The Disagreement That Killed 141 People | Vnukovo Airlines Flight 2801
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This is the story of vnukovo airlines flight 2801. On the 29th of august 1996 a TU 154 was flying from Vnukovo international airport in moscow to Longyear airport in svalbard norway. The plane had 130 passengers on board. This was a chartered flight filled with coal mining families from the towns of barentsburg and pyramiden in svalbard., the captain for this flight had landed in Svalbard before and this was the first officer's first time. The crew was rounded out by a navigator and a flight engineer.
The plane took off from moscow without any issue and soon it was over the barents sea cruising at 35,000 feet streaking towards svalbard at 500 kmph or 310 miles per hour. Before they got in touch with longyear controllers on Svalbard the crew went over their plans. They'd be landing on runway 10. The approach to runway 10 was simple enough you flew along the coast line and then you turned to line up with the runway and you just followed the ILS beacon down to the runway. By 7:55 am they were ready to start their descent, but they couldnt establish communication with Bodo control. Right after that they were in touch with Longyear AFIS. Afis stands for aerodrome flight information system. In this case it was a person that gave out information about the airport to approaching planes. Information like the runway in use the winds temperature that sort of stuff. The AFIS officer was not a controller, he was just a person who gave out information. The AFIS officer told the crew that the runway in use was runway 28, so theyd have to approach the airport from the other side to land on runway 28. But the crew didnt understand this due to language difficulties, they tried asking for runway 10 again but the AFIS officer told them that runway 28 was the runway in use. This seemed to get the point across, the crew began preparing for an approach to runway 28. Compared to runway 10, runway 28 was a different beast altogether. Runway 28 was bordered by high mountains this meant that you couldnt just line up and land. Runway 28 needed what's known as an offset approach. For the offset approach you needed to fly to the ADV beacon and then you needed to make a sharp right turn to fly away from the airport. When you were sufficiently far away you had to make a 180 degree turn and fly towards the airport, this inbound leg took them right down the middle of a valley known as the advental valley. On the inbound leg they could tune a beacon called lima alpha situated at the foot of the runway. This would help to help guide them through the valley. If you flew towards the beacon on a heading of 300 then it would take you straight down the valley, keeping you safe from the 3000 foot peaks on either side. When you were close enough to the runaway you could turn, line up and land.
This is what the crew had to do to land on runway 28 but today it was quite cloudy and that would just make things harder. By 8:15 am the plane was at the ADV beacon, the plane made the right turn that would take it away from the airport. In two minutes they were ready to make their 180 degree turn to turn back to the airport. The navigator said “ah abeam eight miles inbound” to signify that they were almost established on the inbound vector towards the airport and that theyd announce when they were at the 8 mile mark. The AFIS controller checked his VDF display to see if the plane was where it was supposed to be, it was ,so he responded with “correct”. That was that.
As the plane came out of the 180 degree turn confusion was brewing in the cockpit the pilots werent sure if they had made the turns correctly. The first officer said “maybe we took the fourth - วิทยาศาสตร์และเทคโนโลยี
If in doubt; Climb Out. It served me well through 35 yrs and 11000 hrs over some of the world's most difficult terrain and weather, Svalbard included. The Arctic, Afghanistan and, most of Africa.
Indeed once you lose situational awareness climb to a safe height and figure it out.
“If in doubt, Climb Out.” So true!!
As I watched this and thought about the safest alternative to what these guys actually did, that was the only thing that made sense. Be safe, not sorry (or dead!).
There is also this huge problem we as humans have with following our most basic gut feeling in situations like this one - of doing what is right rather than letting others dictate to us what to do. It is really hard to feel justified in being a contrarian when we feel we can’t logically and irrefutably counter someone who acts as if they know something we don’t know. But to survive we have to take the safest course even if it feels “cowardly” or “unmanly.” 😊
@@LawrenceCarroll1234 Another problem is a missed approach looks bad on paper. No pilot really wants to have that documented, so they'll try and make a landing work. In this case, he'd be calling it off pretty far from the airport and at a fairly high altitude (compared to the airport...NOT the mountain he hit...). Even though EVERYTHING would have said go around, it's likely one the airline would have wanted to investigate simply because of distance and height if they called it off. It's why no fault go arounds should be standard. That said, I don't know how this company treats them, but something tells me that they investigate/interview missed approaches...
@@bobd2659 , good points! 👌🏻‼️
@@bobd2659 I thought most airlines have no-fault go-around policies?
Great video. And the biggest contributor to the crash was the crew not abandoning the approach once it became clear that confusion had set it. As soon as the captain was no longer satisfied with the navigators calls, he should have returned the plane to a safe altitude and started the approach from scratch.
@martin warner... no, I wish. I did undertake my CPL once upon a time, but it didnt eventuate in a career. I'm just a passionate aviation enthusiast like many of the people watching these videos.
Yup, I think you're right. A common thing on a lot these CFIT accidents is no one making the abort call even after sensing something isn't quite right.
Even as a non-pilot, that should have thrown red flags up... when there's a disagreement, abort and sort it out.
Clear case of crew was deadset on landing and ignoring any and all warning signs because of that. "If we just make that one correction, then we can land" instead of going around and taking a moment to go everything over in calm manner and making a clear plan for everyone to follow. Going around would have signaled aknowledgment of 'defeat', that they couldn't 'handle it.' Therefore they decided to gamble with evermore worsening odds...
As a Norwegian, I remember this crash with horror. I always wondered why it did not feature on National Geographic "Mayday" series, as the mistakes leading to the crash should have broader interest. Thus, I thank you very much for making this very interesting video on this "forgotten accident"
Eirik, I’m American and unfamiliar with this area. Is the nearby water at sea level? And the mountains protrude +3000ft above that?
