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"We are the protagonists of our stories called life, and there is no limit to how high we can fly."


Type rated on A330, B747-400, B747, B757, B767, B737, B727. International Airline Pilot / Author / Speaker. Dedicated to giving the gift of wings to anyone following their dreams. Supporting Aviation Safety through training, writing, and inspiration.

Wednesday, January 7, 2015

What Happened to Air Asia 8501?

While we wait for the aircraft and black box to be pulled from the bottom of the Java Sea, there is a ton of speculation as to what happened.


Captain Bill Palmer, author of Understanding AF447 wrote a great article: How Air Asia 8501 compares to Air France 447. Included in this article he says,
 
"Many parallels between Air Asia 8501 and Air France 447 in June, 2009 are obvious. Both aircraft were lost in thunderstorm areas of the Intertropical Convergence Zone (ITCZ). Both crashed at sea where floating debris drifted for days from the point of contact with the sea before being discovered, and both were sophisticated fly-by-wire Airbus aircraft (though different models).

While flying into a thunderstorm is always to be avoided, it not likely the sole cause of the accident. The reported requests by the crew to deviate course and change altitude seeking to avoided thunderstorm cells and turbulence are completely normal..."


Captain Palmer is correct... it is never one thing. However, had the pilots not flown into that storm, that plane would still be flying today. Do we blame a bridge for the death of a person who jumps? Or do we blame the height, the depth of water, the roughness of the current or the inability to swim?

Unlike AF447, whose pilots flew at night with an improper radar setting and were caught by surprise, Air Asia 8501 pilots flew in daylight, knew the storm was there, attempted to go around and then over the storm at an altitude 1000 feet below the aircraft service ceiling. 


An airline I once instructed at, demonstrates to their pilots during training the performance of a heavy A320 at maximum altitude (39,000 feet). In stable conditions, the stall and flying speed were divided by a narrow margin of 10 to 15 knots. A turn, or any turbulence, could cause the aircraft to stall. Imagine the plane balancing on the tip of a needle. Add turbulence of a storm that grew to 50,000 feet, with updrafts and cross winds, freezing conditions, moisture, etc., you have just flown into the perfect storm without a way out. Conditions that cannot be duplicated in a simulator.


The question should not be what brought down that plane, but how do we keep pilots from flying into such storms.

When I stated that we needed weather training, this had nothing to do with added simulator training. I was talking about weather theory, so pilots would understand the power of these storms and how to avoid them. Pilots must educate themselves on how to read weather charts, and understand weather systems associated with geographical areas they fly.


Did you know:

"The weather in the ITCZ has some unique qualities compared to your average thunderstorm over land. The storms are driven by the convergence of airflow patterns between the northern and southern hemispheres of the Earth in addition to the usual factors of warm moist air and unstable atmospheric conditions.

The height of the stratosphere –- which tends to put a cap on the height of thunderstorm growth averages about 35,000 feet over the mid latitudes (such as that of mainland USA), but reaches to 50,000 feet or more in the ITCZ, providing for the growth of thunderstorms to great heights and accompanying intensity. These features can lead to some unusual conditions such as icing or heavy rain within those storms where it may not normally be expected, as was the case with AF 447 when its airspeed-sensing probes became clogged." Captain Palmer
 

Shouldn't all pilots be appraised of the power of storms in the ITCZ?


Why Didn't They Turn Back?

Pilots are mission driven get the job done type of people. What that means is they will never throw their hands up in defeat, but always do everything they can to fly their plane. However, this also presents a challenge for many to turn back. The pilot push. Pilots want to complete the mission. Many times it's not even a conscious thought.

Experience also plays factor. We want the most experienced pilots flying our planes, but with that experience comes the human factor aspect of... I've been there and done that before, I can do it again. Most times they can, until they can't. Bottom line... this time they got caught.


The reason more of these types of accidents do not occur is because of captains who have the courage to say, "I don't feel like being a hero today." I experienced two situations in one month last fall, where both captains were heroes in my book. Each captain was highly experienced, and were the seen it all kind of pilots, but they also were able to project the "What If" into the future. 

This projection is the essence of Level 3 Situational Awareness (SA), and will keep pilots and passengers safe. This level of SA is what we strive for in all aspects of aviation safety. More accidents would occur if we did not have pilots who could foresee what might happen, and were flexible to the mission.

