[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