Deadly circle. A video has appeared of the crash of a passenger Boeing in Kazan. The crash of Boeing 737 500 OJSC Tatarstan Airlines

On the evening of November 17, 2013, a Boeing 737-500 passenger plane of Tatarstan Airlines, operating regular flight U9363 on the route Moscow (Domodedovo) - Kazan, crashed at the airport during landing. The crash occurred during a missed approach. As a result, 50 people died.

What happened

Transcript of the crew's conversation before the fall:

Co-pilot: Oh, that’s it, here’s the runway below us. No, we're going high.

PIC: We are leaving for the go-around, non-landing position.

Co-pilot: Rustic? Rustic?!

Co-pilot: Where are we going?

After this, an eerie crash is heard and the recording ends. The airliner of Tatarstan Airlines crashed into the ground at a speed of 450 km/h almost at a right angle and caught fire. Those on board had no chance of survival.

As the pilots later explained, the very fact of a missed approach at the airfield in relatively uncomplicated weather conditions could have become a reason for a debriefing of the flight by the airline.

Rumble, screams, fire. The Kazan airport is urgently closed, the relatives of the passengers will learn about what happened in a very short time. There is no hope that anyone survived the plane crash.

The smallest

The youngest passenger on board the crashed Boeing was the 11-year-old stepdaughter of the famous commentator Roman Skvortsov, Dasha. She flew to Kazan with her mother, Ellina Artashina.

Roman met his future wife at the Gagarin Cup final a little more than a year before the plane crash. Long-distance relationships did not frighten the couple: she flew to Moscow, he visited Kazan. At the end of October 2012, we had a magnificent, noisy wedding with 80 guests and moved to Moscow.

The relatives' wives remained in Tatarstan, so Ellina's and Dasha's flights were a regular occurrence. The girl was literally counting down the days until this trip.

Three days - and Kazan.

It’s so fun that you want to cry,” Dasha wrote on her VKontakte page.

Right before the flight, she wrote: “Everything is fine with me.” We took a photo with my mother on board the Boeing and flew off. The flight from Moscow to Kazan takes approximately one and a half hours. Roman was waiting for Belochka (as he affectionately called his wife) to announce the landing, when she received a call from her mother.

For some reason the board does not land for a long time. “I’m worried,” the woman said.

I went online and came across a recording about a plane crash in Kazan and the death of 50 people. The first thought, like most people: “Probably the wrong flight.” As it turned out later, that one.

Even a year after the tragedy, the man said that every day he comes home and out of habit says: “Hello, girls, I’m home.” Skvortsov also said that he would never be able to talk about Ellin and Dasha in the past tense.

Kazan prodigy

Among the passengers who were on board the Boeing was Mstislav Kamashev. In 2000, he became famous throughout Russia. The fact is that then 13-year-old Mstislav entered the Kazan State University at the Faculty of Computational Mathematics and Cybernetics, where there was a competition among graduates of five people per place. At the same time, the boy did not look like a nerd at all: he went in for swimming and tennis, loved to play “action-shooting games” and hang out with friends. He graduated from university at the age of 18, went to graduate school, and at the same time worked in a bank.

I feel happy. “I have everything I need,” said Mstislav.

A year before the tragedy, the young man got married. Soon his wife, Anastasia, announced that she was expecting a child. There were two weeks left before the birth when the crash occurred. As a result, due to the mother’s stress, the child was born prematurely. The boy was named Daniel - the wife chose this name together.

Even death doesn't separate

Abdulla and Maria Sibgatullin lived together for 60 years. They were returning from their grandson from Kyiv on a flight through Moscow. The Sibgatullin couple was known literally throughout Tatarstan, and a few days before the crash they were celebrated as long-living spouses.

Employees of the Ministry of Emergency Situations are working at the crash site of a Boeing 737 plane of Tatarstan Airlines, which crashed while landing at Kazan airport. November 17, 2013. Photo: © RIA Novosti / RF Ministry of Emergency Situations

They worked together at the Kazan Powder Factory. The couple had two children and four grandchildren. When they retired, they were engaged in education and loved to spend time in “their outlet” - small garden at the house. Maria sold what she grew at the market. As acquaintances with the Sibgatullins later said, it was not a matter of profit, but rather a desire to talk with peers.

