AirAsia crash: Faulty part 'major factor'

[webfact]

AirAsia crash: Faulty part 'major factor'

(BBC) A faulty component was a "major factor" when an AirAsia plane crashed into the Java Sea, killing 162 people last December, Indonesian officials say.

The first major report into the crash found that actions by the crew in response to the malfunction also contributed to the disaster.

Full story: http://www.bbc.com/news/world-asia-34972263


-- BBC 2015-12-01

[webfact]

AirAsia crash investigators say crew lost control after responding to faulty part

Indonesia’s national transport safety committee says fault with rudder control system was major factor in crash last December that left 162 people dead

JAKARTA: -- A fault with the rudder control system was a major factor in the AirAsia plane crash last December in which 162 people died, Indonesian investigators have said.

In their final report into the crash, Indonesia’s official national transportation safety committee also said that crew action in response to the fault caused the jet to lose control.

Repeated problems with the rudder system led to the pilots disengaging the autopilot in stormy weather in an attempt to fix the situation.

Full story: http://www.theguardian.com/world/2015/dec/01/airasia-crew-actions-caused-jet-to-lose-control-say-crash-investigators

-- The Guardian 2015-12-01

[JoePai]

Oh hell that's bad - LINK

[Chicog]

Well a summary from a PPRUNE poster suggest just crap flying again, although if the fault hadn't happened in the first place maybe they would not have had to react so poorly.

Why would you pitch up when the stall warning has sounded?

Summary:

• Aircraft had a history of numerous Rudder Travel Limiter Unit faults which were never resolved
• During the accident flight, the crew received three consecutive Master Cautions related to the RTLUs, which they cleared via ECAM actions
• After a fourth Master Caution, FAC 1 & 2 were reset by pulling the Circuit Breakers
• The aircraft went to Alternate Law
• Aircraft rolled 54 degrees left
• FO applied sidestick input to roll right and pitch up
• FO continued to pitch up as the aircraft zoomed to 38,000 ft at 11,000 fpm
• Aircraft entered a stall
• FO continued to apply maximum pitch up (until the end of recording)
• Captain attempted to take over by pressing the left-sidestick priority button for 2 seconds (*)
• DUAL INPUT activated and the aircraft continued to pitch up
• Captain attempted another take over by pressing the sidestick priority button for 2 seconds (*)
• Aircraft recorded lowest speed of 55 kts, 104 degrees left roll, and then descended at up to 20,000 fpm until the end of recording

(*) The sidestick priority button doesn't latch unless it is activated continuously for 40 seconds

[smedly]

Four things I take from this

1. The aircraft had a longstanding unresolved fault - why was this not rectified, also why were the crew not aware of the history logs for that aircraft, surely if they had known about this faulty/false alarm they would have just ignored it instead of trying to fix it in the middle of a storm

2. The autopilot was flying the plane safely regardless of the indicated fault

3. The co-pilot was unable the fly the plane once the AP was disengaged, seems he wasn't up to it - either poor training or just not good enough, and yes they were probably flying blind in think cloud but the instruments should have told him exactly what was going on

4. The pilot was unable to regain control because he didn't know how to switch back to him (40secs button push) although 40secs may have been too late anyway

A catalog of errors culminating in disaster

Have we reached the stage now were autopilots are used so much that the actual human pilots are not that great at flying planes

[kinmaew]

The take away from this is I will never fly AA Indonesia ever again.

[tigermonkey]

Four things I take from this

1. The aircraft had a longstanding unresolved fault - why was this not rectified, also why were the crew not aware of the history logs for that aircraft, surely if they had known about this faulty/false alarm they would have just ignored it instead of trying to fix it in the middle of a storm

2. The autopilot was flying the plane safely regardless of the indicated fault

3. The co-pilot was unable the fly the plane once the AP was disengaged, seems he wasn't up to it - either poor training or just not good enough, and yes they were probably flying blind in think cloud but the instruments should have told him exactly what was going on

