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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, 17:24
  #3441 (permalink)  
 
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Unless something has changed in the last four years, tdracer is correct, I too was surprised to find that while avionics equipment is exempt from the requirement to use lead-free solder, the use of leaded is not mandated.

The main concern always quoted was 'tin whisker' growth but brittle joints are, in my experience anyway, a much bigger issue, especially in a relatively high vibration environment.

If this was one of the causal factors in this event, you would like to think the powers that be will look at the subject again.
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Old 1st Dec 2015, 17:45
  #3442 (permalink)  
 
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The report leaves a huge gap in events for some reason.
Nothing on the CVR "apparently" & the 9 secs before recognition of the roll.

Wonder why no mention of the fact that pilots can not reach the CB for no2 FAC without getting out of the seat..

So did the Capt. just get up and pull the breakers without telling the F/O what he was up to. So F/O was looking at him wondering what he was doing ?
Or did the F/O unstrap & pull the breaker "on Capt Req" again no one monitoring the PFD.

So if you were not monitoring the PFD & suddenly saw it "all over the place" you may request Capt to 3 to have a look at the PFD indication from that source.

I've only read through the report once so please correct me if I am wrong but seems odd that no mention of how the CB's were Pulled/Re-set.
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Old 1st Dec 2015, 17:48
  #3443 (permalink)  
 
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As for practising high level stall recovery: On what? No sim I ever used had the relevant algorythems for high level characteristics. The sim handled the same at low level or high level, whereas the A/C certainly does NOT.
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Old 1st Dec 2015, 18:51
  #3444 (permalink)  
 
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Unless something has changed in the last four years, tdracer is correct, I too was surprised to find that while avionics equipment is exempt from the requirement to use lead-free solder, the use of leaded is not mandated.
The reason for this is simply that avionics are such a small market (compared to the general electronics industry) that whilst we're *allowed* to use leaded solder there are very few assembly plants that maintain the equipment to use it. They're not about to switch over to leaded solder (with the attendant clean-down, changing of fluxes and solvents, changes to speeds & temperatures) for the very limited run of avionic equipment that may be demanded.

0.03 supplied,

PDR
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Old 1st Dec 2015, 19:11
  #3445 (permalink)  
 
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@tdracer
Perhaps a different method of stall warning is in order - during high stress/workload, the human mind tends to shut out aural 'distractions' - perhaps the "STALL, STALL, STALL" isn't getting through?
At some point, a stick pusher might even be considered. Heresy, I know.

@IcePack
Wonder why no mention of the fact that pilots can not reach the CB for no2 FAC without getting out of the seat.
That is mentioned, in the Findings section, item #29 on page 119.

The Indonesians were somewhat conservative in writing this Final Report -- leaving out aspects which they could not prove or defend.

E.g., there probably was a short exchange between the Captain and the FO prior to the circuit breakers being pulled. But the conversation recorded on the CVR was unintelligible, so it was left out from the CVR transcript.
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Old 1st Dec 2015, 19:21
  #3446 (permalink)  
 
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Solder joint.

I'm sorry, have not read the report.


Was the defective solder joint on the rack side of the connector or on the FAC side of the connector or not on the connector at all?
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Old 1st Dec 2015, 19:29
  #3447 (permalink)  
 
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The report is well crafted and reflects a thorough investigation; furthermore the authors consider some speculative aspects from which we might learn. Obviously it can be read and interpreted in different ways, but there are aspects that could be applied to future activities.

I was surprised that there was not greater focus on the pitch trim which could have resulted in a nose-up moment complicating stall recovery. There may be similarities here with AF447; the condition is not a deep stall but one of a trimmed-in stall. If a separate warning is required it should be for an adverse trim condition at the stall.
Differences with FBW aircraft may be the lack of stick shake when approaching the stall, and stick push at the stall; a conventional tactile interface is more attention-getting than aural alerting during surprising and high workload situations.

