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.
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.
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.
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
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.
> 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.
> 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.
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 sanctions make it very difficult to get spare parts
The crash described in the article is from 2019, so before meaningful sanctions against Russia were implemented. Also, the article makes a pretty good job at mentioning other factors that also contribute to Russia's bad aviation safety:
> The MAK’s final report contains 49 recommendations to improve everything from simulator record-keeping to the location of the SSJ’s on-board megaphones. Many of these recommendations directly address the deficiencies described throughout this article. 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. This is an abysmally inadequate response. Where is the outrage? Where is the commitment to “never again”?
They do get parts through various third party countries.
Sanctions really don't work in aviation either. Iran has faced harsh sanctions through the 2000's, yet they've kept flying Western made planes, lately even newer models. Similar story with Cuba, somehow they operated ATR turboprops for decades, and those certainly do have American made parts.
If you have the money, somebody will supply you the parts.
That's not true, Russia already imports most of the sanctioned products through China, Turkey or Kazakhstan.
Also, the west can't just sanction China. The US just raised tariffs on China, and it already had bad consequences. Outright sanctioning it would be even worse.
>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.
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.
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?
(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
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.
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
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.
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.
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.
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
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.
It is the pilots job to do what is covered in simulation**
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.
Based on the reading I feel the sloppy and inadequate reading at Aeroflot should take some blame.
> 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.
Russia is not a black hole, ASN still has plenty of incident reports: 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 sanctions make it very difficult to get spare parts
The crash described in the article is from 2019, so before meaningful sanctions against Russia were implemented. Also, the article makes a pretty good job at mentioning other factors that also contribute to Russia's bad aviation safety:
> The MAK’s final report contains 49 recommendations to improve everything from simulator record-keeping to the location of the SSJ’s on-board megaphones. Many of these recommendations directly address the deficiencies described throughout this article. 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. This is an abysmally inadequate response. Where is the outrage? Where is the commitment to “never again”?
> Russia is not a black hole, ASN still has plenty of incident reports: 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.
> rely on numerous Western parts.
Can't they get such western parts thru China?
They do get parts through various third party countries.
Sanctions really don't work in aviation either. Iran has faced harsh sanctions through the 2000's, yet they've kept flying Western made planes, lately even newer models. Similar story with Cuba, somehow they operated ATR turboprops for decades, and those certainly do have American made parts.
If you have the money, somebody will supply you the parts.
You mean "can China boycott sanctions"? They'd become sanctioned too, in no time.
That's not true, Russia already imports most of the sanctioned products through China, Turkey or Kazakhstan.
Also, the west can't just sanction China. The US just raised tariffs on China, and it already had bad consequences. Outright sanctioning it would be even worse.
They’re not importing Western goods through China. Otherwise they would not have a problem keeping their aircraft fleet operational. No?
> 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.
>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.
"It will just take a second"
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.
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?
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
Juan Browne (blancolirio on YouTube) is good: 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
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.
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.
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