7 ms·

Trial by Fire: The crash of Aeroflot flight 1492

91 points by shmeeed 1y ago

user_7832 1y ago
Tangential: along with the admiral’s excellent reporting, does anyone have or know any other good sources to read up on aviation safety? The AOPA air safety institute is one I know of (they make excellent YouTube videos on their channel), and I’ve heard the NTSB themselves upload videos to their YT channel to. Any other names/sources?
- ajb 1y ago
  I always check pprune (professional pilots rumour network) on any recent crashes, as many of the posters are pilots. However it's a forum so you have to wade through the usual idiots and arguments.
- user_7832 1y ago
  Just remembered: also Paul Bertorelli‘s videos on AVWeb, though he has now retired. They’re fun to watch even if you’re not primarily into aviation.
  - shmeeed 1y ago
    Sad to hear that Paul has retired, I loved his videos and articles. But I was already expecting it rather sooner than later, and his retirement is certainly well deserved. I hope he enjoys it, and maybe his face comes up again some time.
- brontitall 1y ago
  I assume you’re aware that Admiral Cloudberg writes for Mentour Pilot on YouTube. Also, pretty low volume but also low sensationalism the Australian regulator, ATSB, posts report summaries on YouTube. E.g. https://youtu.be/dum4SfnX8uk https://youtu.be/dum4SfnX8uk
  - deleted 1y ago
    [deleted]
- sokoloff 1y ago
  Juan Browne (blancolirio on YouTube) is good: https://youtube.com/@blancolirio?si=kadw8hC35YGWbRZe https://youtube.com/@blancolirio?si=kadw8hC35YGWbRZe (Dan Gryder is, IMO, on the opposite end of the spectrum from Juan.) VASAviation has a bunch of radar recreations, but if you’re new to aviation safety and never flown under ATC, you might not get as much from it as you would from a more commentary-based treatment: https://youtube.com/@vasaviation?si=__ZSdYSR1YgTOpge https://youtube.com/@vasaviation?si=__ZSdYSR1YgTOpge
the_mitsuhiko 1y ago
> Instead, the accident was the result of a convergence of numerous deficiencies associated with all three, none of which were causal by themselves, but were causal in concert. Furthermore, the breadth and depth of the deficiencies identified in this investigation was such that it calls into question the safety of Russia’s entire aviation sector. > I know as a matter of personal experience that there are many people in Russia who are genuinely dedicated to doing things right, and I have no doubt that many of them work in the aviation industry. Granted, many of the best have left since 2022, but plenty remain. The problem is that apathy has been enshrined on an institutional level, trapping the people who care under the weight of those who do not, or who choose not to for purposes of survival. Such a culture is not easily rooted out. One thing that is very noticeable is that since 2022, incidents in Russia largely no longer show up on avherald. I'm not sure if this is because the website no longer reports them, or because reports are not made in Russia, but it makes me feel a lot less comfortable. In general it has become incredibly hard to judge the safety of Russia's aviation from the west.
- decimalenough 1y ago
  Russia is not a black hole, ASN still has plenty of incident reports: https://asn.flightsafety.org/asndb/country/RA https://asn.flightsafety.org/asndb/country/RA But we already know aviation safety in Russia is on a downward spiral, because the sanctions make it very difficult to get spare parts and, as the article notes, even notionally Russian aircraft like the SSJ-100 still rely on numerous Western parts.
  - the_mitsuhiko 1y ago
    > Russia is not a black hole, ASN still has plenty of incident reports: https://asn.flightsafety.org/asndb/country/RA https://asn.flightsafety.org/asndb/country/RA I know, but last time I was looking they were all sourced from some telegram channels and none of had official data associated with it.
  - ekianjo 1y ago
    > rely on numerous Western parts. Can't they get such western parts thru China?
Zoethink 1y ago
Why don’t we talk more about how fragile the whole system becomes when tech degrades and the human has to take over? In the Flight 1492 case, the lightning strike didn’t bring the plane down — the system’s reaction to it did. It feels like we’ve optimized for normal conditions, but when things go sideways, we rely on the pilot to do the impossible — often without the tools, training, or time.
kynetic 1y ago
> even the passengers, some of whom stopped to retrieve their carry-on bags while their countrymen burned. I'm always astounded by the self-centeredness humans are capable of.
- anonymars 1y ago
  "It will just take a second"
  - anonymars 1y ago
