Adam Air Crash in Indonesien

[FalconJockey]

Habe ich was übersehen oder warum wurde hier nie der Untersuchungsbericht zu diesem Unfall veröffentlicht? Er ist verfügbar: LINK.

 

Wie auch immer: Vor wenigen Tagen ist ein Ausschnitt der Aufnahme des CVR aufgetaucht, den man HIER herunterladen kann.

Ein Kommentar dazu aus PPRUNE:

I saw the link at a local forum yesterday, and a few colleagues took it to bits, and we seem to conclude that this recording is real, and most likely to come from the cockpit area mic... the gaps between the parts of the conversation matches the FDR and whatever transcript was in the accident report.

 

Today I ran into a couple of ex Adam Air pilots, and they wanted to hear this recording. They did say it was the right voices for the Capt. and F/O. The sadness in their faces when hearing this was... beyond words, especially the guy who flew the jet a few days beforehand... with the same problem... He was in the process of quitting when the crash happened.

 

Das Transscript dazu schaut so aus:

1.07 FO “not sure” DME is working fine (on FMS display)

1.10 Capt confirmed …..”yes that was what is wrong with it”

1.12 FO Try to recognize MKS – VOR

1.32 FO Says.. if mean while got the wind direction indicates back in normal

1.53 Capt your DME is totally different with this FMS picture

1.56 Capt Expressive …If DME Indicator (dedicated) was not in agreed with the FMS Displays...

2.00 FO Says….(jokes) this aircraft become/like a wooden vessel.

2.05 FO Says…”oke we must trust with this anyway”,…

2.08 Capt (little laugh)….”yes it is,..”

2.13 Capt “it has gone too far”…..

2.15 Both pilot beginning not sure with the cross track angle become bigger and bigger

2.21 Capt Says,…”Again it was wrong with the heading,…”

2.25 Both pilot try to confirmed/established a/c position,…

While Capt says…(ask FO),.. “established report position to ATC on Radial something

……124 DME”…. (means from MKS)

2.45 Capt Says,…”something wrong with EFIS”

2.47 FO Says,….” No this FMS”

2.50 Capt Says,…”FMS is confusing themselves”

3.13 Capt Says,…“I will try IRS mode change over to ATT” (attitude reference)

<--- My edit: A/P disconnect sound

3.30 FO (open the QRH book),….”it will comes to Fault ,…?” (IRS Fault Procedure on QRH)

3.36 FO “…IRS Mode Selector,..?

3.38 Capt “…Attitude”…..

3.40 FO “…which is ‘Left’…..?

3.53 Capt “…initial called for Altitude,…..?”

3.54 FO “…enter the Heading,..?”

3.55 FO Says,…..”What it was Heading now,..Capt,..?”

3.58 Capt “…Zero,……..zero seven nine ,…ya,..”

4.00 Both pilot confirmed/agreed with the current heading 079

4.20 “Bank Angle”,……!!!........

4.22 Capt “…switch the NAV again”………..(back ground sound….still “Bank Angle”,……!)

4.23 Capt (strong Voice),…. “switch the NAV again”,…. “switch the NAV again”…!!!”

4.25 “Nnooottt”,………(Altitude ‘sign’ Warning “sound”/reminder for 1000 feet to go)

4.27 “Bank Angle”,……!!!........

4.28 Capt “…switch the NAV again”

4.29 FO (strong Voice),….”NAV,…!!!”……oke capt,…

4.33 Capt (Shout,..),…..”Don’t Turning it!!!”….

4.35 Capt (Shout,..),…..”We must keep in these Heading,..!!!”

4.39 FO (Shout,..),.”Captain,…Captain….Captain,..!!!” (ask for command control ‘side’ for MCP/FD???)

4.42 “Clack,…Clack,..clack,….!!....(“Clacker” – Over speed warning “sound”/indicates Exceeding over speed limit)

4.45 FO “….Ach,..Capt,…Capt,…!!

4.46 Capt “…Yak,..yak,…!!

4.53 Allahuakbar”…!!!.(All Mighty Allah),…..

4.55 “Allahuakbar”…!!!

4.66 “Allahuakbar”…!!!

4.57 “Allahuakbar”…!!!

4.58 “Allahuakbar”…!!!

4.59 “Allahuakbar”…!!!

