[P7_TOM]

This story – HERE - nearly slipped by.  Another sad story, from yet another sad day, in a sad world where a crew out to dinner can be indiscriminately mown down.  Not that being crew makes them special, just brings the sorry plight of world a little closer to your front door.  Room service and locked door or, meet at the bar for a beer then dinner should not be a life threatening decision.  

The six Russian men, employees of the airline Volga-Dnepr, were killed in the hotel restaurant when the gunman first opened fire, according to Maria Zakharova, a spokeswoman for the Russian Foreign Ministry.

RIP.

[Gobbledock]

FFS, when will this worlds death and carnage stop?

I'm happy raise a toast to our 6 fellow comrades killed for doing nothing more than relaxing part way through a gruelling schedule. R.I.P boys.

To lighten up an immensely painful occurrence I am going to travel back a few hours in the lives these pilots before their final moments.

I'm picturing them unwinding in the hotel bar. Knocking back a few shots of Smirnoff in between mouthfuls of dressed herring, followed by a couple more shots of Smirnoff, and recapping the days work. Swapping war stories about flying the illustrious An-124, a behemoth of the sky, landing at max weight and praying that the airports PCN will cope! Laughing about their days on the AN-12, and how the poor bastard Engineer would sit in the gun turret and how locals would sometimes call the Firies after seeing 4 trails of burnt kero as she left her signature trail in the sky post takeoff!

As the night draws on the lads start to throw in some 'girl' stories, you know 'blondes vs brunettes, tall vs short, slim vs cuddly', east vs west. Indeed, Russian pilots love their women, food, Vodka and planes.

6 Crew doing their thing, cut short by a violent, psychopathic disintegrating world.

R.I.P

[P1_aka_P1]

Nicely done GD, nicely done indeed, you speak for all crew, everywhere in the world this night.  Bravo.

It is hard to know what would be an appropriate way to bid farewell to a Russian aircrew:-

MOSCOW, Sept. 7— Maksim Bykovsky, a graduate student and businessman, rose slowly to his feet, a full glass of vodka in his hand. It was time for the third toast -- to the dead, he thought, but wasn't sure. He'd had a bit too much to drink already, and the party in his apartment here was just getting under way.

Confusion is common on the complicated etiquette of how to drink and toast in Russia. In the military, it is traditional to drink the third toast to those who've died in war -- unless it's the second toast.

Even the duty officer of the Defense Ministry wasn't sure, and had to call back. "It's the third," he finally said, no doubt after profound research. But there is no disagreement among soldiers that the next toast -- the fourth -- is to the hope that no one will ever drink the previous toast for those around the table.

The next 10 toasts are often reserved, at least among soldiers, to women. This intelligence leads to the main conclusion: that Russians drink to get drunk, and it's only when drunk -- in vodka veritas -- that any Russian really trusts another. But on the way there, toasts are used for many purposes, from the sentimental to the political, and they are often a mechanism for the kind of pointed truth-telling normally avoided in social or business conversations.

There is little confusion about the rules for first and second toasts. It is considered uncivilized to start drinking without a first toast, which is a kind of blessing or sacrament. The second follows quickly. In a well-known Cossack expression, "Between the first and second toasts, a bullet should not pass." The bureaucrats have their own version: "Between the first and second, you shouldn't squeeze a finger" (theirs are normally quite thick).

In the old days, the first toast was always "To Stalin!" -- even at a child's birthday party. Other than personality cults, Communism produced a bizarre collection of strange and lifeless toasts, like a favorite one of the Komsomol or Young Communists: "To the success of the scheduled tasks!"

Among close friends, the first toast may be brief and informal -- as simple as "Budem zdorovy!" -- "Let's be healthy!" -- or even just "Budem!" or, in dire cases, "Boum!" The last is used toward the end of a drinking bout, when it is difficult to articulate anything else.

At a wake, the first toast is raised to the dead person, and glasses must never be clinked.
At birthdays, the first toast is to the health of the celebrator; the second to that of the parents.

At weddings, similarly, the first toast is to the newlyweds, the next to their parents. But then begins the special Russian combination of collective, forced hilarity, common around the twin topics of liquor and love, that still carries a kind of totalitarian flavor.

When the guests drink from their glasses, traditionally the supersweet domestic champagne (still known and sold as Sovetskoye Shampanskoye), there are always one or two who will shout: "It's bitter, make it sweeter!" Suddenly there is a rhythmic chorus, like a chant at a soccer match, of "Gorko! Gorko! Gorko!" -- "Bitter! Bitter! Bitter!"

The poor newlyweds can stop the chant only by initiating a long kiss, during which relatives and friends (even the bride's mother) count in unison: "One, two, three," and so on. The longer the kiss, the greater the applause. A mediocre effort will produce another shout of "Gorko! Gorko!" and force a repetition of the entire humiliating performance.
Sometimes, after numerous repetitions, the couple may be spared by the tamada, a Georgian title for the toastmaster, a semi-dictator who is supposed to know the social intricacies and keep the party, and the vodka, flowing.

Soldiers, bored in peacetime, must often drink without any occasion. Officers in small provincial garrisons commonly catch a cockroach, rarely a difficult task in Russia, and chase it along the table, prompting two quick toasts: "S priyezdom!" or "Happy arrival!" and "S otyezdom!" or "Happy journey!" New Yorkers may practice this at home.

"There is still a manhood thing attached to it all," said Thomas R. Pickering, the American Ambassador here, who long ago discovered that the key qualification for his job is the ability to eat and drink anything. In his many official banquets all over vast, vodka-sodden Russia, he has found that among his hosts, "the worst of them want to get falling-down stone drunk, while the best of them want to get happy, loose and seriously emotional -- peeling away the layers of convention and protection."

But he understands that toasts, especially at official gatherings, are a way to get political points across. After the social graces, warm words and touch of humor, "there is always time for a message." In return, he says, "there's always full equal time for a response and more."

When Westerners appear to be holding back, Russians will shout: "Do dna!" -- "To the bottom!" or bottom's up. Russians, fearing to be more incapacitated than others around the table (the sober one was regarded as a likely stoolpigeon), have a complicated series of fines for those who arrive late. Normally the penalty involves drinking, do dna, the largest available glass, vessel or urn, filled with vodka.

If "do dna" is feared, the toast to remember is equally simple: "Na pososhok!" -- basically one for the road, from the word posokh, for walking stick or staff. It is another Cossack toast, and it is considered extremely bad manners to offer any more toasts or require any more drinking once a guest has uttered it. But it is also extremely bad manners to utter it too soon.

Confusion or no; I shall raise a silent toast tonight, to honour all aircrew.  Godspeed.

Requiescat in pace.

[Peetwo]

Developing story Air Asia QZ8501 Final Report released:

Faulty rudder system major factor in AirAsia QZ8501 crash

Repeated problems with the system led to the pilots disengaging the autopilot in stormy weather in a bid to fix the situation, and then losing control of the Airbus A320-200.

• POSTED: 01 Dec 2015 15:27
  

File photo of a section of AirAsia flight QZ8501's tail being loaded onto a boat for transportation to Jakarta from Kumai Port, near Pangkalan Bun, Central Kalimantan

JAKARTA: A fault with the rudder control system was a major factor in the crash in December into the Java Sea of an AirAsia plane, with the loss of 162 lives, Indonesian investigators said Tuesday (Dec 1).

Repeated problems with the system led to the pilots disengaging the autopilot in stormy weather in a bid to fix the situation, and then losing control of the Airbus A320-200, Indonesia's official National Transportation Safety Committee said. 

Flight QZ8501 was en route from Surabaya to Singapore when it crashed on Dec 28, 2014. 

- AFP/rw

  
Will update as more details come to hand and/or the actual final report becomes publicly available.
MTF..P2  

[ventus45]

Final Report QZ8501

Indonesian National Transport Safety Committee web site..
http://kemhubri.dephub.go.id/knkt/ntsc_home/ntsc.htm

Pdf - 206 pages
Report Link
http://kemhubri.dephub.go.id/knkt/ntsc_a...PK-AXC.pdf

[ventus45]

At 2316:44 UTC
Auto Pilot (A/P) and the Auto-thrust (A/THR) disengaged.
Flight control law reverted from Normal Law to Alternate Law.
The aircraft started to roll to the left up to 54° angle of bank.

Nine seconds after the autopilot disengaged, the right side-stick activated.

The aircraft roll angle reduced to 9° left and then rolled back to 53° left.

The input on the right side-stick was mostly pitch up and the aircraft climbed up to approximately 38,000 feet with a climb rate of up to 11,000 feet per minute.

2317:18 UTC
The stall warning activated and at 2317:22 UTC stopped for 1 second then continued until the end of recording.

The first left side stick input was at 2317:03 UTC for 2 seconds and at 2317:15 UTC another input for 2 seconds, then since 2317:29 UTC the input continued until the end of the recording.

The right side stick input was mostly at maximum pitch up until the end of recording.

The lowest ISIS speed recorded was 55 knots. The ISIS speed recorded fluctuated at an average of 140 knots until the end of the recording.

2317:41 UTC
At 2317:41 UTC the aircraft reached the highest ISIS altitude of 38,500 feet and the largest roll angle of 104° to the left. The aircraft then lost altitude with a descent rate of up to 20,000 feet per minute.

At approximately 29,000 feet the aircraft attitude was wings level with pitch and roll angles of approximately zero with the airspeed varied between 100 and 160 knots.

The Angle of Attack (AOA)5 was almost constant at approximately 40° up and the stall warning continued until the end of recording.

The aircraft then lost altitude with an average rate of 12,000 feet per minute until the end of the recording.

2320:35 UTC
The last data recorded by FDR was at 2320:35 UTC with ISIS airspeed of 132 kts, pitch 20° up, AOA 50° up, roll 8° to left, the rate of descent 8,400 ft/minute and the radio altitude was 118 feet.

