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Air Asia Indonesia Lost Contact from Surabaya to Singapore

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Air Asia Indonesia Lost Contact from Surabaya to Singapore

Old 1st Dec 2015, 07:40
  #3401 (permalink)  
 
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Hi,

Summary:
Remake AF447
Not the same root cause .. but the same effects
Pull on the joystick with stall alarm all the way down ....
How many deaths will be needed for that ...
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Old 1st Dec 2015, 07:47
  #3402 (permalink)  
 
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Resetting FACs by CB inflight......not sure I have seen that written down anywhere?
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Old 1st Dec 2015, 08:02
  #3403 (permalink)  
 
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I'm not an A'bus pilot (Boeing only)but I'd be keen to know what the QRH / ECAM response should have been to this repeated warning? I'm pretty sure it isn't to reset a CB in flight.
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Old 1st Dec 2015, 08:04
  #3404 (permalink)  
 
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Originally Posted by Right Way Up View Post
Resetting FACs by CB inflight......not sure I have seen that written down anywhere?
Spot on. UPRT training (or lack of) is a red herring. Better UPRT could have allowed the crew to recover but there was no reason for the aircraft to end up in that position in the first place.

By use of this non standard cb reset on BOTH FACs, this crew (for whatever reason) put the a/c into ALTN LAW and their inputs subsequently put it into a position from which they could not recover.

In fact, not only is the FAC reset not included in the computer reset QRH table, the table also says (in a big red box) - WARNING DO NOT RESET MORE THAN ONE COMPUTER AT A TIME.

The RTLU fault is a non event. Following the ECAM drill would have stopped the nuisance cautions and the a/c would have been Cat 3A and perfectly flyable. Unless you need Cat 3B, why even try a reset? Especially after 3 previous faults that flight?

The aircraft remained perfectly flyable even after the crew actions disabled the FACs and after they lost control - at this point, UPRT became a potential factor - primarily for the FO though as it appears the CA was trying to make appropriate inputs to recover.

Ultimately though, if the crew had done nothing about the minor RTLU fault, the aircraft would not have crashed.

Last edited by Cripple; 1st Dec 2015 at 08:42.
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Old 1st Dec 2015, 08:45
  #3405 (permalink)  
 
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Originally Posted by tripilot
I'm not an A'bus pilot (Boeing only)but I'd be keen to know what the QRH / ECAM response should have been to this repeated warning?
The correct ECAM response is on page 15 of the report: reset both FACs, using the pushbuttons on the overhead panel.

Originally Posted by Cripple
The RTLU fault is a non event. Following the ECAM drill would have stopped the nuisance cautions and the a/c would have been Cat 3A and perfectly flyable.
Between 2300 and 2315, they suffered four failures of the RTLU, the time between the events decreasing from 9 to 4 and then 2 minutes. That's a lot of nuisance.

Originally Posted by Right Way Up
Resetting FACs by CB inflight......not sure I have seen that written down anywhere?
But when you consider the ground troubleshooting episode three days earlier that is described on pg. 21, it is understandable why the captain, in his growing frustration, decided to try it.
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Old 1st Dec 2015, 08:53
  #3406 (permalink)  
 
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@Cripple I wouldnt say its a red herring

Although clearly the crew contributed/created the upset, their inability to recover the plane - similar to AF447 - is of grave concern.


Originally Posted by peekay4
FO continued to apply maximum pitch up (until the end of recording)
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Old 1st Dec 2015, 09:10
  #3407 (permalink)  
 
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It shouldn't bloody matter how many computers you reset, in what order, or why, or what 'law' you end up in as a result.

A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft into the bloody drink from FL380!
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Old 1st Dec 2015, 09:14
  #3408 (permalink)  
 
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In fact, not only is the FAC reset not included in the computer reset QRH table, the table also says (in a big red box) - WARNING DO NOT RESET MORE THAN ONE COMPUTER AT A TIME.
As usual in most accidents, nothing is quite so simple.

1) The reset table in the QRH isn't limiting. The table only provides information about which computers are most prone to be reset. It does not mean other computers cannot be reset. The FAC is not listed among computers which are not allowed to be reset, and the caution against pulling certain CBs also do not list the FAC CBs.

2) The Captain did not reset both FACs at once. In fact he did them sequentially. FAC 1 was pulled at 2316:29 UTC and was re-energized by 2316:39. FAC 2 CB was only pulled seven seconds later, at 2316:46.

Unfortunately, even though FAC 1 had been re-energized, it was still inactive. Resetting the CB was not sufficient to reactivate the FAC, since the FAC's overhead pushbutton must also be toggled to OFF and then back to ON.

So even though the Captain had restored power to FAC 1, and its pushbutton was at the "ON" position, FAC 1 remained unavailable. When FAC 2 CB was pulled, the aircraft went into Alternate Law.
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Old 1st Dec 2015, 09:15
  #3409 (permalink)  
 
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Cripple,

There seem to be a few red herrings here. The important stuff seems to be:
  • They pulled the CBs (what were they thinking?).
  • Both watched the aircraft roll for 9 seconds to 54° without doing anything.
  • The FO zoom climbed with controlled (not full) backstick.
  • The CP is calling Pull Down repeatedly. The fatal language error?
  • From the stall, the CP is applying full roll with modulated pitch, the FO is applying full back stick with modulated roll.
  • The "stall stall" and "dual input" continue to the impact, with no effect on the crew.

The report is quick to point out that the FO is applying incorrect inputs, but reluctant to report that the CP is doing the same. They key graph is on page 51, with STKPC (decode: stick, pitch, capt).

