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{{Infobox incidente aereo
|Nome = Volo Aeroflot 821
|Immagine = Boeing 737-505, Aeroflot-Nord JP6276458.jpg
|Didascalia = L'aereomobile coinvolto 3 mesi prima dell'incidente.
|Tipo_evento =
|Data = 14 settembre 2008
|Ora = 5:10
|Tipo = Errore del pilota, perdita di orientamento
|Luogo = [[Perm]]
|Nomestato = RUS
|LatGradi = 57
|LatPrimi = 58
|LatSecondi = 17
|LatNS = N
|LongGradi = 56
|LongPrimi = 12
|LongSecondi = 54
|LongEW = E
|Vittime = 88
|Feriti = 0
|Sopravvissuti = 0
|Tipo_aeromobile = [[Boeing 737-500]]<ref name="planesregister">{{cita web
|url=http://www.planesregister.com/aircraft/b737-25792.htm
|titolo=VP-BKO Boeing 737 MSN 25792 - Planesregister.com
|site=planesregister.com
|data=17 settembre 2008
|lingua=en
}}</ref>
|Operatore = [[Aeroflot-Nord]]
|Numero_registrazione = VP-BKO
|Partenza = [[Aeroporto di Mosca-Šeremet'evo]]
|Destinazione = [[Aeroporto di Perm']]
|Passeggeri = 82
|Equipaggio = 6
|Ref = https://planeregister.com
}}
Il '''volo Aeroflot-Nord 821''' era un collegamente aereo tra [[Mosca]] e la città di [[Perm']] operato da [[Aeroflot-Nord]] e [[Aeroflot]]. Il giorno 14 settembre [[2008]] alle ore 5:10 ([[UTC]]+06) si schiantò vicino all'[[aeroporto di Perm']] uccidendo tutti gli 82 passeggeri e 6 membri dell'equipaggio. Ad oggi è il peggiore incidente che ha coinvolto un [[Boeing 737-500]], superando l'incidente del [[volo Asiana Airlines 733]] del 1993.
La causa principale è da attribuirsi alla perdita di orientamento di entrambi i piloti provocata dalla loro inesperienza con l'[[orizzonte artificiale]] di fabbricazione Occidentale. Ulteriori concause sono state la mancanza di un adeguato riposo, la scarsa conoscenza delle tecniche di [[Crew Resource Managemnt]] e l'assunzione di alcool da parte del capitano. Come conseguenza del disastro aereo la compagnia Aeroflot-Nord è stata rinominata in Nordavia.
== Il disastro ==
Il [[Boeing 737-500]], codice di registrazione VP-BKO, era un aeromobile appartenente ad Aeroflot-Nord, sussidiaria di Aeroflot, e stava effettuando il volo Aeroflot SU821 <ref>{{cita news|url=http://www.aeroflot.ru/eng/about.aspx?ob_no=549&d_no=11497|titolo=A Boeing-737 belonging to Aeroflot-Nord crashed today at the airport of Perm |data=14 September 2008 |pubblicazione=[[Aeroflot]] |accesso=14 September 2008|urlarchivo=https://web.archive.org/web/20080918013950/http://www.aeroflot.ru/eng/about.aspx?ob_no=549&d_no=11497|dataarchivo=18 September 2008 |urlmorto=si|lingua=en}}</ref> dall'[[Aeroporto di Mosca-Šeremet'evo]] a [[Perm']] (Russia) quando si schiantò contro una linea ferroviaria a sudovest di Perm alle ore 5:10 del 13 settembre 2018<ref>Final report, synopsis (page 8).</ref><ref name=bbc0914>
{{cita news
|url=http://news.bbc.co.uk/2/hi/europe/7614951.stm
|titolo=Passenger plane crashes in Russia
|pubblicazione=[[BBC News]]
|data=14 settembre 2008
|accesso=14 settembre 2008
| urlarchivo= https://web.archive.org/web/20080914065212/http://news.bbc.co.uk/2/hi/europe/7614951.stm| dataarchivio= 14 settembre 2008 | urlmorto= no|lingua=en}}</ref><ref>
{{cita news
|url=http://www.lenta.ru/news/2008/09/14/aircrash/
|titolo=88 человек погибли при крушении "Боинга-737" под Пермью
|pubblicazione=Lenta.Ru
|data=14 settembre 2008
|accesso=14 settembre 2008
|lingua=ru
| urlarchivio= https://web.archive.org/web/20080915130330/http://lenta.ru/news/2008/09/14/aircrash/| dataarchivio= 15 settembre 2008 | urlmorto= no}}</ref><ref>
{{cita news
|url=http://www.gazeta.ru/news/lenta/2008/09/14/n_1270150.shtml
|titolo=Самолет в Перми упал недалеко от жилых домов
|lingua=ru
|date=14 settembre 2008
|accesso=14 settembre 2008
