Crash: West Atlantic Sweden CRJ2 near Akkajaure on Jan 8th 2016, lost height after emergency call

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Crash: West Atlantic Sweden CRJ2 near Akkajaure on Jan 8th 2016, lost height after emergency call

By Simon Hradecky, created Friday, Jan 8th 2016 14:09Z, last updated Monday, Dec 12th 2016 16:49Z

A West Atlantic Sweden Canadair CRJ-200, registration SE-DUX performing postal flight PT-294 (dep Jan 7th) from Oslo to Tromso (Norway) with 2 crew and 4.5 tons of mail and parcels, was enroute at FL330 about 75nm west of Kiruna (Sweden) in the border region between Norway and Sweden, when the crew declared emergency at about 23:31Z. Radar and radio contact was subsequently lost, the aircraft did not arrive at any airport. The aircraft was later located having impacted the side of a mountain northwest of Lake Akkajaure about 10km from the border to Norway in mountaineous area without road access.

The airline reported in the morning, that the crew declared emergency at 23:31, the aircraft disappeared from radar immediately thereafter. A subsequent search for the aircraft by air located the wreckage at Lake Akkajaure in the Swedish Lapplandsfjällen near the Norwegian border at 03:10. Emergency services are on their way to the crash site on the ground. The captain (42) had accumulated 3,173 hours total and 2,050 hours on type, the first officer (34) 3,050 hours total and 900 hours on type, the aircraft had accumulated 38,601 flight hours in 31,036 flight cycles.

Norwegian Air Force reported the crash site is very small, overall diameter being 50 meters, and is evidence of a high energy impact.

Swedish Police reported the settlement nearest to the crash site is Ritsem, the crash site is located at about 1000 meters above sea level in inaccessible terrain at mountain Oajevagge. There is just a big large hole leaving small fragments at where the plane impacted ground, evidence suggests the aircraft came down near vertical. There is no evidence of survivors, the crew has been declared missing.

Sweden's Statens Haverikommission (SHK) opened an investigation reporting a distress call was received shortly after midnight on Jan 8th 2016, the aircraft disappeared from radar at about the same time. The crash site was located west of Kiruna (Sweden).

On Jan 10th 2016 the SHK reported that about 1.5 cubic meters of fluid, about 1200 kg/1500 liters/2640 lbs of largely aviation fuel, needed to be removed from the crater at the crash site during Saturday (Jan 9th). Rescue and Recovery still focus on finding the crew, which remains unaccounted for. The flight data recorder has been recovered in seriously damaged condition on Saturday, the memory module is now being checked whether it can be read out. On Saturday parts of the cockpit voice recorder, without the memory module, were discovered, on Sunday the memory module was discovered too. The SHK wrote: "Because the aircraft's two black boxes have been found the Commission of Inquiry is hopeful to be able to determine why the aircraft crashed. Extracting information and analyzing it could take a few weeks."

On Jan 12th 2016 the SHK told The Aviation Herald that the distress call just contained the repeated words "Mayday", there was no further information in the call.

On Jan 26th 2016 the SHK reported that the investigation managed to read out both cockpit voice and flight data recorder, the CVR does contain the talks of the crew during the accident flight. The investigation is currently analysing and validating the recordings. A preliminary report is estimated to be released in a week or two.

On Mar 9th 2016 the SHK conducted a press conference introducing a preliminary report (The Aviation Herald later succeeded in receiving the report) to Swedish Media. Swedish Media are reporting that according to the investigator in charge the IRS (Inertial Reference System) data recorded on the flight data recorder do not match the accident flight - the investigation therefore is looking into what data the crew actually received exploring a possible theory that the crew might have received erroneous data prompting them to disconnect the autopilot. An expletive can be heard on the cockpit voice recorder after the autopilot was disconnected. 16 seconds later the distress call was made, after another 17 seconds the aircraft reached the highest recorded speed of 950kph (512 knots), the engines reduced to idle thrust, and the aircraft impacted ground at about that speed (508 knots last recorded speed) 80 seconds after the aircraft departed controlled flight. The investigation is ongoing, a final report is estimated by December 2016.

On March 9th 2016 later the afternoon the SHK released their interim report stating that there had been no significant weather along the planned route of the aircraft which took the aircraft into Swedish Airspace still controlled by Norwegian ATC. The flightplan requested FL330 for cruise.

