4 ms·

This is an extremely long and unfocused analysis of what was a fairly straightforward incident. Following the lightning strike, which created a dangerous, but m

by 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.
  - anonymars 1y ago
    Sure, but if the pilot isn't trained appropriately and has no negative feedback on his skills, how does that situation resolve itself? It's not like the pilot can just take the plane out himself for some practice in normal mode. It reminds me of the parable of the junior developer who wipes the production database: one person may have pushed the button, but a lot of things had to go wrong to get there
  - kjkjadksj 1y ago
    It is the pilots job to do what is covered in simulation**
  - julik 1y ago
    FBW with servo delay, manual trim that you do not use often etc. would be a severe problem in a situation like this, especially for a guy who was captain on an IL-76 (where the yoke is the size of a cab truck steering wheel and has direct feedback from actuators). He "should have been able". Also AFL "should have" provided training in direct mode flying. The OAK "should have" provided an SOP for resetting the flight control computers into normal mode, or some kind of alternate mode which at least would provide auto-trim. Etc. etc. etc. It is very tempting to say "pilot error" but if you drive a car and the way the steering wheel responds to your input drastically changes in an instant, without you having experienced that way of the steering wheel reacting - is it your "error"?
  - heelix 1y ago
    Looking back, much of pilot training is handling things gone wrong and honing skills that keep things safe. CFI would make the joke we were going to practice crashing, as almost every flight would lose a (simulated) instrument, engine, or have something abnormal happen. Looking at my training, I had about 7-8 hours of dual training - landing, takeoff, radio/tower, spins/stalls (w00t) - before I flew solo. From there, my world slowly expanded to not getting lost, staying out of clouds, and other more advanced topics and areas further from home. Suspect it was another 40'ish hours of learning about crashing. :)
anonymars 1y ago
This part resonated with me > 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. As the US gradually starts to resemble its former nemesis and we become numbed to the daily outrage, I can feel myself becoming increasingly resigned and so this passage touched a nerve. I worry what happens when we have driven out those in public service who were committed to doing what's right. Which becomes further dispiriting.
RegnisGnaw 1y ago
Based on the reading I feel the sloppy and inadequate reading at Aeroflot should take some blame.
culebron21 1y ago
It's not 80% pilot error, but poor training, signature of many Russian airlines. In fact, all 3 accidents last 6 years (this one, 2020 Ural Airlines field crash landing near Moscow, 2023 field landing near Novosibirsk) were due to pilot inadequate training, leading to inadequate behavior (ZIA case) or overreacting to issues (the diversion to OVB). If you watch some traffic landing videos, Russian planes sometimes land on the front wheels, exactly because of overspeed. The belief that you need to land slightly faster than the speed in the manual, is very frequent. Some companies did change this recently, though. And the plane in the OP was switched to "direct control mode". The default mode is like Airbus fly-by-wire where the yoke sets vertical speed. The direct control mode is like Boeing's. The pilots were not prepared for this kind of change.
- speed_spread 1y ago
  It's poor pilot judgment, period. Not sure that's the kind of thing that training can overcome. It's downhill from the moment they decide to ignore the incoming storm. I read the whole thing and my conclusion is that the man is a moron and shouldn't have been allowed near an airplane, ever.
  - culebron21 1y ago
    And who did put him the captain seat?
  - deleted 1y ago
    [deleted]
  - brazzy 1y ago
    That "period" is actually the real killer: thinking that human error is a valid reason to explain a disaster. It never is. Never. Because humans are fallible. They will always make mistakes, especially under stress. The only way to achieve real safety is to build a system that works despite humans making mistakes. Pinning blame on individuals is how you avoid the hard work of actually improving safety. You mentioned that they ignored the storm. There are multiple systemic ways to prevent that: clear rules that make it mandatory to avoid storms. Empowering the first officer to question unsafe decisions from the captain. A pre-takeoff checklist that requires the pilots to check weather conditions and discuss how to handle them. And of course training and certification procedures that ensure these things are actually done. Yes, the pilot made grave errors. But not for the first time. It was the airline's job to notice that, put him into more intense training and if he really proves unable to improve, put him in a non-flying position. They completely failed to do any of that. And the insidious thing is that if training and enforcement of safety procedures are lax, it creates an atmosphere where unsafe behavior is normalized and spreads, where people who know better are hesitant to point it out for fear of being seen as troublemakers.
CGMthrowaway 1y ago
Aeroflot 1492 was an emergency landing (due to earlier lightning strike that scrambled electronics) during which the plane bounced off the runway, rupturing fuel tanks and causing a fire. Of the 78 people onboard, 41 died. Hard landing by pilot error/poor training is probably the biggest factor. But "people retrieving their luggage" points to inadequate crew training and emergency response more than anything. I don't believe it's fair to principally blame the pax (over the crew) for the disaster. Perhaps in conjunction with the crew, who ought to undergo scrutiny first. Wrt the pax taking luggage, fta "one of the flight attendants attempted to make a public address system announcement, “Seat belts off, leave everything, get out!” But she forgot to press the PA button and this command was broadcast to the cockpit via the interphone instead. Only a few passengers at the front heard the command to “leave everything.”"
- culebron21 1y ago
  As far as I remember, in the videos (still on YT) people are exiting without luggage.
  - shmeeed 1y ago
    It's hard to imagine the horror and the struggle for bare survival that took place in this narrow space over the span of just a few seconds, but if I had to guess, it might very well be that in the end they did not manage to free their luggage and take it with them to the exit. If I read the article correctly, only three people from the rows behind those reported trying to take their luggage with them survived. It's not in the mentioned whether the people that caused the plug have themselves perished or survived; and tempting as is the speculation when one looks at the seating plan, suffice to say that if those people are still alive, they very probably will be forever haunted by their guilt.

