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Air Asia Pilot Response Leads To Plane Crashing (wsj.com)

hcs_$reboot writes: The investigation took a year, but we finally know why Air Asia Flight QZ8501, en route to Singapore from the Indonesian city of Surabaya on December 28 last year, crashed into the Java Sea, killing all 162 people on board. The crash was caused by a combination of system malfunctions and improper pilot responses to cascading electrical and rudder-system problems. A cracked solder joint on the Airbus A320 resulted in an electrical interruption that caused computer-generated warnings of a rudder malfunction. The problem occurred four times during the flight. The first three times, the flight crew responded according to standard procedure, investigators said. The fourth time, however, the flight-data recorder indicated actions similar to those of circuit breakers being reset. That led the autopilot to disengage. Investigators said the crew was unable to react appropriately to "a prolonged stall condition," ending in the crash. The investigation points to weaknesses in pilot training in dealing with upsets, or when an aircraft is angled greater than 45 degrees.

33 of 226 comments (clear)

  1. Trying to disable the warning? by joncombe · · Score: 5, Insightful

    However whilst the mistake the pilots made is serious it is just as serious in my view that the plane was permitted to fly in this condition in the first place. It seems the problem with this particular plane was well known and had been happening (at least) for a number of days since but had not been fixed.

    1. Re:Trying to disable the warning? by ChuckieG · · Score: 5, Informative

      In pilot lingo "issues" like this are called squawks and I would speculate that many commercial carriers (part 135 under FAA) fly with them every single day. I've flown on an AA MD80 with an engine that had to be started with an external APU (starter was broken), SWA 737 with a missing flap track fairing (one of the pylons out on the wing). Inoperative instrumentation is common too. Nothing surprising about this plane flying in this condition. The problem is the pilots didn't focus on the three objectives, drilled in training (in order): Aviate, Navigate, Communicate. Fail on #1 while they were playing with circuit breakers and silencing alarms. The GA stuff I fly has inop equipment all the time (especially rentals)

    2. Re: Trying to disable the warning? by ChuckieG · · Score: 2

      Aa and Swa were my examples. Others from my personal experience- Aa MD80 hot start situation on the ramp at SGF. Couldn't get the engine to spool up fast enough which overheats the core from insufficient compressor rpm Tried over and over, engine sounded horrible. Eventually deplaned and they rebooked us. Taxi out in the new plane the soot streak out the tail of the right engine was unbelievable on the old plane. I felt lucky they didn't set the plane on fire with us in it. Took a deice during a snowstorm in Bwi, swa 737. Crew missed about half of the left wing. Said something to the pilots on the way off the plane, their response was they couldn't see way back there. Planes leave with squawks from every airline from every airport every day. As a pilot I know what to look for but it really doesn't worry me because there are multiple redundancies. (These two examples rattled me a little though).

  2. 23 times by Anonymous Coward · · Score: 3, Insightful

    They had the problem 23 times in the last 12 months it says. For real? Maybe it might have been a good idea to fix it?

    1. Re: 23 times by guruevi · · Score: 2

      Air lines have to pay out of their own pockets to get something fixed, if the plane falls out of the sky, the insurance will pay for it.

      While that is cynical boiling down of the issue, the airlines do try to squeeze out every penny out of their routes and that does include (well documented across the business) lack of training and lack of maintenance.

      Complain about the lack of qualified candidates and churn out as many pilots out of schools regardless of their passion or grades as you can so you can pay them 30k/year, do the same for the techs.

      --
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  3. Reporting bias by OzPeter · · Score: 3, Interesting

    I love how the headlines on CNN (and now WSJ) lead with "Pilot Error" but the BBC leads with

    Faulty equipment was a "major factor" in the AirAsia plane crash last December that killed all 162 people on board, Indonesian officials say.

    AirAsia crash: Faulty part 'major factor'

    Yes the crew were not fully trained, but according to Airbus the plane couldn't get into the situation it was in, so why train pilots for that? Also the faulty part had been faulty for a significant amount of time. This flight was not the first flight that had issues with the particular equipment.

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    1. Re:Reporting bias by Solandri · · Score: 5, Insightful

      Yes the crew were not fully trained, but according to Airbus the plane couldn't get into the situation it was in, so why train pilots for that?

