1953 Kemerovo mid-air collision

The 1953 Kemerovo mid-air collision was an aviation accident where two Li-2 aircraft collided over Kemerovo Oblast, Soviet Union, on May 27, 1953, resulting in the deaths of all 27 people aboard both aircraft.

1953 Kemerovo mid-air collision

Accident
Date	27 May 1953 (1953-05-27)
Summary	Mid-air collision due to crew errors
Site	16.5 km west of Barzas, Kemerovo Oblast, Soviet Union
Total fatalities	27
First aircraft
Li-2 similar to the one involved in the collision
Type	Lisunov Li-2
Operator	Aeroflot (East Siberian Territorial Directorate)
Registration	CCCP-Л4534
Flight origin	Irkutsk
Stopover	Krasnoyarsk
Destination	Novosibirsk
Occupants	20
Passengers	16
Crew	4
Fatalities	20
Second aircraft
Li-2T similar to the one involved in the collision
Type	Lisunov Li-2T
Operator	Aeroflot (West Siberian Territorial Directorate)
Registration	CCCP-А4031
Flight origin	Novosibirsk
Destination	Novosibirsk
Occupants	7
Crew	7
Fatalities	7

Aircraft

The Li-2 with tail number L4534 (serial number 18429005) from the 133rd Air Transport Unit of the East Siberian Territorial Directorate of Civil Aviation was manufactured on June 30, 1948, and at the time of the accident had logged 3,882 flight hours. On the day of the crash, it was operating flight 18 on the route Irkutsk—Krasnoyarsk—Novosibirsk, piloted by a crew consisting of the commander (PIC) Iosif Danilovich Stanishevsky, co-pilot Valentin Dmitrievich Maksimov, flight radio operator Yuri Yurievich Chernyshkov, and flight engineer Fedor Ivanovich Perevalov. On May 26 at 21:07 MSK, the aircraft departed from Irkutsk Airport and landed in Krasnoyarsk at 00:50 (May 27). After a one-hour stopover, it took off from Krasnoyarsk Airport at 01:50 and climbed to an altitude of 2,100 meters. The flight was conducted along the air corridor Krasnoyarsk—Kemerovo—Novosibirsk, carrying 16 passengers: 14 adults and 2 children.

The Li-2T with tail number A4031 (serial number 18432605) from the 6th Air Survey Unit of the West Siberian Territorial Directorate of Civil Aviation was manufactured on April 30, 1949, and had logged 1,268 flight hours at the time of the crash. On the day of the incident, it was tasked with performing an aerial photography mission in the Gusiny Brod area. The crew consisted of the commander (PIC) Alexander Nikolaevich Lomov, co-pilot Mikhail Konstantinovich Kiselev, navigator-aerial photographer Mikhail Petrovich Shchur, flight radio operator Nikolai Pavlovich Lyallin, flight engineer Evgraf Yakovlevich Kuznetsov, camera operator Zoya Pavlovna Volkova, and aerial photographer Nikolai Alexandrovich Pavlov. At 02:40 MSK, the aircraft took off from Novosibirsk Airport and climbed to the prescribed altitude of 1,800 meters before heading along the route Novosibirsk—Gusiny Brod—Kemerovo to the aerial photography area, located 45–60 kilometers north-northeast of Kemerovo Airport.

The Accident

At the time, the weather was clear, with an air temperature of +10 °C, and visibility exceeding 15 kilometers. On the Krasnoyarsk—Kemerovo section, the commander of aircraft L4534 deviated from the route, resulting in a 47-kilometer deviation. Meanwhile, at 03:36, the crew of aircraft A4031 reported their arrival in the aerial photography area at the assigned altitude of 1,800 meters and began their work. Li-2 A4031 initially flew on a heading of 90° for 6 minutes and 40 seconds, then made a 36-second left turn to 180° and flew on a 270° heading for another 6 minutes and 40 seconds. It then performed a right turn and settled on a 90° heading, now flying directly into the rising sun.

Less than a minute later, in clear skies at 03:50 MSK, the two aircraft, flying directly toward each other (L4534 on a 270° course, A4031 on a 90° course), collided head-on in front of numerous witnesses 16.5 kilometers west of the village of Barzas (Kemerovsky District, Kemerovo Oblast). Aircraft A4031, flying slightly lower, sheared off the left wing of aircraft L4534 with its right propeller, cutting through the wing at the junction of the aileron and flap. The impact also tore through the upper part of A4031's fuselage, destroying the center wing section of the second aircraft. As a result, passengers began falling out of the L4534's cabin, and its left wing, tail unit, and parts of the fuselage were scattered over a 150 by 900-meter area of forest and clearing. The center wing section with engines, cockpit, and right wing crashed into the forest. Aircraft A4031 went into a dive and crashed into the forest 350 meters away, exploding on impact, although no fire ensued. All 27 people aboard the two aircraft (20 on L4534 and 7 on A4031) perished.

