Accident in Kazan: reasons, expert comments, decryption of the "black box"

That day, November 17, 2013, at the airport in Kazan, there was no sign of a catastrophe. All ground services were operating normally and were preparing to receive the Boeing-737, which operated flight U9-363 and completed its flight from Moscow. But fate decreed otherwise. At 7 p.m. 23 minutes Moscow time, diving at a critical angle for him, the plane crashed into the runway. The tragedy claimed the lives of all fifty people who were on board at that moment.

Accident in Kazan

Unanswered Questions

The plane crash in Kazan was studied in detail by the commission of inquiry, which included representatives of the Interstate Aviation Committee, the Federal Air Transport Agency and several other departments. The details of what happened became known from their materials. In December 2015, the official document they drafted called the Final Report was released.

However, experts and the general public, the disaster in Kazan left many questions that could not be answered in this document, and where there is no specific information, as you know, rumors and speculations appear. Let’s try based on the materials we know to reconstruct the picture of the tragedy that happened on a cloudy November evening in 2013 at the airport of the capital of Tatarstan.

Doomed flight

That day, coming off at 18 o’clock. 25 minutes from the runway of Domodedovo International Airport, the Boeing-737 headed for Kazan. On board, in addition to crew members, among whom were two pilots and four flight attendants, there were forty-four passengers. I especially want to note that the disaster in Kazan claimed the lives of several fairly well-known people flying this flight. Among them - the head of the republican FSB A. Antonov, the son of the President of Tatarstan I. Minnikhanov, the famous chess player G. Rashitova, as well as the relatives of the commentator of the TV channel “Russia-2” R. Skvortsov.

The airliner itself, which served flight 363 that day, managed to see a lot in its lifetime. He first flew into the sky in 1990 and in twenty-three years of service, he worked in seven international companies. Before becoming the property of Tatarstan, he served in the civil aviation of Bulgaria, Ireland, Brazil, Uganda and France. It happened to the veteran in extreme situations. Once his chassis failed, and the pilots put him on the "belly". Another time there was a depressurization of the cabin.

Boeing 737

Pilots flying a plane to the sky

When the commission of inquiry examined in detail the personal files of the pilots who flew the plane that ill-fated day, she noted their clearly insufficient qualifications. From the case materials, the ship’s commander, Rustem Salikhov, having worked at Tatarstan Airlines for more than twenty years, was nevertheless a newcomer to the controls of the Boeing-737 aircraft.

Previously, he flew as a navigator and retraining took place in the training center, which had been liquidated by that time. The investigation aroused great doubt about the license obtained by this center, as well as the legality of Salikhov’s receipt of a commercial pilot’s certificate.

His partner - the co-pilot V. Gutsul - having worked in the company for five years, only in 2011 sat at the helm of the Boeing-737. Previously, he performed the duties of a flight mechanic, and, like the commander, did not have sufficient flight experience.

Abnormal situation on board

Kazan Airport met the staying liner with light rain with snow and cumulonimbus clouds. However, visibility was at least ten kilometers, which allowed for a visual control mode. Performing at a speed of 250 km / h the usual landing approach and at a distance of about 500 meters from the start of the runway, the ship's commander informed the ground about the occurrence of an emergency on board. According to him, the plane was in an “off-landing” position, deviating to the right from the axis of the route for four kilometers.

This information completely coincided with the data obtained by the airport dispatcher on the basis of instrument readings. The approach was carried out automatically. Kazan Airport was equipped with the latest electronic guidance system for aircraft on the axis of the runway, and what caused the deviation remained unclear. Perhaps the liner was torn to the side by a strong gust of wind.

The accident in Kazan

Created circumstances required entry into the second round. This maneuver was carried out automatically using the TOGA system, specially designed to help pilots in emergency situations and taking the plane with the help of a lighthouse on the ground to the landing position. The U-turn was successfully completed, but upon its completion something happened, as a result of which the plane crashed in Kazan.

Transition to manual control

In its report, the Interstate Aviation Committee noted that when approaching the landing, the aircraft was controlled manually. As the pilots themselves, familiar with the control of the Boeing-737 board, explain, such a conclusion means that at the time the turn was completed, the second pilot took the helm with his hands, disabling the autopilot, which brought the car to the desired height.

As evidenced by the investigation into the disaster in Kazan, at first his actions were correct and consistent with the maneuver being performed. As subsequently shown flight recorders , recovered from the black box after the accident, the liner entered a mode close to take-off. Its flaps were moved to the appropriate position and the climb began necessary to continue the maneuver. And at this stage, a fatal failure occurred, the result of which was the disaster in Kazan in 2013.