The flight departed normally and was enroute at FL330 without anomaly until about 70 minutes into the flight and until 80 seconds prior to ground impact. About 70 minutes into the flight the captain exclaimed a strong expression, immediately after the cavalry charge (autopilot disconnect aural indication) sounded, the flight data recorder recorded the autopilot disconnect, too. The cavalry charge continued for the next 18 seconds. Following the autopilot disconnect the FDR recorded both elevators went into the nose down positions, all angle of attack sensors indicated negative angles of attack and the aircraft entered a descent reaching a vertical acceleration of -1G causing the G-Load warning system to activate issuing a triple chime, a synthetic voice alert indicated low oil pressure for both engines.

The FDR showed that the stabilizer trim went from 0.9 degrees nose up to 1.7 degrees nose down, the according clacker sound indicating stabilizer trim movement were heard on the CVR. Immediately after a high bank angle warning activated.

17 seconds after the autopilot disconnect the aircraft accelerated through 315 KIAS (VMO, maximum operating speed), the overspeed warning activated, the vertical acceleration turned into positive values.

Another 16 seconds later (33 seconds after the start of the event) the first officer transmitted a "MAYDAY" message which was confirmed by ATC, the aircraft had accelerated to 400 KIAS, the stabilizer trim began to recover and was at 0.3 degrees nose down. The captain called "Mach trim", the engines were reduced to idle thrust. The aircraft continued to accelerate however and reached 508 KIAS (last recorded speed), the vertical acceleration reached +3G, the aircraft's ailerons and spoilerons were mainly deflected to the left throughout the event.

The SHK stated: "Radar data and the accident site position indicate that the track was changed about 75 degrees to the right during the event. The crew was active during the entire event. The dialogue between the pilots consisted mainly of different perceptions regarding turn directions. They also expressed the need to climb. The aircraft collided with the ground one minute and twenty seconds after the initial height loss."

The SHK reported: "The validation of the parameters showed that four of the parameters could not be compatible with the aircraft's actual movement. The concerned parameters were pitch angle, roll angle, magnetic heading and ground speed. Those parameters emanate from the airplane�s IRU units"

The SHK continued that the pitch angle recorded by the FDR does not match the actual progress of the flight (see graphics below, showing blue the actual recorded pitch angles and green the computed pitch angles), the pitch angles were computed based on true airspeed and acceleration data, the computed pitch angles may be a few degrees off as the actual bank angles were not known. The computation of the other parameters is still in progress.

The recorded (blue) and computed (green) pitch values (Graphics: SHK):

Map of the impact crater (Graphics/Photo: SHK):

The CVR memory module (Photo: SHK):

The case of the CVR (Photo: SHK):

The FDR (Photo: SHK):

Radar tracks according to radar station Evenes (magenta) and Kletkov (blue) (Graphics: SHK):

Aerial image of the crash site:

Impact crater:

Local map (Graphics: Lantmateriet.se):

Map (Graphics: AVH/Google Earth):

By Simon Hradecky, created Monday, Dec 12th 2016 16:45Z, last updated Monday, Dec 12th 2016 16:49Z

On Dec 12th 2016 Sweden's SHK released their final report concluding the probable causes of the crash were:

Factors as to cause and contributing factors

The accident was caused by insufficient operational prerequisites for the management of a failure in a redundant system.

Contributing factors were:

- The absence of an effective system for communication in abnormal and emergency situations.

- The flight instrument system provided insufficient guidance about malfunctions that occurred.

- The initial manoeuver that resulted in negative G-loads probably affected the pilots' ability to manage the situation in a rational manner.

Factors as to risk

The fact that fault descriptions regarding aircraft and its components are reported in a less detailed manner might imply that the faults will not be identified and corrected in an efficient way. This can in turn lead to a flight safety issue as, for instance, intermittent faults cannot always be detected by general tests.

The SHK reported that the captain (42, ATPL, 3,365 hours total, 2,208 hours on type), pilot flying, initiated the approach briefing prior to the upset, the first officer (33, CPL, 3,232 hours total, 1,064 hours on type) was pilot monitoring. The autopilot and yaw damper were engaged, the aircraft had been in stable flight since levelling off at FL330 at 275 KIAS and a speed over ground of 422 knots.