Norway looks like a nice country to live in
@@Syclone0044 You are correct, it's sea level with surrounding mountains, i.e. a fjord.
@@eiriksfteland2388 there’re lots of seasons of Mayday Air Crash Investigation the first 3 seasons only had 6 episodes, then the more the series got shares and interest from the public were added more episodes. You will probably see this case in the nexts seasons, considering that COVID-19 slowed down the production of the episodes of the seasons.
Edit the episodes are not in chronological order but each season it’s focused on a specific thematic (issue).
@@Syclone0044 The Longyearbyen Airport has an elevation of only 27 meter (88 ft.) but the valley they had to fly in to approach runway 28 is surrounded by mountains up to almost 1000 meter (>3000 ft.).
- I have marked the airport here: goo.gl/maps/Wq8FzgKH8R413fW3A
- Here is a map of the valley with accurate heights of the mountains: toposvalbard.npolar.no/?lat=78.20201&long=15.85060&zoom=6&layer=map
- Wikipedia: en.wikipedia.org/wiki/Svalbard_Airport,_Longyear
I'd say that if everyone can't agree on the approach, go around.
Agree. Always better to have the time to regroup and figure out a conflict then have a catastrophic outcome.
Yup! Any uncertainty by anyone, buy time and slow things down until you're all sure. Way too many of these CFIT accidents have confused crews who decide to ignore their doubts.
yeah.. if your two navigation tools are giving completely different answers, that is a pretty strong indication that you should go around and figure things out before trying again.
It's not a culture of agreements...
@@SJ-oxy It seems to me that pilots take account of operational imperatives (i.e. don't mar your history with go arounds; save the airline money at all costs) rather than obvious safety.
I have flown with exact combination russian crew (4 man cockpit) as an observer for about 400 hrs to monitor and help them in my country 20 years ago. Tu154M was on wet lease. After GPS installation on Tu154M navigator used to rely on it all the time and always with setting an extended centerline. Unfortunately the navigator had all the lateral navigation control via basic auto pilot function (heading control via bank knob. Vertical control was with one of the pilots. Sounds crazy...
I exactly understand what happened to them. The navigator was trying to intercept the Runway extended centerline...
Btw...the VOR (hence the HSI indication) on Tu154 was not reliable and was fluctuating all the time. That's why pilots gave up and let the navigator do his job! Sad story...
Very interesting - that does explain a lot.
this comment needs to be on top
why do think the plane was designed with control split between the navigator and pilot? on one hand i think it's pretty neat for the navigator to choose the direction, and pilot the elevation. but on the other hand that seems more like the kind of controls you'd want on an airship, and not something that moved as fast as a plane
@@babynautilus
It hasn't been designed like that. At that time, the company had 2 other Tu154M with our own crew. A standard 3 crew without navigator(2 pilots and 1 engineer) and was absolutely fine. May be the reason goes to way back in Soviet union's time. Even one additional crew (5th) for ATC communication. May be to create more jobs and also as security measures. More crew in the cockpit to watch out and report each other.
@@scorpion1349 ... and one more crew member to watch, listen and report to KGB
It's pretty clear to me that this approach should have been discarded. A classic 'mission fulfilment' accident.
Yup, going around and slowing things down is almost never a bad idea.
Exactly, if there is confusion in the cockpit about where your are, you do not have a "stabilized" approach. Going around is the only option.
To hell with a go around, in that valley of death covered in cloud, with no English, I would've gone back to 5000 until someone at ATC could get a translator. Disagreeing instruments in that valley, screw dat!
It would probably be a hit to my imaginary pilot license, like being grounded until some more English lessons (I thought all pilots have to have a passable knowledge of English?) but I wouldn't have killed 150 people.
Where to they fly to discard the approach? They were in a valley. They might not have been able to fly above the mountains in the time they had.
It seems like they should have spent more time either getting the runway they knew how to use or spend time letting the navigator correctly program the GPS points to the difficult runway.
@@ddegn Exactly. And agreed. This was a mess of overconfidence and passing the buck.
There was very bad CRM here. Ultimately the captain should have declared a missed approach and gone around to try again.
Exactly. Go around, slow things down, and figure it out until you're sure. So many of these CFIT accidents have cockpit voice data of some uncertainty when there's still time to recover. If there is any doubt, just use the fuel and figure it out.
Not sure that helps with no visibility and confusion as to your exact location. He should have been more assertive in requesting runway 10 as that looked the safest option. This confusion could be because of unfamiliar or different national procedures for this airport.
What is CRM?
Cockpit resource management
How the crew operate and delegate, they talk about this for emergencies too like an engine out, who’s going to do what (that’s my basic understanding)
@@BramHeerebout The basic CRM (Crew or cockpit resource management) took over from the military style command hierarchy structure. It is a method to plan the stages of the flight, specify duties and effectively share the workload. It also flattens the structure of the cockpit so that the FO has significant authority and the captain must cross check many decisions with the FO.
As a dad, I've always told my kids; if your unsure about a decision; decide if you can live with the worst possible outcome of being wrong and weigh that in determining the correct action to take. In this case the worst possible outcome is death, which makes the decision for abort an easy one.
Excellent advice
Very wise.
I should apply this more often to myself.
Fortunately I’m not a pilot. Looking back a my life I would have crashed many times.
I always use the same type of logic when I ask “what are the chances (magnitude of) I’ll regret doing something vs. chances (magnitude of) regretting I DIDN’T do it.” Used that just a few days ago when considering buying an RV that seemed to be a very, very good price when I wasn’t even thinking about buying one a week ago. It was older and cost of fuel is $150% more now than 2 years ago and will likely be prohibitively high for the foreseeable future. I didn’t buy it and I’ll be happy to forget about very soon instead of worrying about something I have no control over. Maybe I’ll just rent one a few times this summer.
