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December 2, 2015

Investigators blame pilot error for AirAsia crash into Java Sea

Investigators blame pilot error for AirAsia crash into Java Sea

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Wednesday, December 2, 2015

Indonesia’s National Transportation Safety Committee yesterday declared pilot error to be behind the crash of Indonesia AirAsia Flight 8501. All 162 passengers and crew died when the plane crashed into the Java Sea a year ago.

The crashed aircraft, photographed in April 2014.
Image: Oka Sudiatmika.

The Airbus A320-200 was around 40 minutes from Surabaya’s Juanda International Airport to Singapore’s Changi International Airport when it vanished on December 28. Wreckage and bodies were found floating two days later; National Search and Rescue Agency divers led an international recovery effort but over 50 bodies remain lost.

The pilots were facing a fault with the rudder travel limiter, a part involved in rudder control. They repeatedly received warnings on their Electronic Centralized Aircraft Monitoring (ECAM) system. The first three times Indonesian Pilot Iriyanto and French co-pilot Remi Emmanuel Plesel followed correct procedure only for the fault to recur. The fourth time, they tried something else — based on Flight Data Recorder readouts, investigators believe they reset power to their Flight Augmentation Computers.

The computers are principally responsible for rudder control and aircraft stability. With both computers switched off, the entire fly-by-wire system of semi-automation disconnected, as did the autopilot and autothrust systems. The pilots were now left to fly entirely manually, without automation that protects the aircraft from entering unusual and dangerous positions.

A miscommunication followed. Iriyanto asked Plesel, who was flying, to “pull down”. Plesel pulled the controls down, which pitched the nose up; Iriyanto had wanted to descend. The flight ascended without permission through 36,000ft with a ground speed of 353knts. The aircraft would normally be travelling faster, with a nearby Emirates jet at a ground speed of 503knts at 36,000ft. The aircraft also banked as the disengagement of automation left the rudder off-centre.

A ship carries the aircraft’s recovered tail.
Image: Antonio P. Turretto Ramos, US Navy.

The AirAsia flight reached 38,000ft and entered a stall. The crew did not manage to regain control. The 155 passengers and seven crew died when the plane hit the sea. Most were Indonesians, but for three South Koreans, one Malaysian, one Brit, and French national Plesel.

The fault was traced to cracked solder on a circuit board. It had repeatedly occurred in the weeks before the crash. The investigation concluded maintenance failings contributed to the disaster, but Muhammad Alwi of the Indonesian Transportation Ministry said “Repeated trouble in maintenance is a normal thing[…] If the trouble is fixed in accordance with the manual maintenance procedures, then it’s alright”.

Investigators believe the solder crack is attributable to extreme temperature changes in the unprotected compartment near the tail that houses the component.

The investigation further found the flight crew were untrained in recovering from extreme events. AirAsia boss Tony Fernandes said yesterday “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”.

The report also dismisses weather as a contributory factor. The flight was diverting around storms in the area.

Iriyanto and Plessel had over 8,000 hours experience between them. Iriyanto had a decade of experience training other pilots, and previous employers include the air force. They spent three minutes struggling to regain control as the pane fell to the sea. Some bodies were recovered around 1,000km away near Sulawesi.

AFP spoke to Terence Fan, an air industry expert from Singapore Management University, who said “It’s a scenario that has played out in air accidents in the past[…] Pilots are either distracted by a faulty equipment or cannot properly solve the issue and something else is brewing in the background.”

One such accident was the loss of Air France Flight 447 in 2009 into the Atlantic. It was investigated by the BEA of France, which also assisted the AirAsia probe. The BEA issued recommendations on how to train pilots after the Air France crash. Ex-BEA boss Jean-Paul Troadec said to AFP “Several recommendations of the (BEA) on the subject of pilot training were clearly not implemented by [AirAsia].”

Indonesia saw such an accident on New Years’ Day 2007 when Adam Air Flight 574 crashed into the Makasser Strait near Sulawesi. The plane suffered a failure on a navigational instrument. While pilots were troubleshooting for this navigational system they first unintentionally disconnected the autopilot, then lost control and crashed into the sea.



