AF 447 Rio-Paris, 2009

Air Asia QZ 8501 Surabaya-Singapore, 2014

A Common thread

for training ?

Capt. Nathalie de Ziegler

WATS 2016

The sole objective of the safety investigation shall

be the prevention of accidents and incidents.

It is not the purpose of this activity to apportion

blame or liability (ICAO Annex 13).

2

REMINDER

The choice of events was driven by their availability to the BEA

through investigations as investigation leader (AF 447) or an

accredited representative (Air Asia QZ 8501)

This presentation is not a formal study, it has no statistical value

The aim is to suggest ideas for loss of control recovery training

Snapshots are not the replica of the airplane cockpit during the event

(drawn from FDR data, some missing elements recalculated)

3

REMINDER

Air France 447

A330, Rio to Paris, June 2009

Augmented crew : 1 Captain , 2 F/Os

In cruise at FL350, Captain not in cockpit

Aircraft enters ice crystals, 3 pitot probes freeze

4

Summary of event

5

Summary of event

Air Asia QZ 8501

A320, Surabaya - Singapore, Dec 2014

Crew of 2 pilots

In cruise at FL320, crew mismanages an

ECAM procedure, and disables both

FACs

6

For both events, a common final scenario

All Automation suddenly disengages

Flight controls revert from normal to alternate law

Some FE protections are lost, incl. the AOA protection

Crews make inappropriate inputs on the flight controls

Crews are unable to recognize the stall situation

Airplanes enters a developed stall from which crews fail to

recover

Airplanes impact water less than 5 mn after AP disengagement

7

Is there a common thread for training?

Specific flight context?

Particular crews?

Event triggers?

Airplane technical status?

Startle effect ?

Crew performance ?

Aircraft energy awareness

Crew dynamics

8

Topics

Colgan Air, Dash 8 Q400, Newark to Buffalo, during approach, 2009

NTSB report concluded that the leading cause of the crash was the

pilots’ inappropriate response to the SW

West caribbean, MD82, Tocumen (Panama) to Fort de France,

Martinique, FL 310 in 2005

JIAAC report concluded : «Circumstances... of the flight resulted in a

stall. CRM and decision making of the crew were not appropriate»

9

References to other accidents

IMC, crews pre-occupied with weather issues

In cruise at high altitude

Normal SOPs prior to event are conducted uneventfully

(from CVR)

Note 1: West Caribbean Airways MD82 in 2005 (IMC, high altitude)

Note 2: Colgan air is IMC in approach

10

Flight Context

Low experienced PF

Air Asia, 2500 h

AF 447, 2900 h

Non standard cockpit gradient

AF 447, two F/Os under-trained to leadership & decision making

Air Asia , the Captain was very experienced and a high authority gradient is

perceptible in the CVR

Note 1 : Colgan air Dash-8 Q400 : PF 3 300 h (PM 2250 h)

Note 2 : West caribean : PF 5 900h, 1 100 as Captain, (PM 800 h), High cockpit

gradient is found causal in event 11

Flight crew

In both cases, at the initiation of the event , the

usual decision-maker (captain) is not in his seat

therefore « out of the loop »

Note: Rejoining Flight in Progress for an « out of the loop » pilot in

complex situations on complex airplanes could be investigated

further

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Flight crew

Event triggers

AF 447 , event (pitot icing) is un-related to prior crew action

Pitot icing is due to ice-crystals (St Elmo’s fire, rise in SAT

and cockipt temperature, smell of ozone are commented

by the crew)

The crew makes no connexion between symptoms of ice

crystals, pitot icing and possible loss of airspeeds

13

Event triggers

In Air Asia

The trigger is the result of an inadequate crew action

Captain pulls both FAC CBs (not permitted by QRH reset table)

Captain is not aware of the consequence of his actions in flight

F/O not aware that the Captain is going to pull the CBs

F/O not aware of the impact of such action on the handling of the

airplane (alternate law and rudder deflection)

14

Event triggers

Flight controls revert to « Alternate law »

Pitch control is normal, THS is operative

Roll control becomes direct (somewhat sharper than

normal)

Some protections are lost: High pitch, high bank angle,

High AOA

Stall warning system is operative15

Flight controls

Additionally, in Air Asia

The PF has to make a permanent right input on the side-

stick to keep the wings level

Because both FAC CBs were pulled

The initial position of the rudder is approx 2°L

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Flight controls

« Normal » situation …then suddenly:

AP and A/THR disengage, ECAM warnings and Cautions

Initial Startle

Immediate and abrupt pilot actions on side-stick (PF)

Impairment of situational awareness and problem solving ability

Pilots have limited understanding of the situation

Prolonged Startle (fear)

« Startle Cycle »

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Startle

In normal situation on a majority of modern aircraft

PFD speed tape displays current speed (raw number)