My neigbour worked at Svalbard in 1996 as a helicopter pilot. He flew rescue missions three years there. Our family visted them in 97. This accident was huge News in Norway and I got a first hand descrption of What the accident sight was like. There was nothing left. The plane had been obliterated. No body parts bigger than fingers were found and birds quickly started feeding. The force of a jet this size at a pretty high speed completely pulverised everyone and most of the plane.
This is why modern EFB's, GPS and high terrain displays provide so much more useful information these days.
Yet they still fly into mountains.
@@kevinwebster7868 Airliners? IDK, when was the last time a modern airliner crashed into a mountain? Smaller aircraft are an entirely different story...
Approaching through such a narrow valley they knew they had to adhere to the procedure very strictly, but they had an approach chart that showed the area to be hazardous, a localiser, and DME. --Flight director indicator, too, I would think. They knew not to leave altitude if not on course.
@@kevinwebster7868 99% of the time it’s the pilots’ fault for not trusting or following their instruments. Aviation is a series of cogs in a machine. Almost all the time, the instruments and automation function as they were programmed to, and the pilots are the ones who fail to do their duty.
@@kevinwebster7868 Kevin, you saved me a comment. That's exactly what I was going to say!
As a Pilot myself, I have to say much of this rests on the Captain. On any approach ESPECIALLY one like this, all flight crew members should be on the same page and in total agreement. The fact he let this situation become so chaotic is unbelievable. On this kind of approach, at the first sign of general confusion or conflicting information, the Captain should have initiated a missed approach.
I had a really good CFII that taught me to make a decision early and not let small things compound. If things start going squirrely, go missed, regroup and reshoot. Stood me in good stead. I commented on another video somewhere I still hear his voice repeating, "Smaller corrections sooner."
At what point, if any, would it have been reasonable for them to ask for a vector from ATC?
I agree. You need to be 100% certain that you are on the right flight path in cloudy, mountainous terrain. Otherwise, start again.
Main cause: You know you're in mountains, you don't know where you are. CLIMB!
Nope, turn around 180 degrees because you don't know the heights.
@@iuliusfoyas8159 yeah! Upside down 😂
You make a good point there buddeh!
@@santka3739 that's rolling and not banking.
@@iuliusfoyas8159 "around *180 degrees* because you don't know the heights" on the *SAME(!) altitude?*
It's perfect method of *sacrifice yourself.* imho
It was not the disagreement that messed them up, it was failure to brief, lack of awareness.
But the disagreement was the clear signal to abort the approach.
@@brianwest2775 Yes, when one person says "left" and another says "right", you have to realise that you need to clear up why you're disagreeing. And that probably wouldn't have happened if there had been a proper briefing to get everyone on the same page.
And mountains, lots of mountains
It was multiple factors but there shouldn't ever be a disagreement for the direction given that you are not trained in the approach for this runway, there is very low visibility and you there are mountains around!
Just a shitty captain. Doesn't know english, talks to the local weatherman and thinks he's atc, tells a navigator to do his own job, then argues with his crew until they fly into the side of a mountain.
For me, the major cause was their determination to press on with a very problematic approach instead of making an early decision to go around, settle the cockpit and start again.
Did they not have enough fuel or something?
Can't get over this mistake pilots are making. If you don't think you are 100% sure about your approach, GO AROUND.
I agree, if in doubt -GO AROUND , start again , theres too much at stake ! The pilots the man in charge and in control of that aircraft , so sad, so avoidable
That logic doesn’t always work with Russians 😏☹️
Agreed but situational awareness and performance pressures cloud judgement and displace training and the natural instinct "I know better but will acquiesce to the will of the majority" The PIC is the ultimate authority even in a day and age of CRM so Capt should have spoke up declared a failed landing attempt and got a boat load of altitude (climb out hard) and established clearance of the highest obstacle they were close to. Then come around and attempt the landing again. Proves you DO NOT mix up a crew of different languages and backgrounds. Avaiate, navigate and communicate!
@@omegakrest sputnik
I'm not a pilot (I did take flying lessons in my 20s) but this channel is addictive. The narrator is very good and presents things in a logical and clear way.
Tim, you are right... narration is excellent! 👍
It's been great ever since he added the custom animations!
@@Nathan0A I think he did great before he had the resources to do the animations.
Now it’s truly too tier work. I’m glad he was able to upgrade his equipment.
The biggest contributor to this crash was the captains failure to execute a go-around!
thats like a backup, definitely not biggest contributor. Had they briefed the approach, reduced work load on navigator, were able to properly communicate (which is an essential requirement and is taught at flight schools if necessary) they would have been able to maybe land safely. Weather is also a big factor as they gad no visual cues. Overall they were unprepared and everything screamed it wasnt going to end well
@@bray8949 yeah, the 'maybe' is the point here...no way you should try to VFR with different instrument readings on an uncontrolled airport with bad visibity and without any ATC backing you up. There are so many 'No's here...and it's not like they had any issue/problems that forced them to land immediately. So I am with John on this one. Captain should have called it as soon as they were not sure...
@@thethoeby it's IFR not VFR tho
@@thethoeby Its been a while since I've watched this video but if I remember correctly they were IFR (why the fuck would they else try to land a such conditions with low visibility), its been done a million times with IFR but not with VFR so I believe they were using an instrument approach. The airport was also a controlled one, they just didnt tune in the right frequency. Again everything that I stated previous is the main contributor. A go around is the last thing you would do, not like it was all going well untill they were landing, problems were arising well before
I would say CRM failure is the best summary of this. Failed to communicate with ATC, failed to request the proper runway, failed to brief the approach, failed to react to the situation as it deteriorated. With the overloading of the navigator, clouds, and the pilots ignoring their instruments, they were doomed.