If we ever get to no pilots in the flightdeck with remote controlled airplanes at the airlines (don't laugh, the industry is working that direction) we will see more of these types of accidents. Airplanes and technology are more apt to get caught in surprise conditions if a pilot is not on board saying, "Something doesn't feel right." We can program an airplane to navigate, but we cannot program a plane to feel. It's when we don't pay attention to the feelings of something isn't right is when we get into trouble. People make errors because they are human.

How do we make sure that pilots avoid a storm they can see building right in front of them? Education about the power of these storms. Education on how to read weather, how to avoid flying into storms, and instill the courage to turn back if what you see does not feel right. 

These two books are excellent. 
Every pilot should read them:



Truth in Fiction

In Flight For Safety, I had written a scene that mirrors Air Asia 8501. (Asiana 214 was in there too, prior to the actual event).

Darby is flying south to Singapore with a senior pilot in an Airbus, A330. Red is blooming on the radar screen, but the captain (a check airman) attempts to beat the storm flying downwind of a cell, despite Darby's objection. The A330 loses all instruments, just as AF447. Stall. Stall. Stall. The same destination, a similar storm system, and an Airbus. But unlike Air Asia 8501, and AF447, the pilots and passengers survived because I was in control of the outcome. 

If I can see this potential and write about an event a year prior to its occurrence, then this event should never have happened.

 
While a novel, lessons on how to fly an Airbus when encountering a loss of flight instruments should not be missed in Flight For Safety. There are also lessons in CRM on how assertive first officers should be in situations like this. Darby failed, but you don't have to.




We do not know why 8501 fell to it's death. But we do know what caused the initial blow. I have to ask, is there any reason to continue in the face of a storm? Is any life worth getting there itis? And if you do not know how powerful mother nature can be, educate yourself. Your life may depend upon it. 


Enjoy the Journey and fly safe!
XO Karlene 

41 comments:

  1. I'm curious if the culture common in Asia of deference to authority played a part. The crew (nominally in command) asked for a deviation and climb, which was refused by ATC (the authority). A US-trained crew might have been more forceful about demanding what they needed than an Asian one. The same dynamic has played out in several Asian (and other regional) crashes over the past 20 years, while the US adopted CRM early (after having similar issues in the post WW2 period). I'll interested to see the CVR transcript.

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    1. As an Asian myself, I would say there's a good chance that it played a part. What I want to see is the thought process of the controller? Did he know that an A320 had no chance to out-climb the storm? Was he dealing with other aircraft that have requested to go around the storm that would conflict with 8501's climb track? If either was the case, what other steps did the control try to take to stop 8501 from continuing on their path? Or, did the controller decided that he's not in authority to question the pilot's judgement? After all, they know what exactly was in front of them and all he has is a blob on his radar--assuming he didn't configure his scope to filter out the storm.

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    2. Perhaps culture played a part, but he climbed even after being told no. And this time, the climb was not to his benefit. However, controllers are not responsible for managing our routes for weather. We see it, we deviate. For the "no" clearance could be as simple the wrong direction and there was another plane a hundred miles away in another controlling center. We've been turned down for a climb due traffic we couldn't see on TCAS for hundreds of miles. When we go to NextGen, and separation is the pilot's responsibility, this will help.
      But for this, the responsibility for entering a storm or not is the pilots.

      What we really need to understand is at what point the safety chain in decision making broke down, and why. Then maybe this won't happen again. Thank you both for your comments!

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    3. That's exactly the problem!! the Captain 4 stripper on an Middle East/Asia/Far East Airlines are Gods!! and the right side guy and the flight operations don't dare question them!!

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    4. While your suggestion that power-distance may have played a part; it is unlikely, as the FO was French.

      Also, refusal by ATC to permit the climb was due to the potential for traffic conflict as another company aircraft was already overhead at that altitude.

      Safe flying to all.

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    5. Good points. But ATC can refuse climbs due to traffic coming the other way many miles away that did not create pending impact. If pilots need an altitude of direction, we take it and ATC can move the other planes. We also have TCAS and do not fly into the other aircraft because we can see it. So, pilots do not ask for altitudes with traffic in the way. Remember, he did climb despite being told no.

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  2. Good post!!

    Of course until we dissect the black box, this is all speculation. But, at this point it is a well-educated guesses. To me, too, this reeks of "continued flight into deteriorating weather."

