Afriqiyah Airbus 330 Crash
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If ever there was a warning as to the importance of putting correctly constituted crews with the appropriate competence, currency, experience and training in the cockpit of a commercial airliner, this was it. If you select your crews on the basis of who knows Col Gaddafi, his wife, her tennis partners or their beach mates then this is what happens. Flying in marginal conditions is tricky enough for the most competent - why make it more difficult by placing numpties in the cockpit who are partially trained and regulated. Sadly, it will not be the last time we read of crashes involving crazy countries and their poorly-selected and half-trained pilots.
Sadly, it will not be the last time we read of crashes involving crazy countries and their poorly-selected and half-trained pilots.
Sadly, there is nothing new to learn from this accident. It's just a re-hash of previous badly managed and flown flights, that received the final blow from simple and well known illusion.
Even worse, opportunity of re-learning some old lessons that got forgotten will be missed by those ascribing the accident just to awful safety culture in Libya, assuming such-a-thing-can-not-happen-to-oh-so-enlightened-us. Upside of such an attitude is, unlike AF447, this thread won't get much attention from conspiracy theorists trying to deflect the blame from crew to aeroplane, but it's such a terribly small one.
For those having trouble downloading the four sections of the report, (including us Canadians, Capn Bloggs 
), just right-click on the link and select "Save Link As...". Save them and use the usual double-click to open them.
), just right-click on the link and select "Save Link As...". Save them and use the usual double-click to open them.
One shocking aspect is that this same crew flying the same aircraft and on the same approach exactly two weeks before, completely messed it up in a very similar way (descending too early and triggering a terrain warning). The main difference was that they did not crash, but they did bust all sorts of limits on the very poorly flown go around. Based on those two flights the amazing thing is that in their combined twenty thousand hours they did not kill themselves earlier. This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible.
"This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible"
Airline managements generally believe accidents won't happen to them. My bet is not one senior manager nor one executive of any major carrier actually reads an accident report. It always happens to the other airline.
However, this report should be required reading for airline managements who don't/won't implement flight data analysis & monitoring programs.
Had the previous unstable approach been picked up in the data and the crew contacted, (due to the serious nature of the events including EGPWS warnings), perhaps this accident would not have occurred. As it is, Afriqiyah's FDA Program was not operational and the previous approach by this crew was not examined.
Airline managements generally believe accidents won't happen to them. My bet is not one senior manager nor one executive of any major carrier actually reads an accident report. It always happens to the other airline.
However, this report should be required reading for airline managements who don't/won't implement flight data analysis & monitoring programs.
Had the previous unstable approach been picked up in the data and the crew contacted, (due to the serious nature of the events including EGPWS warnings), perhaps this accident would not have occurred. As it is, Afriqiyah's FDA Program was not operational and the previous approach by this crew was not examined.
Last edited by PJ2; 28th Feb 2013 at 20:35.
As the aircraft lost height the terrain-awareness system issued a succession of sink and ground-proximity warnings. But the captain responded with a "sharp" nose-down input, says the inquiry, adding that he might have been subject to somatogravic illusion or was similarly focused on the A330's speed.
He then took control of the aircraft, without warning, via the sidestick priority button and maintained the nose-down input, while the first officer was simultaneously - and in vain - pulling back on his own sidestick.
He then took control of the aircraft, without warning, via the sidestick priority button and maintained the nose-down input, while the first officer was simultaneously - and in vain - pulling back on his own sidestick.
We would need to contact the guys and ask them what they thought...
But then we need to enhance the hearing to invite also pilots from Colgan Air, AF447, etc.
But then we need to enhance the hearing to invite also pilots from Colgan Air, AF447, etc.
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This report should be required reading for all airline executives who think pilots should be sourced and trained as cheaply as possible.
I think it would also be useful for all potential passengers to also read this kind of report
It certainly will not appeal to companies .. and introductory sessions for passengers to overcome their fear of flying .. will certainly be sought ..
I Have Control
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Abundant nonsense.
