Air Asia Indonesia Lost Contact from Surabaya to Singapore
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iceman, I get that. But in normal high risk, high technology, industrial safety systems unsafe human behaviour is significantly mitigated by technology. And I feel it is abundantly clear a number of elements in the airbus human-machine interface exacerbate loss of situational awareness and control. Those are design flaws and should not be left in there. You have to look the other way to reject the evidence.
Standard Toaster
So you're saying that the pilots who ignored a multitude of obvious indicators, would somehow magically look at the tiny AoA indicator in a high stress situation and all would be well? Especially considering the fact that 99.999 percent of the time they don't look at it (if it's available), hence, in a high load scenario, they
So you're saying that the pilots who ignored a multitude of obvious indicators, would somehow magically look at the tiny AoA indicator in a high stress situation and all would be well? Especially considering the fact that 99.999 percent of the time they don't look at it (if it's available), hence, in a high load scenario, they
But a single instrument can tell the summary of those instruments with one glance, there is no need to check others. The AoA indicator sums up those informations in one indication by showing the AOA in real time. Well designed and placed it could be the attention getter. In such a situation the only information needed for recognition and redovery would be the AOA, attitude and speed, and those could be fed into the PFD replacing the normal indications for the critical time frame. Then the mentioned tiny AOA indicator could be placed somewhere as backup.
Those who have never used an AOA (even a tiny one) see a problem, the others see the improvement.
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From the Wall Street Journal, December 3, 2015:
"Air Asia Crash Report Dropped Stronger Language Proposed by French
Indonesia’s report on the fatal crash didn’t include tougher statements from French expert"
Air Asia Crash Report Dropped Stronger Language Proposed by French - WSJ
The article was apparently referring to some of the BEA's comment in the Accredited Representative Comments section of the KNKT's official accident report.
From page 186 of the report:
As others in the thread have said and the BEA has said why is the complete CVR transcript not included in the official accident report?
"Air Asia Crash Report Dropped Stronger Language Proposed by French
Indonesia’s report on the fatal crash didn’t include tougher statements from French expert"
Air Asia Crash Report Dropped Stronger Language Proposed by French - WSJ
The article was apparently referring to some of the BEA's comment in the Accredited Representative Comments section of the KNKT's official accident report.
From page 186 of the report:
The CVR transcript is very reduced.
More items identified in the CVR could be added for better understanding of the event. A complete CVR transcript could be put in appendix. If not change the introduction which says: “the transcript is as follows:” into “hearafter is an extract from the CVR.”
More items identified in the CVR could be added for better understanding of the event. A complete CVR transcript could be put in appendix. If not change the introduction which says: “the transcript is as follows:” into “hearafter is an extract from the CVR.”
As others in the thread have said and the BEA has said why is the complete CVR transcript not included in the official accident report?
Last edited by airman1900; 4th Dec 2015 at 08:40. Reason: More
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Warning: heresy here
[Long time pprune watcher, ex-PPL SLF here]
Thought: Ignoring sidesticks vs control column, isn't an Airbus in Alternate Law just a Boeing minus the stick shaker and stick pusher?
Is it feasible, without contravening the First Law of Airbus ("uncoupled sidesticks are here to stay"), to provide (side)stick shaker and pusher in Alternate Law? Combined with a PFD simultaneously defaulting to the large, brightly-coloured AoA display mentioned earlier, this might get things moving in the right direction (well, until the FO heaves back on the stick again).
There has been extensive talk of aural and visual 'blindess' of crews when under pressure, isn't it time to consider this TACTILE assistance?
JS
Thought: Ignoring sidesticks vs control column, isn't an Airbus in Alternate Law just a Boeing minus the stick shaker and stick pusher?
Is it feasible, without contravening the First Law of Airbus ("uncoupled sidesticks are here to stay"), to provide (side)stick shaker and pusher in Alternate Law? Combined with a PFD simultaneously defaulting to the large, brightly-coloured AoA display mentioned earlier, this might get things moving in the right direction (well, until the FO heaves back on the stick again).