Not knowing the Captain could have landed on a runway of his choosing instead of listening to an unauthorized "controller" insisting on a more difficult runway, thus putting the poor CMR in motion was a major cause in my opinion.
It's pretty clear to me that this kind of cockpit confusion is something that, as a passenger. I never want to encounter!
I'd say the navigator's incompetence caused the accident. However, it's the captain's plane. When he knew something is wrong, he should have said My Plane and declare an immediate go round. And then called ATC to see if they could land at 10.
What happens in these situations is the Captain doesn't want to look more intimidated by the situation than the others. It's incredibly stupid, but I think that's what happens in these spots.
@@someotherdude I wish I could remember the details of what happened in this video to reply but it was almost a year ago!
I feel like this is one of those crashes that wouldn't have happened in clear weather. If they had two conflicting sets of information, but could see that one leads them straight into a mountain, they'd be able to determine right from wrong without effort. Obviously it wasn't JUST the weather, but I think that in good weather this mistake wouldn't have been deadly.
For sure! With visual cues, all the confusion about the success of the 180 turn wouldn't have happened. This thing boils down to loss of spatial awareness and bad CRM.
Right. If you’re even remotely uncertain about where you are in bad weather, the approach needs to be aborted.
This was 25 years ago, now there might be other detectors onboard that can help during a cloudy day.
Yeah duh. “I feel like they wouldn’t have got wet if they didn’t go in the water” very astute observation.
@@awdrifter3394 Your theory would only work in the daytime! In simple terms, ALL Commercial Flights, in the Western World, operate under IFR. Instrument Flight Rules! All flights operate on Instruments and Airline Pilots are trained to do so. Our abilities to do so, in the Western world at least, are assessed every six months in the Flight Simulator. It makes Absolutely Zero Difference weather it’s cloudy or clear, day or night! It’s Always the same. Language and Cultural difference are the biggest problems for many Russian Language Pilots, and this has led to many fatal accidents!
I think one of the biggest factors was an unwillingness to climb and think things through. When you have conflicting information, it’s vital to take time to figure out what’s going on.
That is a beautiful plane. I flew in it a number of times. Back in the day when cockpits remained open you could see the Horizon curvature at around 11 km cruising altitude through its wide cockpit windows, when the weather was clear. It's a little on the noisy side, but it handles turbulence like a pro, very smooth and stable
Failure of CRM. If there was that much uncertainty and disagreement about an approach, **especially near mountains**, they should have discarded the approach and given themselves time to slow things down and figure it out.
The combating male egos didn't make that possible≥
Silly question: what’s CRM?
@@lukas3606 Crew Resource Management. A lot of study and training has gone into how crews interact and how to improve them. For example delighting tasks efficiently. It's also about crew dynamics. The notion that the pilot in charge could ask the navigator for a position and be told "unnecessary" is absolutely nuts.
As someone who lives in longyearbyen and is a pilot, this was a really interesting video! Thank you, very well made :)
Isn’t the most northern airport in the world located in Longyearbyen?
I feel really bad for the navigator, he was doing his best but that wasn't enough. And for everyone who lost their lives, too
Yep, he prob thought he was right until the very last second...
He was using a GPS as his primary information source in spite of the fact the the approach diagram only authorised the approach to be made using the NDB beacon.
Navigator is the one that gave wrong translations to the crew making them think they were talking to the tower, that runway 1 was busy and that they should use new runway. Then navigator wrongly used GPS to set them on wrong approach literally through mountains.
Now the captain should've ordered a go around and the navigator shouden't have had comms task because they should've all been trained in English, but the very circumstances that lead to the crash flightpath were all caused by the navigator.
What went wrong was building an airport in the middle of mountains where plains had to thread it like a needle.
Plains don't do anything, especially threading. You are mistaking long areas of flat fauna for planes perhaps? Don't worry about it, it's probably just the senility kicking in.
Why is the stoopid ocean in the middle of the mountains?
Who put a plain in the middle of a plain ?
The rain in Spain falls mainly on the plain or is it plane?
It's plain to see , the plane was in trouble 🛬
Difficult airport for landing, cloudy weather. And you have someone who is 'just a person' instead of a qualified ATC talking to foreign pilots exacerbating confusion. Why should this even be possible?
QUESTION: Where was ground control? Why was there only an AFIS guy available on such a potentially dangerous airport? Decent ground control guys would probably have seen that the 'plane was positioned incorrectly and could have guided them in.
It's just a small airport with not much traffic and probably not that many people involved in running it. It wasn't made clear in the video, but this airport is the northernmost airport with commercial traffic in the world, certainly an unusual one. These days, I would expect that this might be one of those airports where only pilots who specifically received training for it fly into it.
I checked the charts, even today there is only a "Longyear Information" frequency, no ground control, no approach, no tower. FWIW, the apron is so small that having a dedicated ground frequency would be somewhat redundant.
Edit: reading again, why did you expect ground to do anything? They only handle the apron, not even the runway, certainly not planes on approach or departure in the air.
Ground isn't responsible for landings/approach. They should have kept the plane on 5000feet, figure out that there is something wrong going on (maybe even declare an emergency due to the instruments discrapancies) and then after they collected themselfs just insist on landing on the original runway/heading.
Tim Elwell
Why does Decent ground control have to be guys? as you stated
You did not do so EL Well in describing the Air Traffic Control operators
by defining them a 'Guys"
Do you know any other words that would have been a better use of the English language?
Write a response to yourself, as regrettably I will not have time to read it.
Good luck and goodbye
@@andrew_koala2974 The word 'guys' is in common parlance nowadays for 'people' and is not actually gender specific. Is was NOT inferring that air traffic control needed to be male. When someone asks a group of friends at the pub 'how are you guys doing?' this could equally refer to a group of women, or men, or a mixture of the two genders. I am surprised that you were unaware of this. Are you still living in the 18th Century?
