Ural Airlines Flight 178

On 15 August 2019, Ural Airlines Flight 178, a scheduled passenger flight from Moscow to Simferopol, suffered engine damage and made a forced landing in a cornfield after takeoff from Zhukovsky International Airport. The aircraft, an Airbus A321 with 226 passengers and 7 crew members, was taking off from Runway 12 when it struck several birds during rotation, causing damage to the engines. Due to the resulting loss of thrust and improper actions by the flight crew, the A321 failed to gain sufficient airspeed and altitude to climb safely. The aircraft belly landed and slid across a cornfield before stopping with substantial damage. All 233 occupants survived the accident, although 28 suffered injuries, 3 of them serious.

In the immediate aftermath of the accident, citizens and the media praised the crew for managing to land and evacuate the aircraft without any fatalities. Comparisons were made to the 2009 US Airways Flight 1549 accident, which ditched in the Hudson River following bird strikes and dual engine failure with no fatalities. The event was referred to as the Miracle in the Cornfield by Russian citizens and media. The Kremlin awarded the flight crew with Hero of the Russian Federation, the country's highest civilian honor, and the cabin crew with the Order of Courage.

The accident investigation was conducted by the Interstate Aviation Committee (MAK). During the investigation, they found several factors that caused the accident. Several illegal waste dumps around the airport attracted birds, airport management had failed to implement bird control procedures properly, and the existing guidance on the safety hazards of birds was insufficient. Regarding the accident sequence, the MAK found that after the bird strike and engine damage, the crew failed to apply proper procedures in relation to the engines' failure to produce sufficient thrust. The landing gear was kept extended, the engine thrust was not properly managed, the pitch was at too high of an angle, and the airspeed was not properly tracked. As a result, the aircraft did not have enough thrust to overcome drag, and it impacted the cornfield shortly after takeoff.

Accident

On 15 August 2019, VQ-BOZ was scheduled to fly for Ural Airlines as flight 178 from Zhukovsky International Airport in Moscow to Simferopol International Airport in Simferopol. The crew arrived at the aircraft one and a half hours before the planned departure time of 6:10 am. Yusupov spoke with the aircraft's previous flight crew, who told him that the aircraft was in working order. At 5:55, Yusupov and Murzin began their pre-flight briefing, which included a discussion on rejected takeoff and engine failure after V1, but did not include remarks on the threat of birds. The crew also discussed how they would only address items on the electronic centralised aircraft monitor (ECAM) after climbing 400 ft above ground level. At 6:05, air traffic control (ATC) gave the crew clearance to push back from their current position, which started one minute later. Both engines started during the push back, and the flaps extended to the configuration 1 (CONF1) position of 10°. ATC then gave the crew clearance to follow an escort vehicle to Runway 12. After being cleared to enter the runway at 6:11, Yusupov briefly mentioned a flock of birds that he saw, but continued to taxi into position for takeoff. One minute later, at 6:12:58, ATC cleared the flight for takeoff and cautioned them about "isolated bird activity." The V1 speed and VR speed were 166 kn, and the V2 speed was 168 kn.

As the aircraft accelerated, the presence of birds alarmed Yusupov, and he called out, "Come on, fly past, bird, fuck," but continued with the takeoff. Murzin soon announced, "100 knots" as the plane passed that speed, and Yusupov replied, "Checked." As the aircraft continued accelerating down the runway, Murzin exclaimed "Fucking hell, fuck" in response to the birds. At 6:13:40, he then called out "V1, rotate." Yusupov moved his side-stick back to start rotation at an airspeed of 181 kn. As soon as the aircraft lifted off the runway, several gulls —25 to 30 according to Yusupov's estimation —flew in front of the aircraft. The left engine subsequently ingested at least three birds, one large, and the right engine ingested at least one bird. The recorded vibrations on both engines increased to the maximum measurable value and stayed at it for the rest of the flight. The N1 fan rotation speed of the left engine decreased to near idle while the right engine's N1 reduced to a lesser extent. An erroneous "ENG 1 REVERSE UNLOCKED" warning appeared on the ECAM after a bird struck a sensor, causing the sensor to falsely indicate that the thrust reverser on the left engine was unlocked.