There has been extensive talk of aural and visual 'blindess' of crews when under pressure, isn't it time to consider this TACTILE assistance?
JS
I don't accept that an AOA would have been a safety enhancement. These guys already had task saturation and were unable to perceive the real problem despite the FWC's blaring "STALL STALL" at them all the way to the ground.
During AF 447 that warning stopped at least for a time, so in some respects their confusion despite remaining in the stall was understandable, however Air Asia had no such ambiguity, The FO held full back stick for the last three minutes of the flight and from this point on the captain, for whatever reason was unable to provide any useful assistance, notwithstanding some words that were best described as gibberish.
For the Indonesian authorities to point out that this was at least a flight training problem within the organisation is completely appropriate. If one of them were having a bad day but the other guy knew what to do that might be bad luck but neither of these guys were competent to be in a control seat and that has to speak to a significant organisational failure.
During AF 447 that warning stopped at least for a time, so in some respects their confusion despite remaining in the stall was understandable, however Air Asia had no such ambiguity, The FO held full back stick for the last three minutes of the flight and from this point on the captain, for whatever reason was unable to provide any useful assistance, notwithstanding some words that were best described as gibberish.
For the Indonesian authorities to point out that this was at least a flight training problem within the organisation is completely appropriate. If one of them were having a bad day but the other guy knew what to do that might be bad luck but neither of these guys were competent to be in a control seat and that has to speak to a significant organisational failure.
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So you're saying that the pilots who ignored a multitude of obvious indicators, would somehow magically look at the tiny AoA indicator in a high stress situation and all would be well?
Hell, even the Wright Flyer had an AOA indicator.
AoA tells you all you need to know about the aerodynamic situation you are in.
Ground speed is what you need to plan your further flight (arrival time etc.) and to navigate.
IAS is totally worthless, as you need several other paramters to really draw a valid conclusion from it.
Originally Posted by bud leon
With over 35 years of experience... flaws in the airbus ... HMI... It really is that simple.
- It might be a tiny bit better if it had interlinked sticks. Maybe. So long as new issues are not introduced - and I'd bet they would be. Dual independent electric gives a level of redundancy that everyone conveniently forgets.
- It might be a tiny bit better if it had moving t/l.
- It would be a bit better if the "dual input" and "stall stall" could live side by side with each other.
But none of that matters, when you have pilots who exist in a system where it is fine to pull CB's on a critical flight control system when in flight. Pilots whose training and experience leads to a Pavlovian response of pulling up in the face of undiagnosed adversity. Pilots whose communications are so bad that instructions like "pull down" are given.
To change the aircraft is to accept that the level of piloting is fine and that it's simply the machine that needs fixing. Never has there been an accident where this is so far from the truth. The machine was airworthy and safe, the pilots were not.
The fault lies in the training, standards and culture that the pilots were exposed to. I would bet that the same individuals with different training, standards and culture would have:
- Not caused the fault in the first place.
- Not over reacted to the yaw.
- Not flown a zoom climb all the way to a stall.
- If they had done the above, used SOPs to allow the more experienced pilot to assure control and fly a successful stall recovery (by simply lowering the nose).
If I want to see what the FO is doing with his sidestick (for example, while I am pressing the button during a baulked landing where I have taken control, or even just on a normal approach), I use my eyes. They still work quite well, and give a full picture not just of what inputs the FO is giving, but what his face looks like too - which cannot be replicated by any control column system that I used to operate.
This is all about training (and the cost of doing it properly).
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Actually the Bus does provide AoA indication to the crew, as does any aircraft that displays PATH. It's the difference between PiITCH and PATH, both of which are staring you straight in the face.
Interestingly there was no mention of this in the most recent Airbus training movie related to stall awareness and recovery.
Admittedly the presentation doesn't display the AoA as a percentage or limit, and neither will it function if air data is compromised or lost entirely.
It beggars belief that space cannot be found on the panel (as it was on all biz jets until recently) for a simple, direct reading, non air data instrument, the like of which would clarify the situation as a last resort for a confused crew.
Further, when faced with erroneous air data I would argue that a direct reading AoA is an indispensable piece of equipment that should be mandated.
