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Final Report INTERSTATE AVIATION COMMITTEE AIR ACCIDENT INVESTIGATION COMMISSION FINAL REPORT Type of occurrence Accident Type of aircraft Airplane, Boeing 737-500 (53A) Registration VQ-BBN (Bermuda) Registered Charterer (according to the AWAS (BERMUDA) LIMITED, Clarendon registration certificate) House, 2 Church Street, Hamilton HM 11, Bermuda Operator Tatarstantranslation Airlines, JSC, Russia Aviation Administration Tatar ITO, FATA Place of occurrence Russian Federation, Kazan International Airdrome, coordinates: N 55º 36,5291’ E 49º16,6111’ Date and Time November 17, 2013, 15:24 UTC, 19:24 local time, night time Courtesy In accordance with ICAO Standards and Recommended Practices this Final Report has been published with the sole objective of aircraft accident prevention. It is not the aim of this investigation to apportion blame or liability. The criminal aspects of this accident are described within a separate criminal investigation. Final Report, Boeing 737-500 (53А) VQ-BBN 2 ABBREVIATIONS AND DEFINITIONS ........................................................................................................... 4 SYNOPSIS .............................................................................................................................................................. 9 1. FACTUAL INFORMATION .................................................................................................................... 11 1.1. HISTORY OF FLIGHT ............................................................................................................................ 11 1.2. INJURIES TO PERSONS .......................................................................................................................... 14 1.3. DAMAGE TO AIRCRAFT ....................................................................................................................... 14 1.4. OTHER DAMAGE .................................................................................................................................. 19 1.5. PERSONNEL INFORMATION .................................................................................................................. 19 1.5.1. Flight Crew Information ................................................................................................................ 19 1.5.2. General comments to Boeing 737 flight operations in the airline ................................................. 28 1.5.3. Data on the air traffic service personnel of Kazan center of ATM of “Tataeronavigation” branch of the "State ATM Corporation", FSUE ....................................................................................................... 40 1.6. AIRCRAFT INFORMATION..................................................................................................................... 44 1.6.1. The aircraft construction features to be noted ............................................................................... 49 1.6.2. Elevator control system .................................................................................................................. 51 1.7. METEOROLOGICAL INFORMATION ....................................................................................................... 58 1.8. AIDS TO NAVIGATION, LANDING AND ATC ........................................................................................ 62 1.9. COMMUNICATION ................................................................................................................................ 65 1.10. AERODROME INFORMATION ................................................................................................................ 65 1.11. FLIGHT RECORDERS ............................................................................................................................ 68 1.12. WRECKAGE INFORMATION .................................................................................................................. 74 1.13. MEDICAL INFORMATION ...................................................................................................................... 78 1.14. SURVIVAL ASPECTS ............................................................................................................................. 78 1.15. SEARCH AND RESCUE. FIRE ................................................................................................................. 79 1.16. TESTS AND RESEARCH ....................................................................................................................... 79 1.16.1. Engineering Simulation ........................................................................................................... 79 1.16.2. Results of Speed Trim System Validation ................................................................................ 86 1.16.3. Sensorial Modelling Results .................................................................................................... 91 1.16.4. Flight assessment results ..........................................................................................................translation 94 1.16.5. FFS experiment result.............................................................................................................. 96 1.16.6. Elevator PCU Examination Results ...................................................................................... 101 1.16.7. Pilot’s Seats Fragments, Harness System and Flight Deck Door Lock Expertise ............... 123 1.16.8. Hydraulic fluid examination .................................................................................................. 123 1.17. ORGANIZATIONAL AND MANAGEMENT INFORMATION .................................................................. 124 1.18. ADDITIONAL INFORMATION ............................................................................................................ 126 1.18.1. Analysis of State Requirements to Service Providers’ Safety Management System and SMS Implementation at Tatarstan Airlines ....................................................................................................... 126 1.18.2. Analysis of Training Organizations Certification and Licensing Requirements and their implementation at ANEO S7 Training. .................................................................................................... 131 1.18.3. Analysis of Aviation Personnel Training and Conversion Training System (based on the example of ANEO S7 Training) ................................................................................................................ 133 1.18.4. Analysis of Flight Time, Flight Duty and Rest Planning and Tracking at Tatarstan Airlines 136 1.18.5. Flight Crew English Language Proficiency .......................................................................... 150 1.18.6. Aeroplane State Awareness During Go-Around Safety Study .............................................. 153 1.18.7. Elevator PCU Abnormal Operation Events on Other Boeing 737 Aircraft ......................... 163 1.18.8. Analysis of PIC’s Previous Approaches ................................................................................ 166 1.18.9. Failure to Monitor Flight Parameters During Go-Arounds ................................................. 173 Courtesy1.18.10. IRS Alignment by Tatarstan Airlines Crews Before Flights ................................................. 175 1.19. USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES .................................................................... 176 2. ANALYSIS ............................................................................................................................................ 177 2.1. DESCRIPTION OF ACCIDENT FLIGHT .................................................................................. 177 2.2. AIRCRAFT S YSTEMS OPERABILITY ANALYSIS ................................................................. 186 2.2.1. Aircraft Positioning Accuracy .................................................................................... 187 2.2.2. Longitudinal Control System Operability .............................................................. 189 INTERSTATE AVIATION COMMITTEE МЕЖГОСУДАРСТВЕННЫЙ АВИАЦИОННЫЙ КОМИТЕТ Final Report, Boeing 737-500 (53А) VQ-BBN 3 2.3. CREW QUALIFICATION ANALYSIS ........................................................................................ 191 2.4. FLIGHT C REW AND ATC CONDITIONS AND A CTIONS ANALYSIS .............................. 200 3. FINDINGS AND CONCLUSIONS ............................................................................................... 221 3.1. FINDINGS ....................................................................................................................................... 221 3.2. CONCLUSION ................................................................................................................................ 236 4. SHORTCOMINGS .............................................................................................................................. 238 5. SAFETY ACTIONS TAKEN AND SAFETY RECOMMENDATIONS ......................... 240 translation Courtesy INTERSTATE AVIATION COMMITTEE Final Report, Boeing 737-500 (53А) VQ-BBN 4 Abbreviations and Definitions AAIB UK Aircraft Accident Investigation Board, UK A/P Autopilot A/T Autothrottle AAISTSC Air Accident Investigation Scientific and Technical Support Commission AAL Above Airdrome Level AC Advisory Circular AD Airworthiness Directive Agreement, the
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