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737-500 missing in Indonesia

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737-500 missing in Indonesia

Old 2nd Jun 2021, 07:36
  #841 (permalink)  
 
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I naively assumed that since there is a preliminary report already, the connection of the dots with a CVR should be straightforward. Clearly I am wrong.
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Old 2nd Jun 2021, 07:53
  #842 (permalink)  
 
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Preliminary report has to normally be published within 30 days of the incident/accident, but the full investigaton might take many months or even years after that, depending on the complexity of the case.

If you've read any of their reports, you would see that NTSC (Indonesia's investigating comitee) is amongst the best in the world, unfortunately partly due to the amount of practice they get investigating incident and accidents. Your criticism is unfounded here.
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Old 2nd Jun 2021, 14:50
  #843 (permalink)  
 
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krismiler

This (mal)practice is not constrained to "Third world" only. Am aware of EU operator with suspiciously "clean" Technical Logbook (zero tech snags) but with some little Post-it yellow slips sticked around cockpit.
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Old 10th Jun 2021, 11:47
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FlyingStone

Indeed their reports are very detailed and pull few punches and cover all aspects including ones around people and maintenance and management
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Old 12th Jun 2021, 14:24
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If a Probable Cause has been identified and that has resulted in one or more Safety Recommendations to mitigate the chances of a repetition, those can be (and often are) made during the course of the investigation. They don't have to wait for the Final Report.

There have been two Safety Recommendations to date from the current investigation.
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Old 14th Jun 2021, 09:36
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Dave. Can you provide the safety recommendations please? I can’t find them
in this thread. Many thanks.
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Old 14th Jun 2021, 11:05
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retired guy

04.R-2021-01.01:
KNKT recommends the DGCA to include a requirement of UPRT in the CASR and to develop guidance to increase the effectiveness of UPRT.

04.R-2021-01.02:
KNKT recommends the DGCA to review the requirements of notification of rescue coordination center in the CASR 170 to ensure that the requirement is in accordance with the standards in ICAO Annex 11.
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Old 20th Oct 2021, 12:38
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Has anyone more recently seen/heard of any new info./findings for the cause yet ?
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Old 5th Nov 2022, 12:59
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Report in the Jakarta post. Doesn't make for very good reading. If I was diving towards the sea, retarding the the thrust levers might be a first step in recovery. https://www.thejakartapost.com/indon...port-says.html
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Old 5th Nov 2022, 14:07
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Hard to read. If you continuously fly with planes of that maintenance "quality" you would assume that the basic airmanship of the PF has a good standard. Otherwise Darwin will sort it out as in this case...
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Old 11th Nov 2022, 03:20
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FInal report is published.
Can be found at https://knkt.go.id/Repo/Files/Lapora...nal-Report.pdf

Also attached...
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Old 11th Nov 2022, 05:29
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Originally Posted by EDLB
Otherwise Darwin will sort it out as in this case...
That is disgusting. To a large extent, the performance of the pilots is dictated by their superiors and regulatory authority. Pull your head in.
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Old 11th Nov 2022, 06:37
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Originally Posted by Capn Bloggs View Post
That is disgusting. To a large extent, the performance of the pilots is dictated by their superiors and regulatory authority. Pull your head in.
Ahhh, shooting the messenger of an unpleasant message.

Just live for a longer period in (for example) a poor Asian country, and you start to understand, the people are very friendly, etc, though the reasons why the country is poor is ingrained at EVERY level of the society. It's an all-over cultural problem, not a "chef" problem. The same reasons why Russia is completely failing with its army, the reasons why the Afghan government collapsed faster than the US could withdraw.
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Old 11th Nov 2022, 08:10
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Originally Posted by Dungdang View Post
FInal report is published.
Can be found at https://knkt.go.id/Repo/Files/Lapora...nal-Report.pdf

Also attached...
64 items listed under Findings, plus six more Contributing Factors.

That's one heck of a Swiss Cheese.
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Old 11th Nov 2022, 10:02
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FDR traces from the Final report:

Parameter Set 1 for full flight:




Parameter Set 2 for full flight:




Parameter Set 1 for final 2 minutes:




Parameter Set 2 for final 2 minutes:



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Old 11th Nov 2022, 10:03
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Indeed !
that sentence however is a very big hole :
The maintenance record showed that the A/T problem was reported 65 times since 2013 and the problem was unsolved and still exist on the accident flight.
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Old 11th Nov 2022, 23:59
  #857 (permalink)  
 
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the performance of the pilots is dictated by their superiors and regulatory authority
While true, but as pilot if a system has been written up 60+ times would you not have been watching it like a hawk? But that presumes the maintenance log they reviewed reflected the length of the ongoing problem.
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Old 12th Nov 2022, 05:12
  #858 (permalink)  
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Where to begin