5.02 strong sound noise of airframe stressed due to over speed exceeding beyond limits

5.04 strong sound noise of airframe stressed due to over speed exceeding beyond limits

5.07 “What is this,..?!!!,…..what is this,…?!!!

5.13 sound something hard impact (inside cockpit)

5.14 “Aaaaaauuuuw,…. “Allahuakbar”…!!!

5.20 “Allahuakbar”…!!!

5.27 “Allahuakbar”…!!!

5.28 “Allahuakbar”…!!!

5.33 “Allaaaaaahhhhhuuuuakbaaaaaaaar”…!!!

5.36 ………………..silent…………………….(impact point)

Es sieht so aus, als ob da Schalter (am IRS bzw. der IRU!) umgelegt wurden, obwohl keine Checkliste genutzt wurde und dann wurde wohl noch das falsche Gerät (falsche Seite) ausgewählt wurde. Mit diesem umschalten von NAV auf ATT (Attitude) wollten sie die fehlerhaften Navigationsdaten der IRS' korrigieren. Es scheint auf der 737-Classic aber so zu sein, dass man in ATT bleiben muss, wenn man im Flug von NAV auf ATT umschaltet. Man kann nur am Boden das IRS neu "alignen".

When ATT (Attitude) was selected in the IRS Mode Selector Unit, it resulted in
the autopilot disengaging. The effect on the copilot’s EADI of switching from
NAV to ATT was that the following displays were lost:
· Roll indication
· Horizon scale
· Pitch scale
· Sky/ground shading.
Flight path angle, Acceleration, Pitch Limit display and Traffic Alert and
Collision Avoidance System (TCAS), Resolution Advisory (RA) commands
are also removed when ATT is selected. 

Man sieht auch, dass in diesem Fall das CRM komplett zusammengebrochen ist bzw. gar nicht existierte.

 

Aus PPRUNE möchte ich hier ausgesuchte Kommentare zitieren, man ziehe seine eigenen Schlüsse daraus:

Irony #1:

F/O's voice stress level rising consistently while captain's seems to be on a roller coaster. Captain was PF.

 

Irony #2:

After bank angle alert, F/O put a left roll input as the plane was banking right... Captain said "Don't turn it!"

 

Irony #3:

F/O former fighter pilot, Captain had no upset recovery training. Captain was PF...

 

Irony #4:

F/O former fighter pilot, normally a hard head on CRM, but over recent years, former fighter pilots have been "humbled" in many cases, and as this case shows, resulting in lack of assertiveness. RIP.

 

And how many accidents/incidents have happened in Indonesia involving an F/O knowing a disaster was going to happen and did nothing/not do enough?

Ironically, the CVR confirms the written report's revelation about the crew's utter incompetence of basic airmanship; namely that of maintaining wings level attitude by reference to the independently powered SAI [standby Attitude Indicator] after the synthetic voice generated warning: "Bank Angle, Bank Angle."

I notice that on the second last page(83), it says that " the copilot did not inform the PIC when he selected attitude on the right MSU, even though the PIC instructed him to select the left one".

 

Could this have led to a situation the captain thought that an ADI indication was accurate when in fact it was not and therefore confusion over why the bank angle call was being made? Or is an obvious message annunciated on an ADI when attitude is selected?

Loss of Nav:

Reads kinda like without a warn/fault light on either of the IRU's the F/O was confused about which one deserved to be switched to ATT. This freaked the Captain because he wanted heading info punched into his IRU from the one the F/O just killed!

 

But yelling to go back to NAV was a real systems knowledge failure on the part of the Captain. ATT is a one-way-ticket, as others have pointed out; once you go there the horse has galloped out of the barn and it can only give you reduced presentation attitude info for the rest of the flight.

 

Some great earlier posts in this thread. Looks like the CAM recording has disappeared off those links on the net, so there must be some damage control going on?

 

Looks like these guys were handed a very unenviable situation. One or two bad IRU's (since it sounds like all this airline did was swop them when there was a write up) possible improper differences training (all-too common today,) possible inadequate abnormal checklist distribution.

