- [Petter] A single unexpected instruction
from air traffic control initiates a sequence of events
that looks completely inexplicable. A perfectly working Airbus A320 is hurtling
through the night towards the dark sea below, but why? Stay tuned. - [Radio Altimeter] 100, 50, 40, 30, 20, 10. - All accidents are tragic, but it's the
really unnecessary ones that tends to stick in your memory, the ones that lack
any type of reason or explanation. And the one that I'm about to tell you
about today is definitely one of those. On the 3rd of July, 2006, a crew from Armavia
was getting ready for a short one-hour flight from Yerevan in Armenia
over towards Sochi in Russia. The flight was a scheduled night flight
with a departure time of 40 minutes past midnight and the general weather in the area
was dominated by a low pressure in the eastern part of the Black Sea. This low pressure had caused a cold front
to move over the destination, Sochi, and had brought with it some low clouds,
poor visibility and, at times, very heavy rain showers. The captain was 40 years old at the time
of the accident, and he'd been flying for Armavia for about two years, and as a captain
on the Airbus A320 for less than one year. Previously, he'd been working for
another Armenian airline flying the Yak-40. But he had since taken the type rating
on the Airbus A320, which he did at SAS Flight Academy in Stockholm, where I actually worked at about the same time
as this happened, but not with these crews. During that that training, he had received
okay comments from his instructors, but he also received some notes
about his lack of callouts. He had amassed about 5,500 hours of total time, and 1,436 hours on the Airbus A320. On this evening, the captain was joined
by a 29-year-old first officer who had also joined Armavia
about two years earlier. He had previously been operating the Tupolev 154 and the ATR-42 for a different operator but then he also went up
to SAS Flight Academy, got his type rating on the Airbus 320 and started working for Armavia. He had about 2,200 hours of total time
and about 1,000 hours on the Airbus. The aircraft that they were scheduled to fly this night was a nine-year-old Airbus A320 that, according to technical records,
was in perfect working condition. According to local Armenian laws,
the crew underwent a pre-flight medical check at time 23:30 local time and then they started looking
into their pre-flight briefing material and they saw quite quickly that the weather
at the destination was quite marginal. But given that this was a very short flight,
only about an hour long, they decided that they were going to take fuel
to fly over to Sochi to be able to reach their alternate if they needed to
but also to have the ability to fly back home to Yerevan if that was needed. In order to do that, they calculated
that they needed about 10 tonnes of fuel so they contacted their handling company
and the fueler started to refuel the aircraft. The pilots also checked their NOTAMs
where there was nothing of significance. And then they checked
the low level significant weather chart where there was some indications
of some low level turbulence but nothing that would stop them from flying. So they proceeded over, started briefing
their five cabin crew members for this flight and one flight engineer that was also gonna
come with them over towards Sochi. And then they proceeded out to the aircraft and started boarding their
105 passengers for the flight. The pilots had decided that the captain
was gonna be pilot flying for the first flight. So he went into the cockpit
and started doing the pre-flight preparation while the first officer completed the walk-around. And at this point, everything was normal, except that the pilots were making some comments about them feeling a little bit tired. They did have more than 24 hours
of rest prior to the flight but working nights is always hard and it's really hard
for the body to adapt to it. At 39 minutes past midnight,
the crew received their engine startup clearance and about eight minutes after that,
the Airbus A320 initiated its normal flap one takeoff roll from Yerevan Airport. As the aircraft got airborne,
the captain called for gear up and started retracting the flaps on schedule. At an altitude of 2,370 feet,
he engaged the autopilot and then continued climbing. The first officer was handling the radios
and, initially, they received some vectors to avoid a nuclear power plant
and later also some storm clouds. But eventually they contacted Yerevan control
and received their clearance to climb to flight level 200. The controller also informed the crew that the weather in Sochi
was now 2,000 metres in mist and a cloud base of 170 metres. Yes, I know the Russians uses metres to give altitude distances
while the rest of us uses feet. In my view, that makes total sense
but it makes it a little bit complicated to tell this story so I'm gonna tell you both feet and metres because
that's what's in the final report. The problem with that weather report
was that the minimum weather required in order to be able to start
the ILS approach in Sochi was 2,500 metres visibility and a cloud base of a minimum 175 metres. So with this weather, they wouldn't
be able to start the approach there. The first officer acknowledged
that weather and then received climb clearance to their final cruising level,
flight level 340; 34,000 feet. The cockpit voice recorder indicates
that the pilots were now discussing the weather situation and at this point,
it looked like both of them were open to the idea that they might not be able