    Actually the article (and a sibling comment) touches on this and it's not necessarily so simple ("there but for the grace of God go I") > In one sense, this blame is constructive insofar as shame is an effective motivator for people who might otherwise try to get their luggage during a future evacuation. However, research has shown that when untrained civilians are unexpectedly placed into an emergency aboard an aircraft, many people’s brains revert to what they already know, which is to stand up, grab their bags, and walk to the exit, as though nothing is wrong. This behavioral tendency can be short-circuited if the flight attendants loudly and assertively order passengers to leave their bags behind and exit immediately. But on flight 1492, the order to leave bags behind was not heard by the majority of the passengers because the senior flight attendant forgot to press the PA button before making the announcement.
- xoa 1y ago
  >I'm always astounded by the self-centeredness humans are capable of. In this instance I'm sorry but this is the wrong take. The fantastic article directly addresses that in fact, and it jives with what I was taught as part of first responder and mountain rescue training in the US, as well as have heard from EMTs and volunteer firefighters I know: >"However, research has shown that when untrained civilians are unexpectedly placed into an emergency aboard an aircraft, many people’s brains revert to what they already know, which is to stand up, grab their bags, and walk to the exit, as though nothing is wrong. This behavioral tendency can be short-circuited if the flight attendants loudly and assertively order passengers to leave their bags behind and exit immediately. But on flight 1492, the order to leave bags behind was not heard by the majority of the passengers because the senior flight attendant forgot to press the PA button before making the announcement." Again, this jives with everything from military to emergency response of all sorts: in high stress maximal flight/fight rapid response sorts of situations, humans tend to (a) revert to whatever "muscle memory" or drilled in training they've got, if any, or else whatever basic instinct/patterns they've developed, (b) follow authoritative instructions, if available and simply/rapidly understandable, (c) panic, or (d) freeze up. Just as with everything else with safety, humans must be recognized as humans and be part of an overall systemic approach if we wish to improve outcomes as much as possible. So if you're dealing with untrained random civilians who have no particular "muscle memory" to draw on beyond the typical, then crew procedures, aircraft design etc have to account for that. That's just part of the responsibility of running a civilian facing service involving life/safety. Better training for the cabin crew might have helped here just as better training could have prevented the situation happening at all, and identically better mechanical designs might also have helped and be worth considering in principle if this was frequent enough. This could range from how PA systems work (perhaps when an emergency landing is triggered, PA should automatically go to open mode and stay that way, or perhaps the evac warning including "LEAVE ALL BAGS BEHIND, EVACUATE NOW OR DIE" should be fully automated and just start broadcasting once emergency slides are deployed) to having overhead bins automatically seal and be impossible to open so somebody could at most spend a few seconds trying before realizing they can't (this would require actual study and cost/benefit tradeoff investigation of course). But the take away in disasters should not be any sort of moral one liner. These are massive systems with large numbers of people being forced to deal with a (literally here) by-the-second lethal scenario. Safety is a systemic issue.
mppm 1y ago
This is an extremely long and unfocused analysis of what was a fairly straightforward incident. Following the lightning strike, which created a dangerous, but manageable situation, the main contributors to the catastrophic outcome were (roughly): 80% - Pilot error. Poor adherence to procedures and checklists. Poor choices all around. Poor piloting in manual mode and botched touchdown. Part of the blame for this rests with Aeroflot, for putting such a pilot in the air. 15% - People retrieving their luggage slowed down the evacuation and increased death toll. 5% - Aircraft design. Could be improved in some areas, but no really serious bloopers. ~0% - Delayed emergency response. Not good, but partly caused by incorrect communication from pilot. Also, fire spread so fast, it's not likely they could have changed anything.
- rob74 1y ago
  Such long reads might not be for everyone, but I think the article actually does a very good job at listing all the contributing factors of the accident, while not trying to assign percentages of the blame to the participants. Sure, the pilots made errors, but they were thrown into an unexpected situation (having to manually control a plane with controls that were not designed for doing that) without sufficient training to adequately prepare them for flying in "direct mode" - which, due to various issues with the SSJ, happened far more frequently than initially expected.
  - mppm 1y ago