    We must all remember that the weather radar is a thunderstorm AVOIDANCE tool, NOT a "t'storm penetration" tool.

    It looks like things were changing rapidly, when they climbed, they were close to their Coffin Corner in worsening weather, and by the time they realized it, it may have been too late to turn back.

    Good stuff, Karlene!

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    1. Thanks for the comment Eric. This is so true. Not a penetration tool. I do think the closer someone bypasses the weather, and makes it...then next time they may get closer, and closer. I call it the confidence creep. Then one day they get close enough to get slapped. But we only get lucky so long. Be interesting to interview the First Officers to see if this was standard. Yes...avoid the Coffin Corner.

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  3. As always, thank you for your level headed and informed coverage.

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  4. Great post Karlene, I don't think I will ever board a plane without pilots to fly it.
    Machines and robots just can't think

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    1. Thanks An. I hope everyone holds your conviction!

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  5. What sane pilot would venture to the height where his aircraft was constantly within 10-15 knots of stalling?

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    1. Only someone who never experienced performance limitations. Someone who was not educated on the limitations. However, we don't know how much they weighed. A light plane could handle the altitude. However, only 40 minutes into the flight, and the storms... I would guess they had more fuel than necessary for the two hour flight, and were also full... probably heavy. Some good questions to ask.
      Thanks for your comment!

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  6. In my meager (300+ hours) as a private pilot, I spent five different unscheduled nights in motels because of weather. My flight school drummed into our heads the saying "There are old pilots, and there are bold pilots, but there are no old, bold pilots."

    Back in those days, I subscribed to FLYING MAGAZINE, and Richard Collins had a monthly feature exploring some general aviation accident. In most cases they involved flying into deteriorating weather conditions.

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    1. David, This is the best comment. Yes... so true. And I have that quote in my newest book. Coming soon. You had a good instructor and staying in a hotel kept you alive. Thanks for the comment!!

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  7. We don't know what happened here. Until the fdrs are found and decided we cannot judge this tragedy.

    Was the Asian captain or French Co pilot suicidal like the Embraer jet that went down just north of Botswana?

    Also the BEA AF447 report does not say they were inside a storm cell. They state that there was no severe turbulence. Yes the pilots were temporarily frozen which led to a, stable auto pilot disconnect. What the junior pilots did next, in response to these events, caused the deaths of 228 people.

    It took two years to find the black boxes and the aircraft broke up and sank into very deep water. With air Asia thankfully the water is shallow enough for a faster recovery of data.

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    1. Lukas, You should read Understanding Air France 447 for a factual and clear picture. I'm not sure if you're implying this accident was suicide, but I'm sure we'll all find it was weather related. The question is... why take on a storm of that magnitude? Most planes can't wind. Avoid and you'll be safe! Thanks for the comment.

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  8. We don't know what happened here. Until the fdrs are found and decoded we cannot judge this tragedy.

    Was the Asian captain or French Co pilot suicidal like the captain of the Embraer jet that went down just north of Botswana?

    Also the BEA AF447 report does not say they were inside a storm cell. They state that there was no severe turbulence. Yes the pitots were temporarily frozen which led to a, stable auto pilot disconnect. What the junior pilots did next, in response to these events, caused the deaths of 228 people.

    It took two years to find the black boxes and the aircraft broke up and sank into very deep water. With air Asia thankfully the water is shallow enough for a faster recovery of data.

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  9. Karlene, although you say the AF447 accident was 'weather related', I guess you mean it had a weather element rather than being the actual cause? I haven't read the mentioned book but will search it out.

    For many the BEA report points to a failure in the crew actions (before and?) after the initial icing problem as the cause not the transient icing problem itself. Many of us have been in icing and lived to tell the tale so what did we do that was so right compared to these other pilots?
    Do all of us know our Pitch/Power numbers for our cruise altitudes?

    In the rare cases where weather is an element in an accident (Palm-90, Dryden, etc), the icing doesn't cause the crash so much as the pilots do by their actions, or inactions - unless of course it's EXTREME weathers (freezing rain, windshears, etc) then the question is should the pilots have been there in the first place..!?

    Hence your perfect advice to AVOID is spot on! May I also advocate adding the Pitch/Power numbers to memory to this too...just in case...

