The captain of Air Asia Flight 8501 overrides the computers instructions and his impromptu fix leads to a deadly stall over the Java Sea.
Indonesia AirAsia Flight 8501 was a scheduled international passenger flight operated by Indonesia AirAsia from Surabaya, Java, Indonesia, to Singapore. On 28 December 2014, the Airbus A320 flying the route crashed into the Java Sea, killing all 162 people on board. When search operations ended in March 2015, only 116 bodies had been recovered. This was the third-deadliest aviation accident in Indonesian soil, behind Garuda Indonesia Flight 152 and Lion Air Flight 610.It is also the first fatal crash of an Airbus A320 aircraft since the crash of XL Airways Germany Flight 888T in 2008, as well as the second deadliest involving the Airbus A320 family, behind TAM Airlines Flight 3054 in 2007.
In December 2015, the Indonesian National Transportation Safety Committee (KNKT or NTSC) released a report concluding that a non-critical malfunction in the rudder control system prompted the captain to perform a non-standard reset of the on-board flight control computers. Control of the aircraft was subsequently lost, resulting in a stall and uncontrolled descent into the sea. Miscommunication between the two pilots was cited as a contributing factor.
Aircraft
The aircraft was an Airbus A320-216,[b] with serial number 3648, registered as PK-AXC. It first flew on 25 September 2008, and was delivered to AirAsia on 15 October 2008. The aircraft was six years old and had accumulated approximately 23,000 flight hours over 13,600 flights. It had undergone its most recent scheduled maintenance on 16 November 2014. The aircraft was powered by two CFM International CFM56-5B6 engines and was configured to carry 180 passengers
Investigation
The events leading to the crash were investigated by Indonesia's National Transportation Safety Committee (KNKT or NTSC). Assistance was provided by Australia, France, Singapore, and Malaysia.
Data from the flight data recorder were downloaded.[125] Although the aircraft's route took it through areas of cloud that extended from 12,000 ft (3,700 m) up to 44,000 ft (13,000 m), FDR data showed that weather was not a factor in the accident.
124 minutes of cockpit dialogue was successfully extracted from the cockpit voice recorder. The sound of many alarms from the flight system can be heard in the final minutes, almost drowning out the voices of the pilots. The investigators ruled out a terrorist attack as the cause and then examined the possibility of human error or aircraft malfunction.
Acting director of Air Transportation, Djoko Murjatmodjo, clearly stated that the investigation of the flight route and the investigation of the crash itself are separate. Murjatmodjo said that "AirAsia is clearly wrong because they didn’t fly at a time and schedule that was already determined." Both Singapore's civil aviation authority and the Changi Airport Group stated that Air Asia was allowed daily flights between Surabaya and Singapore. Tatang Kurniadi, head of Indonesia's National Transportation Safety Committee, stated that sabotage was ruled out as a cause of the accident by the black boxes, and a preliminary report was supposedly submitted to the International Civil Aviation Organisation by early February.[citation needed]
Final NTSC report
After studying the wreckage of the Airbus A320-216 as well as the two black boxes and the cockpit recorder, Indonesia's National Transportation Safety Committee issued a report with their conclusions from the investigation on 1 December 2015. The report stated that the sequence of events that led to the crash started with a malfunction in two of the plane's rudder travel limiter units (RTLU).[130] A tiny soldered electrical connection in the plane's RTLU was found to be cracked, likely for over a year, causing it to intermittently send amber master caution warnings to the electronic centralised aircraft monitor (ECAM)—with the plane's maintenance records showing that the RTLU warning had been sent 23 times over the previous year, but was always solved (and never further investigated, which could have addressed the underlying electrical problem) by resetting the RTLU system.On this flight, the RTLU issue sent an amber caution warning four different times, and the first three times that the ECAM system gave the warning "Auto Flight Rudder Travel Limiter System", the pilot in command followed the ECAM instructions, toggling the flight augmentation computer (FAC) 1 and 2 buttons on the cockpit's overhead panel to off and then on. This procedure did clear the amber master caution warnings for each of those first three warnings.
Specifics in the report indicate that French First Officer Rémi Emmanuel Plesel was at the controls just before the stall warning sounded in the cockpit indicating that the jet had lost lift. Investigators also found that, just moments earlier—on the fourth occurrence of the RTLU warning during the flight—the Captain chose to ignore the procedure advised by the ECAM instructions, and, instead, left his seat and reset the circuit breaker of the entire FAC, unintentionally disengaging multiple flight control systems, which would have to be turned on by the pilots after the circuit breakers are reset.This circuit breaker is not on the list of circuit breakers that are allowed to be reset in flight, and disabling both FACs placed the aircraft in alternate law mode, disengaging the autopilot and stopping the automatic stall protection and bank angle protection. The FAC is the part of the fly-by-wire system in A320 aircraft responsible for controlling flight surfaces including the rudder. Without the FAC's computerized flight augmentation, pilots would have to "rely on manual flying skills that are often stretched during a sudden airborne emergency".When the crew was required to fly the Airbus A320 manually, there was an unexplained nine-second delay between the start of the roll and either pilot attempting to take control. After nine seconds, the aircraft was banking at a 54° angle: the rudder had deflected 2 degrees to the left, causing the aircraft to roll. Subsequent flight crew actions resulted in the aircraft entering a prolonged stall from which they were unable to recover.
The report did not specifically conclude that pilot error caused the crash while detailing the chain of events leading to the loss of Flight 8501. One of the investigators, the NTSC's Nurcahyo Utomo, referred to an apparent miscommunication between the pilots (based on the recordings on the cockpit voice recorder) and said that the malfunction should not have led to a total loss of control had they followed the recommended procedure.
Side-stick control issue
The example of miscommunication between the pilots was when the plane was in a critical stalling condition, the co-pilot misunderstood the captain's command "pull down"; instead of pushing the airplane's nose down (pushing forward on the stick to regain speed and escape the stall), he pulled the stick back, which would have ordered the aircraft to pitch up, deepening the stall. Because the captain was also pushing the stick forward and because Airbus has a dual-input system, the two stick inputs cancelled each other out, which led to the plane remaining in a stall condition until the end of the black box recording. (See the similar side-stick control issue in the Air France Flight 447 accident.)[citation needed]
On 3 December 2015, Indonesia's air transportation director general, Suprasetyo, said that the National Safety Transportation Board (KNKT) had provided recommendations as to tightened controls on aircraft maintenance and flight crew competence. He added that the government had implemented "... a series of corrective actions as a preventive measure so that the same accident will not happen again in the future. Suprasetyo also confirmed that the suspension of Indonesia AirAsia's Surabaya–Singapore route would not be lifted until the carrier had completed the steps recommended by the KNKT.
Infrared satellite imagery (taken at 7:32 WIB) with flight path superimposed on the right. On this false-colour image, blue represents warmer temperatures, while red and ultimately black represent the cold tops of high-altitude clouds
Secondary radar image shows Flight 8501 (circled in yellow) at an altitude of 36,300 ft (11,100 m) and climbing, travelling at 353 kn (654 km/h) ground speed.
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