B735, vicinity Kazan Russia, 2013

B735, vicinity Kazan Russia, 2013

Summary

On 17 November 2013, the crew of a Boeing 737-500 failed to establish on the ILS at Kazan after not following the promulgated intermediate approach track due to late awareness of LNAV map shift. A go around was eventually initiated from the unstabilised approach but the crew appeared not to recognise that the autopilot used to fly the approach would automatically disconnect. Non-control followed by inappropriate control led to a high speed descent into terrain less than a minute after go around commencement. The Investigation found that the pilots had not received appropriate training for all-engine go arounds or upset recovery.

Description

On 17 November 2013, a Boeing 737-500 ( VQ-BBN) being operated by Tatarstan Airlines on a scheduled domestic passenger flight from Moscow Domodedovo to Kazan as TAK 363 commenced a go around from 900 feet aal after failing to establish on the ILS to runway 29 at destination in night IMC. The aircraft crashed within the airport perimeter and was destroyed by the high speed impact and post crash fire. All 50 occupants were killed.

Investigation

An Investigation was carried out by the Air Accident Investigation Commission of the Interstate Aviation Committee (MAK). Both the FDR and the 30 minute CVR were recovered from the wreckage in a damaged condition (in the case of the CVR extremely damaged). The data from both were eventually downloaded and together proved crucial to establishing the circumstances which had led to the accident. No evidence was found which indicated that any airworthiness issues had played a part in the accident and most of the Investigation was focussed on the performance of the pilots.

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