Four seconds after rotation, Murzin called out "Positive," referring to the positive rate of climb. However, he did not include "climb," the standard phrase that Yusupov was expecting, which would have alerted him to raise the landing gear. As a result, the landing gear stayed down for most of the flight, resulting in significantly more drag. Yusupov pitched the nose up to 12–13°, and the airspeed reached 183 kn before decreasing. Due to the reduced thrust in the left engine, the aircraft started to yaw to the left. Initially, Yusupov did not use the rudder pedals to counteract this movement. When he started to deflect the rudder pedals to the right, he did not use the rudder trim. Yusupov engaged the autopilot three seconds later at 6:13:59 as the aircraft was passing through 230 ft. The autopilot automatically reduced the pitch to 6° to reduce the ongoing decrease in airspeed. Immediately after the engagement, Yusupov announced, "ECAM action," despite being below the previously discussed altitude of 400 ft, the minimum altitude to respond to ECAM messages. Murzin, reading the ECAM, said, "Engine one reverse unlocked, thrust levers one idle, confirm thrust," calling for the left engine thrust lever to be moved to idle. As the altitude peaked at 315 ft at 6:14:04, Yusupov responded with "check." Two seconds later, the autopilot disconnected, causing a red "AP OFF" warning to appear on the ECAM and a continuous aural alert to sound. Both warnings remained on until the end of the flight. Murzin did not move the left thrust lever to idle when instructed to by Yusupov.

Soon after the autopilot disconnected, an enhanced ground proximity warning system (EGPWS) warning called out "don't sink" as the aircraft descended. In reaction, Yusupov pulled up on his side-stick, and the aircraft's pitch varied between 8.5° and 13° nose up. While this temporarily resulted in a reduction in descent rate, the airspeed continued to decrease. He then attempted to call ATC about their situation by transmitting, "Pan-pan, pan-pan, pan-pan, Sverdlovsk," but never finished his message. At the same time, his input on the rudder pedals lessened, the aircraft started to yaw back left, and drag increased. Both thrust levers were advanced to TOGA power at 6:14:20 while passing the 290 ft (90 m) mark. The left engine did not respond, but the right engine did; the N1 of the engine initially reached 96% before fluctuating between 78–96%. At the same time, several banging sounds came from the right engine, showing symptoms of a compressor stall. This issue reduced the thrust from the right engine, although it remained in the same condition for the rest of the flight. Nine seconds after the thrust levers were advanced into TOGA, Yusupov informed Murzin that the autopilot had disconnected and instructed him to watch the airspeed. Murzin did not reply, nor did he call out the decreasing airspeed. Yusupov then reported the emergency to ATC and transmitted, "Pan-pan, pan-pan, pan-pan, Sverdlovsk 178, one engine failure." He then ordered Murzin to request a return to the airport, which the controller granted, but the crew did not discuss how they would return and never attempted to do so.

At 6:14:47 and descending below 240 ft with an airspeed of 152 kn, the left engine thrust lever was idled. The descent rate at this point was 400–600 ft/s. Murzin, warning Yusupov of the decreasing altitude, called out, "Altitude, altitude." Yusupov reacted by pulling up on his side-stick to a pitch of 12°. At this point, the Airbus A321's alpha protection system — designed to protect against high angles of attack (AOA) and aerodynamic stalls — was activated, preventing the AOA from increasing any further despite Yusupov's continued inputs. The EGPWS then issued a "terrain ahead, pull up" warning. Yusupov reacted by pulling his side-stick as far back as possible and did so for the rest of the flight. Descending below 120 ft at 6:15:10, Yusupov, having just noticed the still-extended landing gear, raised it without communicating with Murzin in hopes of returning to the airport. Despite pulling his side-stick fully up, the alpha protection system kept the AOA at αMAX of 15.5° with a pitch of 13°. There was no preparation for or discussion between the crew about the imminent landing; no brace command was issued, the flaps were not extended beyond CONF1, and the engines were kept running.

The aircraft touched down in a cornfield at 6:15:17 at a speed of 135 kn, 16,240 ft from the end of Runway 12 and to the left of its centerline. The right engine nacelle first made contact with the ground, followed shortly by the lower fuselage and left engine nacelle. The aircraft slid across the ground, bending corn stalks due to the thrust from the right engine. After travelling over a watery ditch, it stopped 17,400 ft from the end of Runway 12 with no post-crash fire.

After the aircraft came to a stop, the crew reported the accident to ATC. The flight attendants immediately started the evacuation by opening the emergency exits and deploying all eight evacuation slides. They instructed passengers by loudspeaker to leave their hand luggage on the plane. All passengers and crew were successfully evacuated. Within several minutes of the accident, various rescue services from Zhukovsky Airport and other Moscow-based emergency services arrived at the site to transport the passengers and crew back to the airport on buses.

All 233 passengers and crew survived the accident. Seventy-eight passengers, including nineteen children, received medical attention after the accident. Thirty-two passengers, including ten children, were taken to Ramenskoe Central Municipal Hospital and Zhukovskiy City Clinical Hospital. Thirty of them were treated and released, while two adults were hospitalized. In total, twenty-eight people sustained injuries; twenty-five minor injuries and three serious injuries, including First Officer Murzin, who fractured a vertebra. Four passengers were injured in the evacuation, while all the other injuries occurred during the impact.

