[HN Gopher] Trial by Fire: The crash of Aeroflot flight 1492
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Trial by Fire: The crash of Aeroflot flight 1492
Author : shmeeed
Score : 80 points
Date : 2025-05-13 07:12 UTC (15 hours ago)
(HTM) web link (admiralcloudberg.medium.com)
(TXT) w3m dump (admiralcloudberg.medium.com)
| user_7832 wrote:
| 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?
| user_7832 wrote:
| 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.
| brontitall wrote:
| 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
| ajb wrote:
| 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.
| sokoloff wrote:
| 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
| the_mitsuhiko wrote:
| > 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 wrote:
| 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_mitsuhiko wrote:
| > 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.
| ekianjo wrote:
| > rely on numerous Western parts.
|
| Can't they get such western parts thru China?
| rad_gruchalski wrote:
| You mean "can China boycott sanctions"? They'd become
| sanctioned too, in no time.
| flexagoon wrote:
| 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.
| rad_gruchalski wrote:
| They're not importing Western goods through China.
| Otherwise they would not have a problem keeping their
| aircraft fleet operational. No?
| weweersdfsd wrote:
| 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.
| rob74 wrote:
| > _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"?_
| kynetic wrote:
| > 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 wrote:
| "It will just take a second"
| anonymars wrote:
| 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 wrote:
| > _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.
| qingcharles wrote:
| I remember the fire alarm going off at a hotel I was staying
| at. Rushed the stairwell and it was already jam-packed by
| people who had brought every single piece of luggage they owned
| with them.
| mrguyorama wrote:
| The scientific record is pretty clear that most humans struggle
| to do even basic things in emergency, high pressure situations
| like _being in arms reach of a 600C fire_
| mppm wrote:
| 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 wrote:
| 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 wrote:
| 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 wrote:
| 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 wrote:
| 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 wrote:
| It is the pilots job to do what is covered in simulation**
| anonymars wrote:
| 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 wrote:
| Based on the reading I feel the sloppy and inadequate reading
| at Aeroflot should take some blame.
| culebron21 wrote:
| 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 wrote:
| 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 wrote:
| And who did put him the captain seat?
| CGMthrowaway wrote:
| 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 wrote:
| As far as I remember, in the videos (still on YT) people are
| exiting without luggage.
| d_silin wrote:
| 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 wrote:
| > 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"
| andrewaylett wrote:
| 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 wrote:
| 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
| nativeit wrote:
| 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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(page generated 2025-05-13 23:01 UTC)