Date:	Sunday 17 November 2013
Time:	19:23
Type:	Boeing 737-53A
Owner/operator:	Tatarstan Airlines
Registration:	VQ-BBN
MSN:	24785/1882
Year of manufacture:	1990
Total airframe hrs:	51547 hours
Cycles:	36596 flights
Engine model:	CFMI CFM56-3C1
Fatalities:	Fatalities: 50 / Occupants: 50
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Kazan International Airport (KZN) -   Russia
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Moskva-Domodedovo Airport (DME/UUDD)
Destination airport:	Kazan International Airport (KZN/UWKD)
Investigating agency:	MAK
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Boeing 737-53A passenger plane, operated by Tatarstan Airlines, was destroyed in an accident at Kazan Airport (KZN), Russia. All 44 passengers and six crew members were killed.
Flight 363 departed from Moscow's Domodedovo Airport (DME) at 18:20 local time on a scheduled service to Kazan (KZN).
En route the crew noted that their navigation system's map was displaced. During the descent towards Kazan did not ask for vectors from air traffic control and continued their approach, which was flown 4 km to the north of the published approach procedure due to the map displacement issue.
After turning to final for runway 29 the aircraft was not able to capture the localizer. The flight crew programmed a heading of 250° in the HDG SEL (Heading Select mode) of the autopilot and hurriedly configured the aircraft for landing. The approach was unstabilized and as the aircraft turned towards runway heading the copilot noticed the PAPI lights and saw they were too high. He initiated a go around. At that time the aircraft was at 270m (900 ft) and configured for landing with gear down, 30° flaps. The autopilot was in ALT HOLD mode with altitude programmed at 270 m.
The use of the TO/GA switch caused the autopilot to be switched off. The flaps were raised to 15°, but no manual control inputs were made. The increase in engine power and retracting the flaps caused a pitch-up of the airplane with the pitch angle reaching a value of about to 25°. Indicated airspeed began to decrease, the stabilizer automatically trimmed nose down.
All the time the copilot was engaged in radio communications with the Kazan Tower controller. Subsequently the copilot reminded the captain to raise the undercarriage.
With the pitch angle exceeding 25° the crew began using the control column to reduce the pitch angle. At this point, the aircraft was at an altitude of about 600 meters (2,000 feet), and continued to climb with a vertical speed of 20 m/s. Due to nose down input by the captain and trim system, the pitch angle decreased quickly. Vertical loads decreased to 0,5 g as the aircraft had reached the top of climbing at 2300 feet / 700 meters. Indicated airspeed had decreased to its minimum value of 117 knots.
Vertical loads then decreased to about 0 g, with a negative pitch angle reaching 20°. The aircraft descended at a rate of more than 5000 ft/min (25 m/s).
The EGPWS gave "sink rate" and "pull up" warnings as the aircraft pitch angle reached -60° with a load of -0.9 g.
The aircraft collided with the ground at high speed, over 450 km/h, and a large negative pitch angle of about 75°. From the beginning of the missed approach until the collision with terrain, 45 seconds passed.
The aircraft impacted the ground between the runway and the main taxiway about 1850 m past the runway 29 threshold.

Investigation revealed that the captain received training to become a Boeing 737 captain after serving as a navigator between 1991 and 2010. The copilot used to be a flight engineer (1989 to 2008) and was also trained to become a Boeing 737 pilot. The captain had a very limited knowledge of English, which was considered insufficient to comprehend English language training documents and manuals. As the oversight of the training facility was poor, shortcomings in training were not noticed. Training and safety management within Tatarstan Airlines was considered equally poor.

PROBABLE CAUSE (translated from Russian):
The cause of the crash Boeing 737-500 VQ-BBN were systemic deficiencies in the identification of hazards and risk control, as well as a non-functional safety management system in the airline and the lack of control over the level of training of the crew members from the aviation authorities at all levels (Tatar MTU BT, Federal Air Transport Agency), which led to the admission of an unprepared flight crew.
When the missed approach was executed the crew did not recognize the fact that the autopilot was off and the aircraft pitched up to a complex spatial position (Nose up Upset). The PIC's (pilot flying) lack of flying skills in complex spatial positions (Upset Recovery) led to the creation of a large negative overload, loss of spatial orientation and transfer of the aircraft into a steep dive (pitch down to 75°) until the impact with the ground.
The need for a go-around was caused by the position of the aircraft relative to the runway, which was the result of "a map shift" effect (Map shift, an error in the determination of the aircraft position by onboard systems) by about 4 km, the crew's inability in the circumstances to integrated piloting and maintenance of navigation with the required accuracy, and the lack of active assistance of the air traffic control service under the long-term monitoring of significant deviations from the approach procedure.

14:30 UTC / local time:
UWKD 171430Z 23009G12MPS 9999 OVC009 03/02 Q0995 R29/2/0055 NOSIG RMK QFE735/0980

15:00 UTC / local time:
UWKD 171500Z 23009G12MPS 9999 -RASN OVC008 03/02 Q0994 R29/2/0055 NOSIG RMK QFE735/0980
Wind 230 degrees at 9m/s, gusting to 12 m/s; light rain, light snow; Overcast at 800 feet; Temperature: 3°C, Dewpoint: 2°C; Pressure: 994 mb

15:30 UTC / local time:
UWKD 171530Z 23008G11MPS 5000 -RASN OVC007 03/03 Q0993 R29/2/0055 NOSIG RMK QFE734/0979
Wind 230 degrees at 8 m/s, gusting to 11 m/s; visibility 5000 m; light rain, light snow; Overcast at 700 feet; Temperature: 3°C, Dewpoint: 3°C; Pressure: 993 mb

RIA, Interfax, RT
Russian Emergencies Ministry

Other occurrences involving this aircraft

17 December 2001	PT-SSI	Rio Sul Serviços Aéreos Regionais	0	Belo Horizonte-Tancredo Neves International Airport, MG (CNF)		sub
Undershoot

photo (c) Russian Ministry of Emergency Situations; Kazan Airport (KZN/UWKD); 17 November 2013

photo (c) Russian Ministry of Emergency Situations; Kazan Airport (KZN/UWKD); 17 November 2013

photo (c) Russian Ministry of Emergency Situations; Kazan Airport (KZN/UWKD); 17 November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD)

photo (c) MAK; Kazan Airport (KZN/UWKD); 18 November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD); 18 November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD); November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD); November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD); November 2013

photo (c) MAK; Kazan Airport (KZN/UWKD); November 2013

photo (c) Timo Blossfeld; Istanbul-Atatürk International Airport (IST/LTBA); 16 September 2010

photo (c) Jürg Sommer; Kerkyra-I. Kapodistrias Airport (CFU/LGKR); 02 October 2011

photo (c) Ferenc Hamori (if); Budapest Ferenc Liszt International Airport (BUD/LHBP); 12 January 2011

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