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Air Astana 1388 was a 11 Nov 2008 repositioning flight that is amongst the most harrowing tales in civil aviation. For 90 minutes, the crew fought their uncontrollable Embraer Regional Jet which pitched, spun, and rolled 360° with seemingly no indication of fault.

Despite doing multiple spins, loops, upsets, as they tried desperately to control their aircraft, the Air Astana crew never stopped fighting. Even when they thought all was lost, they asked for directions out to sea so their inevitable crash would not hurt anyone on the ground

the ATC recordings are harrowing as a minute into their flight the problem manifested itself. The maintenance crew had overhauled the jet had wired in the aileron controls backwards, but the wing spoilers in properly. The plane was fighting itself.

youtu.be/kIc8Rr-cKd8

As per the diagram below, you can see the spoilers and ailerons typically work together to control the plane. When the pilot calls for a roll, the ailerons change the roll while the spoilers reduce lift on the wing assisting in it. Only their ailerons were backwards.

The passengers and crew are experiencing up to 5 Gs of force as the pilots try to stop the rollercoaster ride, doing loops & spins. Eventually the pilots put the plane into fly-by-wire to direct control and realize that if they turn the yoke very slightly, only the ailerons move

The crew discovers that if they only move slightly, the spoilers won't come up and put the aircraft into a chaotic spin. Sure their steering is backwards, but at least backwards is reasonable. Meanwhile the Portuguese Air Force has arrived after hearing their maydays.

However, the Portuguese F-16s have their collision warning beacons turned on, and the plane sensing nearby aircraft, immediately fills the cockpit with shrill warnings that the F-16s are too close. The pilots beg ATC to tell the F-16s to turn off their TCAS system.

Finally under some control, the first officer attempts to land at a nearby airbase. However, they are unable to stay stable and go-around. The first officer is too sick and exhausted, and tells the captain to take over. They make another go but fail.

On the 3rd try, the plane once again drifts. Tired from their ordeal, the pilots realize that while the adjacent runway 19L is narrower and shorter, it's better to attempt that then risk another go-around. After 90 minutes they land safely.

It is only after landing their bruised and battered jet that their display finally flashes an error message "FLT CTRL NO DISPATCH" meaning there's a fatal error with how the controls are configured and they should not take off.

There is only one injury on the flight, one of the passengers had sprained their ankle, and all wanted to vomit. The plane however was worse off, the hull was visibly twisted and wrinkled and the wings bent out of shape. The plane was scrapped.

The 3 pilots on board Air Astana 1388 had done a remarkably piece of flying, staying reasonable in an unreasonable situation, diagnosing the issue, and figuring out half the flight's roll controls were in backwards even as they were being thrown around the air.

The maintenance crew in Portugal did not properly overhaul the aircraft, however the investigation also blamed the manufacturer who published poor maintenance manuals, and the flight crew failed to notice the asymmetrical controls during pre-flight checks.

Ultimately this was good for aircraft safety culture. The crew had excellent communications so while they failed to notice the improper maintenance, they were able to compensate for the mistake and bring an uncontrollable plane back to the ground with everyone alive.

Aircraft safety culture is known as "Just culture" vs "blame culture". In the airline industry, you can admit your mistakes without expecting punishment or sanction. No system is perfect but they should cover each other's mistakes.

This is different from a "no-blame culture" as intentionally doing things wrong, gross negligence, is still punishable.

This is also different from normal "blame culture" where honest mistakes may be hidden due to fear of punishment and the system won't be improved.

Systems can be made safer if we understand all parts CAN and WILL FAIL. People make mistakes, computers have bugs, machines break, instead of blame, if we accept it will happen, we can make a system where 1 failure is not fatal.

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