Summary:It only takes just one major mistake to set a disaster in motion. In this episode of Take to the Sky: the Air Disaster podcast, Shelly shares the shocking story of Aeroflot Nord Flight 821, which crashed upon landing near Perm, Russia in September 2008. The investigation was a staunch reminder of how important it is for every pilot to have quality and timely training so they can effectively avoid a disaster.
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Sources consulted for this story:
- Wikipedia, Aeroflot Flight 821
- Wikipedia, Aeroflot 1492
- Aeroflot 821 CVR Transcript on Tailstroke.com
- The Guardian, Russia: Aeroflot plane crash kills 88
- IAC report on the crash, courtesy of Aviation-safety.net
- Matthew Bodner for the AP, Reports show Russia's terrible aviation record
- Aero News Network
- Ksensia Zubacheva for Russia Beyond, How dangerous is flying in Russia?
- International Air Transport Association (IATA) Safety Report, 2020
- Flight Safety Foundation
Read the Story!Expand the text below to read more about this episode.
Aeroflot 821 Prepares to Land Near Perm
On September 13, 2008, Aeroflot Nord Flight 821 has just spent an uneventful ninety minutes in the air and is now approaching its destination in Perm before returning to Moscow. Onboard are 82 passengers and 6 crew members, mostly of Russian citizenship.
Aeroflot Nord before, it came into existence in August of 2004 when the Russian state-owned airline, Aeroflot, bought 51% of the fleet within an existing airline, which then became Aeroflot Nord. It was a subsidiary of Aeroflot and a busy regional carrier like so many other regional carriers across the world focusing on short-haul flights. At the time in 2008, the airline industry in Russia was experiencing significant growth, and Russian airlines were in desperate need of planes. Many of them purchased aircraft from Western manufacturers, and this explosive growth came with many growing pains.
The plane that is Flight 821 is a Boeing 737 and, it being the workhorse aircraft that it is, has logged 45,000 flight hours. In the cockpit of this particular 737 are two flight crew members. According to Aeroflot-Nord representatives, the crew was described as very experienced and some of the best in the company. Captain Rodion Medvedev was 34 and had a flight record of 3,689 hours (including 1,190 hours on the Boeing 737). First Officer Rustam Allaberdin had 8,713 hours, though only 219 of them were on the Boeing 737. And, yes, this is a First Officer with more than twice the amount of logged flying time than the Captain.
All in all, the ninety-minute flight so far has been uneventful, except for one minor issue: the engines have been running at slightly uneven power. While this does not prevent a flight from operating normally, it did require First Officer Allaberdin, as the flying pilot, to continuously make manual adjustments to ensure they stay on course.
Captain Medvedev makes an announcement to the passenger cabin that Flight 821 is approaching the airport and will be ready to land in about 20 minutes, which also serves as the cue to the cabin crew to begin preparing the cabin for landing. Flight 821 is following an approach path from the west and will plan to make a right turn to line up with runway 21.
As the plane gets closer to the airport, the controller informs the flight crew that Flight 821 will need to wait in the air while control grants permission for a Lufthansa flight to takeoff. After a brief waiting period, control radios back with permission to land, instructing Flight 821 to turn right as planned and descend to 6,800 feet (2100 m). And then, just minutes later, the crew is given permission prepare to enter into their final right turn and descend to 2,000 feet (600 m).
ATC Senses Confusion in the Cockpit of Aeroflot Flight 821
And this is the point at which things start to unravel – and quickly. The controller is following Flight 821 on radar and sees the plane is now climbing instead of descending. Control contacts the flight crew to let them know about the climb and to confirm if that was their intention.
The controller asks, “821 according to my data you are climbing your height 900m can you confirm?” The First Officer responds on the cockpit voice recorder with a “Damn”. The Captain tells control they are now descending as instructed. First Officer Allaberdin adjusts the pitch of the plane to bring them back into a descent.
Now there is another problem: Flight 821 has flown past its approach path, so ATC instructs them to turn right and descend to 2,000 feet. But Flight 821 keeps flying straight. The controller repeats his instruction to turn right and descend. The radar shows that Flight 821 is banking left, further veering off course. After the controller asks the crew three times to descend and turn, he becomes concerned and asks the crew, “Aeroflot 821, is everything okay with the crew?”