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February 8, 2015

Divers retrieve 100th corpse from Java Sea jet crash

Divers retrieve 100th corpse from Java Sea jet crash

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Sunday, February 8, 2015

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Divers yesterday recovered three bodies from December’s air disaster in the Java Sea. Added to four retrieved on Friday, they bring the total to 100. An additional 62 victims remain to be recovered.

The crashed aircraft, photographed in April.
Image: Oka Sudiatmika.

There were no survivors when Indonesia AirAsia Flight 8501 crashed on December 28. The six-year-old Airbus A320-200 was 40 minutes from Juanda International Airport with 155 passengers and seven crew, bound for Singapore’s Changi International Airport. Most were Indonesians, with three South Koreans, one Malaysian, one Brit and one French person on board.

One of the latest bodies was a uniformed man strapped into a cockpit seat, and presumed to be either Indonesian Pilot Iriyanto or French co-pilot Remi Emmanuel Plesel. Underwater currents have complicated recovery of the other body from the cockpit. Efforts to retrieve the entire aircraft last month were abandoned. Some bodies have been found roughly 1,000 kilometres (600 miles) from the crash site, floating near Sulawesi.

Iriyanto and Plessel had over 8,000 hours experience between them. Iriyanto has a decade of experience training other pilots, and previous employers include the air force. Their actions have come under scrutiny as the National Transportation Safety Committee (NTSC) investigates.

A ship carries the aircraft’s recovered tail.
Image: Antonio P. Turretto Ramos, US Navy.

The aircraft entered an excessively steep climb before stalling, the NTSC said last month. It took three minutes for the plane to reach the water, during which time the flight crew tried to regain control. Bloomberg claims the flight crew switched off computers designed to aid them after they issued alerts. AirAsia has declined to comment pending the NTSC investigation, which is expected to continue for several months.

The Agency for Meteorology, Climatology and Geophysics suggests weather caused the disaster, suggesting ice led to engine failure. NTSC head investigator Marjono Siswosuwarno last month reported satellite data showed storms as high as 44,000ft. The plane was attempting to avoid storms in the minutes before contact was lost.

The National Search and Rescue Agency has over 60 divers working to retrieve the bodies.



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August 5, 2011

Air France, pilots union, victims group criticise transatlantic disaster probe

Air France, pilots union, victims group criticise transatlantic disaster probe

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Friday, August 5, 2011

The Air France-owned Airbus that crashed. Both airline and manufacturer are at the center of a controversy over responsibility.

More than two years after Air France Flight 447 crashed into the Atlantic, killing 228, a French pilots union, a group supporting victims’ families, and Air France have all criticised the ongoing investigation. The Bureau d’enquêtes et d’analyses (BEA) is being accused of trying to blame the pilots in order to absolve Airbus.

The controversy follows the release of the BEA’s latest interim report detailing findings so far. At the last moment, the BEA removed a recommendation added by chief investigator Alain Bouillard which called for alarms on Airbus A330s to be modified.

The National Airline Pilots Union (SNPL) is concerned the investigation is degenerating “into a simple charge sheet against the crew,” and says the latest revelations left them with “seriously damaged” faith in the investigators. The SNPL has withdrawn all support in the probe. Air France claim alarms on the A330-200 were “misleading” and contributed to the disaster. Robert Soulas, president of French victims’ families group Entraide et Solidarité AF447, claims the move proves bias in the BEA.

The dispute surrounds stall warning systems. An aircraft stalls if it no longer has sufficient speed to keep itself airbourne. The warnings cut out at extremely low speeds, meaning if a stall progresses far enough the warning can cease. The correct course of action in a stall is to lower the nose, increasing an aircraft’s speed; if the speed increases, the warnings can sound again. This may confuse pilots into abandoning corrective measures.

The BEA have responded that the last-minute call to remove a recommendation calling for changes to stall warning design was owing to a need to examine the issue further. They say behavioral psychologists and cockpit designers have been teamed up to look into the warnings and how crews respond to them. The BEA intends to make a recommendation on the issue in the future, and a spokesperson expressed “deep regret” at the SNPL’s response.