by mppm 1y ago

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.
- anonymars 1y ago
  Sure, but if the pilot isn't trained appropriately and has no negative feedback on his skills, how does that situation resolve itself? It's not like the pilot can just take the plane out himself for some practice in normal mode. It reminds me of the parable of the junior developer who wipes the production database: one person may have pushed the button, but a lot of things had to go wrong to get there
- kjkjadksj 1y ago
  It is the pilots job to do what is covered in simulation**
- julik 1y ago
  FBW with servo delay, manual trim that you do not use often etc. would be a severe problem in a situation like this, especially for a guy who was captain on an IL-76 (where the yoke is the size of a cab truck steering wheel and has direct feedback from actuators). He "should have been able". Also AFL "should have" provided training in direct mode flying. The OAK "should have" provided an SOP for resetting the flight control computers into normal mode, or some kind of alternate mode which at least would provide auto-trim. Etc. etc. etc. It is very tempting to say "pilot error" but if you drive a car and the way the steering wheel responds to your input drastically changes in an instant, without you having experienced that way of the steering wheel reacting - is it your "error"?
- heelix 1y ago
  Looking back, much of pilot training is handling things gone wrong and honing skills that keep things safe. CFI would make the joke we were going to practice crashing, as almost every flight would lose a (simulated) instrument, engine, or have something abnormal happen. Looking at my training, I had about 7-8 hours of dual training - landing, takeoff, radio/tower, spins/stalls (w00t) - before I flew solo. From there, my world slowly expanded to not getting lost, staying out of clouds, and other more advanced topics and areas further from home. Suspect it was another 40'ish hours of learning about crashing. :)

anonymars 1y ago

This part resonated with me > 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. As the US gradually starts to resemble its former nemesis and we become numbed to the daily outrage, I can feel myself becoming increasingly resigned and so this passage touched a nerve. I worry what happens when we have driven out those in public service who were committed to doing what's right. Which becomes further dispiriting.

RegnisGnaw 1y ago

Based on the reading I feel the sloppy and inadequate reading at Aeroflot should take some blame.

culebron21 1y ago

It's not 80% pilot error, but poor training, signature of many Russian airlines. In fact, all 3 accidents last 6 years (this one, 2020 Ural Airlines field crash landing near Moscow, 2023 field landing near Novosibirsk) were due to pilot inadequate training, leading to inadequate behavior (ZIA case) or overreacting to issues (the diversion to OVB). If you watch some traffic landing videos, Russian planes sometimes land on the front wheels, exactly because of overspeed. The belief that you need to land slightly faster than the speed in the manual, is very frequent. Some companies did change this recently, though. And the plane in the OP was switched to "direct control mode". The default mode is like Airbus fly-by-wire where the yoke sets vertical speed. The direct control mode is like Boeing's. The pilots were not prepared for this kind of change.

speed_spread 1y ago
It's poor pilot judgment, period. Not sure that's the kind of thing that training can overcome. It's downhill from the moment they decide to ignore the incoming storm. I read the whole thing and my conclusion is that the man is a moron and shouldn't have been allowed near an airplane, ever.
- culebron21 1y ago
  And who did put him the captain seat?
- deleted 1y ago
  [deleted]
- brazzy 1y ago
  That "period" is actually the real killer: thinking that human error is a valid reason to explain a disaster. It never is. Never. Because humans are fallible. They will always make mistakes, especially under stress. The only way to achieve real safety is to build a system that works despite humans making mistakes. Pinning blame on individuals is how you avoid the hard work of actually improving safety. You mentioned that they ignored the storm. There are multiple systemic ways to prevent that: clear rules that make it mandatory to avoid storms. Empowering the first officer to question unsafe decisions from the captain. A pre-takeoff checklist that requires the pilots to check weather conditions and discuss how to handle them. And of course training and certification procedures that ensure these things are actually done. Yes, the pilot made grave errors. But not for the first time. It was the airline's job to notice that, put him into more intense training and if he really proves unable to improve, put him in a non-flying position. They completely failed to do any of that. And the insidious thing is that if training and enforcement of safety procedures are lax, it creates an atmosphere where unsafe behavior is normalized and spreads, where people who know better are hesitant to point it out for fear of being seen as troublemakers.

CGMthrowaway 1y ago

Aeroflot 1492 was an emergency landing (due to earlier lightning strike that scrambled electronics) during which the plane bounced off the runway, rupturing fuel tanks and causing a fire. Of the 78 people onboard, 41 died. Hard landing by pilot error/poor training is probably the biggest factor. But "people retrieving their luggage" points to inadequate crew training and emergency response more than anything. I don't believe it's fair to principally blame the pax (over the crew) for the disaster. Perhaps in conjunction with the crew, who ought to undergo scrutiny first. Wrt the pax taking luggage, fta "one of the flight attendants attempted to make a public address system announcement, “Seat belts off, leave everything, get out!” But she forgot to press the PA button and this command was broadcast to the cockpit via the interphone instead. Only a few passengers at the front heard the command to “leave everything.”"

culebron21 1y ago
As far as I remember, in the videos (still on YT) people are exiting without luggage.
- shmeeed 1y ago
  It's hard to imagine the horror and the struggle for bare survival that took place in this narrow space over the span of just a few seconds, but if I had to guess, it might very well be that in the end they did not manage to free their luggage and take it with them to the exit. If I read the article correctly, only three people from the rows behind those reported trying to take their luggage with them survived. It's not in the mentioned whether the people that caused the plug have themselves perished or survived; and tempting as is the speculation when one looks at the seating plan, suffice to say that if those people are still alive, they very probably will be forever haunted by their guilt.