Aeroflot Flight 821 Crashes, Killing All 88 People Onboard
But everything is not OK. Flight 821 is rapidly falling out of the sky. The First Officer screams, “What the fuck are we doing?” and then “Shit” while the Captain shouts, “Fuck!”
At this moment, the aircraft makes an almost full barrel-roll with a nose down angle of 65°. It would be impossible to recover from a position like this without a great deal of distance left between the plane and the ground. And Flight 821 has run out of distance. As the plane propels toward the ground, it is banking to the left intensively, and then just 3 seconds before impact, there is a last recorded right bank.
As the plane is coming down, several witnesses reported to The Guardian what they saw happening. One witness said, "I felt an explosion, it threw me off the bed ... My daughter ran in from the next room crying 'What happened? Has a war begun or what?'" Another witness reported, "My neighbors, other witnesses told me that it was burning in the air, it looked like a comet. It hit the ground opposite the next house, trailing like fireworks in the sky." Pavel Shevchenko, a 36-year-old Perm resident, said he was awoken by an explosion and ran outside. He said debris was scattered around the area, along a section of tracks destroyed by the impact of the plane, but the heat from the flames kept him from getting closer. He said a neighbor who witnessed the crash told him the plane hit the ground sharply at a 30- or 40-degree angle.
What the witnesses are seeing is in fact true. Flight 821 careens from the sky and explodes into the ground at a high speed of 250 knots or 287 mph, colliding first with nearby trees and then with the ground, its 8 tons of fuel exploding upon impact. A section of the Trans-Siberian rail track is destroyed in the crash, and the impact scatters paper, clothing, life preservers, plane parts, and human remains for several hundred yards along the track. Sections of the plane's fuselage reading "Aeroflot" and "Boeing" lay askew on the rails and these are the images that appear in the news over the coming days. These parts are some of the only recognizable parts of the fuselage. When all is said and done, all 88 people onboard have died. Luckily, the airplane narrowly missed nearby houses and an apartment building, and thankfully, there are no additional deaths on the ground.
Interstate Aviation Committee (IAC) Investigates Aeroflot 821 Crash
While local fire and rescue work to put out the blaze, the Interstate Aviation Committee (IAC) assembles a team that heads to Perm to begin investigating the crash. The IAC is an executive body of the Civil Aviation and Airspace Use Council of the Commonwealth of Independent States (CIS) and was formed in 1991. It has representation from many state agencies across 10 countries, all from parts of eastern Europe and western and central Asia – basically, most of the former Soviet bloc countries.
Thankfully, both flight recorders, the flight data recorder (or FDR) and the cockpit voice recorder (or CVR) have been located. But investigators will need to wait for them both to be downloaded and analyzed before including them in the investigative evidence.
For now, they start with what the burnt and charred wreckage can tell them about the crash. And it is straight forward: there was no inflight breakup or fire. Flight 821 disintegrated and caught fire only once it impacted the ground. As with so many other stories we have covered, when the wreckage points to this fact pattern, investigators consider a loss of flight control as the cause of the crash. Flight control problems can stem from a variety of causes, including mechanical or maintenance problems with the aircraft itself, or from poor pilot performance. After ruling out weather as a contributor, investigators explore if either a maintenance or mechanical problem may have contributed to the crash, especially since this aircraft had over 45,000 logged flying hours.
Aeroflot Nord’s maintenance records were very badly kept and managed, so investigators had to turn to one of its maintenance vendors to look at records for the aircraft. And one fact about the plane’s performance stands out: the aircraft has a history of asymmetrical thrust. One month before the crash, the right engine was recorded as producing 20% more thrust than the left engine. Listeners may recall that we explored a story that featured an issue with engine asymmetry in Episode 57, TAROM Flight 371. In that story, we explained that when there is a power imbalance in the engines, it makes the plane more vulnerable to flight control problems as this imbalance can make an aircraft yaw (or turn) in one direction, almost like skidding.
And just the day before the crash of Flight 821, another set of pilots who flew this exact aircraft were concerned about how far they had to stagger the thrust levers to control the imbalance. They even took pictures of the levers in their extreme far back position as proof. But investigators know from a technical perspective, this issue certainly made it more difficult to fly the plane, but it should not cause it to crash. And we saw that, too in Episode 57. This is because the auto throttle system should have helped correct the imbalance in most phases of the flight.