Investigation

During the flight, the crew of Li-2 aircraft A4031 maintained communication with the Novosibirsk Aerodrome Dispatch Service and airfield dispatch service but did not contact the Kemerovo ADS. Meanwhile, the crew of Li-2 aircraft L4534 maintained communication with the Krasnoyarsk ADS, RDS, and Kemerovo ADS, but their communication with the Novosibirsk RDS was unsatisfactory. As a result, the exact location of the aircraft within their respective zones was unknown to the RDS. Numerous eyewitnesses on the ground saw the two aircraft heading toward each other at the same altitude, with neither crew taking any evasive action to avoid the collision.

It is worth noting that the 6th Air Survey Unit was originally part of the Main Directorate of Geodesy and Cartography and was transferred to the West Siberian Territorial Directorate of Civil Aviation in March 1953, just two months before the accident. When the unit was integrated, the command of the West Siberian TU GWF failed to adequately address the organization and safety of flights. Only flight training for the crews was conducted, with little attention given to aerial photography operations, which were entrusted to unit commander Klykov, who had only started working in the unit in March 1953 and was also unfamiliar with the specifics of aerial photography operations. Meanwhile, while civil and military aviation flights are stratified, meaning they operate at specific altitudes based on standard pressure settings, the situation is different for aerial survey aviation. These aircraft operate at altitudes dependent on the specified scale of the survey, which in turn is determined by the aerodrome elevation with adjustments for the terrain's relief in the survey area. However, requests for aerial survey operations at Novosibirsk Airport were submitted without specifying the boundaries of the area, and the actual flight altitudes over the survey area did not match the submitted requests. For example, the assignment for aircraft A4031 specified conducting a survey at a scale of 1:17,000. Simple calculations show that the actual flight altitude relative to the departure aerodrome should have been $1700+(290-162)=1828$, where 1,700 is the true altitude above the survey area's terrain, 290 is the average terrain elevation of the survey area above sea level, and 162 is the elevation of Novosibirsk Airport. Based on this, at standard pressure (760 mm Hg), the flight altitude should have been $1828+(760-745,5)*11=1987,5$, where 745.5 is the pressure at Novosibirsk Airport. Since the pressure at Kemerovo Airport was higher, at 747.1 mm Hg, the flight altitude at standard pressure should have been $1987,5-17,5=1970$, where 17.5 is the correction for the higher pressure at Kemerovo Airport. From these calculations, it is clear that before beginning the survey, aircraft A4031 should have climbed to an altitude of not 1,800 meters but 1,970 meters, meaning it should have gained an additional 170 meters. However, according to the barogram data, the aircraft actually climbed an additional 250 meters. It is noteworthy that neither the command of the West Siberian TU GWF, nor the Novosibirsk RDS and ADS, were aware of the correct method for determining survey altitude.

As for aircraft L4534, its commander, Stanishevsky, grossly violated the flight route on the Krasnoyarsk—Novosibirsk track by cutting a portion of the route near Kemerovo and not maintaining the prescribed flight level. Previously, in July 1952, Stanishevsky had been demoted to co-pilot for indiscipline and loss of orientation. He was reinstated in February 1953, despite retaining significant deficiencies in piloting, as well as displaying arrogance, stubbornness, and a lack of understanding.

At the Novosibirsk RDS, a radio direction finder was installed, but during the entire 35 minutes that aircraft L4534 was in its zone, it did not determine its location, leaving the Novosibirsk dispatcher unaware of the air traffic situation in the aerial photography area. The Kemerovo ADS dispatcher, when allowing aircraft L4334 to fly through its zone, was unaware of the aircraft's actual route and did not ascertain its precise location, although in clear weather, he could have observed the aircraft flying over the Kemerovo aerodrome. However, there was no overflight, as Commander Stanishevsky had cut the route to bypass the aerodrome. The Novosibirsk RDS did not warn the passing crews or the Kemerovo and Krasnoyarsk airports about flights taking place within its zone 50 kilometers north of Kemerovo Airport. Finally, the crews of both aircraft, despite the clear weather, did not monitor the air traffic situation and took no action to prevent the collision.

Commission's Conclusions

The causes of the aircraft collision were:

1. Gross violation of the established flight route and criminal negligence in piloting the aircraft by PIC Stanishevsky;
2. Lack of caution by PICs Stanishevsky and Lomov during the flights;
3. Inadequate preparation for aerial photography flights, poor flight organization, and disregard for basic flight safety requirements by the command of the West Siberian TU GWF and the 6th Air Survey Unit, as well as by the Novosibirsk RDS.

Those responsible: both PICs and Klykov, who took a formal approach to ensuring flight safety.