      The plane can't get into that situation while the computer is in control. The Airbus flight computer has a final mode where it basically tells the pilots, "I give up, you fly the plane." Usually this mode kicks in when the computer is getting contradictory information from the instruments (AF447 where one or more of the pitot tubes clogged, causing simultaneous overspeed and stall warnings). So since it's possible for the pilot to end up in full control of the plane, it is imperative that they train for every likely situation. (AF447 crashed because while in this mode, one of the pilots continuously pulled back on the control stick almost the entire time the plane was in a stall, thus keeping it in the stall.)

      That said, several of the recent automation accidents seem to be caused not by the automation itself, but by the crew misinterpreting what mode the computer is in and/or misunderstand what the computer will and will not do when in that mode. Asiana 214 crashed because the pilots thought the computer was in a mode where it would auto-throttle to maintain altitude, when it was in a different mode. TAM 3054 crashed because the thrust reverser on one engine was inoperative so the pilots relied on the autothrottle to slow that engine to idle. But when they moved the other engine control to idle then reverse (to deploy its thrust reverser), that disengaged the autothrottle which caused the other engine to spin up to the full throttle setting it was set at.

      It would probably be worthwhile for the major airliner manufacturers to get together and standardize the automation modes and what is/isn't controlled in each mode. Then pilots can be trained against a consistent standard instead of having to re-learn all the automation when they change aircraft (what the second pilot was doing in Asiana 214 - if both pilots had been experienced in the 777, one of them may have noticed the error). The way it is now, it's like on one plane pulling back on the stick makes it pitch up, while on another plane pulling back on the stick sometimes makes it pitch down.

  4. Imagine a programmer who can't debug by JoeyRox · · Score: 4, Insightful

    And you'll have a good idea on the skill level of many international commercial jet pilots. Air France 447, Asiana 214, and now Air Asia QZ8501.

    1. Re:Imagine a programmer who can't debug by JoeyRox · · Score: 2

      I wasn't referring to training. I was referring to the pilots themselves. I've trained lots of programmers how to debug and some of them just don't get it. Sure they'll be able to solve issues that directly relate to problems they've been trained to solve. But they lack a holistic, intuitive sense of the system they're working with and that shows when they're faced with problems that don't neatly fit within their training.

    2. Re:Imagine a programmer who can't debug by AmiMoJo · · Score: 2

      You don't want pilots to debug in mid-air. That's what often causes these accidents. You want them to follow procedure.

      Japan's high speed rail network, the Shinkansen, has never had a fatal accident, despite being the first such network in the world (started running in 1964) and having to deal with regular severe earthquakes and extreme weather. One of the reasons is that drivers are taught not to do anything but follow procedure. They aren't even allowed to work from memory. When a fault occurs they have to open a manual, read each instruction out loud and follow it. Working from memory is error prone.

      We see this time and time again. People who think they know what they are doing, but end up causing an accident.

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  5. Re:Cracked solder joint by PPH · · Score: 4, Informative

    I believe avionics is still exempt from RoHS rules. It was in the original regulations but the EU has removed exemptions as new versions have been adopted.

    Trouble is: There are very few shops left that will do lead solder work. And if they do, the price will reflect the dedicated production tooling and handling procedures needed. Since there are no FAA or JAR requirements to use leaded solder, some avionics equipment is built on RoHS production lines.

    But think of the children! How about you keep the kids from chewing on the flight controls instead?

    --
    Have gnu, will travel.
  6. Re:Say what? by ChuckieG · · Score: 4, Informative

    It's called unusual attitude training and even the lowly private pilot has to go through it before getting the VFR ticket. Attitudes in excess of 45 degrees don't crash a plane. The anomaly sounds like a perfect case of distraction that consumed the pilots' attention and they crashed a malfunctioning, but flyable plane.

  7. Re:Typical of those poorly trained... by hcs_$reboot · · Score: 4, Informative
    TFA

    The AirAsia pilots had not been trained for that scenario, [the investigator] added, because the manual provided by the plane's manufacturer said the aircraft, an Airbus 320, was designed to prevent it from becoming upset and therefore upset recovery training was unnecessary

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  8. Re: Typical of those poorly trained... by Anonymous Coward · · Score: 2, Informative

    The pilot that was pulling back on the side stick all the way to the ground was a European. The Asian was trying to pitch down and recover but the opposing inputs from the pilots were averaged out by the flight computer.

  9. Re:Typical of those poorly trained... by WolfWithoutAClause · · Score: 4, Informative

    OK I have a few issues with your post:

    a) you're being extremely racist
    b) the copilot was actually French, and not Asian.
    c) it was the copilot that pulled back on the stick, while the stall warnings were on
    d) they were both pretty experienced- thousands of hours flying

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  10. Re: Cracked solder joint by fche · · Score: 2

    Yes. There are photographs in the official accident report.

    http://kemhubri.dephub.go.id/k...