During the approach briefing the flight data recorder recorded an increasing pitch from the Inertial Reference System #1, initially at 1 degrees/second, increasing to 1.7 degrees/second and subsequently at 6 degrees/second.

After the briefing was completed the captain exclaimed a strong expression "What (!)" - according to the flight data recorder the Primary Flight Display showed a pitch angle of 15 degrees nose up with speed and altitude remaining unchanged, the FDR also recorded the Angle of Attack had remained unchanged, the AoA however is not being displayed to the crew. Immediately afterwards the cavalry sounds of the autopilot being disconnected were recorded by the cockpit voice recorder, most likely the autopilot disconnected automatically due to disagreement of the pitch servo commands. The Cavalry charge remained active for 18 seconds.

The elevators moved into a position to command a nose down, the AoA vanes recorded the AoA becoming negative. In addition, nose down trim commands originating from the left control column were recorded over the next 19 seconds. The recorded pitch position reached 30 degrees nose up. The aircraft began to experience negative G-Load reaching -1G, engine oil pressure indications for both engines followed causing by the negative G-load, the audio signal for high trim speed movement over 3 seconds - caused by manual trim input - was activated, a bank angle warning activated, Vmo and Mmo were exceeded, the overspeed warning activated, descending through FL240 the aircraft exceeded 400 KIAS, the pitch trim began to roll nose up and reached 0.3 degrees nose down. The last recorded airspeed was 508 KIAS at a vertical acceleration of now +3G. The aircraft collided with the ground at position N67.7167 E16.9000 at an elevation of 722 meters/2370 feet 80 seconds after the begin of the upset.

The SHK reported: "Concerning the PFD-units, SHK has not found any descriptions in the operator�s manuals regarding the functions unusual attitude, declutter (non-essential information is removed from the display) or the chevron symbols (red arrows indicating direction of recovery). However, these items are described in the manufacturer�s Pilot Reference Manuals (PRM). The operator did not have access to PRM and the operator�s training organization did not use the manuals."

The SHK analysed that the aircraft did not break up in flight supported by the fact that all control surfaces and the aircraft's all four corners were found at the crash site. The motions of the aircraft as recorded were coherent with the movement of the control surfaces. The SHK analysed there was no cargo shift.

The SHK anlaysed the scenario immediately prior to the upset:

Immediately before the beginning of the event the crew was pro-ceeding with the briefing for the approach to Troms�. The fact that the manoeuvring of the aircraft was not handed over to the PM may have contributed to a less than optimal instrument monitoring during the briefing. However this has probably not affected the course of the event since the pitch angle deviation was detected within seconds.

The SHK analysed at the time of the begin of the upset:

The approach briefing was in progress, which probably meant that the pilots partly focused their attention on the approach charts. Since the maps must have been illuminated to be read, and other cockpit lighting could have been lit, the pilots' night vision had probably deteriorated. This meant that external visual references were virtually non-existent. The pilots were therefore entirely dependent on the aircraft's attitude indicators.

The pilot in command�s first strong expression "What (*)" was recorded after approximately two seconds. The expression is inter-preted as a surprise effect due to the rising pitch angle displayed on PFD 1. It also indicates that the attitude indicator was monitored by the pilot in command at this stage.

SHK�s opinion is that the pilot in command at this moment was exposed to a surprise effect because of the difference between what was expected and what was displayed. As the left PFD displayed information that was not consistent with the aircraft's actual movements and external visual references were absent the pilot in command was subjected to a degradation of his spatial orientation.

The SHK analysed the rapid evolution of the upset:

Almost simultaneously the audio warning Single Chime was activated with a delay due to the autopilot disconnect warning that had priority. No verbal acknowledgement from either pilot was heard on the CVR recordings. Both elevators moved towards nose down while the left control wheel trim switch was activated indicating that the pilot in command, who was the PF, was manoeuvring the aircraft.

The action is probably due to several factors. Pilots have learned since basic instrument training to rely on their instruments, which may ex-plain the pilot in command�s actions. The fact that the pitch angle dis-played on the left PFD was high and increased rapidly in combination with the display of the red chevrons requesting pitch down inputs probably contributed to the pilot�s instinctive reaction to act according to the displayed unusual attitude.

