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The Aeroflot flight AFL 593 accident was a classic case of human factor accident in the aviation industry. In the evening hours of March 23, 1994, the aircraft was en route to Kai Tak Airport in Hong Kong from Sheremetyevo International Airport in Moscow (Hayward and Hardimanm, 2022). The report shows that the plane had 75 occupants, 12 of which were crew members and 63 were passengers. A majority of the people on board this plane were Russians and Chinese. It was also noted that there was a proportionately high number of pilots on that plane, some of whom were on a holiday to Hong Kong. There were at least 4 pilots on that day, although only 2 were on active duty on that day. The conditions of flying were perfect on that morning and no one suspected that there would be any trouble at any stage of the flight.
The aircraft was a new plane, Airbus A310-304, which had just been delivered to the company slightly over one year prior to the accident. This was a major shift from the Soviet types of planes that employees of this company had gained massive experience on over the years. Bureau (2022) explains that the warning system in this new plane was significantly different from the Soviet planes. While Airbus A310-304 used warning lights when its autopilot was partially disengaged, the pilots were used to the Soviet planes that gave a sound, making it difficult to ignore (Bureau, 2022). It was estimated that the pilots on this plane had an average of 900 hours flying this type of aircraft. Although its autopilot system was superior to the Soviet planes, making it easier to fly, the lack of experience was a major cause of concern. Figure 1 below shows the specific aircraft that was involved in the accident, a few weeks before the crash.
Aviation experts who reviewed the case believe that the lack of experience on this type of aircraft made all the difference. Without any distress call to the tower, the plane disappeared from the radar. A search team would later locate the planes wreckage on the mountain ranges of Kuznetsk Alatau in Kemerovo Oblast (Hayward and Hardimanm, 2022). None of the 75 people onboard the aircraft survived the impact of the crash. Figure 2 below shows the wreckage of the plane on the mountain ranges after the impact. The level of destruction of the plane helps in determine the magnitude of the impact.
Chain of Events That Lead to the Accident
The Aeroflot flight AFL 593 took off at 4:39 pm local time from Russia to Hong Kong. The 40 year old Andrey Viktorovich Danilov was the Captain in the flight. After 4 hours of navigating the busy skies out of Moskow, he hands over controls to relief captain, 39 year old Yaroslav Vladimirovich Kudrinsky (Hayward and Hardimanm, 2022). It was a peaceful night and the plane was cruising on autopilot. As a routine flight, the first captain did not expect any incident, and as such, had fallen asleep outside the cockpit after handing over control to the relief captain.
The problem started when two children of the relief officer, a 12 year old girl and a 16 year old boy were allowed into the cockpit. The initial intention was to allow them to see the state-of-the-art cockpit of the new plane. However, their father, relief captain Yaroslav Vladimirovich Kudrinsky decided to allow them to sit at the controls against the companys and aviation regulations (Bureau, 2022).
The captain adjusted the autopilot system to give the children the impression that they were flying the plane, although they were not. First on the controls was the 12 year old girl, Yana. Her actions while in the controls did not contradict the autopilot, and there were no issues. The 16 year old son, Eldar, was next to take controls of the commercial aircraft. Unlike Yana, Eldar used enough force on the control column that contradicted the autopilot for more than 30 seconds.
The action forced the flight computer to change ailerons of the plane from autopilot to manual controls (Hayward and Hardimanm, 2022). The other flight systems were not affected and so they remained under the control of autopilot. The problem at this stage was that at this stage, the 16 year old boy was in control of the aircraft. No one in the cockpit realized that the boy was in control of the plane except the boy himself, who believed that the pilots were aware of the same. A light indicator went on as soon as the autopilot was partially disengaged, but the pilots were not aware of this new technology. The cockpit voice recorder indicates that it was the young boy who was the first to detect a problem, when he noticed that the aircraft was banking to the right.
When the pilots attention was drawn to the problem, they were confused, and failed to take corrective measures in time, during which time, the aircraft had banked to an angle of almost 90 degrees, way beyond the 45 degrees allowed by the design. The confusion was caused by the fact that when the plane started banking, it made a 180 degrees turn, and was in a holding position. The pilots could not immediately determine why their plane was in a holding position.
