Aug 172015
 

Flight Path of Trigana Air Crash 3

An Indonesian Trigana Air turboprop with 54 people on board crashed in remote mountains near the Indonesian-Papua New Guinea border. Trigana Air Service flight IL267 ATR 42 turboprop (Registration Number PK-YRN, shown in the photo below), carrying 54 people, lost contact with Indonesian air traffic control just before 3pm (0600 GMT Indonesian local time) shortly after taking off from Sentani airport in Indonesian province of Papua’s capital Jayapura on a flight en route to the village of Oksibil, an extremely remote mountainous region at the Indonesian-Papua New Guinea border.

Flight Path of Trigana Air Crash 2

Performing as Trigana Air flight IL267, the turboprop aircraft departed Jayapura about half an hour before it disappeared from Indonesian air traffic control. The 45 minute flight carried all Indonesians, including 44 adults, 5 children, and 5 Trigana Air crew, and including 5 people on board from parliamentary staff traveling to Oksibil to attend an annual ceremony of Indonesia’s independence. Flight IL267 was expected to arrive at its destination about 7 hours and 30 minutes ago local time, according to the Indonesia search and rescue agency via social media.

“The plane was totally destroyed and all the bodies were burned and difficult to identify,” Henry Bambang Soelistyo, Indonesia Search and Rescue Agency (BASARNAS) Head, told The Associated Press on Tuesday, August 18, 2015. “There is no chance anyone survived.”

“Rescuers have so far recovered 53 bodies from the wreckage of the Trigana Air Service turboprop plane,” Soelistyo added. “The remains will be transported by helicopter to the province capital of Jayapura for identification.”

An infant is the one remaining passenger still missing, Transportation Ministry spokesman Julius Adravida Barata told Reuters.

Soelistyo said “searchers had recovered the (first) black-box, which investigators hope will provide clues as to what caused the accident.”

On August 20, 2015, BASARNAS reported the second black box has been recovered and turned over to aviation crash investigators of Indonesia’s National Transportation Safety Council. All 54 victims have been recovered from the crash site. The remains have already been identified and have been handed over to their families for final arrangements with all of our collective heartfelt prayers and sincere condolences.

In Jakarta, Indonesia on Tuesday, August 18, 2015, Indonesia president, Joko Widodoexpress his deepest sorrow for the 54 passengers and Trigana Air crew lost on flight IL267.

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Photos Show Site of Indonesian Plane Crash

“According to the information, the Trigana Air aircraft that lost contact was found at Camp 3 of the OK (Oksibil) Bape District in the Bintang Mountain regency. The information provided by the local residents said that the flight crashed into Tangok mountain. The detail of this finding is still under investigation.” – Indonesia air transportation official, Director General Suprasetyo Air Transportation reported in Sunday’s news conference (via Reuters)

Flight Path of Trigana Air Crash

Transport ministry spokesman J.A. Barata confirmed the plane had lost contact and said it was supposed to arrive at Oksibil airport just after 3pm (0600 GMT Indonesian local time).

“We are not sure what happened to the plane yet and we are coordinating with local authorities,” he told the French new service AFP on Sunday, August 16, 2015.

“The weather is currently very bad there, it’s very dark and cloudy. It’s not conducive for a search. The area is mountainous,” Indonesian transport spokesman Barata added.

“Nearby villagers in Indonesia’s Papua have reported a crash,” Trigana Air official says after plane went missing on Sunday. Trigana Air Service Operation Director Beni Sumaryanto said, “the airline had received reports of a crash from a village in the forested and mountainous district of Oksibil, adding that search teams would check that area in the morning,” Kompas and Detik portals earlier reported (via Reuters).

On Monday, August 16, 2015, Indonesian Air Force initiated construction of a helipad and helicopter services through Freeport-McMoRan, a mining company, says CNN International, to assist in the evacuation of Trigana Air flight IL267 victims from the rough crash site found in the heavily forested remote area (seen below) in the Bintang highlands village of Oksibil in the Papua province in eastern Indonesia, according to Bambang Soelistyo, the head of Indonesia’s search and rescue agency.

“Officials deployed two ground teams to the site, which is at an altitude of 2,600 meters (8,500 feet), but suspended efforts to get there because of thick fog,” CNN International reports on Monday.

Photo Credit: Remote Crash Site of Trigana Air Service flight IL267 ATR 42 turboprop (Registration Number PK-YRN), near Oksibil, Indonesia

Officials do not know either if any of the 49 passengers and 5 Trigana Air crew have survived and are waiting for rescue below, or if any detection the ATR 42 aircraft’s black-boxes pings can be confirmed for immediate recovery.

