Investigation Summary
The accident was characterized by a systemic failure of both flight crew discipline and air traffic control (ATC) oversight. On the night of the crash, the Instrument Landing System (ILS) at Zhuliany Airport was out of service for maintenance, forcing crews to use a non-directional beacon (NDB) and landing radar. However, the landing controller failed to provide radar guidance or glide path information to Flight 36. Radio frequency congestion further hampered safety, as three aircraft were communicating on the same frequency, causing the crew's requests for distance-to-runway to be 'stepped on' and lost. Despite a 'danger height' alarm sounding at 30 to 35 meters, the crew's late attempt to pull up was insufficient to overcome their high vertical velocity.
Final Conclusions
The investigation concluded that the primary causes were the crew's decision to descend below the decision height (100 meters) without visual contact with the runway and the failure of the aero-meteorological station to report that visibility had dropped below the 700-meter minimum for the An-24. ATC negligence played a significant role, as controllers failed to monitor the aircraft's position on the glide path and did not provide essential distance information. The destruction of the aircraft by fire prevented investigators from determining why the 60-meter altitude warning failed to trigger earlier.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
TESLA Radiolocation System
A landing radar system intended to provide controllers with the aircraft's position relative to the glide path.
Non-Directional Beacon (NDB)
The primary navigational aid used for the approach due to the ILS being out of service.
Danger Height Alarm
An automated audio-visual warning system designed to trigger at 60 meters; it failed to trigger until 30-35 meters.
Interesting Facts
- 01The aircraft was 13 years old and had accumulated 27,244 flying hours.
- 02The airport's Instrument Landing System (ILS) was out of service for maintenance at the time of the accident.
- 03The aero-meteorological station failed to detect or report that horizontal visibility had fallen below the legal minimum.
- 04The aircraft struck a concrete fence 1,265 meters from the runway end before coming to rest on a railroad embankment.
- 05There were only 7 survivors, including one flight attendant and six passengers.
Safety Actions & Advisories
Weather Monitoring Enforcement
The investigation highlighted the critical need for continuous weather monitoring and immediate reporting of visibility changes to ATC, especially when conditions approach aircraft minimums.