Probable pilot error

Obviously, due to the pilot’s mistake, the nose of the aircraft pulled up sharply and reached a critical angle of 25 ° for the Boeing-737. He began to climb, but with this position of the car, a strong resistance was created to the oncoming air flow, which led to a drop in speed from 278 km / h to 231 km / h.

Looking ahead, it must be said that, according to experts, it was at that moment that the fatal point of no return was passed. Having lost speed, the plane went into stall, and given that the altitude at that moment was extremely small to exit the peak - 700 meters, it was already impossible to save it.

The crew took action to reduce the angle of flight and manually, using the capabilities of the steering columns, tried to put the liner into descent mode. But, having lost the necessary speed, the aircraft began to collapse sharply at the peak and rushed to the ground, moving at an angle of 70 °. This fall lasted about twenty seconds, after which it crashed almost vertically into the runway at a speed of 450 km / h.

The first minutes after the disaster

The sound of a deafening explosion was heard for several kilometers. To eliminate the ensuing fire, the airport’s emergency services worked until morning. Only when the fire was completely extinguished did representatives of the investigating authorities begin work. What they saw threw them into shock. At the time of the accident, the speed was so high that none of the people on the plane had any chance of salvation. The catastrophe in Kazan turned a multi-ton car into shapeless debris scattered over a considerable distance. Shuffled pieces of the fuselage, armchairs, luggage and human bodies lay strewn ...

The horror gripped those who arrived at the airport that day to meet their friends and relatives. In the first minutes, none of them could believe in the reality of what happened. For most, the last hope was the likelihood that an error occurred in the list of passengers, and their relatives were not on board. The whole republic was in solidarity with those who lost their relatives and friends. In those days in the Russian and foreign media the most repeated words were: "disaster", "Kazan", "Boeing".

To the credit of taxi drivers, I must say that this evening they did not increase the fare, taking the opportunity. Moreover, they hung signs on the windshields of their cars with the inscription: “To the city for free” and drove everyone who urgently needed to get to Kazan - the disaster on November 17 brought people together. In this regard, I do not want to remember how their Moscow colleagues behaved in 2014, when a crash occurred in the metro.

Black box decryption

The beginning of the investigation

One of the most important tasks of the investigating authorities was the search for "black boxes" - automatic flight recorders containing all the flight parameters and the negotiations of pilots before the crash in Kazan. Soon, among the wreckage of the aircraft, a parametric recorder was found that recorded all the work of mechanisms and electronic equipment.

He was in a damaged condition, but nevertheless was of great interest to the investigation. He was immediately sent to Moscow, where specialists of the Interstate Aviation Committee took up the decryption of his data. It took a lot of work to find the voice recorder and hear the voices of the pilots in a matter of moments before death.

It is bewildering that, subsequently, not all negotiations between the pilots became public. Most of them, by decision of the same committee, remained unpublished. This immediately gave rise to rumors that perhaps one of the VIPs flying on this flight was in the cockpit at the time of the accident, and, as a result of this, there were suspicions that his self-actions did not cause an emergency. Quite a common story - the result of silence is speculation.

Decryption results of the "black boxes"

In anticipation of the results of the decryption of the data stored by the "black boxes", the records of the airport's internal surveillance cameras were carefully studied. They captured the last moments of the liner. The position of his signal lights and portholes clearly indicated that at the time of the disaster he was practically in an upright position. The investigation had to find out the reasons that provoked him to this. The answer to the question could be given only by flight recorders.

Two days later preliminary results arrived from Moscow. However, the decoding of the “black box”, having answered some of the questions posed, gave rise to new ones. The parametric data showed that the crew, making the approach, was forced to go to the second round, but what reasons prevented them from performing this action the first time remained unclear. For both pilots, Kazan Airport was the place of their constant work and, of course, was thoroughly studied. What happened this time?

It was puzzling information that testified to the complete inactivity of the crew both during a sharp climb, ending in a fatal loss of speed for the aircraft, and during its dive, or rather, an almost vertical drop lasting twenty seconds.

Accidents in Kazan

Even a detailed study of the medical records of the pilots and the results of the psychological tests they passed did not give an answer to this question. In any case, doctors say that they behave so inappropriately during the entire period of the deadly peak, which lasted, as already mentioned, twenty seconds, they could either be in a state of uncontrolled panic, or being in a complete stupor.