  11. Re:always scapegoat the pilot by hcs_$reboot · · Score: 4, Insightful

    as more and more planes fall out of the sky

    Wrong.

    they will continue to always scapegoat the pilot / train operator / whatever

    Who is "they"? Anyway the investigation that took a year was performed by rather independent parties. Plus, Airbus interest is to put the blame on the airline / pilots (Air Asia), Air Asia interest is to blame the aircraft (Airbus)... So after a year when all of those people having conflicting interests come up with an agreed outcome, it's likely to be not far from the truth.

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  12. Re:Cracked solder joint by pereric · · Score: 3, Insightful

    Are you sure it cracked because of lead-free solder? Instead of, say, poor soldering process, impurities in the solder, wrongly designed PCB, stress from bad installation? Or perhaps that the should redesign the PCB specs for a new solder composition, but didn’t? It sure could be specifically because of lead-free solder (hard to get the same elasticity or such) but I just don't see that from The Fine Article linked above.

  13. Re:Typical of those poorly trained... by Proudrooster · · Score: 5, Informative
    • From the Official Report

    During the interview with the Indonesia AirAsia management, one of the discussion topics was related to upset recovery training. The approved Operation Training Manual covers the upset recovery training in Chapter 8. The module consisted of ground and simulator training. The ground training provides the flight crew with the background, definition, cause of aircraft upset, aerodynamic and aircraft systems in relation with aircraft upset. Recovery methods consider various aircraft attitude and speed including post upset conditions.

    The upset recovery training had not been implemented on Airbus A320 training, since it is not required according to the Flight Crew Training Manual and has not been mandated by the DGCA.

    worse.......

    The Airbus A320 QRH chapter Computer Reset stated that: In flight, as a general rule, the crew must restrict computer resets to those listed in the table, or to those in applicable TDUs or OEBs. Before taking any action on other computers, the flight crew must consider and fully understand the consequences. The consequences of resetting FAC CBs in flight are not described in Airbus documents. It requires good understanding of the aircraft system to be aware of the consequences.

    So we have a case of...
    1. Alarm keeps going off
    2. Reboot computer, hoping it will shutoff pesky alarm, but instead we don't understand consequences and knock out autopilot.
    3. Without autopilot plane rolls and stalls, both human pilots do opposite things and make condition uncoverable.

    Training issue....

    Planes break, computers fail, and humans spill coffee. Pilots need the training to respond with automaticity when bad things happen We see this time and time again.

  14. Re:Typical of those poorly trained... by WolfWithoutAClause · · Score: 2

    > Sooner or later a combination of events will occur that will be outside the envelope of the crew's training or their ability to respond effectively.

    Sure, but what kind of fucktard pulls back on the stick to a stall warning???

    --

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  15. Re: Say what? by ChuckieG · · Score: 5, Insightful

    Yes each aircraft has specific procedures. And training to go with, it's called type certification. Nothing special here. Quit playing with the circuit breakers and fly the damn plane. That's pilot error.

  16. Re:Say what? by MightyYar · · Score: 2

    Training for unlikely scenarios is the whole point of having human pilots. If we were willing to accept a crash every time something went wrong, we'd just let the computer run the whole show.

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  17. Re:Typical of those poorly trained... by aphelion_rock · · Score: 3, Interesting

    Flight 447 went down fundamentally because the two of the tree pilots ( one in particular) didn't know the fundamentals about flying and held the aircraft in a stalled state until it hit the ocean.
    It amazes me that neither of these pilots owned a license for a light aircraft which is mandatory for all Airliner pilots in my country (Australia)
    The other issue on the airbus is if you pull the stick back until the stall warning goes off then keep it there until the aircraft pitches further up, the stall warning stops when the pitot tubes can no longer get a reliable wind speed.
    Does anyone know if these pilots had light aircraft licenses?

  18. Re:Say what? by deadweight · · Score: 2

    I train my students ALL THE TIME to deal with bank angles past 45 degrees. It might not be everyday flying with passengers aboard, but anyone confused by it should never be at the controls of any kind of airplane.

  19. Re:Is It My Imagination by hcs_$reboot · · Score: 2

    int a_lot = 2; // This one and AF447

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  20. Re:Cracked solder joint by tlhIngan · · Score: 3, Insightful

    Happy with your RoHS regulations now?

