Jul 042015

Transasia AT72 Plane Crashing 5

TransAsia flight GE235 pilot mistakenly switched off the airliner’s only working engine moments before crashing in February, killing 43 people, says officially the Taiwanese Aviation Safety Council in its latest report released Thursday, July 2, 2015.

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Photo Credit: Taiwanese Aviation Safety Council, TVBS TAIWAN / Agence France-Presse (AFP) / Getty Images. Final moments showing idle right-side Pratt & Whitney turboprop engine before the pilot error-induced left-side engine shut-off of TransAsia Airways flight GE235 Regional ATR 72-212A airliner, which had 58 passengers and crew on board, subsequently clipping a bridge and hitting a taxicab before crashing into the Keelung River in Taipei on February 4, 2015. Fifteen people survived.

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.

What was the circumstances of Flight GE235’s turboprop engine flameout?

A turboprop engine flameout is “a run-down of a jet engine caused by the extinction of the flame in the combustion chamber. It can be caused by fuel starvation, compressor stall, insufficient oxygen (at high altitudes), foreign object damage (such as caused by birds, hail or volcanic ash), severe inclement weather, mechanical failure and very cold ambient temperatures,” according to Wikipedia.

For quick reference by laypersons, offered by the Aircraft Performance Toolkit for Air Traffic Controllers, by definition, “a turboprop engine propels the aircraft using a propeller, as well as, an air jet. The air jet is produced in the same manner as the jet of the turbofan. The main driving force comes from the propeller. The turbine in the engine extracts more energy compared to a jet because it must power the propeller as well as the compressor.”

“The amount of propeller thrust varies up to 90% of the total thrust depending on type. The air, compressed and burnt with injected fuel, is discharged through a turbine transmitting its energy to the compressor and via a gearbox to the propeller.”

“The turboprop uses a gas turbine (jet engine) to turn a propeller. There are two main parts to a turboprop propulsion system, the jet engine and the propeller. The jet engine found in turboprops is very similar to a jet engine, except that instead of expanding all the hot exhaust gases through the nozzle to produce thrust, most of the energy of the exhaust gases is used to turn the turbine.”

Data from the flight and cockpit recordings discussed in detail inside the latest Taiwanese ASC factual data report confirms that the pilot indeed in error cut-off fuel to the left-side Pratt and Whitney turboprop engine that would normally keep the airliner flying, and not in the stall mode before crashing as shown below.

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Photo Credit: TVBS Taiwan, via AFP — Getty Images

By now all the world has seen the stunning photo and YouTube video, showing a TransAsia Airways plane clipping a road before crashing near Taipei, Taiwan in February.

Images taken from video provided by TVBS and flight GE235’s final path trajectory given inside the Taiwanese ASC report shows the French-built ATR 72-212A plane’s final moments in the air captured on car dashboard cameras do not appear to show flames, as it turned sharply with its wings going vertical and clipping a highway bridge, before plunging into the Keelung River in Taipei, according to the island’s official news agency, CNA.

Taiwanese ASC reported that “video surveillance from dash-board cameras of vehicles were helpful to the investigation in addition to surveillance videos from two tall buildings nearby. The videos show the aircraft passed near one of the buildings (without contact), the first contact of the aircraft was with the taxi.”

“Wow, pulled back the wrong side throttle,” Captain Liao Jian-zong, 42, was heard to say on voice recordings, flying the aircraft in the left seat inside the “hot cockpit,” as the captain first officer monitoring in the right seat quickly attempted to recover the ATR 72-212A airliner upon the loss of the one remaining left-side turboprop engine seconds before the crash.

Unfortunately, Captain Liao Jian-zong, flying the aircraft in the left seat, reduced the throttle on the only working turboprop engine, the Taiwanese ASC report concludes. Cockpit recordings appear to show that Captain Liao Jian-zong “did not appear to realize his mistake until it was too late,” Reuters identifies from the ASC report.

Liao Jian-zong tried to restart the flamed out turboprop engine before the captain first-officer monitoring this flight in the right seat, shouted: “Impact, impact, brace for impact.”