Interestingly there was no mention of this in the most recent Airbus training movie related to stall awareness and recovery.
Admittedly the presentation doesn't display the AoA as a percentage or limit, and neither will it function if air data is compromised or lost entirely.
It beggars belief that space cannot be found on the panel (as it was on all biz jets until recently) for a simple, direct reading, non air data instrument, the like of which would clarify the situation as a last resort for a confused crew.
Further, when faced with erroneous air data I would argue that a direct reading AoA is an indispensable piece of equipment that should be mandated.
de minimus non curat lex
A QUESTION FOR AIRBUS PILOTS
This accident has highlighted, amongst other things, that when an issue arises where ALTERNATE LAW is use, the crew simply could not cope, with disastrous consequences.
Just how much time is spent in the simulator, once on line, practising these non normal states?
How frequently during normal line operations have drivers had to cope without NORMAL LAW in use.
If you don't keep in regular practice with the "OTHER LAWS", it is hardly surprising that it will prove to be a challenge, even for the more experience crews.
I suspect that this is such an infrequent event, it may well be a "one in a life time event" ?
For the avoidance of any doubt, I have never been AIRBUS rated.
Just how much time is spent in the simulator, once on line, practising these non normal states?
How frequently during normal line operations have drivers had to cope without NORMAL LAW in use.
If you don't keep in regular practice with the "OTHER LAWS", it is hardly surprising that it will prove to be a challenge, even for the more experience crews.
I suspect that this is such an infrequent event, it may well be a "one in a life time event" ?
For the avoidance of any doubt, I have never been AIRBUS rated.
The AoA Indicator could surely improve aircraft safety, if it would be a primary instrument from the first flying lesson. It would be essential to understand that Stall is not an airspeed issue, and to use AoA to maintain a margin to stall. Unfortunalely on a typical SEP you can not install a reliable AoA indicator... So this discussion is pointless.
Unfortunately the typical aircraft design evolved from there, and the propeller mounted at the nose of the fuselage became the standard. So now we all rely on the Airspeed indicator, which fact is one of the must useless instruments we have. AoA and Ground Speed are the two parameters we need to know.
AoA tells you all you need to know about the aerodynamic situation you are in.
Ground speed is what you need to plan your further flight (arrival time etc.) and to navigate.
IAS is totally worthless, as you need several other paramters to really draw a valid conclusion from it.
Unfortunately the typical aircraft design evolved from there, and the propeller mounted at the nose of the fuselage became the standard. So now we all rely on the Airspeed indicator, which fact is one of the must useless instruments we have. AoA and Ground Speed are the two parameters we need to know.
AoA tells you all you need to know about the aerodynamic situation you are in.
Ground speed is what you need to plan your further flight (arrival time etc.) and to navigate.
IAS is totally worthless, as you need several other paramters to really draw a valid conclusion from it.
Aviate, Navigate, Comunicate.
Aviate = fly the wing. If you have trouble here, the other two won't solve the problem.
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Planes have stalled and crashed since planes are flying. Many many times.
Among these are now also 2 recent instances where Airbus have stalled and crashed. To attribute these accidents to non-moving TL or to not-connected sidesticks is an absolute red herring.
Moving TL and connected yokes didn't prevent Amsterdam, nor did they prevent San Francisco. There is however reason beyond reasonable doubt that Amsterdam (thanks to mode selection integrated in the TL and autotrim) and San Francisco (thanks to alpha-floor) wouldn't have happened in an Airbus.
Our industriy continues to see weird accidents from a basic flying skill point of view. We seem to have many crew flying around the world airspaces who just do not have the basic skills necessary to actually hold a seat in a jetliner cockpit. This is not a problem of these pilots, but of the environment which lets pilots without the necessary training into the cockpit.
This is a problem of the regulators and the manufacturers training departments (in the sense of how they setup their type ratings).
Among these are now also 2 recent instances where Airbus have stalled and crashed. To attribute these accidents to non-moving TL or to not-connected sidesticks is an absolute red herring.
