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Within one week, in two former Soviet republics, and now sovereign States, one after the other tragedies occurred - on November 17, the crash of the passenger aircraft Boeing 737-500 in Kazan, which claimed the lives of 50 people, including an Ukraine and British citizen, and 4 days later - the collapse of a shopping center in Riga, the victims of which were 54 people, including two citizens of Russia.
How did the state bodies of Russia and Latvia react to the incident?
Alexander Yavkin – BERIEV Deputy Chief Designer, Chief Designer of the be-200ES-E.

Latvian President, Andris Berzins, said that the collapse of a supermarket in Riga, which killed more than 50 people, can not be called an accident. "This is the real murder." Andris Berzins proposed to investigate the state of emergency under the criminal article "murder". According to him, there was a tragedy of national scale in the country, probably the worst since the restoration of independence in 1991. According to preliminary data, the cause of the collapse of the supermarket Maxima was the negligence of the company that built a winter garden on the roof.
Perhaps, in Russia due to the fact that, aviation accidents have long ceased to be a tragedy of national scale, but have become rather a familiar and expected event, the reaction of Russian state bodies and officials to the death of people is much less emotional.
Everything is familiar and repeatable. The Interstate Aviation Committee (IAC) Commission, once started the investigation of flight accidents, usually called a preliminary cause of the accident shortcomings in the work of the crew of the plane B-737 of airline "Tatarstan" in Kazan airport. IAC stressed that the engines of the crashed aircraft were working before the collision with the ground. No equipment failures were recorded.
And it is true, from the point of view of the Commission, what causes of the disaster may be. Either technical failures, or violations of operating crew. The crew is dead, and the engines were working before the collision with the ground.
"The technical Commission continues to work. The flight documentation of the airline and crew training are studied, including involvement of highly professional line pilots with extensive experience in operating this type of aircraft in the leading airlines of Russia. The technical documentation of the airline, including aircraft maintenance manual and continued airworthiness in accordance with international rules, are being studied. The information of ground means of objective control, data of weather conditions and air traffic service are analyzed”.
Yes, it is, the technical Commission is working. Because it's supposed to be. But who can remember the case when the usual preliminary conclusion about the actions of the crew, as the main cause of the disasters that occurred in recent years, was revised by the results of the work of the technical Commission?
The investigation declared, even the work of the technical Commission was not finished yet. "On the fact of the crash, a criminal case was initiated under part 3 of article 263 of the Criminal Code of Russia ("Violation of traffic safety rules and operation of air transport, resulting in the death of two or more persons by negligence").
And the end is very predictable, because what is happening, almost to the details, is a repetition of the events associated with the first in Russia crash of the same type of aircraft, Boeing 737-500, the Russian airline "Aeroflot-Nord", which occurred on September 14, 2008. The plane crashed near the home airport when going around. And the engines of the crashed plane worked until the collision with the ground. But then, in Perm, the death toll was higher than in Kazan (88 people), including 22 foreigners from 10 countries, and in the list of victims was an adviser to the President of the Russian Federation, Colonel-General, and in Kazan - major General of the FSB. The distinctive features of the disaster in Perm attracted then more powerful forces to the investigation than now. Now there is another catastrophe. We are getting used to.
Perhaps someone warped comparison of the victims of the disaster by rank, but this, unfortunately, is also a characteristic feature of our reality. Here is a message from Kazan: "the families of the crew members who died in the crash with Boeing 737 in Kazan, will challenge in court the "unfair" insurance. Their relatives do not agree with the fact that the lives of the passengers were insured for a much larger amount. “We have a claim to the "Tatarstan" airline which insured passengers (insurance company "SOGAZ" ) for 2 million rubles, and crew members (regional company "AK bars insurance") - only 100 thousand rubles. On what basis do they divide people into "classes", "levels"?”
It is quite possible that "they divide people" on the basis of experience and determine the cause of such a disaster. It is known that, the blame for the disaster will be laid on the crew members, so why spend money on their insurance?