“Those chilling words were the last heard on the data recordings,” according to the Taiwanese ASC’s factual data investigation report on the TransAsia flight GE235 crash on February 4, 2015.

Earl Chapman, of Canada’s Transportation Safety Bureau, told reporters back in February that the plane’s Pratt & Whitney turboprop engines were known for their reliability.

“This engine type has millions of flight hours behind it with a very good safety record. So, it’s fairly unremarkable in that respect,” he added.

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French-built TransAsia Avions de Transport Regional ATR 72-212A, 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).


Photo Credit: Taiwanese Aviation Safety Council

Frantic rescue of fifteen survivors from Keelung River in Taipei.

Rescuers scrambled to pull survivors from the submerged wreckage of the ATR-72-212A twin-engine turboprop aircraft, which went down into the Keeling River shortly after takeoff from the international airport of the Taiwanese capital.

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Photo Credit: WALLY SANTANA/ASSOCIATED PRESS. Emergency personnel try to extract passengers from the plane on Wednesday morning, February 4, 2015.

Taiwanese rescuers used a massive crane to hoist the French-built ATR 72-212A plane from the shallow, murky river after survivors were brought to safety on rubber rafts or scrambled to the Keelung River bank on their own.

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Photo Credit: Wally Santana / Associated Press. The main fuselage from TransAsia Airways flight GE235 is hoisted away in Taipei on Thursday, February 5, 2015.

One injured person was reportedly found in a park along the river, Taiwan News reported. Wu Jun-Hong, a Taipei Fire Department official coordinating the rescue, said he was not “too optimistic” that more survivors would be found.

Earlier Friday, February 6, 2015, Taiwan’s Civil Aeronautics Administration said TransAsia Airways would be grounded for additional new international flight routes for a year. The Southeast Asia regional air carrier had already been grounded from new international flight routes after a crash involving one of its airliners in July 2014 killed 49 people. TransAsia Airways flight GE235 crash extends the grounding period to February 4, 2016, the Taiwanese regulatory agency said.

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Photo Credit: JIN LIWANG/ZUMA PRESS. TransAsia Airways flight GE235’s Regional ATR 72-212A airliner black-box was recovered in February and sent to a lab for analysis by Taiwanese Aviation Safety Council.

“Wow, pulled back the wrong side throttle.”

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.

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.

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

On Thursday, July 2, 2015, the facts of this crash scenario was confirmed, as the Taiwanese ASC report provides this summary of events, as it unfolded early Wednesday morning on February 4, 2015 (all times in local time):

10:51:39 — GE235 began takeoff roll.

10:51:43 — Pilot Monitoring (GE235 Captain serving as First-Officer) called “no ATPCS armed,” and Pilot Flying (GE235 Captain Liao Jian-zong serving as Pilot) replied “ok continue takeoff.” (ATPCS means Automatic Take-off Power Control System)

10:51:51 — Pilot Monitoring called “oh there it is Automatic Take-off Power Control System armed.” The aircraft lifted off and climbed out. Autopilot was engaged after after-takeoff check completed. The aircraft turned right after 1,000 feet.

10:52:38 — After climbing through 1,200 feet master warning sounded. Engine and Warning Display (EWD) showed “ENGINE 2 FLAME OUT AT TAKE OFF” procedures.

10:52:41  Pilot Flying disengaged autopilot while the flight climbing through 1,300 feet.

10:52:43 — Pilot Flying announced “I will pull back engine one throttle” and Pilot Monitoring replied “wait a second cross check.” At this moment ENGINE 1 Power Lever Angle (PLA) record indicated a reduction from 75 degrees to 66 degrees.

10:53:00 — Pilot Monitoring replied “okay engine flameout check” and continued announcing “check up trim yes auto feather yes.”

10:53:06 — Pilot Flying said “pull back number one” and ENGINE 1 Power Lever Angle record showed a reduction to 49 degrees. Meanwhile, Pilot Monitoring said “okay now number two engine flameout confirmed.”

10:53:09 — Pilot Flying replied “okay”; however ENGINE 1 Power Lever Angle remained at 49 degrees. The aircraft reached its highest altitude of 1,630 feet and started to descend at 102 knots.

