Tartarstan Airlines 737 crash November 2013 Accident Report [Archive]

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Centaurus

10th Dec 2019, 11:59

https://aviation-safety.net/database/record.php?id=20131117-0https://aviation-safety.net/database/record.php?id=20131117-0 (https://aviation-safety.net/database/record.php?id=20131117-0)

This accident report is about the Tartarstan Airlines Boeing 737 that crashed during a go around at Kazan, Russia 17 November 2013.

There is a link to the Final Report which is in Russian. Is there a Final Report on this accident produced in English language?

Redredrobin

10th Dec 2019, 12:57

Think this (https://mak-iac.org/upload/iblock/459/report_vq-bbn_eng.pdf) fits the bill

aterpster

10th Dec 2019, 13:22

Centaurus

11th Dec 2019, 11:47

Think this fits the bill

Certainly did. Many thanks RRobin

safetypee

11th Dec 2019, 15:49

The findings may be embarrassing for Russian aviation, but the world industry must not be complacent, nor be afraid of washing ‘dirty laundry’ in public.

The tests and research and findings sections provide an enlightening view of the Russian positive approach to accident investigation and safety. In particular the line pilot assessment (page 94) - simulator and technical knowledge; an example of how we might learn about pilots in general, and how this compares with our views of ability and effectiveness of training.

Note the reference to BEA ASAGA report (page 153); now 5 years on, how little has changed for a wide range of issues. This is a chastise for everyone; what are we doing about this.

The report begs the question ‘could this happen to us / me’, but the all-important aspect is what will be done on a world wide basis, what really will be learnt, what will be changed, how, when.

https://www.bea.aero/etudes/asaga/asaga.study.pdf

vilas

11th Dec 2019, 17:56

Isn't this similar to FlyDubai Rostov on don?

Centaurus

13th Dec 2019, 05:47

Isn't this similar to FlyDubai Rostov on don?
The link was part of the comments found in the Rostov on Don accident.

vilas

13th Dec 2019, 07:05

The link was part of the comments found in the Rostov on Don accident.
In ROD report didn't find any mention of speed trim system operation. Can a 737 pilot explain how STS would operate in this situation?

alf5071h

14th Dec 2019, 15:10

vilas, “similar to FlyDubai ”
There are similarities, … or differences from normal expectations; we tend to find whatever we look for.
However, the imbalance of pilot capability in specific situations and particular aircraft type could be the top issues (similar and yet different).

Other aircraft types have suffered GA mishaps, but differences in the magnitude of trim change, trim rate, and the cues to restoring trim - aircraft ‘feel’ may be significant.

In theory, a go-around is a simple manoeuvre; it involves the transition from the pre-landing flight path to a climb. There is a reduction in drag - flap and gear, and applying sufficient thrust for an adequate rate of climb.
A go-around is like a takeoff - but not from the ground. However, the rate of change of pitching moment and required control-trim input are different. Also the rarity of the situation risks surprise.

Many modern aircraft have large nose-up trim changes due to high thrust; this requires that the elevator and trim are sufficiently powerful to manage the change. A higher rate of change demands quicker pilot reactions, anticipation, and ease of operating controls in a short time scale - a changed ‘feel’ for the aircraft.

The apparent increase in GA events may be the combination of progressively having higher levels of thrust in the same aircraft type, although the control and trim functions are similar, but the crew experience is less due to decreased exposure to the situation.
There has been a drift in the assumptions about crews’ ability to manage situations - “the crew will manage because the changes are small” - but over the years there have been many accumulating small changes - increasing complex aircraft and operational situations, reduced crew exposure / experience. The failure to appreciate the need for quicker and larger control inputs.

Things to consider - the call for more hand flying in benign ‘straight and level’ flight may not improve judgement of the need for quicker reaction and/or larger range of control and trim input. Pilots require a different underatanding of time and control force / movement - when and how to change gear.

Crews might be able to minimise surprise by ‘redefining’ the situation with anticipatory briefing; noting the differences or expectations, e.g. thrust required - possible wind-shear max, or as required for obstacle performance, or just a safe climb - different levels of ‘rarity’ overlaying the already rare need for GA.

SOP flexibility to enable the required agility; specify outcome, do not constrain the method.

Defer potential competing tasks - radio, cabin briefing; - clear the mind.

Technical differences, single or dual AP, availability of auto go around or not, need to plan ahead, anticipate a change of plan.
Be prepared to be surprised.