QZ8501: Telling it how it is

[PoppaJo]

It couldn't be said any clearer. ScareAsia

WHY THE AIRASIA ACCIDENT SHOULD BE A WAKEUP CALL FOR TRAVELLERS
Air travel is fundamentally an extraordinarily safe form of transport. But what travellers may not realise is the training standards for pilots and the regulatory oversight of carriers around the world is not uniform - and airlines from countries with weaker watchdogs can fly to and from Australia.

This was highlighted in a report into the crash of AirAsia Indonesia flight 8501. The carrier is a budget airline that flies to Bali from Perth and Darwin and is merging with long-haul arm Indonesia AirAsia X that flies to Bali from Sydney and Melbourne.

As is often the case, there was no single cause for the crash, which killed all 162 passengers and crew on board last December. Instead, there was a cascade of factors, starting with a recurring mechanical system malfunction that should have been fixed before the flight and ending with the stalled Airbus A320 crashed in the Java Sea instead of landing in Singapore. The very airframe involved had flown to Perth at least once, based on internet video shot by planespotters.

Perhaps the most disturbing aspect of the report involved the pilot training - or rather, the lack of it - by AirAsia Indonesia. After the autopilot was disengaged and the flight controls switched from the highly protective "normal law" to "alternate law", the aircraft rolled to the left by 54 degrees - beyond the 45 degree angle considered to exceed normal parameters, deeming it an "upset".

Litany of errors

While attempting corrective action, the first officer pitched up to the point where stall warnings were triggered and the aircraft climbed to 38,000 feet at a low speed. As the aircraft stalled, the Indonesian-born captain told the French-born first officer him to "pull down" - a confusing instruction given you "pull up" and "push down" - and notably neither were native English speakers.

The flight data recorder never recorded the signature of the first officer trying to recover from the stall by lowering the nose as stated in the quick reference handbook. That was despite the crash of Air France 447 in 2009 - also due to an unrecovered stall following a mechanical malfunction - leading to an industry-wide focus on preventing such an incident from occurring again.

In the wake of the Air France crash, the Civil Aviation Safety Authority required that pilots receive upset recovery training, although it was long a standard practice at Australian airlines. The AirAsia Indonesia crash report said Indonesia's Director General of Civil Aviation has no such requirement and neither of the pilots were trained in upset recovery on an A320.

"The effectiveness of fly-by-wire architecture and the existence of control laws eliminate the need for upset recovery manoeuvres to be trained on protected Airbus aircraft," the Airbus A320 flight crew training manual said, in a statement that AirAsia Indonesia relied on but one that should raise questions within the aviation industry.

An Australian A320 pilot said this crash once again highlighted the issue of pilots becoming too dependent on automation, which was degrading manual flying skills. On a commercial flight these days, it is possible a pilot will spend as little as one minute touching the control stick.

Emphasis on stick flying

Qantas, for example, has placed extra emphasis on manual flying in recent years to combat the complacency that comes with automation. AirAsia Indonesia chief executive Sunu Widyatmoko said in the wake of the crash, the airline was now providing upset recovery training to pilots, but that came too late for the 162 people on board QZ8501.

The previous lack of such training on an airline with the right to fly to and from Australia raises some serious questions. The US Federal Aviation Administration rates Indonesia as a "Category 2" country - as opposed to countries like Australia that are "Category 1" based on a rating of the safety oversight of airlines. Carriers from Category 2 countries - the latest of which is Thailand, having been downgraded on Tuesday - cannot add new services to the US or codeshare with US carriers until they gain a Category 1 rating.

In Australia, CASA issues a foreign air operators certificate to all foreign airlines flying to and from the country, ensuring the airline's safety standards meet the minimum safety standards established by the International Civil Aviation Organisation as does the regulatory system of the carrier's home nation.

A spokesman said if CASA was in any way uncertain or dissatisfied with the safety oversight provided by an operator's home country, it could refuse to issue, suspend or otherwise vary a foreign air operators' certificate. CASA made ramp checks of AirAsia Indonesia after QZ8501 and Thai Airways has been under increased surveillance this year.

