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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 2nd Dec 2015, 16:23
  #3521 (permalink)  
 
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@chefrp
Why would this plane be flying around so long with this known fault?
In addition what Volume mentioned, compounding the issue was AirAsia's use of two different, non-integrated fault reporting systems (the MR1 technical log and the PFR post flight report).

Specifically, intermittent faults from the PFR which were "resolved" by simple resets were not being logged into the MR1. The PFR was mainly used as an aid to troubleshooting.

However, AirAsia's maintenance management system (AMOS) was only based on the MR1. So procedures in place to identify and fix recurring issues did not flag this problem.

Also, AirAsia pilots did not report many of the FAC failures. Maintenance work arising from pilot reports would have been logged in the MR1, and could have resulted in the issue to be flagged as recurring.

But some AirAsia pilots apparently had simply reset the problematic FACs in flight and not subsequently report the issue to maintenance.

Lots of holes in the Swiss cheese.
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Old 2nd Dec 2015, 16:41
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Question Another Hole

I don't know if this might have saved the airplane, but, at least twice now, the pilot in the left seat could have saved the aircraft if the stick priority system were to have been re-thought/re-programmed, i.e., why not make it much easier for the left-seat pilot to take priority, based on their (presumed) added experience? Forty seconds of holding down the button seems to be asking way too much of someone who is fighting for their life (and everyone else's).

Yeah, apparently the Captain did not realize that either (A) his forward-stick inputs were not enough to overcome PF's wrong inputs, and/or (B) did not realize that PF was pulling at all! One cannot make anything completely fool-proof, but this seems like an unnecessary gaping hole in the cheese.

I propose, without really having any idea of what the hell I'm talking about, making the left-seat stick ALWAYS have priority.

Discuss.
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Old 2nd Dec 2015, 16:43
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Volume:
If the fault can not be reproduced on ground (e.g. due to a temperature related problem, like thermal stress on a cracked solder joint) the units are declared "serviceable" and end in an aircraft again. Just when the frequency of one specific fault indicates a real issue which can be pinpointed to one specific system, more action is taken.
The classic, decades-old approach to troubleshooting such problems is to swap components between systems (L vs R engine, PCU#1 vs PCU#2, etc.) or between aircraft (Nxxx vs Nyyy). If the complaint follows the component, then the fault is isolated. If not, keep looking.

This method often works when others fails, e.g. on intermittent problems. Would Air Asia Indonesia have this depth of understanding?
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Old 2nd Dec 2015, 16:52
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@pekay

Points taken but in every report I have read I recall reading that when referring to sounds picked up by the CAM they generally refer to them as "sound similar to"....

Nevertheless, do you not think that there could have been a whole lot more of the CVR transcript published. There are an awful lot of gaps and it beggars belief that the crew were not communicating more than was quoted. Sure if they were praying, which some over there might understand and relate to, I can understand it being deleted, but other than a few 'Oh My Gods" and "pull it" or "push it" surely they MUST have had some kind of discussion and interaction related to the numerous repeated ECAM messages at the very least.

The crew reaction to these warnings IS relevant to the inquiry, but instead of using information that the crew verbalized between themselves it seems to prefer to concentrate on what the FDR recorded as their probable actions. Without the "intent" which would have been gleaned from the CVR data we are left to believe that they may not have left their seat to re-set a CB that should not have been re-set.

I'm sure you get my drift.
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Old 2nd Dec 2015, 17:10
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Devil

When there are so many similar failures (tens !!!) from a sub-system or sytem just restting it is eagerness to be at a time in critical situations! Statistically one crew or another will make a disastrous maneuver at a time, whether in crew is below standard, standard or above standard.


Again we find that fatal law change to alternate like AF447. PIO followed very abruptly.