“If it collided into a mountain, there has never been a case of survivors. But who knows, let’s wait,” said Major-General Heronimus Guru, operations director at Indonesia’s National Search and Rescue Agency (via Reuters on Monday, August 17).

Due to nightfall currently at the crash site and limited visibility in the mountainous area, Trigana Air search and rescue operations for the 54 people on board is now suspended and will continue tomorrow morning at 6am local time.

Trigana Air crash site is a remote mountainous region, making search and rescue challenging.

Turning now towards a brief look at the impact on “people over the devices” surrounding Sunday’s aviation safety incident, Oksibil airport is near an extremely mountainous village of Oksibil at about 1,400 meters (4,600 feet) above sea level with about 4,087 villagers living in the remote area, according to the 2010 Indonesia Census agency. The Oksibil airport is the Indonesian Papua province villagers’ lifeline, mainly because there are no transportation roadways and railways in the remote regional border between Indonesia and Papua New Guinea.

Photo Credit: The Village of Oksibil, Indonesia, courtesy of southeast Asia voyager and traveler, Blogger Wahyu Wijanarko

A security flashpoint currently exists along the border, as a result of Free Papua Movement separatists groups having low-level resistance with Indonesian security forces. Such frontier-like aviation transportation conditions are extremely unusual in relation to the diversity of Indonesian aviation service, as seen in the island of Java which includes Jakarta or the island of Bali which includes Denpensar.

Photo Credit: Oksibil Airport, Oksibil, Indonesia, courtesy of southeast Asia voyager and traveler, Blogger Wahyu Wijanarko

Transportation into the village of Oksibil is governed under the Pegunungan Bintang regency, which operates through a development fund that is typically deplete in fully covering for airline services, the only link to the outside world in the Oksibil area. To subsidize transportation development funding for Oksibil airport, as well as all four remote airports in the area along with an estimated couple dozen airstrips to the most remote villages, having 200-300 inhabitants spread throughout the surrounding area, Pegunungan Bintang regency budgeted US$62 million for transportation services in fiscal year 2013.

Although now a confirmed point at the moment, yet an interesting media depiction of the extreme remoteness of the exclusivity of Trigana Air Services to the Oksibil Airport flight destination, Indonesia’s postal office has told the BBC News that Trigana Air flight IL267 was allegedly carrying four bags of cash, totally nearly 6.5 billion rupiah (which is about US$486,000 or £300,000 British pounds), as part of the post office’s regular periodic delivery to keep the household management and economy running for local villagers living in the remote places in and around Oksibil of the Papua province.

“The government cash for poor families was to help offset a spike in fuel prices, and was to be distributed to about 6,000 impoverished residents during a celebration marking Indonesia’s independence,” Franciscus Haryono, the head of the post office in Jayapura, said Monday, August 17, 2015. 

“Our colleagues carry those bags to be handed out directly to poor people over there,” the head of Jayapura’s post office, Franciscus Haryono, told BBC News.

Four postal workers were on Trigana Air flight IL267 to protect the funds during its journey into Oksibil Airport.

Photo Credit: Oksibil Airport, Oksibil, Indonesia, courtesy of southeast Asia voyager and traveler, Blogger Wahyu Wijanarko

Although villagers concerns continue to persist about receiving adequate telephone and fax services, the people of Oksibil can access free online web services for virtual transportation communications using Bappeda connection.

Southeast Asia voyager and traveler, , who lives in Yogyakarta in Java, Indonesia, and works at PT Global Intermedia Nusantarasay, blogs:

“Central Papua region can (be) accessed only by airplane, there is no way to reach it using car, even more (using) a ship! The problem is lack of infrastructure and (flying into) extreme topographic conditions (of) mountains.

“The consequence of this transportation system is the price(s) of commodities (are) extremely high compared with their price(s) in Jayapura. For example, in some region(s) in Central Papua gasoline price(s) can reach (as high as) IDR 50,000 per liter, or about US$15 per gallon … the biggest (airliners able to land in the surrounding region) (are) Boeing 737-300s operated by Trigana Air Service.”

“The one thing that (Wahyu Wijanarko) likes (in visiting) Oksibil is the people. (Pegunungan Bintang regency) focuses on infrastructure development … including improvements of the (Oksibil) airport and runway … the local government also gives electrical power (still using a generator) to the people of Oksibil from 18.00-23.00 GMT+9 hours (that is from 6-11pm Indonesian local time plus 9 hours to U.S. standard time).”

A dicey aviation safety record for Trigana Air Service.