But the QZ8501 experience - which could just as easily have occurred on a flight full of Perth or Darwin residents coming home from Bali - raises questions over whether a tiered system might be more appropriate in Australia. The Category 2 stigma encourages countries to move rapidly to improve safety oversight - as India did this year - and warns travellers about the higher risk of flying on airlines from those nations.

Politically, that could be a stretch in the case of Indonesia given it is our closest neighbour and the government is looking to improve bilateral relations. But even if CASA doesn't change its system, Australian travellers do have the ability to choose which carrier to fly on. Although accidents are rare, QZ8501 should serve as a wake-up call that price shouldn't be the only consideration when booking an air ticket.
Why the AirAsia crash report should serve as a wake-up call for travellers | smh.com.au (http://m.smh.com.au/business/aviation/why-the-airasia-crash-report-should-serve-as-a-wakeup-call-for-travellers-20151202-gld94f.html)

[KRUSTY 34]

Jesus wept!:ugh:

[chuboy]

But are the flights cheaper?

[ExtraShot]

'Aww but yeah maaate! Those guys are $20 cheaper maaate. Thats like ten Bintangs.

Plus they go when the Volcano blows its lid manatee, but Jetstar an Veeergin don go maaaate… I needa git back to collect me dole muney next week maaate…' :rolleyes::hmm::ugh:

[Buttscratcher]

Computer says 'no'

[neville_nobody]

In Australia, CASA issues a foreign air operators certificate to all foreign airlines flying to and from the country, ensuring the airline's safety standards meet the minimum safety standards established by the International Civil Aviation Organisation as does the regulatory system of the carrier's home nation.

How about they start applying the same onerous regulatory and cost burden on the foreigners as they do the locals! Or would that result in a diplomatic incident?

[gordonfvckingramsay]

"The effectiveness of fly-by-wire architecture and the existence of control laws eliminate the need for upset recovery manoeuvres to be trained on protected Airbus aircraft,"


So explain the two perfectly serviceable airbuses currently in a crumpled heap due to just that type of event then.

[Stanwell]

Gallic arrogance?

[compressor stall]

There are now two events where the stick has been held fully back when outside the normal law protections, all the way to the ground.

I wonder if there was a subconscious thought that you can pull back on the stick without a care in the world (like in a 'normal' EGPWS manoeuvre) and the computers take care of the rest through the alpha protections.

In the heat of the moment, forgetting that the control laws have been downgraded and the alpha protections no longer apply, two pilots have done the same thing they have been trained to do in other emergencies - pulled full back and kept it there.

I think there's more than just UA training at fault here. How much flying training / recurrency was done in Alternate Law? The last stall?

[Capt Fathom]

nose down pitch .... apply

Seems straight forward, but recent events prove otherwise!

Why is this so difficult?

[AEROMEDIC]

Gallic arrogance?

No, just another hole lining up.

[blueloo]

I still think the Airbus's main fault is its interface with the pilot. It seems to be a human factor nightmare in what is otherwise a very capable airliner.

Could it be as simple (and I am sure the work required to do it would be far from simple) as force feedback control side sticks so both pilots get the same tactile feedback which seems to be missing.....& ... Dare I say (side) stick shakers? :} :} :}

[Capn Bloggs]

Seems straight forward, but recent events prove otherwise!

Why is this so difficult?
Fathom, you are obviously not employed in the current jet airline world...

[chimbu warrior]

I took the time to read the NTSC report in full, and generally believe that the investigation has been quite thorough.

What I take from it though, and what was not specifically mentioned in the report, is that we now have a generation of pilots (and engineers in some cases) who believe that any fault is simply a computer glitch, and that it can always be fixed with a reset.

In the past system health was measured by temperatures, pressures, voltages, etc (and by a flight engineer), but nowadays there is a mindset that "green is good" in system indications. Should there not be a green indication, then many pilots think that either
it can be solved by a reset, or,
it must be an indication problem.