    Avionics were excluded from the initial lead-free requirement. And even if they aren't now, unless the plane was literally brand new, it will be using leaded solder because chances are the equipment predates the exclusion removal, if not RoHS.

  21. Re:Typical of those poorly trained... by TheTurtlesMoves · · Score: 2

    I am a NZer and currently live in the EU. I know several pilots personally. While AU and NZ run a similar progression to the US (with much stricter medicals and stuff), the EU for airline pilots does not. We must start with small planes, then get a instrument ratings, turbine ratings etc. Accumulate quite a few hours before we can even consider than an airline will take us on for big plane rating.

    In the EU you do like a uni degree in commercial airlines and 3 years later your rated for the big stuff. Out of the blocks with far far less hours flying that we would have.

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  22. Re:Typical of those poorly trained... by AK+Marc · · Score: 2

    Please provide a list of airlines who do not train their pilots what to do in a stall. I'll avoid those airlines. Apparently Air France and Air Asia are two.

  23. Re:Typical of those poorly trained... by michelcolman · · Score: 5, Interesting

    Air France certainly does train for it now. They didn't use to (and neither did other Airbus operators) because Airbus did not include it in the curriculum. They said their airplanes couldn't stall so it was pointless to train for it. The most we did was an "approach to stall" and recovery without actually stalling.

    I'm sure Air Asia must have trained for it as well since Airbus has updated the curriculum after AF 447 and included stall recovery as a mandatory exercise, sending lots of communications about it to Airbus operators and requiring those exercises to be performed asap during recurrent training or even in separate, dedicated extra sessions.

    But there's something weird going on here. The first officer apparently pulled his stick all the way back and made the plane climb at a rate of more than 10,000 ft/min before it stalled. That's a pretty insane maneuver and I can't find a rational explanation for it no matter what his training was. It's not an "inappropriate response" but rather a completely unprovoked action for no good reason whatsoever.

    It might have been a technical malfunction in the flight control computers. There have been a few cases where Airbus pilots were accused of incorrect inputs in certain incidents where they luckily did live to tell, and where the pilots involved were adamant they did not give those inputs. Maybe there's a bug when the FAC circuit breakers are pulled. I remember one procedure that's sometimes performed on the ground, where such a reset also resets the stabilizer trim so it's vitally important to set the correct trim again. Maybe something like that goes on in the flight control computers during flight as well. Maybe the flight recorder confuses a flight control input with a trim input resulting from a FAC reset? Or maybe some integer overflowed?

  24. Re:Typical of those poorly trained... by Alioth · · Score: 2

    Aviation (and industrial, and marine) accidents are pretty much always an "accident chain" - and if any link in the chain is broken, the accident is prevented. This is why accident investigations don't just end at "Oh it was a cracked solder joint case closed", or "Oh the pilot stalled it what a dumbass case closed". This accident is no different - there will be a long chain of events, any one of them being stopped would break the accident chain and result in the aircraft reaching an airfield and being grounded until an engineer can come and fix the problem.

    So a factor was equipment failure, but it's not the cause. The cause is all the factors in the whole accident chain which may include poor procedures, inadequate training, over-reliance on automation and that kind of thing.

  25. Re: Typical of those poorly trained... by michelcolman · · Score: 2

    Which is precisely why each sidestick has a red override button. And you get a "dual input" aural warning. So that's not an excuse although I do agree that independently moving sidesticks are one of the dumbest ideas ever in aviation.

  26. Re:Typical of those poorly trained... by tibit · · Score: 3, Insightful

    the manual provided by the plane's manufacturer said the aircraft, an Airbus 320, was designed to prevent it from becoming upset and therefore upset recovery training was unnecessary

    This is patently false. Fly-by-wire planes have multiple levels of degraded flight envelope protections, predicated by degraded sensor inputs, lost redundancies, etc. All of this is in the fucking manuals, and don't let anyone tell you otherwise. Stalls that initiate at high altitudes and continue all the way to the ground are a recurring problem and the pilots are to be blamed. If you're in any sort of a plane and there's no reaction to prolonged stick-up input, you have to let go and figure out what the fuck is happening. A mental reset, if you will. Perhaps people who are too easily confused by flight automation shouldn't fly the damn planes.

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  27. Re: Typical of those poorly trained... by piojo · · Score: 2

    Not in China, but I can't speak for the rest of Asia. In China, drivers regularly back up to run over their crash victims again, to kill them and save money on victim compensation. Though I haven't seen any other examples that indicate life isn't valued. Rather, the other stories I've heard are all isolated incidents.

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