Famous passenger

After the plane crash, a number of media outlets wrote that additional psychological stress on the crew could have been exerted by one high-ranking passenger, whose presence on board was known to the aircraft commander. Whether this is true or not is now impossible to find out, but the son of the head of the republic, Irek Minnikhanov, was actually on the plane, who was flying from a business trip to visit his pregnant wife.

Three months earlier, on August 16, the wedding of Irek and his beloved, Frenchwoman Antonia Guichard, was widely celebrated in Kazan. The young people met in Switzerland while studying, dated for several years, and then decided to legalize their relationship. They did not like to talk about the details of their personal lives. Friends of the couple recalled that even on business they always tried to travel together.

Three months after the plane crash, the head of Tatarstan published on Instagram a photo of little Adriana, the daughter of his eldest son.

"Everything is fine. We're flying"

The ship's commander, Rustem Salikhov, never complained about problems with the plane. “Everything is fine. We’re flying,” he joked with friends who talked about problems at the airline. Rumors about problems with the carrier's aircraft spread far beyond airports.

He was married for about 20 years, leaving two children in the family. In 2013, the eldest Kamila was 18 years old, and the youngest Lila was 10. We met his wife when he was still a navigator, and she was an airport dispatcher announcing the weather. However, Rustem became a pilot only in June 2010, and an aircraft commander in March 2013. At the same time, he was considered the most experienced pilot in Tatarstan.

The pilot's widow, Lily of the Valley, later recalled that a few days before the tragedy, her husband was especially affectionate - he tried to spend 100% of his time with his family. The day before we slept until noon, which is rare in this family. After that, Rustem got dressed and left, saying that he would return soon.

Lily of the Valley learned that there were “some problems” with the flight from a friend. However, she was not aware of the details of what happened. The woman began methodically calling her superiors, colleagues - everyone she knew. At some point, colleagues confirmed that the plane had crashed, but the details were unknown - “Moscow does not provide information.” The woman began to get ready for the airport when her friends called and demanded that she not get behind the wheel - they would take her themselves.

Even when Lily of the Valley talked to the airline management, she was sure that there was a mistake, Rustem was not on board, he did not take off, he changed. Only when she saw who was “in the outfit” did the woman begin to realize the terrible truth.

Causes

Representatives of the International Aviation Committee in 2015 officially announced the causes of the crash. Initially, investigators pursued all versions - from a technical malfunction to a terrorist attack. As it turned out, the plane with 50 people crashed due to “systemic deficiencies in the work of the crew, the airline and aviation authorities at all levels.”

General Director of Tatarstan Airlines Aksan Giniyatullin admitted after the disaster that in real life Salikhov never went around.

Former CEO Tatarstan Airlines Aksan Giniyatullin. Photo: © RIA Novosti / Maxim Bogodvid

The PIC had more than 2,500 flight hours on this type of aircraft, of which 1,000 were night flight hours. Co-pilot Viktor Gutsul had 1,900 flight hours on this type of aircraft, more than 900 per night. Weather conditions were not classified as difficult. Well, there were clouds, yes. But the visibility was 5,000 meters, the dry runway, which was also repaired for the Universiade, - in general, the conditions for landing were close to ideal.

Immediately after the crash, the airline began checking all possible levels. Experts identified so many violations by the republican carrier that only one question remained: how could this airline even exist?

Already on December 31, 2013, Tatarstan’s operator’s certificate was canceled, that is, no more airline flights should have been operated.

Employees of the Ministry of Emergency Situations and law enforcement agencies are working at the crash site of the Tatarstan Airlines Boeing 737 plane, which crashed while landing at Kazan International Airport. November 18, 2013. Photo: © RIA Novosti / Vladimir Astapkovich

Soon after, bankruptcy proceedings and the sale of the fleet began. Representatives of the carrier sold the last “carcass” (Tu-154) at the price of an expensive foreign car - for 2.8 million rubles. In addition to the aircraft there were four engines.