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    1. Richard, Thank you for the great comment. The pilots on AF447 made huge errors in negligence going into the storm by not having the radar set and self-induced fatigue... and when they lost their instruments, they did not understand their plane or what was happening, and without that knowledge, they had no way to know what to do. They reacted improperly. They were stuck in level 1 situational awareness and the rest is history.

      The CA of Air Asia had the visual of the storm out his window. His error and poor decision making was going into the storm in the first place.

      What he did inside that storm after he lost his instruments, or the engines, stalled, or any combination of problems will be interesting. But... what we do know in this case, he had the option to avoid.

      And YES!!! Every pilot should know their pitch power numbers at Altitude. I'm hoping all airlines beyond mine has implemented that into the lessons. It could save your life.
      However, in the airbus, if the plane has power set for alt...and disconnects... it maintains the last power setting. So, you don't need to do anything with it. Wherever you had the stick prior to loss, the plane will fly that pitch attitude. So if you don't touch anything, you're golden. Thus...my habit is if I feel any rumble of turbulence, my hands go to the glareshield in the event we were to lose instruments, so not to react and grab the stick to hold on and put it where I don't want to. Then I have time to analyze.

      Thanks so much for your comment.

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  10. It's scary how many large aviation accidents we've had this past year - Sort of unparalleled in a way.

    -Swayne

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    1. Swayne, your job as a new pilot is to look at the big picture. What started the snowball falling. If you see that, and get that part of each of those accidents...then you will become a safer pilot.

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  11. The fact that the radar detected a sharp climb after the crew apparantly requested permission to climb, strongly suggests that they lost speed trying to gain altitude, apparently too much speed due to a steep climb which was also reported. In severe weather, the higher the altitude the less maneuvering capability and the faster the wings will stall. If they got into an upset situation which the circumstances seem to suggest, it is almost impossible to recover from that inside a storm. Experience must be considered but let's not forget that the worst accident in aviation history in Tenerife was caused by a very experienced Captain making a poor decision. I agree with Capt. Cruz that if they had stayed at the same level, Ignition ON, anti-ice on and turbulent penetration speed, the accident may have never happened. A rough ride at worst. I want to be wrong on this and we all must wait for the final report, but the evidence so far strongly supports the mentioned possibility. As per Linda's comment I agree as well. I flew the MD and those planes are not very stable in turbulence at high altitude. There was a similar accident in South America years ago when an MD flying from Panama to Guyana or Trinidad, crashed in Venezuela when they encountered a thunderstrom, entered icing conditions, panicked , climbed and then stalled. And that came from the final report. Too many painful similarities with this case. Airbus may be different but aerodinamics work the same for all commercial aircraft. There is a strong tendency in the airline pilots for climbing, climbing, climbing, as if its the panacea for everything. I have heard pilots in the brink of desperation because they are not allowed to climb and forced to be 4000 feet below where they want due to other traffic. More frecuentrly than not, there is no problem staying at lower altitudes, up to 4000 below optimum. You lose more when you climb about optimum. You are closer to stall speed, less reaction time and faster drop of airspeed in case of losing one engine and less useful consciousness time in case of depresurization. In my long haul flights as an airline captain as well, my fuel burn is usually better staying 2000 to 4000 feet below optimum altitude than climbing above it. I have ample maneuvering capability and more reaction time to an engine or pressurization loss. Also when you climb against a headwind you lose groundspeed as well. In my experienced opinion, you lose more than gain when you insist in climbing just blindly following the onboard management computer. In closing, i am not judging the crew of Air Asia. We are all human and we all can make mistakes regardless of experience as Tenerife painfully proved. I sincerely hope that something else happened to Air Asia that will clear the crew of a not so good decision.

