According to the official investigation report by the Interstate Aviation Committee (IAC), the crash was a result of pilot error, arising from a lack of skill to recover from an excessive nose-up attitude during a go-around procedure. The pilots' deficiencies were caused by a problem with the airline's safety management and a lack of regulatory oversight. One member of the commission filed an alternative opinion report, however, claiming that the commission had ignored the possible malfunction of the aircraft's elevator controls.[3]
Background
Remains of the plane the night after the accident
The plane operating Tatarstan Airlines Flight 363, with the registration of VQ-BBN had been built in the year 1990.[4] This plane was previously leased from Bulgaria Air, the flag carrier airline of Bulgaria in 2008.[5] Previously before the plane was leased by Euralair,Air France,Uganda Airlines, Rio Sul Airlines, and Blue Air.[6] The captain of Flight 363, Rustem Gabdrakhmanovich Salikhov, was a navigator between the years 1991 and 2010. After that, he became a captain after training in the Boeing 737. The captain had a limited knowledge of the English language. The First Officer of Flight 363 used to be a flight engineer from 1989 to 2008.
While on final approach to Kazan International Airport, the crew initiated a go-around due to an unstable approach but crashed onto the runway in a 75-degree-nose-down attitude, at a speed of 242 knots (448 km/h; 278 mph) moments later and exploded upon impact with the ground.[8] A second explosion occurred 40 seconds after impact. One of the airport's surveillance cameras caught the crash on video. All 44 passengers and 6 crew members were killed; there were no casualties on the ground. High winds and cloudy conditions were reported at the airport at the time of the crash.[9][10]
The Kazan International Airport was kept closed for about 24 hours, serving only transit flights, before it was fully reopened on 18 November.[8][11]
The airframe had been involved in two prior incidents:
While in service with Rio Sul, on 17 December 2001, the aircraft crashed about 70 metres (230 ft) short of the runway while landing at Tancredo Neves International Airport under adverse weather conditions, damaging its landing gear. All 108 passengers and crew on board survived.[12][13]
On 26 November 2012, the aircraft made an emergency landing in Kazan due to problems with cabin depressurization shortly after takeoff.[14]
Crew
The captain was 47-year-old Rustem Gabdrakhmanovich Salikhov, (Russian: Рустем Габдлайманович Салихов) who had been with the airline since 1992. He had 2,755 flight hours, including 2,509 hours on the Boeing 737. The first officer was Viktor Nikiforovich Gutsul,(Russian: Виктоп Никифорович Гутсул) who was also 47. He had been with the airline since 2008 and had 2,093 flight hours, with 1,943 of them on the Boeing 737.[15][16][additional citation(s) needed]
The IAC launched an investigation into the crash and arrived at the site on 18 November. Both flight recorders, the flight data recorder (FDR) and the cockpit voice recorder (CVR), were recovered from the wreckage.[18] The Tatarstan Transport Prosecution Office has opened a criminal investigation into the crash.[8] The American National Transportation Safety Board (NTSB) dispatched a team of investigators to the crash site.[19]
On 19 November, Aksan Giniyatullin, the director of Tatarstan Airlines, declared that although the cockpit crew was experienced, the captain of the airliner may have lacked experience performing a go-around maneuver. Moments before the crash the pilot informed the control tower that the aircraft was not properly configured for landing and initiated a go-around, before plunging into the ground as if it had stalled. Investigators said the possible causes of the accident included technical malfunction as well as pilot error.[20]
On 22 November, the British Air Accidents Investigation Branch (AAIB) announced they had joined the investigation and had dispatched investigators to Kazan.[21]
Official reports
According to the criminal case report, released 14 November 2019 by the Investigative Committee of Russia, the investigation determined that crash was a direct result of erroneous actions on the part of the captain (Salikhov) and the first officer (Gutsul). Based on information obtained during the investigation, Salikhov was lacking sufficient piloting skills and was granted piloting on a basis of falsified documents.[22]
On 19 November 2013, the Investigation Board of the IAC reported the following preliminary details after recovering some information from the flight data recorder:[23][24]
Tatarstan Airlines Boeing 737-500 Accident Technical Investigation Board of IAC informs about preliminary results of flight data recorder information recovery.
During the final approach, the flight crew were unable to follow a standard landing pattern defined by the regulating documentation. Having realized the aircraft was not lined-up properly relative to the runway, the crew reported to the ATC and started to go-around using the TOGA (take off / go around) mode. One of the two autopilots, which was active during the final approach, had been switched off and the flight was being controlled manually.
The engines reached thrust level close to full. The crew retracted the flaps from 30 degrees to 15 degrees position.
Affected by the upturn moment generated by the engine thrust, the aircraft started to climb, reaching the pitch angle of about 25 degrees. Indicated airspeed started to decrease. The crew retracted the landing gear. Since initiating the go-around maneuver up to this moment, the crew did not perform control actions through the yoke.
