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Accident description
Last updated: 28 September 2016
Status:Final
Date:Sunday 17 November 2013
Time:19:23
Type:Silhouette image of generic B735 model; specific model in this crash may look slightly different
Boeing 737-53A
Operator:Tatarstan Airlines
Registration: VQ-BBN
C/n / msn: 24785/1882
First flight: 1990-06-18 (23 years 5 months)
Total airframe hrs:51547
Cycles:36596
Engines: 2 CFMI CFM56-3C1
Crew:Fatalities: 6 / Occupants: 6
Passengers:Fatalities: 44 / Occupants: 44
Total:Fatalities: 50 / Occupants: 50
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:Kazan Airport (KZN) (   Russia)
Crash site elevation: 126 m (413 feet) amsl
Phase: Approach (APR)
Nature:Domestic Scheduled Passenger
Departure airport:Moskva-Domodedovo Airport (DME/UUDD), Russia
Destination airport:Kazan Airport (KZN/UWKD), Russia
Flightnumber:U9363
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).

During the approach to Kazan's runway 11/29 the airplane was 'not in a position to land', according to an initial statement by the Interstate Aviation Committee. TOGA (Take Off/Go Around) mode was selected and the autopilot switched off. The engines spooled up to takeoff power and the crew raised the flaps from 30░ to 15░. The airplane began to climb and the pitch angle increased to 25░. Consequently, the indicated airspeed began to decrease. When the airspeed reached 125 knots, the crew reacted by pushing to control column forward. Up until that moment, from the execution of the go around, the crew had not used the flight controls.
From a height of 700 m the airplane entered a nose down attitude, reaching a -75░ pitch.
The airplane impacted the ground at a speed of 450 km/h.
Time from the start of the go-around to the impact with the ground was 45 seconds.


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.

Classification:
Loss of control (presumed)

Sources:
» RIA, Interfax, RT
» Russian Emergencies Ministry

METAR Weather report:
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

Official accident investigation report
cover
investigating agency: Interstate Aviation Committee (IAC / MAK) - Russia
report status: Final
report number: final report
report released:23 December 2015
duration of investigation: 2 years and 1 months
download report: final report

Photos

photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
photo of Boeing 737-53A VQ-BBN
Flight Data Recorder (FDR)
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photo of Boeing 737-53A VQ-BBN
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Aircraft history
date registration operator remarks
18 June 1990 N35135 Boeing first flight
13 July 1990 F-GGML Euralair International delivered
1 June 1992 F-GGML Air France leased
15 July 1995 5X-USM Uganda Airlines leased from AWAS
17 Feb. 2000 PT-SSI Rio Sul leased from AWAS
17 Dec. 2001 PT-SSI Rio Sul accident at Belo Horizonte, Brazil: left main gear broke when it undershot the runway on landing
24 July 2005 N785AW AWAS returned
1 Sep. 2005 YR-BAB Blue Air leased from AWAS
17 May 2008 LZ-BOY Bulgaria Air leased from AWAS
18 Dec. 2008 VQ-BBN Tatarstan Air leased from AWAS
27 Nov. 2012 VQ-BBN Tatarstan Air incident: returned to Kazan following loss of cabin pressure

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Moskva-Domodedovo Airport to Kazan Airport as the crow flies is 710 km (444 miles).

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Boeing 737-500

  • 8th loss
  • 390 built
  • 3rd worst accident
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 Russia
  • 47th worst accident (at the time)
  • 48th worst accident (currently)
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