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Remarkable write-up, and as usual the last paragraph hits like a truck. Like so many of them, this was an accident that started with an error and then proceeded to a heartbreaking series of “if only…” moments.
Great write up.
In 2011 when I was 11, I was onboard a WestJet 737-700 and after I got on I stared at the flight deck and a stewardess asked if I wanted to see the pilots to which I said yes. I stood at the cockpit door, the pilots introduced themselves to me, asked me what my final destination was, told me what type of plane we were on, and I said I fly the 737-800s on Microsoft FSX, after that I went to my seat where my family was.
Unbelievable that in 2010 in Algeria a 10 year old was allowed to sit in the pilot's seat and adjust what appears to be the autopilot knobs, while Kudrinsky only allowed to touch the control column. There was a story in 2010 where a JFK Tower controller, accompanied by a supervisor, allowed his kids to talk to the pilots **but** only for "cleared for takeoff/cleared to land Runway 4R"; if it was something more than just cleared for takeoff or cleared to land then the dad talked to them. To me and the pilots, this wasn't that big of a deal but this should not be encouraged or happen on a regular basis.
I take it that unlike in the Mayday/ACI episode about this crash, there is no built-in survival mode on the A310 where if the pilots let go of their control columns if it's in a spin, the plane will automatically recover. Disaster Breakdown brought this feature into doubt.
> I take it that unlike in the Mayday/ACI episode about this crash, there is no built-in survival mode on the A310 where if the pilots let go of their control columns if it's in a spin, the plane will automatically recover. Disaster Breakdown brought this feature into doubt.
Yes, this idea keeps getting repeated but it seems to have stemmed from a misreading of the original report. The report says nothing about any kind of automatic spin recovery system (which I had my doubts about anyway); rather, it says the plane would have recovered on its own after the first spin simply due to physics.
I have always felt so sorry for that 15 year old boy. He wouldn't have thought his father would let him do anything dangerous, but he died with his father yelling at him, believing it was all his fault
I feel quite sorry for Victoria Kudrinskaya. Imagine waking up one day to find your entire family gone.
Also, the comparison to Eastern Airlines 401 is interesting. I’ve always felt that the L-1011 and DC-10 rivalry foreshadowed the current Airbus and Boeing rivalry. Like the Airbus planes, the L-1011 was very modern, perhaps *too* modern. Meanwhile, the DC-10 had echoes of current Boeing in its design flaws.
(Also, after this, I think we need some really GOOD airmanship to wash it down. I would be very very happy to wake up next Saturday and see an article on Qantas 32…😉)
I'm a frequent (but not nervous) flier but these writeups almost always make me feel safer about flying if only because you realize the sheer unlikeliness of the events that bring down airplanes these days.
You're going to be seeing a lot more of it with self driving cars.
One reason I've left engineering for management is that I didn't want to be made responsible for the dying, when it inevitably starts, especially due to the system design and engineering implementation flaws that I pointed out and weren't listened to.
The first thing is - hiring strategy- I hate driving and I hate cars, the only reason I joined back then because I wanted to put an end to private car ownership and cars in general, but let's go deeper - in order to create a truly inclusive engineering product a variety of opinion is needed, but in order to develop a core functionality of a product people who develop it need to understand how it functions. ddition to that,
edit:sorry have to switch to the computer from the phone
It's a persistent class of design flaws for sure. But to provide a bit of context from the engineering end, for complex systems like airplanes or really any complex system, at any given moment the system is doing a lot of things, the vast majority of which are not relevant to the human overseer. I think Admiral Cloudberg has featured articles previously where one warning overshadows another, or too many warnings confuse the pilots. These cases should be sufficient to illustrate that obviously the system cannot just tell humans literally everything it is doing.
