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Last updated: 14 August 2020
Status:Definitief
Datum:zondag 14 september 2008
Tijd:03:10
Type:Silhouette image of generic B735 model; specific model in this crash may look slightly different
Boeing 737-505
Luchtvaartmaatschappij:Aeroflot-Nord
Registratie: VP-BKO
Constructienummer: 25792/2353
Bouwjaar: 1992-08-22 (16 years )
Aantal vlieguren:44533
Aantal vluchten:35104
Motoren: 2 CFMI CFM56-3C1
Bemanning:slachtoffers: 6 / inzittenden: 6
Passagiers:slachtoffers: 82 / inzittenden: 82
Totaal:slachtoffers: 88 / inzittenden: 88
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:11,5 km (7.2 mijl) NE of Perm Airport (PEE) (   Rusland)
Fase: Nadering (APR)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Moskva-Sheremetyevo Airport (SVO/UUEE), Rusland
Vliegveld van aankomst:Perm Airport (PEE/USPP), Rusland
Vluchtnummer:SU821
Beschrijving:
Aeroflot-Nord flight 821 took off from Moscow's Sheremetyevo Airport at 21:13 hours on a domestic flight to Perm, Russia. Contact with the flight was lost while the airplane was at 3600 feet in "difficult weather conditions", according to Aeroflot officials.
The plane came down on the outskirts of the city, hitting the ground just a few hundred yards from small wooden houses and apartment buildings.
Investigation revealed that the pilot lost spatial orientation during the night-time approach through clouds. This led to a banking of the plane onto its left wing, and its entering into an intensive descent and collision with the ground. The pilot was not familiar with the attitude indicator (ADI) used on Western jets, compared to those of Russian jets. Also, an unspecified amount of alcohol was detected in the pilot's body, and he was overworked.

Probable Cause:

The immediate cause of the accident was spatial disorientation of the crew, especially the Captain who was the pilot flying at the final stage of the flight, which led to the left flip-over, a steep descent and the 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 modern 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 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 [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] 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 conducive to fatigue and did not comply with national regulations.

Accident investigation:
cover
Investigating agency: MAK
Status: Investigation completed
Duration: 257 days (9 months)
Accident number: Final report
Download report: Final report


Veiligheidsmaatregelen

MAK issued 40 Safety Recommendations

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Foto's

photo of Boeing-737-505-VP-BKO
accident date: 14-09-2008
type: Boeing 737-505
registration: VP-BKO
photo of Boeing-737-505-VP-BKO
accident date: 14-09-2008
type: Boeing 737-505
registration: VP-BKO
photo of Boeing-737-505-VP-BKO
accident date: 14-09-2008
type: Boeing 737-505
registration: VP-BKO
 

Aircraft history
date registration operator remarks
08 SEP 1992 LN-BRW Braathens
24 SEP 1992 B-2591 Xiamen Airlines
14 MAR 2008 VP-BKO Aeroflot-Nord

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Moskva-Sheremetyevo Airport en Perm Airport bedraagt 1137 km (710 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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