CRJ down in Sweden
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Sveriges Radio P4 Norrbotten is a radio channel that covers the area where the plane crashed. They are reporting that work with retrieving plane parts have started (as reported the 13th of June) and they are concerned about how the remaining fuel might affect wild life.
Nothing is mentioned about the crew, but having a little knowledge about the area, I would suspect there is very little to do. Polar foxes, wolves, lynx, bears and other predators might have already done their deeds. As I said before, this area is very remote and there are no roads. The ground has not been stable enough (or snow free enough) for retrieving crews to get there until now. Northern Sweden is very similar to, lets say, Alaska, for you who wonder about the environment in which the plane crashed.
I am hoping they find wreckage that might explain why the IRU stopped working! Nothing is mentioned about that in the broadcast.
For those who are interested in hearing Swedish: a link to the broadcast: Det norska postflyget ska nu bärgas - P4 Norrbotten | Sveriges Radio
Sorry I didn't update this immediately I found it. Been busy!
Nothing is mentioned about the crew, but having a little knowledge about the area, I would suspect there is very little to do. Polar foxes, wolves, lynx, bears and other predators might have already done their deeds. As I said before, this area is very remote and there are no roads. The ground has not been stable enough (or snow free enough) for retrieving crews to get there until now. Northern Sweden is very similar to, lets say, Alaska, for you who wonder about the environment in which the plane crashed.
I am hoping they find wreckage that might explain why the IRU stopped working! Nothing is mentioned about that in the broadcast.
For those who are interested in hearing Swedish: a link to the broadcast: Det norska postflyget ska nu bärgas - P4 Norrbotten | Sveriges Radio
Sorry I didn't update this immediately I found it. Been busy!
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Update on this:
Nothing.
Not a word. Zero. Not even local local radio has said anything to my knowledge. Granted, I doubt I know about all amateur radios with very short range capabilities, but the channels I can reach - zilch. Also granted, I am not privy to internal information within Svenska Haverikommissionen - simply because I do not work there... :-)
The official site from SHK - Statens haverikommission is equally quiet. They are working with French, Norwegian, Spanish officials. No mention of an estimated month of completion of the report.
I get the feeling this IRU problem might be a hard one to crack. Still, some little tidbit of information would be nice.
Nothing.
Not a word. Zero. Not even local local radio has said anything to my knowledge. Granted, I doubt I know about all amateur radios with very short range capabilities, but the channels I can reach - zilch. Also granted, I am not privy to internal information within Svenska Haverikommissionen - simply because I do not work there... :-)
The official site from SHK - Statens haverikommission is equally quiet. They are working with French, Norwegian, Spanish officials. No mention of an estimated month of completion of the report.
I get the feeling this IRU problem might be a hard one to crack. Still, some little tidbit of information would be nice.
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Final report seems to be out
Utredningar - Olycka vid Oajevágge i Jokkmokks kommun med flygplanet SE-DUX av typen Canadair CRJ 200
In Swedish, anyone feel like translating it?
Utredningar - Olycka vid Oajevágge i Jokkmokks kommun med flygplanet SE-DUX av typen Canadair CRJ 200
In Swedish, anyone feel like translating it?
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Pegase Driver
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quote 1 : the aeroplane was level flight at FL330 when the incident occurred .
quote 2 : The aeroplane collided with the ground in an inverted position at t80,
one minute and twenty seconds after the start of the event.
quote 3 : The erroneous attitude indication on PFD 1 was caused by a malfunction of the Inertial Reference Unit (IRU 1).
quote 4 :The accident was caused by insufficient operational prerequisites for the management of a failure in a redundant system.
Frightening to read the sequence of events . if you think it could have been be you.
quote 2 : The aeroplane collided with the ground in an inverted position at t80,
one minute and twenty seconds after the start of the event.
quote 3 : The erroneous attitude indication on PFD 1 was caused by a malfunction of the Inertial Reference Unit (IRU 1).
quote 4 :The accident was caused by insufficient operational prerequisites for the management of a failure in a redundant system.
Frightening to read the sequence of events . if you think it could have been be you.
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So, once again, instrument failure leading to a crash. The holes in the Swiss cheese line up yet again.. A chilling read!
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CRJ down in Sweden
Last edited by Latchman; 13th Dec 2016 at 12:21. Reason: review
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According to my understanding of the report, this would be a probable sequence of events:
Pilots briefing maps, using lights and reducing night vision.
IRU malfunctioning.
Pilots startled by strange PFD displays.
Pilots taking action.
No communication who is in control and no double checking of instruments can be heard on the CVR.
This was one malfunctioning instrument that would have been easy to spot if a comparison had been made between LHS and RHS. Noone did, noone thought "pitch, power" and landed safely.
How many AF447 will there continue to be?
Pilots briefing maps, using lights and reducing night vision.
IRU malfunctioning.
Pilots startled by strange PFD displays.
Pilots taking action.
No communication who is in control and no double checking of instruments can be heard on the CVR.
This was one malfunctioning instrument that would have been easy to spot if a comparison had been made between LHS and RHS. Noone did, noone thought "pitch, power" and landed safely.
How many AF447 will there continue to be?
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A very sad read, I feel for the crew. This underscores what I have been taught in de sim after the AF accident: you have to compare ALL indications when faced with unusual attitudes, never instinctively react to just one parameter.
If your PFD shows a ridiculously large nose up pitch angle then your airspeed should decrease. It is impossible for the speed to remain stable with such a pitch angle. If it does, something does not add up...