So sad.
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Old 2nd Dec 2015, 17:46
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Cpn Bloggs
My question on yoke v sidestick was referring to the fact that inappropriate stall recovery is common to all.
Regarding actual handling time of the PF I quite agree with you.
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Old 2nd Dec 2015, 17:50
  #3527 (permalink)  
 
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why not make it much easier for the left-seat pilot to take priority, based on their (presumed) added experience?
Never assume...playing Devil's advocate for a moment: I'd hazard a guess that when performing heavy/augmented crew operations on the likes of the 330 and bigger it's possible at times to find the lower hours pilot in the LHS.....
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Old 2nd Dec 2015, 17:50
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I return to the language question.
If the Captain thought he had told the P2 to push down, then he would therefore not say 'I have control' because he thought he was pushing in the same direction as the P2. Likewise the P2 would also think, thanks to his interpreting the "pull down" command as "pull" (which he was instructed to do later), that the Captain was either not touching the controls or trying to move the stick in the same direction as himself.

The differing misinterpretations of the Captain's "Pull down" command explains the subsequent actions of both.
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Old 2nd Dec 2015, 18:18
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The differing misinterpretations of the Captain's "Pull down" command explains the subsequent actions of both.
*************
Under stress foreign language skills can go out the window and English was the mother tongue of neither
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Old 2nd Dec 2015, 18:38
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The sequence of events that led to the crash of this aircraft was initiated by a failure of the RTL system.

In the aftermath of the loss of Flight 587, NTSB Safety Board member Debbie Hersman made the following statement.

"The sensitivity of the system is critical and needs to be addressed."

The NTSB decreed that modifications were needed to nearly 500 Airbus A300-600 and A310 aircraft in order to provide pilots with greater protection from hazardous rudder pedal inputs at high airspeeds that can lead to aircraft pilot coupling (APC)

At the end of the daylong hearing, NTSB Vice Chairman Mark Rosenker said, "We've seen today a tragic coupling of the pilot and aircraft that brought down Flight 587."

Pending system modifications, the board said that pilots need to be advised in no uncertain terms that back-and-forth pedal inputs to the rudder, or rudder reversals - even within the certified maneuvering speed - pose the risk of imparting aerodynamic loads high enough to break the fin, as was the case in the Flight 587 .

Is it not a sad irony that a system designed to protect against excessive rudder inputs by the crew was the initiating cause of another accident.
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Old 2nd Dec 2015, 18:48
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Frankly, this crew would have been maxed out by practically anything.
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Old 2nd Dec 2015, 18:58
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Stall trainning.

I believe stall training must be done in an aircraft in which a full stall series does not present a danger (Skyhawk, Warrior, etc.)
A pilot must be able to feel his butt rise out of the seat and against shoulder harness and then learn to fight the 'reptile brain' response to "pull back" to arrest the decent.
I suspect we all remember our first few stalls in light aircraft and maybe not wanting to let the yoke move forward.
This needs to be done through out one's flying career or you become fearful of the aircraft.
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Old 2nd Dec 2015, 19:05
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Originally Posted by Chronus
The sequence of events that led to the crash of this aircraft was initiated by a failure of the RTL system.

. . . .
I strongly disagree with this assessment. My reasons for disagreeing so strongly are, I have flown these aircraft A320/A330/A340 as well as all other manufacturer types and while these aircraft are emminently dispatchable, sometimes the MEL is invoked and we must deal with ECAM messages as-dispatched.

The A320 & Airbus types and Airbus philosophy have been around since the late 80's and is, (or should be) well-known and well-understood. Crews simply cannot carry out their own, made-up procedures on any types of transports any more. I'm sure the B777 and certainly the B787 will be the same.

The FCOM, the QRH (Abnormal Ops) and the MEL are the guiding documents by which the aircraft is operated. Deviating from them is done under the captain's authority and responsibility if the safety of the flight is known to be at greater risk than not deviating from these documents. Otherwise it is expected that crews will adhere to the books. They should be in possession of sufficient understanding fo their aircraft to know why such cockpit discipline is paramount, even in trying and annoying circumstances as these must have been.

