Indonesia AirAsia Flight 8501: Crash report released

"ttyymmnn" (ttyymmnn) 12/01/2015 at 16:41 • Filed to: planelopnik

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In any air disaster, it is usually a string of events that leads up to a crash, rather than one catastrophic event (barring an external factor such as a !!!error: Indecipherable SUB-paragraph formatting!!! or a !!!error: Indecipherable SUB-paragraph formatting!!! .) Which is why the headline in today’s !!!error: Indecipherable SUB-paragraph formatting!!! about the results of the investigation into last year’s AirAsia crash is misleading:

AirAsia Crash: Faulty Part ‘Major Factor’

To be fair to the BBC, the headline is quoting the report, which seems to go out of its way to avoid assigning blame. And yes, a faulty part started the string of events that led to the crash, but it was not just that part that was to blame. Poor !!!error: Indecipherable SUB-paragraph formatting!!! (CRM), in my opinion, is a much more important factor.

As the pilots were flying through a large thunderstorm in their !!!error: Indecipherable SUB-paragraph formatting!!! (PK-AXC) over the Java Sea, a faulty solder joint in a rudder control mechanism started giving the crew problems, though apparently, the rudder continued functioning normally. The part was sending faulty warning signals to the crew, as it had done on numerous prior occasions. So the captain relinquished control to the less experienced first officer as he sought to solve the problem.

In previous istances of the fault signal, pulling a circuit breaker (while on the ground) usually caused the fault to reset and go away. However, pulling the circuit breaker in flight also disengaged the automatic pilot. The first officer was suddenly faced with hand flying the aircraft in a thunderstorm, a situation for which he was apparently inadequately trained. Following a sudden change in direction, the first officer became “startled” and “disoriented,” and began to pull back on the control stick. The captain did not take over control as he should have, and there are also indications that the two pilots were pushing the control stick in opposite directions at the same time. The plane continued to climb until it stalled and crashed into the sea, killing all 162 passengers and crew on board.

Map by Andrew Heneen via !!!error: Indecipherable SUB-paragraph formatting!!!

In my opinion, had good CRM been practiced, the more experienced pilot would have been at the controls. Had the captain had a better understanding of the systems of his aircraft, he may not have pulled the circuit breaker, or at least known that doing so would have disengaged the automatic pilot, and he could have warned the first officer about what was going to happen. And had the first officer communicated his concerns about piloting the airliner in those conditions to the captain, the captain would have been in command and possibly had the skills to manually fly the plane.

Ever since the !!!error: Indecipherable SUB-paragraph formatting!!! , there has been discussion about the level of training for some airlines, particularly Asian airlines. There seems to be some credence to the suggestions that these pilots are good at flying programmed approaches, or entering coordinates into the autopilot, but not so good at actually flying the plane if necessary. AirAsia’s Chief Executive, !!!error: Indecipherable SUB-paragraph formatting!!! (familiar to many of us as the owner the !!!error: Indecipherable SUB-paragraph formatting!!! , said via !!!error: Indecipherable SUB-paragraph formatting!!! , “There is much to be learned here for AirAsia, the manufacturer and the aviation industry. We will not leave any stone unturned to make sure the industry learns from this tragic incident.” And Airbus, for their part, have vowed to investigate possible issues with the A320 control system. But it seems to me that, once again, it boils down to a crew that was simply unprepared to handle a problem, and untrained to work togther to solve it.

Photo by Sabung.hamster via !!!error: Indecipherable SUB-paragraph formatting!!!

RamblinRover Luxury-Yacht > ttyymmnn 12/01/2015 at 16:45

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indications that the two pilots were pushing the control stick in opposite directions at the same time

Again? Fucking Airbuses, how do they work?

For Sweden > ttyymmnn 12/01/2015 at 16:45

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“Pull down!”

K

Also, friends don’t let friends fly Airbus.

ttyymmnn > RamblinRover Luxury-Yacht 12/01/2015 at 16:49

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Back in August, I wrote a piece about CRM that got shared to Jalopnik, and I got the following reply.

I’ve got 8000+ hours in A320/A319’s and can make some observations about “sidesticks”:

-any simultaneous use of the two side sticks causes an aural alert “dual input” so the pilots know two people are trying to fly at the same time- a no-no.

-if both sidesticks are used simultaneously, the input is averaged (ie. one full up and one full down is neutral, likewise full left and full right is neutral.)

-one pilot can push the AP disconnect/takeover button and hold it for 30 seconds to lock out the other stick (in case of malfunction).