    What you say is true, but I would still disagree with the overall assessment. To put it bluntly, it is the pilot's job to be thrown into unexpected situations. Modern airliners mostly fly themselves, and the pilots are there to a) coordinate with ATC b) step in when the shit hits the fan, which does happen with some regularity. Ultimately this accident was caused by a confluence of many factors, as is often the case, but my read on the situation is that a competent pilot should have been able to handle this emergency without any losses.
    - Hello71 1y ago
      Modern commercial aviation is extremely safe because of investigators and regulators banning this "well the pilot just fucked up" explanation and instead looking at systemic factors. As pointed out in the article, if the pilot was so incompetent, why didn't they receive further training, or if truly untrainable, fired? The airline and regulator have the responsibility for doing so, and ending the investigation at "pilot error" guarantees that another incompetent pilot will crash another plane.
d_silin 1y ago
I read entire article and here is my summary: Short answer: Pilot training deficiency was the major contributing factor, Aeroflot the party responsible, but other factors contributed: - After the accident, the MAK sought to verify how much time was actually spent flying in Direct Mode during initial and recurrent training at Aeroflot, but they ran up against a brick wall of silence. - The MAK acquired data from seven Direct Mode reversion events between 2015 and 2018, including six from Aeroflot and one from another Russian airline, and the results painted a dismal picture of Russian pilots’ ability to handle this type of emergency. "Manufacturer was not blameless either" - at the time of the accident the flight crew operations manual (FCOM, a Sukhoi product) contained descriptions of Airbus controls laws instead of SSJ control laws... - UAC calculated that the probability of a Direct Mode reversion should be approximately 1 per 1.64 million flight hours... By 2022, the number of known Direct Mode reversions had risen to 21, for a rate of 1 per 63,000 flight hours "Notable pilot errors" - once he initiated a descent, the original trim setting became wildly inappropriate for the flight conditions... Pilots ignored “GO AROUND, WINDSHEAR AHEAD" warning - pitch angle -1.7 ...when the plane touched down on the runway. But instead of applying the recovery maneuver described in the FCOM, Yevdokimov suddenly reversed his input from full nose up to full nose down. "Stress factors aggravated situation" - Yevdokimov beginning to speak before pressing the push-to-talk button, and releasing the button before he was done — a known sign of elevated stress. "Random factors were not on their side either" - In an unfortunate coincidence, Yevdokimov’s request overlapped with a transmission from another aircraft on the standard frequency and the controller never heard it.. - The SSJ’s landing gear, which was designed and produced by French company Safran. As it turns out, the second impact fell into a gray area where the load was sufficient to break the fuse pins attaching the forward end of the landing gear crossarm to the wing box rear spar, but not the fuse pins for the drag brace or crossbeam. "Some desperate heroics prevented the worst-case scenario like in Saudia Flight 163" - Exercising her prerogative, Senior Flight Attendant Kseniya Fogel’ stood up from her seat as soon as the aircraft stopped and opened the R1 door without waiting for a command by the pilots. By 18:30:46, just eight seconds after the plane came to a stop, the door opened and the slide began deploying... - Video evidence showed that within one second of the first passenger leaving the plane, and possibly even earlier, the fire breached the fuselage and began spreading into the cabin itself.... - Also still on the airplane was the passenger from seat 12A, who encountered First Officer Kuznetsov just outside the cockpit and decided to stay to help more passengers "Final words and predictable aftermath" - In its final report, the MAK reserved its harshest words for Aeroflot. - The MAK’s final report contains 49 recommendations to improve everything. But despite the passage of more than 6 years since the crash, the section of the report listing safety actions taken to date contains only one entry, concerning an update to Russia’s USSR-era airport fire rescue standards
rdtsc 1y ago
> According to a footnote in the MAK report, at the time of the accident the flight crew operations manual (FCOM, a Sukhoi product) contained descriptions of Airbus controls laws instead of SSJ control laws. The reasons for this darkly hilarious mix-up are not elucidated in the report. That is shocking, but not that shocking if you're familiar with how things are done in those parts. So SSJ doesn't implement Alternate Law (mode) only Direct Law, but Sukhoi inserted Alternate Law descriptions from Airbus into the manual anyway. Just yolo copy-paste basically. > UAC calculated that the probability of a Direct Mode reversion should be approximately 1 per 1.64 million flight hours [...] In 2015 alone, there were three such events, even though the entire SSJ fleet had accumulated just 81,000 flying hours Heh "Our SLA is still in play, we just extended the time we'll average it by to 100 years"