I'm starting to think that we need to change the stall warning from "STALL STALL" "STALL whoop whoop PUSH DOWN". Or does the industry need a third full-backstick-until-impact event before we make changes?
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Old 1st Dec 2015, 09:27
  #3410 (permalink)  
 
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Originally Posted by Ranger One
It shouldn't bloody matter how many computers you reset, in what order, or why, or what 'law' you end up in as a result.

A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft into the bloody drink from FL380!
+1 What he said.
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Old 1st Dec 2015, 09:32
  #3411 (permalink)  
 
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I’m not an airline pilot but a medic. In the end result, this is a similar crash to AF447 in that there was a very distracted crew in an aeroplane that had its automatic protections off, who were then unable to recognise a pilot induced stall and kept the plane in a stalled condition until it crashed. I can’t believe that experienced pilots don’t know about stalling. There will be other human factors involved such as psychological barriers in a crisis to accepting that the familiar rules have just changed, and that a normally “unstallable” aeroplane might, on this occasion, be doing just that. This should be considered as a training issue.
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Old 1st Dec 2015, 09:37
  #3412 (permalink)  
 
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Originally Posted by Ranger One
A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft
Of course they should. And no doubt this thread will gain many more posts saying the same thing.

But the constructive question is: why did two pilots, qualified to the levels the industry requires, fail to do what they were required to do?

Why?

That's the question that needs to be answered, and then the problem addressed. It's no good saying "idiots, move on".

Is there an issue with non-yoke inexperienced pilots just pulling up when in trouble (training conditioning from W/S, GPWS etc)? Are these problems caused by a complete lack of high altitude flight training? Is this a language/culture issue? Startle? Fatigue?
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Old 1st Dec 2015, 09:56
  #3413 (permalink)  
 
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Stall Warnings

from page 108

First Warning
Following the pitch up input on the right side stick, the aircraft continued climb then at 2316.56 the stall warning activated. ... the right side stick was at neutral then moved forward for two seconds. It caused the AOA decreased below 8°, and the aural stall warning stopped.
Second Warning
One second after the first stall warning ceased, the right side stick command was at 12° backward causing the aircraft pitch up and climbing at a rate up to 11,000 feet/minute.
The FDR recorded that after the first stall warning, the right side stick input was consistently backward. Could the PF become so fixated on levelling the wings that he was oblivious to pitch?
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Old 1st Dec 2015, 09:57
  #3414 (permalink)  
 
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Hierarchy?

It's strange. So many times posters on PPRuNe have pointed out accidents caused by the strictly hierarchical structure of Asian society.

Yet here we have an accident which could have been prevented by the captain telling the FO "I have control", instead of fighting between the two sidesticks.

Why?

Last edited by marchino61; 1st Dec 2015 at 10:17. Reason: Corrected typo: sp -> so
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Old 1st Dec 2015, 10:06
  #3415 (permalink)  
 
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Dual Input

instead of fighting between the two sidesticks.
Of note in the report,

When both pilots move both sidesticks simultaneously in the same or opposite direction and neither takes priority, the system adds the signals algebraically.
When this occurred, the two green Side Stick Priority lights are ON and followed by “DUAL INPUT” voice message activation.
However, the CVR did not record “DUAL INPUT” voice message as it was suppressed by “STALL” voice warning.
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Old 1st Dec 2015, 10:09
  #3416 (permalink)  
 
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But when you consider the ground troubleshooting episode three days earlier that is described on pg. 21, it is understandable why the captain, in his growing frustration, decided to try it.
I have to strongly disagree. He made what was an annoyance into a fatal accident by becoming a test pilot. It would be in the inflight reset list if it was a sensible procedure.

From the QRH
inflight,as a general rule, the crew must restrict computer resets to those listed in the table,or to those in applicable TDUs or OEBs. Before taking any action on other computers, the flight crew must consider and fully understand the consequences.
In this case if it was really annoying emergency cancel the caution then ground the aircraft after landing.
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Old 1st Dec 2015, 10:14
  #3417 (permalink)  
 
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Has anyone explored whether the FO in this accident and the FO of AF447 may have trained on the same programme given their nationalities? Unlikely but a slim possibility.
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Old 1st Dec 2015, 10:16
  #3418 (permalink)  
 
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However, the CVR did not record “DUAL INPUT” voice message as it was suppressed by “STALL” voice warning.
Surely that should not be necessary? All the captain has to do is declare he has control of the aircraft. It's fairly obvious that he knew what to do and the FO didn't.

Could there be some unusual dynamic here, e.g. the Indonesian captain somehow feels inferior to the European FO? Surely not.
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Old 1st Dec 2015, 10:22
  #3419 (permalink)  
 
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because...

why did two pilots, qualified to the levels the industry requires, fail to do what they were required to do?
Because of the level of the industry.

Upset recovery training is new to the industry, post-AF447. As is the strong enphasis of the "I have control" magical words (think: proper task sharing and cross-cockpit communication), that may have saved that day.
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Old 1st Dec 2015, 10:56
  #3420 (permalink)  
 
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That's the point.

Is this the time where we have to have a long hard look at where pilots come from and what is "adequate" in terms of ability, training and experience? Or is it a function of the fact that aircraft now are so reliable, that exposure to things going wrong for real is so small that pilots are not able to cope?

In the past, aircraft were less reliable, so we all had exposure (horribly regular) to things going wrong. Now it is common to achieve command without a diversion or a circling approach. Let alone the a/p dumping you into a state with lots of untrimmed yaw.

My thoughts are that this has to be addressed in the sim. More sim time, and most importantly, less of the prescribed statutory "events" and more random stuff with a focus on initial actions. Once the startle is overcome and the initial quick diagnosis and initial actions done correctly, there is a much greater chance of a successful outcome.

Sim, sim, sim. Sadly though, the mantra is cost, cost, cost.
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