...

The situation indicates that the pilots initially became communica-tively isolated from each other. A contributing factor to this was the lack of regular training of procedures for unusual attitudes. Nor were there any clear rule-based behaviour to fall back upon. Therefore, the situation evolved into problem solving and improvisation, thus a knowledge-based behaviour.

...

By this time, the pilots probably had different perceptions of the situation because of differences in the display on the respective attitude indicator. A basic prerequisite for the crew to jointly cope with the situation was sharing the same perception, or mental model of the situation. In order to achieve a common perception, or mental model, one needs to communicate with each other.

...

At t9 (9 seconds after the captain's "What" exclamation) the co-pilot exclaimed a strong expression which was his first recorded verbal reaction since the beginning of the event. This was answered by the pilot in command with the same expression.

The flight crew communications during the flight, up to the beginning of the event, indicate an open dialogue with mutual forgiveness and exchange of information. SHK therefore concludes that the lack of communication until now in the course of events was not based on any hierarchical conditions that impaired the communication. However, the silence of the crew is a clear indication of a lack of understanding of the current situation and an inability to verbally communicate to troubleshoot the abnormal situation. Variations in G-load probably also affected communication ability.

...

At approximately t13 (13 seconds after the captain's exclamation) the Pitch Angle on the right side PFD reached minus 20 degrees which meant that the declutter mode now was activated on this side (see figure 28 below). The co-pilot exclaimed the first operational callout �Come up�. At about the same time the warning for stabilizer movement, Stab Trim Clacker, was activated and another Triple Chime sounded which was cut-out by two Bank Angle warnings.

The situation at this time meant that the crew were presented with two contradictory attitude indicators with red chevrons pointing in oppo-site directions. At the same time none of the instruments displayed any comparator caution.

None of the pilots verbally referred to the standby horizon. This can be explained by the complex situation facing the flight crew due to variations in G-load and a great number of audio and visual cautions and warnings. This probably further contributed to cognitive tunnel vision and focus on each on-side attitude indicator.

...

The aircraft left its flight envelope at t17 when VMO was exceeded, which activated the overspeed warning. Recorded vertical G-load now turned to positive rates. At the same time irregular sounds were recorded once again. SHK finds it probable that these sounds were due to loose objects falling back down towards the cockpit floor.

The SHK analysed the automated "decluttering mode" of the Primary Flight Displays:

The declutter function means that only roll and pitch angle is displayed on the attitude indicator part of the PFD units during unusual attitudes. This meant that the comparator monitor indication disappeared from the PFD 1 and PFD 2 at an early stage of the sequence.

The purpose of clearing the PFD units from unnecessary information, and thereby providing the pilots with a better display of the situation during unusual attitudes, is easy to understand. It is however more difficult to understand why indications related to instrument errors are removed.

It is possible that such an indication could have helped the pilots to identify the erroneous PFD display. Furthermore, there is a delay of more than 1 second between the caution message and the associated single chime. In case of multiple cautions and warnings, the audio alerts may be desynchronized with the visual messages, causing confusion in the flight crew�s troubleshooting.

Furthermore, as the system does not know which PFD displays the correct parameters when EFIS COMP MON triggers, no declutter function should be automatically performed in this case to avoid the removal of information useful to troubleshoot the situation.

SHK considers that the decluttering of the caution indications on the PFD displays during unusual attitudes is a weakness in the system design.

With respect to the Inertial Reference Unit #1 fault the SHK analysed:

The only plausible explanation to the erroneous data recorded by DFDR is an internal malfunction of IRU 1.

SHK and the manufacturer of the unit have searched for similar events without finding any similar IRU malfunctions.

The manufacturer of the unit performed physical tests and software tests without being able to reproduce the scenario.

Figure 23 shows that only the pitch angle information was erroneous until the aeroplane was changing its roll angle. Until that time, only the pitch gyro was needed to calculate the pitch angle. When the aeroplane started to turn, both the gyros for pitch and yaw were needed to calculate pitch angle and heading. The roll angle will change if a movement in yaw is introduced when the pitch angle is other than zero.

