Air Asia drama ex-Per

[jb747]

In some cultures (particularly Asian cultures). Challenging their superior is frowned upon and would not go down well. I have no idea if this is the same culture in a coughpit but in a normal office in Malaysia, you would find most would just keep their mouth shut

The opposite to good coughpit CRM.

 

[badseed]

Go to www.liveatc.net Search for YBBN. Select YBBN And/Twr/App/Dep archives. 3 July, and time 1230Z. Gets interesting from about 22:30 onwards.

Thanks JB.

Always interesting in situations like these hearing the how the ATC response changes as soon as Mayday is said. The pilot then downgraded it to a PAN when he first spoke to Brisbane tower.

 

[MEL_Traveller]

On line searches suggest Air Asia is in/has been investigated for no less than 6 incidents in Australia in recent years. But the authorities refuse TG to fly their new A350s here because of safety concerns. It's a confusing message.

 

[Strategic Aviation]

But the authorities refuse TG to fly their new A350s here because of safety concerns. It's a confusing message.

Thailand as a whole has an ICAO problem which affects its carriers and services they wish to add. The problem does not stem from TG or the A350, but TG had to be recertified (which was completed in May).

Thailand has forced its mainline operators to undergo recertification as part of the TCAA's push to have two Significant Safety Concerns (SSC) removed. The red flags were imposed by ICAO in June 2015 following a Universal Safety Oversight Audit Programme (USOAP) inspection in January 2015.

At the time, Thailand reportedly only satisfied twenty-one out the 100 USOAP criteria with problem areas said to have included: personnel licensing and training, airworthiness assessment and certification, airline operations oversight and the granting of Air Operator Certificates (AOC) to airlines.

The TCAA says that more than 80% of the SSC's findings have now been addressed with the remainder seeing significant progress. By month-end, the regulator plans to submit a request letter to ICAO to perform an ICAO Coordinated Validation Mission (ICVM) to withdraw the country’s red flag.

 

[MEL_Traveller]

Thailand as a whole has an ICAO problem which affects its carriers and services they wish to add. The problem does not stem from TG or the A350, but TG had to be recertified (which was completed in May).

Quite. Yet Air Asia is allowed to fly no problems. A confusing message.

 

[Strategic Aviation]

The ICAO red flag forces there to be a situation with TG. The fact that the authorities have necessarily been involved with TG has no relation to their discretionary decision not to get involved with AirAsia X (regardless of whether they should or shouldn't).

 

[Ansett]

Quite. Yet Air Asia is allowed to fly no problems. A confusing message.

BUT TG is from Thailand that is red flagged and Air Asia is from Malaysia which is not red flagged. Simples

 

[RooFlyer]

The ATSB has released its report. No direct link, but excerpts from the Oz (probably paywalled, but Google the headline for the whole story)

EDIT: Link here: Investigation: AO-2017-066 - Engine failure involving Airbus A330, 9M-XXE, near Carnarvon, Western Australia, on 25 June 2017

AirAsia pilot told passengers to pray as engine shook plane

An AirAsia X flight from Perth in which the pilot urged passengers to say a prayer when the aircraft began to violently shudder, had a serious engine defect that went undetected through no fault of the airline.

The final Australian Transport Safety Bureau report on the incident, which took place on June 25, 2017, examined how the broken fan blade in the engine was missed and why the flight to Kuala Lumpur did not divert to the closest airport, instead of returning to Perth.

The report said the flight crew first became aware there was a problem with the left engine about an hour into the trip when a metallic bang was heard, and “significant vibrations” started through the airframe of the A330.

An engine stall warning was presented, and the crew began a single engine return to Perth after deciding the emergency was not dire enough to divert to Learmonth Airport which was significantly closer.

...

The ATSB found the problem with the fan blade was due to the time allowed by engine manufacturer Rolls-Royce between scheduled inspections.

“Although the failed blade had been subjected to inspection, the fatigue crack progressed to failure before its next scheduled inspection,” the report said.

“As such it was found that the inspection interval was too great to capture the crack that developed in this blade before it reached a critical size.”

In response to the investigation and a number of other similar incidents, the ATSB said Rolls-Royce had begun a review of the design and manufacturing of the Trent 700 fan blade.

 

[flydoc]

the decision to fly away from a large, capable runway, in daylight and good weather, to fly to a distant airport, with one engine not only shut down, but giving very severe vibration.

From the ATSB report:

“The operator had included Learmonth in the list of nominated aerodromes, but specifically as an emergency alternate. While Learmonth was significantly closer at the time of the engine failure, an emergency alternate aerodrome was only to be used in the case of a dire emergency.

• Following the engine malfunction, the flight crew determined that a dire emergency did not exist, and therefore Learmonth was not required as a diversion aerodrome.
• The ATSB considered the decision by the crew to divert Perth was in line with the operator’s procedures.”

And with that the report goes on to simply consider the fan blade failure.

One more reason why this company is on my personal No Fly list.