After all, what was after the disaster in Perm? Then, the recently appointed head of the Federal air transport agency (Rosaviation) Gennady Kurzenkov during the conference "air transport safety", said that the cause of the accident was "lack of crew interaction and disadvantages of all system of its preparation for flight." But later claims to the system somehow disappeared, and the blame was laid on the pilots.
"A criminal case was opened on the day of the disaster under article 263 of the criminal code. The investigation was terminated on March 15, 2010 with the wording "in connection with the death of a suspect". However, on April 26, 2010, this decision was reversed and the case was sent for further investigation to verify the actions of officials involved in the disaster (another attempt to recall the shortcomings of the system my notice) In July 2012, the criminal case was again dismissed in connection with the death of the person to be prosecuted”.
The people has gone, and the problems of the surviving officials responsible for the safety of flights in civil aviation did not remain. It is conveniently. No worries until the next disaster.
In principle, everything can happen again now. After all, no one seems to pay attention to the fact that in Russia the Federal law No. 260-FZ of December 25, 2012 "on amendments to the Air code of the Russian Federation" has already entered into force in accordance with Article 1 of which the AC of the Russian Federation is supplemented by article 24 1 of the following content:
“Article 24 1 . Ensuring the safety of civil aircraft.
1. The implementation of the state safety management system for civil aircraft is ensured in the Russian Federation in accordance with international standards of the International civil aviation organization”.
It is symbolic that the B-737 disaster in Kazan occurred on the 3rd day after the date of ICAO's entry into force of Annex 19 "Safety management System (SMS)" to the Chicago Convention and the 3rd edition of the " Safety management Handbook”.
To address the causes of the Kazan disaster, ICAO's approach to the evolution of the safety process described in section 2.2 of the SMS Handbook is fundamentally important, according to which an organizational era arrived following the technical and human factors era:
“с) The organizational era - from the mid-1990s to the present. During the " organizational era " safety was considered systematically, i.e. covering both organizational and human and technical factors. Also at this time, the concept of "accidents for organizational reasons" appeared in aviation, taking into account the impact that organizational culture and policy have on the effectiveness of the system of control over risk factors for safety…”.
The introduction of the concept of "accidents for organizational reasons" changed the concept of causality of accidents, focusing on the study of organizational processes such as guidance, planning, information exchange, resource allocation, supervision, etc. The concept takes into account, as a factor affecting safety, the working conditions of people in the aviation industry, "which include: stability, qualification and experience of staff, morale, trust in management…”.
To consider the causes of the B-737 disaster, it is obviously important to qualify the actions of the crew, in terms of the definitions given in the SMS Handbook – were there mistakes or violations? Here is the distinction between errors and violations given in SMS Handbook:
"Suboptimal conditions in the workplace give rise to active failures on the part of operational personnel. Active failures can be viewed as either errors or violations. The difference between mistakes and violations lies in the motivation component. A person who tries to perform a task in the best possible way, following the rules and procedures that he has been taught in the course of training, but who is unable to perform the task assigned to him, makes a mistake. A person who intentionally does not follow the rules, procedures or principles of the training received while performing a task commits a violation. Thus, the main difference between error and violation is intention."
Thus, if in the actions of the crew of B-737 there is no intention to "not follow the rules, procedures that he was taught in the course of training", but, nevertheless, the crew was unable to perform the task assigned to him, then it should be concluded about the error committed by the crew, not about the violation.
Part 3 of article 263 of the Criminal code of Russia is unlikely to apply to the error ("Violation of traffic safety and operation of air transport, resulting in the death of two or more persons"), simply because there was no violation.
The enactment of Federal law No. 260-FL of December 25, 2012 "on amendments to the Air Code of the Russian Federation" breaks the vicious circle, which is habitually closed by accusing the crew of violating the rules of operation and, subsequently, the termination of the criminal case due to the death of the suspect or accused.
And, if, in accordance with ICAO standards, the cause of the disaster was not a violation, but an error of the crew, due to non-compliance with ICAO standards of the state safety management system, then, obviously, it is necessary to identify those responsible for the disaster among those responsible for the safety levels in the state, and it is also necessary to improve the system itself. We must do something to reduce the likelihood of the next such tragedy in Russian aviation.
