Under the Influence: The crash of RusAir flight 9605
On the 20th of June 2011, a Russian airliner on approach to the northwestern city of Petrozavodsk crashed short of the runway, striking trees before sliding down a suburban road, consumed in flames. The fiery accident killed 47 of the 52 passengers and crew and called into question the safety of the aging Tupolev Tu-134. But even as Russian authorities called for the planes to be removed from service, the facts started to point toward a more complex cause for the crash. The sequence of events began with a breakdown in communications between the four cockpit crewmembers as the navigator took command of the situation and bent the others to his will. There was just one problem: the navigator was drunk. With a blood alcohol level too high to legally drive and relying on an unapproved navigation technique, he committed a series of preventable errors which ultimately steered RusAir flight 9605 straight into the ground.
In 2011 Russian regional carrier RusLine operated a regularly scheduled flight from Moscow’s Domodedovo International Airport to the city of Petrozavodsk, capital of the semi-autonomous Republic of Karelia near the border with Finland. For this route it typically used a Canadian-made 50-passenger Bombardier CRJ-200. But on the 20th of June, one of its CRJs had to be taken out of service for “technical reasons,” causing the cancellation of several flights. One of these was flight 243 to Petrozavodsk. With 43 passengers booked on the flight and no plane to get them there, RusLine decided to charter an aircraft on short notice later that same day. RusLine quickly hashed out a contract with the charter carrier RusAir, which agreed to provide a flight crew and a 72-passenger Tupolev Tu-134 in place of the CRJ. Designed in the USSR in the 1960s, by 2011 the Tu-134 was practically a dinosaur, but with only a few hours’ notice it was the best airplane that RusLine was going to get.
In command of the special charter flight, designated RusAir flight 9605, were no less than four pilots: Captain Alexander Fyodorov, First Officer Sergei Karyakin, Navigator Amanberdy Atayev, and Flight Engineer Viktor Timoshenko. Also on board were three flight attendants and two mechanics riding in the passenger cabin, totaling nine crewmembers. Fyodorov and Timoshenko had both been flying the Tu-134 for some time, but neither could hold a candle to Atayev, who had 25 years of experience and more than 13,000 hours on the aircraft type, considerably more than everyone else put together. All four pilots were coming off two days’ rest period, and the Navigator Atayev had apparently been using this break to engage in a popular Russian pastime — that is, drinking. By the time he boarded flight 9605 to Petrozavodsk, he had a blood alcohol level of 0.081%, too high to drive and definitely too high to navigate an airplane.
Prior to leaving Domodedovo, the pilots stopped at the airport’s meteorological office to receive the latest weather forecast for Petrozavodsk. The weather forecast, issued at 9:00 p.m., showed a projected cloud base at 590 feet with visibility of three kilometers in light rain — marginal, but within the landing limits, which required a visibility of at least 2.1 kilometers and a cloud base no lower than 360 feet. The forecast indicated that no change was expected, but this turned out to be wrong. By 10:00, conditions had begun to worsen markedly, and the forecast was revised to project a cloud base at 295 feet — too low to legally land. But by the time this forecast was issued, the pilots had already left the meteorological office. If they wanted to see the forecast they would have needed to request it via radio, which they never did. Had he known that conditions were likely going to be below the landing minimums, Captain Fyodorov probably would not have decided to leave Moscow in the first place.
At 10:30 p.m., flight 9605 took off from Domodedovo Airport and proceeded northward to Karelia. The 43 passengers were relieved to finally be on their way, but the pilots knew that landing in Petrozavodsk wouldn’t be simple. The airport’s equipment was severely outdated and neither runway had an instrument landing system, forcing them to land using a non-precision NDB approach instead. In an NDB approach, the pilots must use their automatic direction finders (ADFs) to track two non-directional radio beacons (NDBs) located along the extended centerline of the runway. When the ADFs show that both NDBs are directly ahead, that means the plane is aligned with the runway. NDB approaches are more difficult than other approach types, are disliked by pilots, and have been out of favor at major airports all over the world for decades. Nevertheless, the pilots had been trained to perform such an approach, and they had done so at similar airports in the past.
