Russia’s Potemkin Miracle: The story of Ural Airlines flight 178
On the 15th of August 2019, Russia awoke to its own “Miracle on the Hudson:” after ingesting birds into both engines, an Ural Airlines Airbus A321 made a dramatic forced landing in a cornfield outside Moscow, sliding to a stop intact amid the tall corn stalks, saving the lives of 233 passengers and crew. The crash dominated media coverage in Russia, providing a fresh change of tone in a country more accustomed to shocking tales of aerial incompetence. Authorities were quick to capitalize on the drama, naming both pilots “Heroes of the Russian Federation,” and their story was soon adapted to the silver screen. But was the fanfare all it seemed to be?
In 2022, the final report on the accident, assembled by the Interstate Aviation Committee, was leaked to several Russian telegram channels, and has been spreading within the country ever since, garnering media attention. The report casts the events of that day in a whole new light, suggesting that perhaps the safe outcome occurred not because of, but in spite of, the actions of the crew. Now, for the first time, an English translation of the report has enabled a comprehensive breakdown of what actually happened aboard Ural Airlines flight 178, and the complicated questions it raises about what we expect from pilots in an emergency. Could they have actually landed the plane simply by following standard procedures? Does it even matter, if everyone survived anyway? The following article will grapple extensively with these topics, as well as another, equally dramatic issue: mounting evidence that the Russian aviation regulator attempted to interfere with the investigation and the release of the final report.
In 2011, in response to the growth of budget airlines in Russia, Vladimir Putin proposed that Moscow acquire a fourth commercial airport in order to serve charter and low cost airlines. The site he selected was Ramenskoe Airport, a flight test facility some 35 kilometers southeast of Moscow that already had a 4,600-meter (15,000-foot) runway and only limited traffic, as Russian aircraft manufacturers once based there had been moving their operations to other parts of the country. Construction began swiftly, and in 2016, Russian authorities unveiled the newly renamed Zhukovsky International Airport, now equipped with a passenger terminal capable of handling four million passengers a year. The actual number of passengers that would end up using it was, however, much less: due to conflicts with traffic arriving at Moscow’s main domestic airport, Domodedovo, the number of aircraft movements at Zhukovsky was initially limited to just 20 per day, which corresponds to an annual passenger turnover well south of one million.
Among the carriers that began using the newly opened Zhukovsky Airport was Ural Airlines, a long-established company that began life as an Aeroflot directorate and was spun off during the privatization and breakup of the former Soviet state airline. Ural Airlines has one of the better safety reputations in Russia, having avoided any fatal accidents or even particularly serious incidents since its privatization in 1993 — except, of course, for the one we’re about to discuss.
At 4:31 a.m. on August 15th, 2019, as pre-dawn light crept over the Moscow region, an Ural Airlines Airbus A321, registration VQ-BOZ, landed at Zhukovsky Airport and taxied to the apron. A few minutes later, a new crew arrived at the airport to accept the plane for its next flight, which would take them to Simferopol, the capital of occupied Crimea, which Russia had forcefully annexed from neighboring Ukraine.
In command was 41-year-old Captain Damir Yusupov, who had about 4,275 hours, a little low for a captain of his age, but almost all of them were on the Airbus A320 family, so he was quite knowledgeable about the type. His First Officer, 23-year-old Georgy Murzin, was still rather green, having been flying for Ural Airlines for just under a year, accumulating about 780 hours in the process. They were joined that morning by five flight attendants, who were collectively responsible for 226 passengers, nearly enough to fill the A321, a stretched, high-capacity version of Airbus’s popular A320.
After running through the pre-flight checks, starting the engines, and calculating their takeoff speeds, the pilots briefed what they would do in the event of an engine failure on takeoff. “In case of GO, continue takeoff,” Captain Yusupov said. “No ECAM actions before… eight hundred, except gear up, when engine secured, push to level off.” Because of the critical nature of an engine failure on takeoff, pilots are required to brief this procedure before every flight. The plan was simple: raise the landing gear; climb to 400 feet above ground level, or 800 feet above sea level; level off; secure the failed engine; and only then begin working through the procedures listed on the ECAM, or Electronic Centralized Aircraft Monitor, which aggregates warning, caution, and advisory messages and informs the crew how to respond to them.
Minutes later, at 6:09 a.m., flight 178 was cleared to follow an escort vehicle to runway 12 for takeoff. At 6:11, nearing the runway, Captain Yusupov said, “Tell him we’re there. So we don’t end up sitting there on the threshold,” and First Officer Murzin contacted the tower and received permission to enter the runway. As they neared the threshold, both pilots spotted a flock of gulls in the grass near the taxiway — a common occurrence at Zhukovsky Airport — but they made no particular comment. The birds’ presence was so ubiquitous that air traffic controllers had developed a habit of warning crews about bird activity on every single takeoff.
As they turned onto the runway, Captain Yusupov scanned the strip for any sign of additional birds. “There are, there are hardly any birds there, no?” he said.
“Yeah no, hardly,” First Officer Murzin agreed.
Suddenly, something caught Captain Yusupov’s eye. “Hardly any?” he said. “But some kind of flock is flying there.”
“Ah, well, there’s something flying,” First Officer Murzin concurred.
“No, I mean on the runway,” said Yusupov.
“No, there are hardly any on the runway,” said Murzin. Presumably the birds they had spotted were off to one side.
Captain Yusupov decided that was good enough. “That’s it, let’s go. We’re ready for takeoff,” he said.
Keying his mic, First Officer Murzin said to air traffic control, “Sverdlovsk 178, ready for takeoff,” using the Ural Airlines callsign.
