AirAsia Engine Failure Mess
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AirAsia Engine Failure Mess
Internal operator investigation said they followed procedures. ATSB says otherwise. Essentially they did everything wrong.
Thats a loooooong way on one engine. Total disregard for Amber LAND ASAP. If they lost the other one, I don’t have much faith that it would have been a survivable forced landing going of their performance.
https://www.atsb.gov.au/media/577717...nal-report.pdf
Thats a loooooong way on one engine. Total disregard for Amber LAND ASAP. If they lost the other one, I don’t have much faith that it would have been a survivable forced landing going of their performance.
https://www.atsb.gov.au/media/577717...nal-report.pdf
Contributing factors
• In response to an engine oil low pressure (ENG OIL LO PR) ECAM, resulting from a fractured shaft within the oil pressure pump, the flight crew continued to monitor the engine parameters instead of shutting the engine down. Due to a mistaken understanding that the alert was a false indication, the flight crew subsequently increased thrust.
• The Airbus A330 engine oil low pressure (ENG OIL LO PR) abnormal procedure included the conditional instruction 'if the condition persists'. This may be interpreted as either requiring the flight crew wait a certain period of time to determine the continuation of the condition, as apparently interpreted by the flight crew, or, as intended by Airbus, that the condition has not changed as a result of the previous procedural step.
• Contrary to operating procedures, the flight crew made two attempts to relight the failed engine.
• The crew diverted to Melbourne instead of the nearest suitable aerodrome. This increased the time that the flight was exposed to the higher risk environment of single engine operations.
• In response to an engine oil low pressure (ENG OIL LO PR) ECAM, resulting from a fractured shaft within the oil pressure pump, the flight crew continued to monitor the engine parameters instead of shutting the engine down. Due to a mistaken understanding that the alert was a false indication, the flight crew subsequently increased thrust.
• The Airbus A330 engine oil low pressure (ENG OIL LO PR) abnormal procedure included the conditional instruction 'if the condition persists'. This may be interpreted as either requiring the flight crew wait a certain period of time to determine the continuation of the condition, as apparently interpreted by the flight crew, or, as intended by Airbus, that the condition has not changed as a result of the previous procedural step.
• Contrary to operating procedures, the flight crew made two attempts to relight the failed engine.
• The crew diverted to Melbourne instead of the nearest suitable aerodrome. This increased the time that the flight was exposed to the higher risk environment of single engine operations.
From the report
”...ECAM procedure required the flight crew reduce the engine thrust to idle and, ‘if [the] warning persists’, then shut the engine down. The flight crew probably interpreted this as a temporal requirement and not a continuation of the condition, as intended by Airbus.”
You mean this? Seems pretty clear to me.
”...ECAM procedure required the flight crew reduce the engine thrust to idle and, ‘if [the] warning persists’, then shut the engine down. The flight crew probably interpreted this as a temporal requirement and not a continuation of the condition, as intended by Airbus.”
You mean this? Seems pretty clear to me.
It is also worth noting that it has taken three and a half years for the ATSB to publish this report.
Is this acceptable? If not how can the time frame be improved?
Is this acceptable? If not how can the time frame be improved?
Four plus minutes at FL380, with one engine at idle. It's a pity that the report doesn't include a speed trace. I recall looking at FR24 a couple of days after this happened, and if my memory is correct, the speed decayed to a point that it was interesting.
It is also worth noting that it has taken three and a half years for the ATSB to publish this report.
I think the bigger story here is FBW saved the day. 5 minutes at FL38-40 at idle on the big girl, without FBW/Alpha saving the day the thing would have entered a spin. Either that or they were on the absolute verge of entering alpha.
I can’t say I’d have any confidence at all they would have successfully recovered from a spin going of previous behaviour here. Eyes were most certainly not on the airspeed which is even more disturbing as I assume speed was moving toward low 200s?
Automation is essentially just arse covering for poor check and training standards in the backwater operators in the far north west.
A good comparison of how well this can be handled was the Jetstar 787 Engine Shutdown near Darwin. A lot of operators globally use this incident for crew training.