And, of course, pilots would have been aware of the thrust imbalance as laid out in the maintenance logs they’d need to sign off on before every flight. In fact, Captain Medvedev signed off on this very fact the day of the crash. Now that investigators know the pilots understood and were aware of the thrust imbalance, the question becomes, were they skilled enough to be able to fly a plane with this kind of problem?
Aeroflot Flight 821 Investigation Focuses on Pilot Performance
Because there likely was a loss of control, investigators interview air traffic control to see if they observed anything odd from their perspectives. The controller who was handling the flight shared with investigators the odd events he remembered from the morning of the crash based on what he saw on his radar screen. Flight 821 had started to climb when ATC had instructed it to descend. Because of this error, the plane had missed its approach path, so ATC instructed the crew to go back around and to turn right. But the crew wanted to keep the previous approach, even though they had passed the approach point. ATC had to give the crew instructions to descend and turn right three different times, which made the controller feel like something was not right with the flight crew. This is what prompted him to check in and ask if everything was OK. And the flight crew reassured him that everything was indeed fine and that they were beginning their descent. But the controller told investigators that the flight crew seemed very confused at what they were supposed to be doing and it unsettled him.
It is because of this account that investigators very quickly focus on the performance of the pilots. Some of the very first information they investigate is the training records of both Captain Medvedev and First Officer Allaberdin. As we mentioned, according to Aeroflot-Nord representatives, the crew was described as very experienced and some of the best in the company. But their training and performance records do not convey that in the slightest.
Aeroflot 821 Pilot, Co-Pilot Received Inconsistent Training
Both pilots attended flight school in the state of Denver in the United States, but as of 2006, when they took the training, the training center in question was neither approved nor accepted by the Russian aviation authorities, which is a violation of aviation regulation. This is despite the fact that Aeroflot Nord had an agreement with the center to train their pilots.
Additionally, the training center was supposed to document all the training conducted using the approved documentation forms, accepted by Russian Aviation Authorities. All the documentation was supposed to be either sent to the airline by express mail within three working days after the end of the transition course or given to the students (on the airline’s agreement). However, the Captain’s file, apart from the course certificate, contained only two more related documents. It was not possible to reveal the cause of the lack of documents in the Captain’s file.
And the depth of Captain Medvedev’s training is questioned. While the Captain had almost 1,200 hours in the 737, Captain Medvedev's flight record as a 737 captain was just 477 hours. He received his 737 training certification in September 2006 but when he returned to the airline, he went right back to flying the Tupolev. He did not fly a 737 again until January 2007, 4 months after his initial 737 training. According to the accident report, pilots who had a break in flights for more than 90 days after the training must receive additional training. The Captain never took the training.
First Officer Allaberdin’s record was no better. While he had almost 9,000 total flight hours, most of those had been in the Antonov An-2, which is a single engine plane that is mostly used for agricultural purposes. This plane is more like a Cessna than a 737. He had just 236 hours on the 737. And his training records reveal that he had trouble managing thrust asymmetry, the exact issue that came up in the cockpit on Flight 821. This evidence proves that First Officer Allaberdin was not ready to be a co-pilot on a 737. And, if he would have needed a more experienced and qualified Captain than Medvedev.
Aeroflot 821 Pilot, Co-Pilot Had Little Experience Flying a 737
When investigators analyzed the quality of experience held by both the Captain and First Officer, investigators make a disturbing discovery. Most of the Captain’s total flight experience was spent flying a Tupolev 2134, which is vastly different from the Boeing 737. For starters, the Tupolev required twice as many flight crew to fly it – instead of 2 pilots, there were 4. In the 737, of course, there are 2 pilots who must fly the plane and also take on navigational and flight engineer duties. In essence, even though the Boeing aircraft was more automated, it required a higher skilled pilot to fly it.
Another major difference between the two planes that mattered to the investigation was the placement of the engines. As was explained in the Air Disasters episode, on the Tupolev, the engines are in the back, so if an issue of thrust asymmetry exists, it is less of a problem because the thrust is coming from the back. When thrust increases, the plane would move straight ahead. In a 737, with the engines under the wing, when thrust increases, it also pitches the nose up and pulls the wing up which could cause the plane to roll to one side. The bottom line is, pilots must make more adjustments to maintain the balance in a 737 than in a Tupolev when there is engine asymmetry.