@@timelwell7002 Just because the application of a word has changed in one part of the world does not mean that others know about it or need to adopt it. Case in point, just because Americans refer to table tennis as ping pong does not mean others know or need to adopt it. Football & soccer also come to mind quick. Terrorist and heroes another example. If one has the time, then the long list could be created.
Without a visual reference due to the weather, and uncertainty about their position they should have immediately climbed out of that approach and reconsidered their plan at a safe altitude. They knew that they had to be right in the pocket of that valley, so the danger of not getting it right should have been ultra clear. Some things have to be 100% without exception.
It seems to me in all these crashes the “close proximity” warning pretty much is just letting you know your about to die. Why does it not say something like “obstruction 5’000 ft”. So they more time to react than 500 ft.
@@SarcasticTruth77 so planes dont have radars for horizontal proximity?
The problem is if it is too sensitive it creates false alarms. When a system consistently creates false alarms, it gets ignored - which of course makes it completely ineffective. The engineering challenge is to design a system that provides a reasonable amount of warning without generating too many false alerts. The technology of the era couldn’t account for very abruptly rising terrain. Newer systems use GNSS and worldwide terrain databases to provide much more “look ahead” than older systems could, which essentially just looked at how far away the terrain was and how rapidly it was rising directly under the aircraft.
I think the primary cause was poor communication and resource management in the cockpit. There was no consensus of confidence regarding the accuracy of their approach. They should have done go around and taken the time to recheck approach settings while they discussed why navigator wanted right turn at the same time pilot wanted left turn. Any time a flight crew has a conflict regarding flight parameters or navigation they need to resolve the discrepancy before initiating a blind approach.
Amazing video as always. Thanks for your hardwork.
I feel the major contributing factor was the AFIS controller not transferring the navigator to ATC. ATC rituals may have helped mitigate the language difficulties. Next is the poor visibility and the captain's lack of control.
Something that wasn’t mentioned at the video’s end as a fault option, they were given a more dangerous approach in bad visibility. The tower was at fault. The tower flew them into a dangerous mountain approach blind. That’s wasn’t necessary, they could have qued landings on the other side as fuel allowed. They was no emergency, no need to land that moment. They could have accepted the request for the other runway after a holding pattern.
You are missing an important fact. There was no "Tower" controller, he was an Airfield Flight Information Officer who was quite correctly identifying himself "Spalbard Information" which any pilot would understand as only an information service.
They were never given a more dangerous approach. The crew asked in broken English which runway was busy and the AFIO complied with the correct answer. The crew interpreted this as having to use the new runway. A massive series of wrong interpretations caused the crew to believe they were talking to the tower, that runway 1 was busy and that they should use the new runway, all of which were wrongly interpreted by the crew.
Where was the air traffic controller in all this? His absence is not explained.
The flight crew were on the wrong frequency , they assumed that they were speaking to a controller.
@@Haywood-Jablomie The actual controller must have seen the flight approaching and wondering why there was no communication, whats the protocol for that?
@@petr6258 I'm fairly certain the AFIS and Controller were in the same place so they could probably poke each other and ask... but in the event that they aren't together, there's a frequency called GUARD that everyone is supposed to listen to along with their desired frequency. If a plane isn't responding or checking in with ATC, usually ATC or other pilots will start trying to get their attention on Guard Frequency. If that doesn't work, most modern planes can accept text messages to their onboard computers.
I thought he said there literally was no controller?
Some smaller airports just don't have the budget for one.
Usually, you need a controller to ensure planes don't crash into each other - the landing can be handled by the pilots just fine, if all the approach equipment works.
So if it's an extremely remote airport like this, where you get one or maybe a few flight per day, it's literally not worth the cost to get a controller.
Also, I could see how radar in such a mountainous area would either be too expensive, or just not work well enough.
This was 1996 after all - not really a time when Russia had a lot of money to spend....
There is no controller, that's why the frequency is called "Longyear Information". This radio operator is only supposed to (and only authorized!) to provide information to planes departing and approaching, not provide separation between planes or between planes and terrain. Think of this frequency like an ATIS, but it's a person.
Great video. Other channels like this make you read a narrative which is a pain in the ass. You narrate so I've subscribed.
CFIT's will always be the hardest to investigate. This one was on the Captain for not being a Captain. When I would get a flight release to an airport that I was not familiar with I would study all approach's enroute and try to find all the easter eggs that can surprise a crew. Getting a runway you weren't expecting is not unusual and happens all the time. Sadly, 141 tombstones to teach us a lesson.
This is a great video. The presentation is concise, accurate, and very well articulated. The animations are very well done and show the issues encountered as they occurred! I believe this is one of the top aviation channels on TH-cam. Kudos to the presenter and the material. I look forward to new material!
Like my flight instructor told me on my first day of training. Taking off is easy to get right. It's the landing you have to get right.
I would think that a contributing factor is GPWS Not giving enough warning or reaction time. That should have been their last defense.
Sadly GPWS only provide the minimum terrain, not how much the slope.
It was working as standard, it just can't comprehend between sea and cliff
This was before E GPWS which is now required equipment. It wouldnhave prevented this crash
@@PeterTheSAGAFan definetly, it woudve sounded the moment they made the wrong 180 deg turn
Absolutely horrific...I'm at a loss for words!! Thank you for uploading and sharing!!
Runway "in use" sounds to me like it's not available right now.
Good point! I mean, no one would want to cross the Bering Strait Railway if it was 'in use'... right? 🙄
To me +1
I get what you mean, but "runway in use" is standard terminology in ATIS messages, it would be clear to any pilot with any sort of knowledge of aviation english what is meant. The radio operator here fills essentially the same role that a recorded ATIS message fills, except it's a person doing the job. A typical ATIS message would be something like "this is information alpha airport something something runway in use visibility more than 10 miles clouds so and so at so and so feet winds 270 degrees 10 knots report you have information alpha on first contact". Then on contact you tell tower you heard the message.