After the airspeed decreased from 150 to 125 knots (278 to 232 km/h; 173 to 144 mph), the crew started control actions through the yoke, pitching the nose down, which led to stopping the climb then starting descent and increasing the airspeed. Maximum angles of attack have not exceeded operational limits during the flight.
After reaching the altitude of 700 metres (2,300 ft), the aircraft started a steep nosedive, with the pitch angle reaching −75° by the end of the flight (end of the recording).
The aircraft collided with terrain at high speed (exceeding 450 km/h (240 kn; 280 mph)) and with highly negative pitch angle.
About 45 seconds have passed between the moment of starting go-around maneuver and the moment the recording stopped, the descent took about 20 seconds.
The propulsion systems were operating up to the collision with terrain. No single commands have been detected by the preliminary analysis, which would indicate failures of systems or units of the aircraft or engines.
Final report
On 24 December 2015, the IAC released their final report stating that the crash was caused by an under-qualified crew who lacked the skills to recover from an excessive nose up attitude during a go-around procedure. The go-around was necessitated by a positional error in the navigation system, a map drift. The pilots' deficiencies were caused by lack of airline safety management and lack of regulators' oversight.[25][15][26]
According to the final report, during the final approach the crew initiated a go-around, but being under high workload, which possibly caused a "tunnel vision effect", they did not perceive warning messages related to auto-pilot disconnection. When the plane climbed to 700 m, its pitch angle reached 25 degrees and the airspeed dropped to 230 km/h. At that moment the captain, who had not performed a go-around outside of training, moved the yoke, pitching nose down, which led to stopping climb and started a descent and increase of the aircraft's airspeed. After reaching the altitude of 700 m, the aircraft started a steep nosedive, with the pitch angle reaching −75° when the aircraft impacted the ground. The plane crashed on the airport's runway with a speed exceeding 450 km/h. The time from the start of the go-around maneuver until the impact was about 45 seconds, including 20 seconds of aircraft descent.[15]
Alternative opinion report
Nikolay Studenikin, the official representative of the Rosaviatsiya in the air accident investigation commission, filed an alternative opinion report, in which he expressed his disagreement with the conclusions of the commission.[3]
In it he stated that the IAC commission concentrated the investigation on the search of the shortcomings in the flight crew training in Russia, and that no direct connection between such shortcomings and the Flight 363 crash was actually established. He also criticized, that the investigation into the possible malfunction of the aircraft's elevators' controls was entrusted to their manufacturer, the US-based Parker Aerospace, which ruled that their controls operated normally during the accident. According to Studenikin, a flight simulation of the crashed flight, which was conducted on the Boeing facilities, was aimed only on proving the crew's fault and didn't simulate a possible mechanical failure in the Boeing aircraft.[3]
Aircraft certificate suspension
Rosaviatsiya refused to accept the results of the IAC's Flight 363 accident investigation, citing their concern over the Boeing 737's elevators' controls.[27] IAC suggested that the position by Rosaviatsiya was caused by their reluctance to accept the shortcomings of Rosaviatsiya's regulatory oversight of pilot training in Russia, which was revealed in the report. On 4 November 2015, IAC unexpectedly announced the suspension of Boeing 737 flying certificates in Russia, explaining it by Rosaviatsiya's refusal to accept the absence of safety issues with 737 elevator controls.[28]
With the Boeing 737 being a work-horse of several Russian airlines, the suspension meant that within days the significant part of the country's passenger fleet could be grounded for an uncertain period of time. Dmitry Peskov, a spokesman for the Russian President, said that Kremlin was aware of the IAC decision to suspend Boeing 737 operation in Russia and believed that the specialized agencies and the Cabinet would make the necessary analysis of the situation.[28]Ministry of Transport said that only six out of 150 Boeing 737 aircraft in Russia have the certificates issued by IAC, the rest got their certificates in other countries and thus IAC has no right to suspend them.[27] Rosaviatsiya announced that the IAC had no right to ban any Boeing 737 operation in Russia, as such a decision could be made only by the federal executive bodies.[28] It called an emergency meeting to discuss the future of Boeing 737 in Russia with the participation of Ministry of Transport, Rostransnadzor, airline representatives and a Boeing representative in Russia, but IAC refused to attend it.[27] The next day the IAC withdrew its suspension of Boeing 737 certificates.[27]
On 10 December 2015, the IAC met and officially accepted its Flight 363 final accident investigation report.[29] Rosaviatsiya and Studenikin refused to participate in this meeting or provide their approval for the report.[29]
^"Боинг 737-500 VQ-BBN 17.11.2013" [Boeing 737-500 VQ-BBN 17.11.2013]. mak-iac.org (in Russian). Interstate Aviation Committee. 14 November 2019. Archived from the original on 13 October 2015.