4. The pilot was unable to regain control because he didn't know how to switch back to him (40secs button push) although 40secs may have been too late anyway

A catalog of errors culminating in disaster

Have we reached the stage now were autopilots are used so much that the actual human pilots are not that great at flying planes

A few comments :

1. The aircraft had an extensive history of problems with the rudder limiter. They had never been resolved. The crew were fully aware of this history both from logs and observation. In fact, pulling the circuit breakers for the FACs was a fix that the Captain had seen ground engineers perform to clear the problem in the past. Unfortunately, he did not seem to be aware that he needed to also cycle the switches on the overhead panel to 'off' then 'on' to complete the process, or perhaps he did not have time.

2. We don't know what effect the malfunction was having on the autopilot's performance. We do know that the malfunctions ( real or spurious) were repeating in rapidly decreasing intervals, down to 2 minutes apart. We also know that the A320 has a long documented history of uncommanded rudder movements. This would have given the pilots a strong sense of urgency to solve the problem quickly.

3. Strange reactions by the First Officer. What is truly troubling is that his reactions were almost identical to First Officer Bonin on Air France 447. Both put the aircraft into a stall, and then held it nose up ( in stall position) all the way from cruise level into the ocean. I'm sure he had completely lost situational awareness and did not believe his instruments, if he even looked. Unbelievable that he ignored the constant loud "STALL...STALL.. STALL " message -- the noise would be deafening !

4. Either he was unaware or he panicked. He also apparently did not reset the FAC switches on the overhead to make AUTOPILOT once again available.

" A catalog of errors ......" In aviation we call each error a "hole in the Swiss Cheese". If the holes all line up, you have big trouble.

"Have we reached the stage now were autopilots are used so much that the actual human pilots are not that great at flying planes" We reached that point some years ago. Pilot training costs a lot of money, even on a Sim. Ask the airline accountants -- they will tell you " We have autopilots. We have aircraft that are impossible to crash. We don't need more pilot training." So the costs go down to the point where "Everyone can afford to die "

Edited December 1, 2015 by tigermonkey

[tigermonkey]

Well a summary from a PPRUNE poster suggest just crap flying again, although if the fault hadn't happened in the first place maybe they would not have had to react so poorly.

Why would you pitch up when the stall warning has sounded?

This First Officer and First Officer Bonin on Air France 447 did exactly the same - full aft on the side stick - full stall all the way from cruise to the water -- why ????

From the A320 FCTM ( Flight Crew Training Manual):

“The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus”

[shamrock09]

Four things I take from this

1. The aircraft had a longstanding unresolved fault - why was this not rectified, also why were the crew not aware of the history logs for that aircraft, surely if they had known about this faulty/false alarm they would have just ignored it instead of trying to fix it in the middle of a storm

2. The autopilot was flying the plane safely regardless of the indicated fault

3. The co-pilot was unable the fly the plane once the AP was disengaged, seems he wasn't up to it - either poor training or just not good enough, and yes they were probably flying blind in think cloud but the instruments should have told him exactly what was going on

4. The pilot was unable to regain control because he didn't know how to switch back to him (40secs button push) although 40secs may have been too late anyway

A catalog of errors culminating in disaster

Have we reached the stage now were autopilots are used so much that the actual human pilots are not that great at flying planes

It is very difficult to hand fly a commercial jet in the cruise. I assume they were in the cruise. The slightest manual input can cause instability as the aircraft is usually at the maximum parameters of the flight envelope. A hasty or clumsy movement can precipitate a stall.

[Enoon]

Over controlling due to insufficient familiarity with manual flight and/or the "feel" (or lack of it) of fly by wire?

+ Pitot/Static system failure?

I believe there was an iced system on 447.

[mcfish]

Well a summary from a PPRUNE poster suggest just crap flying again, although if the fault hadn't happened in the first place maybe they would not have had to react so poorly.

Why would you pitch up when the stall warning has sounded?

This First Officer and First Officer Bonin on Air France 447 did exactly the same - full aft on the side stick - full stall all the way from cruise to the water -- why ????