Say what you will, but the TU-154 is a damn nice looking plane...
Volkier - So, I can say what I will?
Ok then, you asked for it!
I say that the TU-154 is a damn nice looking plane.
Take that, big guy! 😏
Right. And in all of her crashs, she had not the blame.
@@Paka1918 ALL her crashes?! How many have there been?
Yet people perished
Not when it’s impacted a mountain
Wow. You must really study reports to get these complex explanations correct. Bravo. I would always go for the safety of height and then figure out how to safely land well above surrounding peaks. That flying blind in a mountainous area, scares me completely. Sad that they were asked to fly in a dangerous approach without knowledge or previous experience. English fluency might have helped them here. Tragedy resulted. Thanks Mini, you just continue to improve!!!
Major cause? A captain who didn't take charge and abort the approach when the confusion arose. Secondary factor was allowing a flight crew to take an international flight without SOLID English skills.
It always comes down to the Captain. His instincts told him something was wrong, but he let himself be talked out of it. Captains are taught that when confused where you are in dangerous circumstance, get the hell out of there to a place of safety. At anytime he could have declared a pan pan, climbed above the clouds & mountains, and chose whatever runway he wanted to land on.
he was unware he could choose runway and a pan pan is in the case of an emergency where its not that serious and not really a problem to the plane (it can continue flying). So a pan pan could not be declared
@@bray8949 A pan pan is simply declaring a state of urgency, not emergency, and can be declared at any time. Flying thru mountain valleys cover in clouds while three crew members argue about where the hell they are seems pretty damn urgent to me.
@@disturbed4733 it is urgency but in the sense of a threat. Its very confusing but that is not when to declare a pan pan. A pilot doesnt need to declare a pan pan to go around or simply cause theyre scared, they are in the end in charge of the plane and can climb and tell ATC later. Think of it as a notch below Mayday (which is obvious when to use)
@@bray8949 Pilots are meant to use the pan-pan term when they're urgent about something, quoted in the FAAO JO 7110.65; 10-1-1. The captain would've made the right choice of being urgent enough to get the hell out of there since him and the FO were confused and blind of their surroundings.
Almost a 100k subs yay😆
He deserves it. ☺️
@@grmpEqweer I came here to say exactly that haha.
Jeees just noticed that.. i found this channel not long ago at all an it was barely getting to 20K
I just realized I've been watching this channel for months, but wasn't subscribed...my bad
@@splifstar85 that was over a year ago
In the end it was that great killer of pilots: mindset. They insisted on landing when they were not certain where they were. They should have returned to altitude and tried again until they were certain of where they were. This alone would have negated all the other factors which led up to the crash.
I love your videos so much! watching them one by one, every single one, and i have been amused and entertained and also i am learning so much! thank you for all your hard work, I hope you never ever quit!!!
I think that ultimately the reason for the crash was that when the crew became confused about their approach, they did not go back to basics....fly the airplane!! They should have gone back up so they'd be above the mountains, like a go-around, and start over. They needed to clear up any confusion, speak with the correct approach controller, and not descend until they were 100% certain they were on the right path.
I think the importance of all crew members being more fluent in English cannot be overstated. This is not the first time that language has brought an airplane down. Lots of mistakes here. But ultimately, no descent should ever be made when confusion in the cockpit exists. Fly the plane with certainty, not guessing. Great video! This is the second video I've watched from this channel. I like it!! Well done!
Poor Cockpit Resource Management. A weak captain delegating too much work to the navigator and then not resuming his authority when it counted.
biggest factor was the lack of air control. An air traffic controller with radar, etc., would have picked up on the error instantly.
So, radar then, rather than ATC.
Respectfully disagree - these guys should have been ready to land at either runway even before they took off. Not a language issue, no fault of the ATC. Sure, ATC could have helped if they had good radar coverage - which is often spotty in the mountains, and no decent pilot assumes that ATC will keep them out of trouble. This one is clearly a systemic issue at that airline - they just sent the boys out and said "figure it out like real men!" Whoever was in charge of that airline is at fault.
@@dermick I am not sure about that...every one sitting in the cockpit should have called the landing off. It is their responsibility - even if company is sitting on your neck. Just not worth putting your ego over the life of so many...if you do, you have no business beeing in control of a plane.
@@thethoeby I understand what you are saying. These pilots are the product of the company's culture and processes and training. If the company had a culture of safety, then the accident would not have happened. The company culture made it untenable for one of the pilots to say "time out", in addition to getting them into the situation in the first place. Owners and managers of a company need to take responsibility for the actions of their employees.
Amazing detail sir. Thanks for making these videos.
Captain should have asserted his authority. That is really his job at the end of the day.
It was probably the language barrier that was the biggest thing.
Everything else can be sorted if one can communicate effectively.
Internal communications broke down. Did Pilot have authority to fly as he sees fit? Then he should have chosen one course or the other... or the third, a go-around. This was a cock pit piss contest. Capn's gotta cap'n.
I dunno, the descent approval was wrong, but there were still any one of the three crew who could have declared a missed approach and tried again.
HSI was a system that really lent itself to confusion when under stressful conditions.
I leaned to fly shooting approaches using fixed card NDB. I really had to stay proficient by flying a sim as often as possible. The mental math and positional awareness required could be tested severely when operating under very strong winds and in a emergency situation.
I was very fortunate to have sufficient money to own a simulator that allowed me to practice approaches at home. Once I received my “line” (schedule) for the following month, I’d try to fly all of the non precision approaches and review the precision approaches before the trip began.