-AF447 had a significant loss of cockpit disipline regarding who was the flying pilot. In their defense, they were IMC and loaded up with multiple ECAMs. Nonetheless, training was cited as severely lacking in flying in degraded modes at high altitudes, as well as stall recovery.

-other than in nasty crosswinds, fly by wire is much more civilized.

-being able to cross one’s legs and eat meals on a tray table is “tha shizzles”

Even with these safety measures in place, I believe that any system where one pilot can make a control input that is not mirrored in the other stick is just a recipe for disaster. If you’re in a stressful environment, and heaven only knows how many alarms are going off, doesn’t it seem reasonable that a conflicting input command could be missed? Average the input? Really, Airbus?

ttyymmnn > For Sweden 12/01/2015 at 16:49

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If it’s not Boeing, I’m not going. Although, even a 777 can be flown poorly.

jariten1781 > ttyymmnn 12/01/2015 at 16:54

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Averaging the input seems like a really weird design choice.

ttyymmnn > jariten1781 12/01/2015 at 16:56

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Well, it is Airbus. I have no idea if this is possible on a Boeing, with more traditional yokes between the pilots’ legs.

RamblinRover Luxury-Yacht > ttyymmnn 12/01/2015 at 16:57

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Points 1-3 (aural alert, averaging, 30 second clickoff) are all things that require a rationed, understanding, reasonable response. If the two people in the cockpit are a veteran and a spazz, screaming at the both of them that they’re in disagreement is so utterly useless as to be hard to take, let alone hard coding a middle ground fallacy and assuming that the veteran will be up on procedures to click off the twerp’s stick and have the 30 seconds to do so. What the fuck, over. Those aren’t safety measures, they’re a weak cover - nipple band-aids for the naked-breasted silicone scar lumps of WHY DON’T YOU TIE THE STICKS TOGETHER YOU STUPID FUCKS. Ugh.

jariten1781 > ttyymmnn 12/01/2015 at 17:00

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Yeah, I’m sure they tested the crap out of it, but coming from a maritime background we always had a master slave thing for secondary controls. Master always has full control unless it’s either in the dead zone or you manually select override. Intuitively that seems safer to me, but that could just be familiarity speaking.

RamblinRover Luxury-Yacht > jariten1781 12/01/2015 at 17:02

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You misspelled “horrible idiocy that hard-codes a fallacy”.

ttyymmnn > RamblinRover Luxury-Yacht 12/01/2015 at 17:06

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Because (in my unprofessional opinion) the system is designed for efficiency under optimal conditions and operated by a professional crew.

The NYT article about the report has more information, quoting the lead investigator as saying,

“The circuit breaker was pulled out and then pushed in again,” he said at a news conference in Jakarta on Tuesday. “It caused some electrical distraction.”

Well, that’s probably an understatement. And it seems like they are going out of their way to keep from assigning blame. They say “someone” pulled the breaker, since they don’t know which pilot did it. “Someone.” Well, we can probably rule out the passenger in seat 35A. Or any member of the cabin crew who were probably strapped in because of the thunderstorm they were flying through.

Here’s an even better pull from the NYT article:

The investigators did not blame human error for the crash, but the report noted that once the plane’s autopilot and autothrust were disengaged, “subsequent flight crew action resulted in inability to control the aircraft.”

How about, “When they disengaged the autopilot, they lost control of the aircraft.” How can that even be disputed? Unless, of course, you are trying to fix blame on Airbus.

ttyymmnn > jariten1781 12/01/2015 at 17:07

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I think the whole system is designed to keep one pilot from crashing the plane intentionally, as the GermanWings nutjob did. He had to lock the other pilot out of the cockpit first. Remember, the crew is supposed to be working together and communicating. In a perfect world, it’s a fine system. Once the shit hits the fan, who knows what people will do?

RamblinRover Luxury-Yacht > ttyymmnn 12/01/2015 at 17:10

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I’m not trying to fix blame on Airbus. As such. I just remain baffled by the fact that they refuse to acknowledge the classic “worst case scenario on a bad day”, even after that exact issue re: sticks has come up multiple times before. If your system only requires one bozo in a crew of professionals to break down, particularly with how little the modern pilot (even a “Veteran”) spends flying the airplane, let alone keeping a head in a crisis, then it can rightly be described as suboptimal. Even if it’s only enabling one cockup out of a notional 2-4 required for disaster.