- kalleboo 1y ago
  Looking forward to flight manuals being generated by AI in the future
- rob74 1y ago
  Maybe the FCOM was actually the design specification, i.e. how they wanted it to work, which however had significant differences from the final product? The article later points out that the many Direct Mode reversions probably have something to do with the Electronic Interface Units (EIUs) which are responsible for making sure the various off-the-shelf Western components (which were apparently not customized due to cost reasons) could talk to each other. So the only Russian-made (and thus technologically not so advanced) component in your design is also a single point of failure. What could go wrong?
  - rdtsc 1y ago
    > Maybe the FCOM was actually the design specification, i.e. how they wanted it to work, which however had significant differences from the final product? Agree, that's probably what happened, yeah. It was probably a planned feature they had to cut at the last minute.
andrewaylett 1y ago
It always surprises me that system changes like Alternate and Direct Law, or Sukhoi's Direct Mode, are quite so different from normal operation. I'm sure they have a really good reason not to make Normal Law better mimic Direct Law (but with all the safety systems), and maybe the reason I don't understand it is because I tend to read about the times when dropping into Alternate or Direct Law resulted in an incident? One of the patterns I try to follow in designing our operations is that the tasks we need to follow in an emergency should be as close to routine as we can make them. We don't have a manual override to deploy into production in case of emergency, we make sure that our normal deploy process is suitable for emergency use. Which means we won't make the emergency worse by messing up a manual deploy. Similarly, my car has some fancy drive-by-wire features -- the steering is dynamic, and the throttle balances the electric motor and petrol engine seamlessly. But the manufacturer didn't change anything fundamental about the controls, and if the power steering fails (or the cruise control stops working, or the radar can't track the vehicle in front) I lose some affordances and some safety systems but I can still drive the car. It is true that the non-normal modes are supposed to only very infrequently activate, but with that in mind it should surely be more important to not drop users into a totally different control regime? Hoping someone has some more insight. I don't have anything to do with avionics in general, and the day job isn't safety-critical, but I'm always keen to learn and I've definitely learned a lot over the years that I can apply to the day job by reading about how people design systems to stay safe when a failure means loss of life.
- benlivengood 1y ago
  You might be surprised (or not) to learn that some modern cars are fully brake-by-wire; no mechanical connection between the pedal and the hydraulics [0]. Mostly hybrid or fully electric cars. Many "emergency" brakes are now merely parking brakes driven by an electric motor. Afaik there are no fully steer-by-wire cars on the road today, thankfully. I am similarly confused at the lack of sustained training in direct law/mode flight. The primary reason for the difference in operation is convenience and smoothness of flight achieved by intentional control stick movements as opposed to direct aerodynamic surface control, but like the article said pilots should have a comprehensive mental operating model of what the "normal" law/mode is producing at the control surfaces. [0] https://en.m.wikipedia.org/wiki/Brake-by-wire https://en.m.wikipedia.org/wiki/Brake-by-wire
nativeit 1y ago
This is an exhaustive and insightful document of a largely preventable tragedy—one that does justice to those who perished, as well as the victims of all air accidents with its even-handed analyses and unflinching details. Its revelation of how deeply flawed the systems, agencies, companies, and people involved in this accident carries a stark unsaid warning for the direction the United States is heading. Accountability, objectivity, expertise, and transparency are critical in so many aspects, and much like Chernobyl, this article reveals how hardly perceptible erosions of these values build up to untenable states of affairs. Ignoring the warning signs brings down empires. Side note: The author even included a little nugget for the HN crowd: > Aeroflot’s dissenting opinion was typed up in a Microsoft Word document, or similar, with default settings. I don’t know why but I find that vaguely amusing.
vcdjysfj 1y ago
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91 points by shmeeed 1y ago

