9605
2011-JUN-20 · Besovets, near Petrozavodsk, Russia

RusAir — Flight 9605

RusAir Flight 9605 crashed during a night approach in heavy fog after the crew descended below the minimum safe altitude without visual contact with the runway. The investigation revealed a severe breakdown in crew resource management, exacerbated by the navigator's alcohol intoxication. The crew relied on an unapproved GPS unit for the approach while ignoring standard radio navigation aids, leading to a significant lateral deviation. The aircraft struck trees and impacted a highway approximately 570 meters short of the runway threshold.

Aircraft
Tupolev Tu-134A-3
Registration
RA-65691
Phase
Approach
Cause
Pilot Error
Souls on Board
52
Fatalities
47
Origin → Dest
Moscow-Domodedovo Airport (DME) → Petrozavodsk Airport (PES)
Report
Final

Investigation Summary

The flight was a last-minute charter substituted for a RusLine CRJ-200. Despite the challenging weather conditions at Petrozavodsk, which lacked an Instrument Landing System (ILS), the crew attempted a non-precision NDB approach. The navigator, who was the most experienced member of the crew but was found to have a blood alcohol level of 0.08%, took a dominant role in the cockpit. He used a handheld KLN-90B GPS unit to navigate, a practice prohibited by the Tu-134 flight manual for final approach. This led to a false sense of security and a failure to cross-check positions using the Automatic Direction Finder (ADF). As the aircraft descended into thick fog, the crew ignored the Minimum Descent Altitude (MDA) and continued searching for the runway lights until the aircraft clipped trees. The airport's weather reporting was also found to be deficient; the cloud-base measuring devices (DVO-3) were 20-year-old units belonging to the Russian Ministry of Defense. These military-owned devices were not documented in civil aviation logs, and their readings were not standardized, contributing to the discrepancy between reported and actual weather conditions.

Final Conclusions

The primary cause was the crew's decision to continue the approach below weather minimums and descend below the minimum safe altitude without visual contact. Contributing factors included the navigator's alcohol intoxication, which impaired his judgment and led to his dominance over the Captain; poor CRM that excluded the First Officer from the decision-making loop; the use of unauthorized satellite navigation equipment; and inaccurate weather forecasts provided by the airport.

Photographic Evidence (1)

RusAir Tupolev Tu-134 - Simiar to the aircraft involved
© Yevgeny Pashnin · Wikimedia Commons

Video Analysis

No video analysis linked for this case file yet.

Airframe & Maintenance

Airframe Hours
35,591
Cycles
20,977
Engines
Soloviev D-30-III

Crew Experience

Captain

Total hours
8,501
On type
3,100

Had 1,627 hours as Captain on type.

First Officer

Total hours
2,846
On type
1,099

Navigator-instructor

Total hours
13,699
On type
13,464

Found to be under the influence of alcohol (0.08%).

Flight Engineer

Total hours
11,231
On type
2,494

Systems & Failure Modes

i

KLN-90B GPS

A satellite navigation system used by the crew for the final approach despite a flight manual prohibition against its use for that phase of flight.

i

Automatic Direction Finder (ADF)

The primary navigation instrument for the NDB approach, which the crew failed to monitor effectively.

i

DVO-3

Outdated cloud-base measuring devices at the airport that provided inaccurate data to the meteorological office.

Interesting Facts

  • 01The navigator had a blood alcohol concentration of 0.081%, which is above the legal limit for operating a vehicle.
  • 02The aircraft was 390 meters to the right of the extended runway centerline at the time of the first impact.
  • 03Petrozavodsk Airport lacked an Instrument Landing System (ILS) and used outdated 'shield boards' for visibility measurements.
  • 04The Captain had previously resigned from UTair Express following a hard landing accident involving a Tu-134 at Vnukovo Airport.
  • 05Three of the initial eight survivors died in the days following the crash due to severe burns and injuries.
  • 06Flight attendant Yulia Skortsova was the only member of the nine-person crew to survive the accident.

Safety Actions & Advisories

Tu-134 Retirement

Following the accident, Russian President Dmitry Medvedev proposed the accelerated retirement of the Tupolev Tu-134 from scheduled commercial service.

Meteorological Infrastructure Upgrade

The investigation prompted calls for the modernization of weather observation equipment at regional Russian airports to ensure accurate reporting of cloud bases and visibility.

Criminal Prosecution

Russian authorities filed criminal charges against two Petrozavodsk airport officials and a federal air transport official for negligence and safety violations related to the airport's meteorological services and landing equipment.

Location

Besovets, near Petrozavodsk, Russia · 61.8694, 34.1481

Case File History

  1. New evidenceUpdated findings, event timeline and safety actions.
  2. New evidenceUpdated event timeline, findings and investigation summary.

Related Cases

Case ID · rusair-9605-2011Last updated · Filed

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