"(computer reconstruction)
Fall from the echelon
Strangers in the cockpit, unstudied features of the aircraft instruments
Wreckage of the A310 fuselage - fragment of the inscription "AEROFLOT"
Flight SU593 crash occurred on March 22, 1994 near Mezhdurechensk in the Kemerovo region. As a result of the crash of the Aeroflot airline A310, all 75 people on board were killed.
The main cause of the disaster was an unacceptable situation in which the aircraft commander put his fifteen-year-old son at the controls of the airliner, whose unintentional actions led to a partial shutdown of the autopilot. Secondary reasons were the undocumented behavior of the autopilot, and the absence, at that time, of rules for making decisions in such situations in the crew training program.
Crew
Flight
Flight 593 was operated by an Airbus A310-304 (F-OGQS "M. Glinka") from Moscow Sheremetyevo Airport (SVO) to Kaitak Airport, Hong Kong (HKG). The crew commander Yaroslav Kudrinsky took on board his two children - daughter Yana and son Eldar. When the plane flew in the area of Novokuznetsk, Kudrinsky, in violation of the regulations, allowed first his daughter and then his son to sit in the ship’s commander’s chair. This circumstance was ignored by other crew members.
Catastrophe
Before allowing the children to take the command seat, Kudrinsky turned on the autopilot. The commander's daughter did not try to take any action to control the plane. After her, the captain’s son, 15-year-old Eldar Kudrinsky, took the helm. The teenager held the steering wheel, slightly rocking it from side to side, which could not lead to the autopilot being turned off by “overpowering.” However, in the end, Eldar applied a force of 8-10 kg to the steering wheel for 30 seconds, which led to a partial shutdown of the autopilot, which stopped sending commands to the ailerons, which, in turn, caused an uncontrolled roll to the right. Prior to this, this feature of the A310 autopilot was unknown to the crew. The mode disabling light alarm went off, but the crew did not notice this, since a design feature of the A310 is the absence of an audible signal for autopilot deactivation.
Eldar was the first to notice the tilt of the plane and reported it to his father. However, both professional pilots for several seconds could not understand the reason for the abnormal behavior of the aircraft. As the track on the screen changed to a circle, the co-pilot assumed that the plane had entered a “holding area,” that is, making large circles—a flight pattern used while waiting for permission to land.
The plane rolled to the right at a rate of about 1.5° per second, and soon the right bank reached 45°, which is above the permissible limit. This caused significant positive g-forces (4.8 g). When the crew noticed that the autopilot was disabled, they attempted to resume their seats.
Contrary to the instructions, the co-pilot, in the absence of the commander in his seat, moved his seat all the way back, which for a long time did not allow him to take a working position due to the overloads that had arisen. Due to strong overloads and a large roll angle, the aircraft commander could not get into his seat for a long time.
The situation was greatly complicated by the fact that in the left seat there was still the only person who had the physical ability to control the plane - the 15-year-old son of the commander, who received and tried to carry out various, inconsistent and contradictory commands from his father, the co-pilot and the third adult in the cockpit - a friend the family of the crew commander, also a pilot, who was flying on the same flight and came to the cockpit with the children. According to an analysis of the “black box” audio track, Eldar’s attempts to correct the situation were greatly hampered by his lack of knowledge of pilot’s jargon. As an example, the command “Hold the helm!” was given, which the boy took as a command to hold the steering wheel in the extreme right position, while the pilots meant a command to level the plane.
Meanwhile, the roll had already reached 90°, and the plane began to lose altitude. In order to prevent further descent, the autopilot (only the roll automatic was turned off) increased the pitch angle to such an extent that the plane began to quickly lose speed and went into a stall. The co-pilot completely turned off the automatic control and managed to bring the plane out of the stall by lowering the nose. The overload decreased, and the commander finally managed to pull his son out of his chair and take his workplace. The pilots brought the plane into normal flight mode, but were unable to recognize their spatial position in time. Flying over a hill at low altitude, the plane caught on the edges of trees and crashed into the forest near the village of Maly Mayzas, about 20 kilometers southeast of Mezhdurechensk.
Consequences of the plane crash
During the investigation, conducted jointly by Aeroflot and Airbus, changes were made to the aircraft's documentation and Aeroflot's pilot training plan. In particular, now in the flight manual on the website airdisaster.ru
By the beginning of the playback of the magnetic recording of the conversations in the cockpit (17:26:52), there was a reserve PIC in the left pilot's seat, and a co-pilot in the right pilot's seat. The aircraft commander was resting in the passenger cabin.
From 17:40 onwards, the passenger PIC and the children of the reserve PIC were in the cockpit. At 17:43:31, the reserve PIC left his workplace without transferring control of the aircraft to the co-pilot, which was then alternately occupied first by his daughter and then by his son (in violation of the requirements of NPP GA-85 clauses 7.1.3; 7.1.4 ; 7.1.5).