My Initial Simple Summary:
Systems malfunctions led to FO conducting unintended zoom climb to LOC, then held full back stick all the way down.

Verdict:
AF-447 Mk2

[Peetwo]

Thank you Ventus..

Here is the latest from the ABC with additional links for other news outlets:

AirAsia QZ8501: Investigation into downed flight finds maintenance and crew error to blame


By Indonesia correspondent Samantha Hawley, wires
 Tue 1 Dec 2015, 7:29pm

Photo: Analysis of the plane's black boxes has now been released by Indonesia's Transport Safety Bureau. (Reuters: Antara Photo Agency, file photo)


An investigation into the downing of an AirAsia flight last year has found both maintenance and crew error to blame for the crash.

Flight QZ8501 crashed into the Java Sea during a short flight from Surabaya to Singapore in December 2014, killing all 162 on board.

Analysis of the plane's black boxes has now been released by Indonesia's Transport Safety Bureau, showing unresolved repetitive faults with the aircraft.

A fault with the rudder control system was a major factor in the plane's downing, Indonesian investigators said.

Repeated problems with the system led to the pilots disengaging the autopilot in stormy weather in a bid to fix the situation, and then losing control of the Airbus A320-200, Indonesia's official National Transportation Safety Committee said.


Photo: A member of Indonesia's search and rescue team walks past a piece of the plane wreckage. (AFP: Yudha Manx, file photo)

In their final report into the crash, investigators said the soldering on the Rudder Travel Limiter system — which helps control the rudder's movement — was cracked, leading it to send repeated warning messages to the pilots.

When they received the fourth warning, the pilots pulled circuit-breakers on part of the aircraft's control system in a bid to reset the system.

This turned off the autopilot, and the plane then started to roll, the report said.
"Subsequent flight crew action resulted in inability to control the aircraft," the report said.
The plane went into a "prolonged stall condition that was beyond the capability of the crew to recover", it said.

It added the flight data recorders did not indicate the weather had affected the aircraft.
The report also said the AirAsia plane had the same problem with its rudder system 23 times in the 12 months before the December crash.

ABC/wires
From other news sites:

• The Sydney Morning Herald: Crew's actions blamed for AirAsia crash
  
• Mirror: AirAsia Flight QZ8501 plane crash: Live updates as investigators reveal what caused tragedy that left 162 dead
  
• CNN: Report: Pilot response to equipment malfunction led to Air Asia QZ8501 crash
  
• The Independent (UK): AirAsia flight QZ8501: 'Crew action' caused loss of control of flight that crashed into Java sea killing 162
  
• Daily Mail: AirAsia jet crash which killed all 162 on board was caused by cracked flight computer and 'subsequent crew actions', say investigators
  

   

News



 
2015
 
Publications - Update (01/12/2015)
 

Media Release English / Indonesia

Subject: NTSC Final Investigation Report into Airbus 320-216 - PK-AXC
involving Indonesia Air Asia Company Flight QZ-8501 during flight at Karimata Strait,
Coordinate 3�37'19"S-109�42'41"E - Java Sea on 28 December 2014

 FINAL REPORT (Aviation Division) - RELEASED on DECEMBER 1, 2015
Indonesia Air Asia Company Flight QZ-8501, AIRBUS 320-216 - PK-AXC,
During flight at Karimata Strait - Coordinate 3�37'19"S-109�42'41"E,
Java Sea, December 28, 2014

MTF...P2

[Peetwo]

Thank you Ventus..

Here is the latest from the ABC with additional links for other news outlets:

AirAsia QZ8501: Investigation into downed flight finds maintenance and crew error to blame


By Indonesia correspondent Samantha Hawley, wires
 Tue 1 Dec 2015, 7:29pm

Photo: Analysis of the plane's black boxes has now been released by Indonesia's Transport Safety Bureau. (Reuters: Antara Photo Agency, file photo)


An investigation into the downing of an AirAsia flight last year has found both maintenance and crew error to blame for the crash.

Flight QZ8501 crashed into the Java Sea during a short flight from Surabaya to Singapore in December 2014, killing all 162 on board.

Analysis of the plane's black boxes has now been released by Indonesia's Transport Safety Bureau, showing unresolved repetitive faults with the aircraft.

A fault with the rudder control system was a major factor in the plane's downing, Indonesian investigators said.

Repeated problems with the system led to the pilots disengaging the autopilot in stormy weather in a bid to fix the situation, and then losing control of the Airbus A320-200, Indonesia's official National Transportation Safety Committee said.


Photo: A member of Indonesia's search and rescue team walks past a piece of the plane wreckage. (AFP: Yudha Manx, file photo)

In their final report into the crash, investigators said the soldering on the Rudder Travel Limiter system — which helps control the rudder's movement — was cracked, leading it to send repeated warning messages to the pilots.

When they received the fourth warning, the pilots pulled circuit-breakers on part of the aircraft's control system in a bid to reset the system.

This turned off the autopilot, and the plane then started to roll, the report said.
"Subsequent flight crew action resulted in inability to control the aircraft," the report said.
The plane went into a "prolonged stall condition that was beyond the capability of the crew to recover", it said.

It added the flight data recorders did not indicate the weather had affected the aircraft.
The report also said the AirAsia plane had the same problem with its rudder system 23 times in the 12 months before the December crash.

ABC/wires
From other news sites:

• The Sydney Morning Herald: Crew's actions blamed for AirAsia crash
  
• Mirror: AirAsia Flight QZ8501 plane crash: Live updates as investigators reveal what caused tragedy that left 162 dead
  
• CNN: Report: Pilot response to equipment malfunction led to Air Asia QZ8501 crash
  
• The Independent (UK): AirAsia flight QZ8501: 'Crew action' caused loss of control of flight that crashed into Java sea killing 162
  
• Daily Mail: AirAsia jet crash which killed all 162 on board was caused by cracked flight computer and 'subsequent crew actions', say investigators
  

   

News



 
2015
 
Publications - Update (01/12/2015)
 

Media Release English / Indonesia

Subject: NTSC Final Investigation Report into Airbus 320-216 - PK-AXC
involving Indonesia Air Asia Company Flight QZ-8501 during flight at Karimata Strait,
Coordinate 3�37'19"S-109�42'41"E - Java Sea on 28 December 2014

 FINAL REPORT (Aviation Division) - RELEASED on DECEMBER 1, 2015
Indonesia Air Asia Company Flight QZ-8501, AIRBUS 320-216 - PK-AXC,
During flight at Karimata Strait - Coordinate 3�37'19"S-109�42'41"E,
Java Sea, December 28, 2014

Thank heavens for Ben - Finally after all the somewhat regurgitated MSM crap on the QZ8501 Final Report PT shines a light on the bollocks that is being currently smeared around:

Harsh truths about crash of AirAsia QZ8501 come out

Ben Sandilands | Dec 01, 2015 8:25PM |

This AirAsa jet flew with a serious fault for a year before killing 162 people

The headlines tonight in some reports about the Indonesian accident inquiry findings into AirAsia’s Java Sea disaster late in 2014 claim it was pilot error, which is a serious misreading of the situation.

The 162 people who were slaughtered on flight QZ8501 on its way from Surabaya to Singapore last 28 December were killed by AirAsia’s persistent inability to correctly maintain the A320 by failing to repair a cracked solder joint in its rudder travel limiter system despite its being recorded as defective 23 times in the year before the jet plunged out of control into a shallow but fast moving sea.

The statement by Indonesia’s Transportation Safety Board says that this part failed a further  four times immediately before the jet crashed, sending repeated systems warnings to the pilots before one of them pulled circuit breakers on part of the control system in an attempt to reset it.

This disconnected the autopilot and left the two pilots in a position where taking manual control of the jet was outside their trained capabilities. The transportation board statement says “Subsequent flight crew action resulted in inability to control the aircraft … causing the aircraft to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover.”

This is damning stuff. AirAsia is responsible for the safe maintenance of its aircraft and responsible for the skills and actions of its pilots. It killed 162 people, their unborn descendants, their hopes, their destinies,  and harmed those families or relatives who depended on them. Most of them remain in the sea, skeletons that the founder and CEO of AirAsia Tony Fernandes had the hide to call ‘guests’.

This miserable, tragic, disgraceful and shameful incident overtook a jet that is flown in its thousands around the world, and happened in a busy and turbulent part of the skies over Indonesia that tens of thousands of other flights have successfully navigated without such a mishap in the space of a year notwithstanding the disappearance of MH370, which began somewhat to the north over the Gulf of Thailand on  8 March 2014.

When airlines kill their guests, or passengers, they ought not be allowed to slide away behind bland statements which some media turned into a ‘get the pilot moment’ which is the case with some reports this evening.

AirAsia killed its guests through inadequate maintenance. How inexcusable is it to have a repeated fault in a component which is vital to the proper control of an aircraft and fail to fix it for a year? How could it allow its pilots to fly such a compromised jet without the skills required to recover it if the faulty soldering failure to the point of causing an inflight upset?

Just how did this fit in with the safety culture of AirAsia, and how should potential guests react to this situation? These are critical questions for air travellers, and air safety regulators, to carefully consider.

  
Choccy frog Ben if you can stomach it..  


MTF..P2

[Gobbledock]

I agree fully with Bens article, particularly the points about the carriers shitty maintenance, a problem synonymous with Indonesian airline operators (naturally permitted to fly within Australia).

However, with due respect Ben, I think the following issue is also pivotal;

"When they received the fourth warning, the pilots pulled circuit-breakers on part of the aircraft's control system in a bid to reset the system".