Tangential: along with the admiral’s excellent reporting, does anyone have or know any other good sources to read up on aviation safety? The AOPA air safety institute is one I know of (they make excellent YouTube videos on their channel), and I’ve heard the NTSB themselves upload videos to their YT channel to. Any other names/sources?

ajb 1y ago
I always check pprune (professional pilots rumour network) on any recent crashes, as many of the posters are pilots. However it's a forum so you have to wade through the usual idiots and arguments.
user_7832 1y ago
Just remembered: also Paul Bertorelli‘s videos on AVWeb, though he has now retired. They’re fun to watch even if you’re not primarily into aviation.
- shmeeed 1y ago
  Sad to hear that Paul has retired, I loved his videos and articles. But I was already expecting it rather sooner than later, and his retirement is certainly well deserved. I hope he enjoys it, and maybe his face comes up again some time.
brontitall 1y ago
I assume you’re aware that Admiral Cloudberg writes for Mentour Pilot on YouTube. Also, pretty low volume but also low sensationalism the Australian regulator, ATSB, posts report summaries on YouTube. E.g. https://youtu.be/dum4SfnX8uk https://youtu.be/dum4SfnX8uk
- deleted 1y ago
  [deleted]
sokoloff 1y ago
Juan Browne (blancolirio on YouTube) is good: https://youtube.com/@blancolirio?si=kadw8hC35YGWbRZe https://youtube.com/@blancolirio?si=kadw8hC35YGWbRZe (Dan Gryder is, IMO, on the opposite end of the spectrum from Juan.) VASAviation has a bunch of radar recreations, but if you’re new to aviation safety and never flown under ATC, you might not get as much from it as you would from a more commentary-based treatment: https://youtube.com/@vasaviation?si=__ZSdYSR1YgTOpge https://youtube.com/@vasaviation?si=__ZSdYSR1YgTOpge

the_mitsuhiko 1y ago

> Instead, the accident was the result of a convergence of numerous deficiencies associated with all three, none of which were causal by themselves, but were causal in concert. Furthermore, the breadth and depth of the deficiencies identified in this investigation was such that it calls into question the safety of Russia’s entire aviation sector. > I know as a matter of personal experience that there are many people in Russia who are genuinely dedicated to doing things right, and I have no doubt that many of them work in the aviation industry. Granted, many of the best have left since 2022, but plenty remain. The problem is that apathy has been enshrined on an institutional level, trapping the people who care under the weight of those who do not, or who choose not to for purposes of survival. Such a culture is not easily rooted out. One thing that is very noticeable is that since 2022, incidents in Russia largely no longer show up on avherald. I'm not sure if this is because the website no longer reports them, or because reports are not made in Russia, but it makes me feel a lot less comfortable. In general it has become incredibly hard to judge the safety of Russia's aviation from the west.

decimalenough 1y ago
Russia is not a black hole, ASN still has plenty of incident reports: https://asn.flightsafety.org/asndb/country/RA https://asn.flightsafety.org/asndb/country/RA But we already know aviation safety in Russia is on a downward spiral, because the sanctions make it very difficult to get spare parts and, as the article notes, even notionally Russian aircraft like the SSJ-100 still rely on numerous Western parts.
- the_mitsuhiko 1y ago
  > Russia is not a black hole, ASN still has plenty of incident reports: https://asn.flightsafety.org/asndb/country/RA https://asn.flightsafety.org/asndb/country/RA I know, but last time I was looking they were all sourced from some telegram channels and none of had official data associated with it.
- ekianjo 1y ago
  > rely on numerous Western parts. Can't they get such western parts thru China?