Trigana Air has had 14 serious aviation safety incidences, since the airlines’ inception in 1991. In 2007 the European Union prohibited Trigana Air from operating in the European Union due to aviation safety concerns.

Flight Path of Trigana Air Crash 7

A dramatic safety incident most recently was on February 11, 2010, when according to Aviation Herald, a Trigana Air Service Aerospatiale ATR-42-300, registration PK-YRP, performing flight TGN-168 from Berau to Samarinda (Indonesia) with 46 passengers and 6 crew, experienced the failure of the left-hand engine (one of two Pratt & Whitney PW120 turboprops, like those on Trigana Air Service flight IL267 ATR 42 (Registration Number PK-YRN) crash early Sunday morning, August 16, 2015), which prompted the Trigana Air Aerospatiale ATR-42-300 crew to divert to Balikpapan.

The crew however was forced to land gear up in a field at Bone village, about 41 road kilometers from Balikpapan along the Balikpapan-Samarinda road about 18 nautical miles from Balikpapan’s Sepinggan Airport.

One passenger received serious injuries (fractures), all other persons on board escaped without injuries, as shown inside the roped-off area surrounding the saved Aerospatiale ATR-42-300 airliner in the crash site photo above.

Several months later on April 21, 2010, the Indonesian National Transportation Safety Council released their preliminary report stating, “the airplane was on final approach to Samarinda’s runway 04, when the left-hand “Engine Control Unit” (ECU) light illuminated, followed by low torque and low engine oil pressure indications.

“The captain decided to shut the engine down, (then) initiated a “go-around,” and (finally) decided to divert to Balikpapan.

“The airplane was about to climb to 4,000 feet and reached 3,800 feet (at) about 16 nautical miles from the Balikpapan airport, when the right-hand ECU light illuminated, followed by low oil pressure and low torque indications.

“The right-hand engine subsequently failed.

“The crew radioed a “MAYDAY” and decided to perform a forced landing in a clear field 16 nautical miles from Balikpapan.

“After the airplane came to a stop, the crew initiated an evacuation. One passenger received serious injuries.”

“The airplane received substantial damage,” Aviation Herald reports (see photo below of the damaged interior of the ATR-42-300 airliner), “the main landing gear received substantial damage, the nose gear penetrated the cabin and was found in the passenger cabin. Mud was thrown through(out) the cabin, and the 4 propeller blades of the right-hand propeller were substantially damaged.”

Generation-old airliner fleet for performing challenging flight terrains to remote villages.

Trigana Air flight IL267 equipment model employed for Sunday morning’s 45 minute ATR 42 turboprop flight, is nearly a generation old (about 30 years in service), and was delivered to its first operator back in 1988.

Reuters reports, in fact according to the airfleets.com database,  Trigana Air airliner fleet “includes 10 ATR aircraft and four Boeing 737 Classics. These have an average age of 26.6 years, according to the database.”

Such remote mountainous route airlines, such as Trigana Air Service, that tackle these challenging flight terrains to small villages, such as Oksibil, Indonesia, typically deploy older aircraft to perform their flights, purchased on the secondary markets at lower costs. Flying in remote Indonesia is challenging, because of complex terrains, monsoon thunderstorms, thick fog, and isolated airports with limited facilities.

A key scientific and technological innovation that is possible at this stage of aviation safety and security, not only in the exploding southeast Asia commercial passenger air travel market, but also across transatlantic, transpacific, and transpolar commercial, in general, air travel centers upon Automatic Dependent Surveillance-Broadcast (ADS-B), a precise satellite-based surveillance and airliner positioning system, which is already being implemented by the U.S. Federal Aviation Administration at various U.S.-based international airlines around the world.

ADS-B system needs to be mandated by the International Civil Aviation Organization (ICAO) with the system extended to tracking aircraft worldwide through satellites, rather than just relying on conventional air traffic control ground stations, largely non-existent in remote regions, like Oksibil, Indonesia. This would absolutely give the fullest coverage over transatlantic, transpacific, and transpolar oceans and remote regions of the world, like the Brazilian Amazon, the Sahara Desert, and the southeast Asian mountainous terrains and jungles.

Of course, others like myself, have called for streaming limited flight data and aircraft performance conditions, literally putting “The Black-Box in The Cloud,” while being mindful of certain information classified to airlines and aircraft manufacturers, so we can immediately know within hours where lost aircraft are crashed and the location of their black-box flight data.

Is flying in Southeast Asia becoming risky?