The plane went on a rapid descent but the pilots were able to recover the dive. However, because of the confusion, they overcorrected the mistake and the plane stalled because of the steep ascent. They once again struggled to correct this mistake but when they finally levelled the plane, it was too low to recover (Hayward and Hardimanm, 2022). The flight data recorder showed that it crushed at a speed of 160 mph (250 km/h).
Everyone onboard the plane was instantly killed by the impact. The events deteriorated so fast that the primary captain of the plane was not able to make it back to the cockpit. The cockpit voice recorder confirmed that the crew did not make any distress calls. The events happened so fast that they did not have time to make a mayday call. The air crash investigators reported that the solution to the problem created by the boy was to let of the control column, which would have allowed the autopilot to take full control of the aircraft.
Every accident tend to have a negative impact on the image of the airline. As such, it is normal for the management and those in authority to shift the blame. At the time of the accident, the national carrier was struggling to improve its image in the aviation industry. The airline and the Russian government originally denied the fact that there were children in the cockpit and that they were the primary cause of the accident (Hayward and Hardimanm, 2022). However, when the transcripts from the cockpit voice and data recorders were made public, they admitted the mistake committed by the pilots.
Human Factors Which Directly Caused the Accident
The investigation revealed that the accident was primarily caused by human factors. It was revealed that the Airbus A310-304 was in perfect working condition until its aerodynamic limits were breached. There were a series of human errors that were committed, which are worth discussing at this stage of the report. The first human error was allowing children to sit at the controls against regulations of the company, of the aviation industry, and ones best judgment (Bureau, 2022).
At that time, it was a common practice to briefly have the non-crew members into the cockpit. However, that could be done only if it was guaranteed that their presence in the cockpit would not affect actions of the pilot. In this case, the relief captain ignored the regulations and common sense, and allowed his two children to control the plane. This mistake is made worse by the fact that he was not fully versant with the controls of the new plane. This was the start of the serous of problems that led to the crash of the plane and death of everyone else onboard.
The second human factor that caused the accident was the failure of the two pilots to observe closely the actions of the children. The relief pilot trusted the autopilots so much that he did not closely monitor actions of his child. As an experienced pilot, he should have known that if the child applied enough pressure on the control column, the autopilot may be overruled and be disengaged (Seedhouse et al., 2020).
The two pilots, knowing fully that these children knew very little about the plane and the art of flying, should have maintained a close supervision of every action taken during that period. They should have immediately realized that the child was exerting an amount of force that would directly affect the functionality of the autopilot. Instead, the cockpit voice recorder indicated that their attention was switched to explaining to the children how the plane works and the new technology on the cockpit of this new aircraft. Basically, they transformed from active pilots on duty to pilot instructors. It meant that they could not detect the mistake at the time it mattered the most.
Failing to get the warning when the light went on was another major human factor that contributed to the accident. Modern planes are highly automated to help make flying simple but safe (Soekkha, 2020). They are fitted with systems meant to inform pilots of events happening and their possible consequences. In this case, the autopilot that controls the planes ailerons had been switched manual, which was a common practice and the plane responded effectively to the human input. A warning went off, informing the crew that the autopilot was no longer responsible for part of control of the plane. The co-pilot was sitting in the controls and the relief pilots position allowed him to monitor the controls. However, they both failed to read their instruments correctly and in time to avert the accident.
Inability to allow autopilot take control was another human factor that led to the accident. The investigators revealed that the only correction needed at that time was to let go of the controls. The autopilot would have sensed that the planes controls were all being handed back to it. It would have corrected the dangerous banking and gotten the plane back to its right path. However, these pilots started struggling with the plane, overcorrecting the mistakes and exposing it to greater danger. It finally reached a point of no control and went down.
Confusion of the captain and his first officer was another major human error. The cockpit voice recorder indicated that the boy, who had never been to a flying school and had no experience flying, was the first to detect that there was a problem. When he brought the fact that the plane was banking to their attention, they were so confused that they failed to take appropriate measures to save the plane and its occupants. The numerous series of human errors were the primary cause of the Aeroflot flight AFL 593 accident that claimed the lives of everyone on board. Although additional regulations were introduced, based on the report, to avoid similar accidents in future, it was noted that the pilots failed to observe existing regulations.