In the time interval between 17:43:34 and 17:43:37, Yana sat in the left chair and at 17:44:10 asked her father to lift the chair up. At 17:47:06, the reserve PIC invited his daughter to “pilot” the plane (“Well, Yana, will you fly? Hold on to the helm, hold on”). In the period from 17:47:10 to 17:50:44, using the autopilot course setter to demonstrate control of the aircraft to the daughter, a maneuver was performed to the left from a course of 111° to 102°, then to the right to 115°, followed (after 2 minutes 40 sec . after the start of the maneuver) by the aircraft reaching the specified course of 102°. After the plane set out on this course, Yana vacated the PIC seat at 17:51:12, remaining in the pilot’s cabin.
For 7.5 minutes, when the reserve PIC's daughter occupied the PIC's pilot's seat, there were conversations between father and daughter, distracting the crew from monitoring the flight parameters.
From 17:50:04 to 17:50:46, the co-pilot made a report to the dispatchers of Novosibirsk-control and Novokuznetsk-control about the passage of Novokuznetsk and the planned time of passage of the Zakir checkpoint at 17:59.
At 17:51:55 the left PIC seat was taken by the son of the reserve PIC Eldar. The reserve PIC decided to demonstrate to him the principles of piloting an aircraft by performing a maneuver similar to that which had just been shown to his daughter. At 17:54:25, in response to his son’s request to “turn” the wheel, the reserve PIC gave permission and at 17:54:35 said: “So, watch the ground, where you will turn. Let's go left, turn left!"
The son of the reserve PIC, starting at 17:54:39, applied force to the left steering wheel, deflecting it to the left by 3...4° for 5 seconds. At the same time, the autopilot worked to counter the created roll by deflecting the right aileron. At 17:54:44, the reserve PIC switched on the “course setting” submode and turned the autopilot course setting handle to turn left by more than 15° from the initial course of 105°, which created a left bank of 21.5° and reduced the effort at the helm. At 17:54:52, with a left bank of 17...19°, the reserve PIC turned the adjuster handle to the right to return to the original course of 105°. The autopilot deflected the ailerons to reduce left bank.
Thus, unlike the previous maneuver, with the permission of the reserve PIC, his son applied force to the left control wheel, holding it in a position close to neutral
The co-pilot was holding the right steering wheel at this time, possibly protecting it from deviations by the son of the reserve PIC - from 17:54:58, the left or right or simultaneously both steering wheels were held in the position 3...5° to the right.
At 17:55:05 the plane went from a left bank to a right bank.
Holding the control wheels while the aircraft was performing turns with rolls varying in magnitude and direction led to resistance to the autopilot steering gear, the appearance of variable magnitude and direction forces on the held control wheels and was the cause of an unintentional unsignaled (instrumentally) disconnected autopilot from the aileron control wiring, which occurred at 17 :55:25 with an increase in the total forces on the steering wheels to 11...13 kg.
As studies have shown, the autopilot is disconnected from the aileron control while holding the steering wheel(s) occurs with forces less than those stated in the Flight Operations Manual (FManual) and other regulatory documentation (15...17 kg). By holding both control wheels, the forces between them can be distributed in such a way that the moment of disconnection may not be noticed by the pilot.
The Flight Manual lacks proper information, and the flight crew training program lacks methods and training to recognize when the autopilot is disconnected from the roll channel control and the peculiarities of piloting an aircraft with the autopilot disconnected from the roll channel.
Since during the overpowering process and after disconnecting the autopilot, the control wheels were held in a position corresponding to a slight deviation of the ailerons to the right bank, the aircraft continued to increase the roll. The increase in roll went unnoticed by the crew due to the distraction of unauthorized persons in the cockpit and the absence of light and sound signaling on the aircraft to indicate that the autopilot had been disconnected. Moreover, the alarm system available on the aircraft, even after disconnecting the autopilot, continued to provide the crew with information about its operation in the previously specified mode, although the autopilot stopped performing its function of stabilizing and controlling the roll channel.
When the bank reached 20°, at 17:55:36, the ailerons were additionally deflected by 1.5...2° to the right bank. It was not possible to determine to which of the steering wheels efforts were applied to additionally deflect the ailerons. Due to the additional deflection of the steering wheel, the aircraft's right roll began to increase more intensely, and by 17:55:49 it exceeded its operational limit of 45° and continued to go unnoticed by the crew. After reaching this roll, the autopilot could not fully perform its altitude stabilization functions. The plane went into descent.
From 17:55:12 to 17:55:36, the reserve PIC was distracted from monitoring his son’s actions and flight parameters by talking with his daughter.
At 17:55:36 Eldar, still in the left pilot’s seat, was the first to notice “something incomprehensible” and drew the attention of his father, who was busy talking with Yana: “Why is he turning around?” The reserve PIC replied: “Does it turn itself?” Eldar confirmed “Yes.” From that time on, the pilots in the cockpit began searching for an explanation for why the plane was “turning.” At 17:55:45, the PIC passenger suggested that the aircraft was leaving for the holding area and was supported by the co-pilot.