One of my thousands of followers on Twitter, Kerry Barrett (@Kerry Barrett) poignantly brought to my attention a very relevant question on what non-pilots and air transportation consumers think, when they hear breaking news about another airliner lost in the ocean or remote regions of the world or about another airplane stalling or encountering an ‘engine flameout‘.

And, what does an airliner lost or an aircraft stall actually mean to the flying public, as they try to understand the stunning pictures of the TransAsia Airways flight GE235 crash into the Keelung River in Taipei, Taiwan on Wednesday, February 4, 2015, the extraordinary final three minutes of the AirAsia flight QZ8501 crash into the Java Sea off the coast of Indonesia on Sunday, December 28, 2014, or today’s Trigana Air flight IL267 ATR 42 turboprop loosing contact with Indonesian air traffic control over a remote mountainous terrain or jungle in Indonesia.

Such extreme events in rapid succession begs the question “is flying in Southeast Asia becoming risky?”

According to USA Today: “It turns out flying in Asia is actually riskier than in any other region but Africa. Why? Regulatory regimes there are less advanced than in the United States and Europe (Japan is considered as safe as the west). Another factor is that international regional airlines, such as TransAsia Airways (or even Trigana Air Service), tend to use less-experienced pilots than major airlines.”

“It’s not like they’re the wild west, like you might get in some African countries, but they are 10 to 20 years behind,” said Justin Green, a New York aviation lawyer with Kreindler & Kreindler. “If you’ve never heard of the airline that your travel agent is booking you on, you should do some research.”

Unfortunately, the airliner crash case studies are slowly stacking up in the last year. Recapped in the appendix section below are several instances tangential to today’s Trigana Air aviation safety incident that raises some concern among aviation experts about the critical state of aviation safety in the most essential southeast Asia region for international air travel.

Countries and regions with the highest number of fatal civil airliner accidents from 1945 through November 30, 2014 (excluding MH370, MH17, AirAsia QZ8501, and TransAsia GE235) are:

United States, 773; Russia, 326; Canada, 177; Brazil, 176; Colombia, 173; United Kingdom, 103; France, 101; Mexico, 96; India, 94; Indonesia, 94; China, 74; Italy, 67; Venezuela, 61; Philippines, 60; Bolivia, 60; D.R. Congo, 60; Germany, 58; Peru, 56; Spain, 51; Australia, 48.

In just the past year (2014-15), we have lost the lives of over 788 international passengers and flight crews in Southeast Asia (including 54 lives allegedly missing on Trigana Air IL267 lost on Sunday, August 16, 2015, which amounts to about three times more than all fatal civil airliner accident in the last 68 years between 1945-2013) on five compelling global aviation crash events.

These include:

  • and now a Trigana Air flight IL267 ATR 42 turboprop (Registration Number PK-YRN) that has lost contact with Indonesian air traffic control on Sunday, August 16, 2015.

Trigana Air ATR 42 Plane

Photo Credit: Trigana Air flight IL267 ATR 42 turboprop (Registration Number PK-YRN)

According United States Department of Transportation; Federal Aviation Administration (Office of Aviation Policy and Plans), statistics show average estimated annual growth in passenger traffic to and from the United States transported by U.S. and foreign flag air carriers between 2014 and 2034, by region.

During this time period, passenger U.S. air traffic to or from Latin America is estimated to grow by around 4.7 percent per year. Passenger air traffic in the Asia-Pacific region is predicted to grow by about 4.2 percent per year. The Atlantic Oceanic air traffic is projected to grow by nearly 4.1 percent per year. And, the Canadian trans-border is believed to grow by about 3.8 percent per year.

Forecasts are based on historical passenger statistics from the United States Immigration and Naturalization Services (INS) and Transport Canada, and on regional world historical data and economic projections from Global Insight, Inc.

International commercial passenger air travel is expected to explode in the next decade (according to both federal government, and Boeing and Airbus industry projections), particularly in Southeast Asia. This region is highly dependent upon air travel across deep seas and remote oceans for millions of people in the Southeast Asia and Oceania region.

Role of human factors in automated flight management efficiency and decision-making.

Human factor errors are typically the result of ninety percent of catastrophic aviation accidents, according to years of research by the United States Federal Aviation Administration and the National Transportation Safety Board.

Taiwanese Aviation Safety Council’s (ASC), Factual Data Collection Group Report reveals that TransAsia flight GE235 Captain Liao Jian-zong “failed the simulator check in May 2014, when he was being evaluated for promotion. Assessors found he had a tendency not to complete procedures and checks, and his “cockpit management and flight planning” were also found wanting,” according to Reuters.

