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air safety

Jul 2, 2017

How Jetstar (and others) avoided a crash similar to Air France AF447

After all the controversy over Air France AF447 a short ATSB report about a Jetstar incident shows how good safety cultures can avoid tragedy

The Jetstar 787-8 involved in the 2015 incident while flying from Melbourne to Darwin

There are sobering similarities between a Jetstar 787 control incident which is the subject of an ATSB investigation published last month and the loss of an Air France A330 which crashed into the mid Atlantic on its way to Paris from Rio de Janeiro in June 2009.

Fortunately the Jetstar incident in December, 2015, involving the similar temporary blocking of air speed measuring devices called pitots, did not end in a tragedy like that which killed all 228 people on board Air France flight AF447.

The Jetstar pilots did what apparently all other pilots have been done (other than those of AF447) when confronted by a sudden loss of vital data and a consequent disconnection of the autopilot system.

They held their throttle and attitude settings until the pitots self cleared, and then dealt with deciding whether to proceed with the flight or land for the technical reasons outlined by the ATSB.

The AF447 pilot flying did something inexplicably different to the unreliable airspeed procedures used by airlines, by pulling back on the side stick controller and sending the Airbus on a climb which ended with the airliner stalling and soon after, belly flopping with a force of 32G on impact, on the surface of the ocean

His colleagues proved incapable of identifying or rectifying the problem.

An astonishing litany of smokescreens and fierce arguments ensued for months over the conduct of the last moments of AF447.

The ATSB report doesn’t refer to AF447, nor cross reference other well documented cases of scheduled flights suffering from similar transient failures causing unreliable airspeed indications in the cockpits of various types of jets..

Given the bitterness that persists over the loss of AF447, this is understandable. This isn’t a case of safety lessons according to some pilots, but a reminder that degraded safety cultures which forget such lessons can destroy lives.

For all its tactful brevity, the ATSB report is an important contribution to air safety and an endorsement of the professionalism of the Jetstar pilots.

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12 comments

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12 thoughts on “How Jetstar (and others) avoided a crash similar to Air France AF447

  1. comet

    But given Jetstar’s other misdemeanors, I don’t consider them a safe airline.

  2. Tango

    Ben:
    This is actually a rare case (though hope fully more the norm now) of pervious incidents being handled badly, none to the degree of the AF447 crash.

    This is going form memory, the French NTSB equivalent , back tracked 13 similar incidents, only a couple were done right.

    The reality is that if you suddenly loose all speed, either your pitots are gone or you just ran into something.

    If you just ran into something pulling back, push forward (another common reaction) firewalling the engine is not only no good, you should be dead.

    Ergo, wait, assess and take action only if needed.

    Not too long ago, a US Airline (757, Maybe American) was descending into Ireland (forget which city). Same thing, pitot iced up. Co pilot (old dog terminology I know) pushed the nose down and I think firewalled the engines, such extreme speed as to damage hydraulics systems on the aircraft.

    Airlines are supposed to introduce unexpected scenarios in the Simulators to find out if pilots really understand the aircraft and can take correct actions (not just landing and taking off)

    It can’t be the same one over and over.

    Some have gone at it full heatedly, I understand FedEx was doing it before this all came about and is a leader. Others are dragging their feet and doing lip service but not the full intent.

    Its my personal view that there are a group of people out there that I call intelligent incompetents . In the there is a solid case history of doctors and lawyers killing themselves and others in small aircraft.

    Very smart and could memorize all the stuff in the book and pass the tests. When it came to applying it, they failed miserably and a dispopparioa0ntl number of them crashed.

    We seem to have a sim8ilar issue with the airline pilot pool.

    I personally knew one guy who was afraid of the aircraft. He never adjusted to the speed things happened (co pilot, DC-9 as I recall). He quit and went to play guitar to the betterment of all.

    What is also unsettling is the 767 went into alternative law, and they could not get it back out sans a reset on the ground.

    Loss of speed could be programed in to go to the safe mode (85% thrust and 5 degree nose up) with a message. In this case it dumps it in your lap leaving you go figure out why your auto pilot is off, why the aircraft flies funny.

    So much for the robot pilot, if it can’t do that it can’t fly an aircraft.