The autopilot, which continues to perform its functions in the pitch channel to maintain the flight altitude during the development of the roll even after the steering gear is disconnected, brought the aircraft to the aerodynamic shaking mode and high angles of attack.
The crew discovered a dangerous situation only by the increase in overload and the appearance of aircraft shaking (buffeting) from 17:55:52. By this time, the roll had reached more than 50°, the angle of attack was 4...4.5°, and the vertical overload was 1.6 units. Simultaneously with the appearance of buffeting, in 2 seconds the angle of attack changed from 4.5° to 10° with virtually unchanged deflections of the elevator and stabilizer, which indicates the manifestation of “pickup” in the angle of attack.
The reserve PIC gave the command “Hold! Hold the helm! Hold it!” and after 2 sec. after the appearance of buffeting at a bank of 63°, the co-pilot took vigorous measures to bring the aircraft out of the right bank by completely deflecting the control wheel to the left. At the same time, who understood the command addressed to him and literally the son of the reserve PIC, clamped the left steering wheel in a position close to neutral for 3...4 seconds, as a result of which the left aileron and three of the five spoilers on the left wing were not deflected. This, combined with an increase in the angle of attack, reduced the effectiveness of the aircraft's lateral control (although it did not have a decisive effect), which did not allow reducing the right roll, which reached 90° 19 seconds after turning the helm to the left.
The crew's actions to counter the roll were generally inadequate to the situation. Appropriate actions to bring the aircraft to operational angles of attack and restore lateral control would be to disable the autopilot, push back the control wheel to reduce the angle of attack, then bring the aircraft out of the roll and descent.
In the process of countering the roll, the autopilot, upon a signal to reduce the set flight altitude, deflected the elevator to a pitching position, which accelerated the aircraft's approach to high angles of attack and stall. At the same time, executing the commands of the reserve PIC and PIC-passenger “In the opposite direction, turn to the left!”, which they gave over the next 21 seconds, the son of the reserve PIC rejected the steering wheel, thereby preventing the co-pilot, who, with his short stature (160 cm), from piloting. and with the seat moved almost to the rearmost position, he already had limited capabilities for piloting the aircraft.
Between 17:55:58 and 17:56:11 the Altitude Departure (twice), Stall Warning and Autopilot Disable alarms were triggered.
At the same time, the aircraft, with a right bank of 80...90°, increased the pitch angle for a dive from -15° to -50° with an acceleration in speed with a vertical load factor of about 2 units.
The crew's intervention in the pitch control by deflecting the steering column led at 17:56:11 to disabling the autopilot and issuing a corresponding alarm.
After the autopilot was turned off, the automatic protection system against reaching high angles of attack was activated, which deflected the stabilizer into a dive from -1° to -0.5°. At the same time, the elevator was also deflected into a dive from -7.5° to +2.5°. These actions led to a decrease in the angle of attack to +7°, an increase in the average vertical speed of descent to 200 m/s, an increase in vertical overload and speeds above the maximum permissible values. At the same time, from 17:56:04 to 17:56:18, the crew lost spatial orientation due to the roll. Having restored his orientation, the co-pilot pulled the plane out of the roll by deflecting the steering wheel to the left. The plane remained in a dive with a pitch angle of up to 40°. The speed reached 740 km/h by 17:56:29. The co-pilot, taking the helm, deflected the elevator to pitch up to the mechanical stop, which created an overload of 4.6...4.7 units above the established strength limits.
The reserve PIC continued to try to occupy his workplace, giving cues to his son “Get out, get out!”, but Eldar, due to significant vertical overloads and the narrow space between the seat and the left side, could not get out of the seat.
Almost simultaneously with the elevator deflection to pitch up, the crew reduced the engine operating mode. The action of these two factors led to an intense drop in the indicated speed to 185...220 km/h by 17:56:41. At this moment, someone (either Eldar, getting up from his seat, or the reserve PIC, occupying it) sharply deflected the rudder to an angle of about 8° by involuntarily releasing the pedal. The plane went into a sharp right roll with the ailerons deflected to the left, performing a spin roll. After stalling and performing a spin roll at angles of attack of 30...35°, the aircraft went into a left rotation with an increase in the dive angle to 80...90° and a decrease in vertical overload to zero, i.e. to weightlessness.
At 17:56:54, the co-pilot, noticing the decrease in speed to less than 180 km/h, gave the command “Full throttle!” three times. At that moment the plane was almost in a vertical dive and in the initial acceleration phase. The position of the reserve PIC in the seat, who had taken his place by 17:56:40...17:56:46, with his height of 170 cm and the seat shifted to almost the rearmost position, did not provide normal control of the aircraft.