Reference

The Boeing 737 involved in the plane crash, tail number VQ-BBN, first took off on June 18, 1990. The Tatarstan company leased the aircraft in December 2008 from the Greek division of Ansett Worldwide Aviation Services. It was previously operated by companies from France, Uganda, Brazil, Romania and Bulgaria. The aircraft had a flight time of 51,547 hours and 25 minutes and made 36,595 landings since the start of operation.

Below is some background information.

On November 17, 2013, at 19:23 Moscow time, a Boeing 737-500 plane of Tatarstan Airlines crashed during landing at the Kazan airport. All 50 people (six crew members and 44 passengers) on board the aircraft were killed. Among the dead were the son of the President of Tatarstan, Irek Minnikhanov, and the head of the FSB department for Tatarstan, Alexander Antonov.

The crashed airliner was flying on the route Moscow - Kazan. This flight was supposed to be operated by a smaller Bombardier aircraft, but due to the passenger load it was replaced by a Boeing 737.

According to data about the crashed plane, it was operated by seven airlines, including Uganda Airlines (since the summer of 1995). Boeing made its first flight on June 18, 1990. The aircraft was leased from Tatarstan Airlines since December 18, 2008.

Boeing-737-500 took off for Kazan from Moscow Domodedovo Airport. When approaching international airport Kazan, the crew of the airliner reported to ground services that they were not ready to land and asked permission to go around. During the second approach, the plane lost altitude, fell to the ground 150 meters before the start of the runway and exploded. The wreckage of the plane after the explosion was scattered over a radius of about 500 meters. The area of ​​their spread was 23 thousand square meters.

Immediately dispatched to the scene of the incident emergency services, rescue operations began. Significant forces of the Ministry of Emergency Situations of Russia were involved in eliminating the consequences of the disaster, including the Centrospas detachment, specialists from the Leader center and the 179th Rescue Center, as well as branches of the Volga regional search and rescue team of the Ministry of Emergency Situations of Russia. The total strength of the force group exceeded 1.6 thousand people and 260 pieces of equipment.

On the first anniversary of the tragedy, a memorial stele was unveiled at the Kazan airport, on which the names of all 50 dead passengers aircraft and crew members.

Based on the fact of the plane crash, the investigative bodies of the Volga Region Investigation Department for Transport of the Investigative Committee of the Russian Federation opened a criminal case on the grounds of a crime under Part 3 of Art. 263 of the Criminal Code of the Russian Federation (violation of traffic and operation safety rules air transport resulting through negligence in the death of two or more persons).

Later, the criminal case was transferred to the main investigative department of the central apparatus of the Investigative Committee.

According to the results of the examination carried out by the investigation, no signs of drug or alcohol intoxication were found in the blood of the pilots.

After deciphering the “black box,” the Interstate Aviation Committee (IAC) stated that when approaching the runway, the pilots made a number of mistakes, which they tried to correct by diverting the plane to the second circle. One of the two autopilots of the Boeing 737 aircraft was disabled, and the crew of the airliner landed manually. During the second approach, the aircraft crew, gaining altitude, raised the nose of the airliner too much. As a result, the aircraft lost speed. Having reached an altitude of 700 meters, the plane began an intensive dive and collided with the ground at high speed (more than 450 kilometers per hour) and almost vertically (at an angle of 75 degrees to the surface of the earth). About 43 seconds passed from the moment the aircraft began its go-around until the end of the recording on the recorder.

The power plants operated until the plane collided with the ground.

Tatarstan Airlines reported that the commander of the crashed airliner had never performed a go-around maneuver in a real flight before the tragedy.

After the disaster in Kazan, the investigation began studying the training of pilots. It subsequently turned out that the commander of the crashed plane received a diploma in a dubious training center. According to Russian Prosecutor General Yuri Chaika, the commander of the crashed plane had a false pilot's certificate. The co-pilot's license was also obtained illegally without the required flight experience.

After the plane crash, the Federal Air Transport Agency (Rosaviation) conducted unscheduled inspections of a number of flight training centers and suspended pilots from a number of airlines, including the largest ones, from flying until the end of the investigation.