Friday’s 117-page report did examine the actions and training of the pilots. The report says they were untrained in high-altitude manual flying and in how to identify and react to failures of speed sensors. Neither was a standard part of training at the time.

The speed sensing system failed, causing the autopilot and autothrust to switch off. This was followed by stall warnings, which the interim BEA report say were ignored by pilots during a three-and-a-half minute fall of 38,000 feet into the ocean.

“The haste with which these authorities and these officials accused the pilots without any forethought aroused our suspicions,” said Soulas. “We now have confirmation that the affirmations coming from the BEA were not only premature, (but) lacking any objectivity, partial and very oriented towards the defence of Airbus.” For weeks his organisation has mounted protests against the direction taken by the investigation.

Air France, who are battling legally with Airbus over responsibility (both firms are also under criminal investigation), wrote to the European Aviation Safety Agency asking that they examine the stall warnings and seek that they be changed in need be. Air France previously upgraded the speed sensors on their A330s.

Junior Transport Minister Thierry Mariani defended the BEA. “There has never been such a transparent enquiry: it was filmed, took place under the judiciary’s control, with Brazilian [and] American investigators. These controversies discredit an enquiry that is exemplary.” Airbus also responded. “Can you imagine for an instant that, because of economic interests or links between the BEA and Airbus, we’d put in peril all the other airlines operating this plane? It’s neither conceivable nor admissible,” said a statement. About 180 airlines use the Airbus A330.



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February 5, 2010

NTSB says pilot error caused crash of Colgan Air Flight 3407

NTSB says pilot error caused crash of Colgan Air Flight 3407

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Friday, February 5, 2010

Aviation

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A Colgan Air Dash 8 Q400, in in Continental Connection livery, similar to the aircraft involved
Image: Rudi Riet.

The U.S. National Transportation Safety Board (NTSB) has determined that the captain of Colgan Air Flight 3407, which crashed nearly a year ago outside Buffalo, New York during its approach to Buffalo Niagara International Airport, “inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the aeroplane did not recover,” according to a statement issued by the NTSB.

The flight, operating as a codeshare with Continental Airlines under their Continental Connection brand, crashed last year on February 12, 2009 in Clarence Center, New York. The Bombardier Dash 8 Q400, crashed into a residence killing everyone on board as well as one on the ground.

The NTSB has blamed pilot error and poor training for the crash, noting that the plane’s captain, Marvin Renslow, “had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.” Renslow’s career spanned two decades and had failed five performance checks during that time. Colgan Air was only aware of three. Colgan said had they known about the other two, they would not have hired Renslow in 2005.

Colgan Air responded to the NTSB report in a letter: “They [the pilots] knew what to do in the situation they faced that night a year ago, had repeatedly demonstrated they knew what to do, and yet did not do it. We cannot speculate on why they did not use their training in dealing with the situation they faced.”

The Board added that Renslow’s response to the “stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion. The 24-year-old first officer, Rebecca Lynne Shaw, was noted for her young age and lack of experience.

Cquote1.svg It was continuous and one-sided, with the captain doing most of the talking. It was as if the flight was just a means for the captain to conduct a conversation with this young first officer. Cquote2.svg

—Robert Sumwalt, NTSB board member

The Board also concluded that “the pilots’ performance was likely impaired because of fatigue.” Renslow and Shaw had spent the night at the crew lounge at Newark Liberty International Airport in violation of Colgan Air’s company policies. However, the board voted down making fatigue a contributing factor. Shaw, the first officer, had flown the previous night on two separate planes from the Pacific Northwest where she lived with her parents. Shaw also appeared to be suffering from a bad cold.

However, the report also criticized Colgan saying that the airline, “did not pro-actively address the pilot fatigue hazards associated with operations at a predominantly commuter base.” Adding that, “Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.”

Another factor brought up the by the NTSB was the violation of the Federal Aviation Administration’s (FAA) sterile cockpit rule. It was noted that first officer Shaw had sent two text messages before take-off at Newark. The second message was sent two minutes before take-off.