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  12. The fact that the radar detected a sharp climb after the crew apparantly requested permission to climb, strongly suggests that they lost speed trying to gain altitude, apparently too much speed due to a steep climb which was also reported. In severe weather, the higher the altitude the less maneuvering capability and the faster the wings will stall. If they got into an upset situation which the circumstances seem to suggest, it is almost impossible to recover from that inside a storm. Experience must be considered but let's not forget that the worst accident in aviation history in Tenerife was caused by a very experienced Captain making a poor decision. I agree with Capt. Cruz that if they had stayed at the same level, Ignition ON, anti-ice on and turbulent penetration speed, the accident may have never happened. A rough ride at worst. I want to be wrong on this and we all must wait for the final report, but the evidence so far strongly supports the mentioned possibility. As per Linda's comment I agree as well. I flew the MD and those planes are not very stable in turbulence at high altitude. There was a similar accident in South America years ago when an MD flying from Panama to Guyana or Trinidad, crashed in Venezuela when they encountered a thunderstrom, entered icing conditions, panicked , climbed and then stalled. And that came from the final report. Too many painful similarities with this case. Airbus may be different but aerodinamics work the same for all commercial aircraft. There is a strong tendency in the airline pilots for climbing, climbing, climbing, as if its the panacea for everything. I have heard pilots in the brink of desperation because they are not allowed to climb and forced to be 4000 feet below where they want due to other traffic. More frecuentrly than not, there is no problem staying at lower altitudes, up to 4000 below optimum. You lose more when you climb about optimum. You are closer to stall speed, less reaction time and faster drop of airspeed in case of losing one engine and less useful consciousness time in case of depresurization. In my long haul flights as an airline captain as well, my fuel burn is usually better staying 2000 to 4000 feet below optimum altitude than climbing above it. I have ample maneuvering capability and more reaction time to an engine or pressurization loss. Also when you climb against a headwind you lose groundspeed as well. In my experienced opinion, you lose more than gain when you insist in climbing just blindly following the onboard management computer. In closing, i am not judging the crew of Air Asia. We are all human and we all can make mistakes regardless of experience as Tenerife painfully proved. I sincerely hope that something else happened to Air Asia that will clear the crew of a not so good decision.

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    1. Carlos, thank you for the very well thought out extensive response. I want to address a key point... I too wish we could find something that would make the pilots not responsible.

      But then that would mean a perfectly goo airplane, and the thousands of engineers and designers were responsible for building a plane that just falls out of the sky with no help from the pilot.

      Whatever happened to that plane, occurred in that storm. We should not blame the pilots, but learn from their human factors errors, as we all make errors... we learn what not to do. Until you're in the moment, you do not know how you will behave. But we must respect and avoid severe weather. That's the only answer.
      Thank you so much for the comment!

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  13. First, the Pilot/ Co-Pilot MUST fly the PLANE! Once that is done; look around and access the situation. NEVER climb until adequate airspeed is available

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    1. So true. Never try to take your plane where performance is an issue.

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  14. Lets wait for the data from the boxes to be analyzed before judging the pilots. I will say right now, the Air Buss series of aircraft with the fly by wire side stick controller and automated everything has its design issues. Look up the rudder flutter incidents and "pilot over controlling the rudder" crashes which are numerous. The Air Buss has come apart before in turbulence due to flight control over control. Its ridiculous, and this is fly by wire computer controlled flight controls.

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    1. There is no perfect design, and improvements are always in progress. But honestly, I'm not sure that the design should take into account a pilot will fly the plane into a cell of that magnitude. Because a car has design flaws, doesn't mean that it crashed because of those flaws, if the drive drove it into a wall. Yes...we'll find out what happened to the plane once they were in that storm, but the primary takeaway... don't go into the storm. We can learn something from this, even without the black boxes. Creating awareness and don't push the limits. Thank you for your comment.

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  15. But an airliner should be able to handle the average thunderstorm cell without falling out of the sky. Now if your flight controls over control the rudder, causing a vertical fin failure, then all bets are off (AA flight 587) and http://gogov.com/airbusA310.htm
    If this happens to your Air Buss, it may be precipitated by the storm and the pilots flying into that storm, but the cause is still the Air Buss design and their flawed control system. I speak with 30 years experience in flight test and engineering design. Lets see what the boxes show. If they show structural overload caused by flight control input then its not the pilots as they have no direct input into the flight controls during normal control law. And you may be correct also, thunderstorms have awesome power that can overwhelm any aircraft, so that may be what happened but I remain dubious until the boxes show otherwise.

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    1. I don't think a storm up to 50,000 feet is average. And... AF447... the plane did not exactly fall out of the sky. It had a lot of help. Hands off it would have been fine. Another type... hands off, probably not. Maybe we're talking two different planes. I'm discussing an Airbus... not sure if an Air Buss is the same thing? And 30 years experience is wonderful, however do you have fly by wire experience? Perhaps you should read the book, Understanding Air France 447. Fabulous and will give you some insight into the design too.