At 11:30, as flight 9605 descended toward Petrozavdosk, the airport’s meteorologists observed the cloud base at 560 feet with horizontal visibility of 2.1 kilometers, still within limits. The air traffic controller immediately passed this on to the crew, who acknowledged the transmission. But what the pilots didn’t know was that Petrozavodsk Airport had only rudimentary weather observation equipment and this reading was little more than an educated guess made by an observer at the opposite end of the airport from where they would be landing. In reality, a bend in the river and the presence of a forest had created a localized area of higher humidity, leading to the formation of dense fog directly atop the final approach path. The cloud base here was 100 feet or less with visibility of 500 to 700 meters, well below the minimums for landing. But nobody recorded this information or transmitted it to the crew.
At this point, flight 9605 was moments away from making the final turn to line up with the runway. Captain Fyodorov was flying the plane in manual mode; Flight Engineer Timoshenko was monitoring aircraft systems; First Officer Karyakin handled the radio; and the Navigator Atayev was keeping track of their horizontal situation, telling Fyodorov where to turn. Even though he was drunk, Atayev had gotten them this far without anyone noticing, but on this final turn he began to make mistakes. When telling Fyodorov where to turn, he forgot to account for a tailwind increasing their ground speed. As a result, they started the turn too late and overshot the runway axis to the west by four kilometers. “I’ll definitely bring you out here,” Atayev said, assuring Fyodorov that he was aware of the overshoot and would give them a heading to get back on track, which he did. By flying on a heading of 30 degrees, they would soon return to the runway heading of 12 degrees.
Although this was an NDB approach, Atayev was not using the automatic direction finders to navigate. Instead, he was using a KLN-90B Global Positioning System, which was not approved for use during approach to an airport. A satellite navigation system like GPS relies on the use of a “geodetic standard” — a set of mathematical constants which define the parameters used to accurately calculate a position on a global coordinate grid. Several such standards exist, foremost among them the 1984 World Geodetic System, or WGS 84, which is the default standard used by the Global Positioning System. However, not all areas of the world have been surveyed according to this standard. Among the places which had not been surveyed under WGS 84 was Petrozavodsk Airport. In Russia, coordinates of airports, radio beacons, and other aviation-related places and objects are provided by the Center for Aeronautical Information, which uses modern geodetic standards like WGS 84 whenever possible, but otherwise defaults back to the Geodetic Survey of 1942 in areas where modern surveys have not been conducted. This survey, known as GS-42, was nowhere near as accurate as modern standards and could not be used for precise navigation; in fact, it showed Petrozavodsk Airport 130 meters east and 70 meters north of its actual location. However, the Center for Aeronautical Information did not publish which survey its coordinate data came from, and when Atayev looked up the coordinates for Petrozavodsk Airport before the flight, he had no idea that they came from the Geodetic Survey of 1942. This was precisely why flying an approach using only the GPS was not allowed, but pilots at RusAir had apparently become too trusting of its accuracy and were using it anyway because it was easier than trying to track a pair of non-directional beacons.
At 11:37 p.m., at a distance of 18 kilometers from the runway, flight 9605 returned to the runway axis. However, a wind out of the east meant that to maintain a heading of 12 degrees in line with the runway, they needed to point the aircraft to a slightly more easterly heading of 15 degrees. “Drifting three degrees to the left… yeah, it would be until it shows 15,” Atayev said, rambling slightly. Fyodorov turned the plane to a heading of 15 degrees to keep on the runway axis.
Now Atayev seemed to doubt himself. “What is the landing course — 12 or 15 degrees?” he asked, even though his statements just seconds earlier indicated that he knew this information.
“12 degrees, according to the NOTAM,” Fyodorov replied. He then turned to Flight Engineer Timoshenko and asked him to extend the flaps to 20 degrees. The increase in lift from the flaps needed to be countered by a gentle nose down input, but Fyodorov didn’t immediately react, causing them to gain about 160 feet of altitude.
Shortly thereafter, flight 9605 passed over the first NDB at an altitude of 1,440 feet instead of 1,260 as depicted on their approach charts. Noting the discrepancy, Atayev told Fyodorov to increase their rate of descent from 4 m/s (790 feet per minute) to 6 m/s (1,180 feet per minute) in order to get back onto the proper descent path.
Now Atayev noticed that they were still slightly to the left of the runway axis, so he told Fyodorov to increase their heading correction from three degrees to five degrees. However, the wind soon began to die down, rendering this correction excessive. Consequently, the plane began to drift slightly to the right of the runway axis, but because his GPS showed the airport 130 meters to the right of its actual location, Atayev didn’t notice; at 11:39 he announced that they were “on course,” even though they were not. None of the pilots looked at their automatic direction finders, which showed them trending right of the runway axis.