From the A320 FCTM ( Flight Crew Training Manual):

“The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus”

With fly by wire the left hand doesn't know what the right hand is doing. The second Officer on Air France 447 held the stick back but the sticks don't move but are pressure sensitive so the pilot in command of that flight didn't know he was pulling back on the stick! crazy stuff because the second officer kept that plane stalled all the way into the ocean

Edited December 1, 2015 by mcfish

[tigermonkey]

Four things I take from this

1. The aircraft had a longstanding unresolved fault - why was this not rectified, also why were the crew not aware of the history logs for that aircraft, surely if they had known about this faulty/false alarm they would have just ignored it instead of trying to fix it in the middle of a storm

2. The autopilot was flying the plane safely regardless of the indicated fault

3. The co-pilot was unable the fly the plane once the AP was disengaged, seems he wasn't up to it - either poor training or just not good enough, and yes they were probably flying blind in think cloud but the instruments should have told him exactly what was going on

4. The pilot was unable to regain control because he didn't know how to switch back to him (40secs button push) although 40secs may have been too late anyway

A catalog of errors culminating in disaster

Have we reached the stage now were autopilots are used so much that the actual human pilots are not that great at flying planes

It is very difficult to hand fly a commercial jet in the cruise. I assume they were in the cruise. The slightest manual input can cause instability as the aircraft is usually at the maximum parameters of the flight envelope. A hasty or clumsy movement can precipitate a stall.

Yes, "it is very difficult to hand fly a commercial jet in the cruise" but should be well within the capabilities of any pilot holding an ATPL. The accident started with events at FL32 (32,000 ft) so not near " the maximum parameters of the flight envelope". Hasty ? Clumsy ? -- perhaps, but more likely panicking from lack of training/knowledge followed by a complete loss of situational awareness. Did he believe he was in a stall ? I doubt it.

This one is squarely at the feet of:

-Air Asia for not grounding the aircraft until they corrected the problem;

-regulators and airlines for indiscriminate cutbacks in pilot training;

-Airbus for promoting their 'uncrashable' aircraft.

Yes, it's all about the MONEY !

[kingalfred]

Lets hope there are some massive law suits by family of dead. Smash Air Asia out of business

[smedly]

some very informative posts from people that obviously know a lot more than I could ever know about this tragic debacle

one thing I do know is - we have pilots racking up flying hours but it means FA as the autopilot is actually flying most of the time, when they are tested they have no clue how to handle one of these modern aircraft

in this particular instance it seems if the autopilot was allowed to continue to fly the plane then this horrific cluster F would not have happened, only when control was handed over to the crew it seems they where severly challenged as to how to fly

Taking it back further - they were flying a faulty plane..................cluster F right there

and as someone already mentioned - was it really about the money

I'm glad I don't fly as much as I used too - at one time I was flying 4 times a month

some serious issues need resolved with this tragedy, the whole thing is very alarming

those guys with the captain hats that sit in the front - can they actually fly the plane you are sitting in ? or have they become passengers too, entering data in a screen and hoping it all works

Edited December 1, 2015 by smedly

[webfact]

Deadly AirAsia crash: crew response and faulty equipment key factors says inquiry



JAKARTA: -- The crew response and faulty equipment are among a series of factors that caused last year’s deadly AirAsia jet crash which killed all 162 people on board.

Investigators say a system controlling rudder movement had cracked soldering that malfunctioned repeatedly, including four times during the flight and 23 times the previous year. But the warning signs were not picked up.

Officials told reporters there were indications from the black box data recorder that crew had tried to shut off power to the computer that controls the rudder system by resetting a circuit breaker, something not usually done during flight.

Mardjono Siswosuwarno, lead investigator: “At high speed, at high altitude, we should not move the rudder beyond a certain limit, otherwise the aircraft will rapidly yaw or roll.”

The Airbus A320 crashed into the Java Sea on December 28, less than halfway into a two-hour flight from Indonesia to Singapore.