Additionally, one of the big questions that come up for investigators as they consider the Captain’s training is, given that English was not the Captain’s first language, did he truly understand all the training that he received? Think about it: technical manuals and SOPs are all in English. It should be noted that the Captain was rather fluent in using the standard phraseology, which assumes that he at least had met the requirements. However, his previous flights did not contain any abnormal situations, so it was not clear if the Captain was able to use General or Aviation English beyond the standard phraseology. According to the available documentation, the Captain regularly took refresher courses in phraseology. However, the accident report mentioned that unless you were deeply fluent, the pace of the training they received in Colorado would have not been conducive to full comprehension. We also saw language come into play in the case of TAROM 371 – an issue related to the level of fluency of the pilots and how that could impact their ability to communicate in an emergency.
According to news reports in 2008, Gennady Kurzenkov, who was then head of the State Aviation Inspection Service in Russia, said the pilots had also submitted false documents to the airline showing that they had passed preflight courses. He also said the flight attendants on the plane also had false documents saying they were qualified to fly on international flights. I could not find this detailed anywhere in the final accident report.
Was Aeroflot Flight 821 Pilot Impaired Before Crash?
And when looking into the pilots, things seem to get worse. According to the accident report, the investigative team got access to a text message sent from the aircraft by one of the Flight 821 passengers to her friend in United Kingdom. The message was sent before the engine startup and said that the sender was very scared, because when the Captain addressed the passengers, his voice sounded “like he is totally drunk”. According to the message, the passengers were worried, but the flight attendants said everything was all right.
Now everything suddenly changes for the investigation. The question is, does this mean that one or more of the pilots were impaired? Investigators now finally have access to the data from both the FDR and the CVR. And when they line up the data from both recorders, a terrifying picture comes into focus.
Pilot Error Cause of Aeroflot Flight 821 Crash
Everything is normal for the first hour-and-a-half of the flight. It is when there is about 30 minutes left that things begin to unravel, starting with the landing approach. ATC has asked Flight 821 to descend to 6,800 feet, and as they descend, the right engine is running at 60% power while the left one is running at 40% power. This is an extensive power gap, so the auto throttle system shuts off since the imbalance is too great for the system to handle. Now, the First Officer needs to manage the engine asymmetry manually. And as we just explored, this requires a set of skills that he did not possess.
Next, the First Officer inadvertently disengages the autopilot. As he began the final right turn toward the runway, he turns the yoke right, pushes it forward, and engages the stabilizer trim. An investigator in the Air Disasters episode said these inputs had the same effect as slamming on the brakes when you are driving a car in cruise control. These actions tell the autopilot that the pilot wants to fly manually. But there is no reason to do this, and so investigators believe that the First Officer was unaware that he disengaged the autopilot.
And now with no auto throttle and no autopilot, the uneven engines are causing the plane to bank left and climb rather than descending and turning right. And then for a breathtaking 25 seconds, there are no inputs made by either pilot. Most likely this is because neither pilot is aware that the autopilot has disengaged. And they would not notice something like this if they were not scanning their instrument panels and watching indicators like airspeed, subtle turns, or altitude changes.
We saw a very similar situation unfold in the cockpit of Kenya Airways Flight 507, which we covered in our third Patreon-exclusive episode. In that case, the autopilot had never been engaged and neither pilot was aware of this fact, which led to the plane rolling all the way to one side.
And the dynamic between the Captain and First Officer are not helping things. Right as they prepare for their descent, the First Officer, as the pilot flying, calls out for the Captain to retract the flaps, but the Captain does not respond, The First Officer has to ask twice. And then the Captain tells him to do it by himself. Obviously, this is not an action that should be taken by the non-flying pilot. Again, this is similar to the intimidating atmosphere inside the cockpit of Kenya Airways Flight 507.
After the auto throttle is disengaged, the First Officer notices the left bank, but then makes those inputs that lead to the autopilot being disengaged. This causes the plane to climb and continue banking left instead of descending and turning right. But the First Officer notices the continued bank to the left. But he does not know WHY it is happening – and what happens next is the most shocking part of this story to me. First Officer Allaberdin shouts to Captain Medvedez to “take it! Take it!” He wants the Captain to take the controls and help resolve the banking.
But the Captain shouts back, “What do you mean fucking take it?” and then he says, “I can’t do it either.” The Captain begins to turn the control column hard and to the left, putting them in an even steeper left bank. The First Officer, seeing the Captain turning the plane in the wrong direction, shouts, “Other way!” Now the plane is almost in a full barrel roll plunging toward the earth. There is no getting out of this dive – there is not enough space left. The flight is doomed.
