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Trial by Fire: The crash of Aeroflot flight 1492

86 点作者 shmeeed1 天前

10 条评论

mppm1 天前
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):<p>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.<p>15% - People retrieving their luggage slowed down the evacuation and increased death toll.<p>5% - Aircraft design. Could be improved in some areas, but no really serious bloopers.<p>~0% - Delayed emergency response. Not good, but partly caused by incorrect communication from pilot. Also, fire spread so fast, it&#x27;s not likely they could have changed anything.
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andrewaylett1 天前
It always surprises me that system changes like Alternate and Direct Law, or Sukhoi&#x27;s Direct Mode, are quite so different from normal operation. I&#x27;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&#x27;t understand it is because I tend to read about the times when dropping into Alternate or Direct Law resulted in an incident?<p>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&#x27;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&#x27;t make the emergency worse by messing up a manual deploy.<p>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&#x27;t change anything fundamental about the controls, and if the power steering fails (or the cruise control stops working, or the radar can&#x27;t track the vehicle in front) I lose some affordances and some safety systems but I can still drive the car.<p>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?<p>Hoping someone has some more insight. I don&#x27;t have anything to do with avionics in general, and the day job isn&#x27;t safety-critical, but I&#x27;m always keen to learn and I&#x27;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.
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nativeit1 天前
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.<p>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.<p>Side note: The author even included a little nugget for the HN crowd:<p>&gt; 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.
the_mitsuhiko1 天前
&gt; 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. &gt; 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.<p>One thing that is very noticeable is that since 2022, incidents in Russia largely no longer show up on avherald. I&#x27;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.<p>In general it has become incredibly hard to judge the safety of Russia&#x27;s aviation from the west.
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rdtsc1 天前
&gt; 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.<p>That is shocking, but not that shocking if you&#x27;re familiar with how things are done in those parts.<p>So SSJ doesn&#x27;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.<p>&gt; 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<p>Heh &quot;Our SLA is still in play, we just extended the time we&#x27;ll average it by to 100 years&quot;
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kynetic1 天前
&gt; even the passengers, some of whom stopped to retrieve their carry-on bags while their countrymen burned.<p>I&#x27;m always astounded by the self-centeredness humans are capable of.
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user_78321 天前
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&#x2F;sources?
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vcdjysfj大约 14 小时前
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d_silin1 天前
I read entire article and here is my summary:<p>Short answer: Pilot training deficiency was the major contributing factor, Aeroflot the party responsible, but other factors contributed:<p>- 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.<p>- 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.<p>&quot;Manufacturer was not blameless either&quot;<p>- 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...<p>- 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<p>&quot;Notable pilot errors&quot;<p>- once he initiated a descent, the original trim setting became wildly inappropriate for the flight conditions...<p>Pilots ignored “GO AROUND, WINDSHEAR AHEAD&quot; warning<p>- 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.<p>&quot;Stress factors aggravated situation&quot;<p>- 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.<p>&quot;Random factors were not on their side either&quot;<p>- In an unfortunate coincidence, Yevdokimov’s request overlapped with a transmission from another aircraft on the standard frequency and the controller never heard it..<p>- 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.<p>&quot;Some desperate heroics prevented the worst-case scenario like in Saudia Flight 163&quot;<p>- 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...<p>- 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....<p>- 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<p>&quot;Final words and predictable aftermath&quot;<p>- In its final report, the MAK reserved its harshest words for Aeroflot.<p>- 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
vcdjysfj大约 14 小时前
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