to continue towards their destination. However, that is soon about to change
because at time 0120, the first officer called up the Sochi approach controller
and asked him to clarify the weather situation. The approach controller responded
and said that, at this time, the weather is actually below the landing minima
for both the ILS into Runway 06 and the ILS to Runway 02, which are
the only two landing runways in Sochi due to terrain on the other side of the airfield. The first officer then informed the controller that they had about one hour
of holding fuel on board and he asked him whether or not
there were any forecasts of improvement in the weather for the next hour. The controller went way and consulted
with a forecasting expert and when he came back, he said that the weather for the coming hour was forecasted to be 1,500 metres visibility and a cloud base of 150 metres
which is way below the landing minima. What the controller forgot to say was
that this was an at times forecast, meaning that that was
the worst possible weather forecasted during the next hour. It wasn't an accurate full picture
of the weather situation. The aircraft was now about
180 kilometres away from Sochi. And based on that weather report,
the crew now elected to return back to their departure aerodrome of Yerevan. They informed the air traffic controller
who told him to turn left back towards an alternate point called BARUS. And here is where this story could have ended. But unfortunately, that's not what happened. Something else is starting to happen in this cockpit. Even though that decision to return back to Yerevan seemed like a sound decision based
on the weather information they had, the captain now indicated that he was starting to get irritated with the Sochi Approach Controller and the cockpit voice recording indicates
that it looks like the captain thought that the approach controller had
some kind of personal agenda in all of this. This was also the first indication
that it looked like this captain was now getting more and more
focused on getting this aircraft to Sochi. As this discussion was going on,
the Sochi Approach Controller actually contacted the crew
on the second radio box asking them what their decision was. And the captain chose to respond to that saying, Yes! What decision?!
We're returning back to Yerevan," clearly irritated. About 10 minutes later, as the aircraft
is actually returning towards Yerevan, the crew, again, contacted Sochi approach controller to get the updated weather. But this time the crew also tells the controller that they have deputies on board. What they're likely referring to here
is members of the Russian Duma, high ranking politicians. This was not true, but they likely said this in order to try to influence the controller
to give them better weather to enable them to once again turn back towards Sochi. The controller came back and said
that the weather right now is about 3,000 metres with a cloud base of 170 metres
so it's just around minima but for the last few minutes, it's been okay. This caused the crew
to once again change their minds and they now informed the Tbilisi controller they were talking to that Sochi
was again open and asked them if they could get a turn back towards Sochi. The Tbilisi controller approved this
and told them to turn direct towards a waypoint called BANUT. Now the captain starts preparing for the approach. And on the cockpit voice recorder,
you can hear them going through the approach briefing. And as part of the approach briefing,
they're discussing how to do a proper go-around for Runway 06. The approach procedure stipulates
that in case of a go-around, the aircraft needs to turn right
onto a heading of 240 degrees and climb to 2,100 feet or 600 metres,
maintaining an airspeed of maximum 200 knots. Now remember that missed approach procedure because it's going to become important later on. At time 01:52, the crew received
their first descent clearance to 22,000 feet. This was initiated in something called
a MANAGE mode, which means in the Airbus that the aircraft basically follows
a predetermined descent path but for some reason that descent mode
seemed to irritate the captain. He made a remark saying, "This one doesn't
want to keep in the MANAGE, does it, brother? Now have a look here, it doesn't want to. You can't make it." The copilot answered,
"Well, engage your autopilot if you want to. Yours is better in the descent,"
and then they both laughed. The autopilot was then changed
from autopilot two to one. And then the descent mode changed
from the MANAGE to the OPEN DESCENT mode meaning that from now on the autopilot
was going to try to descend following a specified speed rather than the specified path. This could potentially be seen
as a lack of understanding on behalf of the captain
when it came to his autopilot system but it might also be an indication
that he just wanted to descend quicker in order to anticipate maybe shortcuts
and get towards Sochi quicker. One thing that was noticed
was that the captain, during the descent, had a tendency to change modes
and update things without telling his colleague, the first officer, what he was doing. Now, it is mandatory to call out
any changes that we do. And that's not just because we want
to follow standard operating procedures. That's also because it's really important
that both pilots have a shared mental model of what's going on, so that one pilot
doesn't suddenly look up and see a completely different descent mode
on his flight mode annunciator, not understanding why it's there. Anyway, during the descent,
