Aeroflot Flight 821

Aeroflot Flight 821
Fatal accident summary
The Aeroflot-Nord Boeing 737-500 that crashed (VP-BKO)
Date	14 September 2008
Summary	Controlled flight into terrain
Site	Perm, Russia 57°58′17″N 56°12′54″E / 57.97139°N 56.21500°E / 57.97139; 56.21500Coordinates: 57°58′17″N 56°12′54″E / 57.97139°N 56.21500°E / 57.97139; 56.21500
Passengers	82
Crew	6
Fatalities	88 (all)
Survivors	0
Aircraft type	Boeing 737–505^[1]
Operator	Aeroflot-Nord
Registration	VP-BKO
Flight origin	Sheremetyevo International Airport, Moscow, Russia
Destination	Perm Airport, Perm, Russia

Aeroflot Flight 821, operated by Aeroflot-Nord in a service agreement with Aeroflot and as its subsidiary, crashed on approach to Perm Airport on 14 September 2008 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 to date, surpassing the 1993 crash of Asiana Airlines Flight 733.

The main reason for the crash was that both pilots had lost spatial orientation due to their lack of proficiency with the Western type of attitude indicator on the aircraft. Fatigue from lack of adequate rest, poor CRM and possible alcohol consumption by the captain also contributed to the accident.

This air disaster resulted in the rebranding of Aeroflot-Nord into Nordavia, effective on 1 December 2009.

Accident

The Boeing 737–505, registration VP-BKO, an aircraft belonging to the Aeroflot subsidiary Aeroflot-Nord but operating as Aeroflot flight SU821^[2] 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 PM UTC).^[3]^[4]^[5]^[6]^[7] The weather at the time of accident was rainy (unbroken clouds at 240 m, light rain).^[8]

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.^[9] 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.^[10] 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.^[11]^[12]^[13]

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.^[4] 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".^[14]

Aircraft history

The aircraft involved in the crash (msn 25792/cn 2353) 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 Air China, 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.^[1]^[15]^[16] Pinewatch was incorporated in 1995.^[17]

Investigation

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.^[18] 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.^[19] 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).^[20]

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.^[14]

The final investigation report stated the following reasons for the crash:^[14]^[21]^[22]^[23]

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 have 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.^[24] He also did not have adequate rest before the flight.

Lawsuit

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.^[25]

Last minutes of the flight

Irek Birbov, the ATC controller on duty the night of the incident, gave an interview where he told about his communication with Flight 821. He said that on final approach the aircraft was too far right of the landing course, and the controller informed the pilot about that, who corrected the approach course.

But instead of descending to land, the plane then went up. ATC controller noticed this also and reportedly radioed the aircraft with this message: "According to my data, you are climbing. Confirm current altitude 900 m." The aircraft should have been at an altitude of 600 m at that time to descend further 300 m. The pilot replied "Affirmative, 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 did not execute this instruction – instead, he turned left and asked to continue his approach. The controller asked whether everything was all right; the pilots confirmed that it was. The controller then insisted that the aircraft circle, instructing them to switch to another ATC controller. 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. The only thing he heard from pilots was "Aaa shit!" A moment later the controller saw the explosion in the outskirts of the city.^[26]

Crew

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.^[27]^[28]^[29]