Not a good look, and not a smart thing to do, very concerning. However (and yes another however) was pilot training a factor in the pilots making the decision to pull the breakers? On the outset it would appear that pilot error is a factor, however if you look at the quality of training, the airlines culture (as Ben mentioned), the shithouse maintenance and the arrogance of select members of the Executive group you start to garnish an idea about the numerous causal factors that contributed to this crash and all those deaths. Root cause = pilots? No, that is bullshit. They were just one contributing factor. Root cause = dismal maintenance standards? Yes. And for that, some very large heads, heads who are ACCOUNTABLE should roll, and roll now. Let's see if ICAO's 'just culture' applies in this instance. Hardly likely.

P_666

[Peetwo]

Harsh truths about crash of AirAsia QZ8501 come out

Ben Sandilands | Dec 01, 2015 8:25PM |

This AirAsa jet flew with a serious fault for a year before killing 162 people

The headlines tonight in some reports about the Indonesian accident inquiry findings into AirAsia’s Java Sea disaster late in 2014 claim it was pilot error, which is a serious misreading of the situation.

The 162 people who were slaughtered on flight QZ8501 on its way from Surabaya to Singapore last 28 December were killed by AirAsia’s persistent inability to correctly maintain the A320 by failing to repair a cracked solder joint in its rudder travel limiter system despite its being recorded as defective 23 times in the year before the jet plunged out of control into a shallow but fast moving sea.

The statement by Indonesia’s Transportation Safety Board says that this part failed a further  four times immediately before the jet crashed, sending repeated systems warnings to the pilots before one of them pulled circuit breakers on part of the control system in an attempt to reset it.

This disconnected the autopilot and left the two pilots in a position where taking manual control of the jet was outside their trained capabilities. The transportation board statement says “Subsequent flight crew action resulted in inability to control the aircraft … causing the aircraft to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover.”

This is damning stuff. AirAsia is responsible for the safe maintenance of its aircraft and responsible for the skills and actions of its pilots. It killed 162 people, their unborn descendants, their hopes, their destinies,  and harmed those families or relatives who depended on them. Most of them remain in the sea, skeletons that the founder and CEO of AirAsia Tony Fernandes had the hide to call ‘guests’.

This miserable, tragic, disgraceful and shameful incident overtook a jet that is flown in its thousands around the world, and happened in a busy and turbulent part of the skies over Indonesia that tens of thousands of other flights have successfully navigated without such a mishap in the space of a year notwithstanding the disappearance of MH370, which began somewhat to the north over the Gulf of Thailand on  8 March 2014.

When airlines kill their guests, or passengers, they ought not be allowed to slide away behind bland statements which some media turned into a ‘get the pilot moment’ which is the case with some reports this evening.

AirAsia killed its guests through inadequate maintenance. How inexcusable is it to have a repeated fault in a component which is vital to the proper control of an aircraft and fail to fix it for a year? How could it allow its pilots to fly such a compromised jet without the skills required to recover it if the faulty soldering failure to the point of causing an inflight upset?

Just how did this fit in with the safety culture of AirAsia, and how should potential guests react to this situation? These are critical questions for air travellers, and air safety regulators, to carefully consider.

  

I agree fully with Bens article, particularly the points about the carriers shitty maintenance, a problem synonymous with Indonesian airline operators (naturally permitted to fly within Australia).

However, with due respect Ben, I think the following issue is also pivotal;

"When they received the fourth warning, the pilots pulled circuit-breakers on part of the aircraft's control system in a bid to reset the system".

Not a good look, and not a smart thing to do, very concerning. However (and yes another however) was pilot training a factor in the pilots making the decision to pull the breakers? On the outset it would appear that pilot error is a factor, however if you look at the quality of training, the airlines culture (as Ben mentioned), the shithouse maintenance and the arrogance of select members of the Executive group you start to garnish an idea about the numerous causal factors that contributed to this crash and all those deaths. Root cause = pilots? No, that is bullshit. They were just one contributing factor. Root cause = dismal maintenance standards? Yes. And for that, some very large heads, heads who are ACCOUNTABLE should roll, and roll now. Let's see if ICAO's 'just culture' applies in this instance. Hardly likely.

P_666

Top post Gobbles, we really need to get Annex 13 AAI investigation back to ToRs i.e. closing down ALL the contributory factors (holes in the cheese), not just the obvious ones.

The following article from David Learmount highlights the growing statistics on fatalities attributable to loss of control accidents, where one of the most common causal factors is automation dependency:

Loss of control, loss of nearly 2,000 people in crashes

04/12/2015  David Learmount

As the Air Asia Indonesia accident investigators confirm the crash was caused by loss of control following an electrical snag, the tally of people who have died unnecessarily on commercial airliners has taken another step up.

There have now been 18 loss of control accidents since the year 2000, and 1,886 people have died in them because the pilots failed to maintain control of aeroplanes that were completely flyable, and most of which had nothing wrong with them.

The Air Asia accident involved an Airbus A320 at 32,000ft in the cruise over the Java Sea last year on 28 December 2014. The report says an electrical fault – known to the airline and the captain but not resolved – caused an alert to be repeated three times before the captain attempted to resolve the issue by tripping and resetting the circuit breakers for the flight augmentation computers.

The autopilot had been coping with the control effects of the electrical fault, but when the FACs were switched off the autopilot tripped out and left the pilots to fly the aircraft, and they clearly were not ready for that.

The electrical fault was caused by a crack in the solder on a printed circuit board associated with the rudder travel limiter, which prevents the rudder being deflected too far at high speeds. As soon as the autopilot was disconnected, the effect of the fault was to offset the rudder by 2deg, which is not much, but enough to cause the aircraft to roll left to a bank angle of 54deg. Most airliners bank about 20deg (maximum 30deg) for ordinary manoeuvres on commercial flights.

The copilot was flying, and he failed to take action immediately to roll the wings level, so the nose dropped. Some 9sec later when he did roll the wings almost level he also pulled the nose up. Then the bank angle returned to 53deg left, and the pull-up demand on the copilot’s sidestick moved to maximum, actions that suggest the copilot was already seriously disorientated. The aircraft climbed to a maximum height of 38,500ft, stalling on the way.

Once stalled, it descended at a rate of 20,000ft/min into the sea.

The pilots never recovered from the stalled condition. As in the AF447 tragedy the copilot’s nose-up demand – the opposite of what was required to regain control – continued.

There is some evidence that the captain may have left his seat to trip the FAC circuit breakers. At one point in this upset he gave the copilot the confusing instruction to “pull nose-down” (the pilots were different nationalities and neither was a native English speaker), but he then failed to act correctly to take override control with his sidestick.

The industry knows it has this huge weakness in its pilot workforce. The death of 1,886 people since 2000 testifies to it.

There are various components to the problem:

• highly reliable and accurate automated systems in today’s aircraft mean pilots almost never get the physical or mental exercise of controlling the aircraft and its flight path, so many are not ready when they have to take control;
  
• statutory recurrent training requirements are out of date and do not relate to the task of today’s pilots in modern cockpits;
  
• most pilots now have no training for recovering aircraft from upsets involving significant attitude deviations from straight and level;
  
• most have never handled an aircraft at high level and therefore are not familiar with how small the flight envelope is in thin air, and what to do if the aircraft goes outside the flight envelope (like entering a full stall).
  
  

Some airlines, in countries where the aviation authorities allow advanced airlines to vary their training according to evidence of need, the carriers are dealing with this weakness.
But in others where the old recurrent training requirements still dictate training minimums, airlines are still working to the minimums.

It is a tragedy that, in an industry that is very safe and getting safer, there will inevitably be more of these unnecessary fatal accidents. It only takes the smallest snag to trigger one.

Taking the 'automation dependency' discussion to a different place, Karlene Petitt asks some pertinent questions and highlights that this is not just a significant safety issue that the aviation industry needs urgently to address.. :

Wednesday, December 2, 2015

The Automation Problem

Are we over thinking it? 

Captain James Wright

Just when school was over for the quarter, my friend Captain James Wright sent me an inspiring email. One of those writings that make me think!  He posed some interesting questions on automation, and as always sparked the brain cells. 

Backstory: Last year, around this busy time of year, I visited the Pacific Maritime Instituted. PMI. My plan was to do an incredible write up on this training center. There were many things the airline industry could learn from how they train harbor pilots. However, life got away and time flew as I jumped into my first year of school.  But the photos PMI, speak volumes.

Jim says: 

PMI is about to put on a series of Bridge Resource Management classes for Crowley Maritime tug masters and mates working out of Valdez.  The simulator exercises are modified based on the previous classes experiences.  

 

 

The latest modification is aimed at “automation dependency”.  The purpose of this exercise is for the bridge team to develop a comfort level with transitioning from a “glass bridge” to a WW-II type non-automated bridge.  A similar comparison in aviation might be transitioning from a 787 – Dreamliner cockpit to the “The Spirit of St. Louis”.  

The modifications include a full electronics failure (including radar) leaving the bridge team with only hand steering, basic engine control and a magnetic compass.  The bridge team will then be required to make decisions to balance safety and efficiency using the available controls and equipment to either complete or abort the exercise.

Since my age group mostly learned our profession in WWII type ships we tend to think that the transition described above should not be a problem.   

 Evaluations of pilots, masters and mates at PMI suggest the opposite; that mariners from the “automation-era” might find transitioning “back to the basics” somewhat uncomfortable.   

This leads to the questions below:

• Do traditional pilotage / ship-handling (hand flying) skills add value to our profession in the “age of automation”? 
  

• If so, is there a reasonable expectation that traditional pilotage / ship-handling (aviation) skills can be passed on to pilots in “the automation generation”?
  

• If so, what solutions in addition to the above type of exercise might best accomplish this goal?
  

• Alternatively, are we overthinking the “automation” problem?
  

My Dissertation is moving toward

the automation challenge. 

Do I think there is a problem? 

Perhaps when I read articles that state:

"A faulty computer and the crews inadequate response caused the AirAsia A320 to crash...killing 162 people"

The answer is in the results.

What do you think?