Instructors commented that Captain Liao Jian-zong was “prone to be nervous and may make oral errors during the engine start procedure” and displayed a “lack of confidence”, the ASC report cited.

Reuters added: “issues cropped up again during training for the ATR 72-212A in November, when an instructor said Liao Jian-zong “may need extra training” when dealing with an engine failure after take-off.”

“After the crash, Taiwan’s Civil Aeronautics Administration put TransAsia’s 61 ATR pilots through oral proficiency tests on how to handle an aircraft during engine failure.”

“All but one of the pilots passed the tests, although some needed more than one attempt. The lone failure was demoted in rank to vice captain from captain,” Reuters reports.

During a press conference on Thursday, July 2, 2015, TransAsia president Fred Wu said “the airline would buy an ATR flight simulator, bring in outside experts to evaluate pilots, and launch a safety improvement program with Airbus.”

Photo Credit: French-built TransAsia Avions de Transport Regional ATR 72-212A, registration B-22816 and Manufacturing Serial Number MSN 1141

It is essential to have pilots involved in the flight management automation design. “Humans aren’t good monitors of rare events, and monitoring can be a boring job especially for a long haul flight. In some cases pilots have wanted to remove just part of the automation and utilize the remaining features, but are unable to do so, because ‘all or nothing’ are the only options,” says the longstanding authority in the field of human factors in modern aviation, Orlady, H. and Orlady, L. (1999) in Human Factors in Multi-Crew Flight Operations.

A very real problem involved with the almost complete automation present is pilot complacency and over-reliance upon automation. This pilot response occurs in normal operations and also is reflected in the pilot’s reliance on the system to automatically make the correct response during abnormal operations and flight management efficiency inside the crisis of a crash event. Flight crews tend to rely upon the automation to the point that the normal checks that are inherent in good manual operations are sometimes disregarded (Orlady and Orlady, 1999).

Now is the time for consensus on recommendations on the future of international aviation safety and security.

With a deeper integrated focus on “the people just as much as the devices,” in a year and a half (over 17 months), since March 8, 2014, according to Aviation Herald, we have lost the lives of 1,101 international passengers and flight crews on eight compelling global aviation crashes, comprising:

  • the oceanic loss of a Boeing 777-200ER airliner, flown as Malaysia Airlines flight MH370 on March 8, 2014, where the loss of 239 passengers and crewon board are now officially declared an accident and all lives lost;

mh370theft_00

  • a shocking local automobile dash video splashed across international media that recorded a real-time double engine flame-out crash in the Keelung River in Taipei, Taiwan of a Regional ATR 72-212A airliner (see case study in Appendix B), moments after takeoff from nearby Taipei International Airport, operating as TransAsia flight GE235, on February 4, 2015, killing 43 persons on board;
  • a TransAsia flight 222, involving a Regional ATR72 airliner at Makung on July 23, 2014, impacted buildings on approach with stormy weather trailing behind a typhoon, which is now believed to be the likely cause of the airliner crash on a Taiwanese island that killed 48 people on board and injured 10 on the plane and five on the ground. The small Regional ATR-72 airliner, operated by Taiwan’s TransAsia Airways, was carrying 58 passengers and TransAsia crew, when it crashed, while trying to land in the Penghu Island chain in the Taiwan Strait between Taiwan and China late Wednesday night on July 23, 2014, according to the Aviation Herald. The plane was flying from the city of Kaohsiung in southern Taiwan. The victims included 46 Taiwanese and two French medical students, who were interns in Taiwan;
  • a crash Southeast of Gossi, Mali of a McDonnell Douglas MD-83 airliner, operating as Air Algerie flight 5017 on July 24, 2014, causing 110 fatalities of passengers and crew on board;
  • a crash in the French Alps of an Airbus A320-200 airliner, performing as Germanwings flight 4U9525, whereby 150 passengers and crew died.

  • a lost airliner in the Indonesia mountains of a Trigana Air flight IL267 ATR 42 turboprop (Registration Number PK-YRN), carrying 54 people, early Sunday morning, August 16, 2015.

Loosing these 1,101 passenger and crew lives aboard international commercial airliners this past year and a half is the most we have encountered in close succession like this in nearly six and a half decades.

What has happened to our once stellar world of commercial passenger airline safety in this new world slowly grappling from the aftermath of MH17 and MH370, and most recently, Germanwings 4U9525 and Trigana Air IL267?

Photo Credit: IATA Director General Tyler addresses delegates, as he opens the 69th IATA Annual General Meeting and World Air Transport Summit in Cape Town

Commercial passenger air travel industry groups released a report on global flight-tracking recommendations and monitoring standards on Wednesday, December 10, 2014 with adoption at ICAO’s “Second High-level Safety Conference” at its headquarters in Montreal Canada on February 2-5, 2015.