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    2. It's somewhat inaccurate to say that AF447 would not have crashed "hands off", given the degradation of flight control laws to Alternate2. The aircraft immediately lost the envelope protections as well as the roll protections. It became imperative at this point that the crew could fly the aircraft "hands on", which they struggled with and ultimately failed to do. It's unfortunate that the crew lacked the training and experience to do so. I believe that was one of the key recommendations of Palmer's book: that pilots need more "hands on" practice and training in various situations so they are confident and capable of doing it if it were to become critical as it did on AF447.

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    3. Yes... Bill believes we all need more practice. We do... because we fly on the autopilot. However, this plane fell out of the sky because one of the pilots pulled the stick back and held it there. There have been hundreds of similar instrument loss situations... exactly the same...without the same outcome because the pilots did not react and pull the plane into a stall. They allowed the plane to fly.... "doing nothing" but monitoring the parameters and confirming the plane was doing what it was supposed to, and re-engage the autopilot when all came back. This is a very stable plane. She will attempt to fly the where the pilot tells it to go. If the plane was level, with power set for a given speed..even with the instrument loss, that plane would continue to fly. Thanks for the comment!

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    4. I completely agree that the pilot's pitch inputs were completely inappropriate and the cause of the stall. However, he still needed to fly the aircraft "hands on" just to maintain wings level. In alternate2 roll control reverts to direct control of the flight surfaces, and the flight computer no longer maintains bank angle (based on the flight data the pilot struggled mightily with this). Additionally, due to the duration of the airspeed failure, alternate2 was locked in for the rest of the flight and autopilot was no longer available. I can only imagine how difficult and stressful it would be trying to hand fly a commercial aircraft at high altitude, in turbulence, with no visual horizon, in an alternate flight control setting.

      I dislike solely blaming the pilot, because the pilot's ability is primarily a reflection of his/her training and experience. I can only assume that AF447 scenarios are taught in simulators (Is this the case?) and that pilots today are much better prepared for such a situation than the crew of AF447.

      It would be a real tragedy and a disservice to the victims of AF447 if we find out that Airasia suffered a similar fate (I.E. failure of automated flight control systems followed by a loss of control in flight by the pilots).

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  16. This is a more technical article detailing the Air Buss rudder issue. Just saying, its not the best design. http://airbusvertstabs.blogspot.com/

    Thanks,

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  17. Thank you for the article on the Airbus rudder.

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  18. Karlene-
    Can you please give your opinion on the following:
    1. What role did Fly by Wire technology that exists in A320 play in this crash. I was under the impression that pilot steep climb at excessive rate would be prevented by the limits that kick in due to the Fly by Wire.
    2. On what information/basis the pilot requested to climb to 38,000 ft. Is the pilot having both good weather data and other traffic data with altitude in the vicinity. Can a pilot make a good decision with the available information and the reaction time that is available to avoid the storm cell.
    3. On what basis the ATC allowed climb only to 34,000 ft. Do they have both good weather and traffic information.
    4. In this case, the ATC and pilot seem to have different plans to avoid the storm cell. Not sure how a good decision is arrived at to avoid the storm cell. Pilot cannot do what they like due to other traffic. ATC may not have good weather data.

    Thanks
    Ram

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    1. Ram, I do not think the plane was to blame. Yes, pilots can and should use the radar to see and avoid radar. They did not. They cut it too close and got stuck. They tried to out climb the storm and stalled. So sad for all. But the real problem was flying into the storm.

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  19. Most commentators seem to think that pilot got into a storm which he should have avoided. Indonesian pilot virtually cuts his aviation teeth on storms which is a everyday afternoon phenomenon there. It is not very convincing to believe that he was not aware of the complications of entering into it. From the information that is available now there is enough evidence that they may not have entered it at all. There was a failure of FAC (flight Augmentation Computer) and the reset seems to have failed. The crew faced the prospect of negotiating some rough weather ahead without the auto pilot, auto thrust, characteristic speeds on the PFD and the aircraft in alternate law without protections. Same problem this captain had faced even earlier on this particular aircraft. It is possible that the problem was intermittent. To get rid of the problem he tried to reset by pulling out CBs. It is possible that it had worked before. That he tried it himself getting out of the seat may indicate that the aircraft was in control at that time. During this procedure the co-pilot who was flying the aircraft seems to have lost control of the aircraft possibly by inappropriate control inputs. The pilot seems to have returned to his seat but it was too late. The full report will only fill in the gaps.

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