Many pilots don't seem to consider that a component may in fact have failed.

I also see engineers (some at least) who try repeated resets or re-racks to try and resolve an issue. Some engineers seem also to be convinced that there is an indication problem, and are unwilling to consider that a component change may be necessary.

To some degree manufacturers have contributed to this, with most trouble-shooting carried out by computer.

What I found particularly scary in this report was the revelation that the fault had been reported 23 times, but no-one considered any "fix" other than a system reset.

The Captain involved in this accident had experienced the same problem in the same aircraft 3 days earlier, and had returned to the bay. An engineer then came on board and accomplished a reset successfully, after which the Captain enquired if he could pull and reset the relevant circuit breakers if the problem re-appeared. The engineer apparently suggested that he could, but my guess is that the engineer assumed (always a trap) that the Captain would only attempt this on the ground. On the subsequent push-back the problem did reoccur, and was apparently reset successfully by the Captain tripping and resetting the appropriate circuit breakers.

No doubt pleased with his ability to resolve (temporarily at least) the issue, I imagine that the Captain noted this "fix", and attempted it in the air on the accident flight.

I grew up learning that circuit breakers were/are designed ONLY for circuit protection, and that they should NEVER be used as a reset tool or a switch. Modern practice seems to be completely the opposite.

So too, apparently, does the practice of hand-flying the aircraft.

The report mentions the importance of the "startle" factor when confronted with the situation faced by the crew. It also touches on the fact that the limited amount of jet upset/unusual attitude training done in the simulator is always accomplished at low altitude, in the approach configuration, and with the prior knowledge of the crew under training/check. This is a whole different ball-game to an unexpected upset at high altitude in convective weather.

Perhaps there is merit in introducing jet upset training in simulator sessions without advising the crew ahead of time. Whilst I do not want to see a return to the days where crews arrived at the sim without any foreknowledge of what was to come, this particular scenario cannot be properly trained for if it is run to a script.

Looking forward to reading Centaurus' views on this.

[wondrousbitofrough]

I also see engineers (some at least) who try repeated resets or re-racks to try and resolve an issue. Some engineers seem also to be convinced that there is an indication problem, and are unwilling to consider that a component change may be necessary.

To some degree manufacturers have contributed to this, with most trouble-shooting carried out by computer.

What I found particularly scary in this report was the revelation that the fault had been reported 23 times, but no-one considered any "fix" other than a system reset.

I have no idea of the company's engineering structure but this is where a team of defect analysts can be useful, where they review a set of repetitive defects and recommend action taken.

My opinion is that there is a poor culture evident, if it doesn't deter pilots resetting cb's relating to flight controls, and it doesn't look further into the cause of repetitive defects.

[Willie Nelson]

Chimbu Warrior, I think your observations are generally spot on. Just to pick you up on one point.

Chimbu Said:

I grew up learning that circuit breakers were/are designed ONLY for circuit protection, and that they should NEVER be used as a reset tool or a switch. Modern practice seems to be completely the opposite.

That's a bit of a misunderstanding, while I imagine that you've probably got the idea of permissible Airbus computer resets, perhaps I can clarify.

The QRH directs pilots very specifically toward what items can be reset while airborne and while on the ground, for which purpose and which items cannot be.

The QRH specifically states:

In flight, as a general rule, the crew must restrict computer resets to those listed in the table, or to those in the applicable TDU's (Temporary Document Units) or OEBs (Operational Engineering Bulletins). Before taking any action on other computers, the flight crew must consider and fully understand the consequences.

The "as a general rule" perhaps is misunderstood as a get out of jail card, I might suggest that this event didn't really meet the threshold for such an exception particularly given that the Caution could have been cancelled (emerg. cancel pushbutton), at least at that point. The problem may have deteriorated and required the exception to be invoked however I think you are right that the crew perhaps implied that the engineer had given permission.

