Airbus A330-303, VH-QPA 7 October 2008 - ATSB Report
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QANTAS Airbus A330-303, VH-QPA 7 October 2008 - ATSB Report
ATSB Report released 19 December 2011.
Airbus A330-303, VH-QPA 7 October 2008
Investigation: AO-2008-070 - In-flight upset - Airbus A330-303, VH-QPA, 154 km west of Learmonth, WA, 7 October 2008
Airbus A330-303, VH-QPA 7 October 2008
Investigation: AO-2008-070 - In-flight upset - Airbus A330-303, VH-QPA, 154 km west of Learmonth, WA, 7 October 2008
Last edited by mmciau; 20th Dec 2011 at 01:28. Reason: Addition
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Compensation for PAX
150 QF A330 Passengers on flight QF72 have won millions of dollars in compensation settlement from Airbus & Northrop Grumman:
http://www.watoday.com.au/travel/tra...ut-from-airbus-20111220-1p3o7.html
http://www.watoday.com.au/travel/tra...ut-from-airbus-20111220-1p3o7.html
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The ATSB ain't what it used to be
This report is poorly written, contains too much opinion, and features the inappropriate use of flow charts.
Inappropriate use of flow charts is not unusual these days, but I would have expected better from the ATSB. The author appears unaware as to the purpose of flow charts. A hint for him is in the name: FLOW.
The author also appears intent on praising the crew. A factual report on something is not the place for opinion-based praise. PPRUNE is a more appropriate place for opinion-based praise!
But the biggest failing of the ATSB in this investigation would have to be the complete non-recognition of the fact that the flight computers are capable of making control surface deflections that will result in vertical accelerations of this magnitude.
If the ATSB gave any consideration to this issue they haven't made any mention of it.
This upset would have to be very embarrasing to Airbus. This has made their software look very amateurish indeed.
Question for the Airbus drivers: would these pitch-downs have still occurred with the autopilots disengaged? If yes, then what about in alternate law? Can the computers be manually switched to alternate law?
Inappropriate use of flow charts is not unusual these days, but I would have expected better from the ATSB. The author appears unaware as to the purpose of flow charts. A hint for him is in the name: FLOW.
The author also appears intent on praising the crew. A factual report on something is not the place for opinion-based praise. PPRUNE is a more appropriate place for opinion-based praise!
But the biggest failing of the ATSB in this investigation would have to be the complete non-recognition of the fact that the flight computers are capable of making control surface deflections that will result in vertical accelerations of this magnitude.
If the ATSB gave any consideration to this issue they haven't made any mention of it.
This upset would have to be very embarrasing to Airbus. This has made their software look very amateurish indeed.
Question for the Airbus drivers: would these pitch-downs have still occurred with the autopilots disengaged? If yes, then what about in alternate law? Can the computers be manually switched to alternate law?
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This is why there needs to be a big red button that says "Off"
When you press it, when you move the stick back, plane goes up, stick forward, plane goes down.
No if's, buts or maybe's.
Accidents have happened already when the computer takes a mind of its own.
When you press it, when you move the stick back, plane goes up, stick forward, plane goes down.
No if's, buts or maybe's.
Accidents have happened already when the computer takes a mind of its own.
FGD135
Yes
Unders some conditions, yes.
Yes they can. What would be better is switching all the primary computers off and using the secondaries in "direct law". There are no protections in direct law therefore no chance of dud input data sending the flight controls into heart failure.
Question for the Airbus drivers: would these pitch-downs have still occurred with the autopilots disengaged?
If yes, then what about in alternate law?
Can the computers be manually switched to alternate law?
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The ATSB ain't what it used to be
I have read through the report again. It is as bad as I first thought. The author/investigator goes well beyond the normal practice for a factual report in order to praise the crew.
I believe that the pilot's performance was less than ideal (see below) but the intent of the author/investigator seems to be to protect the pilots by building a wall of praise around them.
