| Aeroflot Flight 2808 | |
| Occurrence Type: | Accident |
| Date: | 27 August 1992 |
| Summary: | Pilot error and ATC error |
| Occupants: | 84 |
| Passengers: | 77 |
| Crew: | 7 |
| Fatalities: | 84 |
| Survivors: | 0 |
| Aircraft Type: | Tupolev Tu-134A |
| Operator: | Aeroflot |
| Tail Number: | RA-65058 |
| Origin: | Mineralnye Vody Airport, Russia |
| Stopover: | Donetsk International Airport, Ukraine |
| Destination: | Ivanovo Yuzhny Airport, Russia |
Aeroflot Flight 2808 (Reys 2808 Aeroflota) 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.[1]
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.[2]
The cockpit crew consisted of the following:
The two flight attendants in the cabin were Svetlana Ermilova (Светлана Ермилова) and Tatiana Mokrova (Татьяна Мокрова).
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 10100m (33,100feet) the flight began to descend 6000m (20,000feet) 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 100km (100miles) from the airport and approximately 40km (30miles) 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 440km/h.
After the Tu-134 passed Dobrynskoe as designated by air traffic control, while at a distance of 75km (47miles) from the airport, the crew contacted the air traffic controller who gave them permission descend to an altitude of 1800m (5,900feet) and set them on a bearing of 292° for landing. At 22:39:20 the flight reported to be 28km (17miles) from the airport and at an altitude of 1800m (5,900feet) when they were actually at an altitude of 2000m (7,000feet). As instructed the flight flew level for 25 seconds, decreasing airspeed from 580to. At 22:39:40 while 25km (16miles) from the airport the controller gave the flight permission to descend to 1500m (4,900feet) and transferred the flight to another controller in the tower. When communications with the new controller began the flight reported their altitude to be 1500m (4,900feet) and proceeded with level flight for 25 seconds.
When the flight was 2.5km (01.6miles) 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 500m (1,600feet) and execute a fourth turn at 20°, they flight executed the procedure through a transition level of 1200m (3,900feet) and a 17km (11miles) radial distance. The flight was then 3km (02miles) from the aerodrome and flying at a speed of 450km/h 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 390km/h at a consistent altitude. During the beginning of fourth turn the landing gear was released and the flaps adjusted only when the aircraftwas 2600m (8,500feet) from the glideslope, while at an altitude of 1200m (3,900feet) and a speed of 410km/h. The fourth turn started with a roll of 20° at a distance of 12.5km (07.8miles) 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 330km/h, adjust flaps to 20°, and reach an altitude of 500m (1,600feet) 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 8600m (28,200feet) from the entrance to the runway with a speed of 390km/h and an altitude 100m (300feet) above the limit but with the stabilizer, flaps and slats in the correct positions. At a distance of 7500m (24,600feet) from the runway and an altitude of 320m (1,050feet) 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 270m (890feet) 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.[3]
At a distance of 4500m (14,800feet) from the runway, the aircraft held a lateral deviation ranging from 200m-300mm (700feet-1,000feetm) and an altitude of 200m (700feet). 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 210m (690feet)) while 40m (130feet) 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 100m (300feet) 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 2962m (9,718feet) from the start of the runway while on a bearing of 295° and 60m (200feet) to the left of the intended path. The aircraft crashed into the ground 512m (1,680feet) 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.
Investigation showed that there were no mechanical issues with the aircraft itself and the aircraft was intact until it had crashed.[4]
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.