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14 September 2008 - Aeroflot 821

Aeroflot Flight 821 was a scheduled passenger flight operated by Aeroflot-Nord in a service agreement with Aeroflot and as its subsidiary. On 14 September 2008, the aircraft operating the flight crashed on approach to Perm International Airport at 5:10 local time (UTC+06). All 82 passengers and 6 crew members were killed. Among the passengers who were killed was Russian Colonel General Gennady Troshev formerly the commander of the North Caucasus Military District (including Chechnya) during the Second Chechen War and adviser to the President of Russia. A section of the Trans-Siberian Railway was damaged by the crash. Flight 821 is the deadliest accident involving a Boeing 737-500, surpassing the 1993 crash of Asiana Airlines Flight 733.

The primary cause of the crash was that both pilots had lost spatial orientation due to their inexperience with the Western type of attitude indicator on the aircraft. Lack of adequate rest, poor crew resource management, and alcohol consumption by the captain also contributed to the accident.

This air disaster led to Aeroflot-Nord rebranding as Nordavia, effective on 1 December 2009 and later to Smartavia in 2019.

The Boeing 737-505, registration VP-BKO, an aircraft belonging to the Aeroflot subsidiary Aeroflot-Nord but operating as Aeroflot flight SU821 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 UTC). The weather at the time of accident was rainy (unbroken clouds at 240 m, light rain).

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. At 5:10 AM, radio contact with the plane was lost; minutes later it crashed in the outskirts of Perm.

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. As the aircraft was registered in Bermuda, that government was represented by the UK's Air Accidents 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. The engines were made in France, so that state was represented by the Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA).

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.

The final investigation report stated the following reasons for the crash:

  • The immediate cause of the accident was the loss of spatial orientation by the crew and especially 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 Crew Resource Management 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-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 alcohol in the captain's tissue, with different sample groups suggesting a blood alcohol level of either around 0.05% or around 0.11% abv. He also did not have adequate rest before the flight

 

CVR Transript:


CAP: Aeroflot 821 on final approach
ATC: Aeroflot 821 heading 997
CAP: Aeroflot 99 er sorry aerofloat 921 997 checked desending 600... and on final approach
ATC: Aeroflot 821 understood
CAP: Aeroflot 821 desending 600 and confirming instructions
ATC: Okay uderstood
CAP: Right so as soon as we join this F... marker and we will have to do F... gear down and all that F...
F/O: Flaps 15
CAP: 115 check
F/O: F... the speed
CAP: Whoa
CAP: 150. Why'd you set that see there you go, that's it
CAP:Just about to join marker
ATC: Aeroflot 821 what's your current position?
CAP: Aeroflot 821 approaching 4th course err 170
ATC: 821 understood final approach 6klms away
CAP: Aeroflot affirmiative
F/O: Just a bit that way
CAP: We've just turn left
CAP: Aeroflot 921 localizer has been intercepted VOR LOC set
F/O: Flaps 15
CAP: 240 Aeroflot 821 What?
F/O: Flaps 30 yea
CAP: Do what you fuck..ng have to do, come on !
CAP: 240 set?
F/O: set
CAP: Just do it all yourself okay?
CAP: Perm approach erm aerofloat 821 we're approaching the 4th marker
ATC: Aeroflot 821 perm approach good morning headin 13 and a half right turn 3000
CAP: Aeroflot 821 can you tell us the weather conditions?
ATC: Aeroflot 821 visibility 10km rain
CAP: Aeroflot 821 understood
CAP: Speed
(Autopilot disconnected)
ATC: Aeroflot 821 heading 13 approaching
CAP: Aeroflat 821
ATC: 821 approaching course
CAP: 821
F/O: Damn
CAP: VOR LOC armed VOR LOC increase
CAP: Okay so far flaps 30 what's speed do we need for F..ck's sake
F/O: 140 133
ATC: 821 according to my data you are climbing your height 900m can you confirm?
F/O: Damn
CAP: Aeroflot 821 erm we can confirming and we're descending now
ATC: Aeroflot 821 complete right turn for heading 360 descending to 600
CAP: Course 360 descending to 600 aerofloat 821
CAP: You need to look at the barometre
ATC: Repeat the final approach and calculate go around
CAP: Aeroflot 821, if you don't mind
(Bank angle)
F/O: Oh what you doing
CAP: Can we continue our approach?
ATC: 821 course 360 desend to 600 calculate go around
CAP: Course 360 descending to 600 aerofloat 821
ATC: Aeroflot 821 is everything okay with the crew?
CAP: Aeroflot 821 affirmative
ATC: Aeroflot 821 understood follow my instruntion strictly calculate vectors to final and flot courese tho the 4th turning right turn to heading 360 descending to 600
CAP: Descending to 600 course 360 aerofloat 821
F/O: Take it take it
CAP: What do you mean fuck...ng take it
(Bank angle, Bank angle)
CAP: I can't do it either
(Bank angle, Bank angle)
F/O: Other way other directions
F/O: F..ck sake
(Bank angle,Bank angle)
F/O: Fuck...ng hell
CAP: Well
F/O: What the F..ck are we doing?
(Bank angle,Bank angle)
ATC: 821 contact tower approach 127.1
F/O: Sh..T
CAP: F..ck
(Sink rate Pull up)
SOUND OF IMPACT
END OF RECORDING

 

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