Zoethink 1y ago

Why don’t we talk more about how fragile the whole system becomes when tech degrades and the human has to take over? In the Flight 1492 case, the lightning strike didn’t bring the plane down — the system’s reaction to it did. It feels like we’ve optimized for normal conditions, but when things go sideways, we rely on the pilot to do the impossible — often without the tools, training, or time.

kynetic 1y ago

> even the passengers, some of whom stopped to retrieve their carry-on bags while their countrymen burned. I'm always astounded by the self-centeredness humans are capable of.

anonymars 1y ago
"It will just take a second"
- anonymars 1y ago
  Actually the article (and a sibling comment) touches on this and it's not necessarily so simple ("there but for the grace of God go I") > In one sense, this blame is constructive insofar as shame is an effective motivator for people who might otherwise try to get their luggage during a future evacuation. However, research has shown that when untrained civilians are unexpectedly placed into an emergency aboard an aircraft, many people’s brains revert to what they already know, which is to stand up, grab their bags, and walk to the exit, as though nothing is wrong. This behavioral tendency can be short-circuited if the flight attendants loudly and assertively order passengers to leave their bags behind and exit immediately. But on flight 1492, the order to leave bags behind was not heard by the majority of the passengers because the senior flight attendant forgot to press the PA button before making the announcement.
xoa 1y ago
>I'm always astounded by the self-centeredness humans are capable of. In this instance I'm sorry but this is the wrong take. The fantastic article directly addresses that in fact, and it jives with what I was taught as part of first responder and mountain rescue training in the US, as well as have heard from EMTs and volunteer firefighters I know: >"However, research has shown that when untrained civilians are unexpectedly placed into an emergency aboard an aircraft, many people’s brains revert to what they already know, which is to stand up, grab their bags, and walk to the exit, as though nothing is wrong. This behavioral tendency can be short-circuited if the flight attendants loudly and assertively order passengers to leave their bags behind and exit immediately. But on flight 1492, the order to leave bags behind was not heard by the majority of the passengers because the senior flight attendant forgot to press the PA button before making the announcement." Again, this jives with everything from military to emergency response of all sorts: in high stress maximal flight/fight rapid response sorts of situations, humans tend to (a) revert to whatever "muscle memory" or drilled in training they've got, if any, or else whatever basic instinct/patterns they've developed, (b) follow authoritative instructions, if available and simply/rapidly understandable, (c) panic, or (d) freeze up. Just as with everything else with safety, humans must be recognized as humans and be part of an overall systemic approach if we wish to improve outcomes as much as possible. So if you're dealing with untrained random civilians who have no particular "muscle memory" to draw on beyond the typical, then crew procedures, aircraft design etc have to account for that. That's just part of the responsibility of running a civilian facing service involving life/safety. Better training for the cabin crew might have helped here just as better training could have prevented the situation happening at all, and identically better mechanical designs might also have helped and be worth considering in principle if this was frequent enough. This could range from how PA systems work (perhaps when an emergency landing is triggered, PA should automatically go to open mode and stay that way, or perhaps the evac warning including "LEAVE ALL BAGS BEHIND, EVACUATE NOW OR DIE" should be fully automated and just start broadcasting once emergency slides are deployed) to having overhead bins automatically seal and be impossible to open so somebody could at most spend a few seconds trying before realizing they can't (this would require actual study and cost/benefit tradeoff investigation of course). But the take away in disasters should not be any sort of moral one liner. These are massive systems with large numbers of people being forced to deal with a (literally here) by-the-second lethal scenario. Safety is a systemic issue.

mppm 1y ago

This is an extremely long and unfocused analysis of what was a fairly straightforward incident. Following the lightning strike, which created a dangerous, but manageable situation, the main contributors to the catastrophic outcome were (roughly): 80% - Pilot error. Poor adherence to procedures and checklists. Poor choices all around. Poor piloting in manual mode and botched touchdown. Part of the blame for this rests with Aeroflot, for putting such a pilot in the air. 15% - People retrieving their luggage slowed down the evacuation and increased death toll. 5% - Aircraft design. Could be improved in some areas, but no really serious bloopers. ~0% - Delayed emergency response. Not good, but partly caused by incorrect communication from pilot. Also, fire spread so fast, it's not likely they could have changed anything.