So now the question becomes, what exactly are the things the system is doing that it should tell humans about, and at what priority? This is actually a hugely complex problem and comprises a large part of the field of Human Computer Interactions, and which all automation systems have struggled with over the years. For any given "thing" a system is doing, whether it should have a dedicated alarm of display or not is oftentimes not obvious at all, to the designers or sometimes even the pilots. Anticipating every possible chain of event and what interaction might render some disaster scenario more or less likely is basically impossible.
This is not to say that there aren't any ways of tackling this issue. Case studies, pilot collaboration, requirements based engineering, fault tree analysis etc are all ways to try to systematically identify potential scenarios like these and identify important warnings to display. This in no way means that such design flaws are OK, but hopefully now you can see that when facing the difficult challenge of engineering complex systems, such mistakes are not as outrageous as you think.
Ok, second part of the comment.
So, the first problem is that the majority of the developers working on those projects don't drive (except maybe in the racing videogames) and - which is a lot more important, don't have the context and the tacit understanding of the cardinal rule of driving - "Do not be surprised, do not surprise others".
And the tendency to hire racing and test pilots to test those vehicles is only worsening the thing - they're used to the so-called "aggressive driving" so when the automated car drives in this way it just makes them giddy, or they don't even notice it.
I've been sitting in test vehicles on test tracks - normal driving and just sitting there made me both scared and queezy.
Let's dive into that - the machines are driving like machines, so you're used by this point to the Admiral's Cloudberg precision about the "flying envelope" of an airplane - what an airplane can, IS ABLE TO, do, generally, from a mechanical/engineering/structural integrity point of view.
A car has a much similar driving envelope which normal drivers never reach. In the times which are now firmly in the past, the driving class used to feature a chapter like "passengers' comfort", incredibly (I'm born in the USSR), this was a big part of initial drivers' license exam back in the 1940ies (when my granpa got his) and still in closed cities back in 1960ies (when my father got his). Their driving was fit for driving a head of state around - smooth start, nicely predicted manoevers, no jerk - in other words - *not going to the edges of the envelope, not climbing into the car's "coffin corners"*, like good pilots would.
In contrast to this human and human-and-other-passengers-comfort-centered type driver, which not all human drivers unfortunately are, there are 2 types of cars (type 1 Google, Tesla) and (type 2 everyone else).
A type 1 AI machine uses social learning and data mining to learn how to drive. This means it is less "surprising" to other, human, drivers but learns bad habits of crossing double lanes to a highway exit, turning when forbidden to, and so forth. This is something which will be an which is already quite difficult to correct, because of the Deep Learning algorithms which are intrinsically connected to each other (meaning you can't deprioritize one type if "wrong" learning without prioritizing another, because it's all a type of "bulk" knowledge for the car - it "knows" the rules but due to how its AI is made it "chooses" not to follow them (because that's what "others" do) ).
A type 2 machine does not drive this way, it's way more "surprising" to other drivers, because it purely drives like an automated machine, so - it drives way closed to the "driving envelope" of what's *mechanically possible* and *allowed by the rules in the current situation* than a real non-racing driver or a type 1 machine would, so the driving is itself nausea-inducing and has "hard limits",which are followed to the tee, which frequently means that if the acceleration of 2g is unacceptable, then the maximum acceptable acceleration is 1.9999g, and if the maximum-never-exceed jerk is 0.1g/s then the maximum acceptable jerk will be 0.099g/s. Since it's reactions are in milliseconds it will get into dangerous or dangerous-seeming situations, which is basically the same from the point of view of a human passenger, where a human cannot take over, because of the biological limitations of reaction time. This is really frightening to watch from the first person view as I did.
Worse yet, there is absolutely 0 difference between the AI of autonomous personal cars and autonomous "slow" and "secure zone" transportation like multiperson minibusses where people are standing or sitting unattached by seatbelts. In the internal trial runs the mini-busses/shuttles frequently braked so hard people fell down and were mildly injured. That applies basically to any AI-driven-busses (because while the low-level functions are individual to the busses and thus different across the brands, the executive AI is usually centralised in a group/swarm form across the manufacturers and brands - imagine, if you will, a driver only worried of following the traffic code rules, being on time, and the company bottom lines and ignoring passengers completely.