This praise goes a bit too far as it involves too much opinion.
Snippets from the report are as follows. I have bolded certain words:
"Professional"? That would be a word appropriate to a PPRUNE post, but not an ATSB Final Report.
There were other passages that contained the words "prompt" and "immediate" in relation to pilot actions. There was nothing in the report that was even slightly critical of the pilot's performance.
The report is suggesting that the pilot's performance was flawless. Was it?
The pilot's were confused as to which law the flight computers were in. The law switched to "alternate" after the second pitch down and remained that way until landing. The pilots believed the computers were in "direct" law.
Being in "alternate" law, however, meant that there was thus a greater chance of further, misguided control inputs by the flight computers.
I believe there should have been more effort spent on getting the computers into "direct" law. The pilot's belief they were already in "direct" law seems to have been based on a (flawed) observation by the captain regarding the auto-trim.
It appears to me that the pilots were overwhelmed to some degree, which should be a concern given that:
1. The fault was minor;
2. The aircraft was in clear VMC conditions in broad daylight;
3. There was a 3,000 metre runway less than 100 NM away;
The author/investigator seems to have excused the pilots, on the grounds that they were confused.
The report identifies a couple of safety issues but fails to identify what, to me, are the more significant safety issues. Those are:
1. That the flight computers (in "normal" law, no less) will quite happily command elevator deflections that are capable of producing vertical accelerations of the magnitude experienced in this incident;
2. That the warning/messaging systems, in the case of a minor malfunction, can so easily confuse the crew to the point where they no longer feel they can "trust" the messages/systems;
3. The pilot's management of the flight computers. They knew there was something fishy with the computers but their efforts at isolating, to the greatest degree possible, the computer-generated control inputs, were insufficient.
The author/investigator could have sought advice from Airbus and Qantas regarding the performance of the pilots but does not appear to have done this. Instead, he/she is content to describe it with words like "timely", "appropriate" and "professional".
Poor job, ATSB. Can do better.
I believe that the pilot's performance was less than ideal (see below) but the intent of the author/investigator seems to be to protect the pilots by building a wall of praise around them.
This praise goes a bit too far as it involves too much opinion.
Snippets from the report are as follows. I have bolded certain words:
The flight crew’s responses to the emergency were timely and appropriate.
... the flight crew worked together to provide the captain with all the information he needed to fly the aircraft.
The aircraft only descended a total of 690 ft during the first pitch-down. Although this was due in part to prompt action by the flight crew ...
The captain’s sidestick responses to both pitch-downs were prompt.
However, in addition to being timely, the captain’s sidestick responses were also of the appropriate magnitude.
... the crew’s decision to divert to Learmonth was appropriate.
These tasks were performed with a high degree of coordination and effectiveness by the flight crew.
The flight crew’s responses to the warnings and cautions, the pitch-down events, and the consequences of the pitch-down events, demonstrated sound judgement and a professional approach.
"Professional"? That would be a word appropriate to a PPRUNE post, but not an ATSB Final Report.
There were other passages that contained the words "prompt" and "immediate" in relation to pilot actions. There was nothing in the report that was even slightly critical of the pilot's performance.
The report is suggesting that the pilot's performance was flawless. Was it?
The pilot's were confused as to which law the flight computers were in. The law switched to "alternate" after the second pitch down and remained that way until landing. The pilots believed the computers were in "direct" law.
Being in "alternate" law, however, meant that there was thus a greater chance of further, misguided control inputs by the flight computers.
I believe there should have been more effort spent on getting the computers into "direct" law. The pilot's belief they were already in "direct" law seems to have been based on a (flawed) observation by the captain regarding the auto-trim.
It appears to me that the pilots were overwhelmed to some degree, which should be a concern given that:
1. The fault was minor;
2. The aircraft was in clear VMC conditions in broad daylight;
3. There was a 3,000 metre runway less than 100 NM away;
The author/investigator seems to have excused the pilots, on the grounds that they were confused.
