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The Air Asia QZ8501 investigation and some potential causes considered

As the recovery efforts for the AirAsia QZ8501 disaster continue, the international aviation community has naturally begun to consider some of the technical issues which could have contributed to the crash, in order that known or avoidable circumstances not repeat.

Until the black box recorders are recovered and analysed, together with all the known information obtainable from the wreckage of the aircraft, the points presented below can be no more than speculative.  However, aviation teaches us that the errors and issues of the past can often provide the best indications of future accident causes.

Some of the issues the official investigation will consider include:

  • The role of the amount/weight of fuel carried by QZ8501 in deciding whether the severe weather should be avoided by going up and over, rather than around, the worst areas
  • The role of Government safety oversight of Air Asia Indonesia in the airline’s procedures and processes for taking and considering Government weather forecast briefings before flight
  • Any potential role of failures of Government oversight in allowing the flight to proceed on a date when it did not have Indonesian approval to operate (even though it did have a slot to land at, and permission to operate to, Singapore that day)
  • The true magnitude of the contribution of the particular weather phenomenon experienced in the vicinity of the flight path
  • The potential for known Airbus rudder control issues to have contributed to or exacerbated any attempts at avoiding weather and possible loss of control (such as that which contributed to the crash of American Airlines flight 587 in Queens, New York in 2001)
  • Any known psychological or human factors issues relating to the backgrounds of the crew which could have contributed to the crash
  • The potential for known pitot icing issues to have contributed due to the weather affecting the aircraft (such as that which contributed to the crash of Air France flight 447 in the Atlantic in 2009)
  • The potential for known pilot automation issues to have contributed to the crash.

Over reliance on automated flight path management systems – what we know

The issue of highly automated aircraft was the focus of a study published by the Federal Aviation Administration (FAA) on 21 November 2013, which reviewed 26 accident reports worldwide from 1996 – 2009.

The report revealed that pilots sometimes rely too much on automation, particularly given the modern prevalence of automated flight path management systems, and thus they may be reluctant to intervene with such systems, in certain circumstances, as a result.  The FAA made 18 recommendations which will lead to regulatory changes in future.

The recommendations in the comprehensive (279 page report) include, in summary:

  1. Develop and implement standards and guidance for maintaining and improving knowledge and skills for manual flight operations.
  2. For the near term, emphasize and encourage improved training and flight crew procedures to improve auto flight mode awareness as part of an emphasis on flight path management. For the longer term, equipment design should emphasize reducing the number and complexity of auto flight modes from the pilot’s perspective and improve the feedback to pilots (e.g., on mode transitions) and ensure that the design of the mode logic assists with pilots’ intuitive interpretation of failures and reversions.
  3. Develop or enhance guidance for documentation, training, and procedures for information automation systems, e.g., Electronic Flight Bags (EFB), moving map displays, performance management calculations, multi-function display) or functions.
  4. In the near term, develop or enhance guidance for flight crew documentation, training and procedures for FMS use. For the longer term, research should be conducted on new interface designs and technologies that support pilot tasks, strategies and processes, as opposed to machine or technology-driven strategies.
  5. Research should be conducted and implemented on processes and methods of verification and validation (includes validation of requirements) during the design of highly integrated systems that specifically address failures and failure effects resulting from the integration.
  6. Flight crew training should be enhanced to include characteristics of the flight deck system design that are needed for operation of the aircraft (such as system relationships and interdependencies during normal and non-normal modes of operation for flight path management for existing aircraft fleets).
  7. Develop guidance for flight crew strategies and procedures to address malfunctions for which there is no specific checklist.
  8. For the near term, update guidance (e.g., Advisory Circular (AC) 120-71A) and develop recommended practices for design of standard operating procedures (SOPs) based on manufacturer procedures, continuous feedback from operational experience, and lessons learned. This guidance should be updated to reflect operational experience and research findings on a recurring basis. For the longer term, conduct research to understand and address when and why SOPs are not followed. The activities should place particular emphasis on monitoring, cross verification, and appropriate allocation of tasks between pilot flying and pilot monitoring.
  9. Operators should have a clearly stated flight path management policy as follows:

    • Highlight and stress that the responsibility for flight path management remains with the pilots at all times.
    • Focus the policy on flight path management, rather than automated systems
    • Identify appropriate opportunities for manual flight operations
    • Recognize the importance of automated systems as a tool (among other tools) to support the flight path management task, and provide policy for their operational uses
    • Distinguish between guidance and control
    • Encourage flight crews to tell Air Traffic “unable” when appropriate
    • Adapt to the operator’s needs and operations
    • Develop consistent terminology for automated systems, guidance, control, and other terms that form the foundation of the policy; and
    • Develop guidance for development of policies for managing information automation.
  10. Discourage the use of regional or country-specific terminology in favour of international harmonization. Implement harmonized phraseology for amendments to clearances and for re-clearing onto procedures with vertical profiles and speed restrictions. Implement education and familiarization outreach for air traffic personnel to better understand flight deck systems and operational issues associated with amended clearances. In operations, minimize the threats associated with runway assignment changes through a combination of better planning and understanding of the risks involved.
  11. Continue the transition to performance based navigation (PBN) operations and the drawdown of those conventional procedures with limited utility. As part of that transition, address procedure design complexity (from the perspective of operational use) and mixed equipage issues. Standardize PBN procedure design and implementation processes with inclusion of best practices and lessons learned. This includes arrivals, departures, and approaches.
  12. Ensure that human factors expertise is integrated into the aircraft design process in partnership with other disciplines with the goal of contributing to a human-centred design. To assist in this process, an accessible repository of references should be developed that identifies the core documents relevant to “recommended practices” for human-centred flight deck and equipment design. Early in the design process, designers should document their assumptions on how the equipment should be used in operation.
  13. Revise initial and recurrent pilot training, qualification requirements (as necessary) and revise guidance for the development and maintenance of improved knowledge and skills for successful flight path management.
  14. Review and revise, as necessary, guidance and oversight for initial and recurrent training and qualification for instructor/evaluator. This review should focus on the development and maintenance of skills and knowledge to enable instructors and evaluators to successfully teach and evaluate airplane flight path management, including use of automated systems.
  15. Improve the regulatory processes and guidance for aircraft certification and operational approvals, especially for new technologies and operations, to improve consideration of human performance and operational consequences in the following areas:

    • Changes to existing flight deck design through Supplemental Type Certificates (STCs) Technical Standard Orders (TSOs), or field approvals
    • Introduction of new operations or changes to operations, to include implications for training, flight crew procedures, and operational risk management
    • Actions: The new part 25 rule will help improve processes. Multiple efforts to streamline policy and procedure are ongoing.
  16. Develop standards to encourage consistency for flight crew interfaces for new technologies and operations as they are introduced into the airspace system. Standards should be developed which establish consistency of system functionality (from an airspace operations perspective) for those operations deemed necessary for current and future airspace operations.
  17. Encourage the identification, gathering, and use of appropriate data to monitor implementation of new operations, technologies, procedures, etc., based on the specified objectives for safety and effectiveness. Particular attention should be paid to human performance aspects, both positive and negative.
  18. Develop methods and recommended practices for improved data collection, operational data analysis and accident and incident investigations. The methods and recommended practices should address the following:

    • When reviewing and analysing operational, accident and incident data, or any other narrative-intensive dataset, ensure that the team has adequate expertise in the appropriate domains to understand the reports and apply appropriate judgment and ensure that the time allotted for the activity is adequate
    • Explicitly address underlying factors in the investigation, including factors such as organizational culture, regulatory policies, and others
    • Provide guidance on strengths and limitations of different data sources and different methodologies and taxonomies
    • Encourage the use of multiple, dissimilar data sources to provide better coverage of events
    • Encourage the wide sharing of safety related information and analysis results, especially lessons learned and risk mitigations.


    Notwithstanding the above, no cause can be properly included or excluded without sufficient evidence, a large proportion of which will be reliant on analysis of both the flight data and cockpit voice recorders, once they have been recovered (and presuming they have not been damaged to a degree which makes downloading their data impossible).

The Shine Lawyers Aviation Department continues to watch and wait for news of the recovery of the black boxes so that the families can start to understand how their loved ones were lost on an otherwise routine flight, and how such accidents can be prevented in future.

Written by Shine Lawyers. Last modified: January 11, 2015.

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