The International Air Transport Association (IATA) held a news conference at its Geneva headquarters Wednesday, December 10, 2014, announcing the report recommendations on global flight-tracking for its 240 member airlines. IATA’s 240 member airlines encompass 84% of international passenger air traffic.

ICAO’s “Second High-level Safety Conference” included “various topics covering three major themes: reviewing the current situation, the future approach to manage aviation safety and facilitating increased regional cooperation. In particular, the Conference attendees discussed emerging safety issues, including the global tracking of aircraft and risks to civil aviation arising from conflict zones.”

Attendees included experts and strategic decision-makers of international civil aviation, which convened to “build consensus, obtain commitments and formulate recommendations deemed necessary for the effective and efficient progress of key aviation safety activities,” according to the conference’s website.

Here, airline chiefs, aviation experts, and government officials approved a concept of operations for global flight-tracking, and moved forward in developing a global flight-tracking and monitoring standard, carefully stepping forward beyond February 2015, which should now be accelerated well before a proposed February 2016 plan released by ICAO in the wake and aftermath of the Germanwings flight 4U9525 aviation tragedy.

Given this, consensus must be reached on recommendations of human factor errors of complacency, over-reliance, and over-confidence bias (a “winner’s curse“) in flight management efficiency and flight systems automation, global flight tracking of commercial passenger airliners, jet black-box data streaming, and ejectable flight data recorders.

All of this calls for further consensus to be reached quickly among airline chiefs, aviation experts, and government officials, who have just completed their discussions at the International Civil Aviation Organization (ICAO) “Second High-level Safety Conference” on February 2-5, 2015 at its headquarters in Montréal, Canada.

– END –

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Appendix A

Case of Indonesian AirAsia flight QZ8501 crash.

Indonesia has a patchy aviation safety record. On December 28, 2014, an AirAsia flight QZ8501 (Registration Number PK-AXC) Airbus A320-200 airliner en route from the Indonesian city of Surabaya to Singapore crashed in the Java Sea during stormy weather, killing all 162 people on board.

AirAsia Underwater Crash

Photo Credit: AirAsia flight QZ8501 (Registration Number PK-AXC) Airbus A320-200 airliner, via Oka Sudiatmika (Wikimedia Commons)/CC-BY-SA 3.0

Technical speculation suggest at this point the severe weather-related conditions may have most allegedly caused some degree of human factor errors, mostly likely revealed from the flight deck conversations and flight performance data and information gained from AirAsia flight QZ8501’s Airbus A320-200 black-boxes (one shown below) still to be completely analyzed and transcribed for the crash final report expected to be released early next year.

airasia-black-box

Photo Credit: AirAsia flight QZ8501 (Registration Number PK-AXC) Airbus A320-200 Flight Data Recorder

However, the AirAsia flight QZ8501 crash final report could allegedly reveal additional future learning factors of aviation, navigation, and communication that in this extreme case was driven by the extraordinary monsoon-like cumulonimbus cloud conditions, extending at such high altitudes at 44,000 feet (beyond normal commercial passenger aircraft operating ranges), allegedly creating such a perfect storm event for a naturally catastrophic air disaster upon a commercial passenger airliner.

Known in the Southeast Asia region as the most dangerous inter-tropic cumulonimbus cloud storm conditions with mixtures of extremely high and low air masses, flying temperatures faced inside these clouds can drop as low as minus 100 degrees fahrenheit (F) below freezing akin to temperatures in Antarctica, the Earth’s southernmost continent, containing the geographic South Pole. 

Pilots in the region know that during almost every flight they will be flying around avoiding critical thunderstorms. Previously flown 13,500 flights for over 23,000 flight hours, AirAsia flight QZ8501’s Airbus A320-200, departed at 5:34 am (local time) on December 28, 2014 from Juanda International Airport (Surabaya, Indonesia) en route to Singapore Changi Airport, is the world’s best-selling single-aisle airliner and the most technologically advanced digital “glass cockpit” airliners too.

Twenty-two minutes into the flight, the Airbus A320-200 airliner is cruising at 32,000 feet on complete auto-pilot, comprising of seven digital computers inside this airliner’s “glass cockpit,” which literally flies the aircraft by itself without any input from the pilots.

In the meantime, severe thunderstorms was building in moments of minutes above the Java Sea thousands of feet below the aircraft, then suddenly within a few minutes these thunderstorms climbed several thousands of feet above AirAsia flight QZ8501’s Airbus A320-200 airliner.

