Aeroflot Flight 11

Aeroflot Flight 11

Ilyushin Il-12 of Aeroflot
Accident
Date	1 October 1957 (1957-10-01)
Summary	ATC and crew errors, CFIT
Site	3 km SE of Aksha, Akshinsky District, Chita Oblast (RSFSR, USSR)
Aircraft
Aircraft type	Ilyushin Il-12P
Operator	Aeroflot (East Siberian Directorate of Civil Aviation, 134th Transport Squadron)
Registration	СССР-Л1389
Flight origin	Vnukovo Airport, Moscow
1st stopover	Irkutsk Airport, Irkutsk
Last stopover	Kadala Airport, Chita
Destination	Khabarovsk Novy Airport, Khabarovsk
Occupants	28
Passengers	23
Crew	5
Fatalities	27
Injuries	1
Survivors	1

Aeroflot Flight 11 was an aviation accident involving an Ilyushin Il-12 aircraft operated by Aeroflot, which occurred on Tuesday, October 1 (September 30 MSK) 1957 near the village of Aksha, Zabaykalsky Krai, Russia. The crash resulted in the deaths of 27 people.

Aircraft

The Il-12 (also designated as Il-12P) with factory number 30123 and serial number 123 was manufactured by the "Banner of Labor" plant (Moscow) on October 21, 1947. The airliner was assigned the registration number СССР-Л1389 and was initially delivered to the Main Directorate of Civil Aviation, which subsequently transferred it to the Vnukovo aviation squadron MUTA. In 1955, the aircraft Л1389 was reassigned to the 1st Irkutsk (134th) air transport squadron of the East Siberian Directorate of Civil Aviation. The aircraft had accumulated a total of 9,996 flight hours.

Crew

• Captain – Novikov Leonid Fedorovich
• Co-pilot – Shanin Valentin Vasilyevich
• Flight engineer – Ivanisov Fedor Prokofyevich
• Radio operator – Lipatnikov Alexander Stepanovich
• Flight attendant – Tvorogova Galina Grigoryevna

Accident

On September 30, the airliner operated passenger flight 11 from Moscow to Khabarovsk. A crew change occurred during an intermediate stop in Irkutsk. At 15:10, the Il-12 took off from Irkutsk and headed towards the next intermediate stop on the route — Chita, with an expected landing time of 17:00. On board were 5 crew members and 23 passengers: 21 adults and 2 children. According to the weather forecast, the flight route was expected to have 6-9 oktas of stratocumulus and cumulonimbus clouds at an altitude of 1,000 meters, rain, mountains covered with clouds, icing in clouds, and a north-northwest wind averaging (340° 17 m/s). In fact, the weather in Chita at that time was overcast and calm with visibility up to 10 kilometers.

After flight 11 left the Irkutsk airspace, it gradually began to deviate southward from the route. The Irkutsk air traffic control center was staffed by Butenko, who, 21 minutes after the aircraft's departure (15:31), observed on the radar that the airliner had deviated 17 kilometers southward, but did not require the crew to return to the flight path. The flight operations manager at Irkutsk Airport, Kartavov, did not monitor flight 11 and therefore was unaware that it was deviating southward. When the aircraft was crossing the airspace of Ulan-Ude Airport, the airport's controller (Malkovsky) did not activate the surveillance radar to monitor the aircraft, and after receiving a true bearing of 92°, he did not plot it on the map, therefore not tracking the aircraft's movement. By the time the Il-12 passed Ulan-Ude, it was already 30 kilometers south of the route. The crew was aware that the airliner was deviating further south but took no action to return to the route. Even when a bearing was received at 16:28 from the radio direction finder at Chita Airport, which, despite inaccuracies, also indicated that flight 11 was south of the route, the crew did not use this information. As later established, they did not plot a single bearing on the map.

As the aircraft exited the Irkutsk regional center's airspace and entered the Chita center's airspace, it was already 40-50 kilometers south of the route. At such a distance, the crew could not tune the radio compass to the non-directional beacons of Beklemishevo and Chita, nor could they receive bearings. Unable to establish communication via the command radio, the crew decided to descend to 2,400 meters. They then spotted a road, which they assumed was the Romanovka—Chita road, located north of Chita, and proceeded south along it, intending to reach Chita. In reality, this was the Darsun—Aksha road, which was actually leading them further south away from Chita. Flight operations manager Makarov and air traffic controller Baranov received several clear bearings from flight 11 between 17:25 and 17:33 but did not monitor its flight. Even when the pilots reported that they could not locate the non-directional beacons, could not obtain bearings, and were essentially lost, the air traffic controllers did not offer assistance. The crew had previously received clear bearings indicating that the airliner was veering south, but they did not use this information. Instead, the crew attempted to navigate visually but twice descended over unidentified mountainous terrain.

Meanwhile, the aircraft's fuel reserves were running low. Disoriented over the terrain, at 18:30 the crew reported to the Chita air traffic control center that they would make an emergency landing near a settlement they had spotted. This settlement was the village of Aksha. The crew made three approaches to the chosen landing site, but during the fourth approach, at an altitude of 900 meters (200-250 meters above the selected site), the Il-12 crashed into a forested hill with an elevation of 1,000 meters. The airliner struck trees, resulting in the loss of the left wing. The aircraft then plowed through trees for 340 meters, disintegrating as it went, before coming to rest on the opposite slope of the hill at an altitude of 850 meters. The crash occurred at 18:55 MSK (00:55 on October 1 local time), 3 kilometers southeast of Aksha and 190 kilometers south of Chita. Rescue teams arrived at the crash site and found one severely injured passenger. The remaining 27 people (22 passengers and all 5 crew members) were killed.

Causes

The commission investigating the incident concluded that the crash occurred due to a series of errors and violations. The crew was found to be partly at fault, having lost orientation and subsequently taking incorrect actions in an attempt to recover it. Additionally, air traffic controllers in the Irkutsk and Chita control centers failed to monitor the aircraft's flight and did not attempt to return it to the route. Moreover, the Chita controller (Baranov) did not attempt to determine the aircraft's location during the 2 hours and 15 minutes it was in his airspace, nor did he issue any commands to the crew. Furthermore, when the crash occurred, Baranov attempted to falsely record in the logbook that he had given the command "take course 3°," which had not actually been transmitted. The flight operations managers did not supervise the controllers' work, and when it became known that the crew of Flight 11 had lost orientation, they did not use the available bearings to return it to the route. Finally, the Ulan-Ude airport controller violated instructions by not activating the surveillance radar and not monitoring the flight. The commission also noted poor internal management within the 134th aviation squadron, where leadership failed to adequately supervise crew operations.