When the Captain’s muscle tissue is tested for alcohol, it is discovered that he was in fact impaired. And in this impaired state, with most of his training being on Tupolevs, investigators believe that the Captain got confused about which way the plane was rolling. Investigators think this was due to the Captain reverting back to his old training, which was on eastern planes – and on those planes, the attitude director indicator (or ADI) works in exact opposition to that of western aircraft. In the eastern planes, the airplane symbol moves to indicate which way the plane is rolling while the horizon stays fixed. But in the 737, the airplane symbol is fixed while the horizon moves to the left or right. These two factors would explain why when Captain finally takes control, he banks hard to the left. Again, we explored this very issue in the TAROM 371 story. And we also mentioned there had been a pattern of crashes involving Russian pilots becoming confused about direction, this one being a part of that legacy of crashes.
IAC Issues Probable Cause of Aeroflot 821 Crash
The final report cited the following contributors to the crash of Flight 821:
- Spatial disorientation on the part of the crew, and especially the Captain, which occurred in the dark, while flying in the clouds, with autopilot and auto throttle switched off.
- Poor Crew Resource Management and insufficient training for using the Western type of ADI.
- Inadequate practices by Aeroflot-Nord in managing and operating the Boeing 737 aircraft. Specifically, not addressing the throttle problem. The pilots had a higher workload because they had to operate the throttle levers for the left and right engines independently.
- The Captain was impaired and also did not have adequate rest before the flight.
Following the accident, the IAC recommended an overhaul of the Russian aviation system, with great change emphasis on pilot training and the implementation of safety and compliance regulations. Three years after the deadly crash, Aeroflot Nord was sold out from Aeroflot.
Russian Aviation Industry Struggles With Safety Issues Today
According to the International Air Transport Association (IATA), Russia and the other former Soviet republics have some the world's worst air traffic safety records. According to a 2018 IATA report, it placed the former Soviet Union dead last in a regional ranking of aircraft lost to crashes and other disasters. In 2018, it said the former Soviet region rated 1.19 hull losses per million flights. The next closest competitor was the Latin America/Caribbean region with .76 losses, and then the Asia Pacific with .32 losses.
Experts have historically blamed weak government controls, poor pilot training, and a cost-cutting mentality among many carriers that affects safety.
Aeroflot Nord had grown almost too quickly for its operations, and it found itself in need of spare airplane parts and qualified engineers and mechanics. Many of the issues that the investigators raised as part of the crash of Flight 821 is reflected in what is considered ongoing problems today with the Russian aviation system at large.
As cited in an article by the Associated Press, a 2018 report by the IAC, the same group that conducted the Flight 821 investigation, found that 42 of the region’s 58 aviation accidents in 2018 took place in Russia and led to the deaths of 128 people.
But at least once a year, Russian travelers are reminded of this grim reality.
Mikhail Barabanov, an analyst at the Center for the Analysis of Strategies and Technologies, a Moscow think tank, said in a Facebook post, “In Russia, there is reliably one big crash with corpses per year.”
Another challenge for Russia is a lack of qualified pilots, according to Gennady Nikolayev, an expert at the Academy of Finance and Investment Management, who says, “Experienced professionals often choose to work for foreign companies and it’s not only because of low salaries even in Russia’s largest airline Aeroflot, but because of the extremely difficult working conditions when pilots have to fly more than once a day. The majority of recent accidents could have been avoided if there was an experienced pilot in control.”
What’s horrifying is that the IAC estimates that 75 percent of fatal accidents in post-Soviet countries occur due to human error. The situation is even worse for small airline companies that don’t have enough funds to properly train their pilots.
As of this recording, the most recent plane crash involving a Russian aircraft was on May 5, 2019, when Aeroflot 1492 crashed and partially caught fire after a hard landing, killing 41 of the 78 people onboard. The preliminary report released also in 2019 pointed toward pilot error as a contributor.
And THAT is the story of Aeroflot Nord Flight 821.
Show Notes:In this episode, Shelly and Stephanie talk about a fun meme they want listeners to respond to: You can only visit a place that starts with the same letter as your first name. Where are you going?
Credits:Written and produced by: Shelly Price and Stephanie Hubka
Directed and engineered at: Snow Monster Studios
Sound editor: Stephanie Hubka
Producer: Adam Hubka
Music by: Mike Dunn