“178, runway 12, cleared for takeoff, isolated bird activity,” the controller reported, adding the habitual warning.
“Runway twelve, taking off, Sverdlovsk 178,” Murzin replied.
Takeoff clearance in hand, the pilots set the thrust levers to the calculated position, which in this case was the FLEX setting, an intermediate position that allows for a takeoff with less than maximum thrust. With an extremely long 15,000-foot runway ahead of them, there was no need to induce extra wear and tear on the engines by using full power. Normally, takeoff/go-around, or TO/GA power, is equivalent to 96% of the fan redline speed, or N1; in this case, however, the FLEX setting allowed them to take off with about 91% N1 instead.
Mere moments after starting the takeoff roll, however, Captain Yusupov again spotted birds flying near the runway. “Come on, fly past, bird, blyad’,” he said, letting slip a familiar Russian expletive. At this point their speed was less than 60 knots, far below the calculated decision speed of 166 knots, but Yusupov seemed content to continue the takeoff in the expectation that the birds would stay out of the way.
Seconds later, as they continued accelerating, First Officer Murzin called out, “100 knots,” and Captain Yusupov replied, “Checked.” The sense of normalcy didn’t last long, however, as Murzin suddenly exclaimed, “Yobannyy v rot blyad’,” a beautiful all-purpose expletive that may be translated as “Fucking hell, fuck.” Perhaps he had spotted birds again, but if so, he said nothing about them. Now traveling at 140 knots, it was still technically possible to abort the takeoff, but there is a very specific set of indications that are supposed to prompt such a high-speed abort, and birds in the path of the plane was not normally one of them. In the cabin, passengers filming the takeoff captured gulls taking flight from the grass beside the runway, but within seconds, it was too late to change course.
“V1, rotate,” Murzin called out. They were now traveling too fast to abort the takeoff for any reason. Captain Yusupov pulled back on his controls to climb, but without any apparent sign of urgency. The plane lifted off seconds later — and almost at that very moment, disaster struck.
As the pilots watched in surprise and alarm, a large flock of gulls, perhaps 25 to 30 individuals by Yusupov’s estimation, abruptly took flight from the grass on the left side of the plane, then suddenly cut across their path. There was no way to avoid them. Numerous gulls slammed into every forward-facing surface, careening off the fuselage, wings, and engine nacelles in a flurry of exploding feathers. At least three birds vanished into the left engine, instantly transforming into a fine red mist, while at least one more bird was swept into the right engine as well.
Now, at a height of between 2 and 4 feet above the ground, flight 178 was truly in an emergency. Ingesting three gulls severely damaged the left engine fan blades, leading to a substantial loss of thrust on that side; simultaneously, a bird struck a sensor on one of the blocking doors that constitute the engine’s thrust reverser system, which is used to slow the plane on landing, triggering an erroneous “ENGINE 1 REV UNLOCKED” caution message that appeared immediately on the ECAM display.
In the cockpit, First Officer Murzin called out “Climb,” clipping the normal “positive climb” callout, but Captain Yusupov never replied with “Gear up,” as he normally would. Instead, he was bombarded by a series of dire indications. The left engine was rapidly losing power, causing the plane to yaw to the left, while the left thrust reverser appeared to have unlocked; and to make matters worse, he was still flying the plane manually, as there had been no time to engage the autopilot. He instinctively held their pitch to 12.5 degrees nose up, which was the takeoff pitch angle prescribed in the event of an engine failure, and began pushing on the rudder pedals to counteract the asymmetric thrust and prevent the plane from yawing. He then attempted to engage the autopilot, which was standard procedure for an engine failure on takeoff, but in the chaos, he made an unfortunate error: he didn’t use the rudder trim system to zero out the forces on the rudder before switching on the autopilot. Rudder trim allows the pilot to bias the rudder in a particular direction in order to counter the plane’s desire to yaw, which also allows the pilot to stop applying force to the rudder pedals. This is a required action before engaging the autopilot, because the autopilot will disengage if the pilot moves the rudder pedals to a position that differs from the autopilot’s commanded position by more than 10 degrees.
When he first selected “autopilot on,” the forces that Yusupov was applying to the rudder pedals were under this limit, so the autopilot appeared to engage normally. Detecting that the plane was decelerating, it immediately began pitching the nose down to gain speed. This was because a pitch angle of 12.5 degrees, while useful for becoming airborne, was too high to maintain indefinitely with a failed engine. The Airbus’s advanced computer systems were capable of detecting this fact and commanding a decrease in pitch, either via the flight director, which overlays desired pitch and roll inputs onto the pilots’ primary flight displays, or via the autopilot.
At the moment of liftoff, flight 178 was travelling at a speed of 181 knots; airspeed peaked at 183 knots a few seconds later before beginning to decrease. The primary cause of this decrease was the fact that the badly damaged left engine had rolled back to a thrust level only barely above idle, which is to say it was generating very little forward thrust at all. To make matters worse, heavy vibrations during and after the bird strike had damaged a sensor in the right engine, causing its commanded N1 (fan rotation speed) to drop from 91% to 88%, which was noticeably lower than the power it was expected to provide during a single-engine takeoff. As a result, a shallow pitch angle was required in order to continue climbing without an unacceptably rapid loss of speed.
Now, climbing toward 300 feet with the autopilot apparently engaged but their speed decreasing, Captain Yusupov called for “ECAM actions.” First Officer Murzin began reading off the ECAM display: “Engine one reverse unlocked,” he said. Continuing to the rectification instructions, he read, “Thrust lever one idle. Confirm thrust?”