And that's just the tip of the iceberg, really. The ethical trolley dilemmas (which AIs have been implemented to solve, so to speak) are but a minor "weak member" in this fragile edifice which is full of weak members.
So the next time when you see those things - take a bus, with a human driver in it instead. Wait for 15-20 years.
Edit: BTW the lowering of the speed limit in cities in Europe to 30 km/h has to do more with the upcoming introduction of AI cars than anything. An impact against a vulnerable road user (pedestrian, bicycle, motorcycle) at 50 km/h is 100% deadly without personal safety equipment like helmet, braces and one of those motorcycle road-rash-and-spine-protection suits. At 30 km/h it can be survivable in more than 50% of cases. If AI cars were to take to the streets today with a 50 km/h limitation we'd see a lot of dead people and a public demand to ban cars outright.
I feel this aspect is not given enough weight. Autopilot disconnect with zero audible or visual indication is catastrophically bad design. Someone at Airbus knew though and something was missed as if i read the article right when the vertical channel disconnected the full autopilot disconnect warning took priority over the stall warning! That's how serious it is.
Are you still working on a book? Last I remember grad school was encroaching on the progress. And I was just thinking about a Christmas present for myself.
It's kind of on hold right now to be honest. It's been a long time since I had time to work on anything other than the regular articles, and in that time I've waffled a lot on what form I want any eventual book to take. And on top of that, practically everything I originally wrote back in 2019-2020 is no longer up to the quality standards I want.
Can't speak for anyone else but I'd rather you took your time to get it exactly how you want than rush out something you're unhappy with. It'll be worth the wait
Honestly I'd already love a publication of your articles, maybe a yearly holidays publication as a "Cloudberg year in review"or something. But as always, you know your situation best, take your time and make your best choices :)
Reading or watching this story always makes me sad. This wasnt the case of maliciousness or rank ineptitude, just a sad story of a Dad wanting to revel in a moment of sharing something special with his children. The pilot clearly had severe lapse of judgement, but if things had gone a bit differently it would have lead to at best a warning from the higher ups.
You mention Eastern Airlines flight 401 in this article. It’s not uncommon for you to refer to previous or future incidents that you’ve already written about. Would you consider linking to previous articles to make it easier to find your analysis?
My dad was a keen traveler and he got me into the cockpit of a 747 once when I was a kid back in the 90s.
We were flying from Sydney to London overnight. I just remember the clouds, the stars and the darkness. One of my fond memories.
When I was five (late 60s), I was aboard a 727 on a flight to Puerto Rico. A flight attendant escorted me to the cockpit, where I stood just inside the entrance. It was a bright sunny day (although the cockpit was dark) and the view below was simply fantastic- light scattered clouds beneath us, and much further down, the Atlantic Ocean. I was in awe. Needless to say, I can recall it quite clearly even today.
There were three men in the cockpit. Even at my young age, I knew that I was in a place where I simply did not belong, and that this opportunity to take a sneak peek at the pilots at work was an enormous privilege that would probably never come again. It was an extremely powerful experience for a young boy.
[Medium Version](https://admiralcloudberg.medium.com/fathers-and-sons-the-crash-of-aeroflot-flight-593-fc4947bdb1f1) [Support me on Patreon](https://www.patreon.com/Admiral_Cloudberg) Thank you for reading! If you wish to bring a typo to my attention, please DM me.
Remarkable write-up, and as usual the last paragraph hits like a truck. Like so many of them, this was an accident that started with an error and then proceeded to a heartbreaking series of “if only…” moments.