Rosaviatsia also checked the activities of Tatarstan Airlines, as a result of which it identified a number of violations and, as of December 31, 2013, canceled its operator certificate. The aircraft fleet was transferred to another Tatarstan carrier - Ak Bars Aero airline.

General Director of Tatarstan Airlines OJSC Aksan Giniyatullin was dismissed from his post by decision of the company’s board of directors.

In May 2014, Tatarstan Airlines filed a claim with the court to declare its own bankruptcy; in June, the court declared the airline bankrupt.

The head of the Tatar Interregional Territorial Directorate of Air Transport of the Federal Air Transport Agency, Shavkat Umarov, resigned after the plane crash, which was accepted. The territorial administration itself lost its independence and became a structural subdivision of the Volga interregional territorial administration of the Federal Air Transport Agency.

In September 2014, the IAC reported that the engineering and technical subcommittee concluded that the recordings of objective monitoring equipment of the Boeing-737 that crashed in Kazan, as well as the surviving parts, components and assemblies of the airframe, engines and systems, including the elevator control system, showed signs of There were no aircraft failures during the emergency flight.

At the end of December 2015, the IAC published the final results of the investigation into the plane crash. The cause of the plane crash was systemic deficiencies in identifying hazards and controlling the level of risk, as well as the inoperability of the airline’s flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels (Tatar MTU VT, Rosaviatsia), which led to admission for flights by untrained crew.

November 18, 2013

According to information received, on November 17, 2013 at 7 p.m. 23 minutes Moscow time at the Kazan airport during landing, a Boeing 737-500 plane of the TATARSTAN airline of the Tatar MTU VT FAVT crashed.
Six crew members and forty-four passengers on board the aircraft were killed. The plane is destroyed.
Based on Russian legislation and in accordance with the “Investigation Rules” aviation accidents and incidents with civil aircraft in Russian Federation", approved by Decree of the Government of the Russian Federation of June 18, 1998 No. 609, as well as taking into account the requirements of Appendix 13 to the Convention on International civil aviation, the investigation is being conducted by a commission of the Interstate Aviation Committee with the participation of specialists from the Federal Air Transport Agency and other interested departments.
The commission began work at the scene of the accident.

November 18, 2013

The technical commission of the Interstate Aviation Committee for the investigation of the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a parametric information flight recorder container was found at the scene of the accident.
The recorder container has significant mechanical damage.

November 18, 2013

The technical commission of the Interstate Aviation Committee to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a container for a flight voice data recorder was found at the scene of the accident.
The recorder container has significant damage.

November 18, 2013

The technical commission of the Interstate Aviation Committee (IAC) to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that the containers of on-board means of objective monitoring of parametric and speech information (the so-called black boxes) found at the scene of the accident were delivered to the Interstate aviation committee.
Opening of containers, reading of information recorded on on-board media and its decryption will be carried out at the scientific and technical center of the Committee.

November 19, 2013

The technical commission of the Interstate Aviation Committee (IAC) for the investigation of an accident with a Boeing 737-500 aircraft of Tatarstan Airlines informs about the preliminary results of decoding the information from the flight parametric recorder.
During the landing approach, the crew failed to perform a standard approach in accordance with the procedure established by regulatory documentation. Having assessed the aircraft’s position relative to the runway as “non-landing”, the crew reported to the controller and began a missed approach in TOGA mode (Take Off / Go Around. Takeoff / Missed approach). At the same time, one of the two autopilots involved in the landing process was turned off and the further flight was carried out in manual mode.
The engines reached a mode close to takeoff. The crew retracted the flaps from the 30° position to the 15° position.
Under the influence of the pitching moment from the engine thrust, the plane began to climb and reached a pitch angle of about 25°. The indicated speed began to decrease. The crew cleared the landing gear. From the moment the go-around began until this time, the crew did not take active steps to control the aircraft.
After reducing the speed from 150 to 125 kts, the crew began control actions with the helm column to put the aircraft into a dive, which led to the cessation of the climb, the beginning of the aircraft's descent and an increase in the indicated speed. The maximum angles of attack during flight did not exceed operational limits.
The plane, having reached an altitude of 700 m, began an intense dive with a pitch angle that reached -75° by the end of the flight (end of recording).
The plane collided with the ground at high speed (more than 450 km/h) and a large negative pitch angle.
About 45 seconds passed from the start of the missed approach to the end of the recording; the descent took about 20 seconds.
The power plants worked until the plane collided with the ground. Based on the results of the preliminary analysis, no single commands characterizing failures of systems and components of the aircraft and engines were identified.
The analysis and decoding of parametric information continues.
The Commission notes that when the voice recorder container was opened, the secure container with the tape drive mechanism was missing. The commission continues to search for the device.
The technical commission continues to work at the scene of the accident. The airline's flight documentation and crew training are being studied, including with the involvement of highly professional line pilots who have extensive experience in operating this type of aircraft in leading Russian airlines. The airline's technical documentation is being studied, including on aircraft maintenance and maintaining their airworthiness in accordance with international regulations. Information is analyzed ground means objective control, weather conditions and air traffic services data.
The IAC Technical Commission will regularly inform you about the progress of the investigation.