  3. Ben Sandilands

    Tango,
    Well, it was anything but rare in relation to the BEA report, and a considerable body of info about such incidents came out when it was realised that the most fundamental of data failures had baffled three pilots for long enough to kill everyone on board. The discussion was widely reported here and elsewhere but I agree with the ATSB taking a brief approach, in that the message or learning from the incident was fundamentally simple. Don’t panic, follow the SOP many airlines already had in place, and give the problem a short interval in which to pass.
    Comet,
    I certainly get your point. However this incident was handled in an exemplary manner, and if it points to safety learnings being applied, I’m keen on telling that story.

  4. Zarathrusta

    Hopefully this is an indication of improving safety culture rather than an anomaly.

    1. Tango

      Correct, when all these are handled right then we have gotten someplace.

      But behind that is now the concept that we3 don’t address this stuff one at a time.

      You throw completely unexpected situations at pilots in the simulator and you find out just how well they understand the systems and what to do about those rare but often fatal situations.

      What it amounts to is there are people who react wrong, why you would do what AF$$& did is totally beyond belief.

      Why two other pilots did not recognize it as a stall is also beyond belief.

      The background approach is changing and that is hard to convey, but its not the same old scenario over an over again. Or as one trainer said, these guys do landings all the time. Why are we wasting time checking out their landings? A check pilot will know quickly if the guy can do that or not. Shoot a review of the flight data would show you that (data mining)

      Do they understand that when you put it into FLCH mode the auto throttles turn off?

      So instead of useless work doing the same thing over and over again, you test them with the most unusual things an airplane can do. That’s when you find out if you have a pilot or someone who should be playing a guitar in a lounge.

      Maybe another way to put it is, its a sad state when what should be routine gets applause. It should be routine, it should not have risen to the point where it gets any mention. But something like 12 badly handled similar events shows something is horribly wrong (or was) and is missing in the system.

      Jumping into a raging river to save someone (737 crash on the Potomac) is to be applauded in an example of extreme courage. Doing what you are paid to do should not be.

  5. derrida derider

    All this stuff about training to deal with frozen pitots is fine and correct, but if we have had 13 incidents recently it suggests we need to look at the machines as well as the pilots.

    I assume it’s not easy to design really iceproof pitots or it would have been done (though surely we can think of an alternate approach that, say, squirts tiny amounts of powdered metal into the airstream next to a tiny sonar doppler detector).

    At least it ought not to be beyond the wit of computers to design a system that measures icing conditions and then if airspeed indication gets inconsistent tells the crew the probable diagnosis . And you could also make GPS-derived groundspeed an indicator too so the crew can at least deduce that if it hasn’t changed much from before the icing then IAS probably hasn’t too.

    1. Tango

      Its a lot harder than you think and while they are working on systems, they have not been tested enough to be allowed.

      We also may be enjoying the benefit of more of that type of icing than in the past with Climate Change.

      It is something that should be solved for sure. Even a backup that has less resolution is better than nothing and that may be the direction to go.

    2. JW (aka James Wilson)

      Fear not, the FAA and EASA recently introduced new certification specifications for flight in supercooled large drop, mixed phase and ice crystal icing conditions. Airbus is currently testing and collecting data from aircraft fitted with new pitot probes that meet the new specifications. I dare say Boeing is looking at it too, if they haven’t already done so.

      1. Dan Dair

        “I dare say Boeing is looking at it too, if they haven’t already done so”
        No, they probably won’t be.

        They’ve got a B777-X to finish,
        then they’ve got a new B737 or a B797 to design & build
        and only then will they be able to devote money & resources into any other projects.!!!

        1. JW (aka James Wilson)

          “No, they probably won’t be.”

          They won’t get very far with certifying their new toys if they don’t!

          1. Dan Dair

            “They won’t get very far with certifying their new toys if they don’t!”

            It wouldn’t surprise me a jot if that turned-out to be very close to the truth.?

    3. Dan Dair

      Good point,
      A GPS-derived groundspeed indicator would probably be far too inaccurate for actual aircraft flight,
      but would be quite sufficient to remind pilots (even in the dark) that the aircraft is still flying at more or less the same speed as it was before the airspeed indicators stopped working.?

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