It is not so important in what sequence the approach to the safety management system should change, it is important that it should happen! For many years, the project management of the Be-200 amphibious aircraft variants with type certification in the IAC AR and validation in EASA had to interact with many pilots, both Russians and Italians, French, British, Americans, including test pilots and pilots of the Ministry of emergency situations. And there was no opinion that Russian pilots are more inclined to the intention to violate the rules of operation, compared with foreign colleagues.
And, nevertheless, if in the world, according to the President of the International air transport association (IATA) Tony Tyler, one incident accounts for an average of 500 thousand passenger flights, in Russia and the CIS. It is 275 thousand.
The question arises, what is wrong with us? What does not allow our country to reach the world indicators of flight safety levels?
The answers to these questions should be found in the section of the SMS Handbook on national culture, which includes such concepts as " the role of the individual in society, the way of distribution of power, national priorities for resources, accountability of authorities, morality, the tasks of the state and the peculiarities of the legal system".
Unfortunately, Russia, and the safety of citizens - the realization of the constitutional right to life - has not yet become the number one priority for state authorities. Despite the entry into force of Federal law No. 260-FL of December 25, 2012 "on amendments to the Air Code of the Russian Federation", the state system of safety management of civil aircraft provided for in article 24.1, the implementation of which should be provided in the Russian Federation in accordance with international standards of the International civil aviation organization, has not been developed.
Approved by the order of the government of the Russian Federation in May 2008, the "State program for ensuring the safety of civil aviation aircraft" neither in its format, which includes four mandatory components in the state budget, nor in the tasks, the first of which is formulated in the SMS Handbook:
“4.2.7. The first task of the state in the implementation of the State SMS is to appoint officials responsible for State SMS, and state organization, which will be the administration and coordination of the implementation process and management of the State SMS. In this document, such an organization is called the organization responsible for the State SMS”, does not meet the requirements for the State SMS set out in the ICAO SMS Handbook. The document in force in Russia cannot be the basis for the development of the SMS by aviation organizations, including organizations of developers and manufacturers of aviation equipment, to which the requirements of the ICAO SMS were first extended since November 14, 2013.
Further, you can specify a list of inconsistencies between the requirements of ICAO and the provisions of Russian regulations. In an effort to overcome regulatory obstacles to the promotion of the Be-200 amphibious aircraft to the markets, I addressed a list of inconsistencies, with proposals for the implementation of the SMS of developers and manufacturers of aircraft in various instances. But the system does not respond.
As it turned out, not everyone likes Russian aviation equipment. But in catastrophes all categories of citizens, including generals, officials of various ranks and their relatives perish. An instinctive sense of self-preservation would have to trigger a desire to do something to save lives, even their own and their loved ones. But there is an impression that already instincts atrophied.
The B-737 disaster in Kazan caused a lot of discussion. People are tired of living in fear of another flight accident in Russian aviation, only confirming that the level of safety in Russia is lower than in African countries. We need the political will, the necessary resources, the appropriate organization. And it is necessary to begin work from above, from the state because everything has to begin with the State SMS. But we're wasting time. What is everyone waiting for? Apparently, instructions from the guarantor of the Constitution - the President of the Russian Federation.

The proposal is put forward, in the name of the memory of those who died, and for the sake of preserving the lives of those who fly planes of Russian airlines, including their lives and the lives of their loved ones, to prepare on behalf of those who seek to revive and develop the aviation industry in Russia, an appeal to the President of the Russian Federation:
DRAFT (27.12.2013)
Dear Vladimir Putin,
On November 17, 2013, another crash of the Boeing 737-500 passenger plane in Kazan claimed the lives of 50 people. The victims of the crash were 48 citizens of Russia, a citizen of Ukraine and a British citizen.
Russian aviation industry professionals and the Russian public are deeply concerned about the lack of efficiency of the government system in ensuring the safety of civil aviation in our country. If in the world, according to the International air transport association (IATA), one incident accounts for an average of 500 thousand passenger flights, in Russia and the CIS it is 275 thousand.