At 6:12 am (local time), air traffic control received a final request from flight QZ8501’s cockpit “to make a left turn and climb” several thousand feet to avoid the sudden thunderstorm consuming the aircraft. Their request was denied due to the high volume of nearby aircraft cruising in the range of 34,000-38,000 feet, undergoing similar flight alterations to maneuver around the huge thunderstorm in the same area in order to avoid possibilities of encountering rough turbulence and other storm-related issues inside the cockpit, although never really a problem inside an Airbus A320-200 flying at cruise speed.

At 6:16 am (local time), Indonesia Ministry of Transportation radar picks up QZ8501 cruising at 32,000 feet. Two minutes later disaster happens to 155 passengers and seven AirAsia crew on board. Suddenly, through a simple course correction of the Airbus A320-200 auto-pilot controls, the airliner departs from its forward flight path, making a sharp left turn in a steep climb to 37,000 feet, slowing down to just 400 miles per hour, onto 38,000 feet, before aerodynamically stalling out in forward speed and dropping from radar at 6:18 am (local time), eventually plunging into the Java Sea off the coast of Indonesia.

Here is where the greatest potential human factor error occurs in automated flight management efficiency and decision-making. It is pilot fear of flying into an intimidating severe thunderstorm of unknown origin or to what extent is the storm’s severity. Such a storm looks like a huge 360 degree dark black cloud of complete and severe lightning with torrential rain slamming onto the airliner’s fuselage and wings with a great deal of bending and twisting forces. This is a black weather zone having no-end in sight outside the pilot’s cockpit windows.

According to years of research by the United States Federal Aviation Administration and the National Transportation Safety Board, fifty percent of all fatal air accidents in the last fifty years result from human factor encounters with these kinds of severe thunderstorm incidents. These storms have huge high turbulent energy plunging into an airliner. Of course, this affects human decision-making piloting under such sudden weather crisis.

Indonesia’s National Transportation Safety Committee chief Tatang Kurniadi told reporters back in January, “if one wing engine had stalled, the plane could spin out of control as it plummeted toward the water.”

However, he said that “only the data from the black boxes would ultimately determine what happened to flight 8501, and he declined to say whether the plane had in fact stalled.”

Mr. Tatang said “the comments made by Transport Minister Ignasius Jonan to Parliament in January “were based not on data from the black boxes, but on the ground radar.” Indonesia investigators have now confirmed the transportation minister’s comments made in January 2015.

Mardjono Siswosuwarno, chief investigator of Indonesia’s National Transportation Safety Committee, said the flight data recorder, which was recovered from the Java Sea along with the cockpit voice recorder earlier this month (January 2015), had provided a “pretty clear picture” of what happened in the final minutes of AirAsia flight QZ8501.

Captain Plesel was in charge from take-off until the cockpit voice recording ends, Siswosuwarno said.

“The second-in-command was the pilot flying,” Siswosuwarno said to reporters in Jakarta, adding that “the captain was monitoring the flight,” and that “this was common practice.” He also said that “the plane was in good condition.”

“Things may have gone wrong in a span of just three minutes and 20 seconds, triggering a stall warning that sounded until it crashed into the Java Sea,” investigators of Indonesia’s National Transportation Safety Committee further elaborated in a news conference in Jakarta, Indonesia on Thursday, January 29, 2015, via CNN International.

According to Reuters, Captain Iriyanto was out of his seat and conducting an unusual procedure on the Flight Augmentation Computer (FAC) when his co-pilot, Remy Plesel, lost control. By the time Iriyanto returned, it was too late to save the plane.

The FAC is a “fly-by-wire” device of the Airbus A320 airliner that uses a computer to control a flight process in order to increase airliner flight safety and reliability, as well as flight management efficiency, while reducing the need for human intervention.

In other words, the FAC is designed to ensure normal operation of the aircraft within specific computerized flight safety envelops independent of any alleged human factor errors resulting from possible pilot inputs. FAC “fly-by-wire” devices can supposedly in extremely rare instances affect “operator” decisions, whose primary responsibility shifts from being the “performer” in flight operations to being the “onlooker” in flight management efficiency.

Whereby, the concerns of “complacency” can potentially arise in flight management decision-making with increasing level of automation in modern aviation, particularly in flight and air traffic control operations.

Iriyanto reportedly had previously flown on the Airbus A320 and experienced a faulty FAC, which he apparently went to fix. Reuters was unable to offer independent confirmation of the faulty device.

After trying to reset the device, pilots pulled a circuit-breaker to cut its power, Bloomberg News reported on Friday, February 6, 2015.