Stall training in conventional aircraft use (should use) fixed trim whereby the speed of null-control-force feel represents stable, unstalled flight. Stall recovery involves a combination of pitch control force, attitude, and speed indications, forward control movement would be aided by stick push.
In unprotected FBW aircraft there is greater need to focus on attitude to reduce pitch - vice the absence of force feel. Further, if the aircraft is ‘out of trim’ then an off-centre control positon is required to reduce AOA and subsequent speed increase (pitch and yaw off centre in this instance, where the lack of yaw trim also contributed a roll control offset).
I doubt that any of these failures are trained / demonstrated in FBW aircraft or conventional aircraft.

The induced ‘upset’ is puzzling; following the inappropriate system interruption resulting in autopilot disconnect and roll attitude, the control inputs were not as expected (with hindsight). However, if crews normally use a relaxed rearward seat position during cruise with autoflight, then a sudden need for large or rapid manual control could result in unwanted inputs. Reaching for a side stick from an unusual positon would not involve the normal relationship for muscle-arm movement (learned skill), thus a roll input could have a significant pitch component. There could be similar problems with over-control in roll and with the required nose down movement (cf AF447).

The report's discussion of human factors is particularly well presented, but without factual confirmation human activity has to be speculative and carefully considered in context - surprise, knowledge base, and resultant awareness. Just because aspects are ‘easy to see’ after the event does not mean that the crew were in ‘error’, more likely as discussed in the report that the specifics of this particular rare situation and circumstances were at or beyond human ability.

Check trim, check seat position, review the assumptions made in training scenarios.
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Old 1st Dec 2015, 20:29
  #3448 (permalink)  
 
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A second instance where pilots were pulling back on the stick in what appears to be an obvious pitch up/stall situation.

You do have to wonder whether the stick or ac systems have a failure mode where the inputs are reversed!?

I can't imagine a scenario where a pilot would pull back in a pitch up stall. It seems bizarre, no? Isn't this beyond basic? Even basic instinct would surely have you trying to pitch the nose down?
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Old 1st Dec 2015, 20:32
  #3449 (permalink)  
 
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Jack11111.

re solder joint.

It would be inside the FAC. Aircraft wiring pins and sockets in the vast majority of cases are crimped.
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Old 1st Dec 2015, 20:59
  #3450 (permalink)  
 
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Originally Posted by alf5071h View Post
The report is well crafted and reflects a thorough investigation; furthermore the authors consider some speculative aspects from which we might learn. Obviously it can be read and interpreted in different ways, but there are aspects that could be applied to future activities.

. . . .

etc.
As always, a well-written, well-considered contribution to the discussion, alf5071h.
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Old 1st Dec 2015, 21:02
  #3451 (permalink)  
 
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Holes in the swiss cheese that lined up

If 1 or 2 of these issues had been addressed would it have been just another day at the office:

Lack of training.
Regulatory/airline policy
Solder joint fail
Poor error logging and pattern recognition
Pull both RTL CBs against SOP.
Fail to reset overhead ON/OFF as well as pull CB's.
Lack of CRM/cross cockpit communication/call outs.
CAPT "Pull down" verbal response to stall
Startle response
PF lack of situation awareness
ALT LAW vs NORMAL LAW confusion
CAPT side stick override fail
Lack of dual input 'feel'
Dual input warn suppressed by stall
Stall ignored/poor response

Last edited by xcitation; 1st Dec 2015 at 22:13.
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Old 1st Dec 2015, 21:10
  #3452 (permalink)  
 
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Originally Posted by fenland787 View Post
Unless something has changed in the last four years, tdracer is correct, I too was surprised to find that while avionics equipment is exempt from the requirement to use lead-free solder, the use of leaded is not mandated.

The main concern always quoted was 'tin whisker' growth but brittle joints are, in my experience anyway, a much bigger issue, especially in a relatively high vibration environment.

If this was one of the causal factors in this event, you would like to think the powers that be will look at the subject again.
I have worked for a number of small companies who design and sell equipment for both ground and air use, manufacturing is usually subcontract and the problem is finding a subby who will use leaded solder using only non leaded removes the risk of an error by them.

BTW most component appear to have legs/leads which are Rosh (lead free)

Perhaps this is why it does have to be lead free but doesn't stipulate it has to be leaded.
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Old 1st Dec 2015, 21:21
  #3453 (permalink)  

de minimus non curat lex
 
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Airbus will clearly be deeply unhappy about another event which ended in tragedy. Another non normal event which went horribly wrong.
Bottom line ~ training etc.
Certain aspects similar to AF447.