Moving TL and connected yokes didn't prevent Amsterdam, nor did they prevent San Francisco. There is however reason beyond reasonable doubt that Amsterdam (thanks to mode selection integrated in the TL and autotrim) and San Francisco (thanks to alpha-floor) wouldn't have happened in an Airbus.
Our industriy continues to see weird accidents from a basic flying skill point of view. We seem to have many crew flying around the world airspaces who just do not have the basic skills necessary to actually hold a seat in a jetliner cockpit. This is not a problem of these pilots, but of the environment which lets pilots without the necessary training into the cockpit.
This is a problem of the regulators and the manufacturers training departments (in the sense of how they setup their type ratings).
No one issue ‘caused’ this accident; the circumstances represent an emergent event associated with many (relatively insignificant) aspects coming together at a particular time. A much wider view is required of the potential inputs in order to gain an understanding, amongst which we have to accept that we may never be able to understand specific human contributions.
IMHO all of us posting in this forum should heed the advice of Richard Feynman; write down all of the things that we don’t know ….
The more astute would argue that if we don’t know then how can anything be written, yet the majority of our posts do just that, we expound the unknown based on assumption.
Thus what we should write down are all of the assumptions.
The need for AoA indication assumes that it will be used – seen, comprehended; yet the initial aircraft motion was in roll within the normal value of AoA. Subsequently, even if an excessive AoA was understood, was there sufficient control technique or ‘power’ available; technique could relate to situational understanding and training. Control power could relate to trim position. A complicated logic question posted yesterday asked if there is a difference in autotrim (follow up) with a ‘computed’ law change over and that forced by an electrical interruption.
The need for coupled sticks assumes that this will add to the understanding of what the aircraft is doing. Sidesticks coupled or not, FBW or mechanical, do not always have a direct relationship with the aircraft motion, particularly in upset situations. Asking what the other pilot is doing in manual flight is like asking what the autopilot is doing; it reflects the weakness of situation awareness or disparity in the alternative situations as perceived by the questioner. First look at what the aircraft is doing – then consider what has to be done, what is required, and how to achieve this; avoid the historical of ‘what are you doing’; think to the future.
Over 90% of mental activity involves understanding the situation, comprehending what is sensed. We might benefit from simplifying aspects of understanding – avoid asking how can something be done, but ask 'should we' be doing this.
Should repetitive maintenance action involve resetting a computer; is the reason for this choice of action understood (management and/or maintenance).
If a pilot has to leave the seat to make a selection, consider should this be done. ‘Should I’ ought to be one of those mental shortcuts which are formed by experience, but his depends on how we use what we think we know or don’t know, or that 'something' we just assume to be so.
Many (most) recent LoC accidents involved the absence of ‘protections’ or repetitive ‘maintenance’. A wide view of this would include lack of takeoff config warning (MD 80 maint), rad alt glitches (B 737 regulatory), AoA icing (A 320 maint and regulatory), pitot ice crystals (A330 regulatory), AT protection (MD11 regulatory); all these factors had been identified previously (they were known), yet were not ‘known’ to be a sufficient in isolation to be hazardous, i.e. an assumption that they would not ‘cause’ an accident.
IMHO all of us posting in this forum should heed the advice of Richard Feynman; write down all of the things that we don’t know ….
The more astute would argue that if we don’t know then how can anything be written, yet the majority of our posts do just that, we expound the unknown based on assumption.
Thus what we should write down are all of the assumptions.
The need for AoA indication assumes that it will be used – seen, comprehended; yet the initial aircraft motion was in roll within the normal value of AoA. Subsequently, even if an excessive AoA was understood, was there sufficient control technique or ‘power’ available; technique could relate to situational understanding and training. Control power could relate to trim position. A complicated logic question posted yesterday asked if there is a difference in autotrim (follow up) with a ‘computed’ law change over and that forced by an electrical interruption.
