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> The investigation revealed that the aileron cables were installed incorrectly. This caused reversal of aileron controls. Since the roll control surfaces inclu
by mabbo 5y ago
> The investigation revealed that the aileron cables were installed incorrectly. This caused reversal of aileron controls. Since the roll control surfaces include spoilers, which weren't affected by the mistake, the situation couldn't have been handled with just reversing inputs.
> The investigation blamed the manufacturer of the airplane for the poorly made maintenance instructions, the supervising authorities for lack of oversight over the maintenance crew, who lacked the skill to perform the heavy maintenance, and the flight crew for failing to notice the condition during pre-flight control checks.
https://en.m.wikipedia.org/wiki/Air_Astana_Flight_1388 https://en.m.wikipedia.org/wiki/Air_Astana_Flight_1388
Bad instruction manuals, poorly trained people trying to follow them, and lax preflight checks by the crew. It's a miracle nobody died.
- jhugo 5y agoIt's not a miracle -- most of the holes in the cheese lined up [1] but the final protection (good CRM in the cockpit and capable, well-trained pilots) worked. They certainly screwed up in pre-flight, but they redeemed themselves ten times over in the air. [1] https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model