INTERSTATE AVIATION COMMITTEE AIR ACCIDENT INVESTIGATION COMMISSION FINAL REPORT Type of occurrence Accident Aircraft type Airplane, Boeing 737-505 Registration VP-BKO (Bermuda) Registered owner ARN 737 Limited, Clarendon House, 2 Church Street, Hamilton HM 11, Bermuda Operator Aeroflot-Nord Airline, Russia Regional Aviation Authority Arkhangelsk Regional Office, FTOA Place of Occurrence Russian Federation, near Bolshoye Savino Airport, Perm (N57˚58,255´, E056˚12,632') Date and Time 13 September 2008, 2310 hrs UTC, local time 0510 hrs, 14 September 2008. In accordance with ICAO standards and recommended practices, it is not the purpose of this report to apportion blame or liability. The sole objective of the investigation and the Final Report is the prevention of accidents. Criminal aspects of the accident are tackled within the framework of a separate criminal case. Final report B 737-505 VP-BKO 2 ABBREVIATIONS................................................................................................................................................3 SYNOPSIS..............................................................................................................................................................8 1. FACTUAL INFORMATION......................................................................................................................9 1.1. HISTORY OF THE FLIGHT .......................................................................................................................9 1.2. INJURIES TO PERSONS..........................................................................................................................10 1.3. DAMAGE TO AIRCRAFT .......................................................................................................................10 1.4. OTHER DAMAGE..................................................................................................................................10 1.5. PERSONNEL INFORMATION ..................................................................................................................10 1.6. AIRCRAFT INFORMATION.....................................................................................................................24 1.7. METEOROLOGICAL INFORMATION.......................................................................................................34 1.8. AIDS TO NAVIGATION..........................................................................................................................35 1.9. COMMUNICATIONS ..............................................................................................................................39 1.10. AERODROME DATA..............................................................................................................................39 1.11. FLIGHT RECORDERS ............................................................................................................................44 1.12. WRECKAGE AND IMPACT INFORMATION .............................................................................................45 1.13. MEDICAL AND PATHOLOGICAL INFORMATION ....................................................................................64 1.14. SURVIVAL ASPECTS.............................................................................................................................67 1.15. FIRE AND RESCUE OPERATIONS ..........................................................................................................67 1.16. TESTS AND RESEARCH.........................................................................................................................69 1.16.1. Powerplant and Autothrottle.....................................................................................................69 1.16.2. Flight Simulation.......................................................................................................................73 1.16.3. Speed Trim System ....................................................................................................................76 1.16.4. Independent Flight Test.............................................................................................................78 1.16.5. Expert Conclusion on the Psychological Examinations of the Crew ........................................80 1.16.6. Instrumental Speech Analysis....................................................................................................81 1.17. ORGANIZATIONAL AND MANAGEMENT INFORMATION........................................................................84 1.18. ADDITIONAL INFORMATION ................................................................................................................85 1.18.1. Photographs of the Actual Throttle Stagger in Flight...............................................................85 1.18.2. English Language Proficiency of the Crew...............................................................................86 1.18.3. Text Message (SMS) Sent from the Aircraft Before the Flight ..................................................92 1.18.4. Previous Cases of Spatial Disorientation..................................................................................92 1.18.5. Flights Performed on the Accident Aircraft after August 06, 2008...........................................93 1.18.6. Pilot Training at the FTI Center ...............................................................................................95 1.19. NEW INVESTIGATION TECHNIQUES......................................................................................................95 2. ANALYSIS..................................................................................................................................................96 3. FINDINGS AND CONCLUSION...........................................................................................................128 4. SHORTCOMINGS ..................................................................................................................................136 5. SAFETY RECOMMENDATIONS ........................................................................................................137 INTERSTATE AVIATION COMMITTEE Final report B 737-505 VP-BKO 3 Abbreviations AAIB − Air Accident Investigation Branch, UK AATMC − Automated Air Traffic Management Complex AC − Advisory circular − Alternating Current ACEOS − Aeronautical and Communication Equipment Operation Service AD − Airworthiness Directive ADF − Automatic Direction Finder AFM − Aircraft Flight Manual Agreement − Agreement on Civil Aviation and Use of Airspace ALT ACQ − Altitude Acquire (autopilot mode) ALT HOLD − Altitude Hold (autopilot mode) AMB − Aircraft Maintenance Base AMM − Aircraft Maintenance Manual AOA − Angle of attack AOS-92 − Aerodrome Operation Standards, issued in 1992 A/P − autopilot ARP − Aerodrome reference point ASR − Aerodrome Surveillance Radar AT − Automatic Transceiver A/T − autothrottle ATC − Air Traffic Control − Aviation Training Center ATCC − Air traffic Control Center ATIS − Automatic Terminal Information Service ATM − Air Traffic Management BEA − Air Accident Investigation Bureau, France CA − Civil aviation CAA − Civil Aviation Authority CAFARMS-2002 − Civil Aviation Federal Aviation Rules for Medical Service, issued in 2002 CAFOM-85 − Civil Aviation Flight Operations Manual, issued in 1985 CARMS − Complex Aerodrome Radio Meteorological Station INTERSTATE AVIATION COMMITTEE Final report B 737-505 VP-BKO 4 CAT − category CB − Circuit breaker CBT − Computer Based Training CDU − Control Display Unit CG − Center of gravity CIS − Commonwealth of Independent States CRM − Crew Resource Management CRP − Compulsory Reporting Point CVR − Cockpit Voice Recorder CWS − Control Wheel Steering DME − Distance Measuring Equipment DC − Direct Current DCA − Department of Civil Aviation E − Eastern longitude EADI − Electronic Attitude Director Indicator EASA − European Aviation Safety Agency ECG − Electrocardiogram EPI − Emergency procedure ESR − En-route Surveillance Radar FAA − Federal Aviation Administration, USA FAF − Final Approach Fix FANA − Federal Air Navigation Agency, Russia FAP − Final Approach Point FAR − Federal Aviation Rules FATA − Federal Air Transport Service FBS − Fixed Base Simulator FCOM − Flight Crew Operations Manual FCTM − Flight Crew Training Manual FCTM-92 − a common Flight Crew Training Manual issued in 1992 FD − Flight Director FFS − Full Flight Simulator FL − Flight Level FDR − Flight Data Recorder INTERSTATE AVIATION COMMITTEE Final report B 737-505 VP-BKO 5 FLP − Flight Plan FMA − Flight Mode Annunciator FMC − Flight Management Computer FMS − Flight Management System FOOD − Flight Operations Oversight Department FSUE − Federal State Unitary Enterprise FTI − Flight Training International (Aviation Training Center, Denver) FTOA − Federal Transport Oversight Agency GE − General Electric GSL − Glideslope Localizer HDG SEL − Heading select – autopilot mode HPC − High Pressure Compressor HPT − High Pressure Turbine IAC − Interstate Aviation Committee, Russia IAF − Initial approach fix IAW − in accordance with ICAO − International Civil Aviation Organization ILS − Instrument Landing System IRS − Inertial Reference System LNAV − Lateral Navigation LMM − Compass Locator at the middle marker LOC − Localizer LOM − Compass Locator at the outer marker LPC − Low Pressure Compressor LPT − Low Pressure Turbine LTD − Limited LVL CHG − Level Change – autopilot mode MAC