Government agencies, in fact, did not begin to execute the Federal law No. 260-FL "on amendments to the Air Code of the Russian Federation", adopted on December 25, 2012 (with a delay of entry into force for 270 days), which supplemented Article 1 of the AC of the Russian Federation with article 24 1 of the following content:
"Article 24 1 . Ensuring the safety of civil aircraft
The implementation of the state safety management system for civil aircraft is ensured in the Russian Federation in accordance with international standards of the International civil aviation organization."
Despite the entry into force of the Law, the State safety management system, which meets the requirements of Annex 19 to the Chicago Convention adopted by ICAO on November 14, 2013, has not been developed in Russia. ICAO's primary requirements for the implementation of state SMS set out in the ICAO safety management system Handbook have not been met:
"4.2.7. The first task of the state in the implementation of the state SMS is to appoint officials responsible for state SMS, and state organization, which will be the administration and coordination of the implementation process and management of the state SMS. In this document, such an organization is called the organization responsible for the state SMS “.
We appeal to You - the guarantor of the Constitution of the Russian Federation, first of all, on the protection of the constitutional right of citizens to life. In accordance with article 2 of the Constitution of the Russian Federation: "Man, his rights and freedoms are the highest value. Recognition, observance and protection of human and civil rights and freedoms is the duty of the state”.
Unacceptably low level of safety of civil aviation in Russia creates a constant threat of death of the country citizens, leads to the destruction of the aviation industry in Russia, reduces the faith of young people in the development of high-tech industries, which contributes to their leaving their homeland, lowers the image of the Russian state in the eyes of the world community.
We know and believe that, imbued with the purpose, You use your will, powers and means to the state apparatus carried out the task of improving and ensuring the safe level of civil aviation. For our part, we are ready to render all possible assistance to the solution of this important state task.
Best respect,
Ildus Kamalov, - head of sector, developer of aviation electronics, Moscow, Avionics
Ruslan Kashirin
German Vlasenko
Boris Maloy, - head of the certification Center, head of the certification Directorate of Tupolev (1995 — 2012)
Maria Klishina
Yevgeny Myzin
Igor Kasyanov
Vyacheslav Sharikov, - Navigator
Alexander Nikitin
Oleg Ovsyannikov, - Director of legal Affairs International Association of Airports
Vladimir Redko, - Captain B767
Andrew Biryukov
Alexander Azarov, - instructor pilot
Gorlov Igor
Sergei Bogdanov
Olga Komarova
Ildus Kamalov
Anton Usvyatsov
Stanislav Korolev
Alexander Mikitas, - Head of the club of young pilots
Yegor Yegorovich Nazarov, Head of the aviation service of Nizhne-Lenskoe
Vladimir Lomazov
Sergey Shevchenko – captain, the pilot-instructor of Il -76, В-737,757,767,747-400, Gulfstream V(550/450), EASA ATPL
Ivan Kovalenkov, - General Director of NTF Aviaks
Alexander Prokopiev
Nikita Obruchev, - captain A-320
Valery Plaksin
Valery Fedchenko, - Deputy General Director for aviation security
Gennady Kalyakin, - captain, instructor pilot DA-40 UVAU GA
Anatoly Pavlenko, - Deputy Chairman of the safety Committee
Anatoly Vladimirovich Lipin, - Head of the technology and rules development group of the technology Department of the production management Department of "Airline " Russia", Professor of the Department of Air Navigation
Alexander Gorbova, Air Traffic Controller
Arkady Makarov
Andrey Gennadyevich Lyakhov, - Partner of SAYENKO KHARENKO, lawyer of Ryazan regional Collegium, doctor of law
Evgeny Suvorov
Alexander Zakharov
Oleg Bothin
Farhad Nurmatov
Alexander Yavkin, - Deputy General Designer BERIEV aircraft company, Chief Designer of Be-200ES-E
Of course, the text of the appeal can be corrected by joint efforts, but now it is important to determine how many of us, those who consider it impossible for themselves to remain silent again. And this can be done by the number of collected electronic signatures. Leave your comments below the article and discuss on social networks... Join us!

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