November 20, 2013

The technical commission of the Interstate Aviation Committee (IAC) to investigate the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that a voice data carrier unit of the flight recorder was found at the scene of the accident.
The found block will be delivered to the IAC for the necessary work to be carried out at the scientific and technical center of the Committee.
The scientific and technical center continues to carry out a large amount of work on further decoding and analysis of parametric recorder information, including the Kazan-Domodedovo flight that preceded the emergency, and other flights.
Work is planned to synchronize and jointly process records of ground-based and airborne objective monitoring equipment.
The technical commission continues its work at the scene of the accident.

November 22, 2013

In connection with the funds that have appeared mass media With questions about the causes and versions of the crash of the Boeing 737-500 of Tatarstan Airlines, the Technical Commission of the Interstate Aviation Committee (IAC) informs:
According to on-board objective monitoring equipment, no failures of aircraft systems, components and controls, including the elevator channel, were recorded. The plane's engines were running until it hit the ground.
The IAC has repeatedly explained that ICAO standards for so-called “old” and “new” aircraft do not exist. The main thing for safety is the airworthiness of the aircraft, not its age. There is no direct relationship between aircraft crashes and their age. Over the past five years, the number of accidents in the world, including Russia, with aircraft with a passenger capacity of more than 50 seats is the same for aircraft under 5 years old and over 30 years old. According to available information, the average age of Boeing 737-500 aircraft operated in the United States is 20.4 years. In Europe – 20.3 years. More than 7,600 Boeing aircraft are in operation around the world. Their total flight time is 257.6 million flight hours. The crash rate of Boeing 737 aircraft per 100 thousand flight hours is less than 0.05.
The Interstate Aviation Committee asks to refrain from “PR” and populism against the backdrop of a serious tragedy. This traumatizes the relatives and friends of the victims and disrupts the work of the aviation transport industry.
The IAC Technical Commission continues its professional work to establish the circumstances and causes of the disaster in accordance with ICAO standards.

November 22, 2013

At the IAC Scientific and Technical Center, work continues to decipher the information recorded on the in-flight voice recorder of the TATARSTAN Airlines Boeing 737-500 aircraft that crashed on November 17, 2013 at the Kazan airport. There remains a significant amount of work to recognize and identify the voices of flight crew members, and subsequent synchronization of recorded information from ground-based and on-board objective monitoring equipment.
The IAC technical commission continues its work.

November 28, 2013

At the Scientific and Technical Center of the Interstate Aviation Committee, with the participation of representatives of the flight crew of Tatarstan Airlines, who know the voices of the crew members well, work was carried out to identify voices in the cockpit of the aircraft recorded on the recording of the flight voice recorder. These specialists signed a preliminary protocol of negotiations between crew members. At this stage, there were no signs of strangers in the pilot's cabin. Work on decoding and identifying voices continues.