10:53:13 — Stall warning sounded with stick shakers activated. Pilot Monitoring called “okay push push back.”

10:53:15 — Pilot Flying said “shut” and Pilot Monitoring replied “wait a second throttle throttle.” Between 10:53:13 and 10:53:15, ENGINE 2 Power Lever Angle was advanced to 86 degrees and ENGINE 1 Power Lever Angle was retarded to 34.5 degrees (idle position).

10:53:19 — Pilot Flying said “number one,” followed by “feather shut off.” Meanwhile, Pilot Monitoring said “number feather.” Stall warning revived and stick pusher was in effect until 10:53:27.

10:53:22 — Pilot Monitoring said “okay” and Pilot Flying said “uh number one.”

10:53:24 — ENGINE 1 Condition Lever (CL) was in fuel shut off position. Six seconds later ENGINE 1 propellers were in feather position.

10:53:35 — Pilot Monitoring declared emergency on engine flameout to Songshan tower. Between 10:53:46 and 10:54:04, Pilot Flying attempted to reengaged autopilot twice but failed. The aircraft stalled again during the time.

10:54:05 — Pilot Monitoring said “both sides lost.” Two seconds later Pilot Monitoring said “no, engine flameout we lost both sides.”

10:54:09 — Pilot Flying announced “restart the engine” while the aircraft was at 545 feet with speed 105 knots.

10:54:20 — ENGINE 1 Condition Lever was advanced from fuel shut off position.

10:54:25 — Pilot Monitoring said “cannot restart it,” while the aircraft was at 401 feet with speed 106 knots. ENGINE 1 actual propeller shaft rotational speed corrected for engine temperature (NH1) recorded an increase to 30%.

10:54:27 — Pilot Flying said “wow pulled back the wrong side throttle,” while aircraft was at 309 feet with speed 105 knots.

10:54:34 — “Pull-up” warning issued by Enhanced Ground Proximity Warning System (EGPWS) sounded. The aircraft was at 83 feet with speed 108 knots.

10:54:35 — At altitude of 55 feet with speed 106 knots, aircraft increased its left bank from 10 degrees to 80 degrees and its left-wing collided with a taxi driving on an elevated expressway at the left bank of Keelung River. The left-wing continued to hit the fence of the expressway as well as a light pole, before it crashed into Keelung River.

Thomas Wang, executive director of the Taiwanese Aviation Safety Council, said in February “preliminary findings from the aircraft’s black boxes showed the right engine sounded an alarm seconds after taking off, moving into idle mode,” The Independent (U.K.) reports.

Remarkably, the British newspaper added:

“Data showed it had not shut down, or “flamed out,” as the pilot told the control tower in his last “mayday” distress call, but went idle with no change in the oil pressure.

Then, 46 seconds later, the left engine was shut down, apparently by one of the pilots, who then attempted a full re-start. The plane crashed into the Keelung River just 72 seconds later.

Their bodies were found in the cockpit still gripping the plane’s joystick with their legs badly broken, investigators said.

A survivor said the plane did “not feel right” from the moment it left the ground.

French aircraft manufacturer ATR has expressed its deepest sympathy to the families, friends and to those affected by the accident.

TransAsia Airways has reached a settlement with the families of seven passengers, and negotiations were underway with the rest, said TransAsia CEO Peter Chen. “Relatives of the victims of the crash were offered over $470,000 in compensation, but many of them rejected it, citing dissatisfaction with the amount and the method of payment,” International Business Times reports.

Taiwanese Aviation Safety Council leads the ongoing investigation to a final report in April 2016. The Taiwanese Council is the official source of all causal information surrounding the crash and safety recommendations for the future.

According to the United Nations’ International Civil Aviation Organization regulations, TransAsia Airways flight GE235’s aircraft manufacturer, ATR of France will advise the French Bureau d’Enquêtes et Analyses (BEA), the safety investigation authority representing the Sovereign State of the aircraft manufacturer. ATR is a joint venture between Airbus and Alenia Aermacchi, a subsidiary of Italian aerospace firm Finmeccanica. 

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Photo Credit: Taiwanese Aviation Safety Council

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 an airplane stalling or an ‘engine flameout‘.

