Russia's Interstate Aviation Committee has concluded that inexperienced crew, poor training and weak safety standards at the airline has caused the near vertical Tatarstan Airline Boeing 737 crash on 17 November 2013, that killed all the 50 on board.
The Boeing 737 pilots while landing at Kazan airport, opted to execute a go-around after unsuccessful attempts to bring the aircraft back on course and stabilize the unstable approach.
Both pilots had not realized the autopilot had disengaged as they attempted the go-around, during which the aircraft was around 270 m above the runway.
The 737-500 initially pitched up excessively, exceeding the ATC specified height of 500 m for a go-around. After stabilizing at 700 m, the aircraft entered a steep dive from which it never recovered.
The aircraft entered a 75-degree-nose-down steep dive at a speed of 242 knots (448 km/h) and exploded upon striking the ground near to the designated Runway 29.
The report says the crew failed to follow the ‘aviate, navigate, communicate’ principle, which prioritises control of the aircraft over matters such as radio communications. Unnecessary communications with the air traffic control led to prolonged co-pilot distraction from their duties and monitoring of flight parameters.
Also the captain's lack of skills to recover the aircraft from the complex spatial position (Upset Recovery) led to the creation of significant negative overload, loss of spatial orientation and transferred the aircraft into a steep dive.
The go-around was required as the aircraft was considerably off course due to map shift error (by 4 km) and the lack of active support from the ATC. The map shift error was attributed partly to incorrect positioning data fed on ground.
Investigators believe an incorrect perception of the aircraft’s attitude (somatogravic illusion) could also have played a role in the fatal crash.
The Flight 363 took off from Domodedovo International Airport in Moscow at 6:25 p.m. local time. The crash was caught on security camera in the airport.
Photo: The Kazan airport crash site