November 29, 2013

The Technical Commission of the Interstate Aviation Committee for the investigation of the crash of the Boeing 737-500 aircraft of Tatarstan Airlines informs that, based on a preliminary analysis of data from objective control means and other available information, in accordance with the provisions of the Rules for the Investigation of Aviation Accidents and Incidents with Civil Aircraft in the Russian Federation (PRAPI), the commission considers it appropriate to implement the following operational recommendations to improve flight safety:
1. Consider the feasibility of conducting additional classes and training with flight personnel:
on practicing actions during a go-around in director mode, paying special attention to the procedure for leaving an intermediate altitude when the altitude value that needs to be gained during the go-around is close to the current value, as well as the procedure for conducting radio communications;
on recognizing a difficult spatial position of an aircraft (Upset) and practicing actions to recover an aircraft from a difficult spatial position (Upset recovery);
on the order and features of the operation of aircraft systems (autopilot, flight director) during approach and missed approach, depending on specific conditions;
to study the features of the aircraft navigation system (section FCOM: FMC Navigation Check and Navigation Position).
2. Consider the need to refine the work technologies of ATS specialists in terms of providing (in case of significant deviations from the route) more active assistance to aircraft crews if technical capabilities are available, for example, by submitting a request to the crew to perform vectoring to put the aircraft on a landing course.
3. Hold a flight technical conference to exchange experience in operating Boeing 737 family aircraft.
The specified recommendations in the form of a Subsequent Report on an Aviation Accident in accordance with the PRAPI were communicated to the Federal Air Transport Agency.
The flight documentation of Tatarstan Airlines is being checked for initial training, as well as for retraining on the Boeing 737 and undergoing periodic training and inspections by flight crew members.

September 16, 2014

The technical commission of the Interstate Aviation Committee for the investigation of an accident with a Boeing 737-500 aircraft of Tatarstan Airlines informs that the work of the engineering and technical subcommittee has been completed to study and analyze the performance of aircraft equipment, including the elevator control system, in an emergency flight.
To assess the performance of the elevator control system, a number of studies were carried out:
three-dimensional tomography of hydraulic drives of the left and right halves of the elevator;
complete disassembly and assessment of the condition of hydraulic drives;
bench testing of main switchgears (spool valves) of hydraulic drives;
preparation (cutting) of a number of hydraulic drive elements to assess the condition of internal surfaces;
mathematical modeling of aircraft movement and operation of the elevator control system using records of objective control equipment.
An engineering analysis of the operation of the system of two hydraulic elevator drives was also carried out, simulating all possible jamming scenarios of the main switchgears.
The history of operation of this type of hydraulic drives and materials from the investigation of events related to abnormal operation of the elevator control system that occurred in operation on Boeing 737 aircraft previously were studied. The analysis showed that the circumstances of the events that took place related to abnormal operation of the hydraulic elevator actuators differ from the circumstances of the emergency flight.
Based on all the work carried out, the engineering and technical subcommittee concluded that the records of objective monitoring equipment, as well as the surviving parts, components and assemblies of the airframe, engines and systems, including the elevator control system, showed no signs of failure of the aircraft during the emergency flight.
The commission is completing work to establish all the causes and factors of the accident.

April 29, 2015

The technical commission of the Interstate Aviation Committee (IAC) has completed a set of works to investigate the crash of the Boeing 737 500 VQ-BBN aircraft of Tatarstan Airlines.
During the investigation, the entire necessary amount of work was carried out, including: the field stage of the investigation, including drawing up maps of the accident site, as well as a full-scale layout of the surviving fragments of the aircraft; decoding and analysis of recordings of ground and airborne objective monitoring equipment; special studies of hydraulic elevator drives; mathematical modeling of flight; flight evaluation of crew performance by test pilots and experienced flight pilots; simulator experiment; study of data on crew training, work and rest schedules, organization of flight work and the airline’s flight safety management system; study of medical documents and results of forensic medical research; study of data on aircraft maintenance and technical operation.
Based on the results of the work, the Technical Commission prepared a draft Final Report.
In accordance with the Standards of the International Civil Aviation Organization, after translation into English, the draft report will be sent to authorized representatives: the US National Transport Safety Bureau, the UK Aircraft Accident Investigation Agency, and the French Air Accident Investigation Bureau. These states took part in the investigation.
After receiving and considering comments from states, the Final Report will be published on the official IAC website on the Internet.