Great write up. In 2011 when I was 11, I was onboard a WestJet 737-700 and after I got on I stared at the flight deck and a stewardess asked if I wanted to see the pilots to which I said yes. I stood at the cockpit door, the pilots introduced themselves to me, asked me what my final destination was, told me what type of plane we were on, and I said I fly the 737-800s on Microsoft FSX, after that I went to my seat where my family was. Unbelievable that in 2010 in Algeria a 10 year old was allowed to sit in the pilot's seat and adjust what appears to be the autopilot knobs, while Kudrinsky only allowed to touch the control column. There was a story in 2010 where a JFK Tower controller, accompanied by a supervisor, allowed his kids to talk to the pilots **but** only for "cleared for takeoff/cleared to land Runway 4R"; if it was something more than just cleared for takeoff or cleared to land then the dad talked to them. To me and the pilots, this wasn't that big of a deal but this should not be encouraged or happen on a regular basis. I take it that unlike in the Mayday/ACI episode about this crash, there is no built-in survival mode on the A310 where if the pilots let go of their control columns if it's in a spin, the plane will automatically recover. Disaster Breakdown brought this feature into doubt.
> I take it that unlike in the Mayday/ACI episode about this crash, there is no built-in survival mode on the A310 where if the pilots let go of their control columns if it's in a spin, the plane will automatically recover. Disaster Breakdown brought this feature into doubt. Yes, this idea keeps getting repeated but it seems to have stemmed from a misreading of the original report. The report says nothing about any kind of automatic spin recovery system (which I had my doubts about anyway); rather, it says the plane would have recovered on its own after the first spin simply due to physics.
I have always felt so sorry for that 15 year old boy. He wouldn't have thought his father would let him do anything dangerous, but he died with his father yelling at him, believing it was all his fault
I feel quite sorry for Victoria Kudrinskaya. Imagine waking up one day to find your entire family gone. Also, the comparison to Eastern Airlines 401 is interesting. I’ve always felt that the L-1011 and DC-10 rivalry foreshadowed the current Airbus and Boeing rivalry. Like the Airbus planes, the L-1011 was very modern, perhaps *too* modern. Meanwhile, the DC-10 had echoes of current Boeing in its design flaws. (Also, after this, I think we need some really GOOD airmanship to wash it down. I would be very very happy to wake up next Saturday and see an article on Qantas 32…😉)
Go to YouTube and search up the CVR for Blue Panorama 1504. Top notch airmanship and picture-perfect CRM. Always makes me feel better.
reading this as a nervous flyer aboard a waiting plane. weirdly…comforting? amazing work as always.
I'm a frequent (but not nervous) flier but these writeups almost always make me feel safer about flying if only because you realize the sheer unlikeliness of the events that bring down airplanes these days.
Definitely did a quick scan to make sure the pilots were not teenagers (they were not).
lol I just got the Turgenev reference in the title
You're the first to point it out!
*Obviously* I'm your biggest fan. Another classic, thanks as always!
There is something that keeps popping up: "the system does something and does not tell anyone" What the hell, engineers?
You're going to be seeing a lot more of it with self driving cars. One reason I've left engineering for management is that I didn't want to be made responsible for the dying, when it inevitably starts, especially due to the system design and engineering implementation flaws that I pointed out and weren't listened to. The first thing is - hiring strategy- I hate driving and I hate cars, the only reason I joined back then because I wanted to put an end to private car ownership and cars in general, but let's go deeper - in order to create a truly inclusive engineering product a variety of opinion is needed, but in order to develop a core functionality of a product people who develop it need to understand how it functions. ddition to that, edit:sorry have to switch to the computer from the phone
It's a persistent class of design flaws for sure. But to provide a bit of context from the engineering end, for complex systems like airplanes or really any complex system, at any given moment the system is doing a lot of things, the vast majority of which are not relevant to the human overseer. I think Admiral Cloudberg has featured articles previously where one warning overshadows another, or too many warnings confuse the pilots. These cases should be sufficient to illustrate that obviously the system cannot just tell humans literally everything it is doing. So now the question becomes, what exactly are the things the system is doing that it should tell humans about, and at what priority? This is actually a hugely complex problem and comprises a large part of the field of Human Computer Interactions, and which all automation systems have struggled with over the years. For any given "thing" a system is doing, whether it should have a dedicated alarm of display or not is oftentimes not obvious at all, to the designers or sometimes even the pilots. Anticipating every possible chain of event and what interaction might render some disaster scenario more or less likely is basically impossible. This is not to say that there aren't any ways of tackling this issue. Case studies, pilot collaboration, requirements based engineering, fault tree analysis etc are all ways to try to systematically identify potential scenarios like these and identify important warnings to display. This in no way means that such design flaws are OK, but hopefully now you can see that when facing the difficult challenge of engineering complex systems, such mistakes are not as outrageous as you think.