|urlarchivio= https://web.archive.org/web/20080914234700/http://www.gazeta.ru/news/lenta/2008/09/14/n_1270150.shtml|dataarchivio= 14 settembre 2008 |urlmorto= no}}</ref><ref>
{{cite web
|url=http://gazeta.ru/news/lenta/2008/09/14/n_1270144.shtml
|titolo=При падении Boeing 737 повреждена Транссибирская магистраль
|pubblicazione=Gazeta.ru
|data=14 settembre 2008
|accesso=14 settembre 2008
|lingua=ru
| urlarchivio= https://web.archive.org/web/20080914234641/http://www.gazeta.ru/news/lenta/2008/09/14/n_1270144.shtml| dataarchivio 14 settembre 2008 | urlmorto= no}}</ref> Al momento dell'incidente c'era una leggera pioggia<ref>
{{cita web
|url=http://avherald.com/h?article=40cba259
|editore=Aviation Herald
|titolo=Crash: Aeroflot-Nord B735 at Perm on Sep 14th 2008, impacted ground while on approach to Perm
|accesso=14 settembre 2008
|lingua=en
}}</ref>
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.<ref name="ATC">
{{cite web
|url=http://www.gazeta.ru/news/lenta/2008/09/14/n_1270291.shtml
|title=Диспетчер: экипаж Boeing вел себя неадекватно – Газета.Ru: Хроника дня
|publisher=Gazeta.ru
|accessdate=15 September 2008
|language=Russian
| archiveurl= https://web.archive.org/web/20080916102110/http://www.gazeta.ru/news/lenta/2008/09/14/n_1270291.shtml| archivedate= 16 September 2008 | deadurl= no}}</ref> 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 {{convert|1100|m|ft}} and air controllers lost its blip.<ref name="Tor">{{cite news |title=88 die in Russian jet crash |page=26 |agency=[[Associated Press]] |work=[[Toronto Star]] |date=15 September 2008}}</ref> 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 recorder]]s 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 [[Chusovoy|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.<ref>{{cite news|url=http://afp.google.com/article/ALeqM5gJgjC63RTDeMPUx-47gaOd3xnRFg |agency=Agence France-Presse |title=88 including 21 foreigners killed in airplane crash in Russia's Urals |deadurl=yes |archiveurl=https://web.archive.org/web/20080918153810/http://afp.google.com/article/ALeqM5gJgjC63RTDeMPUx-47gaOd3xnRFg |archivedate=18 September 2008 }}</ref><ref>{{cite news|url=http://ukpress.google.com/article/ALeqM5h5n82mQKM3elWCDfl_6mM8GnSjpg |publisher=ukpress |title=Plane crash kills all on board |deadurl=yes |archiveurl=https://web.archive.org/web/20080918212258/http://ukpress.google.com/article/ALeqM5h5n82mQKM3elWCDfl_6mM8GnSjpg |archivedate=18 September 2008 }}</ref><ref>
{{cite news
|url=http://www.reuters.fr/news/articlenews.aspx?type=newsOne&storyID=2008-09-14T055621Z_01_LE463005_RTRUKOC_0_US-RUSSIA-CRASH.xml&WTmodLoc=Home-C2-TopNews-newsOne-1%20reuters.fr/news
|date=14 September 2008
|title=Russian Aeroflot plane crashes, 88 people killed
}}</ref>
It was reported that its engines caught fire at an altitude of {{convert|1000|m|ft}}. Eyewitness reports stated that the plane was visibly on fire prior to crashing, and hit the ground at a 30–40-degree angle.<ref name=bbc0914/> 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".<ref name="aaib.gov.uk"/>
==Aircraft history==
The aircraft involved in the crash 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.<ref name="planesregister" /><ref>[http://www.airfleets.net/ficheapp/plane-b737-25792.htm b737-25792] Airfleets.net.</ref><ref name="Clarify">{{cite pressrelease|url=http://www.aeroflot-nord.ru/news/actual/?file=5000171409200829 |title=[Clarifying information] |publisher=Aeroflot-Nord |date=14 September 2008 |language=Russian |deadurl=yes |archiveurl=https://web.archive.org/web/20080917150650/http://www.aeroflot-nord.ru/news/actual/?file=5000171409200829 |archivedate=17 September 2008 }}</ref> Pinewatch was incorporated in 1995.<ref>[http://www.ukdata.com/numbers/E0228369.html "Pinewatch Limited"] {{webarchive |url=https://web.archive.org/web/20080918110014/http://www.ukdata.com/numbers/E0228369.html |date=18 September 2008 }}</ref>