December 23, 2015

The Commission of the Interstate Aviation Committee completed the investigation of the accident involving the Boeing 737-500 VQ-BBN aircraft of Tatarstan Airlines OJSC, which occurred on November 17, 2013 at Kazan airport.

The cause of the crash of the Boeing 737-500 VQ-BBN aircraft was systemic deficiencies in identifying hazards and controlling the level of risk, as well as the inoperability of the airline’s flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels (Tatar MTU VT, Rosaviatsia), which led to the admission of untrained crew to flights.

During the go-around, the crew did not recognize the fact that the autopilot had been turned off and allowed the aircraft to fall into a difficult nose-up position. The PIC's (pilot's) lack of skills to recover the aircraft from a difficult spatial position (Upset Recovery) led to the creation of a significant negative overload, loss of spatial orientation and the aircraft being put into a steep dive (dive pitch angle up to 75°) until it collided with the ground.

The need for a missed approach was caused by the non-landing position of the aircraft when approaching the runway, which was a consequence of the “Map shift” effect (an error in determining the location of the aircraft by on-board systems) by about 4 km, the inability of the crew in these conditions to integrated aircraft navigation and navigation with the required accuracy, as well as the lack of active assistance from the ATS service during prolonged observation of significant deviations from the approach pattern.

The accident was the result of a combination of the following factors:

Lack of initial flight training by the PIC;

Admission to retraining on Boeing 737 flight crew members who do not fully meet the qualification requirements for being sent for retraining, including in English;

Methodological imperfection of the retraining process, formal control over the results and quality of retraining;

The low level of organization of flight work at the airline, which led to the failure to eliminate shortcomings that had been identified for a long time in working with navigation equipment, piloting techniques and interaction between crew members, including during a go-around;

Systematic violation of the work and rest schedule of crew members and large debts for vacations, which could lead to the accumulation of fatigue and negatively affect the performance of crew members;

The absence of an element of missed approach from an intermediate altitude with two operating engines in the simulator training programs;

Increased psycho-emotional stress of crew members before go-around due to prolonged inability to determine the location of the aircraft with the accuracy necessary for landing;

Violation of the principle “Aviate - Navigate - Communicate” by both the crew and the ATS service, which led to the crew’s failure to comply with standard operating procedures during the missed approach stage due to the second’s prolonged distraction the pilot from performing his duties and monitoring flight parameters;

Failure by the crew to recognize the fact that the autopilot was turned off and later intervention in the control of the aircraft, which led to the aircraft getting into a difficult spatial position for pitching up (Nose up Upset);

The imperfection of the applied simulator training programs for recovering an aircraft from a difficult spatial position (Upset Recovery) and the criteria for assessing its quality, which led to the inability of the crew to restore the spatial position of the aircraft;

Possible influence of somatogravitational illusions.

Lack of a proper control system over the issuance of pilot licenses, compliance of the training of crew members with the established requirements and the assignment of qualification marks;

The inoperability of flight safety management systems in airlines, the lack of methodological recommendations for their development and approval, a formal approach to the approval/coordination of flight safety management systems and flight crew training programs by the authorized body;

The imperfection of the work of the training center and the actual lack of control over the results of retraining;

Lack of knowledge requirements for flight personnel in English for retraining for foreign types of aircraft and a formal approach to testing the level of language knowledge;

A formal approach to conducting periodic and qualification inspections of flight personnel;

Systematic violation of the work and rest regime of flight personnel;

Insufficient training of flight personnel for go-around from an intermediate altitude, piloting the aircraft in the control (manual) mode and when recovering from a difficult spatial position;

Appears on unequipped GPS aircraft the “map shift” effect and insufficient training of crew members to perform flights in these conditions;

The need for active assistance to the crew from the ATS service when significant long-term deviations from established patterns are detected;

Violation of the principle “Fly the aircraft - Navigate - Communicate”,

did not prevent this accident.

Based on the results of the investigation, recommendations were developed to improve flight safety.

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