A lot of confusion here, coming from folks who clearly do not fly for a living.
Good pilots always read accident reports, which are always circulated and studied by Safety Departments of good airlines.
Passengers will not benefit from reading such reports, unless they are dumbed down for layman comprehension. They will only misinterpret much technical information, having not been trained as pilots.
You can't pull down and pull up! That is possibly the very first lesson a student pilot learns. (Effects of Controls)
As an aside, like space pig I flew for a while in Libya on A320's alongside Libyan Captains and FO's. Most of them were appalling, and very quickly were taken off the line. And many more were chopped in sim training. They simply lacked the technical abilities to understand and consequently fly these advanced automated aircraft. Their CRM was non-existent. The Libyan Cabin Crew (all male) were equally dodgy, but more pleasant people.
Good pilots always read accident reports, which are always circulated and studied by Safety Departments of good airlines.
Passengers will not benefit from reading such reports, unless they are dumbed down for layman comprehension. They will only misinterpret much technical information, having not been trained as pilots.
You can't pull down and pull up! That is possibly the very first lesson a student pilot learns. (Effects of Controls)
As an aside, like space pig I flew for a while in Libya on A320's alongside Libyan Captains and FO's. Most of them were appalling, and very quickly were taken off the line. And many more were chopped in sim training. They simply lacked the technical abilities to understand and consequently fly these advanced automated aircraft. Their CRM was non-existent. The Libyan Cabin Crew (all male) were equally dodgy, but more pleasant people.
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Spoke to the TRE who failed exactly this crew in the sim only to be overridden by his local counterpart. Met him shortly after the accident.
One of the reasons he quit.
One of the reasons he quit.
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Other view
I can't fathom why a pilot would respond to GPW wit a sharp nose done input... ?!
Read up on somatogravic illusion phenomena, Appendix 6 in part of the report.
I guess he misunderstood the situation, and thought that they were stalling, sow he imputed an aggressive nose down command to recover from that illusory stalling!
Note that this is another CFIT, where bad communication between pilots, bad instrument skills, and overall tiredness should have played an important role.
I also think that a good envelope protection in a airplane should prevent things like this !!! The speed was ok to maintain airplane flying the airport was relatively far, so i guess that a well done envelope should override captain’s disastrous inputs !
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Tripoli response
Here you can read the response of the Dutch Safety Board on the Tripoli crash.
It's another sad example how things go wrong in an aviation world were these things still occur, when will we ever learn...... Ofcourse a lot of responses will appear in the next weeks and many will confess that this will never happen to them, however it happened again. When will we ever learn.....
http://www.onderzoeksraad.nl/docs/ra...vV_1250152.pdf
It's another sad example how things go wrong in an aviation world were these things still occur, when will we ever learn...... Ofcourse a lot of responses will appear in the next weeks and many will confess that this will never happen to them, however it happened again. When will we ever learn.....
http://www.onderzoeksraad.nl/docs/ra...vV_1250152.pdf
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Clandestino - I would draw your attention to the informed comments of RoyHudd who has genuine first hand experience of the situation. Every nation on Earth has its fair share of imbeciles who should never, ever darken the door of a complex commercial aircraft like an Airbus. The difference between the western and non-western world is that, generally speaking, the western world has selection processes in place to ensure the pilots selected to fly these machines, particularly the captains, are fundamentally competent to do so. Sure, there will be notable exceptions, but they are few and far between.