== Investigation ==
[[Image:Пермь. Место падения Боинг-737-500. Общий вид. Август 2011 года.JPG|Panorama of the crash site and the memorial.|thumb|300px|upright]]
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]].<ref>{{cite press release|url=http://www.ntsb.gov/Pressrel/2008/080914.html |title=NTSB assists government of Russia in aviation accident |publisher=US [[National Transportation Safety Board]] |date=14 September 2008 |deadurl=yes |archiveurl=https://web.archive.org/web/20080916010257/http://ntsb.gov/Pressrel/2008/080914.html |archivedate=16 September 2008 }}</ref> 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 (Bermuda)|Department of Civil Aviation]] as advisors.<ref>"[http://www.aaib.gov.uk/cms_resources.cfm?file=/AAIB%20Press%20Release%20VP-BKO%20160908.pdf AAIB PARTICIPATE IN RUSSIAN AVIATION ACCIDENT INVESTIGATION]." ([http://www.webcitation.org/6E8mHAnP0?url=http://www.aaib.gov.uk/cms_resources.cfm?file%3D/AAIB%20Press%20Release%20VP-BKO%20160908.pdf Archive]) [[Air Accidents Investigation Branch]]. 16 September 2008. Retrieved 2 February 2013.</ref> 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).<ref name="DCA08RA097">
{{cite web
|url=http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA08RA097&rpt=fa
|archive-url=https://web.archive.org/web/20081205183758/http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA08RA097&rpt=fa
|dead-url=yes
|archive-date=5 December 2008
|format=PDF
|title=Factual report, NTSB ID: DCA08RA097
|publisher=US [[National Transportation Safety Board]]
}}</ref>
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.<ref name="aaib.gov.uk">"[http://www.aaib.gov.uk/sites/aaib/publications/foreign_reports.cfm Foreign Reports]." ([http://www.webcitation.org/6E8mdzljz?url=http://www.aaib.gov.uk/publications/foreign_reports.cfm Archive]) [[Air Accidents Investigation Branch]]. Retrieved 2 February 2013.</ref>
The final investigation report stated the following reasons for the crash:<ref name="aaib.gov.uk"/><ref>{{cite web|url=http://www.mak.ru/russian/investigations/2008/boeing-737-500.html|title=Boeing-737|publisher=|accessdate=23 January 2017}}</ref><ref>"[http://www.mak.ru/russian/investigations/2008/boeing-737-500.html Боинг-737-500 VP-BKO 14.09.2008]." ''[[Interstate Aviation Committee]]''. Retrieved 19 February 2009.</ref><ref>[http://www.aaib.gov.uk/cms_resources.cfm?file=/VP-BKO_Report_en.pdf IAC – Final report B 737-505 VP-BKO (full text)]</ref>
* 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 [[Cockpit resource management|CRM]] and insufficient training for using the Western type of [[attitude indicator]]s contributed to the accident. The pilots had previously flown [[Tupolev Tu-134]] and [[Antonov An-24]] 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.<ref>{{cite web|url=http://www.avia.ru/news/?id=1233561507|title=AVIA RU Network: Новости|publisher=|accessdate=23 January 2017}}</ref> He also did not have adequate rest before the flight.{{Citation needed|date = September 2016}}
== 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]].<ref>{{cite news |url=http://www.kommersant.ru/doc.aspx?docsid=1034392 |title=[Former Moscow Youth Palace deputy director has her sentence reduced]|date=2 October 2008|publisher=[[Kommersant]]|accessdate=2 October 2008|language=Russian}}</ref>
== ATC communications before the crash ==
A recording of the conversation between ATC and Flight 821 was published online. According to the final investigation report, the pilot was 'mildly intoxicated', and this can be heard in the audio.
