1992 aviation accident
Aeroflot Flight 2808 was a scheduled domestic passenger flight from Mineralnye Vody to Ivanovo, both in Russia, with a stopover in Donetsk, Ukraine on 27 August 1992. While attempting to land at Ivanovo airport, the Tupolev Tu-134 crashed into a group of buildings in the village of Lebyazhy Lug. Investigators determined the cause of the accident was errors made by the crew and the air traffic controller. There were no fatalities on the ground, but all 84 people on board the flight died in the crash.
Aircraft.
The aircraft involved in the accident was a Tupolev Tu-134A registered RA-65058 to Aeroflot. At the time of the accident, the aircraft had sustained 26,307 flight hours and 16,388 pressurization cycles.
Crew.
The cockpit crew consisted of the following:
The two flight attendants in the cabin were Svetlana Ermilova (Светлана Ермилова) and Tatiana Mokrova (Татьяна Мокрова).
Synopsis.
The second phase of the flight took off from Donetsk at 21:03 Moscow Time. On board the aircraft were the seven crew members and 77 passengers, of whom 21 were children. No issues in flight from Donetsk were reported. At 22:27 and at an altitude of the flight began to descend on a bearing of 60° in preparation for the approach, which was to be carried out by the pilot in command. The decrease in altitude occurred approximately from the airport and approximately from the point where the flight was due to turn for the approach. After the descent the flight remained at its current altitude for two minutes at a speed of .
After the Tu-134 passed Dobrynskoe as designated by air traffic control, while at a distance of from the airport, the crew contacted the air traffic controller who gave them permission descend to an altitude of and set them on a bearing of 292° for landing. At 22:39:20 the flight reported to be from the airport and at an altitude of when they were actually at an altitude of . As instructed the flight flew level for 25 seconds, decreasing airspeed from . At 22:39:40 while from the airport the controller gave the flight permission to descend to and transferred the flight to another controller in the tower. When communications with the new controller began the flight reported their altitude to be and proceeded with level flight for 25 seconds.
When the flight was to the right of the cut-off point of the glideslope they requested permission to enter landing mode. The flight, having deviated 9 kilometers from the route, had reached the transition level at 22:40. Upon receiving permission to reduce their altitude to and execute a fourth turn at 20°, they flight executed the procedure through a transition level of and a radial distance. The flight was then from the aerodrome and flying at a speed of when it had still not deployed the landing gear; in the preparations for landing the navigator forgot to set his altimeter to the correct pressure. During the third turn the aircraft reduced speed to at a consistent altitude. During the beginning of fourth turn the landing gear was released and the flaps adjusted only when the aircraft
was from the glideslope, while at an altitude of and a speed of . The fourth turn started with a roll of 20° at a distance of from the entrance to the runway; due to previous lateral deviations the roll would have had to reach 30° in order to proceed with the route.
At 22:41 the air traffic controller informed the flight crew of weather conditions with visibility being 1,200 meters and mild fog. Having lost two minutes of needed time to execute the planned route, there was not enough time to sufficiently reduce speed to , adjust flaps to 20°, and reach an altitude of safely to continue with the landing. Nevertheless, the crew continued with the landing and the air traffic controller did not give the crew any warnings. The aircraft exited the fourth turn at a distance of from the entrance to the runway with a speed of and an altitude above the limit but with the stabilizer, flaps and slats in the correct positions. At a distance of from the runway and an altitude of the navigator picked up on the deviation and asked the captain about correcting the deviation to which the captain initially refused. While descending to the glidepath at an altitude of the copilot corrected the left bank by adjusting the horizontal stabilizer in one procedure (changing the stabilizer required fulfilling three procedures); doing so caused the aircraft to become less stable.
At a distance of from the runway, the aircraft held a lateral deviation ranging from and an altitude of . To enter the glidepath, the captain began to turn to the right causing the aircraft to roll up to 35°. The procedure was carried out uncoordinated fashion, causing the vertical speed to increase to up to . After passing the Non-directional beacon at an altitude of (which should have been ) while to the left of the correct position relative to the runway, the navigator again warned the captain but was ignored. At an altitude of approximately the captain attempted to take the aircraft out of the bank but did not attempt to slow down the vertical speed. After the navigator's last attempt to convince the captain to abort the landing and make a go-around, the aircraft banked sharply to the right 10°.
The aircraft struck foliage to its right at a distance of from the start of the runway while on a bearing of 295° and to the left of the intended path. The aircraft crashed into the ground after first striking the trees; several brick buildings and cars were damaged by debris but no one on the ground was killed. All 84 passengers and crew were killed in the crash.
Conclusions.
Investigation showed that there were no mechanical issues with the aircraft itself and the aircraft was intact until it had crashed.
The primary cause of the accident was the captain's decision to continue the route under unsuitable parameters for landing. Insufficient crew communication and poor cockpit resource management also led to periodic loss of control compounded by failure to follow guidelines for maximum rate of descent as outlined in the Tu-134's flight manual.
The air traffic controller at Ivanovo airport acted in violation of aviation guidelines by not notifying the crew about their deviations from the course and glide path.
References.
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