Enjoy the Journey!!
XOX Karlene
- See more at: http://karlenepetitt.blogspot.com.au/201...9YFIq.dpuf

 
MTF..P2

[Gobbledock]

Well done P2 and well done Ben, some interesting discussions taking place. Great to see.

"There have now been 18 loss of control accidents since the year 2000, and 1,886 people have died in them because the pilots failed to maintain control of aeroplanes that were completely flyable, and most of which had nothing wrong with them".

A sobering and concerning trend. It's an interesting yet disturbing set of statistics. But lets take a step back over the last 4 decades to see at what other times in any aviation history we have had a legacy of frustrating accidents;

1. We had CFIT in the 70's. One strong form of mitigation was the invention of GPWS. Many future lives have been saved. Commercial airliners were consistently being flown into high terrain or the ground. Often for no valid, logical reason at all. Thank god for GPWS.

2. TCAS - another superb piece of kit which really became mandatory in the 80's. Many many accidents have been avoided as a result due to the invention of TCAS. Prior to TCAS midair accidents were all too common.

3. CRM - remember the old days where the authority gradient between Captain and F/O was large, leaving an atmosphere on the flight deck that was at times palpable? The late 90's, but especially 2000 onward has seen a huge change. Anyone remember long haul flights where the only word shared between the left and right hand seat were 'I'm going for a piss or a sleep' or the verbal completion of checklists!! Not so bad today, and better communication has created a more effective team, less misunderstandings on the flight deck and better communication with people beyond the flight deck door.

But, 2000 onward has seen the ramping up of 'avoidable accidents'. The age of computer and fly by wire technology. A joystick from which you cannot feel the aircrafts idiosyncrasies, where you need to have less aeronautical skills and have greater software/techo type skills to fly a plane. The question really must be asked; has the aircraft technology really outsmarted human ability? Tough question which undoubtedly can cause much debate.
But the facts remain - there has been too many aircraft crashes where the aircraft was modern, high tech and on many occasions perfectly serviceable, yet utter chaos and confusion had broken out on the flight deck leading to the machine being crashed with an ensuing high number of fatalities, and leaving the experts with dumbfounded looks on their faces and scratching their heads.

So perhaps it is time that ICAO, the supposed guardian and promulgator of all things safety got off its arse and tried to work out that the hell is going wrong?
Because people, there is a problem and it isn't going away any time soon.

P_666

[ventus45]

My dear Gobbles:

The problem, simply put, is one of discombobulation.



In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.



The result, is needles disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

[Peetwo]

AIOS - & the 21st Century??


The (other) Big "V" said.. :

My dear Gobbles:


The problem, simply put, is one of discombobulation.



In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Love it "V" - The head in sand bit is absolutely spot on, especially here in Oz where we presently have a totally dysfunctional regulator & an irrelevant, "non-independent" AAI (Aviation Accident Investigator).  An AAI that is now so busy being 'PC' that ironically they have become a regular part of the causal chain (holes in the cheese), rather than the chief safety issue identifier to help prevent/mitigate repeat occurrences/accidents.

The classic - but not isolated - example of discombobulation/AIOS (Aussie style ) is of course the PelAir investigation, & now re-investigation: 

Example references: PelAir MK-I (& probably MK-II ) - Beyond Reason - & the pale?? + O&O thread 

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason model is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning...

However while all this AIOS is going on ( ), the rest of the aviation safety world is struggling to get ahead of the game with the implications of the findings of repeat tragic accidents like QZ8501, Colgan etc.  

The following is an excellent (TY 4 link Tinkicker ) overview article of QZ8501, courtesy Aviation Week:

AirAsia Crash: Are Regulators Moving Too Slowly On Upset Recovery?

Findings in the Indonesia AirAsia Flight 8501 crash highlight lessons learned—but not implemented—from high-profile crashes in 2009
Dec 7, 2015 John Croft | Aviation Week & Space Technology

[/url]Indonesia is calling for the U.S., Europe and its own regulators to accelerate mandatory upset-recovery training for airline pilots in the wake of the Indonesia AirAsia Airbus A320-200 crash in December 2014. The accident has key similarities to the 2009 Air France Flight 447 and Colgan Air crashes in which pilots, for a variety of reasons, failed to properly respond to aerodynamic stalls and upsets, resulting in rapid, largely uncontrolled descents into terrain or water.

The 2009 accidents spawned a variety of countermeasures in the international community, with the International Civil Aviation Organization (ICAO) publishing new standards and recommended practices in November 2014 and the European Aviation Safety Agency (EASA) and FAA set to implement their version of training upgrades in 2018 and 2019, respectively. That is not soon enough from the perspective of the AirAsia crash investigators. Loss-of-control accidents, which are often preceded by a stall and upset scenario, are the deadliest types of airline accidents, representing only 2% of all accidents but 25% of all fatalities in 2006-13.


Flight simulators will be the tool of choice to combat loss-of-control accidents as upset-recovery training becomes routine. Credit: NASA


Along with a call for upset prevention and recovery training, the final report on the Dec. 28, 2014, crash also highlights how maintenance and pilot procedural flaws, crew resource management shortcomings, and ignorance of A320 avionics and electrical design combined in a manner that overwhelmed the two pilots.

Indonesia’s National Transportation Safety Committee (NTSC) did not assign a probable cause or blame for the accident, but issued 10 recommendations for the airline, the Directorate General of Civil Aviation (DGCA), the FAA, EASA and Airbus. AirAsia in the interim had voluntarily initiated 49 safety actions, including dedicated simulator sessions for Airbus-designed upset and stall recovery training, more hand-flying during departures and approaches, and assigning an aircraft “custodian” to monitor defective equipment.
The first officer, with 2,247 flight hours, mostly in the A320, was the pilot-flying as the aircraft reached its cruising altitude of 32,000 ft. in the midst of cumulonimbus buildups shortly after 6 a.m. on the route from Surabaya to Singapore. The captain monitoring the flight had logged more than 20,000 hr. flight time in military jet fighters and airliners.

AirAsia’s Operation Training Manual, approved by the DGCA, included ground- and simulator-based upset training, but the airline had not implemented the curriculum because it was not mandated by the DGCA nor was it called for by the Airbus-supplied Flight Crew Training Manual, according to the NTSC. “The [manual] stated that the effectiveness of fly-by-wire architecture and the existence of control laws eliminate the need for upset recovery maneuvers to be trained on [envelope-protected Airbus aircraft],” notes the NTSC. Three months after the crash, Airbus published upset training guidelines for airlines, noting that while it is “extremely unlikely” that an upset will occur in the normal envelope-protected control mode, pilots should nonetheless experience pitch-up and roll upset excursions as high as 30 deg. and 67 deg., respectively, in different configurations and potentially in degraded control modes. 

Twelve minutes after AirAsia Flight 8501 leveled off that morning, a series of amber advisories flashed on the electronic centralized aircraft-monitoring display in the cockpit, indicating the sequential failure of the two rudder travel limiter units, a safety feature that reduces rudder displacement as speed increases. In the next 11 min., as the crew turned to remain clear of cloud buildups and requested a climb to 38,000 ft., there were three additional failures. In each case, the pilots reset the two flight augmentation computers (FACS) that control the rudder limiters via two reset buttons on the overhead panel.



The captain had experienced this failure three days earlier in the same aircraft during pushback. A company engineer came into the cockpit and pulled circuit breakers for the two flight augmentation computers per the airline’s troubleshooting manual. One of the circuit breakers is in the overhead panel; the other is located on the wall behind and out of reach of the first officer’s seat. The captain had asked the engineer whether the circuit-breaker method could be used whenever the problem reappeared, to which the engineer said it could be done “whenever instructed on the ECAM [Electronic Centralized Aircraft Monitoring],” according to the NTSC. On Dec. 28, the ECAM instructed the pilots to disengage then reengage each flight augmentation computer via the push buttons. 

This particular problem had been recurring at an increasing rate, 23 times during the previous year on PK-AXC, the accident aircraft, nine of which occurred in December. The troubleshooting manual advice—either resetting the FACS via the push buttons or pulling the circuit breakers—generally cleared the fault, so the issue was not considered a “repetitive problem” in the documentation, and the pertinent electronic modules were not changed out. 

While ICAO standards call for pilots to record “all known defects” after a flight, the requirement was not specified in Indonesian regulations, and pilots often did not file reports regarding the rudder-limiter failure. Following the accident, investigators found evidence of solder cracking caused by temperature cycling in the electronics. Airbus had responded to similar reliability problems with upgraded electronic units in 1993 and 2000, both of which were installed in the accident aircraft, and again in 2015 following the accident. AirAsia in its post-crash safety actions made improvements to its maintenance processes to track repetitive issues, including assigning custodians to each aircraft.
 
One minute later, when the rudder-limiter-failure caution appeared for the fifth time, investigators surmise the captain resorted to pulling the circuit breakers. The NTSC notes that the limiter or FACS failure itself is not considered dangerous (rudder limits are maintained and the aural and textual alerts can be silenced by selecting the Emergency Cancel button). Although Airbus allows for pulling circuit breakers to reset various computers when on the ground, the airframer says “as a general rule,” resets using circuit breakers in the air must be limited to the air pack regulators and avionics ventilation system. The “general rule,” however, opens a door for other resets, providing both pilots “consider and fully understand the consequences of taking the action,” according to Airbus.
 
Based on the cockpit voice recorder (CVR), the accident pilots did not appear to discuss any consequences and were likely startled by what happened when the captain presumably pulled the breakers. Along with a series of fault messages on the ECAM, the autopilot and autothrottle disconnected, the control law transitioned to “alternate,” removing most of the fly-by-wire envelope protections, and the rudder deflected approximately 2 deg. to the left, resulting in a roll rate of 6 deg./sec. to the left. The first officer responded 9 sec. later—when the roll angle had reached 57 deg.—with a right control input initially and a nearly fully deflected rearward stick pull, rapidly increasing the pitch angle and causing an 11,000 ft./min. climb. 

