Air Asia Indonesia Lost Contact from Surabaya to Singapore
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Again, blame the dead - flight crew action resulted in inability to control the aircraft ...
Final report is released:
http://kemhubri.dephub.go.id/knkt/ntsc_home/ntsc.htm
JAKARTA - REUTERS, Indonesian investigators said on Tuesday that crew action caused a loss of control and the stalling of an AirAsia passenger jet that crashed into the Java Sea last year, killing all 162 aboard.
The plane's flight control computer had a cracked solder joint that malfunctioned repeatedly, including four times during the flight, and 23 times the previous year.
"Subsequent flight crew action resulted in inability to control the aircraft ... causing the aircraft to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover," the national transport safety committee said in a statement.
The plane's flight control computer had a cracked solder joint that malfunctioned repeatedly, including four times during the flight, and 23 times the previous year.
"Subsequent flight crew action resulted in inability to control the aircraft ... causing the aircraft to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover," the national transport safety committee said in a statement.
http://kemhubri.dephub.go.id/knkt/ntsc_home/ntsc.htm
I think this quote from the report sums it up:
The Upset Recovery training was included in the aircraft operators training manual. The aircraft operator advised the KNKT that the flight crew had not been trained for the upset recovery training on Airbus A320, and this referred to FCTM Operational Philosophy: “The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus”. There was no evidence of DGCA findings for this incompliance of training.
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Summary:
- Aircraft had a history of numerous Rudder Travel Limiter Unit faults which were never resolved
- During the accident flight, the crew received three consecutive Master Cautions related to the RTLUs, which they cleared via ECAM actions
- After a fourth Master Caution, FAC 1 & 2 were reset by pulling the Circuit Breakers
- The aircraft went to Alternate Law
- Aircraft rolled 54 degrees left
- FO applied sidestick input to roll right and pitch up
- FO continued to pitch up as the aircraft zoomed to 38,000 ft at 11,000 fpm
- Aircraft entered a stall
- FO continued to apply maximum pitch up (until the end of recording)
- Captain attempted to take over by pressing the left-sidestick priority button for 2 seconds (*)
- DUAL INPUT activated and the aircraft continued to pitch up
- Captain attempted another take over by pressing the sidestick priority button for 2 seconds (*)
- Aircraft recorded lowest speed of 55 kts, 104 degrees left roll, and then descended at up to 20,000 fpm until the end of recording
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"Issues such as flight approval considered did not contribute to the accident and was not investigated. The FDR data did not show any indication of the weather condition affecting the aircraft."
In the earlier discussion in this thread there was a feeling that bad weather was a significant factor.
In the earlier discussion in this thread there was a feeling that bad weather was a significant factor.
wheels down
If we are honest, I don't think anyone has done a particularly good job with UPRT or extended stall envelope so far, whether it be regulators, OEMs, Training Organisations, TDMs or Airlines. Lots of talk , many committees etc these past years but not much concrete action.
Organisations such as ICATEE have been around for a long, long time now yet there is very limited progress at the delivered end of the training business.
How many crews today could really state they have received comprehensive UPRT or stall training? I would hazard a guess that not that many.
To sum up the report in three words.
Rubbish Training standards. In all corners of their business.
Rubbish Training standards. In all corners of their business.
Organisations such as ICATEE have been around for a long, long time now yet there is very limited progress at the delivered end of the training business.
How many crews today could really state they have received comprehensive UPRT or stall training? I would hazard a guess that not that many.
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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 ...
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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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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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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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?
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.
Originally Posted by Right Way Up
Resetting FACs by CB inflight......not sure I have seen that written down anywhere?
@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.
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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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!
A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft into the bloody drink from FL380!
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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.
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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Cripple,
There seem to be a few red herrings here. The important stuff seems to be:
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?
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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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!
A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft into the bloody drink from FL380!
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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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Originally Posted by Ranger One
A pair of ATPLs should be able to avoid stalling a basically serviceable aircraft
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?
Stall Warnings
from page 108
First Warning
Second Warning
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?
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.
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.