Irek Birbov, the air traffic controller on duty at the time of the incident, said that on final approach the aircraft was too far right of the localizer. He advised the pilot to change heading. Furthermore, instead of descending to land, the plane then went up.
The controller requested Flight 821 to check the altitude: "According to my data, you are climbing. Confirm current altitude 900 meters." The aircraft should have been at an altitude of 600 m at that time to descend further 300 m. The pilot replied "Roger, 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 failed to comply. Instead, he turned left and asked to continue his approach. The controller asked whether everything was all right with the crew; the pilots confirmed that it was.
The controller then insisted on a [[go-around]], instructing them to switch to another ATC frequency. 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. In response, the pilots' final radio transmission was "Aaa (expletive)!" A moment later the controller saw an explosion.<ref>
{{cite pressrelease
|url=http://www.rian.ru/society/20080915/151274111.html
|title=Диспетчер о последних минутах перед авиакатастрофой в Перми
|agency=[[RIA Novosti]]
|date=15 September 2008
|accessdate=15 September 2008
| archiveurl= https://web.archive.org/web/20080918003856/http://www.rian.ru/society/20080915/151274111.html| archivedate= 18 September 2008 | deadurl= no}}</ref>
== 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-24]] 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.<ref>[https://web.archive.org/web/20081121180954/http://www.moscowtimes.ru/article/1010/42/372073.htm Perm Crash Pilots Used Fake Papers] ''Moscow Times'' 31 October 2008 (archived 21 November 2008).</ref><ref>"[http://www.novayagazeta.ru/data/2008/71/10.html Все нормально в экипаже? – Первым заподозрил неладное диспетчер аэропорта Большое Савино]" ''Novaya Gazeta'' (in Russian).</ref><ref>[http://www.aero-news.net/index.cfm?ContentBlockID=5e2b3ade-a1df-4414-84c7-3c5803363b75& Aeroflot Nord pilots reported to have used false papers] ''Aero News Net'' 3 November 2008.</ref>
==Casualties ==
{|class="wikitable"
|-style="background:#ccccff;"
!rowspan=1|Nationality<ref>Final report, section 1.1.</ref>||colspan=1|Casualties
|-style="background:#ccccff;"
|-valign=top
|{{flag|Russia}}||align=center|66
|-valign=top
|{{flag|Azerbaijan}}||align=center|8
|-valign=top
|{{flag|Ukraine}}||align=center|5
|-valign=top
|{{flag|Belarus}}||align=center|1<ref>{{cite web|url=http://news.tut.by/society/117322.html |title=МЧС России: На борту разбившегося в Перми самолета находилась гражданка Беларуси |publisher=tut.by |language=be|date= 16 September 2008|accessdate=16 September 2008| archiveurl= https://web.archive.org/web/20080918070302/http://news.tut.by/society/117322.html| archivedate= 18 September 2008 | deadurl= no}}</ref>
|-valign=top
|{{flag|People's Republic of China}}||align=center|1<ref>{{cite web|url=http://news.xinhuanet.com/overseas/2008-09/15/content_10009070.htm |script-title=zh:在俄客机空难中遇难中国公民为26岁浙江籍女性 |agency=Xinhua News Agency |language=Chinese |date= 15 September 2008|accessdate=15 September 2008| archiveurl= https://web.archive.org/web/20080918142704/http://news.xinhuanet.com/overseas/2008-09/15/content_10009070.htm| archivedate= 18 September 2008 | deadurl= no}}</ref>