By 17:57:11 the speed had reached 370 km/h, the plane slowed down its roll rotation (the roll leveled off within 20...22°, the pitch angle decreased to -20°. With the elevator remaining deflected completely "towards itself", the plane went over The reserve PIC, by alternately deflecting the pedal against the rotation, tried to stop it, which he managed to do at 17:57:56 at an altitude of about 300...400 m. However, the elevator deflected to the nose could not ensure that the aircraft entered controlled flight. After stalling, having made two turns in a corkscrew to the left, with an average vertical speed of 75 m/s at 17:58:01 (0:58 on March 23 local time), the plane collided with the surface of the earth, completely collapsed and partially burned. passengers died.
March 22, 1994 in the Mezhdurechensk area (Kemerovo region) at 20 o'clock. 58 min. An Airbus A-310, owned by Russian Airlines and flying on the Moscow-Hong Kong route, crashed and crashed. There were 63 passengers and 12 crew members on board the plane. The opening of the black boxes subsequently showed that the cause of the disaster was the human factor, poor knowledge of this type of equipment by the crew and a gross violation of instructions.
3.5 hours after takeoff, crew commander Yaroslav Kudrinsky called his two children into the cockpit - daughter Yana and son Eldar, where, in violation of the regulations, he allowed first his daughter and then his son to sit in the ship’s commander’s chair. This circumstance was ignored by other crew members. In addition, in the cockpit was a friend of the Kudrinsky family, Makarov, also a pilot, flying on the same flight as a passenger.
Before allowing the children to take the command seat, Kudrinsky turned on the autopilot. First, the commander’s daughter, 13-year-old Yana Kudrinskaya, was in the pilot’s seat. She did not attempt to take any action to control the aircraft. After her, the captain’s son, 15-year-old Eldar Kudrinsky, took the helm. The teenager held onto the steering wheel, rocking it slightly from side to side. Everything was perceived as entertainment and adults had no control over the teenager. At one point, the guy shook the steering wheel harder and the autopilot, mistaking this for the pilot’s command, turned off. In one second, the plane became obedient to the teenager, who continued to play pilots.
The light alarm for disabling the autopilot mode went off, but the crew did not notice this, since a design feature of the A310 is the absence of an audible alarm for disabling the autopilot. Once again tilting the steering wheel to the side, the boy put the airbus into a deep roll, which soon reached 45 degrees and caused an overload of about 5g. In the first seconds, both professional pilots for several seconds could not understand the reason for the abnormal behavior of the aircraft. And when the crew members noticed that the autopilot was disabled, they tried to take their seats again.
Contrary to the instructions, the co-pilot, in the absence of the commander in his seat, moved his seat all the way back, which for a long time did not allow him to take a working position due to the overloads that had arisen. And the aircraft commander, due to strong overloads and a large roll angle, could not get into his seat for a long time.
The situation was greatly complicated by the fact that in the left seat there was still the only person who had the physical ability to control the plane - the 15-year-old son of the commander, who received and tried to carry out various, inconsistent and contradictory commands from his father, the co-pilot and Makarov. According to an analysis of the “black box” audio track, Eldar’s attempts to correct the situation were greatly hampered by his lack of knowledge of pilot’s jargon. As an example, the command “Hold the helm!” was given, which the boy took as a command to hold the steering wheel in the extreme right position, while the pilots meant a command to level the plane.
Meanwhile, the roll had already reached 90°, and the plane began to lose altitude. In order to prevent further descent, the autopilot (only the roll automatic was turned off) increased the pitch angle to such an extent that the plane began to quickly lose speed and went into a stall. The co-pilot completely turned off the automatic control and managed to bring the plane out of the stall by lowering the nose. The overload decreased, and the commander finally managed to pull his son out of his chair and take his workplace. The pilots brought the plane into normal flight mode, but were unable to recognize their spatial position in time. Flying over the hill at low altitude, the plane caught on the edges of trees and crashed into the forest near the village of Maly Mayzas, about 20 kilometers southeast of Mezhdurechensk.
Crew negotiations, chronology of events
Symbols used in the text:
PIC - aircraft commander Ya. V. Kudrinsky
Yana is the commander’s daughter, born in 1981.
Eldar - son of the commander, born in 1978.
2P - co-pilot I.V. Piskarev
Makarov - pilot flying to Hong Kong as a passenger
E - one of the pilots in the cockpitAbout half an hour before the disaster. The plane flies on autopilot. In the cockpit there are the aircraft commander, the co-pilot and two strangers - the aircraft commander's daughter Yana and passenger Makarov.
17:43:30: PIC [addressing his daughter Yana]: Come sit here now, on my chair, do you want to?
17:43:31: PIC left his workplace
17:43:34-17:43:37: Yana sat down in the PIC chair
17:44:10: Yana: Dad, lift me up [Yana asked to lift her chair up]
2P: Novosibirsk, Aeroflot, 593rd we pass your point at flight level 10,100.
17:47:06: PIC: Well, Yana, will you pilot?
Yana: No!
PIC: Don't press the buttons. Don't touch this red one!
Yana: Dad, can this be played?