And, what does 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, or 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.

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, tend to use less-experienced pilots than major airlines.”

Nonetheless, the ASC reported that “there were two captains, Captain Liao Jian-zong (42, ATPL, 4,914 hours total, 3,151 hours on ATR-72-500, 250 hours on ATR-72-600) was pilot in command occupying the left-hand seat being pilot flying. Captain B serving as first-officer (45, ATPL, 6,922 hours total, 5,687 hours on ATR-72-500, 795 hours on ATR-72-600) occupied the right-hand seat and was pilot monitoring. A first-officer complemented the crew occupying the observer’s seat, the first officer (63, ATPL, 16,121 hours total, 7,911 hours on MD-80s, 5,306 hours on ATR-72-500) was in conversion training to ATR-72-600 with 8 hours on the aircraft type.” The crew had signed the flight papers, that showed no unusual circumstances.

“It’s not like they’re the wild west, like you might get in some African countries, but they are 10 or 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.”


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

Aviation expert David Learmount, operation and safety editor at Flight Global, says it is clear from the video footage that TransAsia Airways flight GE235’s French-built ATR 72-212A airliner was ‘fully stalled’.

In a blog post on the possible causes of the crash, Learmont writes:

“An aircraft stalls because it’s flying too slowly to generate sufficient lift from its wings and it starts to fall.

If an aeroplane is flying too slowly in level or descending flight, it is normally because there is insufficient power to keep the aircraft’s speed up. The question for the investigators is why was there insufficient power?

Reports are coming in that the pilots made a Mayday call declaring an engine flameout.

Both propellers were clearly turning, but that does not necessarily mean they were being supplied with sufficient power to fly safely.

If engine power is lost, the un-powered propeller can cause a lot of drag by windmilling, making the aircraft too difficult to handle. Under those circumstances the crew would normally “feather” the propeller to cut the drag.”

Taiwan’s Aviation Safety Council on Friday, February 6, 2015 said flight GE235 issued five speed-loss warnings before crashing. This is the essence of the key cause of the crash, mainly because fundamentally non-dimensional engine thrust is a sole function of the turboprop engine flow velocity ratio. This is a ratio of the engine exit flow velocity of the air slipstream far downwind of the turboprop to the engine inlet flow velocity of the air slipstream far upwind of the turboprop.

Closely related to this is the non-dimensional engine thrust power, which is a sole function of the square of the turboprop engine flow velocity ratio. Without engine thrust power coming from either one of TransAsia Airways flight GE235’s French-built ATR 72-212A turboprop engines, aircraft stall is imminent, resulting in the stunning last photos and dash cam videos gone viral online and widely seen on international broadcast media.


Photo Credit: AGENCE FRANCE-PRESSE/GETTY IMAGES. The front section of the wreckage of the TransAsia plane is lifted onto the bank of the Keelung River, outside Taiwan’s capital of Taipei.

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.

The Taiwanese ASC 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.”

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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).

To overcome this problem, the design of automation has required:

  • “The automated systems must also be able to monitor the human operator and the human must be able to monitor the automatics.

This emphasizes two real problems, first, humans are fallible and are not the perfect monitors because of human limitations. Secondly, even the highly capable computers available today can fail partially or completely and cannot anticipate all of the circumstances that might be encountered in a line operation. Therefore, the performance of the computers and the human operators must be monitored by each other. For example, the computers should be able to send warning signals when human operator has made an error, and at the same time, when the automation is making incorrect decisions, humans need to understand and be aware of it.”

  • “Each element of the system must have knowledge of the others intent.

A very basic principle in cross-monitoring, which must be effective in achieving maximum safety, is that it can only be effective if the monitor knows what the system is trying to accomplish. This principle requires good communication between the pilot flying and pilot-not flying for it is virtually impossible to be sure of intent without effective communication.”

“The issue of safety due to automation that arises due to the pilot or controller making rare errors can be reduced by having two pilots in the cockpit who are well-trained to monitor the automatics as well as monitoring each other’s operational performance during flight. This process of monitoring both the systems performance along with the pilots performance is further improved by the automated warning systems in the cockpit,” writes Orlady and Orlady (1999).