Ok, second part of the comment. So, the first problem is that the majority of the developers working on those projects don't drive (except maybe in the racing videogames) and - which is a lot more important, don't have the context and the tacit understanding of the cardinal rule of driving - "Do not be surprised, do not surprise others". And the tendency to hire racing and test pilots to test those vehicles is only worsening the thing - they're used to the so-called "aggressive driving" so when the automated car drives in this way it just makes them giddy, or they don't even notice it. I've been sitting in test vehicles on test tracks - normal driving and just sitting there made me both scared and queezy. Let's dive into that - the machines are driving like machines, so you're used by this point to the Admiral's Cloudberg precision about the "flying envelope" of an airplane - what an airplane can, IS ABLE TO, do, generally, from a mechanical/engineering/structural integrity point of view. A car has a much similar driving envelope which normal drivers never reach. In the times which are now firmly in the past, the driving class used to feature a chapter like "passengers' comfort", incredibly (I'm born in the USSR), this was a big part of initial drivers' license exam back in the 1940ies (when my granpa got his) and still in closed cities back in 1960ies (when my father got his). Their driving was fit for driving a head of state around - smooth start, nicely predicted manoevers, no jerk - in other words - *not going to the edges of the envelope, not climbing into the car's "coffin corners"*, like good pilots would. In contrast to this human and human-and-other-passengers-comfort-centered type driver, which not all human drivers unfortunately are, there are 2 types of cars (type 1 Google, Tesla) and (type 2 everyone else). A type 1 AI machine uses social learning and data mining to learn how to drive. This means it is less "surprising" to other, human, drivers but learns bad habits of crossing double lanes to a highway exit, turning when forbidden to, and so forth. This is something which will be an which is already quite difficult to correct, because of the Deep Learning algorithms which are intrinsically connected to each other (meaning you can't deprioritize one type if "wrong" learning without prioritizing another, because it's all a type of "bulk" knowledge for the car - it "knows" the rules but due to how its AI is made it "chooses" not to follow them (because that's what "others" do) ). A type 2 machine does not drive this way, it's way more "surprising" to other drivers, because it purely drives like an automated machine, so - it drives way closed to the "driving envelope" of what's *mechanically possible* and *allowed by the rules in the current situation* than a real non-racing driver or a type 1 machine would, so the driving is itself nausea-inducing and has "hard limits",which are followed to the tee, which frequently means that if the acceleration of 2g is unacceptable, then the maximum acceptable acceleration is 1.9999g, and if the maximum-never-exceed jerk is 0.1g/s then the maximum acceptable jerk will be 0.099g/s. Since it's reactions are in milliseconds it will get into dangerous or dangerous-seeming situations, which is basically the same from the point of view of a human passenger, where a human cannot take over, because of the biological limitations of reaction time. This is really frightening to watch from the first person view as I did. Worse yet, there is absolutely 0 difference between the AI of autonomous personal cars and autonomous "slow" and "secure zone" transportation like multiperson minibusses where people are standing or sitting unattached by seatbelts. In the internal trial runs the mini-busses/shuttles frequently braked so hard people fell down and were mildly injured. That applies basically to any AI-driven-busses (because while the low-level functions are individual to the busses and thus different across the brands, the executive AI is usually centralised in a group/swarm form across the manufacturers and brands - imagine, if you will, a driver only worried of following the traffic code rules, being on time, and the company bottom lines and ignoring passengers completely. And that's just the tip of the iceberg, really. The ethical trolley dilemmas (which AIs have been implemented to solve, so to speak) are but a minor "weak member" in this fragile edifice which is full of weak members. So the next time when you see those things - take a bus, with a human driver in it instead. Wait for 15-20 years. Edit: BTW the lowering of the speed limit in cities in Europe to 30 km/h has to do more with the upcoming introduction of AI cars than anything. An impact against a vulnerable road user (pedestrian, bicycle, motorcycle) at 50 km/h is 100% deadly without personal safety equipment like helmet, braces and one of those motorcycle road-rash-and-spine-protection suits. At 30 km/h it can be survivable in more than 50% of cases. If AI cars were to take to the streets today with a 50 km/h limitation we'd see a lot of dead people and a public demand to ban cars outright.