there were also some more signs that, at least, the first officer
was experiencing a bit of fatigue, because at one point, he said,
"Screw it, who operates such flights with the jitters and not enough sleep?" As they descended further,
the pilots also discussed that they weren't going to contact
the Sochi approach controller anymore until they absolutely had to
out of fear that he might be giving them, again, worse weather so that
they couldn't start their approach. But at two o'clock in the morning,
the Tbilisi controller handed them over to the Sochi approach controller
for their final descent in towards the airport. They did so and were cleared to descend 5,900 feet and proceed towards a waypoint called GUKIN. They were also given the latest weather
which was okay at that point, a visibility of 4,000 metres,
ceiling of 180 metres in light rain showers, temporary visibility of 1,500 metres,
temperature was 11, dew point 11 and the pressure, 1,016 hectoPascal. The controller also told them that it looked
like they were way too high on profile and that they needed to expedite the descent. If not, they were not going to be able
to make the final turn in towards the approach. The crew read this back and increased
the speed to 280 knots indicated to try to regain the profile. At this point, they were about 47 kilometres away
from the airfield; that's about 25 nautical miles, and they were at an altitude of 12,700 feet. And just to give you an idea, at that distance,
they should really be at about 8,000 feet. So they were indeed quite high. The pilots were now reminded again
by the controller that they were high on profile before he handed them over to the next controller. And the cockpit voice recording
is indicating that the pilots were quite annoyed with how the controller was handling this. And it is likely that the fact
that they were so annoyed and that they were also starting
to get a little bit stressed about being high on profile
could potentially start to have an effect on how they were operating the aircraft. At time 02:03:56, the captain tries to turn
towards the final approach track using the heading select mode. The problem though is that,
at this point, he is at 10,260 feet with an indicated airspeed of 280 knots, which is just way too high. He realises this, he engages
the vertical speed mode and increases that to
about 2,500 feet per minute. But by doing so, that increases the vertical speed but it doesn't slow down the aircraft. And because of this, the aircraft flies
through the centerline on final approach and ends up on the left hand side. The captain now disconnects
the autopilot for a short while probably trying to correct the aircraft
back onto final approach, but after about 14 seconds,
he reengages this autopilot and sets a heading of 090 degrees to intercept. And at the same time as he's doing that,
the approach controller calls them up notifying them that they're left of centerline and tells them to turn to heading 090, to which the crew responds
that that's what they've already done. At this point, the cockpit voice recording
indicates that the captain is starting to get really annoyed with the controllers
and he's also doing all sorts of things, including, for example, disconnecting the autopilot without telling the first officer
about what he's doing. We're now getting into the
accident sequence of this flight. But before we go into that,
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had shot through the centerline gave the crew a couple of extra track miles in order to reduce their altitude down
to where they should be. And at time 02:07:02, the captain changed over to the open descent mode again
and the aircraft descended down and levelled off at their
cleared altitude of 620 metres. The captain activated the approach control mode in order to capture the localizer
and the crew now finished the approach checklist. Half a minute later, the controller, again,
came back to the crew telling them that the weather had now dramatically deteriorated. The cloud base was now 160 metres
which was less than what they needed in order to start the approach. And he told them to continue tracking
the centerline but to not initiate the descent. It's worth pointing out here that under Russian rule an approach controller have the ability
to stop an aircraft from initiating an approach and even to stop a ongoing
approach from continuing if the weather falls below the required criteria. Now, those are Russian rules. Under ICAO rules, most of
that is put on the captain. The captain is the one that decides
whether or not to continue an approach. And this flight was flown under ICAO rules
because it was an international flight so ICAO rules should have been followed. But that was not the case. Anyway, as the pilots received this weather update, they reacted furiously in the cockpit,
started swearing about the controller even though they were in the middle
of the approach checklist at that point. The aircraft had now captured the localizer and the captain called out,
"Let's extend flaps one. Screw him!" Indicating that he was intending
to continue this approach anyway. He then continued to extend flaps two
and reduced the speed of the aircraft back to minimum manoeuvre speed. As the flaps were extending,
the controller now again contacted the crew and said that the weather had now improved
above cat one minima and that they were cleared to continue the approach. He also told them to contact
the tower controller in order to get landing clearance, which the crew did. They proceeded with extending the landing gear and activating the glide slope capture mode. And 15 seconds later, the mode changed over to glide slope track