rob74 1y ago
Such long reads might not be for everyone, but I think the article actually does a very good job at listing all the contributing factors of the accident, while not trying to assign percentages of the blame to the participants. Sure, the pilots made errors, but they were thrown into an unexpected situation (having to manually control a plane with controls that were not designed for doing that) without sufficient training to adequately prepare them for flying in "direct mode" - which, due to various issues with the SSJ, happened far more frequently than initially expected.
- mppm 1y ago
  What you say is true, but I would still disagree with the overall assessment. To put it bluntly, it is the pilot's job to be thrown into unexpected situations. Modern airliners mostly fly themselves, and the pilots are there to a) coordinate with ATC b) step in when the shit hits the fan, which does happen with some regularity. Ultimately this accident was caused by a confluence of many factors, as is often the case, but my read on the situation is that a competent pilot should have been able to handle this emergency without any losses.
  - Hello71 1y ago
    Modern commercial aviation is extremely safe because of investigators and regulators banning this "well the pilot just fucked up" explanation and instead looking at systemic factors. As pointed out in the article, if the pilot was so incompetent, why didn't they receive further training, or if truly untrainable, fired? The airline and regulator have the responsibility for doing so, and ending the investigation at "pilot error" guarantees that another incompetent pilot will crash another plane.

d_silin 1y ago

I read entire article and here is my summary: Short answer: Pilot training deficiency was the major contributing factor, Aeroflot the party responsible, but other factors contributed: - After the accident, the MAK sought to verify how much time was actually spent flying in Direct Mode during initial and recurrent training at Aeroflot, but they ran up against a brick wall of silence. - The MAK acquired data from seven Direct Mode reversion events between 2015 and 2018, including six from Aeroflot and one from another Russian airline, and the results painted a dismal picture of Russian pilots’ ability to handle this type of emergency. "Manufacturer was not blameless either" - at the time of the accident the flight crew operations manual (FCOM, a Sukhoi product) contained descriptions of Airbus controls laws instead of SSJ control laws... - UAC calculated that the probability of a Direct Mode reversion should be approximately 1 per 1.64 million flight hours... By 2022, the number of known Direct Mode reversions had risen to 21, for a rate of 1 per 63,000 flight hours "Notable pilot errors" - once he initiated a descent, the original trim setting became wildly inappropriate for the flight conditions... Pilots ignored “GO AROUND, WINDSHEAR AHEAD" warning - pitch angle -1.7 ...when the plane touched down on the runway. But instead of applying the recovery maneuver described in the FCOM, Yevdokimov suddenly reversed his input from full nose up to full nose down. "Stress factors aggravated situation" - Yevdokimov beginning to speak before pressing the push-to-talk button, and releasing the button before he was done — a known sign of elevated stress. "Random factors were not on their side either" - In an unfortunate coincidence, Yevdokimov’s request overlapped with a transmission from another aircraft on the standard frequency and the controller never heard it.. - The SSJ’s landing gear, which was designed and produced by French company Safran. As it turns out, the second impact fell into a gray area where the load was sufficient to break the fuse pins attaching the forward end of the landing gear crossarm to the wing box rear spar, but not the fuse pins for the drag brace or crossbeam. "Some desperate heroics prevented the worst-case scenario like in Saudia Flight 163" - Exercising her prerogative, Senior Flight Attendant Kseniya Fogel’ stood up from her seat as soon as the aircraft stopped and opened the R1 door without waiting for a command by the pilots. By 18:30:46, just eight seconds after the plane came to a stop, the door opened and the slide began deploying... - Video evidence showed that within one second of the first passenger leaving the plane, and possibly even earlier, the fire breached the fuselage and began spreading into the cabin itself.... - Also still on the airplane was the passenger from seat 12A, who encountered First Officer Kuznetsov just outside the cockpit and decided to stay to help more passengers "Final words and predictable aftermath" - In its final report, the MAK reserved its harshest words for Aeroflot. - The MAK’s final report contains 49 recommendations to improve everything. But despite the passage of more than 6 years since the crash, the section of the report listing safety actions taken to date contains only one entry, concerning an update to Russia’s USSR-era airport fire rescue standards

