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AirAsia... fault caused by cracked soldering... and human error

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    AirAsia... fault caused by cracked soldering... and human error

    Rudder Problem Led to AirAsia Crash
    Tue Dec 1, 2015 06:34 AM CST
    JAKARTA, Indonesia (AP) -- A rudder control system problem that had occurred 23 times in the previous 12 months coupled with the pilots' response led to last year's crash of an AirAsia plane that killed all 162 people on board, Indonesian investigators said Tuesday.

    The National Transportation Safety Committee said an analysis of Flight 8501's data recorder showed the rudder control system had sent repeated warnings to the pilots during the Dec. 28 flight between the Indonesian city of Surabaya and Singapore.

    Aircraft maintenance records for the Airbus A320 showed that problems with the rudder system had been reported 23 times during the year prior to the crash, with nine occurring in December. The investigators said the fault was caused by cracked soldering on an electronic circuit board.

    Investigator Nurcahyo Utomo said the problem by itself should not have been dangerous. But after the fourth time an alarm went off during the flight, a crew member apparently went against recommendations and removed a circuit breaker to try to reset the system, he said.

    The autopilot became disengaged, and the aircraft began to roll, but no movement was detected on the plane's manual control stick for nine seconds, he said. It then began climbing rapidly before stalling and plummeting into the Java Sea.

    Utomo said the voice recorder showed the pilot said "pull down," but in fact the plane was ascending.

    "It seemed that there was a miscommunication between the pilot and co-pilot after the fourth fault," he said.

    The same warnings had occurred three days before the crash with the same pilot, who witnessed a technician on the ground addressing the problem by removing the circuit breaker and then replacing it, according to Utomo and the investigation report.

    The last contact the pilots had with air traffic control indicated they were entering stormy weather. They asked to climb from 32,000 feet (9,753 meters) to 38,000 feet (11,582 meters) to avoid threatening clouds, but were denied permission because of heavy air traffic. Four minutes later, the plane dropped off the radar. No distress signal was issued, and investigators said weather conditions did not play a role in the crash.

    "There is much to be learned here for AirAsia, the manufacturer and the aviation industry," tweeted Tony Fernandes, chief executive of the Malaysia-based budget carrier. "We will not leave any stone unturned to make sure the industry learns from this tragic incident."

    #2
    What safety lesson is to be learned from this Accident? OHS... would fine the employer... because the pilot went AGAINST the manual... and removed a circuit breaker... it is the employers fault... not the Pilots error...

    Background;

    "The autopilot became disengaged, and the aircraft began to roll, but no movement was detected on the plane's manual control stick for nine seconds, he said. It then began climbing rapidly before stalling and plummeting into the Java Sea.

    Utomo said the voice recorder showed the pilot said "pull down," but in fact the plane was ascending.

    "It seemed that there was a miscommunication between the pilot and co-pilot after the fourth fault," he said.

    The same warnings had occurred three days before the crash with the same pilot, who witnessed a technician on the ground addressing the problem by removing the circuit breaker and then replacing it, according to Utomo and the investigation report."

    Comment


      #3
      Scarey, isn't it. To think that no pilot refused to fly this plane with a chronic problem like that. Are they afraid to speak up?This isn't the first crash where a chronic mechanical problem was found to be to blame. Guess the safety board needs to take a more proactive stance in guaranteeing that mechanics do their job properly. You can't really expect pilots to be trying to fix electronic problems at 32000 feet.

      Comment


        #4
        Tom, how do you know the employer would be fined and not the pilot in this case? Pilots and copilots have been fined for safety violations. Alberta OHS allows penalties to be levied against workers as well as companies: "OHS administrative penalties can be imposed against any parties regulated by OHS legislation – workers, contractors, suppliers, prime contractors and employers" (http://work.alberta.ca/occupational-health-safety/ticketing-and-administrative-penalties.html)

        And I am more worried about the 162 people who were killed and making sure that does not happen again for the same reason than whether it should be the pilot/airline or anyone getting fined. The purpose of OHS is not collecting fines it is preventing accidents.

        Comment


          #5
          DML,

          I asked OHS...last Tuesday in Vermillion... if an employee refuses to follow safety protocol... and the employer knows... who is responsible.

          Answer was.. the employer.

          Comment


            #6
            And the key is: "if the employer knows"

            Comment


              #7
              DML,

              "If the employer knows"

              If I do not know what is going on ... then I really am an accident waiting to happen.

              Cheers

              Comment


                #8
                BTW DML

                I will bet... if the chief maintenance engineer for AirAsia had know what was going on with the A320 warnings... in 5 minutes one toll free phone call...with Airbus; they could/would have found out and fixed the problem months before this tragedy.

                This is about a communication culture... NOT gov rules and regulations... Farming is EXACTLY the same.

                Comment


                  #9
                  Tom:
                  When I took my private pilots training, one thing my flight instructor did was pop a circuit breaker during a training flight. The correct response at the time was to reset it and if everything was okay then continue the flight. It was common practice for even commercial pilots to reset a breaker after a few minutes to allow it to cool.

                  After the Swiss air disaster off Canada's east coast, when an electrical fire doomed the plane, new safety proceedures were implemented that pilots should not reset breakers.

                  In the case you brought up we do not know if the circuit breaker/safety ruling applied to the Indonesian airline. We do not know if the airline knew there was a problem; if after everytime the problem occurred it was immediately looked at by a mechanic and reported as fixed. We do not know if the pilot reported the problem to a mechanic by radio when it kept reoccurring in flight and if he was told to check the circuit breaker or if he did it on his own. We do not know if the pilot considered diverting and landing ASAP and was told by the company to continue. All of these and many more questions come into play before the pilot/mechanic/airline would be fined.

                  It may be that the pilot should carry most of the blame by resetting the breaker on his own volition. Or it may be a case that the airline pushed the pilot to continue to fly the plane even after knowing there was a problem (which in the words of the investigator "in itself should not have been dangerous")in which case a fine is likely warranted as the airlines actions resulted in 162 deaths. But unless you can answer these questions you are simply trying to mislead people by insinuating that OHS only finds employers at fault and not employees.

                  Comment


                    #10
                    You Missed the point... DML you do not get it.

                    There was a very simple A320 fix... that was not done... because communication channels and the culture of safety failed... EXACTLY the same on every farm... everywhere... when there is an accident.

                    Comment

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