PIC: Do you see Novokuznetsk on the left?
Yana: Are we flying so low?
PIC: Ten thousand one hundred meters.
Yana: That's a lot, right?
KVS: A lot...
Yana tries to leave the chair.
PIC: Wait, don’t rush...
Yana: I’m already careful...
17:51:12: Yana left the PIC chair
The son of the aircraft commander, Eldar, appears.
17:51:47: Makarov: The counter is being removed.
17:51:55: Eldar sat down in the PIC chair.
17:52:46: Eldar [addressing Makarov]: Are you filming?
17:52:48: Makarov: I’m filming.
Eldar: Can this be turned?
17:54:25: PIC: Yes! If you turn left, where will the plane go?
Eldar: Left!
PIC: Turn! Turn left!
17:54:35: PIC: So, watch the ground, where you will turn. Let's go left, turn left!
Eldar: Great!
17:54:37: PIC: Off I go, huh?
17:54:39: Eldar turned the helm to the left by 3..4 degrees.
17:54:40: PIC: Is the plane going to the left?
17:54:41: Eldar: Coming.
17:54:42: PIC: Not visible, right?
E:< неразб>
17:54:50: E: Now it will go to the right
17:54:53: Makarov: Set the attitude indicator for him properly.
17:05:05: The plane began to roll to the right.
17:55:12: PIC: What do you want, Yana?
Yana:< неразб>
17:55:15: PIC [addressing Yana]: Why?
Yana:< неразб>
17:55:18: PIC [addressing Yana]: In first class you will only sleep.
17:55:27: PIC [addressing Yana]: Don’t run around there, otherwise they’ll kick us out of work.
17:55:28: From this time on, unnoticed by either the PIC or the co-pilot, a gradual increase in the right roll began.
17:55:36: Eldar [about the plane’s course]: Why is it turning?
17:55:38: PIC: Does it turn itself?
17:55:40: Eldar: Yes.
17:55:41: E: Why does he turn?
17:55:42: Eldar: I don’t know.
17:55:45: PIC: You won’t throw off the course?
17:55:45: Makarov: He’s still moving the zone, guys. [Makarov assumed that the plane was leaving for the holding area]
17:55:46: 2P: We went to the area, waiting.
17:55:48: PIC: Yes?
17:55:49: 2P: Of course.
17:55:50: Makarov: Damn! [Thus Makarov reacted to the rapid increase in vertical overload in the plane]
17:55:52: PIC: Hold it! Hold the helm, hold it!
17:55:55: 2P: Speed!
17:55:56: 2P: In the opposite direction.
17:55:58: 2P: In the opposite direction.
17:55:59: 2P: Back!
17:55:59: PIC: Turn left! Left! Right! Left!
17:56:06: E: Right?
17:56:08: E: You don’t see, or what?
17:56:11: Autopilot disabled.
17:56:14: E: Turn right.
17:56:17: PIC: Right!
17:56:18: 2P: Yes, to the left! The earth is here!
17:56:24: FAC: Eldar, come out!
17:56:26: PIC: Crawl back.
17:56:28: PIC: Crawl back, Eldar.
17:56:30: E: You see< неразб>No?
17:56:34: 2P: Small ores!
17:56:38: PIC: Come out!
17:56:40: E: Come out, Eldar.
17:56:41: E: Come out< неразб>.
17:56:43: E: Come out.
17:56:44: E: Come out.
17:56:47: E:< неразб>.
17:56:49: E: Come out.
17:56:52: E: Come out, I say.
17:56:54: 2P: Full throttle! Full throttle! Full throttle!
17:56:55: By this moment, the PIC had taken his workplace.
17:56:56: 2P: Gave on the gas!
17:56:57: PIC: Full throttle!
17:56:58: 2P: Gave!
17:56:59: E:< неразб>.
17:57:00: E: Full throttle.
17:57:05: E: I gave it gas, I gave it.
17:57:08: E: What is the speed?
17:57:09: E:< неразб>.
17:57:13: E:< неразб>.
17:57:17: E: Yes.
17:57:23: PIC: Full gas!
17:57:25: 2P: The speed is very high!
17:57:27: E: Big, right?
17:57:28: E: Big.
17:57:29: E: I turned it on.
17:57:30: PIC: Okay, that’s it, let’s go out, let’s go out.
17:57:32: PIC: Right! Leg to the right!
17:57:35: PIC: High speed.
17:57:36: PIC: Turn off the gas!
17:57:37: 2P: Cleaned it up!
17:57:42: PIC: Quietly!
17:57:47: 2P: B..., again!
17:57:48: E: Don’t turn to the right.
17:57:50: E: Added speed.
17:57:53: PIC: Let's go out now! Everything is fine!
17:57:55: PIC: Slowly on yourself.
17:57:56: PIC: Slowly.
17:57:57: PIC: Slowly, I say!
17:58:01: The plane collides with the ground.
