AF 447 Rio-Paris, 2009 Air Asia QZ 8501 Surabaya-Singapore, A Common thread for training? Capt. Nathalie de Ziegler WATS 2016

Transcription

1 AF 447 Rio-Paris, 2009 Air Asia QZ 8501 Surabaya-Singapore, 2014 A Common thread for training? Capt. Nathalie de Ziegler WATS 2016

2 REMINDER 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

3 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

4 Summary of event 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

5 Air Asia QZ 8501 Summary of event A320, Surabaya - Singapore, Dec 2014 Crew of 2 pilots In cruise at FL320, crew mismanages an ECAM procedure, and disables both FACs 5

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 6

7 Is there a common thread for training? 7

8 Specific flight context? Particular crews? Event triggers? Airplane technical status? Startle effect? Crew performance? Aircraft energy awareness Crew dynamics Topics 8

9 References to other accidents 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

10 Flight Context 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

11 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 Flight crew 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 h (PM 2250 h) Note 2 : West caribean : PF 5 900h, as Captain, (PM 800 h), High cockpit gradient is found causal in event 11

12 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 12

13 Event triggers 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

14 In Air Asia Event triggers 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

15 Flight controls 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 operative 15

16 Additionally, in Air Asia Flight controls The PF has to make a permanent right input on the sidestick to keep the wings level Because both FAC CBs were pulled The initial position of the rudder is approx 2 L 16

17 Startle «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» 17

18 Aircraft Energy 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 18

19 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 19

20 Aircraft Energy 1 The crews energy awareness appears to be more dependent on speed tape indications, than on basic parameters : pitch, thrust 20

21 AF 447 Speed values are grossly erroneous at the initiation of event «SPD LIM» Flag is apparent Speed trends disappears Aircraft Energy 21

22 Air Asia Speed values are correct Characteristic speeds (boundaries) disappear (CBs pulled) «SPD LIM» flag is apparent Speed trends disappear Aircraft Energy 22

23 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») 23

24 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) 2 Air Asia : level, level, level Aircraft Energy 24

25 Aircraft Energy «Stall» is not verbalized* / Procedure not applied 3 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») 25

26 Crew Dynamics 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 26

27 Crew Dynamics PF likely unaware of high pitch PF does not correct wide pitch excursions 27

28 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

29 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 correctly 29

30 Crew Dynamics During the event, the normally expected crew dynamics is lost : Pilots do not share the same picture (energy awareness) Crew appears «dissociated» 30

31 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

32 Specific flight context Yes : IMC, avoiding adverse weather Specific crew Yes : Latent leadership issues (problematic authority gradient)? : Low experience Event triggers Topics Review Different but almost same operational consequences 32

33 Crew performance Before the event, SOPs are applied uneventfully During the event, main issues appear to be: Prolonged Startle Topics Review Loss of pilot know-how in basic handling Loss of energy awareness, especially for PF Dissociation of the crew, loss of dynamics 33

34 TRAINING STATUS 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 34

35 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 Key training issues Rehearse systematic immediate reaction to Stall warning 35

36 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 36

37 AF 447 and Air Asia reports Links to the reports : AF Air Asia (QZ8501) Final report issued 1 december

38 Thank you for your attention 38