I spoke to a European FO who did a contract at Afriqiyah, and let me tell you his observations. He said that it was an accident waiting to happen and everyone knew it. Basically, they re-equipped with Airbuses but had no Libyans to fly them. This was due to years of sanctions and the fact that some Libyan pilots had not flown for more than ten years. Not to worry, they could employ westerners - which they did. As soon as a Libyan got the absolute minimum hours for command they booted out a westerner and replaced him by a Libyan. This was part of the 'Libyanisation' of the company in the best traditions of such nations. There was no real training department, and all checks were done on a pass/fail basis by outside agencies at various sim centres round Europe - ie no marks were awarded as would be the case elsewhere so managers, even if they cared, could not pick up trends and minimum level passes etc. A go-around was regarded as an 'emergency manoeuvre' that was tantamount to failure. Therefore to actually find yourself in one was a big deal - again very different to most western companies where a properly-executed go-around is a non-event in terms of management perception. One day it became apparent that no one was LVO qualified - the next week every single pilot received a certificate in his drop file to formally qualify them for LVOs. It certainly is one way of avoiding all that nasty training cost associated with LVO training. The final observation he made was that selection of Libyan pilots was almost exclusively on who you knew and absolutely nothing to do with ability. He said the Libyan pilots, particularly the FOs, were idle layabouts who made no effort to improve their professional knowledge or standard of English. They were an embarrassment but were kept on because they could not be seen to lose face and bin them.
If these tales are true, and I have no doubt they are, we should not be the slightest surprised at what happened on this flight. Some people reading this will be offended and see this as anti-Libyan or anti-Arab. My statement to them would be that this is factual, as is the appalling report just released. I have one glimmer of hope here - the fact that such a dreadful flight has been released into the public domain is a little sign that someone, somewhere in Libya may actually have a sniff of professionalism and want this never to happen again. More importantly, they may even take action to ensure it does not happen again.
I spoke to a European FO who did a contract at Afriqiyah, and let me tell you his observations. He said that it was an accident waiting to happen and everyone knew it. Basically, they re-equipped with Airbuses but had no Libyans to fly them. This was due to years of sanctions and the fact that some Libyan pilots had not flown for more than ten years. Not to worry, they could employ westerners - which they did. As soon as a Libyan got the absolute minimum hours for command they booted out a westerner and replaced him by a Libyan. This was part of the 'Libyanisation' of the company in the best traditions of such nations. There was no real training department, and all checks were done on a pass/fail basis by outside agencies at various sim centres round Europe - ie no marks were awarded as would be the case elsewhere so managers, even if they cared, could not pick up trends and minimum level passes etc. A go-around was regarded as an 'emergency manoeuvre' that was tantamount to failure. Therefore to actually find yourself in one was a big deal - again very different to most western companies where a properly-executed go-around is a non-event in terms of management perception. One day it became apparent that no one was LVO qualified - the next week every single pilot received a certificate in his drop file to formally qualify them for LVOs. It certainly is one way of avoiding all that nasty training cost associated with LVO training. The final observation he made was that selection of Libyan pilots was almost exclusively on who you knew and absolutely nothing to do with ability. He said the Libyan pilots, particularly the FOs, were idle layabouts who made no effort to improve their professional knowledge or standard of English. They were an embarrassment but were kept on because they could not be seen to lose face and bin them.
If these tales are true, and I have no doubt they are, we should not be the slightest surprised at what happened on this flight. Some people reading this will be offended and see this as anti-Libyan or anti-Arab. My statement to them would be that this is factual, as is the appalling report just released. I have one glimmer of hope here - the fact that such a dreadful flight has been released into the public domain is a little sign that someone, somewhere in Libya may actually have a sniff of professionalism and want this never to happen again. More importantly, they may even take action to ensure it does not happen again.
Dog Tired
Endorsed.
In the 320 sim with the fleet manager conducting and me, left seat, with f-w FO (won't mention the country, but Arab) in the right seat, the FM smacked me on the head and said: 'the next mistake he makes, I'm gonna blame you'.
It's all to do with 'saving face'. Don't ask.
True story.
In the 320 sim with the fleet manager conducting and me, left seat, with f-w FO (won't mention the country, but Arab) in the right seat, the FM smacked me on the head and said: 'the next mistake he makes, I'm gonna blame you'.
It's all to do with 'saving face'. Don't ask.
True story.
Last edited by fantom; 1st Mar 2013 at 15:42.
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Capn Bloggs:
Upon the advice of a friend I downloaded the latest version of Acrobat Reader. Problem solved.