During the investigation, conducted jointly by Aeroflot and Airbus, changes were made to the aircraft documentation and the Aeroflot pilot training plan. And during simulator flights performed by Russian instructor pilot Vladimir Biryukov together with Airbus test pilots, it turned out that if both pilots were unable to reach the controls, the automatic control system would be able to take over control and quickly restore a straight-line safe flight.
© Bureau of Aircraft Accidents Archives. Plane crash site
22 Mar 2019, 13:17March 23 marks the 25th anniversary of the crash of the Airbus A310 airliner near Mezhdurechensk. 75 people died. The cause of the disaster was that the pilot put his son at the controls. Taiga.info recalls the most unusual disaster in the history of Russian aviation and tells what has changed after a quarter of a century.
Causes of the tragedy
On the evening of March 22, 1994, an Airbus A310 airliner of Aeroflot (RAL) took off on the route Moscow - Hong Kong. Passing near Mezhdurechensk (at 00:58 local time), the plane crashed in the forest near the village of Maly Mayzas.
75 people died: 63 passengers and 12 crew members. In addition to the Russians, there were citizens of China, Hong Kong, India, Great Britain and the USA on board. It is known that the hero of Socialist Labor Dmitry Melnikov and the avant-garde director Igor Aleinikov flew on this flight. As Igor Muromov notes in his book “100 Great Air Disasters,” the passengers were “wealthy people.”
The cause of the plane crash was the human factor - the commander of the airliner put his 15-year-old son at the helm, the teenager’s actions led to the autopilot being turned off and the plane crashing (falling from the flight level).
For the last three hours, the plane flew without deviations from the plan, all systems worked properly. According to the investigation report, there were “simple weather conditions” on the night of the disaster.
What is known about Airbus A310 pilots?
Flight SU 593 Moscow - Hong Kong included aircraft commander Andrei Danilov, reserve PIC Yaroslav Kudrinsky, co-pilot Igor Piskarev - all first class pilots. Before the flight, they underwent a medical examination: there were no comments regarding their health or professional training. Each of the pilots had a family and children.
Kudrinsky was taking his children - 15-year-old Eldar and 13-year-old Yana - on a four-day vacation to Hong Kong. Once a year, Aeroflot provided the families of pilots with the right to a preferential flight.
Negotiations in the cockpit before the crash
30 minutes before the crash, commander Kudrinsky and co-pilot Piskarev are in the cockpit. Commander Danilov, who served the required amount of time at the helm, is resting in the passenger compartment.
From 00:40 local time, Kudrinsky’s children and his friend Makarov, also an experienced Aeroflot pilot who was flying as a passenger, entered the cockpit. In fact, only Kudrinsky is responsible for piloting the plane. He invites Yana to sit in the pilot's seat.
Come sit on my chair, would you like?
The girl replaces her father at the helm.
Dad, lift me up [in the chair], she asks.
Well, Yana, will you pilot? Hold on to the helm, hold on.
After about 5 minutes, the plane turns left and then right, after which it enters the program course. Kudrinsky shows his daughter how to control the plane using the autopilot. Later, in the accident investigation report, this maneuver will be regarded as a “distraction for the crew.”
Yana vacates the helm, and Eldar takes her place. A friend of the Makarov family is filming what is happening in the cabin on a video camera. Kudrinsky shows Eldar the same maneuver as for Yana. Three minutes before the crash, the son asks to “turn” the steering wheel:
Can this one be rotated?
Yes, - the father allows. - So, watch the ground, where you will turn. Let's go left, turn left.
Eldar executes the command - a properly working autopilot reacts to this. The automatic control of the ailerons responsible for the roll of the aircraft is disabled. Further, piloting is essentially carried out manually, but no one notices the fact that the autopilot is turned off.
After ten seconds, the plane gradually moves to the right and reaches a critical bank. Eldar notices “something incomprehensible”:
Why is it [the plane] turning?
Does it turn on its own? - Kudrinsky clarifies.
The pilots do not understand what is happening to the plane. Makarov suggests that the plane entered the “holding zone” - the space for waiting for the landing approach. Piskarev and Kudrinsky agree with him. (The navigation display may be displaying “false” flight paths.)
The plane falls into a deep roll, the pilots do not notice this immediately. Overload is growing.
Guys! - Makarov drawls.
Hold it! Hold the helm, hold it! - Kudrinsky shouts to his son, noticing the shaking.
The co-pilot tries to pull the plane out of the right bank, but it’s too late - the plane is tilted 90 degrees, it begins to stall.
In reverse! Turn left! Left! - Kudrinsky and Makarov command alternately.
Pilot Piskarev gives the same commands to Eldar, but the boy interferes with his actions by holding onto the steering wheel. (The commission that conducted the investigation calls the crew’s actions to counter the roll “inadequate to the situation.”)
The plane departs from a given altitude, the “Stall Warning” signal appears in the cockpit, and the autopilot turns off.
Yes to the left! The earth is here! - Piskarev shouts.
Eldar, come out! Crawl back.
