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The INSANE Story of Aeroflot Nord flight 821!

Mentour Pilot・44 minutes read

The tragic crash of Flight 821 was caused by a series of errors and miscommunications stemming from inadequate pilot training, technical knowledge, maintenance issues, and poor decision-making, ultimately leading to the loss of all 88 people on board. The investigation revealed systemic failures in various aspects of the aviation industry, resulting in 40 safety recommendations to prevent similar incidents in the future, emphasizing the critical need for improvements in pilot training, English proficiency verification, and adherence to safety procedures.

Insights

  • 1. Transition from Soviet to Western aircraft like the Boeing 737 posed significant challenges for Airfield North pilots due to technical differences, language barriers, and lack of specific training in aircraft upset prevention and recovery, underscoring the importance of comprehensive training programs for pilots transitioning between different aircraft types.
  • 2. Inadequate crew resource management, combined with technical issues like trust lever problems and maintenance oversights, contributed to the tragic crash of Flight 821, highlighting the critical need for effective communication, situational awareness, and adherence to safety protocols in aviation operations to prevent catastrophic incidents.
  • 3. The investigation into the crash led to 40 safety recommendations aimed at enhancing pilot training, verifying language proficiency, and addressing systemic failures in training, maintenance, and regulations, emphasizing the necessity of rigorous safety protocols and oversight to prevent similar accidents and ensure passenger safety.

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Recent questions

  • What caused the crash of Flight 821?

    Pilot errors, technical issues, and lack of adherence to procedures.

  • What were the implications of the crash investigation?

    40 safety recommendations and systemic failures identified.

  • How did the crew handle the approach and landing?

    Crew faced confusion, errors, and instability during approach.

  • What were the challenges faced by the pilots?

    Transition to Boeing 737, language barriers, and lack of training.

  • What were the key factors contributing to the crash?

    Pilot errors, technical issues, and lack of adherence to procedures.

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Summary

00:00

Flight 821: Boeing 737 Training Challenges

  • Airfield North, originally Archangel's United Aviation Squadron, formed in the Soviet Union in 1963, was acquired by Aeroflot in 2004, leading to a shift to Western-built aircraft like the Boeing 737-500.
  • The transition to the Boeing 737 posed significant challenges for pilots accustomed to Soviet aircraft requiring a 3-4 man flight crew, necessitating not only technical knowledge but also a shift in crew resource management and flying philosophy.
  • The pilots of Flight 821, relatively inexperienced on the Boeing 737, faced language barriers as all manuals and system descriptions were in English, a language they had rudimentary knowledge of.
  • The captain, with 3,900 hours of flying experience, had only 713 hours on the Boeing 737, while the first officer, with 8,900 hours, struggled with English and handling the aircraft after engine failures due to his Soviet aircraft background.
  • Both pilots lacked specific training in aircraft upset prevention and recovery, highlighting a gap in the airline's training syllabi.
  • The Boeing 737-505, registered in Bermuda, had a unique flight director system and a history of trust lever problems, with the right engine producing more thrust than the left due to a trim issue.
  • Maintenance issues with the aircraft's trust levers were not properly addressed, leading to the outer throttle being labeled as inoperative without deactivation, causing potential safety risks.
  • On the night of the accident, the crew, consisting of two pilots and four cabin crew members, arrived at Moscow Metievo airport for a normal passenger flight to Perm with 82 passengers booked.
  • The first officer, set to be the pilot flying, made errors in aligning the inertial reference system, leading to inaccuracies in the aircraft's position tracking, compounded by the lack of GPS and nearby navigation stations for updates.
  • Despite initial errors and inaccuracies, the crew proceeded with the flight, unaware of the potential risks posed by the aircraft's navigation system inaccuracies and trust lever issues, setting the stage for the tragic events that followed.

15:45

Flight Crew Errors Lead to Critical Incident

  • Aircraft began taxiing for takeoff at 0306 local time from Runway 07 left, with no cockpit voice recordings available for the taxi out phase due to the limited coverage of the cockpit voice recorder.
  • Inoperative outer throttle was activated just before departure, causing a thrust asymmetry issue as the captain handed over controls to the first officer during the lineup turn.
  • Incorrect thrust levels were set during lineup, leading to a slower initial acceleration and failure to push the toga buttons for correct takeoff thrust.
  • During climb, the aircraft experienced issues with the IRS position update and continued with the outer throttle connected to maintain thrust symmetry.
  • Crew omitted the approach briefing and descent checklist, leading to a lack of shared understanding and preparation for the approach.
  • Confusion arose regarding the arrival route change due to a departing Lufthansa aircraft, with the crew failing to re-brief the new route adequately.
  • Miscommunication with the air traffic controller regarding the landing runway led to confusion and stress in the cockpit, with the crew not confirming the expected runway.
  • As the aircraft descended, the crew failed to notice the deviation from the cleared route towards the Papa X-Ray beacon, impacting their position accuracy.
  • Trust asymmetry issues arose during descent due to the outer throttle compensating for speed maintenance, leading to control wheel displacement unnoticed by the pilots.
  • Controller instructions for descent to 2100 meters and a right turn towards the back course were not accurately predicted by the crew, highlighting a lack of situational awareness and communication.

31:00

Confusion and Errors Lead to Near-Crash

  • The captain and first officer were uncertain about which runway to land on, with the captain assuming Runway 2-1 while the first officer believed it was Runway 03.
  • The flight management computer had likely been programmed for Runway 2-1, causing the aircraft to start a right turn even before being cleared by the controller.
  • Due to the aircraft's speed and inability to reach the threshold point for Runway 2-1, it started turning left, leading to confusion among the crew.
  • The captain instructed the first officer to engage heading select and turn right to heading 030 degrees for downwind, as they descended to 2100 meters.
  • Manual thrust control by the first officer led to considerable asymmetric thrust production, causing the autopilot to adjust the control wheel to maintain course.
  • The crew finally confirmed an ILS approach for Runway 21, 12 minutes after the initial confusion, and began descending with flaps one.
  • The first officer's erratic thrust adjustments and failure to monitor N1 led to significant thrust asymmetry, affecting the aircraft's stability.
  • The captain's decision to lower the landing gear and extend flaps to 15 caused the aircraft to be too high above the glide path, complicating the approach.
  • The first officer's struggle with manual thrust control and speed management led to a series of control inputs that destabilized the aircraft's flight path.
  • The captain's abrupt control inputs and failure to monitor the aircraft's attitude resulted in a steep right bank, rapid climb, and ultimately, loss of control, leading to a near-crash situation.

46:22

Fatal crash due to pilot error and intoxication.

  • The aircraft, due to pilot confusion, executed an almost full barrel roll in landing configuration, resulting in a 65-degree pitch down angle and a crash at 250 knots in a 30-degree left timed turn, leading to the loss of all 88 people on board. The impact occurred near the Trans-Siberian Railway, damaging it severely but causing no harm to individuals on the ground. Airport rescue personnel and firefighters quickly secured the area, recovering damaged black boxes that revealed the crew's lack of adherence to procedures, poor technical knowledge, and the captain's intoxication, with 0.5 to 1 promile alcohol in his blood during the accident.
  • The investigation following the crash implicated Russian Aviation authorities, the airline, maintenance organization, and air traffic controllers, resulting in 40 safety recommendations. These included enhancing pilot training, particularly in prevention and recovery techniques, verifying English proficiency, and providing additional training for pilots transitioning between Soviet and Western aircraft. The incident highlighted systemic failures in training, maintenance, regulations, and individual responsibility, emphasizing the importance of avoiding airlines with poor safety records, as indicated in the EU Blacklist of dangerous Airlines.
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