Aeroflot Flight 593
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|Date||23 March 1994|
|Summary||Pilot error, untrained minor in command of controls|
|Site||20 km (12 mi) E of Mezhdurechensk, Russia
|Aircraft type||Airbus A310-304|
|Operator||Aeroflot – Russian International Airlines|
|Flight origin||Sheremetyevo International Airport, Moscow, Russia|
|Destination||Kai Tak Airport, Hong Kong|
Aeroflot Flight 593 was a Moscow–Hong Kong passenger service operated by Aeroflot – Russian International Airlines, flown with an Airbus A310-300, that crashed into a hillside of the Kuznetsk Alatau mountain range, Kemerovo Oblast, Russia, on 23 March 1994. All 63 passengers and 12 crew members perished in the accident.
No evidence of technical malfunction was found. Cockpit voice and flight data recorders revealed the presence of the pilot's 12-year-old daughter and 16-year-old son on the flight deck. One of the children had unknowingly disengaged the A310 autopilot's control over the aircraft's ailerons while seated at the controls. The aircraft rolled into a steep bank and near-vertical dive. Despite managing to level the aircraft off, the pilot over-corrected the attempt to pull up, causing the plane to stall and then crashed into the hillside.
The aircraft involved in the accident was a leased Airbus A310-304, registration F-OGQS, serial number 596, that was delivered new to Aeroflot on 11 December 1992. Powered with two General Electric CF6-80C2A2 engines, the airframe had its maiden flight as F-WWCS on 11 September 1991, and was one of five operating for Russian Airlines, an autonomous division of Aeroflot – Russian International Airlines that was set up for serving routes to the Russian Far East and Southeast Asia. On average, the crew of three operating the aircraft had logged 900 hours on the type.
Description of the accident
The jet was en route from Sheremetyevo International Airport to Hong Kong Kai Tak International Airport with 75 occupants aboard, of whom 63 were passengers. Most of the passengers were businessmen from Hong Kong and Taiwan who were looking for economic opportunities in Russia.
The relief pilot, Yaroslav Kudrinsky (Russian: Ярослав Кудринский), was taking his two children on their first international flight, and they were brought to the cockpit while he was on duty. Aeroflot allowed families of pilots to travel at a discounted rate once a year. Five people were in the cockpit: Kudrinsky, copilot Igor Piskaryov (Russian: Игорь Пискарёв), Kudrinsky's son Eldar (Russian: Эльдар Кудринский), his daughter Yana (Russian: Яна Кудринская), and another pilot, V. Makarov, who was flying as a passenger.
With the autopilot active, Kudrinsky, against regulations, let the children sit at the controls. First his daughter Yana took the pilot's left front seat. Kudrinsky adjusted the autopilot's heading to give her the impression that she was turning the plane, though she actually had no control of the aircraft. Shortly thereafter Eldar occupied the pilot's seat. Unlike his sister, Eldar applied enough force to the control column to contradict the autopilot for 30 seconds. This caused the flight computer to switch the plane's ailerons to manual control while maintaining control over the other flight systems. A silent indicator light came on to alert the pilots to this partial disengagement. The pilots, who had previously flown Russian-designed planes which had audible warning signals, apparently failed to notice it.
The first to notice a problem was Eldar, who observed that the plane was banking right. Shortly after, the flight path indicator changed to show the new flight path of the aircraft as it turned. Since the turn was continuous, the resulting predicted flight path drawn on screen was a 180-degree turn. This indication is similar to the indications shown when in a holding pattern, where a 180-degree turn is intentional to remain in one place. This confused the pilots for nine seconds. During this confusion, the plane banked past a 45-degree angle to almost 90 degrees (steeper than it was designed for). The A310 cannot turn this steeply while maintaining height, and the plane started to lose altitude quickly. The increased g-forces on the pilots and crew made it extremely difficult for them to regain control. The autopilot (which no longer controlled the ailerons) used its other controls in a bid to compensate, pitching the nose up and increasing thrust. The plane began to stall. The autopilot, unable to cope, disengaged and its display went blank. To recover from the stall, an automatic system lowered the nose and put the plane into a nosedive. The reduced g-forces enabled the captain to re-take his seat. The co-pilot then managed to pull out of the dive, but over-corrected, putting the plane in an almost vertical ascent, again stalling the plane, which fell out of the sky into a corkscrew dive. Though the captain and the co-pilot regained control and leveled out the wings, their altitude by then was too low to recover, and the plane crashed at high vertical speed, estimated at 70 m/s (160 mph). All 75 aboard were killed.