The crash was part of a string of aviation disasters in south-east Asia’s biggest economy, where rapid growth in air travel has overcrowded airports and stirred safety concerns.

-- (c) Copyright Euronews 2015-12-02

[Michael8511]

Hope that the result of this accident will wake up the authorities in Asia to enforce strikter controll on maintenance also that Thai authorities understand that they have to step up and fix the list of problem in Thai air safety that was given to them. We don't need any more severe accident that could have been prevented.

[Katipo]

This is more than a little frightening. Poor maintenance, and incompetent crew is a recipe for total disaster, as is evident

[paddyjoe41]

The real problem here is lack of good competent supervision,such as when this particular fault appeared so many times and was allowed to be soldered,surely the inspector or Supervisor should never have passed it fit to operate again,this has to be total missconduct in the Supervisors part,without doubt he or she has to be held responsible for this terrible accident.Typical Asean if it looks right it is right,life does not come into the equasion,time is ticking we are loosing money,we are ready for takeoff.RIP all aboard her.

[jacko45k]

This is more than a little frightening. Poor maintenance, and incompetent crew is a recipe for total disaster, as is evident

You would expect that a system that had malfunctioned 23 times would be investigated and repaired.

I would be interested to know if this occurred on 23 separate flights or we had multiple malfunctions on flights (4 times on the last flight alone). I do not understand how this would not be picked up unless it was not reported, or no actions were taken on multiple reports.

Shocking....

[rosst]

Well I read all that and the first comment is: I fly Air Asia all the time as they have prices I can afford.

Second: I usually think that the guy up the front does not want to die so I trust him with my life.

Third : Air Asia is a first class Airline organisation in which some people may fail with fatal consequences.

Their safety record is good enough for me. Hopefully they have learned something from what appears to be a very thorough investigation.

[ScottMallon]

The take away from this is I will never fly AA Indonesia ever again.

Right, and do you seriously think Thai AA is any different? I don't.

[jacko45k]

Well I read all that and the first comment is: I fly Air Asia all the time as they have prices I can afford.

Second: I usually think that the guy up the front does not want to die so I trust him with my life.

Third : Air Asia is a first class Airline organisation in which some people may fail with fatal consequences.

Their safety record is good enough for me. Hopefully they have learned something from what appears to be a very thorough investigation.

Item 2 has proven to be not the case on another airline recently, and there is a possible case still open.

Item 3 and Item 2 overlap.

There was an article in a UK paper about a year ago - A list of the most dangerous airlines in the world has been released and while AirAsia Indonesia is included. So what do you base item 4? That just leaves prices......

[atyclb]

aa used to (maybe still does?) offer financial incentives to ground staff that catch/charge passengers with overweight bags. one wonders if financial incentives are also in place for the maintenance side? other thing i heard is experienced non malaysian pilots were getting canned and replaced with recent malaysian grads of the flight school aa owns.

[ronwparker]

One of themany reasons I never fly air Asia!

[timendres]

The take away from this is I will never fly AA Indonesia ever again.

Right, and do you seriously think Thai AA is any different? I don't.

Indonesian planes seem to fall out of the sky at a slightly higher rate than their neighboring countries, so I suspect there is some difference.

[MaxYakov]

The alleged "faulty part" was not a "major factor" until the Captain made it one.

Then the Captain and the First Officer became the "major factors".

[sanukjim]

n old adage about aviation states that "Aviation in itself is not inheirently dangerous,but it is extreemly unforgiven for mistakes". With this Airlines's pilots,maintenance practices ,and adminastrators ,the in this" adage" one could add the word "STUPID " before mistakes.

Edited December 2, 2015 by sanukjim

[JHolmesJr]

The take away from this is I will never fly AA Indonesia ever again.

Yes mate…you'll be safe as houses on Lion Air.

[Digitalnomade]

did a flight with air Asia.

captain was 25 years old. at this age, we are not able to take reasonable and mature decision. if girlfriend quit him, what would happen?

[Nemesis7]

some how Indonesian aviation history has too many fatal air accidents...wonder why/