Flight crew actions

The MAK analyzed the actions made by the crew during the flight based on interviews and the flight recorders. The MAK found that the crew did not apply proper procedures for engine damage or failure during the flight. At no point did the crew determine the remaining thrust the engines were producing, nor did they evaluate the damage sustained to the engines. They also did not raise the landing gear after takeoff, a required part of standard operating procedures (SOPs) relating to engine failure after V1. The cockpit voice recorder (CVR) showed that Murzin did not properly call out "Positive climb," which resulted in Yusupov's failure to raise the gear. In later interviews Yusupov gave to the MAK, he said he never heard Murzin call out "Climb." The MAK attributed the breakdown in communication to increasing levels of emotional stress. The flight data recorder (FDR) showed that instead of following the flight directors, Yusupov pitched the aircraft's nose up to 12.5°, which was the flight crew training manual's (FCTM) recommended pitch angle after takeoff in the event of an engine failure. However, the FCTM only provides this figure for immediate use after rotation, not for continued climb. The MAK deemed that Yusupov continuing to pitch the nose up to the angle listed in the FCTM demonstrated that he was losing situational awareness.

The investigation determined that Yusupov's increased levels of emotional stress and loss of situational awareness led to his autopilot engagement without using rudder trim to trim out the manual inputs he was making on the rudder pedals. In interviews with the MAK, Yusupov stated that he called out "ECAM action" despite being below 400 ft because he thought that the reverser on the left engine might have deployed and believed it to be a critical warning needing to be addressed. He evaluated that the actions for engine failure after V1 were complete, and he could focus his attention on the ECAM. However, the MAK deemed that his assessment of the situation was incorrect. The aircraft was not on a stable climb path, the airspeed was below V2 (the recommended airspeed after an engine failure) and falling, and the flight director commands were not followed. After the disconnection of the autopilot, the flight recorders indicated that there was no discussion between the crew about the disconnection, no attempts to re-engage autopilot, and no silencing of the aural disconnect warning. The MAK determined that Yusupov likely never comprehended the warning due to his emotional stress. When the EGPWS activated, Yusupov pulled fully up on his side-stick and advanced the thrust levers to TOGA power. The damaged right engine started to suffer a compressor stall as a result, but the flight recorders revealed that neither crew member discussed the state of the engines or applied the correct procedure to stop the stalling from occurring.

Rather than addressing the unsafe flight path the aircraft was currently on, Yusupov attempted to call ATC about their emergency. The MAK deemed this action to violate crew resource management principles, which stated that the non-flying pilot, First Officer Murzin, should make radio calls when no ECAM actions are being taken. The MAK also deemed that Yusupov's communication was not in lines with aviate, navigate, communicate, which dictates that crews should focus on safely flying their airplane before communicating with ATC. The aircraft was not on a safe flight profile when he made his radio transmission. The MAK concluded that throughout the entire flight, Murzin was confused, failed to call out the airspeed when instructed, and failed to fulfill the duties of pilot monitoring. His stressed condition resulted in a startle effect and an inability to perceive the situation properly. The FDR recorded that he made small inputs on his side-stick at the same time as Yusupov did, although not with sufficient force to trigger a dual input warning. The MAK determined that Yusupov also failed to perceive the situation fully; he experienced tunnel vision and failed to maintain the necessary rudder pedal inputs needed to keep the aircraft flying straight without any sideslip. In interviews given to the MAK, Yusupov said he retracted the landing gear just before impact in order to prevent the aircraft from digging into the wet soil or cartwheeling on touchdown. Murzin stated that there was a discussion between him and Yusupov and that they agreed to raise it. However, there was no recording of a discussion on the CVR, and it showed that Yusupov raised the landing gear without informing Murzin.

In addition to analyzing the crew's actions, the MAK carried out psychological testing to determine their personalities. Yusupov showed results for having reactionary behavior, being excitable and impulsive, a tendency towards dominance, difficulty following authority, and denying negative information presented to him. The MAK determined that in high-stress and abnormal situations, his personality could have resulted in latent reactions where his behavior becomes disorganized, chaotic, and inconsistent in high-stress and abnormal situations. Murzin showed similar results to Yusupov, with the addition of being immature and competitive. Like Yusupov, the MAK determined that his personality could have led to procedure violations and disorganized actions.

The MAK concluded, "From the very beginning of the event, the actions of the crew, especially the captain, were characterized by disorganization, inconsistency, and chaos, indicating partial psychological incapacitation." The investigators deemed that the crew failed to carry out the procedures for engine failure after V1 properly. In particular, the investigators highlighted that the crew did not raise the landing gear, follow the flight directors, or trim the rudder out before engaging the autopilot. The MAK noted that the crew suffered from several psychological effects in the abnormal situation they were experiencing, including the startle effect and psychological incapacitation. Additionally, the MAK found that both crew members had accumulated many unused rest days, with Murzin having not taken a break for the 10 months prior to the accident. The lack of sufficient breaks might have resulted in the crew's chronic fatigue.