Less than a minute later, still descending at 1,180 feet per minute, flight 9605 descended through the proper descent path at a distance of three kilometers from the runway. Their altitude at this point was 490 feet, right about where they expected to break through the clouds, and Fyodorov had fixed his whole attention outside the plane in an attempt to spot the runway. None of the pilots knew that the actual base of the clouds was at just 100 feet above the ground.
According to proper procedures, the navigator needed to call out “assessment” (the Russian equivalent of “approaching minimums”) at a height of 460 feet. This would prompt the captain to search for the runway until reaching 360 feet, the minimum altitude or “decision height,” where he would announce whether they were to continue the approach or go around. But Atayev never called out “assessment,” and the plane continued to descend below the approach path while drifting to the right. Neither pilot was expecting to have to make this decision until after breaking out of the cloud base.
As the pilots searched through the eerie gray fog for some sign of the runway, Flight Engineer Timoshenko saw that they had descended to 230 feet (70m) and began calling out their altitude in 10-meter increments, as he was trained to do. Simultaneously with Timoshenko’s callout of “Sixty meters,” Captain Fyodorov’s radio altimeter emitted a chime warning that they were descending through their pre-set “dangerous altitude,” but no one reacted.
“I still don’t see it. I’m looking,” said Fyodorov.
“Half a kilometer,” Atayev announced.
“Forty meters,” said Timoshenko.
Two seconds later, still enveloped in cloud, the Tu-134 began to strike trees. The impact caught everyone completely by surprise. First Officer Karyakin just had time to shout, “Yob tvoyu mat’,” a curse which does not bear translation, as the trees tore off the tip of the right wing and sent the plane rolling inverted. The jet flew on for more than 500 meters before slamming upside down into the intersection of the Suoyarvi-Petrozavodsk highway and the airport perimeter road, where it broke into several pieces and burst into flames. Chunks of the airplane tumbled across the street behind a row of dachas before coming to rest some 830 meters from the runway threshold.
As witnesses rushed to the scene to search for survivors, airport authorities remained unaware that the plane had crashed. The Tu-134 sliced through an electrical line on its way down, knocking out power to the entire airport. The runway lights suddenly went out, and the controller ordered flight 9605 to abandon its approach, but there was no reply from the plane. With radios and radar running on a backup generator, the controller tried for several minutes to find the flight; it was not until 11:45, five minutes after the crash, that he put emergency responders on standby. By this point witnesses had called the emergency number and a city fire engine had already arrived at the scene, but there was no communication line set up between the Petrozavodsk fire department and the airport fire services. In fact, airport authorities didn’t know where to send the firefighters until a neighbor of the deputy airport manager called his personal phone number and reported that a plane had crashed in front of his dacha!
Rescuers from the airport soon joined local firefighters and random civilians on the scene, where a frantic effort was underway to pull survivors from the burning plane. Firefighters managed to drag eight people from the wreckage before a large explosion drove them back; after that, no one else was found alive. By the time the fire was extinguished at 12:37 a.m., 44 people were dead, and three of the badly injured passengers died in hospital soon after, bringing the death toll to 47. Among the five survivors were a flight attendant as well as a 14-year-old girl, who lost her mother and younger brother in the crash.
Within hours, investigators from the Interstate Aviation Committee (MAK) arrived on the scene to begin the inquiry into the crash. They noted that the plane had first struck trees 1,260 meters short of the runway and 270 meters east of the runway axis. The plane was both too low and off course — but why? News media speculated that the failure of the runway lighting could have led to the accident, but it was soon established that this was a result of the crash, not the cause of it.
A review of the cockpit voice recording and the flight data recorder readout showed that the flight was essentially normal until the crew began the final turn onto the runway heading about four minutes before the crash. The speed and accuracy with which the navigator determined their position at several points during this turn showed that he must have been using his GPS, because it would have taken much longer to derive this information from ADF readings. Using the GPS to fly an approach was prohibited because the published coordinate data was not always updated to the geodetic standard used by the GPS; in this case, the airport was shown 130 meters east of its actual location. Could this have played a role in the crash?
The answer was yes, but with a caveat. As the crew maneuvered the plane back onto the runway axis, they had to correct their heading to account for the wind, which is always necessary when flying an NDB approach. But when the wind decreased in velocity, they failed to reduce their heading correction, causing them to deviate to the right of the runway axis, which nobody noticed. The only obvious explanation for this failure was that the navigator thought they were still on course due to the rightward offset of the airport on his GPS.
