A repetitive maintenance issue and flight crew inexperience contributed to the crash in the Java Sea on December 28 during a flight from Surabaya to Singapore.
All 162 people on board were killed, including 155 Indonesians, three South Koreans and one person each from France, Britain, Malaysia and Singapore.
Although the flight did experience bad weather, this was not considered to be a significant factor in the crash.
After an exhaustive investigation, Indonesia’s National Transportation Safety Committee found a cracked solder on the Rudder Travel Limiter System led to an electrical disruption, and the disengagement of autopilot. The damage led to sending repeated warning systems to the pilots.
The first three times a “master caution” alarm sounded, pilots responded appropriately but after a fourth alarm, the remedy failed.
The pilots had pulled circuit breakers on part of the control system in a frantic attempt to reset the system. Tragically, it turned off the autopilot and caused the plane to start to roll.
“The (co-pilot) might have been startled when he realised the unusual attitude of the aircraft,” the report said.
“The (co-pilot) may have experienced spatial disorientation and overcorrected by shifting the sidestick to the left, which cause the aircraft to roll back to the left by up to 50 degrees.
“ ... he did not react appropriately in this complex emergency resulting in the aircraft becoming upset.”
The issues that arose from “flight crew action resulted in inability to control the aircraft ... (causing it) to depart from the normal flight envelope and enter a prolonged stall condition that was beyond the capability of the flight crew to recover was beyond the capability of the flight crew to recover”.
The committee made a range of recommendations, and acknowledged Indonesia AirAsia’s own reviews of training for pilots in the areas of upset recovery and stall recovery procedures, and manual flying handling.
The A320, like most Airbus aircraft is a “fly-by-wire” aircraft, that is designed to almost fly itself.
The committee also recommended Airbus consider “developing a means for flight crews to effectively manage multiple and repetitive Master Caution alarms to reduce distraction”.
The report said the faulty component, the Rudder Travel Limiter, had suffered 23 problems in the past 12 months, citing maintenance records.
It said that maintenance records were “unable to identify repetitive defects and analyse their consequences”.
It added the flight data recorders did not indicate the weather had affected the aircraft.
An Airbus spokesman said: “Airbus has given Indonesian authorities all the support and technical expertise requested, and is studying the detailed contents of the report and its recommendations.”
The AirAsia plane crashed less than halfway into a two-hour flight from the Indonesian city of Surabaya to Singapore.
The crash of triggered a huge international search, with ships and aircraft from several nations involved in a lengthy hunt that was hampered by strong currents and bad weather.
The bodies of 56 people who died have never been recovered from the Java Sea, including that of the pilot.
AirAsia CEO Tony Fernandes described the crash as his “worst nightmare” and proposed a permanent memorial for the victims.
The disaster capped off a disastrous year in aviation, following on from the disappearance of MH370 and the shocking missile strike that brought down MH17.
news.com.au
1/12/15
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