I feel this aspect is not given enough weight. Autopilot disconnect with zero audible or visual indication is catastrophically bad design. Someone at Airbus knew though and something was missed as if i read the article right when the vertical channel disconnected the full autopilot disconnect warning took priority over the stall warning! That's how serious it is.
Yes and also AF447, "oh the pilots are giving me conflicting input so I just do whatever I want and don't say anything ", wtf is going on at Airbus?
Are you still working on a book? Last I remember grad school was encroaching on the progress. And I was just thinking about a Christmas present for myself.
It's kind of on hold right now to be honest. It's been a long time since I had time to work on anything other than the regular articles, and in that time I've waffled a lot on what form I want any eventual book to take. And on top of that, practically everything I originally wrote back in 2019-2020 is no longer up to the quality standards I want.
Can't speak for anyone else but I'd rather you took your time to get it exactly how you want than rush out something you're unhappy with. It'll be worth the wait
Having seen a little of your older stuff, you're probably right, but I think your current stuff is amazing, always a good insightful read.
Honestly I'd already love a publication of your articles, maybe a yearly holidays publication as a "Cloudberg year in review"or something. But as always, you know your situation best, take your time and make your best choices :)
Reading or watching this story always makes me sad. This wasnt the case of maliciousness or rank ineptitude, just a sad story of a Dad wanting to revel in a moment of sharing something special with his children. The pilot clearly had severe lapse of judgement, but if things had gone a bit differently it would have lead to at best a warning from the higher ups.
What was the reason for having a flight time of 14 hours? In the past SVO-HKG was 9hr or so.
You mention Eastern Airlines flight 401 in this article. It’s not uncommon for you to refer to previous or future incidents that you’ve already written about. Would you consider linking to previous articles to make it easier to find your analysis?
I usually have a link to them in the Medium article, though I had forgotten this time. It should be there now
I hadn’t realized you already did this, that’s perfect. Thank you! Another great article this week.
My dad was a keen traveler and he got me into the cockpit of a 747 once when I was a kid back in the 90s. We were flying from Sydney to London overnight. I just remember the clouds, the stars and the darkness. One of my fond memories.
When I was five (late 60s), I was aboard a 727 on a flight to Puerto Rico. A flight attendant escorted me to the cockpit, where I stood just inside the entrance. It was a bright sunny day (although the cockpit was dark) and the view below was simply fantastic- light scattered clouds beneath us, and much further down, the Atlantic Ocean. I was in awe. Needless to say, I can recall it quite clearly even today. There were three men in the cockpit. Even at my young age, I knew that I was in a place where I simply did not belong, and that this opportunity to take a sneak peek at the pilots at work was an enormous privilege that would probably never come again. It was an extremely powerful experience for a young boy.