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Volo Aeroflot 821
L'aereomobile coinvolto 3 mesi prima dell'incidente.
Data14 settembre 2008
Ora5:10
TipoErrore del pilota, perdita di orientamento
LuogoPerm
StatoRussia (bandiera) Russia
Coordinate57°58′17″N 56°12′54″E
Tipo di aeromobileBoeing 737-500[1]
OperatoreAeroflot-Nord
Numero di registrazioneVP-BKO
PartenzaAeroporto di Mosca-Šeremet'evo
DestinazioneAeroporto di Perm'
Passeggeri82
Equipaggio6
Vittime88
Feriti0
Sopravvissuti0
Mappa di localizzazione
Mappa di localizzazione: Federazione Russa
ArTrix/Sandbox
https://planeregister.com
voci di incidenti aerei presenti su Wikipedia

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 [2] 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[3][4][5][6][7] Al momento dell'incidente c'era una leggera pioggia[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 metri (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 metri (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 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

 
Panorama of the crash site and the memorial.

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

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]

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.[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-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.[27][28][29]

Casualties

Nationality[30] Casualties
  66
  8
  5
  1[31]
  1[32]
  2
  1
  1
  1
  1
  1
Total 88

Notable death

See also

References

  1. ^ a b (EN) VP-BKO Boeing 737 MSN 25792 - Planesregister.com, su planesregister.com, 17 settembre 2008.
  2. ^ (EN) A Boeing-737 belonging to Aeroflot-Nord crashed today at the airport of Perm [collegamento interrotto], in Aeroflot, 14 September 2008. URL consultato il 14 September 2008.
  3. ^ Final report, synopsis (page 8).
  4. ^ a b (EN) Passenger plane crashes in Russia, in BBC News, 14 settembre 2008. URL consultato il 14 settembre 2008.
  5. ^ (RU) 88 человек погибли при крушении "Боинга-737" под Пермью, in Lenta.Ru, 14 settembre 2008. URL consultato il 14 settembre 2008 (archiviato il 15 settembre 2008).
  6. ^ (RU) Самолет в Перми упал недалеко от жилых домов. URL consultato il 14 settembre 2008 (archiviato il 14 settembre 2008).
  7. ^ {{{title}}}, su gazeta.ru (archiviato dall'url originale il 14 settembre 2008).
  8. ^ (EN) Crash: Aeroflot-Nord B735 at Perm on Sep 14th 2008, impacted ground while on approach to Perm, su avherald.com, Aviation Herald. URL consultato il 14 settembre 2008.
  9. ^ (Russian) Диспетчер: экипаж Boeing вел себя неадекватно – Газета.Ru: Хроника дня, su gazeta.ru. URL consultato il 15 September 2008 (archiviato il 16 September 2008). Lingua sconosciuta: Russian (aiuto)
  10. ^ 88 die in Russian jet crash, in Toronto Star, 15 September 2008, p. 26.
  11. ^ 88 including 21 foreigners killed in airplane crash in Russia's Urals.
  12. ^ Plane crash kills all on board, ukpress.
  13. ^ Russian Aeroflot plane crashes, 88 people killed, 14 September 2008.
  14. ^ a b c "Foreign Reports." (Archive) Air Accidents Investigation Branch. Retrieved 2 February 2013.
  15. ^ b737-25792 Airfleets.net.
  16. ^ Template:Cite pressrelease
  17. ^ "Pinewatch Limited" Archiviato il 18 September 2008 Data nell'URL non combaciante: 18 settembre 2008 in Internet Archive.
  18. ^ NTSB assists government of Russia in aviation accident, su ntsb.gov, US National Transportation Safety Board, 14 September 2008 (archiviato dall'url originale il 16 September 2008).
  19. ^ "AAIB PARTICIPATE IN RUSSIAN AVIATION ACCIDENT INVESTIGATION." (Archive) Air Accidents Investigation Branch. 16 September 2008. Retrieved 2 February 2013.
  20. ^ Factual report, NTSB ID: DCA08RA097 (PDF), su ntsb.gov, US National Transportation Safety Board.
  21. ^ Boeing-737, su mak.ru. URL consultato il 23 January 2017.
  22. ^ "Боинг-737-500 VP-BKO 14.09.2008." Interstate Aviation Committee. Retrieved 19 February 2009.
  23. ^ IAC – Final report B 737-505 VP-BKO (full text)
  24. ^ AVIA RU Network: Новости, su avia.ru. URL consultato il 23 January 2017.
  25. ^ (Russian) [Former Moscow Youth Palace deputy director has her sentence reduced], Kommersant, 2 October 2008. URL consultato il 2 October 2008. Lingua sconosciuta: Russian (aiuto)
  26. ^ Template:Cite pressrelease
  27. ^ Perm Crash Pilots Used Fake Papers Moscow Times 31 October 2008 (archived 21 November 2008).
  28. ^ "Все нормально в экипаже? – Первым заподозрил неладное диспетчер аэропорта Большое Савино" Novaya Gazeta (in Russian).
  29. ^ Aeroflot Nord pilots reported to have used false papers Aero News Net 3 November 2008.
  30. ^ Final report, section 1.1.
  31. ^ (BE) МЧС России: На борту разбившегося в Перми самолета находилась гражданка Беларуси, su news.tut.by, tut.by, 16 September 2008. URL consultato il 16 September 2008 (archiviato il 18 September 2008).
  32. ^ (Chinese) {{{title}}}, su news.xinhuanet.com, 15 September 2008. URL consultato il 15 September 2008 (archiviato il 18 September 2008). Lingua sconosciuta: Chinese (aiuto)
  33. ^ Russian plane crash kills 88, faulty engine blamed – Yahoo!! News, su news.yahoo.com, Yahoo! News, 14 September 2008. URL consultato il 15 September 2008. [collegamento interrotto]

Further reading

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