Cquote1.svg Recent NTSB investigations have identified personal wireless technology use on the job. This phenomenon is becoming more widespread, and these phone calls, texts and other distractions have deadly consequences and must be addressed with all due haste by the transportation industry. Cquote2.svg

—Deborah Hersman, NTSB Chairwoman

Prior to landing, the cockpit voice recorder recorded that the pilots were holding a conservation that potentially distracted the captain from operating the plane. Robert Sumwalt, a member of the NTSB board said, “It was continuous and one-sided, with the captain doing most of the talking.” He added, “It was as if the flight was just a means for the captain to conduct a conversation with this young first officer.”

An animated reconstruction by the NTSB, which shows the last 2 minutes of Colgan Air Flight 3407. (2:38)
Image: National Transportation Safety Board.

The chairwoman of the NTSB, Deborah Hersman, has noted that electronic devices are becoming a hazard to transportation. Hersman said, “Recent NTSB investigations have identified personal wireless technology use on the job. This phenomenon is becoming more widespread, and these phone calls, texts and other distractions have deadly consequences and must be addressed with all due haste by the transportation industry.”

The agency noted that distractions from electronics have played a part in many recent accidents and incidents, such as the August 2009 mid-air collision between a small private Piper aeroplane and a tour helicopter over the Hudson River in New York City killing all involved. The NTSB noted that one of the air traffic controllers was making a phone call and failed to warn the aircraft of the conflict that existed between each other in their airspace. However, this was disputed by the National Air Traffic Controllers Association which represents air traffic controllers nationwide. The NTSB later retracted some of its statements.

The other notable incident was that of Northwest Airlines Flight 188 in October, that overshot its destination of Minneapolis-Saint Paul International Airport by 150 miles (241 km) before the pilots noticed. The pilots claimed they were checking schedules on their laptop computers in violation of basic piloting rules, the sterile cockpit rule and the policy of Delta Air Lines, who had recently acquired Northwest.

The NTSB’s last board meeting which was held two weeks ago, about the 2008 train collision between a Metrolink commuter rail train and a Union Pacific freight train in Chatsworth, California also pertained to distractions by electronic devices. In the statement released by the NTSB for that meeting, the board stated that “according to records from the wireless provider, on the day of the accident, while on duty, both the Metrolink engineer and the Union Pacific conductor used wireless devices to send and receive text messages.” The NTSB has recommended that audio and video recorders be installed in locomotive and control cabs because of the collision.



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February 18, 2009

Buffalo, New York plane crash may have resulted from pilot error

Buffalo, New York plane crash may have resulted from pilot error

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Wednesday, February 18, 2009

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A Bombardier Dash 8 Q400, similar to the aircraft involved in the incident

The investigation into Continental Connection Flight 3407, which crashed near Buffalo, New York last week, suggests that the pilot of the turboprop commuter airliner may have put the aircraft into its plunge.

A source close to the investigation says that information from the flight data recorder on board the aeroplane indicated that the pilot’s control column, the device which is used to steer the aircraft, was pulled upward abruptly, thereby causing the nose of the aeroplane to pitch up.

The sudden pitch-up movement happened soon after the flight crew received a warning in the cockpit that the aircraft was about to stall. In aviation, a stall is when the air no longer flows over the wings of an aeroplane, and the aircraft can no longer keep the lift necessary to keep it airborne, causing it to fall.

The normal manoeuvre to recover from a stall for wing icing is to apply full power to the engines and push the nose down. For a tail stall recovery, the opposite procedure is used: the nose should be pulled up and engine power reduced. In this instance, the pilot seems to have pulled the nose upward, but also increased the engine throttles to their full setting.

After the aeroplane pulled up abruptly, it then pitched down at an angle of 31 degrees, rolling left and right, partially upside-down. This sort of stall is known as an aggravated stall, and it can be very difficult to return the aeroplane to normal flight from one. In this case, the pilot had less than two thousand feet to do so before the aircraft crashed into the ground.