Current speed is assessed in relation to « known » limits (MMO,

Green dot, VLS or equivalent ) which represent visual thresholds or

boundaries

Current speed is « projected » via SPEED TRENDS

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Aircraft Energy

Crews’awareness of the aircraft energy seems fragile

For both crews :

1. Energy awareness appears to be more dependent on speed tape

indications, than on pitch / thrust

2. The initial focus is to keep the wings level, not to control the aircraft

energy

3. « Stall » is not verbalized, the Stall recovery procedure not applied

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Aircraft Energy

1

The crews energy awareness appears to be more

dependent on speed tape indications, than on

basic parameters : pitch, thrust

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Aircraft Energy

AF 447

Speed values are grossly

erroneous at the initiation of

event

« SPD LIM » Flag is apparent

Speed trends disappears

21

Aircraft Energy

Air Asia

Speed values are correct

Characteristic speeds (boundaries)

disappear (CBs pulled)

« SPD LIM » flag is apparent

Speed trends disappear

22

Aircraft Energy

When some « familiar » elements of the speed

tape are suddenly missing, flagged , or

inconsistent

The crew does not revert to pitch and thrust

(« FLY »)

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Aircraft Energy

2

The main focus is to keep the wings level, not to control

the aircraft energy

AF 447: “Essaie de ne pas toucher les commandes en

latéral” (try not to touch to the controls laterally)

Air Asia : “level, level, level”

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Aircraft Energy

3

«Stall » is not verbalized* / Procedure not applied

Crews do not make reference to Stall warning, do not

identify / understand deterrent buffet (CVR)

Stall warning does not trigger the expected action

*Except West Caribbean (« Es el Stall Capi »)

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Aircraft Energy

Crew dynamics and mutual support ability are affected

PF is not aware, almost incapacitated :

Over-correcting, not correcting, tunnelling, frozen

PM shows some awareness of the pitch /energy

PM does not support PF efficiently (indicate deviations, take

over when necessary)

*Note : West Caribbean Airways, the Captain is tunneling on

engine parameters

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Crew Dynamics

PF likely unaware of high pitch

PF does not correct wide pitch excursions

27

Crew Dynamics

PM seems to have some awareness of high pitch

and low energy (CVR)

AF 447 “redescends” (“go down”)

Air Asia: “pull down”

28

Crew Dynamics

PM does not support PF efficiently

PM does not announce deviations with standard calls,

orders provide un-clear or inconsistent targets : ie « pull

down », « go down »

PM unable to take over controls in due time

When PM takes over, priority take over procedure is

not carried out correctly29

Crew Dynamics

During the event, the normally expected crew

dynamics is lost :

Pilots do not share the same picture (energy

awareness)

Crew appears «dissociated»

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Crew Dynamics

Finally, when the stall is fully developped, both crews

express they are “completely lost”

AF 447: “Tu comprends ou pas ce qui se passe?” (do

you understand what is going on or not ?)

Air Asia : “Qu’est ce qu’il fout, là ?” (what is it doing

here?)

31

Crew Dynamics

Specific flight context

Yes : IMC, avoiding adverse weather

Specific crew

Yes : Latent leadership issues (problematic authority gradient)

? : Low experience

Event triggers

Different but almost same operational consequences

32

Topics Review

Crew performance

Before the event, SOPs are applied uneventfully

During the event, main issues appear to be:

Prolonged Startle

Loss of pilot know-how in basic handling

Loss of energy awareness, especially for PF

Dissociation of the crew, loss of dynamics

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Topics Review

Crews had not been trained extensively to manual flying at high

altitude in the simulator and never practice on the line

Crews had been trained to « approach to stall » in the simulator,

but always in a known and predictable environment

Simulator training scenarios do not always provide realistic

startling situations possibly encountered in flight

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TRAINING STATUS

Areas of Improvement in training:

Improve understanding of aircraft energy : ie relation

between pitch, thrust, speed

Increase the ability to revert to basic flying without delay, if

any doubt about speed display

Improve recognition of Stall

Rehearse systematic immediate reaction to Stall warning

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Key training issues

Explain to crews how and why the crew dynamics may

be lost during stall

Consider stall as a possibly startling, incapacitating,

situation, for some crews, especially for the PF

Train the PM to recover in case of inappropriate PF’s

actions, in case he/she is startled

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Key Training issues

Links to the reports :

AF 447

https://www.bea.aero/fileadmin/documents/docspa/2009/f-

cp090601.en/pdf/f-cp090601.en.pdf

Air Asia (QZ8501)

http://kemhubri.dephub.go.id/knkt/ntsc_home/ntsc.htm

Final report issued 1 december 2015

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AF 447 and Air Asia reports

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Thank you for your attention