This means that, upon manoeuvring in several dimensions simultane-ously, the roll and heading information will become erroneous if the pitch gyro provides erroneous information. The errors in ground speed can be explained by the erroneous calculation of the heading angle.

The internal continuous self-test accepted the attitude parameters as valid thereby providing the erroneous information to both PFD 1 and DFDR.

When SSM (Sign Status Matrix) sets an error on the attitude parameters from IRU 1 the system shall display a failure flag on PFD 1. This means that the attitude information is removed and replaced by a red �ATT� flag. The failure of the self-test to discover the error can be logical if the failure consisted of an error from a single gyro unit within the system�s limitations.

The aeroplane�s two IRUs had different part numbers and thereby different software. Such a setup is not approved, which meant that the installation of IRU 1 was not a correct maintenance action. However, this is not considered to have had any impact on the sequence of the event.

The SHK analysed in summary:

The malfunction occurred when the crew was performing the approach briefing, which meant that attention was divided between two simultaneous tasks. This probably contributed to the surprise effect.

This meant that the pilot in command�s PFD indicated a sharp increase in pitch angle although the aeroplane was in level flight. Moreover, this led to the automatic disconnection of the autopilot.

At the same time, the co-pilot's PFD displayed information which was consistent with the aeroplane's actual attitude.

The aircraft was equipped with three independent attitude indicators, one of which indicated incorrect values. Thus there were two working attitude indicators that could give the crew the correct attitude information to operate the aircraft safely. However, this requires that the crew has the ability to identify the malfunction and to rationally evaluate the situation.

The PIT miscompare indication on the PFD displays, supposed to in-form the crew about the miscompare between PFD 1 and PFD 2 was probably activated, but was displayed on PFD 1 for a very short pe-riod of time. By design, the miscompare indication, along with other information considered secondary, disappears at unusual attitudes to allow the crew to focus on a more limited set of information.

The crew was trained to rely on their instruments, in the absence of external visual references. This may explain the reflexive manoeu-vring that induced the rapid descent of the aeroplane when the red chevrons appeared.

The captain's and first officer's instrument readings at the captain's exclamation "What (!)" (Photo: SHK):

The captain's and first officer's instrument readings at the captain's exclamation

The captain's and first officer's instrument readings 9 seconds after the captain's exclamation "What (!)" (Photo: SHK):

Reader Comments: (the comments posted below do not reflect the view of The Aviation Herald but represent the view of the various posters)

Cross
By Jan on Thursday, Dec 29th 2016 09:18Z

I am reading right?... "yes the iru self test failed, it should put a big old red cross on the pfd but it didnt, telling the cpt, with emergency chevrons, to crash the plane, because of maintenance issue and we identify it as a fault, but it has no impact on the crash"... as usual the deads are silent and easy to charge on.

By SYN on Tuesday, Dec 27th 2016 10:04Z

In my opinion, the disagreement of devices should be way more pronounced displayed, then it sure would be first thing for pf to check the disagreement (and standby device) and would have quite simple solution (do nothing and youre ok)...
This is not the case when there was major sensor disagreement/fault (like say AF477), it was just small fault of one (minority) sensor, but (prolly partially due to the briefing) it put pilot under time pressure, in which he omitted check of stadby device and handled quick, bud sadly wrong...

@Peter - Flight Director
By PeterH on Sunday, Dec 18th 2016 20:48Z

Under normal circumstances it is a help to have the flight director tell you what to do in order to get to a desired place in space; however, that obviously assumes that the flight director knows where you want to go and how to get there. In this case the flight director thought they were pitching up and issued directions to rectify that - when in actuality they were not pitching up.

I agree wholeheartedly with your thoughts. Airplanes do not crash because the flight director malfunctions or because the attitude indicator malfunctions - I'd long be dead if that was the case. But they do crash if the crew does not respond appropriately to the malfunction.

By peter on Sunday, Dec 18th 2016 19:05Z

@PeterH: All I am saying is that perhaps the pilot thought that what's on the display must be correct, ignoring what his body tells him (or in this case ignoring the absence of noticing anything different).

What I really don't understand is why the computer is giving the pilot an instruction, such as push or pull. The only situation where this is appropriate is TCAS. Why would the flight computer ever clear up the display and thus change the layout of the display? When the display has a certain layout 99% of the time, I expect it to be the same during the 1% time of an emergency too.