“Check,” said Yusupov.
But before anyone could actually move the left thrust lever to idle, the autopilot abruptly disconnected, six seconds after Yusupov had engaged it, as the Captain’s rudder pedal forces exceeded the disconnect threshold. A red autopilot disconnect warning message appeared at the top of the ECAM display, accompanied by a loud, continuous cavalry charge alarm. Captain Yusupov immediately retook manual control, but the situation was already escalating. In fact, at that moment, the altitude peaked at 313 feet above ground level, at which point the plane began to descend. The enhanced ground proximity warning system, or EGPWS, immediately activated, calling out, “DON’T SINK!” But why was this happening?
All twin-engine airplanes are required to be able to climb to a safe altitude at a safe speed using thrust from only one engine, should the other engine fail on takeoff. But while the Airbus A321 was fully capable of doing this, the requirement came with a set of important conditions, including, most notably for the scenario in question, an assumption that the thrust output by the remaining engine would not change from the takeoff setting. All else being equal, an A321 in such a condition was certified to achieve a climb gradient of at least 2.4% with the landing gear retracted, and a positive climb gradient with the landing gear extended, should the crew be unable to stow it.
On flight 178, however, the right engine’s N1 had fallen below the takeoff setting due to the aforementioned sensor failure and due to fan blade damage from the bird impact, and it was not providing enough power to overcome the considerable drag induced by the extended landing gear. As a result, the only way to gain altitude was by sacrificing airspeed, so as the plane climbed away from the runway, its speed decreased.
Lift, at its most basic level, is a function of airspeed and angle of attack, or the angle of the lifting surfaces relative to the oncoming airflow. In this case, the relationship between the two was unsustainable, because as the airspeed decreased, angle of attack had to increase in order to maintain enough lift to continue the climb; in turn, this increased angle of attack presented more of the fuselage to the oncoming air, resulting in more drag and a further loss of airspeed. By the time flight 178 reached 313 feet, its speed had decreased to 164 knots, and a further increase in angle of attack would have been required to continue climbing, so the aircraft began to descend.
The plane was now in a position where it lacked sufficient energy to maintain altitude. There were two obvious ways to rectify this: either decrease drag, or increase thrust. In practice, that would mean either retracting the landing gear or applying takeoff/go-around (TO/GA) power on their working engine. But instead of doing either of these things, Captain Yusupov simply pulled back on his side stick to increase the angle of attack even more, which caused the plane to level off, but it didn’t climb, and their airspeed began ticking steadily downward again.
At that moment, Yusupov attempted to make an emergency call, transmitting “Pan-pan, pan-pan, pan-pan, Sverdlovsk,” but he never finished his sentence. At the same time, he started unconsciously releasing the rudder pedal, causing the plane to yaw toward the failed left engine; this presented the right side of the fuselage to the oncoming air, resulting in even more drag and a further decrease in speed. An orange message also appeared on the ECAM display, warning that the damaged left engine was overheating.
At this point, with the plane now descending through 290 feet, Captain Yusupov decided to take action, and he advanced both thrust levers to the TO/GA position, commanding maximum thrust. The left engine didn’t respond, but the right engine did begin accelerating toward TO/GA power — only for the pilots to discover the hard way that it, too, had been damaged. The bird that went into the right engine had caused relatively minor fan blade damage that did not prevent it from operating at 88% N1, where it had been since the moment of the bird strike, but which did interfere with its ability to sustain TO/GA thrust. As the engine accelerated toward TO/GA, or 96% N1, the damage to the fan blades disrupted airflow into the compressor section, causing air from the high pressure compressor to burst forward into the low pressure compressor. This momentary reversal of airflow is known as a surge or compressor stall. In this case, each surge caused the right engine’s N1 value to drop to 78%, at which point it would begin rising back toward the commanded value, causing pressure in the high pressure compressor to increase until the engine surged again, over and over, every couple of seconds, like continuous backfiring. This caused the total available thrust to decrease even further.
As loud bangs and shudders rocked the aircraft, they continued losing speed and altitude, dropping inexorably toward the ground below. Captain Yusupov reduced power in the dying left engine, but this did nothing to help their situation. In fact, he was still struggling to catch up with events, as he finally called out, “Autopilot off.” He then ordered First Officr Murzin to “Watch speed,” since they were decelerating alarmingly. But Murzin didn’t reply, nor did he ever call out their airspeed.
With the emergency growing in seriousness with each passing second, Captain Yusupov picked up the radio again and said, “Pan-pan, pan-pan, pan-pan, Sverdlovsk one seven eight, one engine failure!” He then ordered Murzin to request a return to the airport, which he did, and permission to turn back was granted. But with their altitude and speed decreasing dangerously, turning back would be virtually impossible. Their height above the ground was only 240 feet and their airspeed just 152 knots. Captain Yusupov finally moved the left thrust lever to idle, as commanded by the ECAM instructions, but this didn’t help.
“Altitude, altitude,” First Officer Murzin warned.
In response, Captain Yusupov pitched the nose up even more in a desperate attempt to climb, again reaching 12.5 degrees, at which point the A321’s flight envelope protection systems kicked in to prevent the airplane from stalling. The alpha protection system, which protects against high angles of attack, ensured that the angle of attack would not continue increasing if Yusupov were to release his side stick. But Yusupov did not release it; instead, he pulled back even more, until the angle of attack reached 15.5 degrees — a hard ceiling known as “alpha max.” The alpha protection system now prevented any further angle of attack increase at all, no matter how hard Yusupov pulled back on the stick. Had it not done so, the plane would have exceeded its critical angle of attack, stalled, and plunged to the ground.