However, this wasn’t a case where the crash would have been avoided if just one link in the chain were broken. Even if they hadn’t deviated to the right, they still would have crashed because they were too low; and if they hadn’t flown too low, they would have crashed because they were too far to the right. They were off course in two separate parameters, each of which could have been deadly all on its own. As for the reason that they were too low, the MAK found that the navigator had called for a steeper descent rate after passing slightly too high over the first NDB, but that no one reduced this rate again after they intercepted the correct descent path.
Both of these errors were significant, but neither would have led to the crash had the pilots performed a go-around at any point after they reached their decision height. FDR data showed that Captain Fyodorov attempted a go-around after the plane started hitting trees, but by then the plane was too badly damaged to gain altitude. That’s when the MAK noticed an important discrepancy: the official weather observations taken 10 minutes before and 10 minutes after the crash showed a cloud ceiling of 560 feet, but at a height of just 200 feet during the descent, Fyodorov said he couldn’t see the runway, and at 100 feet the crew were unable to see the trees with which they were about to collide. Based on these facts and witness statements describing dense fog in the area of the crash, the MAK determined that the real cloud base in the area where the accident occurred was no higher than 100 feet, and possibly even lower. The meteorologists at the airport failed to detect this because, in violation of regulations, there was no observation point under the final approach path. The dense fog that led to the accident didn’t pass over the designated observation point until around 1:00 in the morning, even though it had been present just south of the airfield for several hours. This major weather reporting error was made possible by a meteorological observation system at Petrozavodsk Airport which fell short of regulatory requirements in almost every conceivable way, from the number of observation points to the lack of equipment to the fact that the weather office had gone without a manager for years. A surprise inspection of the airport also turned up numerous regulatory violations that were not connected to the crash, from an incomplete perimeter fence to runways that were too narrow to airport buildings left in a state of disrepair. It was clear that Petrozavodsk Airport would need a major overhaul to bring it into compliance.
The erroneous weather reports issued by the airport turned out to be instrumental in the sequence of events. Captain Fyodorov, and probably the other pilots as well, had developed a mental picture of the approach prior to their arrival which included a cloud base somewhere between 430 and 560 feet above the ground. Because Fyodorov fully expected to see the runway before reaching the decision height of 360 feet, he was not mentally prepared to react when they descended past this altitude while still in cloud. His association of the decision height with the cloud base caused a dangerous sort of mental “ordering” where the decision height, by definition, came after the cloud base. He continued to descend without looking at his altimeter or paying attention to the flight engineer’s altitude callouts because he was subconsciously stuck on the “in clouds” phase and could not move on to the “decision height” phase while still in the cloud.
It was the navigator’s job to snap him out of this by calling out “assessment” and “decision height” at the appropriate altitudes. But Atayev didn’t call out “assessment” until just a few seconds before the crash, when they were at 230 feet instead of the required 460. The MAK theorized that, having forgotten the “assessment” callout at 460 feet, the flight engineer’s announcement that they were at “70 meters” (260 feet) reminded him of the “assessment” height on an instrument landing system approach, which actually was 260 feet. So he called out “assessment,” making Fyodorov think they had reached the assessment height of 460 feet and had plenty of time left to search for the runway. The flight engineer’s altitude callouts might as well have been spoken into a void.
The CVR transcript raised some eyebrows at the MAK because of who seemed to be running things in the cockpit. Most of the decisions during the approach were made not by Captain Fyodorov, but by the Navigator Atayev. Atayev told Fyodorov where to turn, where to descend, how fast to descend, how far they were from the runway, and so on; he seemed to be directing the flight like a puppet master with the other pilots as his puppets. Furthermore, the vast majority of the words captured on the CVR could be attributed to Atayev. It was clear that he was in command, not Fyodorov. This unusual authority gradient had probably developed due to Atayev’s vastly superior seniority and experience, which caused the other pilots to trust him unconditionally. Autopsy results revealed why this was so dangerous: on flight 9605, Atayev was drunk. Alcohol intoxication rendered him overconfident, highly talkative, and lacking in his ability to focus, which left him unable to properly monitor flight parameters such as altitude and descent rate. And yet it was clear that the other pilots were relying on him to perform these tasks. Having placed full control of the flight path in the hands of Atayev, who was incapable of safely keeping track of everything at once, they focused almost all their attention on the search for the runway. Now nobody was checking to see if they were too low or whether the ADFs showed them on course or not. After all, they thought, Atayev was doing that — wasn’t he?