First time I discover this channel. A demo version of Mentour Pilot (no annoying ads 2-3 times in a 30 minute video) and uploading tons of content - love it!
Why did the person without authority approve their descent? Did they investigate that?
I suspect he was just 'trying to be helpful'. In any event, this had no earing on the matter. The crew were clear to descend at their own discretion, which they did.
@Schlomo Baconberg The Tenerife dual 747 disaster partly occurred precisely because of the use of non-standard terminology. Especially the KLM's use of the phrase 'we are at takeoff'. A 'heterodyned' VHF transmission (occurs when 2 transmissions happen simultaneously) completed the train of mishaps, meaning that PanAm never heard it.
"Approve" isn't the same as "clear", which is the mandatory term, so it shouldn't have been confusing.
@@grahamstevenson1740 When did this turn into a video about KLM and PanAm? I thought it was about Vnukovo flight 2801.
@@rickmyrick5470 they're giving an example of incorrect use of flight terminology - which may have contributed to the accident 👍
I feel so sorry for the navigator.
THEY MAKE HIM DO TO MUCH THEN ARGUE.
I THINK ANYTIME YOU GET LOST YOU NEED TO CLIMB.
@@ronniewall1481 I agree. Even a well trained person in the ground doing Maths while talking English (when its not your first language) will be under a lot of stress already. Add the pressure of flying AND arguments AND controls.
Poor guy😔
I feel sorry for the pax that boarded with confidence a professional flight crew will get them to their destination. The Captain failed ultimately.
As always love your content, thank you :-) One small gripe, while I understood your intent perfectly, this line was a touch confusing on first listen:
"They got in touch with the AFIS controller. Remember, he was not a controller"
Thanks Mini. Love the vids. Cheers!
If u find 2 instruments that completly disagree u need to ask to go into a hold at a higher alt and sort it out by resetting both and performing tests to isolate the fault....
Language was only a factor. The reason was lack of briefing, and thus they didnt know what to do and which instrument they should rely on.
Any competent pilot should be able to land on any properly equipped airport under instruction from ATC. The mere fact that they didn't realise that they were not talking to a controller demonstrates how language is crucial and was the primary cause of this accident. They didn't even know that they could have landed on the other runway if they had wanted to, also because of communication issues
@@2000globetrotter Even with the lacking communication - if they had simply taken the time to brief and prepare the approach that they assumed they had to fly, everyone would have been safe. Even with no communication at all, that would have been the case. This could have happened exactly the same way as it did without the communication issue: Say the winds just turned from what they expected earlier, so they had to switch to the other runway to do the landing. Same result.
Considering this happen in 1996 it's not something that would have happened today. Aviation has taken these and several other crashes into account and made to changes so it does not happen today. Pretty easy to say how you would do things different today while not understanding how very different things were back when.
@@notme2day Not necessarily, it should not happen today, but accidents and near misses are happening fairly regularly, most of these can be attributed to confusion, confusion about what the problem is, confusion about where you are, confusion about how to handle your confusion. Pilot training has definitely improved over the intervening years, but the human brain has not, it's just as easy to be confused now as it was then. And then there are the cases of non confusion, where pilots deliberately risk the lives of all of their passengers, because they had to get to the destination aiport, even though they were only flying on 1 engine, and they "accidentally" deleted the CVR recording to disguise their orders to the crew to disregard all safety protocols, and to do what they, the Captain, ordered.
@@wolfen210959 I would argue that the amount of confusion you're talking about is happening with smaller planes today and NOT with the large commerical plane pilots .. or do you have data to provide to prove this accident would happen with today's technology?
I'm starting to feel like airports in between valleys and around mountains aren't such a good idea
In a place like svalbard there is nowhere else to put to put the airport
WORD
I think the pilots' lack of English was the greatest contributing factor. It overloaded the the navigator, delayed communications, and greatly limited PIC's decision making speed and confidence.
Russian air crews should by now all be able to communicate outside of Russia, where the ATC language is universally English.
Love this video. Another awesome job.
Idk if you know it but you always upload at a perfect time for your Aussie fans and I really appreciate it!!!
He sure does even it’s about my bedtime
I would have thought that moment the confusion kicked in the captain should have aborted the landing and climbed to a safer altitude while they come up with a plan b. I thought pilots were supposed to be bright. Flying around in zero visibility with a mountain in the vicinity is taking one hell of a risk.
I don’t know what the winds were but I’m using RNWY 10 until my tailwind component is exceeded. The guy at the airport is just for advisories. The active RNWY is the one you choose to use. The Captain blew it early by not sticking to his guns and staying on RNWY 10. I’m taking a 10knot tailwind or a 20 knot crosswind rather than flying 140 peeps down a damn gulley.
seems like the biggest contributor to the crash was the navigator not having enough time to reprogram the gps. He should have told the captain he needed more time, and to go around until he was finished with the programming. Or he could have communicated to the tower that they didn't have time to reprogram the gps and needed to land on the other runway.
Conventional radio navigation--not RNAV--was the safe way to go with this approach.
That's a bad time to get into a navigation argument when you're in the clouds, flying low around mountains and that landing approach is the first time to experience it. I wonder why manual flight systems do not have warnings that tell when pilots are right or wrong when following the correct guide path (e.g. LA beacon for this case) then when at a certain correct position only then it signals them to meet the extended center line as they adjust their direction to land. Also their landing map probably should have warnings to watch out for when flying low and too close to the mountains upon executing such maneuver. Doesn't this plane have autopilot waypoint instrumentation so it can be programmed to fly the correct path and do it for them automatically until their final approach on landing? I'm not an expert on airport systems and planes so just my suggestion.
Building an airport in an area surrounded by mountains and where cloudy weather is frequent was asking for trouble.
Also, why wasn't there proper ATC on duty at the airport?