The pilot’s training has now been put into question, and it was discovered that the captain, Marvin Renslow, aged 47, had logged only 110 hours in this particular aircraft, though he had thousands of hours in similar aircraft. Experts say his experience should have adequately prepared him.

A spokesman for the National Transportation Safety Board, Keith Holloway, said that it is currently too early to definitively say what caused the crash. “We have not concluded anything,” he said.

Continental Connection Flight 3407 crashed into a house in Clarence Center, a suburb of Buffalo on February 12 in icy weather, killing all 49 people on board the aeroplane and one person on the ground.



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October 11, 2008

Preliminary report released on Spanair disaster that killed 154

Preliminary report released on Spanair disaster that killed 154

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Saturday, October 11, 2008

A preliminary report has been released into the disastrous crash of Spanair Flight 5022 in Madrid, Spain on August 20, which killed 154. The report confirms an earlier leaked finding that the wing flaps failed and no warning sounded to alert the pilots.

The MD-82 was headed from Barajas airport to the Canary Islands. Video footage from airport security cameras shows the airliner travelling across an unusually long distance of runway before take-off. It failed to maintain altitude and quickly dropped back down at the runway’s end, before bursting into a fireball. Just eighteen people survived the accident.

The report confirms that the aircraft failed to get beyond forty feet off the ground before entering a stall and crashing. The tail of the jet struck the ground first, and the Spanish Civil Aviation Accident Investigation Commission (CIAIAC)’s report also notes that the aircraft was carrying 10,130 litres (2,673 gallons) of fuel.

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The wing flaps were “fully retracted” at “0 degrees” according to the 12-page report, which also notes that the cockpit voice recorder indicates a complete failure of the take-off warning system (TOWS) – which is supposed to alert pilots attempting to take off in a plane that is not properly configured – to sound prior to the failed ascent. Spanair checks the TOWS each day and after every change in flight crew, but neither of these occurred between the accident flight and the flight before.

It is not known when the CIAIAC’s final report will be ready, but estimates vary from a few months to two years. The latest report notes “The investigation continues. It will be necessary to carry out tests and an exhaustive examination of the recovered parts of the plane.” A separate judicial investigation also continues.

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June 6, 2008

US B-2 bomber crash in Guam caused by moisture on sensors

US B-2 bomber crash in Guam caused by moisture on sensors

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Friday, June 6, 2008

A file photo of a B-2 Spirit bomber

The final report into the crash of a B-2 Spirit bomber belonging to the United States Air Force (USAF) in Guam has determined that the crash was caused by moisture on sensors which caused the jet to receive inaccurate data. It was the first loss of a B-2, which costs US$1.4 billion.

The aircraft, belonging to USAF’s 509th Air Wing and carrying the name Spirit of Kansas, was attempting takeoff from Andersen Air Force Base on February 23 this year when the crash occurred. Moisture in three of the 24 air pressure sensors caused the sensors, all on the port side, to feed back inaccurate data to the flight computer.

The aircraft crew believed the bomber had reached the takeoff speed of 140 knots when in reality it was traveling ten knots slower and rotated for takeoff. The malfunction also meant that the sensors showed the plane to be in a nose down position, causing it to command a high level of pitch, around 30 degrees. This, combined with the low takeoff speed, caused the aircraft to stall and veer to the left.

Major Ryan Link and Captain Justin Grieve, who were piloting, ejected as the left wingtip struck the ground. They were injured, with Grieve suffering compression fractures to his spine, but survived. The wreckage came to rest to the runway’s left.

The report also noted that more effective communications could have prevented the crash. The vulnerability of the sensors to moisture was first detected by aircrews and maintenance staff in 2006, at which time it was discovered that turning on the 500 degree pitot heat prior to sensor calibration would evaporate the water and cause a return to normal readings. However, this was never formally noted and so the pilots of the aircraft were unaware of the potential problem or its solution.

They were also unaware that, at an earlier time at the same base, another B-2’s takeoff roll was aborted at 70 knots due to abnormal indications. After inspection by maintenance personnel, it was determined that moisture in the sensor system was to blame. After turning on the pitot heat the aircraft took off without incident.

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