“You can reset the FAC, but to cut all power to it is very unusual,” one A320 pilot, who declined to be identified, told Reuters. “You don’t pull the circuit breaker unless it was an absolute emergency. I don’t know if there was one in this case, but it is very unusual.”

Pulling the circuit breaker is also an unusual move, because the captain would have had to rise from his sea.

President Joko Widodo said the crash exposed widespread problems in the management of air transportation in Indonesia.

Transasia AT72 Plane Crashing 5

Appendix B

Case of Taiwanese TransAsia Airways ATR 72-212A Turboprop: “Wow, pulled back the wrong side throttle.”

French-built TransAsia Avions de Transport Regional ATR 72-212A (a much larger aircraft than Indonesian Trigana Air ATR42 Turboprop), registration B-22816 and Manufacturing Serial Number MSN 1141, performing as TransAsia Airways flight GE235 from Taipei Songshan to Kinmen (a small resort island near the coast of Taiwan) with 53 passengers and 5 TransAsia Airways flight crew on board, departed Songshan’s runway 10, upon which the airliner was involved in an accident, crashing into the nearby Keelung River in Taipei, early Wednesday morning, February 4, 2015 at around 10:45 am (local time).

Taiwanese Aviation Safety Council’s (ASC), Factual Data Collection Group Report, which neither assigns responsibility, nor suggests recommendations, showed that Captain Liao Jian-zong was operating GE235’s Regional ATR 72-212A airliner at the time of the crash.

According to Reuters, Captain Liao Jian-zong had “failed simulator training in May 2014, in part because he had insufficient knowledge of how to deal with an engine flameout on take-off.”

Taiwanese air transport crash investigators state in the report that the right-side Pratt and Whitney turboprop engine went idle on TransAsia Airways flight GE235, only 37 seconds after taking off from nearby Taipei International Airport. After this right-side turboprop engine malfunctioned, the flight data recorder revealed, “fuel to the only functioning turboprop engine on the left-side was manually cut off.” This critical finding was also discovered in a The Wall Street Journal report back in February 2015.

The turboprop engine aircraft is now generally believed to have incurred an ‘engine flameout‘ moments before the crash in into the Keelung River in Taipei, Taiwan on Wednesday, February 4, 2015, according to early preliminary analysis of the flight data recorder and independent air-traffic control voice recordings of the TransAsia Airways ATR 72-212A airliner.

In an attempt to re-start both turboprop engines, Taiwan’s Aviation Safety Council believes the pilots may have shut off the plane’s left-side turboprop engine upon encountering a right-side engine malfunction immediately 37 seconds upon becoming airborne at takeoff in Taipei.

“Wow, pulled bak the wrong side throttle”

Unfortunately, the pilots did not have enough time before the ATR-72-212A airliner crashed into the Keelung River in Taipei, Taiwan, as air-traffic control lost communication with the plane’s pilots four minutes after takeoff from Taipei’s Songshan Airport.

According to CNN International and The Wall Street Journal reports, supposedly a pilot on a recording of radio conversations between air traffic control and TransAsia Airways flight GE235 says,

“GE235. Mayday, Mayday. Engine flameout.”

The recording released Wednesday, February 4, 2015 was verified by an independent website, which records air traffic control feeds from around the world.

Photo Credit: French-built TransAsia Avions de Transport Regional ATR 72-212A, registration B-22816 and Manufacturing Serial Number MSN 1141

Nonetheless, regarding the operating conditions surrounding the February 4, 2015 TransAsia Airways flight GE235 crash into the Keelung River in Taipei, the Taiwanese Aviation Safety Council reported that “there were two captains, Captain Liao Jian-zong (age 42, a Airline Transport Pilots License (ATPL)-rated certification, had 4,914 hours total, of which 3,151 hours on ATR-72-500 aircraft, and 250 hours on ATR-72-600 airliners) was pilot in command occupying the left-hand seat being pilot flying. 

Captain B serving as first-officer (age 45, an ATPL-rated certification, had 6,922 hours total, of which 5,687 hours on ATR-72-500 aircraft, and 795 hours on ATR-72-600 airliners) occupied the right-hand seat and was pilot monitoring. 

A first-officer complemented the crew occupying the observer’s seat, the first officer (age 63, an ATPL-rated certification, had 16,121 hours total, of which 7,911 hours on MD-80s airliners, and 5,306 hours on ATR-72-500 aircraft) was in conversion training to ATR-72-600 airliners with 8 hours on the aircraft type.”

The crew had signed the flight papers, that showed no unusual circumstances.

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