In a steady descent, wallowing along with its nose high in the air, the plane held on precariously, hanging from the digital hand of the almighty alpha protection system. The cockpit was filled with a cacophonous din, as the autopilot disconnect alarm continued to blare amid bangs and roars from the surging right engine, punctuated every few seconds by the sound of the ground proximity warning system calling out “DON’T SINK!” and “TERRAIN AHEAD! PULL UP!” Ahead of them stretched empty cornfields, crisscrossed by roads and ditches — this would be their impact zone, and they had just seconds to prepare.
At 120 feet, just moments from impact, Captain Yusupov abruptly retracted the landing gear, then pulled his side stick as far back as it would go, keeping the angle of attack pinned at alpha max. No words passed between the pilots, no landing site was selected, no command to brace was issued. Instead, seconds later, with the landing gear doors still half way open, flight 178 crashed to earth in a cornfield at a speed of 136 knots, the still-running right engine flattening large swathes of ripening corn in its wake. Jolting and shuddering, the plane slid on its belly through the field, cleared a water-filled ditch, and then skidded to a halt, miraculously intact and surrounded on all sides by corn.
As soon as the plane came to a stop, the flight attendants opened the doors and deployed the slides, and the passengers, stunned by the crash but grateful to be alive, filed out into the cornfield, illuminated by the early morning sun. Crewmembers used megaphones to bark orders and prevent anyone from wandering off, while bewildered survivors stared at the plane, phone cameras rolling, expressing disbelief at the sudden turn of events. In the cockpit, meanwhile, the pilots found that the plane still had electrical power, so they informed air traffic control of their position before shutting down the engines and evacuating themselves. Emergency services arrived soon after, cutting a path through the corn to evacuate the passengers. Those who had been injured were taken to hospitals, while the remainder were bused back to the terminal at Zhukovsky Airport, where some presumably boarded the next available flight to Simferopol.
In all, 32 of the 233 people on board were treated at Moscow-area hospitals, including 23 passengers who were injured in the impact and four who hurt themselves during the evacuation. Only three people suffered injuries classified as serious, one of whom was First Officer Murzin, who fractured a vertebra.
Before long, the story was breaking news around the world, with an oddly familiar story: an airliner hit birds; both engines failed; a forced landing was carried out away from the airport; everyone on board survived. Captain Yusupov and First Officer Murzin were immediately hailed as heroes, having seemingly broken a long Russian tradition of snatching defeat from the jaws of victory. Comparisons were immediately made to the famous 2009 “Miracle on the Hudson,” in which pilots Chesley Sullenberger and Jeffrey Skiles successfully ditched an Airbus A320 on New York’s Hudson River after ingesting geese into both engines. In a humorous portmanteau, Russians began calling Ural flight 178 “Chudo na kukurudzone,” literally “the Miracle on the Cornson,” hailing Captain Yusupov as a “Russian Sully.” “They did everything quickly and properly,” a pilot told media outlet Novaya Gazeta shortly after the accident. “And judging by the fact that not only did everyone survive, but the aircraft is essentially in one piece, I give them five points [out of five].”
Russian President Vladimir Putin appeared to agree. Just one day after the crash, he issued a statement announcing that Damir Yusupov and Georgy Murzin would be awarded the honorary title “Hero of the Russian Federation,” Russia’s highest civilian honor, while the cabin crew would receive the Order of Courage. Putin personally handed the awards to both pilots during a lavish ceremony at the Kremlin in November 2019.
Fortunately for all of us, under Russian law, Putin was not responsible for the investigation into the “Miracle on the Cornson.” That responsibility fell, and still falls, to the Interstate Aviation Committee, known by its Russian acronym MAK, a supranational organization that certificates airports and aircraft and conducts accident investigations in ten former Soviet republics, including Russia. In 2016, following a dramatic public fight between Russian authorities and MAK chairwoman Tatiana Anodina, Russia stripped the agency of its certificating authority, but allowed it to continue investigating accidents because no Russian entity possessed the required expertise. The details of this dispute are beyond the scope of this story, but I covered them in some detail in a 2021 paper on the destruction of Transaero Airlines. In any case, the important takeaway is that there is no love lost between the independent MAK and the Russian government, especially Rosaviatsiya, the Russian equivalent of the Federal Aviation Administration, whose representatives frequently file baseless dissenting opinions in order to disrupt MAK accident investigations.
Today, four years after the accident, the MAK still has not officially released its final report on the crash of Ural Airlines flight 178, even though its website has long indicated that the investigation is over. Instead, the complete final report, including the Rosaviatsiya representative’s dissenting opinion and the MAK’s strongly worded response, began appearing in Russian aviation channels on the Telegram messaging app in the summer of 2022. Some Russian opposition and independent media have since reported on the findings, but both the MAK and Rosaviatsiya have maintained their silence. Suspecting that the “leak” of the final report was intended to send a message, I decided to acquire a copy, verified its authenticity, and translated it into English. Although I’m fluent in Russian, the report was long, the language was dense, and my time was limited, so I didn’t finish until July 2023 — but now that it’s done, I can finally share the complex truth about flight 178, as the MAK saw it.
In organizing its investigation, the MAK focused on three overarching areas: the presence of the birds, the performance of the airplane, and — Hero of the Russian Federation awards notwithstanding — the actions of the flight crew. All three areas yielded interesting conclusions, some of which were completely unexpected.
The fact that a collision with birds caused the accident was known from the first hours of the investigation. Fragments of birds were found on the runway, inside both engines, lodged in the landing gear, and wedged in between skin panels on the wings. In total, the MAK estimated that the plane struck at least 15 birds, which ornithologists identified as either European herring gulls, Caspian gulls, or a mixture of the two.