Resetting of both FACs in the air is prohibited by the Computer-reset section of the QRH Abnormal procedures. Here are the relevant excerpts:

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Last edited by FDMII; 2nd Dec 2015 at 19:25. Reason: Edit graphics to help visibility on smaller screens!
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Old 2nd Dec 2015, 19:23
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I have had several students who were scared stiff of stalls after poor initial instruction, and it was my task to fix that at a professional airline training school.
Given the reluctance to teach stalling properly, and the ubiquity of low-time instructors hours-building towards their ATPLs, it is very much a case of the blind leading the blind. It is,however, extremely difficult now to earn a decent living as an experienced flight instructor, so I don't see the situation changing anytime soon.
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Old 2nd Dec 2015, 19:46
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[QUOTE=FDMII;9198758]I strongly disagree with this assessment. My reasons for disagreeing so strongly are, I have flown these aircraft A320/A330/A340 as well as all other manufacturer types and while these aircraft are emminently dispatchable, sometimes the MEL is invoked and we must deal with ECAM messages as-dispatched.

The A320 & Airbus types and Airbus philosophy have been around since the late 80's and is, (or should be) well-known and well-understood. Crews simply cannot carry out their own, made-up procedures on any types of transports any more. I'm sure the B777 and certainly the B787 will be the same.

The FCOM, the QRH (Abnormal Ops) and the MEL are the guiding documents by which the aircraft is operated. Deviating from them is done under the captain's authority and responsibility if the safety of the flight is known to be at greater risk than not deviating from these documents. Otherwise it is expected that crews will adhere to the books. They should be in possession of sufficient understanding fo their aircraft to know why such cockpit discipline is paramount, even in trying and annoying circumstances as these must have been.

Resetting of both FACs in the air is prohibited by the Computer-reset section of the QRH Abnormal procedures. Here are the relevant excerpts:

What would have been the outcome if the RTL had not failed. I would suggest it would have been a no event. The causa sine qua non.

The RTL failed and the crew were duly informed the protection it offered was no longer available. The following best describes that which became operative thereafter.

"It is found that anything that can go wrong at sea generally does go wrong sooner or later, so it is not to be wondered that owners prefer the safe to the scientific .... Sufficient stress can hardly be laid on the advantages of simplicity. The human factor cannot be safely neglected in planning machinery. If attention is to be obtained, the engine must be such that the engineer will be disposed to attend to it." Alfred Holt 1877.

My question is why make a system to protect against human misuse which then when not available renders the whole unsafe in the hands of a human operator. Which then brings me to pose the questions, what would the outcome have been if this was a pilotless robot aircraft and how would the computer controlled robot would have resolved the issue of flying without an RTL. Perhaps the robot would not have had any need for an RTL system. In which case the RTL system was designed solely for protection against the human operator and it must therefore follow that the weakness is the human operator. Not the sort of conclusion that any one of us would wish to come to I would have thought. But there again it is always easy to blame the pilot, especially if he is dead.
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Old 2nd Dec 2015, 20:23
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The differing misinterpretations of the Captain's "Pull down" command explains the subsequent actions of both.
*************
Under stress foreign language skills can go out the window and English was the mother tongue of neither

When I first moved to Denmark (from the UK), I was confused by the signs on doors.
One read TRYK and the other TRAEK.

How confusing!

Then I realised how confusing PUSH and PULL might be to someone not brought up on English.
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Old 2nd Dec 2015, 21:08
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Chronus, you're making this out to be far more complicated than it is. We deal with these kinds of things as a matter of routine. The "whole" is most certainly not rendered unsafe when there are degradations in the flight control system. Seen it, done it hundreds of times in the sim...no big thing. But you have to know your airplane, and you have to respect the books, period.

The RTL problem did not cause the accident. No crew action was required, even though the warnings were a distraction and a nuisance.

An attribution of original cause is not "blaming" a dead crew - they needlessly paid the ultimate price - the airplane would have continued safe flight just fine until the 2nd FAC CB was pulled, with the captain out of his seat, which is contraindicated by the AOM as described.

A decision to execute a non-standard procedure plus the inability to control the result caused the accident.

At present, a "robotic" aircraft has far more serious shortcomings than one with competent crews but pilotless flight is another thread entirely.
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Old 2nd Dec 2015, 21:15
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No accident

The starting point is that that the aircraft actually was an A320 with side sticks and fly by wire. It is too late to permanently ground all side stick equipped fly by wire airliners and in my opinion this is not needed.

