On 17 November 2013, a Boeing 737-500 operated by Tatarstan Airlines crashed during its second landing attempt at Kazan International Airport. All 50 occupants, including 44 passengers and six crew members, were killed. The aircraft, Flight 363, was on a scheduled domestic flight from Moscow’s Domodedovo Airport to Kazan.
Flight Background
• Flight Number: Tatarstan Airlines Flight 363
• Aircraft Type: Boeing 737-500
• Registration: VQ-BBN
• Route: Moscow Domodedovo (DME) to Kazan (KZN)
The flight took off from Moscow at 18:25 local time for a 1-hour, 30-minute flight to Kazan. On approach to Kazan International Airport, the crew aborted the first landing attempt due to unstable weather and challenging landing conditions, subsequently initiating a go-around procedure.
Sequence of Events
Flight 363 was on its final approach to Kazan when, during the second landing attempt, it entered an unstable descent. The crew attempted a go-around maneuver but experienced difficulty controlling the aircraft. As the aircraft climbed steeply, it lost speed and entered an aerodynamic stall, plunging to the ground near the runway. Upon impact, the aircraft exploded, leaving no survivors.
The crash occurred at 19:25 local time, just one hour after takeoff, and within moments of the second approach. The wreckage spread over a significant area of the airport, and the fire that followed the crash required immediate response from emergency services.
Investigation Findings
The Interstate Aviation Committee (MAK), the organization responsible for investigating aviation incidents in Russia, led the inquiry into the accident. The investigation revealed several contributing factors:
1. Pilot Error: The crew failed to maintain proper control of the aircraft during the go-around procedure. The pitch angle became too steep, and the aircraft lost airspeed, resulting in a stall. Investigators found that the crew lacked experience in go-around maneuvers in the Boeing 737, particularly in handling complex situations.
2. Inadequate Training: Both the captain and first officer were found to have limited experience in flying the Boeing 737, especially in emergency or non-standard situations like go-arounds. The captain, a former helicopter pilot, did not have sufficient training to handle the situation effectively, which led to improper handling of the aircraft during the critical phase of flight.
3. Crew Resource Management (CRM) Issues: The investigation highlighted poor communication and coordination between the captain and the first officer. In high-stress situations like go-arounds, effective CRM is essential for decision-making and ensuring safe flight operations. In this case, the lack of coordination contributed to the crew’s inability to recover from the stall.
4. Autopilot Disengagement: During the go-around, the autopilot disengaged, requiring the crew to manually control the aircraft. The abrupt transition from autopilot to manual control was not handled effectively by the crew, which contributed to the loss of control during the climb.
Contributing Factors
The investigation identified several key contributing factors to the crash:
• Inadequate Simulator Training: The crew had not received adequate simulator training, particularly for handling non-standard situations such as go-arounds in the Boeing 737. This lack of training was a critical factor in the accident.
• Fatigue and Decision-Making: Fatigue may have played a role in the crew’s decision-making processes during the approach. The first officer had been on duty for a long period, which may have impaired his ability to react quickly and effectively in a high-stress situation.
• Weather Conditions: While the weather conditions at the time of the accident were challenging, they were not solely responsible for the crash. However, the presence of gusty winds and low visibility contributed to the crew’s difficulty in managing the landing and go-around attempts.
Safety Recommendations
Following the investigation, the MAK issued several safety recommendations to improve pilot training, crew resource management, and airline safety protocols. These recommendations emphasized the importance of:
1. Enhanced Go-Around Training: Airlines were advised to improve simulator training programs, particularly focusing on go-around procedures, stall recovery, and handling emergency situations in complex aircraft like the Boeing 737.
2. CRM Training: The investigation highlighted the need for better CRM training, encouraging airlines to improve communication and coordination skills among flight crews, especially during high-stress scenarios.
3. Reassessment of Pilot Qualifications: It was recommended that pilots transitioning from one type of aircraft to another undergo thorough training and evaluation to ensure that they are fully qualified to operate the new aircraft safely.
4. Review of Autopilot Procedures: The accident highlighted potential issues with the transition from autopilot to manual control during go-arounds. Airlines were advised to review their autopilot disengagement procedures to ensure that pilots are adequately prepared to handle manual control of the aircraft.
Conclusion
The Tatarstan Airlines Boeing 737 crash at Kazan International Airport on 17 November 2013 was a tragic accident caused primarily by pilot error and insufficient training. The crew’s inability to handle the go-around maneuver, coupled with poor communication and coordination, led to the loss of control and subsequent stall. While the weather conditions presented additional challenges, the root cause of the accident lay in the crew’s lack of experience and training.
This accident serves as a stark reminder of the importance of proper pilot training, especially in emergency procedures such as go-arounds and stall recovery. It also underscores the need for continuous improvement in CRM to ensure that flight crews can work together effectively during critical phases of flight. In response to this tragedy, the aviation industry has taken steps to address the issues raised by the investigation, helping to prevent similar accidents in the future.