The fact that large flocking birds like gulls can pose a significant danger to aircraft is well known and has been for decades. For that reason, keeping birds away from airports is a full-time job, but the staff at Zhukovsky Airport told Russian media outlets that they were overwhelmed — no matter what they did, the birds simply would not go away. Many commentators pointed toward illegal waste dumps near the airport as a possible reason, since gulls are attracted to household leavings. Furthermore, gulls like to stop to rest in large, open spaces without dense vegetation, such as airports. This became an especially big problem at Zhukovsky during the months of August and September, when gulls in the Moscow area begin abandoning their nesting sites and wander aimlessly in search of food.
Although local authorities denied that waste dumps near the airport were attracting birds, this was quickly contradicted by reporters with Russian news site Vesti.ru, who visited one of the offending dumps and witnessed a flock of gulls departing from the roof of the administration building as they arrived. Employees showed them a button that they said would activate a bird-repellant system, but no one could say how it worked. The fact that gulls were loitering at the dump sites, one of which was practically within sight of the airport, was also confirmed by the MAK, which even pointed out birds visible in aerial imagery of the Mikhailovskaya Sloboda neighborhood dump and a nearby lake.
Officials at the M. M. Gromov Flight Institute, which operates the airport, had previously tried to get these dump sites shut down, because such activities are not supposed to be allowed within 15 kilometers of a major airport. In 2012, a lawsuit was filed against a company operating one of the dump sites in an attempt to force it to cease operations, but a local judge ruled in favor of the dump. Attempts by the Flight Institute to contact authorities in the cities of Zhukovsky and Ramenskoe concerning the dump sites were made as recently as May 2019, but city officials did not reply.
Unable to liquidate the sites that were attracting birds to the area, Zhukovsky Airport personnel faced a hopeless task, especially because the bird control program lacked both funding and expertise. The MAK found that bird observation logs were not being properly maintained, and although bird repellent systems were installed along the runway, including propane cannons and “bio-acoustic devices,” their effectiveness was limited. According to official guidelines, such systems should be activated only to scare away specific flocks of birds, but Zhukovsky Airport had automated their network so that the cannons would go off on a regular schedule throughout the day and night, regardless of whether birds were present. This had caused the local bird population to grow accustomed to the noises, and before long, the repellent systems were useless.
The presence of birds had in fact become such a permanent fixture that air traffic controllers warned every flight crew about bird activity, but this provided little comfort, and at least two other flights also hit birds at Zhukovsky Airport in August of 2019 alone. Airport patrols were supposed to disperse birds prior to the first flight of the day, but an airport manager who inspected the runway some 23 minutes before the ill-fated takeoff didn’t spot any, possibly because they were hidden under tall grass — or because the patrol was only conducted on paper, which the MAK appears to have suspected, but could not prove.
Pre-flight briefings at Ural Airlines were also technically supposed to include discussions of bird activity, but this was such a given at Zhukovsky that the pilots of flight 178 apparently skipped it. In interviews, they described seeing birds while taxiing, including a large flock that took off from the runway, but the pilots appeared to consider the situation normal and took no special precautions. Furthermore, although both pilots claimed in interviews that they stopped at the head of the runway to wait for the birds to disperse, the cockpit voice recording contradicted this; in fact, even though the pilots’ conversations indicated that they saw birds while lining up with the runway, they spent less than 10 seconds waiting “in position” before taking off. Then, once underway, the pilots saw birds again, prompting some profane statements, but the possibility that it might not be safe to continue the takeoff roll seemingly never occurred to them. Aborting a takeoff because there were birds nearby wasn’t something they were trained or expected to do, and besides, if every crew who saw birds rejected their takeoff, hardly any planes would ever depart from Zhukovsky!
In the end, therefore, the collision with birds became essentially inevitable due to the normalization of their presence at Zhukovsky and a lack of guidance for flight crews about when bird activity might constitute a flight safety risk. With these two factors propelling them, the crew of flight 178 accelerated down the runway, knowing that birds were surely present, but guided by the ultimately fruitless hope that they would not hit any.
In the story of the Miracle on the Hudson, the plane hits the birds, the birds go into the engines, and the engines fail. Initially, most people assumed that was what happened to Ural Airlines flight 178 as well, but it was apparent to the MAK investigators quite quickly that this was not actually the case. Flattened stalks of corn showed that the right engine was producing appreciable power at impact, and vegetation deep inside its core showed that the left engine was running on touchdown as well, albeit without producing much thrust. Furthermore, the electrical generators continued to operate throughout the flight and the backup turbine was never deployed. The inescapable conclusion, later confirmed by the flight recorder data, was that neither engine failed as a result of the bird strike.
With the help of detailed teardowns, the MAK determined that the left engine ingested three birds, one of which was categorized as “large” (between 2.5 and 4.0 lbs), while the other two were of an undetermined, but smaller, size. The right engine ingested a single bird that was probably categorized as “medium” (1.5 to 2.5 lbs) but could have been “large.” According to certification requirements in force at the time the A321’s CFM-56 engines were certified, an engine that ingested one large bird need not continue producing thrust, but must avoid fire, uncontained disintegration, or other severe side effects. The left engine certainly met this requirement. As for the right engine, certification rules required that an engine that has ingested one medium bird continue to operate with a loss of thrust not greater than 25%. The flight data recorder showed that after the bird strike, the right engine N1 dropped from 91% to 88% due to a sensor failure, which corresponded to a 10% loss of thrust. Mechanical damage to the fan blades reduced the thrust output by another 10%, totaling 20%, which was within certification requirements.