The need for coupled sticks assumes that this will add to the understanding of what the aircraft is doing. Sidesticks coupled or not, FBW or mechanical, do not always have a direct relationship with the aircraft motion, particularly in upset situations. Asking what the other pilot is doing in manual flight is like asking what the autopilot is doing; it reflects the weakness of situation awareness or disparity in the alternative situations as perceived by the questioner. First look at what the aircraft is doing – then consider what has to be done, what is required, and how to achieve this; avoid the historical of ‘what are you doing’; think to the future.
Over 90% of mental activity involves understanding the situation, comprehending what is sensed. We might benefit from simplifying aspects of understanding – avoid asking how can something be done, but ask 'should we' be doing this.
Should repetitive maintenance action involve resetting a computer; is the reason for this choice of action understood (management and/or maintenance).
If a pilot has to leave the seat to make a selection, consider should this be done. ‘Should I’ ought to be one of those mental shortcuts which are formed by experience, but his depends on how we use what we think we know or don’t know, or that 'something' we just assume to be so.
Many (most) recent LoC accidents involved the absence of ‘protections’ or repetitive ‘maintenance’. A wide view of this would include lack of takeoff config warning (MD 80 maint), rad alt glitches (B 737 regulatory), AoA icing (A 320 maint and regulatory), pitot ice crystals (A330 regulatory), AT protection (MD11 regulatory); all these factors had been identified previously (they were known), yet were not ‘known’ to be a sufficient in isolation to be hazardous, i.e. an assumption that they would not ‘cause’ an accident.
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HundredPercentPlease: There are improvements that can be made in every machine when new levels of human ineffectiveness are explored. But the "non-linked sidestick" seems to be of significant issue only to those who don't actually fly the Airbus.
It might be a tiny bit better if it had interlinked sticks. Maybe. So long as new issues are not introduced - and I'd bet they would be. Dual independent electric gives a level of redundancy that everyone conveniently forgets.
It might be a tiny bit better if it had moving t/l.
It would be a bit better if the "dual input" and "stall stall" could live side by side with each other.
But none of that matters, when you have pilots who exist in a system where it is fine to pull CB's on a critical flight control system when in flight. Pilots whose training and experience leads to a Pavlovian response of pulling up in the face of undiagnosed adversity. Pilots whose communications are so bad that instructions like "pull down" are given.
To change the aircraft is to accept that the level of piloting is fine and that it's simply the machine that needs fixing. Never has there been an accident where this is so far from the truth. The machine was airworthy and safe, the pilots were not.
The fault lies in the training, standards and culture that the pilots were exposed to. I would bet that the same individuals with different training, standards and culture would have:
Not caused the fault in the first place.
Not over reacted to the yaw.
Not flown a zoom climb all the way to a stall.
If they had done the above, used SOPs to allow the more experienced pilot to assure control and fly a successful stall recovery (by simply lowering the nose).
If I want to see what the FO is doing with his sidestick (for example, while I am pressing the button during a baulked landing where I have taken control, or even just on a normal approach), I use my eyes. They still work quite well, and give a full picture not just of what inputs the FO is giving, but what his face looks like too - which cannot be replicated by any control column system that I used to operate.
This is all about training (and the cost of doing it properly).
It might be a tiny bit better if it had interlinked sticks. Maybe. So long as new issues are not introduced - and I'd bet they would be. Dual independent electric gives a level of redundancy that everyone conveniently forgets.
It might be a tiny bit better if it had moving t/l.
It would be a bit better if the "dual input" and "stall stall" could live side by side with each other.
But none of that matters, when you have pilots who exist in a system where it is fine to pull CB's on a critical flight control system when in flight. Pilots whose training and experience leads to a Pavlovian response of pulling up in the face of undiagnosed adversity. Pilots whose communications are so bad that instructions like "pull down" are given.
To change the aircraft is to accept that the level of piloting is fine and that it's simply the machine that needs fixing. Never has there been an accident where this is so far from the truth. The machine was airworthy and safe, the pilots were not.
The fault lies in the training, standards and culture that the pilots were exposed to. I would bet that the same individuals with different training, standards and culture would have:
Not caused the fault in the first place.
Not over reacted to the yaw.
Not flown a zoom climb all the way to a stall.