If your PFD shows a ridiculously large nose up pitch angle then your airspeed should decrease. It is impossible for the speed to remain stable with such a pitch angle. If it does, something does not add up...
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Very sad but at that time of night most would be startled. But again it shows how modern cockpits & automation has eroded basic flight skills. Something I found coming from a more basic type where a good instrument scan was natural. To tunnel vision as everything you need is on the PFD. Methinks in the past a artificial horizon failure woul just cause a que? Moment as your instrument scan (more like a total look) would immediately alert you to it not being right. I realise the pfd saves the big scan but think it is a human brain thing. More human research should have been done before creating complex displays.
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This was an accident stemming from a 'hazardous misleading display', which according to AMC 25.1302 2.1 requires that 'The probability of indication of dangerously incorrect information without a warning being given should be Extremely Remote'.
We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard. Was the probability proven by numbers, or risk assessed such as the crew were expected to notice (regulatory generated black swan).
The EFIS software appears to have been designed to remove the alerts, the accident was 'as designed'; thus how did the various checking processes fail to meet the safety requirement.
The above questions are easy to ask with hindsight, but how might these aspects be turned into foresight.
Is the current emphasis on LoC training, immediate action, and SOPs now biasing pilots to react with little thought, no crosschecking, particularly in surprising situations.
Is the industry generating this type of accident, misunderstanding or seeking to address the difference between what is assumed to happen against the reality of rare accidents, with unrepresentative regulation.
Can the current safety and regulatory processes be expected to identify and manage events beyond the certification boundaries.
There are many approaches to safety, all necessary for achieving the current high level of safety, but is their more recent application now endangering future safety. Regulatory restraint, 'SOP for everything', and train for 'everything', except that not everything can be foreseen, offers diminishing safety return. There is greater need for the interpretation of requirements for training, emphasis on a checking mentality vs educating and understanding, which if misapplied decrease the opportunity for experience further weakening crews' ability to manage the unforeseen. This accident may have been foreseen, but it was parked the other side of a regulatory line 'of assumption' to become 'unforeseeable', yet still expecting crews to manage the surprise when it happens.
Time to change the way we think about safety.
We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard. Was the probability proven by numbers, or risk assessed such as the crew were expected to notice (regulatory generated black swan).
The EFIS software appears to have been designed to remove the alerts, the accident was 'as designed'; thus how did the various checking processes fail to meet the safety requirement.
The above questions are easy to ask with hindsight, but how might these aspects be turned into foresight.
Is the current emphasis on LoC training, immediate action, and SOPs now biasing pilots to react with little thought, no crosschecking, particularly in surprising situations.
Is the industry generating this type of accident, misunderstanding or seeking to address the difference between what is assumed to happen against the reality of rare accidents, with unrepresentative regulation.
Can the current safety and regulatory processes be expected to identify and manage events beyond the certification boundaries.
There are many approaches to safety, all necessary for achieving the current high level of safety, but is their more recent application now endangering future safety. Regulatory restraint, 'SOP for everything', and train for 'everything', except that not everything can be foreseen, offers diminishing safety return. There is greater need for the interpretation of requirements for training, emphasis on a checking mentality vs educating and understanding, which if misapplied decrease the opportunity for experience further weakening crews' ability to manage the unforeseen. This accident may have been foreseen, but it was parked the other side of a regulatory line 'of assumption' to become 'unforeseeable', yet still expecting crews to manage the surprise when it happens.
Time to change the way we think about safety.
SkyGod
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Time to change the way we think about safety.
No idea what they were thinking...
Last edited by TowerDog; 12th Dec 2016 at 17:04.
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Sit on your hands and count to ten. One thinks it would have helped save the day, but who knows. The Swiss cheese holes are lining up in more and more accidents.
Originally Posted by TowerDog
No idea what they were thinking...
The final report is chillingly clear. PF startled by the aural warning and all the blue on the PFD instinctively pushed the nose down without thinking. PNF seeing correct display was totally out of the loop on why. All this in the small hours on a 5th & last leg, with cockpit lights on for the approach briefing during a pitch black night with zero outside visual references. By the time they started to get their act together the situation was beyond recoverable.
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We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard.
SkyGod
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,
No idea what they were thinking...
The final report is chillingly clear. PF startled by the aural warning and all the blue on the PFD instinctively pushed the nose down without thinking. PNF seeing correct display was totally out of the loop on why. All this in the small hours on a 5th & last leg, with cockpit lights on for the approach briefing during a pitch black night with zero outside visual references. By the time they started to get their act together the situation was beyond recoverable.
No idea what they were thinking...
The final report is chillingly clear. PF startled by the aural warning and all the blue on the PFD instinctively pushed the nose down without thinking. PNF seeing correct display was totally out of the loop on why. All this in the small hours on a 5th & last leg, with cockpit lights on for the approach briefing during a pitch black night with zero outside visual references. By the time they started to get their act together the situation was beyond recoverable.
Pretty basic, but yes, I understand they were tired, lights were on, etc, etc.
Well, too late now and there is lessons to be learned here: Same as in basic training: Fly the good side, don't rush too into action, etc.
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When you have a mechanical gyro in the center of your panel in the back of your mind maybe you might think "My attitude gyro just died".
The beautiful Integrated PFD's are just so convincing.
The beautiful Integrated PFD's are just so convincing.