Cé hé sin > For Sweden 12/01/2015 at 17:14

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Statistically, you’re about as likely to be killed in an Airbus as in a Boeing, ie not very.

ttyymmnn > RamblinRover Luxury-Yacht 12/01/2015 at 17:19

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I’m not trying to fix blame on Airbus either, but I have to question if their design decisions have some culpability here. The same lack of mirroring was cited as a factor in the Air France 477 crash off South America. I wonder just how much those sticks even move. I used to talk at length with a former F-16 pilot who flew in the first batch of operational Falcons. He said that the stick in those planes didn’t move at all. It merely sensed the amount of pressure the pilot was applying and the FBW reacted accordingly. At the behest of the pilots, General Dynamics put a little bit of movement into the sticks. But only a little. I’m no pilot, but I am a driver, and it just seems more intuitive to me that, if you’re driving a giant bus through the air, you would want a steering wheel in front of you. Who knows? Maybe a sidestick keeps pilots from overflying the plane. But it also seems to me that such a system only further removes a pilot from the physical envolvement of flyng.

RamblinRover Luxury-Yacht > ttyymmnn 12/01/2015 at 17:20

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Following up further, I absolutely agree it’s a CRM breakdown. However, if you have the two sticks averaging, that only makes sense of both pilots are trying to fly the plane steady at the same time and differing only in their fine detail - something that should never crop up, and if it did, is notionally prevented by the multiple input alarm. The lockout makes sense to *have* for things such as the eating/etc., but requires too much practically speaking in an emergency situation.

I agree that “autopilot switches off, leading to crash” is a terrible sentence and facially horrifying, immediately implying massive human error. That doesn’t negate that the three items above all have elements of serious risk to freaked out crews, and can act as force multipliers to one determined idiot, even opposed to someone on hand keeping their cool. Human error is at fault with virtually every loss of control of an auto, but we still at least try not to do bugfuck insane, counter-intuitive things in user interface.

jariten1781 > ttyymmnn 12/01/2015 at 17:21

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Sure, but if I’m choosing between system 1 that allows a psycho to purposefully murder hundreds or system 2 that allows a single bonehead to override the veteran in an emergency I’m going system 1 all day. There aren’t a whole lot of psychos out there (especially not with flight credentials) who want body counts in the hundreds but there’re nigh on infinite boneheads who will unintentionally make poor decisions in crisis.

RamblinRover Luxury-Yacht > ttyymmnn 12/01/2015 at 17:26

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At least with Jariten’s described setup of control priority, you have no worse than a 50% chance that the control inputs will result in the plane doing loopy things (no averaging) Probably less, if the priority control is in the hands of the guy who should have priority, though you would get exceptions (like the Asiana incident). Ganged controls that move are nice because they point out conflict so much more viscerally than “ding ding ding”.

ttyymmnn > RamblinRover Luxury-Yacht 12/01/2015 at 17:28

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Exactly. If one of the pilots had kept their head—and it sounds like one of them did—he could have said, “No, you idiot, point the nose DOWN!”

RamblinRover Luxury-Yacht > jariten1781 12/01/2015 at 17:30

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...and detection of those people who will break down in a crisis is tricky. Very tricky. Breakdown freakouts could even be described as learned behavior in the case of a pilot who could react properly when young and nervy but has had time to grow complacent and barely even lays hands on the controls anymore, for hours and hours at a time, for years.

Cé hé sin > RamblinRover Luxury-Yacht 12/01/2015 at 17:44

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The pilot who wants to become the pilot flying doesn’t have to hold a button for 30 sec first. As soon as (s)he presses the button control is established for as long as the button is being pressed. After 40 sec (s)he can release the button and maintain control. While doing this the pilots are supposed to communicate with each other - it’s basic stuff, just say “I have control”. They’re taught this and after the Air France crash training techniques were supposed to be revised to make sure that everyone knows who’s doing what.

RamblinRover Luxury-Yacht > Cé hé sin 12/01/2015 at 18:00

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Good to know it’s not as bad as the pilot’s summary above made it sound, but I would still argue it’s highly artificial and requires a reaction cycle (contrary input - > alarm - > press of button - >takeover) which is almost guaranteed to fail under pressure and inherently holds a greater delay than the alternatives and requires greater presence of mind - mental capital which might be better served actually flying the plane. In short, I just don’t like it.

Jason Parker > ttyymmnn 12/02/2015 at 23:23

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“...the captain would have been in command and possibly had the skills to manually fly the plane...”

I have read the reports and articles but it just just seems so unprofessional; they are pilots first, Boeing and Airbus tech support second.