However, while each engine individually met certification requirements, the combination of a near-total loss of thrust on the left engine and a 20% loss of thrust on the right engine was not a condition that the A321 had been tested for, and there were no particular requirements or guarantees that would define its behavior in such a state. As a result, the MAK had to conduct an entirely new engineering simulation to determine whether the plane was capable of maintaining altitude with the available thrust. Most observers’ first guess would probably have been that it was not, given the outcome, but that’s why investigators always have to double-check — the results can be surprising.
In fact, the engineering simulation showed that as long as the right engine maintained 88% N1 and didn’t incur further damage, the plane would have had enough thrust to climb — but only with the landing gear retracted. Although the plane was required to achieve a positive climb rate with one failed engine and the gear extended, an additional 20% loss of thrust on the “good” engine would make this performance unachievable; the available thrust would be insufficient to overcome drag, and the plane would decelerate until it stalled or a descent was initiated. However, if the landing gear was retracted, the thrust-to-drag ratio would become positive, and a climb would be possible. The MAK found that this wasn’t even particularly time sensitive: even if gear retraction was postponed until 20 seconds after liftoff, around the time their altitude peaked, it still would have been possible to continue climbing.
This conclusion did come with one significant caveat — namely, it assumed that the behavior of the right engine wouldn’t change. Even if the pilots had left its thrust lever alone, retracted the gear, and climbed to a safe altitude, there was no guarantee that the damaged engine would last long enough to get them back to the airport. Modern certification regulations require that an engine continue to operate for at least five minutes after ingesting a medium bird, but the CFM-56 engines on the accident aircraft predated this rule and hadn’t been tested against such a strict standard. Nevertheless, the odds of a safe return to the airport might have been reasonable.
In the Miracle on the Hudson, investigators famously determined that it was technically possible to have guided US Airways flight 1549 back to the airport instead of ditching on the Hudson River, but only if the pilots displayed superhuman reaction and decision-making times. The judgment call to land in the river was therefore correct. So, one might ask, was it not the same in the case of Ural Airlines flight 178? Sure, it might have been possible to return to the airport, but was that a reasonable expectation to place on the crew? The answer, as it turns out, is complicated.
One simple and uncomfortable truth was that the pilots of flight 178 did not follow the standard procedures for an engine failure on takeoff. These were procedures that they were supposed to have memorized and briefed before every takeoff: pitch to 12.5 degrees until liftoff, then follow the flight director; establish a positive climb rate; retract the landing gear; counter the yaw, then trim out the rudder pedal forces; engage the autopilot; level off at 400 feet; then follow the ECAM actions. But as the MAK noted in its report, the pilots failed to accomplish many of these steps, and performed the rest out of order. And it was this failure to follow procedures that led to the plane’s descent into the ground.
Immediately after liftoff, the First Officer, probably surprised by the bird strike, called out “climb” instead of “positive climb,” which apparently failed to trigger the Captain’s normally instinctive reply of “gear up.” As a result, both pilots simply forgot to raise the landing gear, until Captain Yusupov finally did so about five seconds before impact. This omission alone precluded any possibility of a safe return to the airport.
From there, however, the mistakes only escalated. Captain Yusupov instinctively aimed for a pitch angle of 12.5 degrees, but by then the plane was already in the air and he should have been following the flight director guidance on his primary display, which would have told him to maintain a lower pitch angle. The excessive pitch angle resulted in further loss of speed. Then Yusupov attempted to engage the autopilot without “trimming out” the rudder forces, which the manual specifically warns against, causing the autopilot to disengage after six seconds. During those six seconds, at a height of less than 300 feet, he also called for the ECAM actions, which aren’t supposed to be accomplished until the plane is stabilized at 400 feet.
In his interviews, Yusupov explained that he was alarmed by the ECAM caution message indicating an unlocked left thrust reverser, which diverted his attention during the climb and prompted him to initiate the ECAM actions earlier than normal. Unfortunately, this warning was spurious, caused by the impact of a bird against a sensor, and it merely distracted the crew from much more serious problems, like their decaying airspeed, excessive pitch angle, and extended landing gear.
Although the ECAM actions were started, they were never finished, as the autopilot disconnected and the plane began to descend. (In hindsight, we know that the ECAM actions wouldn’t have helped anyway.) After that, Captain Yusupov became singularly focused on preventing the plane from descending into the ground, as he made numerous nose up side stick inputs and advanced both thrust levers to TO/GA power. This actually worsened the situation, triggering a series of surges in the right engine that caused further damage and loss of thrust. Pilots are trained to react to a surge by decreasing power until the surge clears, then maintain a power setting that avoids further surges, but neither pilot did so; instead, they let the right engine keep surging until the plane hit the ground. Nor did anyone cancel the continuous autopilot disconnect warning, which is as simple as pushing a button. Evidently, the pilots were losing the plot.