Question: would this be likely to have happened had it been a Boeing?

Airbus far better flight deck, and easier to fly with everything functioning normally.
However, when things start to go wrong, want would you rather be flying?
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Old 1st Dec 2015, 21:35
  #3454 (permalink)  
 
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Airbus will clearly be deeply unhappy about another event which ended in tragedy. Another non normal event which went horribly wrong.
Bottom line ~ training etc.
Certain aspects similar to AF447.

Question: would this be likely to have happened had it been a Boeing?

Airbus far better flight deck, and easier to fly with everything functioning normally.
However, when things start to go wrong, want would you rather be flying?
It's not a question of Airbus vs. Boeing, it's a question of training and the degradation of piloting skills. Have a look at this study. A couple of years old but unfortunate nothing changed so far.
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Old 1st Dec 2015, 22:38
  #3455 (permalink)  
 
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@Parkfell

Certain aspects similar to AF447.

Question: would this be likely to have happened had it been a Boeing?

Airbus far better flight deck, and easier to fly with everything functioning normally.
However, when things start to go wrong, want would you rather be flying?
It boils down to knowing your a/c and not getting behind its situation.
In both this incident and AF447 the central issue appears to be PF failing to adapt/recognize the a/c changing from Normal Law to Alternate Law.
  • In Normal Law with protections a full stick back input is safe/helpful.
  • In Alternate Law a full stick back input is potentially fatal/detrimental.
The biggest strength of airbus being unstallable is turning out to be its biggest weakness i.e. are pilots affected by a denial or state of disbelief when confronted with a stall.
This issue was addressed in AF447 BAE final report. Clearly there is much more to be done to prevent future recurrence of highly experienced bus pilots entering stall and failing to recover.
Airbus is amazingly safe equipment so long as it is not flown into the ground when the protections are turned off.
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Old 1st Dec 2015, 22:53
  #3456 (permalink)  

de minimus non curat lex
 
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The bottom line is that unless you continue to practice your basic skills, your ability to cope will deminish.
Exceed 28 days without a "top up" then the slippery slope begins.
Even those who flew raw data for years before glass cockpit will not maintain their skills. It how the brain works.
Training is critical ~ agreed
Problem is to convince the beancounters that it is a sound investment.
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Old 1st Dec 2015, 23:04
  #3457 (permalink)  
 
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xcitation

With due respect, the problem in this incident was not a failure to recognize a change in law - pulling back on the stick was inappropriate with normal law protections in place or not. The main issue in this accident, as was the case with AF447, is the failure of the PF to recognize that if the aircraft is descending at >10000 ft/min and is not in a dive then it is stalled, and to respond to this appropriately.

Last edited by xyze; 1st Dec 2015 at 23:18.
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Old 1st Dec 2015, 23:10
  #3458 (permalink)  
 
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Lead free solder

I have read that lead free solder has 5% the shock resistance of conventional leaded solder. Leaded solder works fine on the tin plated leads of ROSH integrated circuit packages(better than unleaded). Tin whiskers are a problem with pure tin plating or unleaded solder.
The lead free solder debacle was brought to you by the Commissars in the EU even after it was obvious there were good alternatives to leaded solder. Another case of lunatic "green" policies causing harm.
The EU was worried about disposal of electronic assemblies containing lead. I'd have thought this was a disposal/re-cycling problem but they turned it into an enormous manufacturing/operational problem.
The funny thing is that of all the lead mined, 80% goes in to lead acid batteries, 5% into ammunition, around 5 to 10% in various industrial uses and a whole 1% in electronics. This was figures from 10 to 15 years ago that went around the electronics industry.
Certainly nowadays there is no more lead used in cathode ray tube leaded glass shielding (remember CRT's?) and surface mount components use vastly less solder than do through hole plated components with wires on each end.
I doubt the authorities will mandate leaded solder in aviation as it would contradict the narrative about lead being bad.
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Old 1st Dec 2015, 23:11
  #3459 (permalink)  
 
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Sorry, that should read " NO good alternatives".
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Old 1st Dec 2015, 23:38
  #3460 (permalink)  
 
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PPRuNe back to its usual

Report is quite lacking in explanation of technical matters, it's HF side is even worse, there are pages upon pages of copypasted material with limited connection to the issues investigated, graphs are hard to read and compare, whole enterprise looks like (feeble, I admit) attempt to protect image of well respected aviator who made string of errors that eventually proved to be fatal, recommendations are quite weak. However, I am very pleasantly surprised by the report.