 

Loss of A/P: (I'm assuming the A/P was lost as a result of the #2 MSU selected to ATT by the F/O)

But assuming a functioning SAI, (can we on this ship, PK?) both guys, if they're any good, should be doing a cross scan at all three attitude displays: Cpts, F/O's and the SAI before platform alteration occurs. #2MSU is switched to ATT:A/P lets go. A/P horn is cancelled. When the bank angle warning goes off, your primary horizon reference can no longer be trusted. When the altitude alerter tone goes of at ~250' off assigned, you're probably already doing unintended steep turns and losing altitude with increased load factors, who knows. You've had two clues that you're losing it; it's time to abandon the Captain's ADI and go back to the SAI (the F/O's ADI is not usable for 30 secs, right?).

 

Hard core instrument pilots flying junk call this: maintaining critical triangles of agreement.

 

But, because of good automated instrument comparator systems today, this old stick and rudder skill (cross-cockpit scan) is sorely lacking in todays air line pilot. Not all the guys I flew with in later years were even capable of flying without a flight director, let alone hand flying raw data across the cockpit at altitude for very long. If you don't keep current hand flying you will pay the price one night when "Outto" decides he's had enough of this flakey maintenance at this place and drops out when ATT is selected.

 

Ideally, before you start changing anything, you should have an idea which of the three horizon displays is presenting good info. You should then verify that your chosen primary horizon ref (for example: the Captain's ADI) is selected to it's normal display source: (e.g: The #1 IRU?) Instrument switching (which they never even got to) can be tricky, and before you get to restoring displays or even altering platforms as they did, the handing pilot has got to have faith that his interim source of wings level info is working for him.

 

But you should realize that failures can be progressive, and that you have to keep up the critical triangles of agreement going. Compare both remaining horizons with heading raw data change.

 

The no checklist way:

Normally, you just vote the odd horizon out. In this case, knowing the ship history and the airline, that's not good enough. The Pilot Flying (Capt) should be verifying partial panel behavior. He should instruct the co-pilot to get a flashlight out and dig out the wiskey compass taking readings of it for a minute in S&L and make sure his selected attitude reference is not changing heading on him (sounds like it did.)

 

Again, today's modern airline pilot almost never has to do this. But in this case, I wouldn't feel confident in choosing either of these IRU platforms to supply either the attitude reference OR the nav function.

 

Sounds to me like: This flight was beyond the abilities of most auto-pilot dependent line pilots.

 

But the colleague that you criticize for hand flying all the time (John Wayne) would have made it to the bar alive maybe.

I am wondering if the captain was thinking that the #2 ADI was working because he had asked for #1 to be switched to ATT(#2 was switched to ATT instead by the copilot, for whatever reason quite possibly without the captain's knowledge).

 

Therefore in the captain's mind, when the 'bank angle' callout was made, he thought it was a false warning based on what he was now assuming to be the now unreliable #1 ADI(which was in fact reliable) and then didn't use or took too much time to use the standby horizon for confirmation until it was too late.

 

It certainly doesn't give you much confidence in crews when once again we hear yelling for Allah over and over instead of working to correct the situation. For those tempted to do so in the future, perhaps you could yell "gear down", "speedbrakes" and recovery techniques instead. I guarantee it will provide more help to you and your paying passengers in this life than Allah ever will.

 

Wer noch mehr darüber bei PPRUNE lesen will, der folge diesem LINK.

[flowmotion]

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Bearbeitet 2. Oktober 2019 von flowmotion

[FalconJockey]

Hallo Iris,

 

danke für die Ausführungen bzgl. der Checklisten, sehr interessant! Kann man da nicht ein neueres IRS einbauen, das man auch im Flug alignen kann? Würde wohl in einem schlechten Kosten-Nutzen-Verhältnis stehen...

Ich vergass: Die EASy-Avionics bzw. die mitgelieferten IRS' erlauben ein Inflight Alignment, das 5 Sekunden nach einem Stromunterbruch beginnt. Hat man in diesen 5 Sekunden auch nicht gross die Lage im Raum geändert, so erhält man die Attitude Indicators wieder zurück, ansonsten gibt es ein FAIL-Flag. Das Alignment im Flug dauert dann zwischen 5 und 17 Minuten. Je weniger man die Lage (Kurs, Pitch) ändert, desto schneller geht es. All dies geschieht automatisch.

[flowmotion]

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Bearbeitet 2. Oktober 2019 von flowmotion