rdtsc 1y ago

> According to a footnote in the MAK report, at the time of the accident the flight crew operations manual (FCOM, a Sukhoi product) contained descriptions of Airbus controls laws instead of SSJ control laws. The reasons for this darkly hilarious mix-up are not elucidated in the report. That is shocking, but not that shocking if you're familiar with how things are done in those parts. So SSJ doesn't implement Alternate Law (mode) only Direct Law, but Sukhoi inserted Alternate Law descriptions from Airbus into the manual anyway. Just yolo copy-paste basically. > UAC calculated that the probability of a Direct Mode reversion should be approximately 1 per 1.64 million flight hours [...] In 2015 alone, there were three such events, even though the entire SSJ fleet had accumulated just 81,000 flying hours Heh "Our SLA is still in play, we just extended the time we'll average it by to 100 years"

kalleboo 1y ago
Looking forward to flight manuals being generated by AI in the future
rob74 1y ago
Maybe the FCOM was actually the design specification, i.e. how they wanted it to work, which however had significant differences from the final product? The article later points out that the many Direct Mode reversions probably have something to do with the Electronic Interface Units (EIUs) which are responsible for making sure the various off-the-shelf Western components (which were apparently not customized due to cost reasons) could talk to each other. So the only Russian-made (and thus technologically not so advanced) component in your design is also a single point of failure. What could go wrong?
- rdtsc 1y ago
  > Maybe the FCOM was actually the design specification, i.e. how they wanted it to work, which however had significant differences from the final product? Agree, that's probably what happened, yeah. It was probably a planned feature they had to cut at the last minute.

andrewaylett 1y ago

It always surprises me that system changes like Alternate and Direct Law, or Sukhoi's Direct Mode, are quite so different from normal operation. I'm sure they have a really good reason not to make Normal Law better mimic Direct Law (but with all the safety systems), and maybe the reason I don't understand it is because I tend to read about the times when dropping into Alternate or Direct Law resulted in an incident? One of the patterns I try to follow in designing our operations is that the tasks we need to follow in an emergency should be as close to routine as we can make them. We don't have a manual override to deploy into production in case of emergency, we make sure that our normal deploy process is suitable for emergency use. Which means we won't make the emergency worse by messing up a manual deploy. Similarly, my car has some fancy drive-by-wire features -- the steering is dynamic, and the throttle balances the electric motor and petrol engine seamlessly. But the manufacturer didn't change anything fundamental about the controls, and if the power steering fails (or the cruise control stops working, or the radar can't track the vehicle in front) I lose some affordances and some safety systems but I can still drive the car. It is true that the non-normal modes are supposed to only very infrequently activate, but with that in mind it should surely be more important to not drop users into a totally different control regime? Hoping someone has some more insight. I don't have anything to do with avionics in general, and the day job isn't safety-critical, but I'm always keen to learn and I've definitely learned a lot over the years that I can apply to the day job by reading about how people design systems to stay safe when a failure means loss of life.

benlivengood 1y ago
You might be surprised (or not) to learn that some modern cars are fully brake-by-wire; no mechanical connection between the pedal and the hydraulics [0]. Mostly hybrid or fully electric cars. Many "emergency" brakes are now merely parking brakes driven by an electric motor. Afaik there are no fully steer-by-wire cars on the road today, thankfully. I am similarly confused at the lack of sustained training in direct law/mode flight. The primary reason for the difference in operation is convenience and smoothness of flight achieved by intentional control stick movements as opposed to direct aerodynamic surface control, but like the article said pilots should have a comprehensive mental operating model of what the "normal" law/mode is producing at the control surfaces. [0] https://en.m.wikipedia.org/wiki/Brake-by-wire https://en.m.wikipedia.org/wiki/Brake-by-wire

nativeit 1y ago

This is an exhaustive and insightful document of a largely preventable tragedy—one that does justice to those who perished, as well as the victims of all air accidents with its even-handed analyses and unflinching details. Its revelation of how deeply flawed the systems, agencies, companies, and people involved in this accident carries a stark unsaid warning for the direction the United States is heading. Accountability, objectivity, expertise, and transparency are critical in so many aspects, and much like Chernobyl, this article reveals how hardly perceptible erosions of these values build up to untenable states of affairs. Ignoring the warning signs brings down empires. Side note: The author even included a little nugget for the HN crowd: > Aeroflot’s dissenting opinion was typed up in a Microsoft Word document, or similar, with default settings. I don’t know why but I find that vaguely amusing.

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