You must be Amercian, Terps. I only downloaded the first part and it opened OK. Hit the ground doing 260KIAS at -4400ft/min sink, captain on the controls. 
CATIIIBnoDH, Kalium Chloride, thank you for posting links to these valuable documents and presentations concerning this accident. They provide support for impressions left upon reading the accident report that the organization's safety processes, standards / training / checking processes and internal as well as regulator oversight processes which are expected to be part of airline operations were in fact minimal or entirely absent.
The Dutch Safety Board response, dated November 29, 2012 to the CAA's draft report is respectful of the fact that the report was produced under challenging circumstances. The Dutch Safety Board correctly observes however, that the report provides only limited discussions concerning these factors.
Some have commented that there is nothing to learn from this accident because we've seen it all before and some have even cited other accidents such as Colgan and AF447. The thing most obviously remaining to learn is of course, that there remains things to learn because this kind of accident happened again.
Elsewhere in PPRuNe there is a discussion on CRM, and the view expressed that it is over-rated because "good pilots" always already practice good communications naturally. While I agreed that pilots who were deemed good at their job were also good communicators, not all cultures practice communications and personal relationships in the same way particularly in command-and-control circumstances and so the formalization of communications techniques which convey important safety information in a timely manner either in the organization or the cockpit in neutral but effective ways is sometimes needed, as is clearly demonstrated in this accident.
Flight data analysis is also very briefly mentioned in the report but the program was not functioning at the airline, (nor was FOQA implemented/functioning at Colgan prior to their Buffalo accident and my bet is that it still isn't operational...another thread). This is the clearest example of the value of data analysis by trained, experienced people who know flying. The fact that the same crew did the same thing two weeks prior to the accident and the airline did not know is, I think, inexcusable in modern transport operations.
I look forward to the Dutch Safety Board's further responses to the CAA's limited work.
Artic flyer, interesting view because it sets aside the notion of "somatogravic" as a root cause and forces examination of other factors which come under the general heading of 'competence'.
The Dutch Safety Board response, dated November 29, 2012 to the CAA's draft report is respectful of the fact that the report was produced under challenging circumstances. The Dutch Safety Board correctly observes however, that the report provides only limited discussions concerning these factors.
Some have commented that there is nothing to learn from this accident because we've seen it all before and some have even cited other accidents such as Colgan and AF447. The thing most obviously remaining to learn is of course, that there remains things to learn because this kind of accident happened again.
Elsewhere in PPRuNe there is a discussion on CRM, and the view expressed that it is over-rated because "good pilots" always already practice good communications naturally. While I agreed that pilots who were deemed good at their job were also good communicators, not all cultures practice communications and personal relationships in the same way particularly in command-and-control circumstances and so the formalization of communications techniques which convey important safety information in a timely manner either in the organization or the cockpit in neutral but effective ways is sometimes needed, as is clearly demonstrated in this accident.
Flight data analysis is also very briefly mentioned in the report but the program was not functioning at the airline, (nor was FOQA implemented/functioning at Colgan prior to their Buffalo accident and my bet is that it still isn't operational...another thread). This is the clearest example of the value of data analysis by trained, experienced people who know flying. The fact that the same crew did the same thing two weeks prior to the accident and the airline did not know is, I think, inexcusable in modern transport operations.
I look forward to the Dutch Safety Board's further responses to the CAA's limited work.
Artic flyer, interesting view because it sets aside the notion of "somatogravic" as a root cause and forces examination of other factors which come under the general heading of 'competence'.
Last edited by PJ2; 1st Mar 2013 at 16:25.
This accident is similar to incidents 2, 3, 5, and 6 with respect to the early descent and failure to crosscheck altitude against distance (DME) or the locator check altitude. Again note the lack of an altitude / distance table (charted or operator provided).
These contributed the surprise of the unexpected EGPWS alert, where the problems of the GA started.
These contributed the surprise of the unexpected EGPWS alert, where the problems of the GA started.