Overall I really have to disagree with the 3 listed reasons for the crash, to me it's exclusively 'pilot in command was unable to handle an abnormal situation.'

Instrumentation
By DB on Friday, Dec 16th 2016 21:08Z

I also struggle with how the Captain missed the differential between an extreme nose up attitude indication on his PFD and the completely normal indications on all the other instruments, including the co-pilots PFD and the standby. However, is this aircraft type unique in the magenta arrows indicating which way to move the control column under unusual attitudes? They are very compulsive but clearly only driven by the failed unit on the Captains display, and I assume likely were not present on the right side display. Now we have magenta arrows the educated should ignore on occasions as well as magenta lines! (Before anyone chips in I do know that the Collins FD108 clockwork flight system had stars, followed by "PUSH" at the top of the display, and "PULL" at the bottom but I'm not telling how I found out)

@ peter - trusting you "own instruments"
By PeterH on Friday, Dec 16th 2016 00:08Z

Peter -
Nobody was suggesting that you can fly IFR on your built-in instruments - we wouldn't need attitude-indicating instruments if we could. You don't have to spend much time under the hood to get convinced of that.

My point was that if you really had an increasing pitch change like indicated here going from 0-6 degrees/second in short order, you would most certainly feel it because it would be associated with a positive load of somewhat more than 1G.

However, here there was no increase in G-load and there was no change in altitude, airspeed, vertical airspeed, or attitude as indicated by the standby artificial horizon - because the airplane was still flying straight and level like it was presumably also trimmed to do. Accordingly, the display's pitch-up indication would have been a complete surprise and thus should have been verified before any action was taken. That is what a scan is for.

regarding the last comments
By peter on Thursday, Dec 15th 2016 14:12Z

Without any reliable visual reference such as the ground itself you cannot trust your "own instruments," so to speak. Even if you feel a change, you couldn't tell whether the airplane is climbing or descending, or rolling or not. If you do trust your instincts you will crash eventually. You will notice very sudden changes, but gradual ones, no chance.

But I agree that the pilot should have instantly noticed that the most basic instruments were not in agreement and the altimeter especially.

@Johan - it is rather bizarre indeed
By PeterH on Thursday, Dec 15th 2016 01:25Z

It is also rather bizarre that the captain pushed the airplane into a steep dive without first performing a rudimentary instrument scan - including the standby artificial horizon - which would have told him that the airplane was flying just fine. And the airspeed indicator, altimeter, and vertical airspeed indicator would have told him the same story - as would the seat of his pants. You don't suddenly get that kind of pitch change without being able to feel it.

Back in the old days we learned - some times the hard way - that instruments (and vacuum pumps) do indeed fail. Of course that was before we had a magenta line to mindlessly follow...

Not a word from FO seeing everything was normal?
By Johan on Wednesday, Dec 14th 2016 22:50Z

One thing I cannot understand: How a FO could just sit there observing fully normal instruments with no changes; no changed G-load, no sound/noise changes, level flight, steady altitude and suddenly the captain pushes down the aircraft abnormally and the FO does NOT SAY A WORD about it despite the altimeter counting down to hell?!?

Troubling
By (anonymous) on Tuesday, Dec 13th 2016 22:31Z

This is the most troubling part in the excerpts:

"The manufacturer of the unit performed physical tests and software tests without being able to reproduce the scenario."

In other words, the same instrument fault will happen again, and we cannot say when and under which conditions!

@Brian Johnson
By PB on Tuesday, Dec 13th 2016 17:15Z

Re AF447, I also had that in mind. In both events the plane was perfectly fine for flying, and yet it crashed. The small difference if I remember correctly is that here the instruments were (partly) not working properly, so this was additional complication pilots had to cope with, while instruments on AF447 showed everything correctly after initial confusion just pilots did not have time to understand the situation.

Human factors after an unexpected event
By Brian Johnson on Tuesday, Dec 13th 2016 16:51Z

"...The lack of a prescribed procedure and standard callouts for automatic autopilot disconnection might explain why this was not commented upon or acknowledged by the crew..." and
"...The crew was subjected to an unexpected change in the aircraft's automation level with automatic disconnection of the autopilot, which occurred during a flight phase where you normally do not expect any changes..."