If they had done the above, used SOPs to allow the more experienced pilot to assure control and fly a successful stall recovery (by simply lowering the nose).
If I want to see what the FO is doing with his sidestick (for example, while I am pressing the button during a baulked landing where I have taken control, or even just on a normal approach), I use my eyes. They still work quite well, and give a full picture not just of what inputs the FO is giving, but what his face looks like too - which cannot be replicated by any control column system that I used to operate.
This is all about training (and the cost of doing it properly).
I'm not arguing that there should not be investment in training. But it's not a choice of one or other of the two factors. I don't argue with the obvious errors that resulted in the abnormal conditions in the first place, but I do see strong evidence that confusion escalates quickly and the design philosophy only makes that worse.
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Report in the balance
Having been able to read the complete report only once (certainly requires more than one read). and following Pprune. My first impression... Sorry that it is a bit long, but I want to start with the balance, and then indicate where I think it tilts the wrong way.
The report is more, but also less, than was expected or hoped for (on PPrune). In some places it has more information than required. In some very important places less than required. And also contains information that you do not expect (and as far as I know should not be) in an accident report.
More than expected by some, because it gives a good impression of the sequence of events. Good enough for the informed reader to get a baseline understanding and test the conclusions. A baseline which gives part of the answers you are looking for, but in this case also creates a foundation for asking some questions that are suggested but not explicitely answered by the report.
More information than required, because of the multiple copy/paste pages. Excerpts plus source reference would improve reading and ease of understanding. The larger pieces of text should have been moved to appendices.
Certainly less information than required because of the INCOMPREHENSIBLE omission of an almost complete sound and voice CVR transcript (with normal privacy protection). Incomprehensible, because of this specific accident, recent previous accidents (AF447 A330, Mali AA MD83, MH370 B777) and the primairy accident report purpose of prevention and future aviation safety.
This 'type' of LOC accidents (rare, but deadly, as they are) MUST provide us with increasingly MORE detailed FACTS (and thereby understanding, and thereby foundation for improving design and training) of what has happened in the cockpit. Next to a complete sound and voice transcript, there should at least be a 'voice stress level analysis' covering a timeline of at least the start of the master warnings till just before impact). If there is a 'startle moment' for each pilot you want to 'see', 'sync', and 'feel' them. Key in this type of accident are 'man','man/man' and 'man/machine'. The report does not provide these required FACTS. You would expect an ICAO request by now to ask for a full CVR transcript in 'Good Aircraft but LOC' cases.
Information that you certainly do not expect in an accident report is an extensive list of the actions of the operator adressed to the accident investigator based on an interim report. Positive as the actions may be, you expect these to be adressed to the regulator (DGCA), and for the regulator to put them in publications and Lessons Learned. Insertion in an accident report is not appropriate. The report is about accident facts, analysis, and safety recommendations. The actions are literally 'after the fact'.
Explicit questions that you get, if you want to reduce the number of probable scenario's (and could well have been stated and explicitely answered by the NTSC in the report), are:
A. "If the pilots had just followed the usual ECAM instructions and cleared the warnings in their normal manner, would that have been enough to continue the flight without any subsequently required pilot intervention?".
B. Same question as A. but now with the BEA suggested use of the CLR/CLEAR pushbutton.
C. How much time would it take to perform A. and B. respectively?
D. Would it require a pilot to stand up or even leave his seat?
Note - Explicitely asking and answering these questions does not assign responsibility and/or blame.
Another question is of course, rumours early on suggested this being 'true', "DID the CAPT leave his seat to pull CBs"? It is clear from the report that the NTSC does not want to state this explicitely.Note that Silk Air 185 has a comparable issue ! That case shows detailed CB CVR analysis ! If the NTSC does this because of lack of evidence, then in future you would expect a safety recommendation for CBs to also generate sufficient sound (already 'loud' in overload) in manual pull/push cases !