[url=http://aviationweek.com/site-files/aviationweek.com/files/uploads/2015/11/DF-AIRASIA_map.jpg]

When the initial stall warning occurred, the first officer briefly responded by pushing forward on the stick, as called for in standard procedures, but soon after returned to the full-back stick, where it caused the aircraft to enter a fully developed, deep stall, a state in which it remained for the remainder of the flight. The nose-up input after a stall, which is contrary to recovery techniques issued by the airline and the international community, was a common element in the Air France Flight 447 and Colgan accidents in 2009.
 
The captain attempted to control the aircraft through his stick, but he did not press the “take over” pushbutton on the stick to transfer control from the first officer, as is allowed for in AirAsia standard procedures during an emergency. With both pilots controlling, the A320 control system averaged the two sidestick inputs—nearly full aft stick from the first officer and slightly nose down by the captain—for a nose-up command. The NTSC recommended that AirAsia “reemphasize” with its pilots the “taking-over-control procedure in various critical situations of flight.” 

At approximately 29,000 ft., the pilots were able to level the wings, but the angle of attack remained well beyond the stall, and the descent rate settled at 12,000 ft./min., with the audible stall warning and buffeting of the wings evident on the CVR. The aircraft remained in a relatively flat attitude until striking the water. “The condition of stall at [nearly] zero pitch was not a standard on pilot training as the training for stall is performed at high pitch attitude,” says the NTSC, adding that the pilot might have not recognized that the aircraft was in a deep stall despite the stall warning and the buffet.
The inability of some pilots to recognize and correctly recover from upsets and stalls has been a key safety concern in the industry for more than a decade, but it became a top priority after the 2009 crashes. 

ICAO in November 2014 called for member nations to require on-aircraft upset prevention and recovery training for multi-pilot and commercial pilot licenses, and simulator upset training for multi-crew type ratings and airline pilot initial and recurrent training programs. Last January, EASA proposed new rules similar to the ICAO standards, to be implemented in April 2018. 

The FAA’s upset training requirements for airline pilots, largely the result of Colgan, go beyond the ICAO and EASA. They mandate full-stall demonstrations in full-motion simulators by March 2019, an addition that will most likely require new expanded aerodynamic models for the devices. The agency plans next to update Part 60 rules detailing how to upgrade and gain approval for the extended simulators, although preliminary guidelines the FAA published in 2014 have already been used by FlightSafety International and Gulfstream to create an extended model for a business jet simulator. 
It is doubtful the FAA can accelerate its plan, given the training infrastructure that must be put in place, but some airlines have already taken the initiative of providing third-party upset training to their instructors in order to set up in-house training programs. South African Airways and Delta Air Lines are two of the carriers that have such programs underway. 

Somewhat promotional but I just had to include this must read post/comment from apstraining : 

First-hand Experience in Airline Upset Training


As a leading Upset Prevention and Recovery Training (UPRT) provider for pilots from airlines around the world, the reaction of this crew as described in the Indonesian Accident Report is not surprising. Regularly - on a daily basis - we see professional pilots, who have not yet had first-hand modern UPRT experience, having serious difficulty in handling time critical upsets effectively. ‘Modern UPRT’ is in compliance with 2014 ICAO and 2015 IATA UPRT guidance on its effective delivery, together addressing more than 200 training elements to enhance awareness, prevention and recovery of airplane upsets.

An airplane upset is a precursor flight condition to loss of control in-flight (LOC-I) that meets certain attitude and/or speed criteria as defined by industry. Of equal importance to modern UPRT is that the provided UPRT is of sufficient intensity, delivered by expert instructors, conducted in appropriately certified airplanes and simulators, following a comprehensive building-block curriculum.

For example; on page 107 of the report, the FDR recorded the pilot flying's (SIC) first reaction to the over-banked attitude of 57 degrees (with likely the nose dropping since the autopilot was disconnected) was to pull and then apply right aileron … three seconds later the aircraft entered a stall. In our experience, this "rolling pull" technique is very common among pilots who have not been given both academic and practical understanding of the dangers of this often-inappropriate technique in a wide diversity of upset scenarios.

"Remf" mentions that "no amount of acceleration of training/warnings will replace common sense." Based on first-hand experience, we respectfully disagree. This conclusion is not substantiated by what we see when our professional pilot customers return for recurrent upset training anywhere from one to two years after their initial UPRT and consistently prove themselves to be very disciplined and effective in a startling upset scenario. It is certainly understandable how certain "techniques" would be considered “common sense” when they are being discussed in an academic context. However, and again based on years of first hand experience delivering UPRT, when non-UPRT trained pilots are put in time-critical, life-threatening situations, "common sense" is typically replaced by ineffective and unsafe "gut-reactions" on the controls due to knowledge and skill deficiencies further degraded by the pilot/crew’s state of mind due to human factors such as startle, surprise and fear.

As alluded to above; ICAO and IATA - with EASA in the process of implementing UPRT interventions in 2016 - have recognized the benefit of integrated (on-aircraft and simulator) upset training in a pilot's skill sets. They each have proposed significant upset training changes to our current licensing and type rating system (see ICAO Doc 10011, EASA NPA 2015-13, and IATA GMBP UPRT). We certainly agree with the Indonesian Report Conclusions that integrated (on-aircraft and simulator) upset training must be implemented across the globe sooner rather than later. The FAA has yet to make this same official conclusion. However, through Advisory Circular (AC) 120-111, the FAA is requiring upset recovery in simulators for Part 121 air carriers by 2019. Improved stall training across all FAA pilot training is also already underway through AC 120-109 - soon to be superseded by AC 120-109A, which likely will include full aerodynamic stall training.

The future is looking brighter when it comes to the worldwide mitigation of LOC-I.

Meanwhile what do we get.. Beard on...beard off..mi..mi..mi..mi..mi..mi..mi..mi..Beaker-UFB!

 

  
MTF..P2

[Peetwo]

Qatar Miami runway overrun - Err..Ops Normal??

There has been a bit on the QATAR CAA preliminary report.

First this from Planetalking - Qatar issues alarming report about Qatar Airways flight

The damage a Qatar 777 and Miami runway light did to each other

The just released factual interim Qatari report about a serious incident involving a Qatar Airways 777-300ER  in September isn’t something you would like to read while about to board one of its flights...

 
However probably more disturbing was this SMH story today - from the latest recipient of the Aviation Press Club golden gong award Jamie Freed  :

Runway overruns 'happen quite often': Qatar Airways CEO Akbar Al Baker


Date December 11, 2015 - 11:39AM


Jamie Freed
Senior Reporter

Happens all the time? Qatar Airways plans to double its flights to and from Australia next year.

Akbar Al Baker, the chief executive of Qatar Airways, which is doubling its flights to and from Australia next year, has claimed runway overrun incidents like one that damaged one of his airline's Boeing 777s upon take-off from Miami in September "happen quite often".

A preliminary report into the Miami incident by the Qatar Civil Aviation Authority this week found the runway overrun left a 46 centimetre tear in the aircraft's fuselage, which breached the pressure vessel as well as numerous dents and scratches in the airframe with 18 square metres of damaged skin.

There were 90 individual areas of damage requiring assessment and fixing, as well as some damage to a metal guard on the left landing gear. In addition, there was damage to three of the runway approach lights at Miami International Airport which the aircraft clipped upon take-off before completing its 13.5 hour flight to Doha, Qatar and arriving with damage to the airframe.
The Qatar Airways Boeing 777 damaged by a runway overrun incident clipped the landing lights in Miami. Photo: Supplied

The report found the aircraft, with four pilots in the cockpit, had mistakenly taken off using only part of the runway as they entered via a taxiway due to a misreading of information on a tablet computer. Around 1000 metres of the runway was behind them, and the recorded data from the aircraft showed they overran the runway by nearly 300 metres upon take-off but flew on to Doha, apparently oblivious to the damage.

But Mr Al Baker, rather than taking responsibility for the incident and committing to fixing the airline's procedures, on Wednesday told reporters it was the fault of air traffic control rather than the pilots - in direct contradiction of the report.

According to Flightglobal, he also said: "Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights."

On the Professional Pilots Rumour Network online forum, the reaction to Mr Al Baker's comments were scathing. 

"This is probably the scariest thing I have seen in aviation in years," one poster said. "An admittance that practices are not just poor but dangerous to anybody travelling."

A second person's post said: "Oh yes... Super normal to overrun the runway and take some approach lights with you. Happens every day. Dangerous? Of course not! A perfectly calculated manoeuvre!"

Runway overruns are a relatively rare occurrence in commercial aviation and in some cases have proven deadly. International Air Transport Association data shows there were 98 runway or taxiway excursion accidents between 2009 and 2013 out of millions of commercial flights during those years. Of those incidents, seven resulted in fatalities, with 191 passenger and crew deaths in total.

In 2009, an Emirates A340 with 18 crew and 257 passengers overran the end of the runway at Melbourne Airport after using incorrect take-off performance parameters. The aircraft became airborne but struck a light and damaged the airport's instrument landing system before returning for an emergency landing. As a result of the accident, which heavily damaged the aircraft, Emirates took a number ofactions to improve its safety procedures.

Qatar, which already flies to Melbourne and Perth from its Doha hub, has announced plans to launch flights to Sydney and Adelaide next year as it looks to better compete against rivals Emirates and Etihad Airways in the local market.

Qatar has won industry accolades for the quality of its in-flight product, but it has also drawn the ire of unions around the globe for its workplace policies. Until this year that included firing female employees who got married or became pregnant within the first five years of their employment. Another concern for staff is a mandatory 12-hour rest rule before shifts, which the company enforces by monitoring employees in company housing, according to Bloomberg.