My own outfit has come afoul of this process in the past, thankfully with no safety consequences and we have learnt as a result. In that case engineering were also contacted and this was perceived to be reason to not follow the QRH. That has since been addressed through a substantial change in communication processes.

On a separate note.

I think from the pilot's point of view this incident is disturbingly familiar to AF447 in so much as nobody was (effectively) flying the plane.

I think flight crew at least in the Bus have traditionally struggled to implement a practical response to the Airbus Golden Rule of Fly Navigate and Communicate.

My experience led me to come up with the following process that can be transposed on to almost any abnormal:

R.I.S.S.E. (recalls will always take precedence over this)

Review the FMA and PFD and respond accordingly. In the case of the Airbus: Obviously read any changes to your FMA; if the FMA asks you to place it in "LVR MCT/LVR CLB" do it. If the little brown chevrons have appeared, hey presto you're now in alternate law, whether ECAM has informed you or not, take note of your pitch and power, QRH unreliable airspeed tables will tell you what you need of you need if you're not sure, etc. Almost everything you need to aviate is on the PFD, if the heart is pumping the pilot flying should not look away until it is all addressed and you've taken a breath.

Identify and confirm the failure or issue in as much as it is possible while still flying the plane, if you can't, come back to flying the plane, all will be revealed in time.

Signs on

Safe position Get yourself to a safe position. It may require following the obstacle clearance procedure, climbing to the MSA, entering a PPOS hold, or just spending a bit of time clarifying the pitch and thrust setting between yourself and your offsider that you'll be looking for while you troubleshoot.

Then and ONLY then:

ECAM actions or QRH procedure as the case may dictate.

[chimbu warrior]

Willie....

Good points, and I think your own little analytical mnemonic is excellent.

Regarding allowable resets, yes I was aware that Airbus specifies allowable resets using circuit breakers, however I wonder if in the modern era this leads some pilots to the assumption that all circuit breakers are a form of reset button. As you point out the the statement

In flight, as a general rule, the crew must restrict computer resets to those listed in the table

........is a little too vague for some.

Perhaps a more dogmatic statement would clarify this, however there are always going to be those who simply do not have the background knowledge to understand the ramifications of pulling and resetting C/B's other than those specified by Airbus.

My post was not intended to ignore the golden rules, nor, heaven forbid, have this thread reduces to an A versus B argument. I think that in an age where we use devices in everyday life that play up occasionally and are "cured" by a reset, a reset mindset has developed.

We also have a number of engineers who I believe rely too heavily on this mindset, and I fear that these may have been but a couple of the many holes in the cheese that aligned on this occasion.

I agree 100% that pitch and power will always give you control of the aircraft, and lament that an apparent lack of such basic skills appears to have again led to substantial loss of life.

[fruitloop]

"I also see engineers (some at least) who try repeated resets or re-racks to try and resolve an issue. Some engineers seem also to be convinced that there is an indication problem, and are unwilling to consider that a component change may be necessary".......
"the fault had been reported 23 times, but no-one considered any "fix" other than a system reset."......"Modern Thoughts !!

[waren9]

notwithstanding the arguments about which law the aircraft was in and whether or not the pilots should have been capable of flying it...

i would like to think there are still some of us still around who would not accept that aircraft given the history that surely was in the tech log and "deferred" or "successful reset iaw..." etc particularly when we'd flown the same heap of **** 3 days earlier.

when is enough enough?

[Keg]

when is enough enough?


Good question waren. I reckon it's heavily influenced by organisational culture. A good culture and it's early on. A poor culture and it may be too late!

[neville_nobody]

Good question waren. I reckon it's heavily influenced by organisational culture. A good culture and it's early on. A poor culture and it may be too late!

I think you would have a hard time in any airline avoiding disciplinary action if you refused to take an aircraft that was signed out as legal to fly.

You would want to have a really strong argument and know exactly what you are on about.

QantasLink had that memorable incident where the engineers refused the sign out aircraft because they could prove that the door locks were faulty. Yet the airline and the regulator disagreed.