This reminds me a little of AF447. Severn years on, it seems to me that the industry urgently needs to modify training and improve procedures so that crews are more aware of and better prepared to deal with such unexpected occurrences.

CVR transcript
By PB on Tuesday, Dec 13th 2016 16:26Z

After reading report and CVR transcript I am amazed how easily such event can happen. And it was so avoidable, if pilots just shared a few simple words about what they see before starting actions from which there was no return... I really hope the pilots take lesson from this crash and start acting as a team and share information in the cockpit in a better way.

By (anonymous) on Tuesday, Dec 13th 2016 09:03Z

this is why when I'm flying (as a passenger) on a nightly oceanic crossing I can never really be thouroughly calm...

Spotlander
By Thomas on Tuesday, Dec 13th 2016 06:16Z

Spotlander, basically when you graduate from flying school with all atpl subjects passed, you will be graduated with a CPL license (frozen Atpl) until you get an certain number of flying hours 1500hrs min with certain limitations to it'so flying hours to be promoted to an atpl license, but indeed there are still a few oldies with a CPL amongst us that can only operate to a certain class of aircrafts and a CR2 is definitely too big for that if flown commercial.

Thank You
By Passenger on Monday, Dec 12th 2016 22:51Z

Thanks once again to AV for professional reporting of technical details.

Perfect storm
By Passenger on Monday, Dec 12th 2016 22:37Z

Reading this is most horrific and frightening - so deeply sad for the two pilots at their peak, yet they were in a perfect storm that finished everything within 80 seconds from FL 330. Sensory overload is part of modern life and somehow we have to simplify things and get to basics to protect ourselves.

@Brian Johnson
By jerry311 on Monday, Dec 12th 2016 22:12Z

"...you are therefore not at all qualified to pass any judgement on this crew's performance whatsoever..."

Judgement can come from anywhere and anyone. Relevance and weight of the judgement is a different question.

Do you have to be a parent to tell someone is doing a bad/good job as parent? Do you have to be a janitor to judge her/his performance based on the cleanliness of a toilette?
No.

The PF looked on 1 instrument and acted on what he saw on it.
Relied on 1 failed instrument without checking any of the backups. His mistake cost his and his copilot's life, unfortunately. So there is no next time where he could use the knowledge gained from this experience.

I am not a pilot either. Still, I learned in my occupation that 1 measurement is not a measurement I should rely on. Why? Because my mistake can cost me (and my employer) a lot of money.

Disagree
By Bubba on Monday, Dec 12th 2016 21:47Z

Here's the thing. Yes, the safe course of action was to do nothing. But it wasn't easy.
The pilot flying has the autopilot shut off, the artificial horizon fills with sky and big red down arrows instructing him to lower the nose.
Now, in the simulator, a disagreement in the pitch reading between the pfds (which was the cause of the problem) causes a flashing PIT warning also to appear
In the aircraft, that warning is eliminated upon throwing the red arrows, to avoid distracting the pilot from the abnormal pitch condition with the news that the condition may be spurious.
So the machine wants action on a situation the crew could only have negatively trained for, after midnight, in a brightly-lit cockpit.

Visual illusions & instant reaction
By LW on Monday, Dec 12th 2016 21:41Z

For all those wondering how a competent, well trained crew can make an error like this....

Have you ever been sitting in a car at a stop light, looking down, and in your peripheral vision seen the vehicle beside you move backward, then pushed harder on the brake pedal, assuming you were moving forward?

Have you, as a professional pilot, ever been sitting at the gate, brakes set, and in your peripheral vision seen the jetway move, then have your feet instinctively jump up to the brake pedals?

I'm not saying the crew did the right or wrong thing, just saying as a professional with my own 30,000 hours in those front seats that I can see it happening, I can understand what happened, and I'm glad I wasn't there.

Nice analysis by the investigators. Well done.

@Ted
By BlueMax on Monday, Dec 12th 2016 21:25Z

Unless you can prove that the length of the investigation is being caused by "your friends in Egypt" (whoever that is), then I am afraid to say that this is a very stupid comment.
There are all sorts of parties involved in those investigations including Airbus, the Airlines, the Irish aviation authorities (Metro), the Russian intelligence agencies, the engine manufacturers (USA) etc. etc. How long did the US take to find the root cause of the TWA 747 crash - years. Both 737 crashes caused by rudder hard-over in the USA - also years. What about Itavia DC9 in Italy - its still being argued over, Silk Air B737 in Malaysia - cause never determined beyond doubt, MH370. And they are only the ones I know of off-hand. For sure there are more.