I have been in discussions where availability and accessibility of CBs in the cockpit was the main subject. If he indeed did leave his seat, then that would validate the fear of some designers, and would invalidate the certainty of some pilots that this would never happen. Today you would have to put 'leave seat' on the list of items and add a probability value to that. And include in pilot-training items like the effect of WoW-switches for instance. And in ground-engineer-training add items about how to communicate with pilots ... "we/you can reset this, but ONLY on the GROUND"... It would be very interesting knowing what the ground engineer LITERALLY said at the time. In this context his statement gets the same importance as an airborne CVR remark.
The report is more, but also less, than was expected or hoped for (on PPrune). In some places it has more information than required. In some very important places less than required. And also contains information that you do not expect (and as far as I know should not be) in an accident report.
More than expected by some, because it gives a good impression of the sequence of events. Good enough for the informed reader to get a baseline understanding and test the conclusions. A baseline which gives part of the answers you are looking for, but in this case also creates a foundation for asking some questions that are suggested but not explicitely answered by the report.
More information than required, because of the multiple copy/paste pages. Excerpts plus source reference would improve reading and ease of understanding. The larger pieces of text should have been moved to appendices.
Certainly less information than required because of the INCOMPREHENSIBLE omission of an almost complete sound and voice CVR transcript (with normal privacy protection). Incomprehensible, because of this specific accident, recent previous accidents (AF447 A330, Mali AA MD83, MH370 B777) and the primairy accident report purpose of prevention and future aviation safety.
This 'type' of LOC accidents (rare, but deadly, as they are) MUST provide us with increasingly MORE detailed FACTS (and thereby understanding, and thereby foundation for improving design and training) of what has happened in the cockpit. Next to a complete sound and voice transcript, there should at least be a 'voice stress level analysis' covering a timeline of at least the start of the master warnings till just before impact). If there is a 'startle moment' for each pilot you want to 'see', 'sync', and 'feel' them. Key in this type of accident are 'man','man/man' and 'man/machine'. The report does not provide these required FACTS. You would expect an ICAO request by now to ask for a full CVR transcript in 'Good Aircraft but LOC' cases.
Information that you certainly do not expect in an accident report is an extensive list of the actions of the operator adressed to the accident investigator based on an interim report. Positive as the actions may be, you expect these to be adressed to the regulator (DGCA), and for the regulator to put them in publications and Lessons Learned. Insertion in an accident report is not appropriate. The report is about accident facts, analysis, and safety recommendations. The actions are literally 'after the fact'.
Explicit questions that you get, if you want to reduce the number of probable scenario's (and could well have been stated and explicitely answered by the NTSC in the report), are:
A. "If the pilots had just followed the usual ECAM instructions and cleared the warnings in their normal manner, would that have been enough to continue the flight without any subsequently required pilot intervention?".
B. Same question as A. but now with the BEA suggested use of the CLR/CLEAR pushbutton.
C. How much time would it take to perform A. and B. respectively?
D. Would it require a pilot to stand up or even leave his seat?
Note - Explicitely asking and answering these questions does not assign responsibility and/or blame.
Another question is of course, rumours early on suggested this being 'true', "DID the CAPT leave his seat to pull CBs"? It is clear from the report that the NTSC does not want to state this explicitely.Note that Silk Air 185 has a comparable issue ! That case shows detailed CB CVR analysis ! If the NTSC does this because of lack of evidence, then in future you would expect a safety recommendation for CBs to also generate sufficient sound (already 'loud' in overload) in manual pull/push cases !
I have been in discussions where availability and accessibility of CBs in the cockpit was the main subject. If he indeed did leave his seat, then that would validate the fear of some designers, and would invalidate the certainty of some pilots that this would never happen. Today you would have to put 'leave seat' on the list of items and add a probability value to that. And include in pilot-training items like the effect of WoW-switches for instance. And in ground-engineer-training add items about how to communicate with pilots ... "we/you can reset this, but ONLY on the GROUND"... It would be very interesting knowing what the ground engineer LITERALLY said at the time. In this context his statement gets the same importance as an airborne CVR remark.
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Per the report, pilot conversations during the critical period right before the CBs pulls were unintelligible.