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

Case of 2014 AirAsia flight QZ8501 crash. 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 still to be completely analyzed and transcribed for the crash final report expected to be released early next year.

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.


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, 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.

Case of 2009 Air France flight AF447 crash. Notwithstanding, recent aviation disaster history confirms an excessively rapid ascent is indeed likely to cause an airplane to go into an aerodynamic stall.

In 2009, an Air France flight AF447 Airbus A330-200 disappeared over the Atlantic Ocean in bad weather, while flying from Rio de Janeiro to Paris.

Investigators determined from the jet’s black boxes that it began a steep climb and then went into a stall from which the pilots were unable to recover, The Independent (U.K.) reports.

A synopsis of what occurred during the course of the doomed Air France AF447 Airbus A330-200 airliner’s final few minutes is here.

Airbus spokesman Justin Dubon said that it was too early to comment on possible similarities between the two crashes.

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Photo Credit: SAM YEH / AGENCE FRANCE-PRESSE / GETTY IMAGES. Rescuers on Wednesday, February 5, lift the wreckage of the plane out of the river in Taipei. Early Thursday, February 6, officials said 35 people died and 15 injured. Eight people remain missing.

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

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 734 international passengers and flight crews in Southeast Asia (which amounts to about three times more than all fatal civil airliner accident in the last 68 years between 1945-2013) on four compelling global aviation crash events.

These include the oceanic loss of a Boeing 777-200ER airliner, flown as Malaysia Airlines flight MH370 on March 8, 2014, the shooting down over a war-torn eastern Ukraine region of a Boeing 777-200 airliner, performing as Malaysia Airlines flight MH17 on July 17, 2014, a crash in the Java Sea off the coast of Indonesia of an Airbus A320-200 airliner, operating as AirAsia flight QZ8501 on December 28, 2014, and a crash in the Keelung River in Taipei, Taiwan of a French-built ATR 72-600 (72-212A), flown as TransAsia Airways flight GE235 on Wednesday, February 4, 2015.

AAEAAQAAAAAAAAOBAAAAJDhkNDM0NmQwLTk1YzQtNDQzNC1hODA4LWQ5Y2QzY2NlMzFlNw - Pilot Error Caused GE235 Prop-Engine Flameout

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

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.

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.

2ccbd4e - Pilot Error Caused GE235 Prop-Engine Flameout


International Civil Aviation Organization

Working Paper



Montréal, Canada

2-5 February 2015


Whereas the Convention on International Civil Aviation and its Annexes provide the essential framework required to support for the safe operation of a global aviation system;

Whereas aviation safety is a prerequisite for the sustainable development of air transport which is a catalyst for the economic and social development;

Whereas Member States have a collective responsibility for aviation safety and its enhancement can only be possible through a cooperative, collaborative and coordinated effort among all stakeholders under the leadership of the International Civil Aviation Organization (ICAO);

Recognizing the efforts of the international community towards the implementation of Conclusions and Recommendation of the High-level Safety Conference held in 2010;

Recognizing the actions taken by ICAO and the role of the Regional Aviation Safety Groups (RASGs), Member States and aviation safety partners in identifying and attaining of the objectives and priorities of the Global Aviation Safety Plan (GASP) endorsed by the 38th Session of the Assembly;

Recognizing that Performance-Based Navigation (PBN) is the primary air navigation priority and that effective regulatory oversight is an essential requirement to achieve its safe implementation;

Recognizing that recent events showed the need for improvements in the timely identification and localization of aircraft in distress as well as the effective search and rescue efforts (SAR) and recovery operations;

Recognizing that the recent event of the downing of a civil aircraft have demonstrated the urgent need to provide accurate and timely information to States and airlines regarding risks to civil aviation arising from conflict zones and to enhance existing mechanisms to share such information;

Recalling that mutual trust between States, as well as public confidence in the safety of air transportation is contingent upon access to relevant and timely safety information;

Recognizing the role of aviation in public health emergencies and the importance of collaboration between the aviation and public health sectors in preparedness planning and response to public health events;

Recognizing the challenges faced by States in achieving a mature safety oversight system and implementing a State safety program (SSP) to attain the GASP objectives;