[Willie Nelson]

Chimbu,

I agree with the reset culture as you say. Most of our ginger beers are pretty good hands, we have all seen the guys who are perhaps a bit too quick to call it a one off reset without any reference to the history.

Warren 9, I agree with the idea of not accepting the aircraft if it's obvious that there has been no troubleshooting going on for repetitive faults but many cases are not as black and white as the Air Asia and there is a legitimate issue of not going too far in to second guessing the often very detailed and highly informed job of the engineers.

I would suggest that the vast majority of our engineers do a stand up job. Perhaps one issue could be resolved by providing more information to us on how many resets are permissible for one, and I would certainly advocate a thorough going over the tech log history pre flight but certainly after any particular ECAM pops up as all good operators will.

[waren9]

i never had any trouble neville

[600ft-lb]

The reset culture isn't really a culture, the Airbus troubleshooting manual actually directs the engineer to perform a single reset per flight leg. If the fault reoccurs in the same leg more action is required. With that in mind and the tendency for Airbuses self report faults that dont exist, for example through power transfers, it may seem like the engineers are just making the message go away.. It's not quite true.

The thing about Airbuses though is it will travel many sectors after a reset before another reoccurrence happens of a previously reset fault but as latent fault in the computer itself will manifest itself as more frequently occurring faults as exactly was the case in this crash. A competent MOC will monitor a trending fault with tools provided by Airbus themselves and competent engineers won't keep penning off a fault which occurs each flight or with a regular occurrence, that's what the DDG is for.

The airline won't want to wear an unnecessary delay and they definitely don't want engineers replacing computers that would go to a repair shop and subsequently returned as no fault found. Trend reporting is important but only if it's acted upon, which in this case it's plainly obvious it wasn't.

[Capt Fathom]

Fathom, you are obviously not employed in the current jet airline world...

Good guess Bloggs, hence my question! So what's your genius take on it then ? :rolleyes:

[Wombaticus]

"The effectiveness of fly-by-wire architecture and the existence of control laws eliminate the need for upset recovery manoeuvres to be trained on protected Airbus aircraft,"

When in alternate or direct law an Airbus is no longer fully protected, Airbus pilots should undertake upset recovery training to cater for such contingencies.

'Stall Stall Stall'
nose down pitch .... apply

Seems straight forward, but recent events prove otherwise!

Why is this so difficult?


Regarding the "Stall Stall Stall" when forward airspeed is less than 60kts this warning is inhibited. Imagine dropping like a brick, forward speed less than 60kts, attempting a stall recovery and then activating "Stall Stall Stall" as you begin to recover.

Confused?? I would say most would be.

I am not saying this occurred in this instance, however the situation that crew can find themselves in can be very challenging.


As always it is not the actions of the pilots alone that lead to such tragedies.

[Capt Claret]

I think you would have a hard time in any airline avoiding disciplinary action if you refused to take an aircraft that was signed out as legal to fly.

I don't see why. Somewhere in the preamble of the MEL that affects my operation there's a comment, for example, that the PIC must assess the implications of multiple MEL, and other operating conditions.

I recall an incident many years ago under Mr Smith's Class E from FL245 to A045 (or similar) where an F/O left an aeroplane because "expediency" approved flight with a u/s TCAS, rather than fix it. That captain's position on the day was, "it can be MELd so I can't say no." This thought process overrode the Ops Manual that required repair in a location that repairs could be made, and the warning preamble.

The F/O in my opinion made the correct decision and whist asked to explain their actions there was no disciplinary action.

An impartial observer may have said that the original approval to operate was designed solely to avoid a delay.

[Lead Balloon]

In Australia, CASA issues a foreign air operators certificate to all foreign airlines flying to and from the country, ensuring the airline's safety standards meet the minimum safety standards established by the International Civil Aviation Organisation as does the regulatory system of the carrier's home nation.Wow - those certificates must be very special and magical. :eek:

Certificates have the effect of ensuring compliance with standards? Of what are they made? Unicorn poop?