This imbalanced cockpit power dynamic resulted in a failure to utilize all the available human resources. The navigator made all the decisions, while the captain followed orders, everyone ignored the flight engineer, and the first officer was so silent and passive he might as well have not been there at all. RusAir flight 9605 is thus a perfect example of poor crew resource management — and a reminder that excessive authority can accrue on any crewmember, not just the captain.
This also was not the first time a Russian airliner had crashed for very similar reasons. In 1996, Vnukovo Airlines flight 2801 crashed into a mountain on approach to Longyearbyen Airport in Svalbard, killing all 141 people on board. The cause of the crash was an error by the navigator, who was using a GPS unit in an unapproved manner. He failed to properly program the GPS for an “offset” approach, where the final approach heading was not the same as the runway heading and a sharp left turn had to be made at the last moment. The result of his error was that the approach path shown on his GPS was merely the extended centerline of the runway, which passed over a high mountain. While flying between the real approach path and the approach path shown in the navigator’s GPS, the captain and the navigator could not agree on whether they needed to fly left or right; ultimately, however, the navigator overruled the captain and the plane crashed into the mountain. Like Rusair flight 9605, this case illustrated the dangers of the improper use of GPS and the risk of letting one crewmember’s opinion rule the day.
In its final report on the crash, the MAK recommended that Russia’s aviation authority Rosaviatsiya install an instrument landing system at Petrozavodsk Airport; that the meteorological observation equipment at Petrozavodsk be modernized as soon as possible; that the Center for Aeronautical Information indicate what geodetic standard each coordinate set belongs to; that all the published coordinates be updated to WGS 84 as soon as possible; that improvements be made in several specific areas of pilot training, including the use of GPS and the conduct of non-precision approaches; that RusAir have enough planes on hand to substitute one of its own aircraft when a flight is cancelled, as is required under Russian law; that Petrozavodsk Airport establish lines of communication between airport firefighters and city firefighters; as well as numerous other suggestions. Although pilots drinking alcohol has long been a problem in Russia, no recommendations were made in this area.
The crash of flight 9605 also highlighted a growing problem in Russia: the fate of the country’s large fleet of aging Soviet-era airliners. Although use of these older models had long been in decline, at the time of the crash most operators still planned to keep the Tupolev Tu-134 in service for many more years. However, there was one big problem with that plan: the entire Tu-134 fleet lacked Ground Proximity Warning Systems (GPWS). A GPWS, had it been installed on flight 9605, would have sounded the alarm long before the plane hit the ground, giving plenty of time for the crew to pull up and avoid the crash.
Just three days after the accident, the Russian government announced an accelerated timeline for the removal of all Tu-134s from passenger service on the grounds that the absence of GPWS technology presented an unacceptable risk. The government wanted all 90 operational Tu-134s in Russia to be retired by 2012, a timeline which ultimately didn’t bear fruit. However, Rosaviatsiya did mandate that every aircraft with more than nine seats be fitted with a ground proximity warning system, becoming one of the last major countries to do so. Many airlines chose to retire their Tu-134s rather than upgrade them, but a few remained in service for several more years. The last passenger flight of the Tupolev Tu-134 was performed by Siberian airline Alrosa on the 21st of May 2019, after which the plane was put in a museum. Flight 9605 was the type’s last fatal crash.
As a result of the MAK’s findings, the head of radar and radio flight systems safety at Rosaviatsiya was charged with negligence for failing to detect the grossly outdated meteorological equipment and procedures at Petrozavodsk Airport. He was supposed to have inspected and certified this equipment, but the inspection never took place. Two officials at Petrozavodsk Airport were also hit with criminal charges. In 2017, all three officials were sentenced to between five and six years’ exile in a “prison colony,” but the court amnestied them all a few days later (a common practice in Russia). Years spent fighting the case in court along with the permanent loss of their jobs seemed like sufficient punishment for an accident in which they were only involved indirectly. By the time the sentence and amnesty were handed down, the situation had changed drastically: the old Soviet airliners were on their way out, the airport had launched an aggressive modernization program, and a monument had been thoughtfully constructed on the site of the crash. The story, it seemed, had already found its way to an acceptable conclusion.
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