Analyzing the Relationships and Interactions between Human and Their Environment
Shell model, shown in figure 3 below, is one of the tools that have widely been used to explain the chain of events leading to aviation accidents. It argues that human error is rarely the sole reason why aviation accidents occur (Li, 2020). It identifies four building blocks of software, hardware, environment, and liveware as human factors that often cause aviation accident. These factors are intertwined, and play a role in any accident. In the Aeroflot flight AFL 593 accident, liveware was the central cause of the accident. It started when the pilots made the deliberate decision to allow two children into the cockpit. The problem was worsened when these pilots allowed a child with no flying background to sit on the controls.
The actions of the child deliberately caused the chain of events that led to the accident, as discussed in the section above. Liveware also failed to correct the mistake as the two pilots were unable to arrest the situation and stabilize the plane. The investigation revealed that the only action needed to correct the problem was for the boy to let go of the controls. Autopilot was capable of taking over the controls, hence the accident would have been avoided.
Software is another factor that can be a possible cause of an accident in the aviation industry. The pilot feeds in data to the computer system, which then instructions various functions of the plane (Soekkha, 2020). In this accident, the autopilot was already configured and would have been responsible for flying the plane to its destination. However, the input made by the pilot had the effect of changing the instructions. The software acted promptly as per the input. It informed the crew about the changes made and it worked well throughout this flight as it was designed. Based on the existing technologies at the time, software did not play any significant role in the accident. The only weakness is that the plane was designed to give a light instead of sound as a warning.
Hardware has been reported in the past to be the primary cause of an accident in the industry. When the structural component of the plane fails, it can easily cause an accident. In this accident, the hardware of the aircraft did not play a major role. However, the report noted that the boy was able to switch the controls of the ailerons from autopilot to manual. It is an indication that the structural design of the center stick, especially its location, should be reviewed.
The first officer, who was monitoring the system, should have noticed that there was a major input made by the boy, who effectively was the captain of the plane. The report indicates that there was no sign that either of the pilots detected the actions of the boy. The flight data recorder revealed that the boys input on the control column lasted over 30 seconds, which was an adequate time to detect the problem and take the necessary measure. Introducing a sound warning is an additional hardware improvement needed in these planes to help remind pilots that there is a problem.
The environment is the fourth factor that has to be considered when investigating aviation accident. Extreme weather conditions such as thunderstorms, down-drops, extreme cold conditions, powerful winds, mountainous terrains near the airports, and busy skyways are all the possible environmental conditions that can cause an accident. On this day of the accident, it was reported that the conditions were perfect for flying and the primary captain handed over controls to the relief captain after navigating the busy skyways of Moscow. The only environmental issue that possibly worsened the problem is that it was dark. As such, the crew and those in the cockpit could not see that the plane was in a holding pattern.
Policy Recommendations Based on the Accident Case
The report indicated that Aeroflot flight AFL 593 accident was primarily caused by human error. These mistakes were worsened by the fact that the crew did not have enough experience on the new plane, hence did not understand how it fully works, especially its warning system. In the aviation industry, the primary reason why air crash investigators spend millions of dollars to determine the cause of accident is to ensure that measures are taken to avoid a repeat of the same. In this case, although human errors were identified as the main causes, the following policy recommendations can help eliminate the mistakes and improve the design of the planes control system to help improve their efficiency:
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Banning of unauthorized persons from the cockpit is the first recommendation that should be observed strictly by airlines in this industry. Cockpit is the most sensitive part of the plane during the entire period of the travel. As Walmsley (2020) observes, cases have been reported where hijackers breached the security, accessed the cockpit and took control of the plane. In many of these cases, such as Ethiopian Airlines Flight 961, the outcome was an accident. As such, airlines should have strict policies that limits the accessibility of the cockpit to the pilots, flight engineers, and selected members of crew. The rules should be enforced, because this accident was caused by the inability of the captains to observe the existing regulations.
