Name: David, Arvin John A.

Section: AE- 502

Subject: Reliability Engineering

Title:
Aeroflot Flight 593: Children in the Cockpit, Moscow to Hong Kong March 23, 1994
Executive Summary:
On the 23rd March 1994, an Airliner Airbus A310-304 crashes into a hillside of the Kuznetsk Alatau mountain range,
Kemerovo Oblast, Russia, killing all 63 passengers as well as 12 crew members on board. This Aeroflot Flight 593 was a
scheduled flight from Sheremetyervo International Airport, Moscow to Hong Kong Kai Tak International Airport. The
relief Captain Yaroslav Kudrinsky, throughout the flight allowed his son (Eldar Kudrinsky) and daughter (Yana
Kudrinsky) to enter the flight deck and sit at the controls while in autopilot as they headed to Hong Kong. During in
which they were at the controls, Kudrinsky adjusted the autopilot’s heading to give his children the perception that they
were actually turning the plane. While Kudrinsky’s son was at the controls he applied enough pressure to the control
column to disable the autopilot. This caused the aircraft to bank at an angle that was more than 45 degrees, which resulted
in the aircraft to dive nose down. During the dive, although the first officer managed to regain some control once it was
out of the dive it eventually lead to the stalling of the aircraft and plummeted to the ground before the control was fully
recovered by the captain.

Findings:
2 Hours after the crash the search was begun to locate the crash of Flight 593. It was soon clear there were no survivors of
the crash putting the total of fatalities to 75 people. Initial speculation was that it was a form of terrorist act, but was soon
ruled out after the analysis of the cockpit voice recorder. The Russian government authorities conducted the investigation
and determined that the main cause of the crash was due to pilot error.
The poor decision made by the Captain to allow his children to be at the controls and manipulate the aircraft even though
the aircraft was on autopilot was a key factor that leads to the crash.
The lack of authority shown when the aircraft was beginning to lose its direction was another element that should have
been addressed.
Complacency with the condition of the flight as well as not following protocols in the situation experienced further
doomed the flight.
The crew’s unfamiliarity with the foreign built Airbus A310, the crew of Flight 593 was not aware of an aspect to the
aircraft, that when force was enforced on the controls that the auto pilot will partially disengage, without a warning sound.

Probable Cause:

The A310 disaster was caused by a stall, spin and impact with the ground resulting from a combination of the following
factors:
1. The decision by the PIC to allow an unqualified and unauthorized outsider (his son) to occupy his duty station and
intervene in the flying of the aeroplane.
2. The execution of demonstration manoeuvres that were not anticipated in the flight plan or flight situation, with the
PIC operating the autopilot while not at his duty station.
3. Application by the outsider and the co-pilot of control forces that interfered with the functioning of the roll channel of
the autopilot (and are not recommended in the A310 flight manual), thus overriding the autopilot and disconnecting it
from the aileron control linkage.
4. The co-pilot and PIC failed to detect the fact that the autopilot had become disconnected from the aileron control
linkage, probably because:
- The A310 instrumentation has no declutch warning. The provision of signals in accordance with the requirements of
Airworthiness Standard NLGS-3, para. 8.2.7.3., and international recommended practices, could have enabled the
crew to detect the disengaged autopilot in a timely manner.
- The co-pilot and PIC may have been unaware of the peculiarities of the declutching function and the actions to be
taken in such a situation because of a lack of appropriate information in the flight manual and crew training
programme;
- It was difficult for the co-pilot to detect the disengagement of the autopilot by feel, either because of the small
forces on his control column or because he took changing forces to be the result of Eldar's actions;
- The PIC was away from his position and distracted by the conversation with his daughter.
5. A slight, unintentional further turn of the control wheel(s) following disengagement of the autopilot caused a right
roll to develop.
6. The PIC and co-pilot failed to detect the excessive right bank angle, which exceeded operating limits, and were late in
re-entering the aircraft control loop because their attention was focussed on determining why the aircraft had banked
to the right, a manoeuvre they interpreted as entry into a holding area with either no course line or with a new (false)
course line generated on the navigational display.
A strong signal indicating that the aeroplane had exceeded the allowable operating bank angle, taking account of the
delay in recognizing and assessing the situation and making a decision, could in this situation have attracted the
crew's attention and enabled them to detect the bank at an earlier stage.
7. The aeroplane was subjected to buffeting and high angles of attack because the autopilot continued to perform its
height-keeping function even after the actuator declutched and as the right roll developed, until the pilot disconnected
it by overriding its longitudinal channel.
8. Inappropriate and ineffective action on the part of the co-pilot, who failed to disconnect the autopilot and to push the
control column forward when the buffeting occurred and the aeroplane entered an unusual attitude (high angles of
attack and pitch). These actions, which caused the aeroplane to stall and spin, could have resulted from:
- the presence of an outsider in the left-hand pilot's seat and the resulting delay before the PIC re-entered the
aeroplane control loop;
- the less-than-optimum working posture of the co-pilot, whose seat was pushed back to its rearmost position;
- the occurrence, 2 seconds following the onset of buffeting, of an unintentional pitching up of the aeroplane, which
sharply increased the angle of attack and reduced lateral controllability;
- unpreparedness of the crew to act in this situation because of lack of appropriate drills in the training programme;
- temporary loss of spatial orientation in night conditions.

Recommendations:

In order to improve state oversight of flight safety, proposals should be prepared and submitted to the Government of the
Russian Federation concerning the strengthening of state inspection units and the inclusion of highly qualified specialists
within them. The necessary steps should be taken to increase cockpit discipline in flight and to organize effective
monitoring of compliance with flight procedures, using airborne voice and data recorders. Flight crew training should be
improved to take account of the special factors revealed by the investigation of this accident, including the monitoring of
aircraft attitude during instrument flight and methods of recovering from unusual attitudes. Review the question of
creating, within the Russian civil aviation system, single-type operations centres for aircraft of foreign manufacture.
Together with the aircraft designers and in cooperation with specialists from the research organizations of the Russian
Federation, determine the measures necessary to prevent aeroplanes from exceeding their operating bank and angle of
attack limits and to prevent the autopilot from disengaging its aileron control function without warning. Make a number of
amendments and additions to the A310 flight manual and other regulatory documents in response to the material in the
Report and the shortcomings revealed during the accident investigation.
Source:
https://reports.aviation-safety.net/1994/19940323-0_A310_F-OGQS.pdf
http://aviationknowledge.wikidot.com/asi:aeroflot-flight-593:child-in-the-cockpit