I clearly see the need for better training, including the requirement to follow FM procedures. The WARNING about resetting more than one computer at a time was either ignored or not known. This was a major part of the accident, but even so, it was still not inevitable.

After that, in spite of the language difficulty, the situation was still manageable if the captain had pressed and held his takeover pushbutton.

What can we do to prevent similar situations? The position can be like vaccinations giving humans "herd immunity". If enough pilots consistently report malfunctions in the aircraft technical log, it becomes more difficult for airlines to ignore. It isn't enough to see a previous report and assume that the company knows about the problem.

This particular FAC problem escaped correct reporting as a repetitive defect, so insufficient attention was taken. It was always a collective pilot responsibility but apparently pilots failed to act. A starting point would have been to write up every single instance of this malfunction. After a few instances of successful BITE tests, each subsequent write up should include reference to page and item numbers of all known previous reports re this malfunction.

Even in a significant airline, this might not get the full attention of management. Obviously they need more incentive to act. Finally, it is still up to the captain. And finally the captain must decide if the instances of this malfunction are more frequent on his flight and return to base for rectification. Now we have the attention of the company.

Do it once and maybe captain still has a job. Company will become more proactive and maybe same flight deck crew will be rostered for next day flight with same aircraft, maybe with 2 new or replacement FACs. Crew should critically quiz engineers about rectification work before deciding to fly. Assume they claimed 2 replacement FACs fitted and ask for critical comments after the flight. Assume crew accept the aircraft.

If the fault remains, return to base. Company might be very upset at captain decision. Crew might even be grounded pending investigation. The good news is that the aircraft will probably be also grounded pending investigation. In a week or two, when the problem is fixed, the same crew will be rostered for the first flight.

No accident.
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Old 2nd Dec 2015, 22:59
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Would a few additional (and specific) aural warnings be helpful?

Instead of repeatedly blaring 'STALL, STALL, STALL' until the plane impacts the ocean -- would it make sense to briefly interrupt that alarm to convey other critical information, so long as the stall is at a high enough altitude that there is time to convey vital additional information?

For instance, might 'ANGLE OF ATTACK 48 degrees' have been far more helpful to the 8501 crew than yet another round of 'STALL, STALL, STALL' ? (With the stall warning then resuming, so the crew isn't misled into thinking the stall has been remedied).

(If 48 degrees is too late to recover, then substitute an appropriate number to trigger the first alert.) The computers may distrust such high AoA numbers, but the warning hopefully will have alerted the pilots to a potentially excessive AoA, which they may be able to quickly verify and ensure they are making appropriate inputs.

Also -- With 8501, the Cptn may have been aware of dual inputs -- CVR excerpts have him giving instructions to the FO-- yet neither may have realized their inputs were in conflict.

Perhaps a "CONFLICTING INPUT - PITCH" aural alert (between the rounds of 'STALL, STALL') would be helpful, when the input deviations are substantial (and possibly if the computer also recognizes that the plane's current pitch/AOA is very abnormal).

Such a warning should immediately alert the flight crew to conflicting inputs, and also that one pilot may need to assert control. (They already "know" that, but bitter experience shows in very stressful situations some basics can get overlooked.)

I understand the importance of not overloading pilots with too much input. However, am I wrong to think that interposing a few specific aural warnings might be more useful than just repeatedly blaring "STALL, STALL"?

It would require some software and perhaps even hardware modifications (and careful testing to ensure new problems are not introduced). I don't know if there would be legal issues, such as certifications.

But something must be done. More training is vital, but only one part of addressing this problem (especially if under extreme stress some pilots seem to be overlooking basics). Unfortunately, the reality we face is a rapid global expansion of aviation coupled with a strong emphasis on beancounting and relatively little experience handflying.

Given this, would it make sense to add a few very specific alerts as a last layer of defense, at the critical moment when a fatal accident may be imminent?
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Old 2nd Dec 2015, 23:15
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ANGLE OF ATTACK 48 degrees
The NTSB, etc., have been trying to get AOA indicators available to airline pilots for DECADES. But so far the regulators and industry remain opposed to the idea.
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