On 17 November 2013, the crew of the Tatarstan Boeing 737-500 engaged go-around thrust after assessing the aircraft’s position relative to the runway. The autopilot was disconnected and the aircraft flown manually.
As the engines increased power the crew retracted the 737’s flaps from the 30° position to 15°. But the thrust from the underwing engines pitched the aircraft nose-up, and it climbed at a pitch of 25°. This led the airspeed to bleed away from 150kt to 125kt.
The pilots, after retracting the landing-gear, countered the climb and the loss of airspeed by pushing the control column forward – pushing the aircraft into a dive at a height of just 700m (2,300ft).
During the “intense” dive the aircraft reached 75° pitch down and it slammed into the ground at over 240kt just 45s after initiating the missed approach. None of all 50 occupants survived.
However, investigators point out that the aircraft did not exceed its angle-of-attack limit, indicating that there was no stall. Also, Both CFM International CFM56 engines were functioning until the moment of impact, and there is no immediate indication of system failure.
- systemic deficiencies in the identification of hazards and risk control, as well as a non-functional safety management system in the airline and the lack of control over the level of training of the crew members from the aviation authorities at all levels (Tatar MTU BT, Federal Air Transport Agency), which led to the admission of an unprepared flight crew.
- PIC’s (pilot flying) lack of flying skills in complex spatial positions (Upset Recovery) led to the creation of a large negative overload, loss of spatial orientation and transfer of the aircraft into a steep dive (pitch down to 75°) until the impact with the ground.
- “a map shift” effect (Map shift, an error in the determination of the aircraft position by onboard systems) by about 4 km, the crew’s inability in the circumstances to integrated piloting and maintenance of navigation with the required accuracy
- the lack of active assistance of the air traffic control service under the long-term monitoring of significant deviations from the approach procedure.