I expected it to be even worse.

At least, now we know what happened, even if we are left wondering why.

Originally Posted by ZFT View Post
How many crews today could really state they have received comprehensive UPRT or stall training? I would hazard a guess that not that many.
Whaddaya think, would former F-5E driver be exposed to comprehensive UPRT and stall training anytime in his career? Yea or nay?

Originally Posted by Cripple View Post
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?
It certainly would not as ECAM actions were done 3 times before resorting to pulling the breakers and I suspect that alert was triggered when both RTLU channels lost power simultaneously. Still, question is valid: "There is problem with RTLU, so what?" Good answer to it requires excellent system knowledge, something mere ECAM operator might be tragically lacking.

Originally Posted by Cripple View Post
it appears the CA was trying to make appropriate inputs to recover.
Originally Posted by marchino61 View Post
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.
Originally Posted by RAT 5 View Post
Here, it seems the captain was trying to do the correct thing with control input, but was thwarted.
CVR transcript is utter disgrace but if the DFDR traces are anything to go by, well, feeble and intermittent nudges forward on the stick are just not appropriate action when faced with horrendous pitchup and stall warning.

Captain was lost too.

Originally Posted by HunderPercentPlease View Post
Is there an issue with non-yoke inexperienced pilots just pulling up when in trouble (training conditioning from W/S, GPWS etc)?
Not so limited. Issue was identified by certain W. Langewiesche in 1944, when the only sidestick around was one on B-17s and that wasn't used at all. It killed people in yoked aeroplanes. It killed in western in eastern aeroplanes. It killed after stickpusher override.

Originally Posted by unwory View Post
Could the PF become so fixated on levelling the wings that he was oblivious to pitch?
1. No
2. to support point no 1: rent A320 sim for 10 minutes, disable FACs, pull stick to aft stop, observe the amount of blue on PFD and force needed to hold stick full back

Originally Posted by wanabee777 View Post
That the FAA would certify a commercial aircraft designed with duel flight controls which have no tactile feedback between the two pilots is unconscionable!
Not the first time a PPRuNer claims he knows better than FAA. Stay tuned to see if it's really so.

Originally Posted by mac76 View Post
only last week we did first high stall recovery in bank & with wings level we took 3 to 4000 feet to recover
Either you did not do stall recovery or your sim is even bigger PoS than usual.

Originally Posted by Denti View Post
Since AF447 we had high and low altitude stall recovery in virtually every simulator event on my previous aircraft (737) with the new stall recovery procedures once they were available.
There is no low alt stall recovery for 737. If you really stall her down low, best course of action is to put your head between your legs and kiss your ar$ goodbye.

Originally Posted by tdracer View Post
Perhaps a different method of stall warning is in order - during high stress/workload, the human mind tends to shut out aural 'distractions' - perhaps the "STALL, STALL, STALL" isn't getting through?
What workload?

Originally Posted by peekay4 View Post
At some point, a stick pusher might even be considered. Heresy, I know.
Not heresy, just ignorance. If I were to give one advice to aspiring & current airline pilots, it would be:

RTFHTBJ!

Stickpushers are not completely harmless, their malfunction can be lethal so they are used only when necessary and have to be overridable. They were overriden with fatal results a couple of times.

Originally Posted by alf5701h;
I was surprised that there was not greater focus on the pitch trim which could have resulted in a nose-up moment complicating stall recovery.
What stall recovery? The one following stall recognition that never happened?

Originally Posted by JFZ90 View Post
I can't imagine a scenario where a pilot would pull back in a pitch up stall.
You don't need to imagine; just read reports: Colgan, Birgenair, Pinnacle, I am too lazy to Google who wrecked 727 at Stony Point...
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