After the first pitch-down, the flight crew were presented with a situation that was even more confusing ...
The report identifies a couple of safety issues but fails to identify what, to me, are the more significant safety issues. Those are:
1. That the flight computers (in "normal" law, no less) will quite happily command elevator deflections that are capable of producing vertical accelerations of the magnitude experienced in this incident;
2. That the warning/messaging systems, in the case of a minor malfunction, can so easily confuse the crew to the point where they no longer feel they can "trust" the messages/systems;
3. The pilot's management of the flight computers. They knew there was something fishy with the computers but their efforts at isolating, to the greatest degree possible, the computer-generated control inputs, were insufficient.
The author/investigator could have sought advice from Airbus and Qantas regarding the performance of the pilots but does not appear to have done this. Instead, he/she is content to describe it with words like "timely", "appropriate" and "professional".
Poor job, ATSB. Can do better.
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I believe there should have been more effort spent on getting the computers into "direct" law. The pilot's belief they were already in "direct" law seems to have been based on a (flawed) observation by the captain regarding the auto-trim.
It appears to me that the pilots were overwhelmed to some degree, which should be a concern given that:
1. The fault was minor;
2. The aircraft was in clear VMC conditions in broad daylight;
3. There was a 3,000 metre runway less than 100 NM away;
The author/investigator seems to have excused the pilots, on the grounds that they were confused.
It appears to me that the pilots were overwhelmed to some degree, which should be a concern given that:
1. The fault was minor;
2. The aircraft was in clear VMC conditions in broad daylight;
3. There was a 3,000 metre runway less than 100 NM away;
The author/investigator seems to have excused the pilots, on the grounds that they were confused.
aircraft landed. No-one dead. Success.
1a...
It wasn't the dive that did the damage; it was the pitch rate which put people into the ceilings and back onto seats/carts/armrests, which in turn caused the injuries. Such was the nose-down attitude that the pilots could not see the horizon until pitch control was restored. Fortunately, the pilots in the flight deck had their seat belts "securely fastened".
and FGD...
what other words would you have the ATSB use if indeed they have assessed that crew actions were "timely/appropriate/prompt"? I don't see your selective quotes as praising the crew but, rather, stating the facts as the ATSB found them. The "complete non-recognition of the fact that the flight computers are capable of making control surface deflections that will result in vertical accelerations of this magnitude" is surprising though, and I'll read the report to form a view on that.
and FGD...
what other words would you have the ATSB use if indeed they have assessed that crew actions were "timely/appropriate/prompt"? I don't see your selective quotes as praising the crew but, rather, stating the facts as the ATSB found them. The "complete non-recognition of the fact that the flight computers are capable of making control surface deflections that will result in vertical accelerations of this magnitude" is surprising though, and I'll read the report to form a view on that.
Actually looking at the Vid the actual pitch change in deg's was a total of near 11 deg's From +2.5 up normal flight Att to around -8.4 deg's downward. That's a large change in a short space of time.Also as we all know an aircraft pivots for want of a better word about it's wing so the further away from that balance point the more dramatic the pitching effect on anyone not strapped in.
We've all had fun pushing & pulling the control column of a light A/C to create pos & neg G's for our poor unsuspecting friends but the moment arm for the change was tiny compared to a large airliner.
Still I hear some of the pax are going to reject the $400K that QF are offering (in the news 2day) as they are doing a class action suit for millions !...ouch!!!
Wmk2
We've all had fun pushing & pulling the control column of a light A/C to create pos & neg G's for our poor unsuspecting friends but the moment arm for the change was tiny compared to a large airliner.
Still I hear some of the pax are going to reject the $400K that QF are offering (in the news 2day) as they are doing a class action suit for millions !...ouch!!!
Wmk2
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Against Airbus and Northrop Grumman
It should be aimed at Airbus exclusively - it was their dopey software that decided the bunt was a good idea.