Signing the final report of the commission of inquiry

Since the decryption of the “black box” did not give an answer to the question about the causes of the disaster that caused the death of a large number of people, specialists from Boeing Corporation involved in the development of this aircraft were involved in the work. They came to the aid of representatives of the French engine manufacturing company, which were equipped with the liners of this model.

The subcommission formed from them worked until September 16, 2014 and unanimously gave the conclusion that the plane was in good condition at the time of the accident. No signs of aircraft failure were found either in the records of objective controls, that is, recorders, or in the surviving fragments of the components and assemblies of the crashed airliner.

In April 2015, all members of the commission of inquiry put their signatures on the draft final report. This document did not cause any comments from anyone, including the official representative of the Federal Air Transport Agency. It was also agreed with representatives of all countries that participated in the commission. Among them were: America, France, Great Britain and Bermuda.

Separate opinion of the representative of "Rosaviation"

But after two months, such a community of views was violated. A representative of the Federal Air Transport Agency unexpectedly withdrew his signature on the document. For reasons unclear to the rest of the commission, this agency has returned to the previous version of the reasons for the disaster in Kazan, namely, the failure of the elevator control system. Their position was impossible to explain, since world practice testifies to the failure-free operation of these elements, and so far no cases of their failure have been recorded.

This statement of theirs had unexpected consequences. The leadership of the Interstate Aviation Committee issued a decree according to which the operation of Boeing-737 aircraft was suspended throughout the country. However, “Rosaviatsiya” also showed obstinacy - it simply ignored the order of a higher organization, and the liners of this model continued to fly as if nothing had happened.

Kazan disaster investigation

Problems with the preparation of the flight crew

Throughout the entire period of the investigation, the Director General of Tatarstan Airlines V. Portnov was in the field of vision of the prosecutor's office. It was his responsibility to ensure that, as the company's flight director, he allowed his commander Rustem Salikhov to control the passenger airliner, who, according to the investigation, had no legitimate reason for that. In November 2015, a recognizance not to leave was taken from V. Portnov.

The catastrophe (737) in Kazan forced us to pay close attention to the general level of training of the company's flight personnel. It turned out that in recent years, due to material difficulties experienced by Tatarstan, it was not possible to allocate sufficient funds to maintain the professional level of pilots. By the way, the same problem faces many foreign carriers. As follows from European media reports, a number of companies admitted that due to budgetary constraints they had to reduce the training hours of pilots.

The point in this case was set a week before the onset of the new year, 2016, when the Interstate Aviation Committee published the text of the final version of the results of the investigation. The catastrophe in Kazan, the reasons for which were indicated in the document, in the opinion of its drafters, was a consequence of both the technical malfunction of the aircraft, which the representative of Rosaviation stated in the dissenting opinion, and the lack of professional training of the pilots.

Insurance payments to the families of the deceased

In accordance with the law, the aircraft, its crew and all passengers on board were insured. As a result of the catastrophe, the insurance company made the appropriate payments. Of these, 580 million rubles per aircraft and 100,000 rubles for the death of each crew member. Families of passengers on this flight, and there were forty-four of them, received 2.025 million rubles from the insurance company.

The total amount of payments amounted to 9.5 million dollars. It should be noted that these amounts are lower than those that should have been received by the relatives of the dead crew members, and relatives of some of them announced their intention to sue Tatarstan Airlines due to low insurance payments. The same applies to the relatives of passengers for whom this flight was the last in life. The compensation they received is clearly underestimated.

Suggestive statistics

To summarize all of the above, one cannot but touch upon the issue of the problems experienced by Russian civil aviation as a whole, the manifestation of which was the catastrophe in Kazan. Pilots of other domestic air carriers, which in our country number about one hundred twenty-two, are in the same position as their colleagues from Tatarstan. The professional level and safety of passengers depend on the financing of the educational process, and this area of ​​activity of companies is very difficult to control.

Kazan disaster November 17

The statistics of accidents that have occurred on civil airlines in recent years does not add optimism. According to available data, Russia accounts for approximately 15% of those killed in all air crashes of the world. Given that Russian passenger traffic is only 2.8% of the world, this number of deaths makes us think about the level of flight safety. Within the framework of common problems, aviation accidents in Tatarstan should be considered, of which there have been many in the history of domestic civil aviation.

Source: https://habr.com/ru/post/G27431/


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