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June 22, 2019

The deadly crash of SU 1492 and pilot errors

I am not a native English speaker and perhaps I'm quite wrong about this, but in my mind, a "pilot error" is an error that a pilot commits. He needs to press the top rudder, but he presses a bottom rudder — a deadly error. In case of Atlas 3591, the error is hitting the TOGA button. So, when my friend Kirill said that the crash of SU 1492 was caused by "pilot error", I was very tempted to deliver a lecture. Well, Kirill is more correct than journalist Mike Eckel when he blames lightning. Still, it's not an error that killed 40 passengers, it's a series of strange actions by the captain that followed his error. In a way, I want to draw a distinction between a pilot error and pilot incompetence.

Errors are abundant in pilot's life, but what matters is what happens after tthem. Just a week ago, I made an error following a takeoff from Big Spring, Texas: forgot to raise the gear. So, I detected an anomaly (the aerodynamic noise), identified a root cause (my error), and took a corrective action (lifted the nose sufficiently for the airspeed to decrease below Vlo and raised the gear).

Of course, incompetence prompts errors, sometimes dangerous ones. Worse, it results in errors in response to errors, thus contributing to an accident chain. So, I guess we can consider SU 1492 as a sequence of errors: let the airplane settle below the glideslope, keep the power on for too long, thus causing an overspeed at touchdown and a bounce, command a nose-down input that turns a bounce into a porpoise, forget that spoilers do not deploy automatically, fixate on sticking the landing instead of going around. But I think it is more productive to look at the episode as a whole, rather than decompose it into pilot errors. Maybe we can talk about deficient training and lax standards at Aeroflot instead.

Posted by: Pete Zaitcev at 11:19 AM | No Comments | Add Comment
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