 

[AviatorInsight]

So let me get this straight...a LAND ASAP message appears on their ECAM screen, they declare a mayday (now an emergency??) because they couldn’t maintain altitude (um...of course they couldn’t maintain altitude they’re now single engine at 38,000ft!), but that is still not enough for them to go to Learmonth and they felt that flying the hour back to Perth single engine with visible smoke (and no other indications), 1 out of 2 fire bottles now gone and severe vibration (as you would get with a snapped blade due to the engine now being out of balance) was the safest course of action?

Hmm...

 

[MEL_Traveller]

So let me get this straight...a LAND ASAP message appears on their ECAM screen, they declare a mayday (now an emergency??) because they couldn’t maintain altitude (um...of course they couldn’t maintain altitude they’re now single engine at 38,000ft!), but that is still not enough for them to go to Learmonth and they felt that flying the hour back to Perth single engine with visible smoke (and no other indications), 1 out of 2 fire bottles now gone and severe vibration (as you would get with a snapped blade due to the engine now being out of balance) was the safest course of action?

Hmm...

Yes yes. I get it, avoiding 'blame' and accusations of wrongdoing may encourage self reporting. But sometimes there might be important safety lessons in actually calling things out. You know, for the avoidance of doubt an' all that.

 

[jb747]

It was the cheapest action.

Safety was not a consideration.

Mind you, I don’t know that I’d trust that mob to manage a landing at Learmonth.

 

[Quickstatus]

ATSB just glossed over pilot actions. Incredible...

 

[flydoc]

ATSB just glossed over pilot actions. Incredible...

Politics. Or diplomacy. Possibly both. Almost 3 years to release the final report, with the release date progressively put back quarter by quarter whilst delicate negotiations took place to develop a palatable, face-saving narrative. IMHO. (speculation entirely mine)

 

[Quickstatus]

Here is the other one.

weather: CAVOK
Immediate turn at 300 ft After takeoff towards the Perth Hills
final report released last month:

https://www.atsb.gov.au/media/5777951/ao-2017-114_final.pdf

 

[eastwest101]

The ATSB considered the decision by the crew to divert Perth was in line with the operator’s procedures.”

Now I am really worried about the ATSB, their argument seems to be as long as the pilots follow company procedures then all is fine, what if the company procedure said that after an engine failure the procedure is to dive the aircraft at max speed into the ground? That could be a published company procedure, does the ATSB think that is an acceptable outcome?

 

[MEL_Traveller]

Now I am really worried about the ATSB, their argument seems to be as long as the pilots follow company procedures then all is fine, what if the company procedure said that after an engine failure the procedure is to dive the aircraft at max speed into the ground? That could be a published company procedure, does the ATSB think that is an acceptable outcome?

I guess it's a tough call. On the one hand, companies define procedures for pilots and crew to the nth degree so that they don't deviate and don't make decisions that will lead to mistakes. They don't want pilots 'doing their own thing'. On the other hand you have to wonder what the tipping point is when pilots will make the decision to go against company rules. And if they get it wrong? No medals there either.

 

[eastwest101]

I guess it's a tough call. On the one hand, companies define procedures for pilots and crew to the nth degree so that they don't deviate and don't make decisions that will lead to mistakes. They don't want pilots 'doing their own thing'. On the other hand you have to wonder what the tipping point is when pilots will make the decision to go against company rules. And if they get it wrong? No medals there either.

I agree with your post, in general the preference should be for pilots to follow procedure but I think that more emphasis should be on manufacturer procedure rather than company procedures which can possibly be hijacked by commercial priorities. The ATSB seems to have a bit of an almost unhealthy and myopic fixation with "following procedures".

At some point you need to give pilots the latitude to depart from company procedures (think about Capt Sully putting that plane in the Hudson River as an example).

If the Air Asia A330 pilots had opted for Learmouth instead, and most likely would have landed without incident, but the inconvenience and added cost of a single engined stranded A330 at Learmouth and some inconvenienced pax, what's the worst that would have happened? Both pilots demoted or sacked from the company? Yes that's bad for them but I wonder what the ATSB would have said about the decision to land at Learmouth vs back tracking to Perth given the similar conclusions about fan blade failure and engine damage? It's intriguing to think of these other possibilities.

I trust that the ATSB is looking into airline procedures and training to see some systematic warning signs, I'm sure their investigation of the fan blade failure is useful and important stuff, but I wonder about their capability to investigate the softer training/cultural and skills part of the of the investigation process.

They are called the Australian Transport Safety Bureau, and are not the Australian Transport Procedure Adherence Bureau for a reason.

As we have seen elsewhere, weak regulators allow the conditions for corporate and commercial pressures and cultures of denial to cost lives. Think Boeing 737-Max incidents and the recent Pakistan A320 bellly landing go around fiasco as two recent examples.

 

[jb747]

Procedures are there for guidance. Yes, you follow them if you can, and if they make sense, but there are often times when going your own way is the safest course of action. The aircraft manufacturers specifically address this is their guidance, pointing out that there may be times when there are no appropriate procedures, or when the best result comes from merging a couple of different procedures. In the case of QF30, there were only five memory items, before we fell back into the paper checklist, but one of those five was actually making things worse, so we didn’t do it.

People on the ground cannot write procedures that will cover every possible issue, even for normal day to day operations. That’s why it was always a good idea to hire actual pilots, and not gamers.