1. Hmmm.
2. The thrust levers split on a vanilla, fly by #8 gauge wire B737, for a little less than 1&1/2 minutes before someone woke up that the reason their ear was hurting was because they were flying sideways... whatever movie they were watching, I hope it was worth it.
3. The logbook, post-its notes etc... do not make up for having 2 pilots that had not an idea of what they were doing in the plane. Had this been a C310, or a Baron, they would have had the same outcome. The fact that a post it note, or INOP sticker was going to be the saving grace is vacuous. If the guys had the problem at any other time, are they supposed to do a Tom Hanks, and roll down a window and ask where the nearest gas station with a toilet is?
4. UPRT training [1]. I'm involved in that, I have done high alt stalls, Mdive, windups, mid altitude full stalls in all configurations in this type and various others. the ICAO UPRT program is a nice glossy concept, it will increase the cost of simulators, increase the problem with getting QTGs sorted out, (I'm in the middle of one of those things.. ) it increases the problems of TTT, and the quality of what is taught is still going to be dependent on the day. Do I believe it is an improvement? Well, it is a great stand-in for not training correctly in the first place, and not being able to come to grips with the fundamental problem, that is, LOSS OF SITUATIONAL AWARENESS. Had a pilot with a modicum of SA been looking at the world around him or her, then the fact that they were flying sideways, and that the thrust levers were not in an eye pleasing arrangement might have been caught.

Good Grief

This is not even the pilots fault. Someone "trained" this group, someone "hired" this group, and someone "standardised" this group. Someone "oversaw" their competency, as surely they had no awareness.

Nice barrel roll though, a bit of top rudder would help.

It took almost a minute and a half to get the thrust to symmetrical, at idle. Well, shoot. 90 seconds, lets call this speedy. After all they were doing 100m/sec to start with, and then when they got the noise makers into harmony they were pointing 80 degrees nose down, had rolled through inverted, and were doing apparently well over 400KCAS. I would be impressed that there weren't bits of plane, probably the elevators released into the air before they got wet.

Lets be honest for a change, instead of politically correct. Lets give a bit of consideration to the passengers. They pay and can reasonably expect a professional crew to sit in control of their existence for the period of time that they are on board the bus. This is in one word, embarrassing. it is also not a cultural issue, this is barely any different to the shambolic delivery by Prime into the water off Houston of a B767F. I know a number of really good Indonesian pilots, pity there wasn't a pilot in the cockpit of this aircraft.

Startle? seriously, if you are jamming your ear into the rail that the DV window slides on, one can assume that anyone with a heartbeat and a modicum of interest in the proceedings would respond with some level of curiosity.

golly.


I am sorry, this is about as annoying as a data set can be.


FDR

[1]
  • FAA AC 120.111 UPRT
  • ICAO Doc 9859 AN/ Safety Management Systems
  • ICAO Doc 10011 AN/506, Manual on Aeroplane Upset Prevention and Recovery Training
  • ICAO PANS-TRG, Doc 9868, Procedures for Air Navigation Services – Training
  • ICAO Annex 1 — Personnel Licensing
  • ICAO Annex 6 — Operation of Aircraft, Part I — International Commercial Air Transport — Aeroplanes
  • ICAO Doc 9625 Manual of Criteria for the Qualification of Flight Simulation Training Devices – Volume 1 Aeroplanes
  • CASA AC 121-03 v1.0 Upset prevention and recovery training
  • CASA AC 61-16 v1.0 Spin avoidance and stall recover training

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Old 12th Nov 2022, 08:57
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the fundamental problem

"… the fundamental problem, that is, LOSS OF SITUATIONAL AWARENESS."

If something has been lost by the crew (apparently both simultaneously), then what is this 'awareness' which existed beforehand, how was it gained, maintained, and then why was it lost.

The fundamental problem is human nature, our limited ability to comprehend everything - a necessary limitation to function normally; but most of all our view with hindsight, and recognition of this bias.
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Old 12th Nov 2022, 08:59
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Originally Posted by megan View Post
While true, but as pilot if a system has been written up 60+ times would you not have been watching it like a hawk? But that presumes the maintenance log they reviewed reflected the length of the ongoing problem.
Yep, out of the ordinary (hmmmm, only somewhat, see the MAX saga) this to happen in Western countries, though, it's pretty normal for Indonesia and many other Asian countries and just live with the "inconveniences".

Have no money to buy food today, well, then we will be hungry today, but tomorrow, we have money again and eat for 2. Strange, though pretty normal in (poor) Asian countries. And for those with a little more money, it's not the daily food, but many, many other inconveniences, for example, a phone which doesn't work, a flat tire, or whatever.

That's the Complacency item, just consider unpleasantries normal and not realizing it's sometimes outright dangerous.
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