Apparently, the crew is bringing the plane out of a deep roll, but the airliner goes into a dive and picks up speed. The overload reaches 4.6 units - approximately the same amount astronauts experience when descending to Earth. Kudrinsky is trying to take the helm, but under overload conditions Eldar cannot get out of his chair.
After 30 seconds, the plane enters a “spin” and a vertical dive begins. After several attempts, Kudrinsky finally takes his place. (The commission of investigation believes that at the moment of the “spin” the crew could still bring the plane into controlled flight modes.)
Full throttle! - Piskarev shouts.
Gas on! - Kudrinsky answers.
The speed is very high! Remove the gas! Little by little!
Let's go out now! Everything is fine! Slowly, damn it!
At 0:58 the plane collides with the ground in the vicinity of the village of Maly Mayzas. The liner is completely destroyed and a fire starts.
Decoding black boxes:
What did the plane pilots violate?
According to the commission, commander Kudrinsky left his workplace and put his 15-year-old son Eldar, who did not have the appropriate rights and qualifications, at the helm.
According to NPP GA-85 (manual for flight operations in civil aviation), “the commander is allowed to leave the workplace under favorable flight conditions.” In this case, control of the aircraft falls on the co-pilot. The commission of investigation calls the actions of commander Kudrinsky “complete carelessness and a consequence of low discipline.”
Another violation: Eldar Kudrinsky and co-pilot Piskarev acted against the autopilot - as a result, the system ceased to be responsible for the aircraft’s roll state. Probably, the fact that the autopilot was disengaged was not noticed by the crew due to the absence of a warning signal in the cockpit. It is possible that the co-pilot and PIC Kudrinsky did not have time to react to the sudden transition to manual control mode.
The crew noticed the tilt late - the plane began to fall. The crash investigation commission calls the actions of pilot Piskarev “inadequate and ineffective” because he did not disable the autopilot in a critical situation. The Airbus A310 operating manual states that operating against the autopilot is an "abnormal procedure".
Also, Piskarev could not level the plane because Kudrinsky’s son Eldar was at the second helm.
“After all, children have been put at the helm before. In fact, there’s nothing wrong with a kid sitting in the pilot’s seat while the autopilot controls the plane. The question is different: what was the happy father’s “partner” doing while he was working with his son?” - recalled seven years after the accident Vladimir Kofman, then chairman of the commission to investigate MAK plane crashes.
First versions after the crash. Why did the Novokuznetsk riot police come?
The crash of the airliner became known only two hours after the disaster - after the crew stopped responding to requests from ground services. A local resident reported burning wreckage of a plane in the forest. A group of policemen moved out from the village of Maly Maizas to cordon off the area.
The search helicopter immediately discovered a strong fire, but was unable to land due to the mountainous, forested terrain and poor visibility. Rescuers were unable to approach the crash site for a long time: only by noon on March 23 were they able to build a toboggan road, when, in fact, there was no one left to save. For three days, 238 people carried out emergency work, searched for and evacuated bodies.
Journalist Vasily Gorbunov, who flew in with the rescuers, recalled the strong smell of kerosene and fragments of the plane scattered over half a kilometer. Two of the three black boxes were seriously deformed.
“It looks like the plane literally crashed to pieces. Almost everything that was left of the people was pressed heavily into the snow. Cans of beer, bags, clothes, dollars are scattered everywhere,” Gorbunov said in Igor Muromov’s book.
Jewelry, several thousand dollars, and gold jewelry were found at the crash site. Apparently, many passengers on the Airbus were flying to Hong Kong on vacation. During the search operation, troops and the Novokuznetsk riot police had to be used to protect the place from looters.
At first, employees of the Ministry of Transport and the Ministry of Emergency Situations expressed theories about a terrorist attack, an instant depressurization of the cabin, which occurred as a result of an explosion or collision with a foreign object. Deputy Head of the Air Transport Department of the Ministry of Transport Yuri Korenevsky noted that the preparedness and professionalism of the crew was beyond doubt.
“The case was unprecedented,” recalled Vladimir Kofman after the investigation. “At that time, as they say, we did not have enough conscience or courage to declare that the plane was destroyed by a child.”
What has changed since the investigation?
The investigation into the crash ended in March 1995, with experts identifying a number of shortcomings in the field of civil aviation. It turned out that in Russia there was no document regulating the acceptance of foreign aircraft for operation. The corresponding order was adopted only in 2003.
The crash of the airliner had a negative impact on Aeroflot's image. According to the results of the first half of 1994, the airline lost about 30% of potential passengers. By 1996, Aeroflot had paid compensation (minimum amount - 20 thousand dollars) to 80% of the victims' relatives. The rest of the relatives were not satisfied with the amount of payments; they went to court.
As investigative experts note, the crew of the Moscow-Hong Kong flight did not have the appropriate training to bring the plane out of the “spin.” In 1999, Aeroflot and the Airbus Industrie consortium launched Russia's first simulator for pilots of the A310 airliner. It was possible to simulate the situation in which the airliner found itself when it crashed near Mezhdurechensk.
