later about 50 km from Osinovy Mys. All four occupants were injured.
Probable cause:
Engine failure for unknown reasons.

Explosion of a Tupolev TU-154M in Saint Petersburg

Date & Time: Jun 30, 2008 at 1548 LT
Type of aircraft:
Operator:
Registration:
RA-85667
Flight Phase:
Survivors:
Yes
Schedule:
Saint Petersburg - Moscow
MSN:
89A825
YOM:
1989
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, at a speed of 32 knots, the engine n°1 (a Soloviev D-30KU-154-II) exploded. The crew abandoned the takeoff procedure and started an emergency braking manoeuvre. The aircraft was stopped on the main runway and all 112 occupants evacuated safely. The aircraft was considered as damaged beyond repair as several compressor elements punctured the engine n°1 nacelle, hit the fuselage and n°2 engine structure. A fire erupted on the left engine and destroyed the nacelle and a part of APU as well.
Probable cause:
Left engine compressor disintegration during the takeoff roll.

Crash of a PZL-Mielec AN-2 in Dmitrievskaya

Date & Time: Jun 28, 2008 at 1930 LT
Type of aircraft:
Operator:
Registration:
RF-00403
Flight Phase:
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was performing a local test flight following an engine overhaul. En route, the engine lost power. The pilot attempted an emergency landing when the aircraft crashed in an open field located 6 km northeast of Dmitrievskaya, bursting into flames. The aircraft was destroyed and the pilot was seriously injured.
Probable cause:
Engine failure for unknown reasons.

Crash of a PZL-Mielec AN-2 in Bol’shoye Gryzlovo: 5 killed

Date & Time: Jun 27, 2008 at 1756 LT
Type of aircraft:
Operator:
Registration:
RA-01132
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bol’shoye Gryzlovo - Bol’shoye Gryzlovo
MSN:
1G238-60
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The single engine aircraft departed Bol’shoye Gryzlovo Airport at 1753LT on a local aerial photography mission, carrying three photographer and two pilots. Three minutes after takeoff, the engine failed. The crew attempted an emergency landing when the aircraft struck power cables and crashed in a wooded area, bursting into flames. All five occupants were killed.
Probable cause:
Collision of the aircraft with power lines during a forced landing following an engine failure in flight.
The following contributing factors were identified:
- The aircraft was refueled with a poor quality fuel prior to the last flight,
- Lack of fuel quality control during its storage, transportation and refueling process.