and the aircraft started descending down the glide slope. The second autopilot was now engaged
and the crew extended the flaps to three and then to flaps full which
is what they had briefed to do. And at 1,525 feet, the aircraft was fully established on the glide slope descending normally,
with all the checks complete. At this point, this looks like
a completely normal approach. The first officer made a small call saying, "Add a bit, it's almost sitting at VLS." And the captain responded by increasing
the speed with about four knots showing that the cockpit work at this point
is actually working quite well. It's safe to assume that both pilots
probably fully expected a landing at this point or, in a worst case scenario,
a go-around from the minima. We pilots are always mentally
preparing for a go-around. But, generally, a go-around
is something that happens at the very end of the approach
as we reach our minima. If we have to execute what we call
a non-standard go-around, that happens further up on the approach,
it's generally a much more complicated manoeuvre that require a lot
of crew coordination and communication. And the reason for that is that the aircraft might not be in the landing configuration,
or we might be much closer to our missed approach altitude,
which means that we will have less time to do a proper go-around. Generally, the key to executing
a successful non-standard go-around is to take a few seconds
and discuss with your colleague what you're gonna do,
what configuration are you gonna use, what altitude are you gonna climb to,
and only when both of you share a common picture of where you are
and what you're gonna do, do you execute the go-around. Normally, there's plenty of time
to have this little discussion because even though airr traffic control
might tell you to go around, unless there's an aircraft
that's actually passing ahead of you on the approach path,
you can continue to descend on the glide slope having this discussion before
you execute the go-around. There is time to do that. That's worth remembering for what's happening next. At time 02:11:40, the tower controller
who had previously given the aircraft landing clearance suddenly comes back
onto the frequency saying, "Armavia 967, stop descent.
Clouds at 100 metres. Turn right and climb to 600 metres." It's worth noting here that he
does not tell them to go around. The aircraft was now at a distance of about 3.8 nautical miles
and an altitude of 1,280 feet. Now the correct go-around procedure
that the pilots should have followed in this situation would have been
to move the thrust lever forward into the TOGA position. That would have activated the go-around mode and then they should have asked
for the correct go-around flap, which, in this case, moving it from full to three, and then pitch for the go-around. Since the autopilot was engaged here,
the autopilot would have then flown the go-around for them. Unfortunately, that is not what happened here. Instead the first officer read back,
"Turning right, climbing to 600." But instead of activating the TOGA mode,
the captain press the PTLO, the Push To Level Off button. This caused the aircraft to immediately
stop flying the approach and, instead, it levelled off in vertical speed and heading mode. It also caused the second autopilot disconnect, generating a warning in the cockpit,
but the first autopilot remained engaged. The captain now also moved the heading bug
to the right onto heading of 173 degrees, which initiated a 25-degree bank turn
towards the right and curiously, he now also started inputting right rudder, which is something you would do
on a smaller aircraft in order to coordinate the turn, but not something you need to do on an aircraft
like the Airbus A320. This could be a sign that the captain
is now starting to get into a state of mental capacity overload,
in which we frequently move back on to procedures that we've learned
way back in our experience. The aircraft is now maintaining an altitude
of 1,114 feet with still gear down and full flaps extended, which means
that it's now flying with considerable drag. The tower controller comes back in
and reminds the crew to turn right and climb to 600 metres,
which the first officer reads back. And now, curiously, the captain reaches up
and changes the altitude selector from 600 metres which was already set
as part of the preparation for the go-around to 975 metres or 3,200 feet. And there is no real explanation
to why he's doing this. It could be just a reaction to him again
being told to climb and the aircraft not climbing. We don't really know that. What we do know is that the thrust levers
were now moved not into the TOGA position but into the climb position, and this activates
the open climb mode in the autopilot. And here now comes the next problem. Because of a preset Airbus logic
if the open climb mode is activated, and the target altitude set
is more than 1,200 feet above the aircraft's altitude, the open climb will set a target pitch attitude to reach about 8,000 feet per minute
and the autothrust will go into the speed Mach mode. The speed drops to 129 knots
which is eight knots below the selected value, and a warning saying,
- Speed! Speed! Speed! - Can be heard in the cockpit. At this point, the autopilot also realises itself
that it cannot do the type of climb rate that it's aiming for with this amount
of drag hanging out and it starts to pitch down in order to preserve the airspeed. But it's very likely that this warning,