The aircraft crashed with its landing gear up, and all passengers had been prepared for an emergency, as they were strapped into their seats. No distress calls were made prior to the crash. Despite the struggles of both pilots to save the aircraft, it was later concluded that if they had just let go of the control column, the autopilot would have automatically taken action to prevent stalling, thus avoiding the accident.
The wreckage was located on a remote hillside approximately 20 kilometres (12 mi) east of Mezhdurechensk, Kemerovo Oblast, Russia; the flight data recorders were found on the second day of searching. Families of western victims placed flowers on the crash site, while families of Chinese victims scattered pieces of paper with messages written on them around the crash site.
The airline originally denied that children were in the cockpit. The Moscow-based magazine Obozrevatel (Russian: Обозреватель, Observer) published the transcript on the week of Wednesday, 28 September 1994. The Associated Press said that, according to the transcript, "the Russian crew almost succeeded in saving the plane". The New York Times said that "A transcript of the tape printed in the magazine Obozrevatel shows that the Russian crew nearly managed to save the Airbus plane and the 75 people on board, but that it was hampered by the presence of children and its unfamiliarity with the foreign-made plane." The New York Times said that an analysis by an aviation expert published in Rossiiskiye Vesti (Российские вести) supported that analysis.
(N.B.: All timestamps refer to the flight data recorder time, not GMT or local time.)
2258 Eldar: Why's it turning?
2259 Kudrinsky: It's turning by itself?
2260 Eldar: Yes ...
2261 Kudrinsky: I don't know why it's turning
2266 Eldar: Is it going off-course?
2267 Piskarev: We're entering a holding pattern
2268 Kudrinsky: Really?
2269 Piskarev: Of course.
2270 Makarov: Guys ...
The plane exceeds a 45-degree bank angle. The g-forces increase, making it difficult for Kudrinsky to return to his seat.
2272 Kudrinsky: Hold it, hold the stick, hold it
2275 Makarov: The speed ...
2276 Piskarev: The other way!
2277 Kudrinsky: The other way, turn it left
2281 Piskarev: Left!
2281 Kudrinsky: Left... The other way!
2282 Piskarev: Left!
2284 Eldar: I am turning it left ...
2284 Piskarev: To the right!
2285 Kudrinsky: To the right
2288 Piskarev: Can't you see, or what?
Altitude warning and autopilot disengage warnings sound in quick succession. The plane begins to descend at speeds of up to 1000 feet per second.
2291 Piskarev: Turn right. Turn right! Turn right!
2297 Kudrinsky: RIGHT!
2298 Piskarev: Left! There's the ground!
2303 Kudrinsky: Eldar, get out ... Climb back out ... Climb back out, Eldar. You see the danger, no?
2314 Piskarev: Throttles to idle!
The first officer pulls out of the dive, but over-corrects. The aircraft now starts climbing almost vertically.
2319 Kudrinsky: Eldar, get out! Get out, Eldar, get out ... Get out, Eldar, get out, get out ... get out ... [gasping] get out ... Get out, I say!
2334 Piskarev: Full power! Full power! ... Full power!
2336 Kudrinsky: Got full power, got it
2337 Piskarev: Full power!
2338 Kudrinsky: Got it ...
2340 Piskarev: Full power!
2346 Kudrinsky: I gave it full power, I gave it
2348 Piskarev: What's the speed?
2350 Makarov (?): Look on the left, it's three-forty
2354 Kudrinsky: ... Okay ... [sobbing] Full power!
2365 Piskarev: Speed is very high
2367 Kudrinsky: High, is it?
2368 Piskarev: Yes, isn't it?
2369 Kudrinsky: I switched it off
2371 Piskarev: We're coming out, coming out, coming out! Right! Foot to the right! Speed is high, reduce power!
2377 Kudrinsky: Done
2382 Piskarev: Gently! ... Shit, not again
2388 Kudrinsky: Don't turn it right! The speed [unintelligible]
2392 Piskarev: There!
2393 Kudrinsky: We'll come out in a sec. Everything's all right ... Gently [unintelligible], gently ... Pull up gently!
2400 [Sound of impact, end of recording]
The airline has modified its schedules and reassigned flight numbers; as of December 2014[update], the only flight servicing Hong Kong is numbered SU212, and is operated on a daily basis using Airbus A330-300 equipment.
- Accident description at the Aviation Safety Network
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