In the final moments of the flight, the plane was being held in the air by the alpha protection system, their speed was dangerously low, and ground impact was imminent. For some reason, under these conditions, Yusupov’s final act was to retract the landing gear. In their interviews, the pilots told investigators that they discussed raising the landing gear before touchdown, but the cockpit voice recorder showed that this was not the case. In fact, not only was there no discussion of the landing gear, in reality neither pilot uttered a word about the impending forced landing at all. As a result, the MAK was actually unable to determine whether the pilots even intended to land in the cornfield. On the one hand, Captain Yusupov claimed he raised the landing gear because he was afraid it would dig into the wet soil and cause the aircraft to break up. On the other hand, this runs directly counter to the forced landing procedures, which call for the gear to be extended, and the last transmission the pilots made to air traffic control indicated their desire to return to the airport. The lack of discussion of a forced landing, the absence of a call to “brace,” and the fact that Yusupov pulled all the way back on his side stick moments before touchdown could also be interpreted as evidence that he was still trying to avoid ground impact. In this scenario, he might have retracted the landing gear because he noticed it was extended and realized it was causing excessive drag, not because he was worried about its behavior on touchdown. However, it was also possible that Yusupov was telling the truth about why he retracted the gear, and that the lack of discussion of a forced landing — without even so much as a “we’re going to be in the Hudson” — was due to limited time or mental paralysis.
In summing up its analysis of the flight crew’s performance, the MAK wrote, “from the very beginning of the event, the actions of the crew, especially the Captain, were characterized by disorganization, inconsistency, and chaos.” It was difficult to deny that this was true: overall, the pilots followed procedures faithfully until the moment of the bird strike, but once the emergency started, they did more wrong than right. In fact, the safe outcome appears to be at least as attributable to Airbus software engineers as it is to the pilots. So what went wrong? Why weren’t they capable of rising to the moment?
Interestingly, the MAK found nothing wrong with Ural Airlines’ training for engine failures after V1, or with the pilots’ training histories; in fact, both were above average airmen who passed training with flying colors. Instead, the MAK ultimately attributed the breakdown in performance to their individual personalities, which an independent psychologist determined to contain traits such as increased excitability and disorganization under pressure. However, the use of personality test results to explain flight crew actions during an accident is not something I’ve seen outside the former USSR, and the history of psychiatric determinism in that part of the world gives me considerable pause. Instead, I would like to highlight a number of other factors identified by the MAK that have more universal acceptance in the global practice of aviation accident investigations.
One of these was fatigue. Although the pilots had adequate rest time before the flight, the hour was early, and records showed that both crewmembers had accrued a substantial quantity of unused vacation days. First Officer Murzin in particular hadn’t had a single break from flying since he joined Ural Airlines nearly a year before the accident, which could lead to a chronic buildup of fatigue. This kind of withholding of guaranteed vacation days is a common problem at airlines in Russia, and the MAK has criticized it in the past.
Another possible contributor was the introduction of confounding factors that differentiated the accident scenario from the engine failure on takeoff exercises that the pilots had performed in the past. One of these was obviously the partial loss of thrust on the “good engine,” but the spurious thrust reverser warning might have been more significant. The appearance of this warning might have derailed Captain Yusupov’s train of thought, after which he was never able to get back on track due to the speed at which events unfolded.
And finally, there’s the simple fact that simulator scenarios and real emergencies are not the same. In a real emergency there are all kinds of noises and vibrations that the simulator can’t replicate, not to mention the stress imposed by the imminent threat of grievous bodily harm. Being able to handle an emergency in the simulator improves one’s odds of handling it in real life, but it doesn’t provide a guarantee. Indeed, when asked why he dropped the ball on flight 178, First Officer Murzin simply replied, “Because real life is nothing like the simulator.”
The MAK’s findings regarding flight crew performance serve as a reminder that handling an emergency is not easy, even for a trained pilot. The pilots made mistakes, but the extent to which those mistakes were important is up for debate. After all, the system still worked — the plane stayed in the air, descended safely, and struck the ground at a survivable speed, as a result of which everyone walked away. Perhaps the pilots could have returned to the airport, but they didn’t, and everything was still more or less fine. On the other hand, Zhukovsky Airport is located at the very fringe of the Moscow metropolitan area, where there’s not very much to run into. The cornfield where the plane came down was even mentioned as a suitable forced landing site in airport documents, although the pilots probably didn’t know this. Therefore, in one respect, they got lucky, and the outcome could have been very different if the incident happened over an urban area. In that alternate universe, the pilots might have had very little time to realize they needed to make a forced landing and maneuver to a suitable location without striking buildings. A safe outcome would have been far from guaranteed. And in that world, the question of why the pilots failed to adhere to proper procedures would acquire considerably more importance.
At the same time, even though standard procedures would have helped, the scenario faced by the crew of flight 178 was hardly a “normal emergency.” It required the crew to stick to their training and exercise good judgment amid a milieu of unexpected and sometimes misleading indications. Not everyone is capable of that. The famous Captain Sully and his first officer certainly made the cut, because their dual engine failure really did occur over a major city, and their adherence to procedures and rapid choice of landing site proved critical to the outcome. But despite the lack of obstacles, the situation on Ural 178 was in some ways more challenging, because the loss of thrust occurred immediately after liftoff instead of at 3,200 feet, and the entire flight lasted only 90 seconds, whereas US Airways flight 1549 lasted four minutes from bird strike to splashdown. All things considered, the Ural Airlines crew had much less time to react, and even though they did have the option of avoiding a forced landing altogether, they had few chances to realize it before they found themselves on the ground. Most pilots would probably hope to react better, but more to the point, they would hope never to find themselves in such a dire situation in the first place.
In the end, due to the difficulty of projecting the airplane’s hypothetical performance into the future, the MAK declined to reach a conclusion about whether the pilots’ actions contributed to the accident. They also identified various latent deficiencies in the way airports are operated and overseen in Russia, which may or may not have contributed to the failure to keep the runway free of birds, including outdated legislation, limited federal guidance, and unresponsive officials. But perhaps the most interesting point made by the MAK was one that probably had nothing to do with the accident: namely, the fact that, in their view, Zhukovsky International Airport didn’t have a valid certificate of operations.