together with this unexpected reaction from the autopilot has deeply startled the pilots. So what has actually happened here so far? Well, it looks like the captain reacted
to the tower controller's instruction literally rather than executing a go-around
which was the controller's intention. The reason for that might be fatigue
or mental confusion and overload but the result is that the aircraft
is now doing something, it's behaving in a way
that the pilots have not seen before. And that's probably just adding to the confusion. The correct pilot response
to a speed, speed, speed warning is to add thrust and this is actually
what the pilots now do. They move the thrust levers
into the TOGA position which finally activate the go-around mode. The only thing that the pilots now have to do is follow the standard go-around procedure,
start reducing flaps, taking the gear up and so on. But, unfortunately, that's not what happens. Instead the remaining autopilot
is disconnected manually using the button on the side stick
and now the aircraft is flown manually with only flight director guidance. We don't know why the captain decided
to disconnect the autopilot. It might have been in response
to the speed, speed, speed warning, where he maybe thought that the aircraft wasn't responding quickly enough, because what he now does is that he pitches forward
to about eight degrees pitch up and he reduces the bank angle to about 20 degrees. This still means that the aircraft continues
to climb in a shallow right hand turn, but at a slower pace than what
the flight director wanted, meaning that the flight directors
are now showing a much higher pitch up on his primary flight display. As he's turning, the captain
is now also inputting more right rudder, which, again, goes against his training on the type. And the cockpit voice recorder
is indicating that both of the pilots are now experiencing significant
levels of higher stress. At time 02:12:20, the altitude selected
on the mode control panel is moved down from 3,200 feet to 2,000 feet
following intense discussions in the cockpit. Because the selected altitude
has now been moved down, the flight director recognises this
and moves down in order to reduce the climb rate. Now there is a possibility that that movement
of the flight director bar could have been interpreted by the captain as a sudden pitch up. At the same time as that happened,
the aircraft climbed through 1,500 feet. And at that point, the thrust levers
was moved from the TOGA position into the climb position
as they should at that altitude. This also meant that the selected speed
that the autopilot had now moved into the acceleration phase
in order to facilitate flap protraction and the aircraft started accelerating. This acceleration happened at the same time as the aircraft turned more than 90 degrees off the centerline meaning that the aircraft
was now pointing out over the sea, moving away from the shoreline,
and removing all visual outside cues for the captain. And there is a possibility that this loss of external visual cues
is a clue to what happened next. You see, the human inner ear
is not equipped to distinguish between an acceleration and pitch up
without external visual references. This means that an acceleration
can be felt as a pitch up and vice versa. This is known as somatogravic illusion,
and it's actually what we use in full flight simulators in order to simulate acceleration and deceleration. There is a possibility that the captain,
while executing this manoeuvre was not properly understanding
or monitoring his primary flight display. And the combination of the loss of outside visual cues, the sudden acceleration
and the flight director command bar coming down, could have been
interpreted as a sudden pitch up. And that's what he reacted to
because the next thing that happens is that the captain starts pitching forward
to an initial attitude at 1.4 degrees. This levels the aircraft off,
and then he increases the bank angle to about 30 degrees bank to the right. As this is happening, the tower controller hands
the aircraft over to the approach controller again and the first officer reads this back. The aircraft now continues to accelerate
in level flight with full climb thrust set. And when the captain realises this,
he tells the first officers to start retracting the flaps. He does so in the middle
of a call from first officer to air traffic control interrupting that call. The maximum altitude that the aircraft reached
during the go-around was about 1,700 feet or 500 metres before the forward inputs that the captain is making is now starting
to make the aircraft descend. This is causing a much faster acceleration,
meaning that the aircraft speed is soon exceeding the maximum speed for the current flap setting,
causing a CRC or cricket warning to go off in the cockpit and that warning continues on and off for the remainder of the flight. The first officer continues to try
to retract the flaps in order to avoid the overspeed warning, but as he's doing so, the captain just continues
to pitch down more and more and increasing the bank angle to the right. Now it has been suggested
that in the state of confusion and mental overload that the captain
was likely in during this situation, he might have been trying to avoid
the barber's pole on the speed tape, just like he would with a TCAS warning where you try to dive below the red warning. Now we will never know
if that was the case or not. But it is a possible reason
for the captain continuing to do this pitch down. At time 02:12:47, the first key GPWS warning-- - Pull up!