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I don't see your selective quotes as praising the crew but, rather, stating the facts as the ATSB found them.
To those like me that read these reports all the time, these statements stick out like the proverbial.
To me, the author/investigator is intent on building a wall of protection around the flight crew. He does not miss an opportunity to lavish praise on the captain.
It appears the author/investigator has studiously avoided any kind of examination of the flight crew's performance. The report makes clear that, after the pitch-downs, they were experiencing "mode confusion" and were overwhelmed to some degree, but the author/investigator just doesn't want to go there.
Why not?
Maybe the investigator is a former Qantas pilot himself. Maybe he is an old friend of the Captain. Maybe he has a son or daughter that is trying to get into Qantas.
Or could it be related to some nationalistic sentiment about the much-vaunted aussie pilots? Aussie pilots wouldn't get "mode confusion" would they?
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In an earlier post, I listed three major safety issues raised by this accident that have all been missed by the ATSB.
Here is the fourth:
4. That there are no procedures/training for when the computers begin making dangerously misguided control surface deflections.
From the report:
For an airliner that is almost 100% computer controlled, I find it utterly astonishing that Airbus and/or Qantas haven't established procedures or conducted training for when the computers get confused.
I am only a plodding GA driver, but to me, the immediate action would be to isolate, to the greatest degree possible, the computers.
This means, firstly, manually switching to "direct law". Then, switching the computers so that a different "prim" (primary flight control computer) is manipulating the surfaces.
Here is the fourth:
4. That there are no procedures/training for when the computers begin making dangerously misguided control surface deflections.
From the report:
There were also no other procedures available for the situation they were experiencing.
For an airliner that is almost 100% computer controlled, I find it utterly astonishing that Airbus and/or Qantas haven't established procedures or conducted training for when the computers get confused.
I am only a plodding GA driver, but to me, the immediate action would be to isolate, to the greatest degree possible, the computers.
This means, firstly, manually switching to "direct law". Then, switching the computers so that a different "prim" (primary flight control computer) is manipulating the surfaces.
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FGD, From the report,
Although the crew received numerous ECAM caution messages, none of them required urgent action, and none of them indicated any potential problems with the aircraft’s flight control system.
Do you have any idea of the number of computers on an A330 that have a direct input into the FMGEC?
The actual fault was with ADIRU 1, which never came up on the ECAM. So, which computer or computers do you isolate? All of them?; leaving yourself on the Rudder backup and the manual trim to control the aircraft with?
The loss of the autotrim is a symptom of direct law, but the report states that the "Use Manual trim" message never appeared on the PFD's.... so what Law is the aircraft operating in? Is it any wonder that there was confusion?
Utimately is doesn't matter what Law the aircraft is operating in if you apply the "Golden Rules" of flying an Airbus... that is, if it isn't doing what you expect, take over and fly it manually. Which is what the captain did.
....Manual thrust, manual trim and using the standby instruments... go through all the checklists, look after the passengers and accomplish a safe landing with a highly suspect flight control system and no clue as to the real culprit.
This crew was faced with a Black Swan event. It had never happened before.
I hope to half as well if something like this ever happens to me.
As to your amateur intimations that the ATSB somehow erred in their estimation of the performance of this crew; you are out of your depth and it shows.
Although the crew received numerous ECAM caution messages, none of them required urgent action, and none of them indicated any potential problems with the aircraft’s flight control system.
Do you have any idea of the number of computers on an A330 that have a direct input into the FMGEC?
The actual fault was with ADIRU 1, which never came up on the ECAM. So, which computer or computers do you isolate? All of them?; leaving yourself on the Rudder backup and the manual trim to control the aircraft with?
The loss of the autotrim is a symptom of direct law, but the report states that the "Use Manual trim" message never appeared on the PFD's.... so what Law is the aircraft operating in? Is it any wonder that there was confusion?
Utimately is doesn't matter what Law the aircraft is operating in if you apply the "Golden Rules" of flying an Airbus... that is, if it isn't doing what you expect, take over and fly it manually. Which is what the captain did.