@Peter
By Brian Johnson on Monday, Dec 12th 2016 21:14Z

"I am not pilot, but I just don't see how..."
No offence intended Peter, but you are therefore not at all qualified to pass any judgement on this crew's performance whatsoever. I am also not a pilot, but I have read many, many reports over the years including ones like this one, where the pilots were suddenly plunged into a confusing situation, hence if I merely try and imagine myself in the scenario that this unfortunate crew were placed in, I can easily understand why it happened. I too still ask "if only this" and "what if that", but I can still understand it. Analysing a situation from the comfort of a stationary armchair with limited experience of real world flying is very easy, almost anyone can do that.
My sincerest condolences to the crew's families and friends

Question for aviation experts!
By SpotLander on Monday, Dec 12th 2016 21:09Z

Hi guys, just wondering, what is the difference between the Captain having ATPL and the First Officer having CPL?

I always thought that with just a CPL rating, you can't really fly, as you would need at least a frozen ATPL? What am I missing?

Thanks!

Too many bells and whistles.
By Kalle on Monday, Dec 12th 2016 21:05Z

I am not a professional pilot, but engineer. We learned to keep matters, in emergeny situations (chemical industry, NPP), simple.
I believe that in modern airplanes too many signals, in an emergency, produce confusion. Does a cavalry charge help to stay calm and controlled?

Back up attitude indicator
By 1310 USN on Monday, Dec 12th 2016 20:49Z

Correct me if I'm wrong but is there not a standby attitude indicator between the MFDs? One would think that would be a tie breaker.
Got it that there was no visible horizon but what training does a captain get for partial panel. You know, constant heading equals wing level and constant airspeed while maintain altitude equals level flight.
Hate to sound like an old fa*t but I see this as a training problem.

Efficient work
By Ted on Monday, Dec 12th 2016 20:31Z

Good work Sweden. Any chance we can barrow your investigators to help our friends in Egypt solve 2 airbus mysteries. Clearly they need assistance to complete a report.

Final report
By peter on Monday, Dec 12th 2016 19:33Z

The pilot looks at his instruments and immediately sees that the nose is pitching up, but there is no change in speed or altitude. Thus he should instantly come to the conclusion that the instruments are faulty, before he's had a chance to push the nose down. He might have concluded in a split second that indeed at least one of the readings is incorrect, but even if he assumed that the airplane was actually pitching up and that the other readings were faulty, why would he not double check before initiating an action that could crash the airplane if his assumption was incorrect after all?

I am not pilot, but I just don't see how communication issues or the flight computer are at fault here. It's a matter of correctly interpreting instrument readings. You first check the artificial horizon, the altimeter, the airspeed and the vertical speed indicator and see that they are not in agreement. Is this not the very basics, no matter how dire the situation?

These poor guys
By WTF on Monday, Dec 12th 2016 19:20Z

The flight crew was overwhelmed by contradictory data which was just beyond any human capacity to make sense of without external visual cues under that sort of stress and within the available timeline. The CVR transcript in the report is horrifying.

Inasmuch as modern glass cockpits have, on average, made aviation an order of magnitude safer, this accident would not have happened with a steam gauge flight deck. I hope the relevant authorities take the recommendations of this report very seriously indeed.

Final report now available
By Lurker on Monday, Dec 12th 2016 15:07Z

The final report was released earlier today, check the SHK's website.

I guess Simon's team is already studying it.

Unending questions.
By Rudolph on Saturday, Apr 30th 2016 04:46Z

There are a lot of questions.
I fly only rotary winged.
Things like airspeed are nearly irrelevant.
With a rotary wing aircraft, as a rule,it will center itself, simply let go.
By its very nature, a stall would mean hovering too long in one place, moving even 5 MPH will prevent that.
Why not have a default, hands free, free fly.
Older aircraft such as the piper cub will all but fly themselves.
Something as complex as a helicopter can have a safe default.

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