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Pilots should be instructed to never allow anyone to sit on controls, especially during the flight. There is always the assumption that once the plane is at the cruising altitude, nothing can every go wrong, especially on a new state-of-the-art aircraft that is functioning well. However, human error can cause a chain of activities that can lead to an accident, as witnessed in this accident. It is a common sense that unauthorized persons should not be allowed to access the controls, and all airlines following ICAO, IATA, and other aviation organizations policies have guidelines banning the same. However, this accident demonstrated that even where common sense is expected to prevail, mistakes do occur. As such, there is a need to introduce measures to help enforce such policies. Airlines should not only be able to know when such regulations are breached but also articulate punitive measures for the offenders. There is also a need to ensure that every crew member is held individually responsible for action or inaction that leads to the breach.
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Effective communication is another recommendations that should be embraced by the industry based on the report of this accident. When the pilots realized that there was a major problem, they got confused. The process of rescuing the plane from the dangerous dive was not effectively coordinated. It was obvious that the two were confused and were unable to work as a unit and manage the problem. With proper communication and coordination, it would have been possible to avoid confusion, understand the nature of the problem, and take appropriate measures.
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The accident clearly demonstrated that there was a need for an improved training for the pilots, especially when handling new planes. According to Wittmer, Bieger, and Muller (2021), all warnings in the cockpit are critical, and the pilot should be able to know about the same immediately. The report indicated that these pilots were used to a sound warning when any aspect of the autopilot was disengaged. In this case, the warning was given in form of a light, which easily went unnoticed for over a minute. It is a demonstration that there was a mismatch between skills of the pilots and the expected capabilities.
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There is a need to adjust some of the designs of the warning system on Airbus A310-304. The systems of the airline were functioning perfectly and they communicated with the crew as per its design. However, this accident was caused because of the inability of the crew to determine the warning and act as appropriately. When a pilot is preoccupied with something in the cockpit, as was the case in this flight, they may fail to see a warning light. However, one cannot easily ignore a sound warning. Airbus should consider making design changes to ensure that such lights are accompanied with specific sounds. The five people, including the two children without flight training, would have heard the sound and brought it to the attention of the pilots immediately. Chances are that the right steps would have been taken immediately and the dangerous experiment stopped at the right time.
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Information obtained from the flight data recorder revealed that the problem was worsened when the pilot overcorrected the mistake. He ended up pitching the nose up, which led to the stalling of the engines. The manufacturer can make steps to eliminate the possibility of such a problem happening again. The manufacturer should introduce a system that can override overcorrection in such instances. It should allow the pilot to make the correction within the limits provided. Beyond the maximum point set, the system should not respond to the extra force to protect the integrity of the aircraft. In case it is not possible to introduce such a system, then there should be a warning when overcorrection is made. The system should alert the pilots that the inputs they are making overstretches the capabilities of the aircraft.
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The report indicated that the aircraft was in a holding position, and none of the pilots was not aware. It was a major change of course from the preset destination, at half the journey and at a cruising altitude. That is a major design weakness that needs to be addressed in a major commercial flight. The system should send a message, a sound that can be accompanied with an explanation on the instruments, stating that there was a sudden change of course. It should seek a confirmation from the pilots about the need to proceed with the new inputs made. If such a technology was present in this aircraft, the pilots would have been informed about the inputs the boy had made. They would have been expected to approve such changes, probably by a simple press of the button.
Reference List
Bureau, M. (2022) Aeroflot flight 593: ill-fated crash caused by children in cockpit. Zee News. p. 1. Web.
Hayward, J. and Hardimanm, J. (2022) Aeroflot flight 593: how a family cockpit visit brought down an Airbus A310. Simple Flying. p. 1. Web.
Li, L. (2020). Safety and risk assessment of civil aircraft during operation. London: IntechOpen.
Seedhouse, E. et al. (2020). Human factors in air transport understanding behavior and performance in aviation. Springer International Publishing.
Soekkha, H. (eds.) (2020) Aviation safety, human factors: system engineering, flight operations, economic strategies, and management. Rotterdam: CRC Press.
Walmsley, S. (2020) Human factors for the private pilot. Stephen Walmsley. Cambridge: Cambridge University Press.
Wittmer, A., Bieger, T., and Muller, R. (eds.) (2021) Aviation systems: management of the integrated aviation value chain. 2nd Ed. Springer.
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