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I like this analysis because it highlights that airliners and their working cultures are the primary cause of these crashes. Quite often, unfortunately, the presenters only point at violations and waive their hands: "why on Earth?" But in reality, personell often skips procedures under the pressure of the management, and this works without consequences. In this Armavia case, the crew had an option to not fly at all, but I suspect, hesitated to delay, expecting being reprimanded (even if unjustly).


I feel like that's a mis-reading of the situation here. Yes, there was cultural friction (Russian ATC vs International norms). Yes, these guys were pushing the envelope of operating conditions. That all influenced the creation of this situation. But when push came to shove none of that actually made them crash. Blindly going around is something any IFR pilot can do and they had two pilots. If either one person had just flown the damn plane they wouldn't have wound up in the drink. Trying to incessantly push buttons and turn knobs to make the plane track some imaginary line thorough the sky that procedure said they should follow is what killed them. They didn't run out of flying talent. They ran out of button pushing talent.

Or, of course they could have fully committed to procedure and a) gone home b) gone to their alt airport. But that's kind of uninteresting because if they didn't crash the next guys flying an A320 in on a foggy early morning could have repeated the same mistakes.


Putting blame on two individuals that "just" could not push the buttons right, you ignore the whole text around that.

Who created many of the stressful conditions (flight at 1 am and crew not had enough rest), put the underskilled captain there, and pushed the pilots to not do delay and overcome weather? Management.

Could they have spoken up? Maybe, but management creates a system that suppresses such individual protests and penalize them.

CRM in aviation (created back in the 1980s) made aviation in the Western countries almost 0-fatalities for over 2 decades now. And what it did was to not to scrutinize the men at the flight stick, that push the wrong buttons, but look at the process and management, and fix them first.


You have it backwards. I'm saying that the standard operating procedures and the normal "computer operator" like way of performing a landing or go-around caused perfectly qualified pilots to botch what should have been a simple go-around that either of them likely could have pulled off drunk and blindfolded.

I think if they had kicked everything off and flown it rawdog from the instant they were told to go around everyone would be alive but they remained too dedicated to doing things "by the book" until it was too late and they had been too confused by the system behavior and didn't have the situational awareness to fly it manually.

Sure, the stress of the situation, the poor communication, etc, aren't ideal and surely contributed to lining up the dominoes here but the final straw was the go-around process.


This is the outcome of almost all of her crash analyses. They're all worth a read IMHO


Sort of. Some are the lessons in blood that made the industry safer. Some are the (sometimes) shitty result of capitalism (like the Alaska Airlines crash).


Almost all are lessons in blood that made the industry safer. Still, almost all have at least part of the blame (and more often than not a BIG part) on the airline, for cutting corners one way or another (maintenance, personnel, training, ...)


Exactly that -- the airline was making the crew fly late at night without rest, not the crew. Also notice they mention the crew was committed to landing and not delaying the flight -- knowing post-soviet authoritarian management style, I suspect they expected a tough talk with the seniors, had they delayed the flight (a 1-2 hour delay of departure would probably exceed crew's working day and need an even bigger delay and a new crew).

Also, it's just the culture. Many Russian planes like Il-76 land on the front wheels. Why? There's an old belief that you need to fly a bit faster than in the operation manual. To avoid stalls, just in case. I guess, it's an old superstition from the military. Until the last decade, it wasn't reviewed, just perpetuated over generations of pilots.

Often, such companies demand soft touchdowns and reprimand for hard touchdowns. Combined with overspeed, this produced 2012 Red Wings crash[1] -- the plane touched down so softly, and was significantly overspeed, that interceptors and reverse thrusters didn't turn on, and the plane kept just touching the surface without braking.

All this can only be fixed by fixing the management. And that's what CRM system focuses on.

[1] https://en.wikipedia.org/wiki/Red_Wings_Airlines_Flight_9268




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