The basic problem was that the MAK had itself issued a certificate to the airport in November 2015, only for the MAK to be stripped of its right to certificate airports about one month later. This power was transferred to Rosaviatsiya (again, the Russian equivalent of the FAA), which never issued a new certificate of its own. Since the MAK was no longer able to fulfill its obligations as guarantor of the certificate, in their view it became invalid under the Air Codex of the Russian Federation, Article 8, Part 1, Paragraph 1, which required that airports open to civilian flights possess a certificate issued “by an organ empowered to do so by the Government of the Russian Federation in accordance with the Federal Regulations.” Indeed, the MAK was very explicitly no longer “empowered to do so,” and moreover, the relevant section of the Federal Aviation Regulations, which previously governed certification of airports, was apparently cancelled by the Ministry of Transport in January 2016 without replacement.
The MAK’s decision to point out this discrepancy angered A. A. Averkiev, the head of Rosaviatsiya’s airport activities department, who also happened to be a sitting member of the investigation commission for Ural Airlines flight 178. In a strongly worded dissenting opinion, Averkiev criticized several aspects of the MAK’s report. First, he wrote that “the analysis of psychological aspects ultimately underlies the Accident Investigation Commission’s conclusions regarding the flight crew’s actions,” including the finding of “disorganization, inconsistency and chaos,” and he argued that these conclusions were based on the opinion of a single psychologist, in a brazen attempt to dispel the notion that the pilots did anything wrong. Needless to say, the fact that the pilots made errors is clearly evident from the flight recorder data, and no psychological analysis is needed. But Averkiev’s most bitter criticism was reserved for the issue of airport certification, where he argued that no provisions of the law transferring certificatory authority to Rosaviatsiya invalidated the existing MAK certificate, which was otherwise valid until 2020. He then accused the MAK of a conflict of interest, writing, “It may be suggested that the above conclusion by the MAK Commission regarding the invalidity of [Zhukovsky] Airport’s MAK certificate at the time of the accident indicates the MAK’s desire to avoid responsibility for a possibly deficient certification carried out by the same.” On the basis of this argument, he called for the MAK to entirely remove the section of its final report concerning the certification of the airport.
In a very strongly worded reply, the MAK hit back even harder. The agency wrote that its position on the certificate had been presented “clearly and unambiguously,” and pointed out that Averkiev had never raised any questions about the airport’s certification during the investigation. The tables were then turned on Averkiev’s accusations, and in scathingly bureaucratic language, the MAK wrote, “Furthermore, A. A. Averkiev is executing the responsibilities of the head of Rosaviatsiya’s airport activities department, which directly handles questions related to airport certification; that is to say, he bears responsibility for the fact that [Zhukovsky] Airport has lacked a certificate for a considerable length of time. The Commission believes that A. A. Averkiev’s suggestion to completely eliminate section 1.18.8 because it contains what he calls “unreliable information” is the proposal of a subjectively interested official who is ignoring obvious facts in order to uphold the departmental interests and esprit du corps of Rosaviatsiya.”
The MAK’s anger didn’t stop there, however, as the agency launched into a full-throated criticism of Rosaviatsiya’s conduct across numerous investigations, noting that “existing structures do not guarantee the independence of serious aviation incident investigations carried out by Rosaviatsiya” and that “an impartial and independent approach is also not guaranteed when Rosaviatsiya representatives participate in aviation accident investigations,” taking direct aim at Averkiev’s own role as a member of the investigation commission. The MAK then not-so-gently reminded Averkiev of Russia’s poor safety record and Rosaviatsiya’s hand therein, writing that “Indicators of the aviation safety level in the Russian Federation are substantially lower than the world average; furthermore, the reoccurrence of aviation accidents due to the same causes that were unambiguously determined by investigation commissions, and which were addressed by specific recommendations, remains unacceptably high.”
This latest dramatic display of tension between the MAK and Rosaviatsiya, part of a cold war between the two since at least 2015, appears symptomatic of a broader increase in bureaucratic dysfunction and erosion of the rule of law in Russia over the past decade. This dispute is possibly responsible for the final report’s failure to materialize through official channels. It also does not bode well for the MAK’s safety recommendations, which Rosaviatsiya is generally responsible for implementing. The report indicates that various actions were taken, including elimination of illegal waste dumps near Zhukovsky Airport and new training at Ural Airlines, but nothing in the listed safety actions leads me to believe that such an accident couldn’t happen again at other airports and airlines in Russia — and that’s exactly what the MAK was complaining about when it penned the lines quoted above.
In conclusion, then, the crash landing of Ural Airlines flight 178 was, as so many things in Russia turn out to be, a disheartening series of unforced errors, empty words, meaningless rules, and bitter recrimination. The investigators and the regulators hate each other, no one knows who is responsible, and two pilots now bear the title Hero of the Russian Federation, even though it’s difficult to say which of their actions could possibly qualify as “heroic.” But Putin already handed out the awards, so for any Russian official to admit that would be just as miraculous as the forced landing itself.
As if to complete the mockery of reality, a movie based on the crash was released in Russian theaters in January 2023, which proved to be but a sad imitation of Clint Eastwood’s blockbuster “Sully.” “Everything about it is bad,” one Russian reviewer wrote, noting that the writers had made up most of the characters and that the movie contained less information about the accident than the Wikipedia page.
Somewhere amid this mess of a story, there are real lessons that pilots might take to heart, if they can find them. Ideally, these should be the legacy of every aviation accident. But in the end, those lessons seem difficult to discern against a background of that most Russian of feelings: the bitter tang of disappointment.
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