Air Asia Indonesia Lost Contact from Surabaya to Singapore

[wingspan68]

It's already a while ago since I flew the A320 (which is in deed a very good aircraft!). But regardless of the type of aircraft:

They crashed because the crew was unable to fly the plane raw data...

Basically its very simple: If not really needed, do not reset a computer via CB in flight, especially when a failure continues to reoccur. They easily could have continued with this problem to Singapore. It's a short flight only, or divert if you don't feel comfortable. No big deal...

Bad luck paired with a bad decision, paired with bad flying skills (training...) = crash

[phil gollin]

.

Quote from HundredPercentPlease ;

"Those look like stills from an animation not published.

Note the BEA complaint on page 186 "The CVR transcript is very reduced" - and the fact that this complaint was rejected. Shame."

---------------

Well spotted - so what worth is there to commenting on pilots' actions ?

[tdracer]

Originally Posted by fchan

I am surprised the official report does not tell us what sort of solder it was that cracked. It is well known that lead free solder is brittle and more easily cracks under fatigue loading than the old leaded solder. I have personally repaired many electronic items with cracked lead free solder (although not avionics as it’s not my field).

In space applications lead free solder is banned, although I think that is more to do with tin whisker growth in a vacuum than cracking.

The banning of lead in solder may have saved the odd life from lead poisoning but the loss of life in this accident more than outweighs it and a relaxation of the requirement for safety critical applications like avionics would I am sure hardly affect the rate of lead poisoning, as the volume of avionic products turned out is far less than say consumer electronics. Or do avionics already have such a relaxation?

I'm not an expert on the hardware side, but my understanding is that aircraft avionics are exempted from the ban on leaded solder, but leaded solder is not mandated. Over the last 30 years there has been a big shift to the use of "Commercial Off The Shelf" (COTS) electronics for aircraft avionics (vs. the Mill Spec stuff we used to use). COTS normally uses lead free solder (we've had occasional issues with tin whiskers in the FADEC world).
IMHO, the big carrot for lead free solder was plumbing (where the lead could end up in the water supply). Leaded solder in electronics is not a major risk provided basic precautions are taken.

[HundredPercentPlease]

Toscana,

No, the AH is misleading, as it may well look normal (slight pitch up). The speed will be low, but this could be misdiagnosed as unreliable airspeed. At low altitude the recovery for that is.... pitch up high and lots of thrust.

Once misdiagnosed, HF determine it's hard to undiagnose and rediagnose.

[RAT 5]

If you are really in a hurry, you may try 3 Words instead...
"I have Control"

This might be one of those situations where more words might be better.

"let go of the fecking stick you nunce."

In AF both pilots were bemused and the captain unable to intervene even if he had become aware of the problem,, its cause, and the solution. Here, it seems the captain was trying to do the correct thing with control input, but was thwarted. How he could have been thwarted for so long is a question. Is the F/O's seat too far for a punch, or was g an inhibiting factor in restraining the frozen rabbit.
Similar to ASF seems to be that the stall was broken by control input and then re-entered also by control input. Worrying times. In the past 15 years there have been an astounding number of flyable a/c stalled into CFIT. In various cultures and XAA regimes and on various types. OK, they might have had a tech problem = 1st hole in the cheese, but no reason to keep chewing and make more. And what has been the worldwide XAA reaction to this astonishing phenomenon? Not too much. What has been the operators reaction to this risk? Rigid SOP's so you stay even further away from the boundaries. And the reaction of the manufacturers? more warnings, back ups and automatics. Oh Dear.
There was a thread on AI speeding up the pilotless aeroplane. Some advocated it and might even use this scenario as supporting evidence. I wonder, in the case being discussed under "Captain fired from Allegiance Air for an EVAC." what an AI a/c would have done. And there are other scenarios which mitigate in favour of pilots. Hopefully this sad case will not lead to further clamouring for more automatic a/c. I think the solution lies else where.

[mac76]

We don't have any procedure for resetting facs other than the push button on the overhead ,there is no procedure in QRH in resets section,i have 5022 hrs on airbus and have been flying it since 2007,we only did our first high level stall training last week in the sim ( fl350) ,so for 8 years i have done only a basic stall at 5000 ft and only last week we did first high stall recovery in bank & with wings level we took 3 to 4000 feet to recover ,as we take a little time to ensure the aircraft is unstalled before adding thrust,whereas before airbus taught us to add toga thrust and lower the wings .

These guys prob have not had the chance to practice high level stall recovery ,the startle factor, the design of the side sticks is not really helpful when one guy is frozen on the stick ,even though the take over push button is supposed to allow the other pilot to take over.i studied the af 447 accident in detail and there are many many similarities here ,it seems we must do more high level stall training in the sim ,the companies have to spend more time and more money in the sim for their crews.As other pilots have discussed the f/o was totally absorbed in leveling the wings at the expense of not paying enough attention to lowering the nose and the ease at which he pulls back on the stick instead of pushing forward is a serious problem .

The airbus test pilots need to speak to the airline pilots at training briefings and give them more understanding and more insight into stall recovery of airbus aircraft at high levels above fl200.There is too much confidence that the a/c is in normal law and u cant stall it when the aircraft is actually in alternate law and u can stall it.

[tdracer]

Part of me is thinking perhaps we need a 'different' warning for a "deep stall" - it shouldn't be hard to detect (stall=true, AOA>X, vertical speed negative and >Y).
OTOH, any competent pilot should know that the correct action to any stall warning is to push the stick/yoke forward (unless ground contact is imminent - certainly not a concern at high altitude). So if they are ignoring the current stall warning, would a deep stall warning be any different?
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?

[Denti]

Interesting, mac76, apparently operators are very different about that. 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. Well, to be honest we did them every six months for the last 15 years, but before AF447 mainly low level with a renewed focus after the THY accident.

I'm only on the bus for a bit over a year, however during typerating we had to do the high level stall recovery a couple times in several sessions and since then in the two simulator events since i had to demonstrate it as well. However, there is still some focus on manual flying raw data in my company. We just realised that it will be easiest to fly raw data on every approach once we start the airbus SOPs in mid december, there's no FMA callout once everything is off.

[fenland787]

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.

[IcePack]

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.

[IcePack]

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.

[PDR1]

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

[peekay4]

@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.

[jack11111]

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?

[alf5071h]

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.

[JFZ90]

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?

[ampclamp]

Jack11111.

re solder joint.

It would be inside the FAC. Aircraft wiring pins and sockets in the vast majority of cases are crimped.

[FDMII]

Originally Posted by alf5071h

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.

[xcitation]

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

[oldoberon]

Originally Posted by fenland787

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.