....Manual thrust, manual trim and using the standby instruments... go through all the checklists, look after the passengers and accomplish a safe landing with a highly suspect flight control system and no clue as to the real culprit.
This crew was faced with a Black Swan event. It had never happened before.
I hope to half as well if something like this ever happens to me.
As to your amateur intimations that the ATSB somehow erred in their estimation of the performance of this crew; you are out of your depth and it shows.
Nope.... Sorry FGD
The ATSB don't just interview the crew, decide they're nice blokes, and then shield them from criticism by contriving the evidence. The report is the product of many thousands of hours work by many highly qualified people using input from more of the same.
The unprecedented happened, redundancy wasn't, automatic diagnosis didn't, and it fell to the crew to make a successful outcome from the most confusing, trying and stressful of circumstances. Where the ATSB has 'praised' it is deserved and recognizes that, in the circumstances, this crew acted in the most timely/appropriate/prompt manner possible.
It sounds like you wanted the ATSB to say something like "The crew took action in 1.2seconds, which is considered timely in the circumstances".
I'm afraid I'm with Kremin on this one.
The unprecedented happened, redundancy wasn't, automatic diagnosis didn't, and it fell to the crew to make a successful outcome from the most confusing, trying and stressful of circumstances. Where the ATSB has 'praised' it is deserved and recognizes that, in the circumstances, this crew acted in the most timely/appropriate/prompt manner possible.
It sounds like you wanted the ATSB to say something like "The crew took action in 1.2seconds, which is considered timely in the circumstances".
I'm afraid I'm with Kremin on this one.
I must side with FDG on this, that is being critical of part of the report's writing style (not the crew or their actions). The ATSB should state fact not opinion.
From the ATSB website, their goals are to:
• conduct impartial, systemic and timely safety investigations
• report safety issues clearly and objectively, without attributing blame or liability.
The definition of Objective from the OED, "Not influenced by personal feelings or opinions in considering and representing facts"
The reader should infer that an action was a "Good Decision, Son" by reading that the crew were faced with no better options available.
And as an aside, when did the ATSB start naming the companies involved? I always recalled that the company name was omitted (although it was pretty obvious who it was to those in the industry)?
From the ATSB website, their goals are to:
• conduct impartial, systemic and timely safety investigations
• report safety issues clearly and objectively, without attributing blame or liability.
The definition of Objective from the OED, "Not influenced by personal feelings or opinions in considering and representing facts"
The reader should infer that an action was a "Good Decision, Son" by reading that the crew were faced with no better options available.
And as an aside, when did the ATSB start naming the companies involved? I always recalled that the company name was omitted (although it was pretty obvious who it was to those in the industry)?
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Good points, Stallie. This report falls short of the "objective" standard stated by the ATSB's own website. As we have seen, in places throughout the report where just plain facts should be the order of the day, we have in many instances, opinions - opinions that are slapping the crew on the back.
Every single one of those opinions that I quoted earlier could have been left out of the report entirely.
This deviation from the ATSB's own "objective" standard could be put down to the author's lack of report writing experience. (It is my assumption that he lacks experience in this regard. Other aspects of the report would suggest this).
Or, the deviation could be for the reasons I have given earlier. I'm no conspiracy theorist, but it does just sound so much like he is trying to shield the pilots.
I have only come this far on this because of those opinionated statements. When the final report became available, I looked at it with the intention of skimming through the executive summary and findings. In the executive summary was this statement:
I was immediately struck by this statement as it stood out like the proverbial. I have never seen such a bald statement in such a key place of an air safety report before. Come to think of it, I have never seen a statement like it anywhere, in any air safety report, ever!
But, Jetsbest, it is not their place to praise. If praise is in order (and I believe it is), then this should be done by those that normally do it (e.g., the airline, the unions, the passengers, professional pilot groups, etc).
