Friday Fact – Visual Controls In Place to Save Lives

February 7, 2020by Faber Infinite

Did you know, all the 162 passengers and the flight crew of Air Asia Flight 8501 were killed right after 40 minutes from its take-off because of ignoring quality warning signals?

Right after 40 minutes from take-off, the Airbus A320-200 which was carrying 162 passengers from Surabaya-Indonesia to Singapore lost its contact from the radar. The two-and-a-half-hour flight was almost half-way towards its destination point when it disappeared.

In the beginning, it was said that the aircraft crashed due to bad weather conditions. This was said because the flight when reached the altitude of FL320 that is 32,000 ft. it approached the line of a thunderstorm. As a result, the captain asked for permission from Air Traffic Control (ATC) to climb FL380 to fly above the thunderstorm.

But, the actual reason behind the plane crash was the error in the plane’s rudder control system along with the crew’s ignorance of the warning signal that kept appearing again and again. There was a crack in a small electronic module which caused the system to send an error warning repeatedly which was responded to the first few times by resetting the system.

This came to notice when the pilot was about to request ATC, the first AUTO FLT TRV LIM 1 (AUTO Flight Rudder Travel Limiter) signal appeared on the ECAM. A minute later, failure of both the rudder travel limit units resulted in alarming chime and master caution light. This is a device used to mechanically limit the maximum rudder deflection.

Later, the ECAM (Electronic Centralised Aircraft Monitoring) showed the signal of AUTO FLT TRV LIM SYS (AUTO Flight Rudder Travel Limiter System).  The ECAM also shows the direction to resolve the error.

The captain followed the procedure and resolved the warning error. Later, to avoid the storm ahead the pilot asked for permission to deviate the plane to left. The AUTO FLT TRV LIM SYS signal appeared on the ECAM. The pilot again resolved the signal as per the system suggestions. This warning signal appeared on the ECAM 4 times. But the captain did the same procedure three times and for the fourth time, the captain decided not to follow the instructions to resolve the error. This time the captain decided to reset two circuit breakers of the aircraft.

This action is violated in flights. This action triggered the autopilot and auto thrust disengaged and the flight started rolling sharply to the left. After the 9 seconds of disengagement, the first officer corrected by turning the stick hard to right. Again, the aircraft rolled back to the left by 50%. The aircraft climbed to 38,000 feet, twice with a climb rate.

Within a few minutes, the stall warning was activated. However, the first officer kept pulling on the side stick which increased the climb rate of flight even further. In response to this, the captain applied the nose-down command. The aircraft than reached the highest altitude of 38,500 feet and at the largest rolling angle of 104 degrees. After that, the plane started to drop at a rate of 20,000 feet per minute. After 43 minutes from the take-off at 24,000 feet, the flight disappeared from the radar. The flight was later discovered on the third day in the Java Sea.

Though the flight gave back to back 4 warning signals for the correction of the failure due to the ignorance of the warning signals, the flight crashed in the Java Sea. Similar episodes happen in organizations as well. Usually, accidents are a result of ignored warnings. Therefore, visual controls are to be placed on each machine and the moment any warning takes place, the first thing that should happen is a check-up of the machine. Even the smallest of the error can lead to major accidents. So, have you deployed visual controls in your organization? 

by Faber Infinite

Faber Infinite is an International Business Management Consulting Organization offering consulting solutions and services for Increase Profitability in Business.

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