Recognizing the complexities in safely integrating remotely piloted aircraft systems (RPAS) into their national air navigation systems;

Recalling that the safety framework must be fully utilized by all stakeholders and evolve into the implementation of proactive safety management practices to ensure its sustained effectiveness and efficiency in the changing regulatory, economic and technical environment of the 21st century;

Recognizing that the protection of certain accident and incident records, other information collected for the purposes of maintaining or improving safety and its related sources is essential to ensure the continued availability of information in support of accident investigation and safety management activities;

Recognizing that sharing of safety information is essential for the evaluation and identification of risks associated with operational safety at the State, regional and global levels;

Recognizing that regional frameworks are effective and efficient cooperation mechanisms to support States in addressing safety deficiencies;

Recognizing that enhanced resource mobilization strategies can support States in establishing effective safety oversight systems due to insufficient resources;

The Directors General for Civil Aviation, meeting in Montréal, Canada from 2 to 5 February 2015, on the occasion of the Second High-level Safety Conference:

(A) Commit to act upon the plans agreed during this Conference for aviation safety improvement by:

  • actively participating in the activities of the Regional Aviation Safety Groups (RASGs) that were established to facilitate the GASP objectives;
  • making use of all available resources to expedite full implementation of PBN regulatory oversight;
  • applying safety risk management principles on the SSP in their States and ensuring implementation of such principles in the safety management systems across the aviation system;
  • cooperating with each other to facilitate the effective implementation of the GASP new-, mid and long-term objectives;

(B) The Conference:

  1. Calls upon States to contribute technical expertise to the activities of the RASGs and to implement their safety initiatives while focusing on their priorities;
  2. Calls upon States and aviation safety partners to maintain the confidence of the public in the safe air transportation system by improving flight tracking, especially over oceanic and remote areas, and improving SAR procedures;
  3. Calls upon States to assist in the development of procedures that facilitate improved public health event management and response in the aviation sector;
  4. Calls upon States to take appropriate measures, based on their USOAP effective implementation, to progress the implementation of their SSP and indicate its progress to ICAO;
  5. Call upon States to refer to the ICAO guidance when developing or amending RPAS regulations and establish a formal means to educate users on the risks associated with their operation;
  6. Calls upon States, ICAO and aviation safety partners to cooperate with each other to facilitate the resolution of safety concerns of airlines operating internationally;
  7. Urge States, supported by ICAO, to implement new and enhanced provisions on the protection of certain accident and incident records, and other information collected to maintain or improve safety and related sources;
  8. Calls upon States, RASGs and other aviation stakeholders to support ICAO in the development of a global information sharing framework to collect and share harmonized information associated with operational safety;
  9. Calls upon States, RASGs, aviation safety partners and the industry to support the update of the GASP particularly as it relates to best practices in States and regions, sharing of safety information and development of safety roadmap(s);
  10. Calls upon ICAO to:
  • continue assisting States in implementing safety-related SARPS and an effective safety oversight system through additional guidance material, training and tools;
  • continue assisting States in implementing PBN;
  • define and update related guidance material on risk assessments of civil aircraft operations over or near conflict zones as well as develop and host a centralized repository of information available on conflict zones;
  • continue supporting States in achieving the GASP objectives by refining and harmonizing the identified SPIs to facilitate monitoring and measurement;
  • monitor the implementation of SSPs by Member States;
  • expedite the development of provisions to enable a harmonized approach to the regulation of RPAS and provide a forum for States to share their experiences and best practices;
  • adopt new and enhanced provisions on the protection of safety management information as well as accident and incident records and support States in their implementation;
  • develop a global information sharing framework to collect and share harmonized safety information and provide the means to adequately protect the resulting safety information;
  • support the implementation of the GASP through the development of safety roadmap(s) and its stable evolution using a data-driven approach;

(Note: The content for Topic 3.1 will be included following the discussion by the conference.)

In view of the above, the Directors General of Civil Aviation and the Conference have approved conclusions and recommendations to be acted upon by all involved.


(Note: To be extracted from the final report of the conference.)

Done and adopted in Montréal, Canada on 5 February 2015.


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