|-valign=top
|{{flag|France}}||align=center|2
|-valign=top
|{{flag|Germany}}||align=center|1
|-valign=top
|{{flag|Italy}}||align=center|1
|-valign=top
|{{flag|Latvia}}||align=center|1
|-valign=top
|{{flag|United States}}||align=center|1
|-valign=top
|{{flag|Uzbekistan}}||align=center|1
|-valign=top
|'''Total'''||align=center|'''88'''
|}
===Notable death===
* [[Gennady Troshev]], [[Colonel General]] in the [[Military of Russia|Russian military]], formerly the commander of the [[North Caucasus Military District]] (including [[Chechnya]]) during the [[Second Chechen War]] and adviser to the [[President of Russia]].<ref>{{cite web|url=https://news.yahoo.com/s/nm/20080914/ts_nm/russia_crash_dc |title=Russian plane crash kills 88, faulty engine blamed – Yahoo!! News |publisher=Yahoo! News |date=14 September 2008 |accessdate=15 September 2008}} {{Dead link|date=October 2010|bot=H3llBot}}</ref>
==See also==
{{Portal|Russia|Aviation|Disasters|2000s}}
*[[Crossair Flight 498]]
*[[Flash Airlines Flight 604]]
==References==
{{reflist|colwidth=30em}}
==Further reading==
* Kaminski-Morrow, David. "[http://www.flightglobal.com/news/articles/both-recorders-badly-damaged-in-aeroflot-nord-737-crash-316018/ Both recorders badly damaged in Aeroflot-Nord 737 crash]." ''[[Flight International]]''. 15 September 2008.
* Krainova, Natalya. "[http://www.themoscowtimes.com/news/article/jet-flight-recorders-damaged-in-crash/370958.html Jet Flight Recorders Damaged in Crash]." ''[[The Moscow Times]]''. 16 September 2008. Issue 3989.
==External links==
{{commons category|Aeroflot Flight 821}}
*[http://www.aaib.gov.uk/cms_resources.cfm?file=/VP-BKO_Report_en.pdf Final accident report] – [[Interstate Aviation Committee]] – Unofficial English translation – Hosted by the [[Air Accidents Investigation Branch]] (AAIB) ([http://www.webcitation.org/5zb7mKIWe?url=http://www.aaib.gov.uk/cms_resources.cfm?file%3D/VP-BKO_Report_en.pdf Archive])
*[http://www.mak.ru/russian/investigations/2008/boeing-737-500.html Investigation] ([http://www.webcitation.org/5zlXc4Vd0?url=http://www.mak.ru/russian/investigations/2008/boeing-737-500.html Archive]) – Interstate Aviation Committee {{ru icon}}
**[http://www.mak.ru/russian/investigations/2008/vp-bko_report.pdf Final report] {{ru icon}} ([http://www.webcitation.org/5zb7kc2AO?url=http://www.mak.ru/russian/investigations/2008/vp-bko_report.pdf Archive])
*[https://web.archive.org/web/20080917234227/http://www.lenta.ru/news/2008/09/14/list/spisok.htm Lenta.ru page listing passengers of the flight]
*[https://web.archive.org/web/20080918013942/http://www.aeroflot.ru/eng/about.aspx?ob_no=549 Aeroflot news archive]
*[https://web.archive.org/web/20080918155428/http://www.aeroflot.ru/eng/about.aspx?ob_no=549&d_no=11538 Aeroflot page listing passengers of the flight]
*{{ru icon}} [https://web.archive.org/web/20080917150634/http://www.aeroflot-nord.ru/news/actual/?file=3431101409200862 АЭРОФЛОТ-НОРД ПРИНОСИТ ГЛУБОКИЕ СОБОЛЕЗНОВАНИЯ РОДСТВЕННИКАМ ПОГИБШИХ]." Aeroflot Nord. 14 September 2008. – Aeroflot Nord press release about the accident
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