Read more: http://www.smh.com.au/business/aviation/runway-overruns-happen-quite-often-qatar-airways-ceo-akbar-al-baker-20151210-glkzi6.html#ixzz3tyhuXfYb
Follow us: @smh on Twitter | sydneymorningherald on Facebook

  
"..Ops normal, nothing to see here.."- UFB!
MTF..P2  

[Peetwo]

Qatar Miami runway overrun - Err..Ops Normal??

There has been a bit on the QATAR CAA preliminary report.

First this from Planetalking - Qatar issues alarming report about Qatar Airways flight

The damage a Qatar 777 and Miami runway light did to each other

The just released factual interim Qatari report about a serious incident involving a Qatar Airways 777-300ER  in September isn’t something you would like to read while about to board one of its flights...

 
However probably more disturbing was this SMH story today - from the latest recipient of the Aviation Press Club golden gong award Jamie Freed  :

Runway overruns 'happen quite often': Qatar Airways CEO Akbar Al Baker


Date December 11, 2015 - 11:39AM


Jamie Freed
Senior Reporter

Happens all the time? Qatar Airways plans to double its flights to and from Australia next year.

Akbar Al Baker, the chief executive of Qatar Airways, which is doubling its flights to and from Australia next year, has claimed runway overrun incidents like one that damaged one of his airline's Boeing 777s upon take-off from Miami in September "happen quite often".

A preliminary report into the Miami incident by the Qatar Civil Aviation Authority this week found the runway overrun left a 46 centimetre tear in the aircraft's fuselage, which breached the pressure vessel as well as numerous dents and scratches in the airframe with 18 square metres of damaged skin.

There were 90 individual areas of damage requiring assessment and fixing, as well as some damage to a metal guard on the left landing gear. In addition, there was damage to three of the runway approach lights at Miami International Airport which the aircraft clipped upon take-off before completing its 13.5 hour flight to Doha, Qatar and arriving with damage to the airframe.
The Qatar Airways Boeing 777 damaged by a runway overrun incident clipped the landing lights in Miami. Photo: Supplied

The report found the aircraft, with four pilots in the cockpit, had mistakenly taken off using only part of the runway as they entered via a taxiway due to a misreading of information on a tablet computer. Around 1000 metres of the runway was behind them, and the recorded data from the aircraft showed they overran the runway by nearly 300 metres upon take-off but flew on to Doha, apparently oblivious to the damage.

But Mr Al Baker, rather than taking responsibility for the incident and committing to fixing the airline's procedures, on Wednesday told reporters it was the fault of air traffic control rather than the pilots - in direct contradiction of the report.

According to Flightglobal, he also said: "Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights."

On the Professional Pilots Rumour Network online forum, the reaction to Mr Al Baker's comments were scathing. 

"This is probably the scariest thing I have seen in aviation in years," one poster said. "An admittance that practices are not just poor but dangerous to anybody travelling."

A second person's post said: "Oh yes... Super normal to overrun the runway and take some approach lights with you. Happens every day. Dangerous? Of course not! A perfectly calculated manoeuvre!"

Runway overruns are a relatively rare occurrence in commercial aviation and in some cases have proven deadly. International Air Transport Association data shows there were 98 runway or taxiway excursion accidents between 2009 and 2013 out of millions of commercial flights during those years. Of those incidents, seven resulted in fatalities, with 191 passenger and crew deaths in total.

In 2009, an Emirates A340 with 18 crew and 257 passengers overran the end of the runway at Melbourne Airport after using incorrect take-off performance parameters. The aircraft became airborne but struck a light and damaged the airport's instrument landing system before returning for an emergency landing. As a result of the accident, which heavily damaged the aircraft, Emirates took a number ofactions to improve its safety procedures.

Qatar, which already flies to Melbourne and Perth from its Doha hub, has announced plans to launch flights to Sydney and Adelaide next year as it looks to better compete against rivals Emirates and Etihad Airways in the local market.

Qatar has won industry accolades for the quality of its in-flight product, but it has also drawn the ire of unions around the globe for its workplace policies. Until this year that included firing female employees who got married or became pregnant within the first five years of their employment. Another concern for staff is a mandatory 12-hour rest rule before shifts, which the company enforces by monitoring employees in company housing, according to Bloomberg.


Read more: http://www.smh.com.au/business/aviation/runway-overruns-happen-quite-often-qatar-airways-ceo-akbar-al-baker-20151210-glkzi6.html#ixzz3tyhuXfYb
Follow us: @smh on Twitter | sydneymorningherald on Facebook

  
"..Ops normal, nothing to see here.."- UFB!
 

Update with additional incident courtesy PT.. :

Qatar Airways incidents send it screeching into PR, safety crises

Ben Sandilands | Dec 12, 2015 7:29AM |

Qatar has been flying A350s like this for almost a year

It is astonishingly how quickly Qatar Airways has been plunged into a PR nightmare over two serious incidents involving a Boeing 777-300ER and an Airbus A350-900.

The latest involves a rejected takeoff at JFK on an inaugural return flight to Doha, in which it appears that the Airbus A350 had started to roll down the wrong runway.

That incident is reported in detail, and with a video from within the cabin, in this Fairfax report.

An earlier incident at Miami Airport, in which a Qatar 777 stayed on the ground for 300 metres past the end the runway in a botched take-off which saw the jet extensively damaged without somehow coming to the notice of its pilots, is dealt with in this earlier report in Plane Talking.

The harsh facts about the conduct of that flight are set out in a Qatar safety inquiry report that most certainly didn’t shield the state owned carrier from the enormity of the situation that flight was in as it continued for 13.5 hours with a pierced pressure vessel to its destination in Doha.

We need to be clear about several things, contrary to statements made by the airline or its CEO.

Had the 777 incident at Miami happened at the city end of the main runway used for such heavy long haul flights at Sydney the jet would have been destroyed, and it would have been at severe risk of a similar outcome headed south over Botany Bay because of the drop down to the water beyond the end of the runway in that direction.

Qatar Airways was very lucky with the airport layout at Miami and the lack of things to hit in that 300 metres of open space that the 777 traversed at high speed before beginning to climb away from the ground.

The serious of that situation, and the amazing ignorance of its pilots of the true situation their jet and its passenger were in all the way to Doha, rings a very loud warning to all and sundry about the state of safety culture and operational excellence at Qatar Airways in relation to that flight.

But it also requires an open mind as to what happened at JFK. This may not have been the fault of the airline. The responses of the pilots to the apparent error were clearly immediate and highly professional. The causes of that incident may lie elsewhere, and they require the same diligent and fearless inquiry that was shown in the Qatar safety authorities preliminary factual release concerning the Miami incident to bring out the truth.

&..courtesy 'The Points Guy' - Watch This Aborted Takeoff During Qatar’s First A350 Flight from the US By: Zach Honig

MTF...P2

[Gobbledock]

What a joke. No amount of fine dining service, silver plated cutlery and spiffy awards will do you much good if your fragmented corpse needs to be shoveled out of a smoking hole.

Safety culture starts at the very top. And if the comments by Shitar's senior executive are a yard stick, then this mob should be banned from Australia. Runway overruns are not an accepted practise and certainly shouldn't be considered to be the norm. There is something seriously wrong with this airline. I believe they have proved to be a certain contender for the 2015 tick tock award.

[Kharon]

Issuance of the Preliminary Report for the Metrojet Russian Airplane accident.


Cairo, December 14, 2015  - HERE -  (N.B. My split of paragraphs - the report is a solid block of text - tough to read; so E&OE) .

Captain Ayman ElMokaddem, chief of the International investigation committee (Investigator in Charge), investigating the accident of the Metrojet airplane declared that, as a progress in the investigation work, and in accordance with Annex 13 to the Convention on International Civil Aviation ICAO, the committee has finished the "Preliminary Report". This report has been sent to all Accredited Representatives for the States that have the right to participate in the investigation, in addition to the International Civil Aviation Organization ICAO.

Captain ElMokaddem added that the report includes 19 typical articles well known in accidents investigations, and includes the preliminary information that is available to the investigation committee up till this date. The report includes also some information that will be subjected to developments through the next phases of investigation.

Captain El Mokaddem indicated that the scope of investigation for the wreckage parts has extended for more than 16 kilometers from the main wreckage site. He assured also that the members of the forensic medicine task group within the investigation committee had received the reports regarding the examination of the bodies made by the forensic doctors. The committee is waiting for the comparison reports from the Russian side to identify the victims status after knowing the DNA analysis for their families and kins.

The committee received support from Egyptian experts, faculty of engineering, Cairo University for producing photos for the airplane wreckage, using a three dimensional advanced camera, to assist in making a record for the status and shape of the wreckage and its relative positions at the impact site. About 30 working hours were dedicated to this task. In addition, a specialized team from the "Metallurgy Center for Researches and Development" had visited the wreckage site for the visual examination, preparing for the second phase of wreckage analysis after transferring it to Cairo.

The committee has offered the full opportunity to all the concerned parties including the insurance company officials and the Russian working team to examine the wreckage at the site. This was done in accordance with the international regulations, before transferring the wreckage from the site for the following investigation phases.

Flight Data Recorder FDR information indicated that all the flights made by this airplane, five days before the accident were between Russian airports and Egyptian airports. For the flight just before the accident flight, the airplane departed from Samara Russia and landed in Sharm El Sheik. The system group within the investigation committee, spent about 30 hours in removing 38 computer units belonging to the airplane, in addition to two other computer units belonging to the engines from the wreckage at the accident site. The units had been transferred to Cairo for the purpose of thorough investigation by the specialized task groups.

The operation group within the investigation committee, with the Russian side, had examined the pilots’ information related to their flying licenses and their medical check. Detailed examinations of the information related to the pilots training are being done now, after translating this information from the Russian language. The technical status, and the detailed repairs that were carried out on the airplane, its structure, systems and engines since the date of production up to the date of the accident, are being studied now. This study is supported by the relevant airplane technical documents and records delivered from the Russian side. This study needs plenty of time, as the airplane had been produced on 1997.