In 2015, the Federal Air Transport Agency punished Saratov Airlines for “gross non-compliance” with safety rules: an acquaintance of the airline’s general director, who was not a crew member, was flying in the cockpit. The woman was allowed on board under the wording “official passenger.” Saratov Airlines has been restricted from flying to international destinations.
Prepared by Egor Fedorov
The plane crash of flight SU593 occurred on March 22, 1994 near Mezhdurechensk in the Kemerovo region. As a result of the crash of the Aeroflot airline A310, all 75 people on board were killed.
The main cause of the disaster was an unacceptable situation in which the aircraft commander put his fifteen-year-old son at the controls of the airliner, whose unintentional actions led to a partial shutdown of the autopilot. Secondary reasons were the undocumented behavior of the autopilot, and the absence, at that time, of rules for making decisions in such situations in the crew training program.
Catastrophe
Flight 593 was operated on an Airbus A310-304 (tail number F-OGQS) from Moscow Sheremetyevo Airport to Hong Kong. The crew commander Yaroslav Kudrinsky took on board his two children - daughter Yana and son Eldar. When the plane flew in the Novokuznetsk area, Kudrinsky, in violation of the regulations, allowed first his daughter and then his son to sit in the ship’s commander’s chair. This circumstance was ignored by other crew members.
Before allowing the children to take the command seat, Kudrinsky turned on the autopilot. The commander's daughter did not try to take any action to control the plane. After her, the captain’s son, 15-year-old Eldar Kudrinsky, took the helm. The child held the steering wheel, slightly rocking it from side to side, which could not lead to the autopilot being turned off by “overpowering.” However, in the end, Eldar applied a force of 12-14 kg to the steering wheel, which led to a partial shutdown of the autopilot, which stopped sending commands to the ailerons, which caused an uncontrolled roll to the right. Before this, this feature of the A-310 autopilot was unknown. The light signaling system for disabling the mode went off, but the crew did not notice this, since a design feature of the aircraft is the absence of an audible signaling system for disabling the autopilot.
The plane turned to the right along the longitudinal axis at a speed of 1.5° per second, and soon the right roll reached 45°, which is above the permissible limit. This caused significant positive g-forces (4.8 g). When the crew members noticed that the autopilot was disabled, they attempted to resume their seats. This was not difficult for the co-pilot, since his seat is on the right side of the cockpit, and the plane was banked to the right. The commander could not get into his seat for a long time due to severe overload and a large roll angle.
Meanwhile, the roll had already reached 90°, and the plane began to lose altitude. In order to prevent further descent, the autopilot (only the roll automatic was turned off) increased the pitch angle to such an extent that the plane began to quickly lose speed and went into a stall. The co-pilot completely turned off the automatic control and managed to bring the plane out of the stall by lowering the nose. The overload decreased, and the commander finally reached his place. Now the plane was quickly gaining speed and rapidly losing altitude. The crew reduced the engine operating mode and pulled the steering wheel to the limit, but the altitude reserve was not enough, and 2 minutes 6 seconds after entering the spin, the plane crashed into the forest several kilometers southwest of Mezhdurechensk.
Transcript of negotiations
Co-pilot: Novosibirsk, Aeroflot, 593rd we are passing your point at flight level 10,100.
Commander: Well, Yana, will you pilot?
Yana (sitting in the ship's commander's chair): No!
Commander: Don't press the buttons. Don't touch this red one!..
Yana: Dad, can this be played?
Commander: Do you see Novokuznetsk on the left?
Yana: Are we flying so low?
Commander: Ten thousand one hundred meters.
Yana: That's a lot, right?
Commander: A lot...
Yana tries to leave the chair.
Commander: Wait, don't rush...
Yana: I’m already careful...
The son of the Eldar ship commander appears. Sits in the first pilot's seat.
Eldar: Can this be turned?
Commander: Yes! If you turn left, where will the plane go?
Eldar: Left!
Commander: Turn! Turn left!
Eldar: Great!
Commander: Is the plane going to the left?
Eldar: Coming.
Several minutes pass.
Eldar: Why is he turning around?
Commander: Does it turn on its own?
Commander: Hold the helm!
Pilot: Speed!
Commander: Turn left! Left! Right! Left! The earth is here! Eldar, come out!
Get out, Eldar! Come out! Come out! Come out! Come out! Come out, I say! Full throttle!
Pilot: Gave the gas!
Commander: Full throttle!
Pilot: Yes!
Commander: Gas full!
Pilot: The speed is very high!
Commander: Yes! Let's go out! Right! Leg to the right!
Commander: Turn off the gas!
Pilot: Cleaned it up!
Commander: Quietly!
Pilot: B..., again!
Commander: Let's go out now! Everything is fine!
Commander: Slowly, I say!
End of recording.
Audio recording of negotiations