Another break from convention is the usage of rank to identify the pilots. The norm when reporting actions and observations from the pilots is to refer to them as "PF" and "PNF".
Capt Kremin,
Not sure what you're getting at here, but the upset certainly required urgent action.
By "isolate" I mean reduce, tothe greatest extent possible, the influence of the computers on the flight controls. From what I understand, this is achieved by manually forcing the computers into "direct law".
There was an ECAM message stating that "alternate law" had been entered. I am suggesting that the best course of action would have been to force "direct law".
Like the ATSB investigator, you seem to be accepting the confusion as normal - and not something that may be a serious safety issue.
Not a very golden rule in this case. Flying it "manually" did not prevent the upsets. Being in "direct law" would have.
On a Chieftain or a Baron, disengaging the autopilot and "flying it manually" is a sound course of action when the autopilot starts doing funny things on the controls.
But on the Airbus, "flying it manually" means the computers are still just as involved as they are when "on autopilot", so although this would be a sound move for a range of other situations, it is not a smart move when the computers are doing dangerous things with the control surfaces.
I would dispute this. The captain was getting clues on his PFD as to who the culprit was, but I will go into that more on a future post.
So how do you explain the lack of interest by the ATSB in the crew's performance subsequent to the pitch-downs? This was a minor malfunction in broad daylight VMC conditions, yet the crew were experiencing "mode confusion" and were somewhat overwhelmed. We also know they had reached a point of "distrust" of the warnings and messages.
Surely you can see that these are serious safety issues. Why can't the ATSB see this?
The ATSB needs to be seen to be objective but it has failed in many keys areas of this report. But this is only my most minor gripe. My big gripe is that there are four major safety issues that the ATSB don't seem to have recognised.
The author/investigator has zeroed in on a minor malfunction in a single component. He has missed all the systemwide safety issues.
Every single one of those opinions that I quoted earlier could have been left out of the report entirely.
This deviation from the ATSB's own "objective" standard could be put down to the author's lack of report writing experience. (It is my assumption that he lacks experience in this regard. Other aspects of the report would suggest this).
Or, the deviation could be for the reasons I have given earlier. I'm no conspiracy theorist, but it does just sound so much like he is trying to shield the pilots.
I have only come this far on this because of those opinionated statements. When the final report became available, I looked at it with the intention of skimming through the executive summary and findings. In the executive summary was this statement:
The flight crew’s responses to the emergency were timely and appropriate.
Where the ATSB has 'praised' it is deserved and recognizes that, in the circumstances, this crew acted in the most timely/appropriate/prompt manner possible.
... when did the ATSB start naming the companies involved?
Capt Kremin,
Although the crew received numerous ECAM caution messages, none of them required urgent action,
... which computer or computers do you isolate?
... so what Law is the aircraft operating in? Is it any wonder that there was confusion?
Like the ATSB investigator, you seem to be accepting the confusion as normal - and not something that may be a serious safety issue.
Utimately is doesn't matter what Law the aircraft is operating in if you apply the "Golden Rules" of flying an Airbus... that is, if it isn't doing what you expect, take over and fly it manually.
On a Chieftain or a Baron, disengaging the autopilot and "flying it manually" is a sound course of action when the autopilot starts doing funny things on the controls.
But on the Airbus, "flying it manually" means the computers are still just as involved as they are when "on autopilot", so although this would be a sound move for a range of other situations, it is not a smart move when the computers are doing dangerous things with the control surfaces.
... no clue as to the real culprit.
The ATSB don't just interview the crew, decide they're nice blokes, and then shield them from criticism by contriving the evidence.
Surely you can see that these are serious safety issues. Why can't the ATSB see this?
The ATSB needs to be seen to be objective but it has failed in many keys areas of this report. But this is only my most minor gripe. My big gripe is that there are four major safety issues that the ATSB don't seem to have recognised.
The author/investigator has zeroed in on a minor malfunction in a single component. He has missed all the systemwide safety issues.