The wreckage group within the investigation committee, and for about 250 working hours, have done an extensive photography, identified the locations, sorted and classified the wreckage parts scattered within the wreckage site, developed a wreckage plan to deduce the different effects on each part of the airplane, linking this with the technical history to use that in the following investigation phase. Work in this area is still under progress. Captain El Mokaddem added that, all the Accredited Representatives representing the states participating in the investigation have been granted all the rights that are defined in Annex 13 to the Convention on International Civil Aviation. Cooperation and communication with them are still in a continuation process to exchange information regarding the accident.

Fifteen trips to the wreckage site have been organized by the Egyptian Air force using helicopters. Coordination is still under progress with the Egyptian Army, to benefit from their capabilities so as to transfer the wreckage from the accident site, after completing all the required examinations, and to collect it in a secure place in Cairo that allow the committee to start new phases of investigation.

Captain El Mokaddem revealed that, the committee did not receive up till now any information indicating unlawful interference, consequently the committee continues its work regarding the technical investigation.

[Peetwo]

Twist in the tale of MH17 tragedy?

In breaking news today from AFP via ABC online:

MH17: Dutch investigators to study claims identifying Russian soldiers implicated in MH17 crash

Posted about 6 hours agoMon 4 Jan 2016, 2:01pm
Photo: Dutch prosecutors say they will "seriously study" claims citizen journalists have identified Russian soldiers implicated in the crash of MH17. (AFP: Bulent Kilic)

Related Story: Victorian coroner accepts Dutch findings into MH17 deaths

Dutch prosecutors say they will "seriously study" claims citizen journalists have identified Russian soldiers implicated in the crash of MH17.

The claims were made by a British-based group of citizen journalists called Bellingcat, which specialises in trawling through data on social media and other open sources.

A spokesman for the Dutch prosecutor's office, Wim de Bruin, said Bellingcat's report was received just after Christmas.

"We will seriously study it and determine whether it can be used for the criminal inquiry," Mr de Bruin said.

Malaysia Airlines flight MH17 was downed over war-torn eastern Ukraine on July 17, 2014, by a BUK surface-to-air missile, killing all 298 people on board, including 38 Australians.

Western nations and Ukraine said the missile was fired from territory held by pro-Russian separatists, but Moscow denied the claim, pointing the finger instead at the Ukrainian military.

The Netherlands has launched a criminal probe into those responsible for the shooting, but many experts doubt whether it will succeed.

In 2014, Bellingcat reported a BUK mobile launcher, spotted on July 17 in an area controlled by pro-Russian rebels, came from a military convoy belonging to Russia's 53rd anti-aircraft brigade.

The unit is based in Kursk but was sent on manoeuvres near the Ukrainian border.

The launcher was later filmed again, but at least one of its missiles was missing.

According to Bellingcat an instagram user by the name of "rokersson" posted a picture on June 23, 2014 showing a column of military hardware passing through the city of Staryy Oskol before moving towards the Ukraine border (pictured).

In an interview with the Dutch TV channel NOS on Sunday, Bellingcat founder Eliot Higgins said his organisation had now identified 20 soldiers in the brigade.

Mr Higgins said that was "probably" the group that either knew who had fired, or had that individual amongst its numbers.

The sources for this include photos posted on the internet and army data about personnel deployment that was available online, NOS said.

It added that a redacted version of the report should be published "shortly."

Mr De Bruin said Dutch prosecutors had "been in contact" with Bellingcat in the past.
AFP

And this from Ben Sandilands in Plane Talking today: 

MH17 criminal probe ticks on, and could blow up in our faces

Ben Sandilands | Jan 04, 2016 11:00AM |

A DSB graphic of the BUK detonation that destroyed MH17
Updated with link to new ‘citizen journalist’ report*

A recent Dutch news report, picked up by Live Leak, is a reminder that the Australian government’s rhetoric about the MH17 atrocity is on course for a rough ride this year as the Dutch criminal inquiry continues its pursuit of guilty parties in the shooting down of a Malaysia Airlines 777 while in transit over a civil war zone in Ukraine on 17 July 2014 with the loss of 298 lives.

It all seemed so simple for a while. Russian backed separatists used a Russian BUK missile to destroy the jet. Unless you live in some sort of fairy tale land, the Dutch Safety Board investigative findings into the cause of the crash, published on 13 October last year, make it abundantly certain that such an atrocity was committed, although precisely from where, or by whom, as in name rank and serial number, wasn’t established.

That DSB report was about what brought down MH17, rather than who dunnit. But contrary to the narrative televised live that day, and it seems relied upon by much of the media to the exclusion of the actual contents of the report, it also contained some damning evidence about a failure of standards of care by the airlines that accepted claims by Ukraine and EU air traffic control that flying over the terrain being traversed by MH17 was perfectly safe above 32,000 feet.

The report revealed that Malaysia had failed to fully cooperate with the accident inquiry, with an inference that what Malaysia’s intelligence services knew about the Ukraine skies situation had not been communicated to the airline. It also revealed that Russia had issued a notice to pilots for 17 July 2014 that any airspace below 53,000 feet on its side of the east Ukraine border was unsafe.

Which in effect would have meant to the thickest of airline operations staff, that continuing from east Ukraine skies into Russia controlled airspace presented them with a 21,000 feet increase in minimum safe altitude which would have been unattainable for every jet airliner in service in the world that day, and most likely for decades to come.

This altitude restriction needs to be kept in mind when considering the Live Leak report, which is primarily concerned with a reputable Dutch newspaper reporting that Ukraine continues to say it has no radar records for that part of the sky showing what else might or might not have been near MH17 when it was shot down by what was undoubtedly a Russian made BUK missile. (It is perfectly normal for air traffic control services to continue to separate civilian traffic without seeing it on radar, which happens over a very large part of the Australian continent and in oceanic airspace.)

What is the elephant in the clouds in this story, and many similar to it in recent months, is whether or not Ukraine had a military aircraft in that part of the sky at that moment that the militia manning the BUK launcher might have been looking for when unfortunately MH17 came into range and was locked upon.

If it did it compounds the indifference to civilian air traffic safety that Ukraine had when it made that corridor, and some adjacent to it, available to flights by Malaysia Airlines, and by other carriers. The operational settings of those airlines that were continuing to use at risk Ukraine airspace on that day are called into question in no uncertain manner in the passages in the DSB report that most media didn’t read or chose not to report.

The DSB was blunt in its report, as distinct from circumspect in its media presentation.

It cast an entirely new and serious light on the discharge of safety responsibilities by the airlines that continued to fly through airspace over a war zone in which at least 16 aircraft including helicopters had been shot down during hostilities between Ukraine and Russia backed separatist forces in the previous month.

While there is outrage over the slaughter of the 298 people who were on board MH17, and what seems like some pathetic lies and evasions in the various and amateurish Moscow narratives, the behavior of Malaysia Airlines, and other luckier airlines, and Ukraine authorities, doesn’t appear likely to conveniently slip below the radar in this on-going criminal inquiry which is due to report sometime this year.

By Australian legal standards airline managements and boards are liable for safety outcomes. A bit of courage seems called for in Canberra, to pursue those responsible for accepting the Ukraine flight path situation that destroyed MH17 with as much theatrical indignation as has been applied to the as yet unknown Russian supported militia who launched a missile in the course of an on-going conflict.

*Updated
The Dutch public prosecutor will ‘take seriously’ analysis by the citizen journalist Bellingcat group that it says has potentially identified Russian soldiers who may have been involved in the shootdown.

An early story on this is on the ABC News website here.

If these claims can be validated it would be a vital breakthrough. As would be public interrogation of the decision makers in those airlines that chose to continue to fly through air space over a missile active war zone, and for the full picture, their counterparts in airlines that withdrew Ukraine overflights before the shootdown.

MTF...P2

[Peetwo]

AirAsia Crash: Are Regulators Moving Too Slowly On Upset Recovery?

 
..The fruit of Alan's labour is perhaps best highlighted in the exemplary Final Report on QZ8501, completed within a year of the tragic accident and as yet with little criticism...

5 SAFETY RECOMMENDATIONS

While the KNKT acknowledges the safety actions taken by the aircraft operator, there still remain safety issues that need to be considered. The KNKT issues the following Safety Recommendations addressed to:

5.1 Aircraft Operator

1. The KNKT recommends that Indonesia AirAsia to re-emphasize the importance of the Standard Call-Outs in all phases of flight.

2. The KNKT recommends that Indonesia AirAsia to re-emphasize the taking over control procedure in various critical situations of flight.

5.2 Directorate General Civil Aviation


1. The KNKT recommends that the Directorate General Civil Aviation to ensure the implementation of air operators‟ training of flight crew is in accordance with the approved operations manual.

2. The KNKT recommends that the Directorate General Civil Aviation to ensure that air operators under CASR 121 conduct simulator upset recovery training in timely manner.

3. The KNKT recommends that the Directorate General Civil Aviation ensures that air operator maintenance system has the ability to detect and address all repetitive faults appropriately.

4. The KNKT recommends the Directorate General Civil Aviation ensures the Indonesian Civil Aviation Safety Regulations to regulate the duties of the pilot in command as specified by ICAO Annex 6.

5.3 Aircraft Manufacturer

1. The KNKT recommends that Airbus to consider in developing a means for flight crews to effectively manage multiple and repetitive Master Caution alarms to reduce distraction.

2. The KNKT recommends that Airbus to consider and review the FCTM concerning the Standard Call-Outs in all phases of flight.

5.4 United States Federal Aviation Administration and European Aviation Safety Agency

1. The KNKT supports the previous French BEA recommendation (Recommendation FRAN-2015-024) on ensuring that future programs to include initial and recurrent training relating to taking over control of aircraft equipped with non-coupled control stick.

