|Aircraft registration number
|Place of aircraft departure
|Airport of departure
|Intended Airport of arrival
|в аэропорту г. Пермь
|авиакомпания «Аэрофлот-Норд» Архангельскго УГАН ФСНСТ
|The date of the completion of the investigation (report)
|Number of fatalities
|Degree of aircraft destruction
Investigation team of the Interstate Aviation Committee which includes official representatives of Federal Air Transport Agency, Rostransnadzor, Federal Air Navigation service and Roshydromet has completed works on investigation of the fatal accident with Boeing 737-500 VP-BKO operated by Aeroflot-Nord occurred near Perm Airport (RF)on 14.09.2008. The investigation was conducted in full compliance with Investigation of Air Accidents and Incidents in the Russian Federation (PRAPI) approved by RF Government Regulation № 609 from 18.06.1998. In accordance with Annex 13 to Convention on International Cicil Aviation official representatives from USA (state of aircraft design and manufacture), France (state of engines design and manufacture), and Great Britain which acted for state of aircraft registry - Bermuda participated in the investigation.
In course of the investigation full range of activities on evaluation of operational and maintenance documentation on aircraft operation and crew training, examination of remained aircraft and engines fragments, decoding and analysis of onboard and ground recorders data was carried out. Mathematical simulation of aircraft flight and engines operation was performed, impartial flight evaluation with participation of test pilots and current line pilots was conducted.
Final report on the investigation results with findings, conclusion and flight safety recommendations has been signed by all members of the Investigation team without comments and dissenting opinions. Conclusion on accident causes was officially approved by representatives of Great Britain, USA and France.
According to the Investigation team's conclusion:
"The immediate cause of the accident was spatial disorientation of the crew, especially the Capitan who was the pilot flying at the final stage of the flight which resulted in left flip-over, a steep descent and crash of the aircraft. The spatial disorientation was experienced during the night time operation in clouds with both autopilot and autothrottle disengaged. Contributing to the development of the spatial disorientation and failure to recover from it was a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using "western"- type attitude indications that are found on foreign and Russian-made aircraft. This type of indication differs from the one used on aircraft types previously flown by the crew (Tupolev 134, Antonov 2).
The cause above was determined on the basis of flight recorders and ATC recorder data analysis, examination of the airframe and engine wreckage, results of the accident flight simulation, findings of the independent expertise conducted by test pilots from State Research Institute of Civil Aviation and Gromov Flight Research Institute as well as line pilots, and also on the basis of all the works conducted with participation of experts from Bermuda, France, Russia, UK and USA in the course of the investigation.
The systemic cause of the accident was insufficient management by the airline of flight and maintenance operations of the Boeing 737 type of aircraft. These deficiencies in the aircraft maintenance also revealed through safety inspections conducted by the Russian Transport Oversight Authority and the Russian CAA after the accident.
Deficiencies in the aircraft maintenance led to a situation when flights were performed for a long time with a throttle stagger that exceeded the limitations in the AMM and when the maintenance staff did not follow the AMM
recommended troubleshooting procedures. The need to manage the throttle stagger during the approach increased crew workload.
The forensic medical examination performed in the state Healthcare Center of Special Status "Perm Regional Forensic Expertise Bureau" confirmed the presence of ethyl alcohol in the Captain's body before his death. The captain's recent work schedule during the time period before the accident was conductive to fatigue and did not comply with national regulations".
In compliance with international standards Final report after translation will be sent to official representatives of Great Britain, USA and France. After receiving and considering comments from states participating in the investigation in compliance with ICAO requirements and Russian legislation the Final report will be published in accordance with the procedure established.
Final report will be presented to the Government Commission. All materials will be sent to aviation authorities of Russian to take the necessary measures.
1The throttle stagger is understood as a difference in trim of right and left engines, when matching throttle position leads to a split in engine thrust while matching thrust leads to different throttle position.
Reports emerged in a number of media on comments alleged after press conference on the investigation results of the fatal accident with Boeing-737 aircraft operated by "Aeroflot-Nord" Airlines in Perm of the IAC Vice-Chairperson O.K. Yermolov "on improper actions of Perm controller who did not accept aircraft from the first approach" are not correct.
O.K. Yermolov did not make any comments on causes of the fatal accident with aircraft connected with air navigation service in flight.
The Interstate Aviation Committee informs that on May 26 in Federal Air Transport Agency (FATA) building the analysis of circumstances and causes of this fatal accident was made by Chairperson of the Investigation team of the fatal accident with Boeing 737-500 VP-BKO aircraft operated by "Aeroflot-Nord" Airlines occurred on 14.09.2008 in the area of Perm Airport in compliance with the civil aircraft accident and incident investigation regulations in the Russian Federation.
Heads of FATA and its territorial departments, heads and pilots of leading Russian Airlines, test pilots took part in the analysis.
Detailed information about the investigation results, identified deficiencies and recommendations on prevention of similar accidents developed as a result of the investigation was presented during analysis.
Chairperson of the Investigation team answered all questions completely.
Speakers who included airline pilots supported the Investigation team's conclusions.
Final report on the investigation results with findings, conclusions and recommendations on flight safety will be published within a week.
In accordance with Standards of International Civil Aviation Organization (ICAO) and on the basis of clause 2.6.3 of Civil Aircraft Accident and Incident Investigation regulations in Russian Federation the Interstate Aviation Committee brings official information on the investigation results of the fatal accident with Boeing 737-500 VP-BKO aircraft operated by "Aeroflot-Nord" Airlines occurred near Perm Airport on September 14, 2008. Full text of Final report following the investigation results is attached.
The Interstate Aviation Committee emphasizes again that this Report is issued with the only purpose to prevent accidents and is not intended to ascertain someone's guilt or responsibility.
Central Investigation Department of the Investigative Committee within Prosecutor’s Office of RF is in charge of criminal case in connection with the fatal accident.