- Can be heard in the cockpit. That happens almost simultaneously
as the first officer calls out, "Level off!" But the captain just continues his downward spiral. The first officer now intervenes
by giving full left sidestick trying to get the aircraft out of the right hand turn, but it doesn't seem like he's trying
to pull up from the dive. Instead, while putting the side stick
into the full left position, he inadvertently actually puts it into a position
where he increases the pitch down even further. He does not push the takeover button
which means that with Airbus logic, the inputs of both of the sticks
are now being averaged out. The really sad thing here is that the captain
actually did try to pitch up twice at this point, possibly in response to the GPWS warning. But since the first officer
was now inputting full left side stick on his side with a little bit of forward pressure,
the pitch up command from the captain did not get any response from the aircraft. And also the dual-input warning
which would have highlighted to the captain that the first officer was also inputting
couldn't be heard because the GPWS warning had a higher priority,
thus cancelling out the dual input warning. The speed of the aircraft had now increased
well beyond the maximum speed for the current configuration and the auto-throttle had started to try to decrease the thrust in order to reduce the speed
as much as possible and protect the aircraft. But here, one of the pilots, we don't know who, reduced the thrust lever back to idle and then put it back into the climb position again. That disconnected the autothrust
and meant that the aircraft speed just continued to increase. At the same time, the fact that the captain
was giving right side stick and the first officer was giving left, meant that the average of the two now became almost wings level
and the aircraft started to level off from the turn but the vertical speed,
as in the descent rate was still close to 6,000 feet per minute as the aircraft descended
past 900 feet above the sea. During the very last seconds of this flight,
a couple of pitch up inputs were recorded on the flight data recorder,
but it was too little too late. And at time 02:13:03, the aircraft impacted the Black Sea,
immediately killing everyone on board. (sombre music) Later computer simulations showed
that the aircraft was recoverable, down to an altitude of about 200 feet
over the water provided that the pilots would have inputted the correct control inputs. They also showed that the aircraft in itself
functioned exactly as it was designed to do. As soon as air traffic control
lost radio and radar contact with the aircraft, they alerted the rescue services but because the weather was so poor,
the rescue helicopter was unable to take off. Instead, it took a few hours before a ship
out on the Black Sea could locate the remains of the aircraft that was floating
on the surface of the water. The investigation started immediately
and soon the cockpit voice recorder and the flight data recorder
was recovered from the crash site. The investigation showed that
the poor weather had been the triggering factor for the accident that had led the air traffic controller to issue a non-standard
go-around clearance to the crew. This, in turn, had probably led to a startle event for the crew where the captain had incorrectly started inputting the wrong procedures, which eventually led to the fatal accident. It was also shown that the first officer
had not been properly monitoring the situation nor calling out deviation and none of the pilots had executed the proper procedures
associated with AGPWS warning. The French aviation authorities, the BEA,
who are the regulating authorities for Airbus also came with some additional points
to the investigation showing that the lack of standard operating procedures and proper call outs probably
had something to do with the outcome as well. They also pointed a little bit more of a finger
towards the air traffic control services in Sochi. And the recommendations that came
out of this terrible accident included increase in training
for pilots for how to deal with somatogravic illusion,
mainly trust your instrumentation, but also how to deal with a non-standard go-around and a GPWS warning and how important it is to keep sterile the cockpit
during critical phases of flight. Now check out this video next
about how an air crew managed to fly an aircraft for almost two hours
without properly working flight controls. Check out this playlist if you want
to binge more accident videos. Consider becoming part of my lovely Patreon family or buy yourself some merch. Have an absolutely fantastic day
and I'll see you next time. Bye-bye.