2. The KNKT recommend expediting the implementation of mandatory for upset recovery training earlier than 2019.

While on the Indonesian aviation safety SSP, on another strange parallel irony, 10 days before the NTSC release of the QZ8501 Final Report, I intercepted this informative article from the Jakarta Post -  Policy-making in aviation needs to involve industry players :

Indonesia’s intention of becoming a member of the UN International Civil Aviation Organization (ICAO) council may backfire if the government implements regulations without considering their impacts on flight-industry players. Air Law Community chairman Andre Rahadian said in a discussion on Thursday that several regulations imposed by the government aimed to improve flight safety and security had burdened airlines.

“Regulations should consider the airlines, especially in terms of their businesses continuity,” he said, adding that some regulations had prevented airlines from making achievements while already being affected by the slowing global economy.

Andre highlighted several regulations that weighed in airlines’ costs, such as a minimum paid-up capital requirement and minimum fleet age. He expressed concern that a regulation obligating airlines to deposit paid-up capital of Rp 500 billion (US$36.57 million) in the form of fresh funds and/or capital goods would only increase costs.

He said only two airlines in the country owned such capitalization, leaving others to struggle to meet the requirement in three-years time. The Transportation Ministry introduced earlier this year the minimum capital regulation in response to a major plane accident. The ministry was of the opinion that the accident occurred on account of improper maintenance as a result of the airline’s insufficient capitalization.

Andre said that by involving industry players in the regulation-making process, the government would be able to measure the possible impact of the proposed regulation.

“This can also ensure legal certainty as chances to revise the regulation will be smaller,” he said. The government aims to become a ICAO council member for the 2016-2019 period to introduce Indonesian interests in the organization’s policies. To support the objective, the government must improve flight safety to meet the ICAO requirements.

The move is in line with the ministry’s commitment to focus on transportation safety next year, as it plans to allocate 20 percent of its Rp 48.5 trillion ($3.57 billion) budget in the 2016 state budget to improve safety in air, land, sea and rail transportation.

Coordinating Maritime Affairs Minister Rizal Ramli said on Thursday that the government had asked the Australian government to support Indonesia in its efforts to become a council member. “I assisted in talks with the Australian government to convince Australia and other countries support us,” he said as quoted by kompas.com. The ministry claimed earlier this month that it had implemented corrective recommendations from the ICAO and the US Federal Aviation Administration (FAA) in its efforts to become a council member.

The ministry’s director for air transportation, Muzaffar Ismail, said the corrective actions, which were in line with recommendations from the ICAO, were 96.2 percent complete. The ICAO officials will carry out an evaluation and conduct an inspection this year to follow up and validate the adjustments.

Rizal stated that the large size of Indonesia’s airline business encouraged such an effort.

Data from the ministry said that the country’s airlines had flown around 87 million passengers last year. It aims to fly around 162 million people by 2019. To support the growth, the ministry plans to build 62 new airports by 2030, adding to the existing 237.

  
 Although the findings of the QZ8501 final report could be seen as a set back for the stated Indonesian effort above, it should also be recognised that the NTSC have proven their effectiveness as a properly independent & compliant State AAI (Annex 13). This integrity & independence is fundamental to the implementation of a proper ICAO Annex 19 SSP. Sadly the same cannot be said for our State AAI, the currently much maligned ATSB...    

AIOS strikes again?? - GFT catches disease.  

With the above Indonesian/QZ8501 related posts in mind, yesterday Geoffrey-I Qantas-Thomas (reference SMH article: Indonesian airlines rank lowest in world for safety)
made this (IMO) defamatory comment:

"Aviation is critical to the economic development of Indonesia yet the government appears unwilling or incapable of meeting its international obligations by upgrading its oversight of its airline industry," he said.

GFT have you been living under a rock? You are truly ill informed if you believe that regulatory oversight has anything remotely to do with the excellent safety record of your beloved QF. It is Qantas that make CASA look good, just look at this post if you don't believe me - AAI in a parallel universe - or this quote by Ben Sandilands (from the Planetalking featured article in that post):

Both incidents are grounds for an urgent inquiry into the fitness of Jetstar to continue to hold an air operator certificate, and the appointment of an independent audit into the capacity of CASA to discharge its obligations to maintain air safety standards in this country.

Indonesia may be struggling to administer effective regulatory oversight but at least they have a truly independent State AAI not intimidated (without fear nor favour) to deliver quality investigation reports like the excellent QZ8501 Final Report.

MTF..P2     

         

[Peetwo]

AIOS? - Acquired Institutionalised Ostrichitis Syndrome.

Question for V on AIOS - Is this disease a strictly Australian affliction?  

The reason I ask is because it seems that other prominent aviation nations & developing nations appear to be very aware of what the safety risk issues are and are determined to proactively attempt to mitigate the risks. This is highlighted in the following excellent Joan Lowy article (via the Seattle Times). Where the US Transportation Department’s internal watchdog - the Office of the Inspector General - is determined to insure that the FAA does not become complacent in oversighting the legislated measures put in place to mitigate these significant safety issues identified in the Colgan, AF447 and now QZ8501 air disasters:  

APNewsBreak: Government not ensuring pilot skills are sharp  

Originally published January 10, 2016 at 7:05 am Updated January 10, 2016 at 9:05 am

FILE – This Aug. 26, 2010, file photo, shows the view from inside a Boeing 787 full-flight simulator in Renton, Wash. The Federal Aviation Administration’s efforts to ensure airline pilots keep up their flying skills and get full... (AP Photo/Elaine Thompson, File) More  

By JOAN LOWY
The Associated Press

WASHINGTON (AP) — The government is falling short in ensuring airline pilots keep up their flying skills and get full training on how to monitor sophisticated automated control systems in cockpits, according to the Transportation Department’s internal watchdog.

Most airline flying today is done through automated systems that pilots closely monitor. Pilots typically use manual flying skills only briefly during takeoffs and landings. Studies and accident investigations have raised concern that pilots’ manual flying skills are becoming rusty and that pilots have a hard time staying focused on instrument screens for long periods.

But the Federal Aviation Administration isn’t making sure that airline training programs adequately address the ability of pilots to monitor the flight path, automated systems and actions of other crew members, the Transportation Department’s Office of Inspector General found. Only five of 19 airline flight simulator training plans reviewed by investigators specifically mentioned pilot monitoring.

The FAA also isn’t well positioned to determine how often airline pilots get a chance to manually fly planes and hasn’t ensured that airline training programs adequately focus on manual flying, according to the report, obtained by The Associated Press. It has not been released publicly.

In January 2013, the agency issued a safety alert to airlines encouraging them to promote opportunities for pilots to practice manual flying in day-to-day operations and during pilot training. But the FAA hasn’t followed up to determine whether airlines are following the recommendation, the report said.

The FAA published new rules in 2013 requiring airlines to update their training programs to enhance pilot monitoring and manual flying skills, but the agency is still working on guidance to airlines on how to do that, the report said. Airlines aren’t required to comply with the rules until 2019, the report said.

“Because FAA hasn’t determined how carriers should implement the new requirements or evaluated whether pilots’ manual flying time has increased, the agency is missing important opportunities to ensure that pilots maintain skills needed to safely fly and recover in the event of a failure with flight deck automation or an unexpected event,” the report said.

The rules on enhancing training were prompted in part by the 2009 crash of a regional airliner while approaching Buffalo, New York. The crash killed all 49 people on board and a man on the ground.

An investigation by the National Transportation Safety Board revealed that the pilots weren’t closely monitoring the plane’s airspeed, which began to decrease to dangerously slow levels. Thus the captain was startled when a safety system called a “stick shaker” automatically went on, violently rattling the control yoke. Instead of pointing the plane downward to pick up speed, the captain pulled back on the yoke to increase altitude.

That slowed the plane even more, eventually leading to an aerodynamic stall. The plane fell from the sky and landed on a house.

The board concluded that the monitoring errors by the flight crew demonstrated the need for more specific training on active monitoring skills.

The U.S. and other countries are transitioning to satellite-based air traffic systems and reducing their reliance on radar. Among the advantages of satellite-based navigation is that planes can fly more direct routes, reducing flying time. But the precision of automation is needed to allow planes to safely fly closer together and to increase takeoffs and landing in order to reduce congestion and meet growing demands for air travel.

As automation increases, pilots have fewer opportunities to use manual flying skills.

Industry studies and committees have found that pilots who don’t get to use their manual flying skills may not be prepared to handle unexpected events. Two of the nine airlines visited by investigators actively discouraged pilots from manual flying under normal conditions.

“The opportunities air carrier pilots have during live operations to maintain proficiency in manual flight are limited and likely to diminish,” the report said. “While the FAA has taken steps to emphasize the importance of pilots’ manual flying and monitoring skills, the agency can and should do more to ensure that carriers are sufficiently training their pilots on these skills.”

Clay Foushee, the FAA’s director of audits and evaluations, said in comments submitted to the inspector general that the FAA is concerned about “an overreliance on automation and the importance of training pilots to handle unexpected events and manually fly an aircraft.”

He said the FAA agrees with a recommendation about developing standards to determine whether pilots have enough opportunities to practice manual flying skills.
The FAA hopes to provide guidance to airlines on pilot monitoring by Jan. 31, 2017, he said.

___

Follow Joan Lowy at twitter.com/AP_Joan_Lowy. Her work can be found at http://bigstory.ap.org/content/joan-lowy
JOAN LOWY

Meanwhile in Dunce-unda land....

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

And this is despite several perfect opportunities in two Senate Inquiries (one of which even had a recommendation to look into the AF447 Final Report, once released) & several related serious incidents since. Yet our seriously dysfunctional three Aviation Safety stooges - CASA/ATSB/ASA - are in self-preservation mode and are too busy obfuscating & delaying any real attempt at cultural reform..   


MTF..P2

Ps "...the Transportation Department’s Office of Inspector General found..." -

Hmm..wonder if that is where NX got the idea? Maybe if it was structured similarly to the US system it may carry far more clout??