The recorder showed that the FAC 1 CB was reset 54 seconds after the activation of the 4th master caution. During this period communication between the SIC and PIC recorded on the CVR was unintelligible. Assuming that during these 54 seconds both pilots discussed the plan and consequences of resetting the FAC CB, the time available would not have been sufficient. The discussion should have included a review of the CB's allowed to be reset in flight in the TDU and OEB table. The evidence of the SIC delayed action when the autopilot disengaged indicated that the SIC did not anticipate the autopilot disengagement.
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But the CVR transcript seems to be heavily edited (censored), its hard to get a real impression of the communication that went on from the published report.
In general its a strange report, quite different from the NTSB, AAIB and others i have read. It skirts over actually making hard conclusions, there's the largely unexplained appendices, and it really should have been proof-read by a professional/native English speaker to remove grammatical and typo errors it contains.
Too add my 2c - Appointing blame to the A/C design or even maintenance of the FAC is irrelevant. The fact is the the pilots flew a perfectly airworthy plane into the ground. The FAC errors and subsequent (incorrect) remedial action were a trigger, but not the cause. Poor communication & poor basic flying skills were.
In general its a strange report, quite different from the NTSB, AAIB and others i have read. It skirts over actually making hard conclusions, there's the largely unexplained appendices, and it really should have been proof-read by a professional/native English speaker to remove grammatical and typo errors it contains.
Too add my 2c - Appointing blame to the A/C design or even maintenance of the FAC is irrelevant. The fact is the the pilots flew a perfectly airworthy plane into the ground. The FAC errors and subsequent (incorrect) remedial action were a trigger, but not the cause. Poor communication & poor basic flying skills were.
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Well if the conversations were largely unintelligible, then I can see why the would leave them out of the CVR transcript. This is different from "censorship".
Otherwise they'd have a CVR transcript filled with items such as "xxx said something similar to yyy" and "cockpit sound heard similar to zzz", which by nature becomes subjective. The transcript is supposed to be an objective record.
Then we'd be here criticizing them for not just "sticking with the facts".
Otherwise they'd have a CVR transcript filled with items such as "xxx said something similar to yyy" and "cockpit sound heard similar to zzz", which by nature becomes subjective. The transcript is supposed to be an objective record.
Then we'd be here criticizing them for not just "sticking with the facts".
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StickMonkey3:
The problem is hardly new, but is creeping into higher strata in an ostensibly professional industry. My father had been a civil service AT-6 flight instructor, but never felt motivated to get a CFI ticket postwar; he was a machinist and toolmaker by trade, and the market was flooded by ex-military pilots.
But occasionally Dad's friends had "problem" students who were either nervous in slow flight regimes or whatever. Even though Dad had no authority to sign their logs for dual time, he had a reputation for getting them comfortable in confidence-building slow flight. So on a strictly volunteer basis, he took them through stall approach and recovery and other exercises.
And the students' landings improved remarkably after a few sessions of this.
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.
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.
But occasionally Dad's friends had "problem" students who were either nervous in slow flight regimes or whatever. Even though Dad had no authority to sign their logs for dual time, he had a reputation for getting them comfortable in confidence-building slow flight. So on a strictly volunteer basis, he took them through stall approach and recovery and other exercises.
And the students' landings improved remarkably after a few sessions of this.
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A question from an outsider:
Is it a regular practice on normal flights in flight phases with no stress (weather, hurry, ...) to fly with autopilot off, with the intent to keep the feeling for the airplane handling and the routine checks of AOA, speed, horizon, thrust alive?
Is there in said calm phases a kind of emergency preparation like the captain asking: "Now that we have time: both FACs die in smoke - what would you do? Oil pressure left engine drops. What would you do? Recurring component failure because of broken solder joint - what would you do? ..."
Is it a regular practice on normal flights in flight phases with no stress (weather, hurry, ...) to fly with autopilot off, with the intent to keep the feeling for the airplane handling and the routine checks of AOA, speed, horizon, thrust alive?
Is there in said calm phases a kind of emergency preparation like the captain asking: "Now that we have time: both FACs die in smoke - what would you do? Oil pressure left engine drops. What would you do? Recurring component failure because of broken solder joint - what would you do? ..."