This mob will most likely use this event as an internal training tool on how to successfully conduct this practice. After all their internal investigation said they followed procedure, so the cancer will spread to other crews and we will be back here shortly with another instalment of similar behaviour!
Last edited by PoppaJo; 5th Jan 2020 at 01:02.
A good comparison of how well this can be handled was the Jetstar 787 Engine Shutdown near Darwin. A lot of operators globally use this incident for crew training
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Heard a sim instructor say he was teaching 2 cadets who could not read or understand English very well . Translator was supplied by airline . They cancelled any caution as not important and a warning was handled by learning the shape of letters on ecam and what response was required . The report suggested it would be easier to train translator to fly !
Not AirAsia
Not AirAsia
Darwin was was the erratic airspeed which was the example being used at other operators on a well handled manual decent and landing.
I don’t agree with many of the statements in the ATSB report. EDTO has lots of grey areas as the ICAO SARPS simply cannot be prescriptive for all situations. The report suggests the author only has a basic idea how ETDO rule times for an airframe are published/calculated, and then actually applied in practice if a failure occurs.
The rule distance for the first hour are different to the second hour etc. These are defined under the operators certificate and varies between airlines. Crews are under no obligation to reach a diversion airport within the maximum approved time.
My biggest criticism of the report is the apparent lack of understanding of the aircraft weight, fuel system (no fuel dump), and drift down profile of the A330. It will take around 90 minutes for a single engine drift down from FL380 at green dot. At the end of the drift down they would be TOD for MEL
An immediate diversion to ASP would result in an unplanned overweight landing onto a shorter runway at night at higher density altitude with reduced flap setting at an airport they never operate into.
I don’t agree. I would be more critical if the crew rushed a diversion decision without considering all available information.
Amber LAND ASAP means CONSIDER landing at the nearest suitable, it does not mean land at the nearest. The report clearly indicates the crew did consider ASP, and the chose not to go there which is entirely their operational decision to make.
The normal procedure is to have MCT on the other, auto thrust off, set green dot for the speed.
The rule distance for the first hour are different to the second hour etc. These are defined under the operators certificate and varies between airlines. Crews are under no obligation to reach a diversion airport within the maximum approved time.
My biggest criticism of the report is the apparent lack of understanding of the aircraft weight, fuel system (no fuel dump), and drift down profile of the A330. It will take around 90 minutes for a single engine drift down from FL380 at green dot. At the end of the drift down they would be TOD for MEL
An immediate diversion to ASP would result in an unplanned overweight landing onto a shorter runway at night at higher density altitude with reduced flap setting at an airport they never operate into.
I don’t agree. I would be more critical if the crew rushed a diversion decision without considering all available information.
Amber LAND ASAP means CONSIDER landing at the nearest suitable, it does not mean land at the nearest. The report clearly indicates the crew did consider ASP, and the chose not to go there which is entirely their operational decision to make.
The normal procedure is to have MCT on the other, auto thrust off, set green dot for the speed.
Last edited by swh; 5th Jan 2020 at 09:21.
I know what it is.
I just find it hard to believe that an A330 with about 5 hours to go to destination would have sufficient excess power to remain at altitude for 4-5 minutes. And did they have MCT on the other at that point?
Only half a speed-brake
It is an EPR limit not a N1 limit. As both engines are still operating, autothrust is still active while in one is CLB and the other in IDLE. Autothrust would deliver up to the EPR limit value associated with the CLB thrust rating mode to maintain the speed target. As you suggested at that sort of cruise level a change of thrust rating mode from CLB to MCT or even TOGA would not change the EPR limit value.
Outcome, probably not a great deal. Mindset...quite different. One is "I'm having a play with the engines", whilst the other is "I have an engine failure".
And there is a discussion of the system behaviour here, in relation to another incident:
A320 x A330 Alpha Floor Activation During Cruise
And there is a discussion of the system behaviour here, in relation to another incident:
A320 x A330 Alpha Floor Activation During Cruise
Last edited by mrdeux; 5th Jan 2020 at 22:11.
Hear, hear. A bog standard engine failure should not take this long to investigate. Anywhere. But in particular in Australia. Isn't safety everyone's No. 1 priority?