[wheels_down]

My major gripe with this mob is the volume of low hour, and very young pilots they pump out. They basically crew every delivery off cadets. Most reputable carriers have solid check and training standards that back these programs up (think Easy/Ryan). These guys do not.

This mob has at least a dozen "Senior First Officer's" on its A330 fleet younger than 25. Can't say I'd be too crash hot going from a 172 to an A330.

Now everyone can fly..

[PoppaJo]

They were advertising for captains for the A330 recently.

"Minimum Age 26"

Quite simple I said, just hire one of your 26yr old A320 Captains..:ugh:

[dr dre]

has at least a dozen "Senior First Officer's" on its A330 fleet younger than 25. Can't say I'd be too crash hot going from a 172 to an A330.


While I do see the point about better airlines having better training schemes, there's nothing preventing a mid twenty something from being an airline Captain (at one of the better airlines) if they're up to the job. Get them out of High School at 18, then a two year comprehensive training course and then 5/6 years as an FO will give them 4/5000hrs jet time, nothing stopping them from then progressing to the LH seat if they're up to the task. It has happened in Aus carriers in the past:

British Airways hands 21-year-old dream job as a pilot | Daily Mail Online (http://www.dailymail.co.uk/travel/travel_news/article-2759478/His-career-really-taking-British-Airways-hands-high-flying-21-year-old-dream-job-pilot-passengers-think.html#ixzz3uCTdRb00)

[cessnapete]

Age doesn't matter, its the basic training that counts.
British Airways put many new entrants in their early 20s from their training Academy into the RH seat of B737/A320/B757 with 200 + hours. After 50 sectors under supervision released to line, initially for some months with experienced Capt.
Many are now retiring as Capts after after many years of safe accident free operation.
I have a friend in the RAF, she was a Capt. on the TriStar Tanker/transport, in her late 20s, with 2000 hours total. Flew into many 'In Theatre' airfields in various recent war zones safely and competently.
Its the quality of the person and training that counts.

[SRM]

One simple solution regarding system resets:


Make a log entry for every defect.


Too often Engineers are called to the aircraft with a defect just prior to departure. A simple reset rectifies the defect and no Maintenance Log entry is made.


Every Maintenance Log entry has to be rectified / cleared IAW approved data.


No log entry means no record.

[600ft-lb]

Yes. I have seen some disturbing incidents of this myself.
I was given an airbus for dispatch, on which the previous sector the recirc fan has overtemped and stopped, triggering the overhead fault light on. The previous crew had started the smoke/fume checklist before the recirc fan managed to stop itself. Fumes were evident in the cabin, as per the cabin log.

The engineers solution was to simply reset the recirc fan, as per the fault/pushbutton.

At no point did they express any intention to inspect, or replace, the fan. They simply reset an overtemped recirc, and signed it off as [test satis].

Needless to say, we were not happy with this, and the engineers grumbled and carried on when we told them to track down a spare from another carrier. Took 2 hours, but who cares.
Did the previous crew write it up as a smoke/fume event? No engineer in their right mind will pen off a smoke event which stops after a recirc fan is isolated, with just a reset. That sort of negligence should be reported to CASA.

[SRM]

"This was greeted with confused looks, and a chat in a walkie talkie, and then the asian equivalent of "she'll be right mate".


What can I say!!!!!!!!!!!!!!!!!!!!!!

[LHLisa]

A few (maybe 7 ) years ago I got to an aerobridge about 730 am . Smoke was coming out of the plane onto the aerobridge . The CSS insisted I come onboard and start safety checks etc . I didn't . WTF. The tech crew arrived shortly after and got everyone (crew only - bar me ) off . Sometimes get there itis is very dangerous. There had been multiple write ups about the "issue" in the tech log I think .

[Eddie Dean]

Trouble shooting systems is a dying art.
Seems to me that only those who are "mechanics" can do so, "engineers" seem to be in love with their title.

FWIW