The lack of an ATC or an airport surrounded by mountains are just excuses. The pilot was not in command≥
There are plenty of airports in mountainous areas, and this is a small one with not much traffic literally at the end of the world. If airlines felt it wasn't safe to fly there, they wouldn't fly there. This was simply caused by pilots who did not brief their approach and did not maintain situational awareness, combined with lacking CRM and no knowledge of aviation english, which is a situation that could just as easily have lead to disaster at a towered airport.
Hmm yeah it'd be like blaming the people who built a sharp curve at a mountain highway for reckless drivers crashing there
I think the biggest mistake was the pilots continuing their descent despite their confusion. You can always try and approach a 2nd time.
Thanks for continuing to cover Soviet and Russian incidents - really interesttnig
They got lured deeper and deeper into the mess until it was too late!
When any approach in IFR is in question especially dealing with terrain, GO THE FK AROUND. Don't fall into get home itis. I've gone around before and that's why I'm here writing a comment.
Thank you for a great job. As a Norwegian I remember this accident like it was yesterday.
seriously where do you get the background footage for these videos?
The Captain should have taken over command of the plane if he was in doubt of the information he was being given. Sad and unnecessary loss of lives😔
I agree. The captain is the person in charge and if he see a problem or conflict it is up to him to work it out. He should have told the navigator that he was the captain he was going to do it the way he felt was right. When he gave up and let the navigator take over he gave up his right to be captain.
@@dlb4299 Agree 💯 percent!
I think they should have practiced both approaches. Weather and wind aren't guaranteed.
I don't know why I started watching air line videos but I am enjoying it thus far. I was a little confused with the map path details since I'm not a pilot. I still enjoyed your video.
Your videos are really great!
I would have to say that a huge contributing factor if not the cause was lack of CRM and lack of task sharing.
The pilot was capable of landing the plane by himself if necessary.
@@DaddyinVancouver He was capable of landing but he didn't. Did he?
The graphics towards the end of a correct landing really confused me while you were talking about the crash
Thanks for the video 😀👍
Your presentation of the „correct“ lineup is wrong. Approaching from the west, you are not allowed to join the ADV racetrack procedure with an offset (aka teardrop) entry and intercept the LA localizer in the first pass. Also you are not allowed to join directly the ADV baseturn outbound leg as the direction they were coming from was outside of the allowed +/-30° entry cone. Refer to ICAO Doc 8168 PANS OPS.
The crew would have needed to join the ADV racetrack via a parallel entry, going back over ADV, joining the outbound leg of the racetrack, and then on the inbound turn intercepting LA localizer.
Thank you, I was going to point that out as well. Now the question is is the video wrong, or did the crew perform that incorrectly as well?
They knew, they were off the approach line, they couldnt agree on how to get back on the line, and bad weather blocked visibility. There was only 1 correct action here - go around, do the approach briefing for the correct runway, give the navigator time to prep the plane properly for the approach, and only then try again.
This was so avoidable. This kind of accident is the worst kind, the kind that couldve been avoided at any point, if only the pilots had followed procedures or just admitted to themselves, they were off track and gone around. God, it really gets to me, that so many ppl died due to something so stupid.
I guess they were using one of these portable GPSs with some wild wiring to the charging socket. It might give the crew a feeling of accurate navigation, specially when you end up flying to places without navaids and in bad weather, but it is not integrated to the pilots’ instrumentation, it is only viewable by the navigator and it’s simply not approved. I’ve seen this before and had to “fight” against using it.
The pilots clearly would have flown the approach correctly would they have followed the approach plate the way they were used to, only trusting the old style approved navaids their aircraft was fitted with.
Another great episode!
A lack of EFFECTIVE communication between the crew members seems to have been at the root of the accident.
Lack of CRM. Also, pilots generally need proficiency in Aviation English and that contains about 300 words.
Agree 100%
With an approach like this, any confusion should lead to an immediate go around, especially in IMC.
Had there been an air traffic controller he could have seen the flight’s flawed path into the mountain. Then the foolish captain declared, “I’m familiar with it”... that was the last complacent declaration of his career.
/Lonewolf Liberties
nice info dude. you should make one on Air India express 1344 too.
waiting for the final report to come out
@@MiniAirCrashInvestigation I love your videos. I want to know which crash shocked you the most?
This is an extremely well-put-together video and recreation of what happens with a breakdown of CRM. As James said, "When in doubt, climb out"! This is very good advice indeed. I fly a 737 in the USA and Mexico, and we have several areas with this kind of approach. The advent of RNAV/RNP makes this much safer, but I do remember my early days of flying NDB approaches in the BE1900 Super D. And it was during this tenure flying in mountainous terrain that we almost met a similar fate. Before we judge the Russian crew, let's think about how this confusion can happen to all of us. The best safeguards are training, standardization, an unhurried briefing, and, most importantly, a cockpit environment that rewards crewmembers for speaking up. A GO AROUND is a successful completion of any approach, and had they done just that, the outcome would have been better. In the end, as Southern Gospel Pilot says, the final responsibility rests with the Captain. Very good work!
Hi, I really appreciate your videos. Maybe you do one on Luxair Flight 9642?
This ones interesting I’ll add it to the list
@@MiniAirCrashInvestigation what happened there
@@kirilmihaylov1934 spoilers 😆
@@gettothepoint2707 sounds bad
Main cause based on your story: Capitan not having enough authority to "order" the plane onto the correct path. Add to that, poor planing.
If you don't know where you are in potentially hazardous terrain, why not abort the landing, climb to a safe altitude and fly a new approach? Was there any hurry to get down? (Fuel, medical emergency, weather etc.)
Is there a reason real audio doesn’t get played on these TH-cam channels. Your videos are great, if you combined audio from the cockpit or with the atc you’d be even better. I have seen plenty on tv shows.