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Air Inter Flight 148 Accident, 21 Years Ago  
User currently offline802flyguy From United States of America, joined May 2012, 187 posts, RR: 0
Posted (1 year 7 months 1 week 4 days 4 hours ago) and read 8834 times:

It has been 21 years since the Air Inter A-320 crash near Strasbourg (SXB). I did know that the primary cause was the flight crew mis-entering information into the autopilot (descent rate of 3300ft/min vs 3.3 degree descent angle); what I did not realize until reading the summary at ASN was that the aircraft did not have GWPS.

http://aviation-safety.net/database/record.php?id=19920120-0

According to the Wikipedia article
http://en.wikipedia.org/wiki/Air_Inter_Flight_148
Air Inter chose not to install GPWS because of too many spurious warnings. I find it rather astonishing that the French aviation authorities did not mandate GPWS on French registered airliners (false alarms or not). Does anyone habe more background on this?

15 replies: All unread, jump to last
 
User currently offlinetribird1011 From Canada, joined Mar 2005, 208 posts, RR: 0
Reply 1, posted (1 year 7 months 1 week 4 days 2 hours ago) and read 8557 times:

The very simplistic answer to that is that all regulations (and/or) aircraft equipment requirements are written in blood - meaning a rule exists because someone died because that rule did not exist. I'm not sure if this crash was the one that made GPWS mandatory or if there was one after this, but let's say this was it, and it didn't happen, GPWS may still not have been mandatory today (although I'm sure another one would have made it mandatory).

Picture this... if we lived in a perfect world where we could guarantee (without GPWS) no CFIT accidents, I can say that although GPWS would be availabe, very few (if any) airlines would actually install it.

The same can be said about many other a/c requirements. i.e TCAS being another good example of that!!


User currently offline802flyguy From United States of America, joined May 2012, 187 posts, RR: 0
Reply 2, posted (1 year 7 months 1 week 4 days 1 hour ago) and read 8428 times:

GPWS became mandatory in the US following the TWA flight 514 crash in 1974, I thought that other nations had followed suit.

http://www.aopa.org/asf/asfarticles/sp9806.html

( It has been a long time since I read it, but F Lee Bailey's "Cleared for the Approach" is a great book about that accident and the aftermath)


Then again, cockpit voice recorders were not required for UK registered aircraft until the BEA Trident accident at Staines, long after they became FAA mandated.

The "Tombstone Effect" again.


User currently offlineAlsatian From France, joined May 2005, 422 posts, RR: 0
Reply 3, posted (1 year 7 months 1 week 4 days ago) and read 8296 times:

Quoting 802flyguy (Thread starter):
It has been 21 years since the Air Inter A-320 crash near Strasbourg

Each year during the two last decades, Air France CEOs were present in the crash site to be part of the ceremony. This will not be the case anymore on as the last official commemoration took place in 2012.



Ok I am French but I am not on strike
User currently offlineairmagnac From Germany, joined Apr 2012, 307 posts, RR: 44
Reply 4, posted (1 year 7 months 1 week 4 days ago) and read 8276 times:

As said above the FAA had made GPWS mandatory for large airliners in the mid-seventies. And IIRC ICAO recommended that GPWS should be mandatory some time around 1978. This is for a system that appeared in the late sixties.
French DGAC did not follow the ICAO recommendation because the system at that time produced many spurious warnings. This was especially true for Air Inter operations, which involved very short hops with "agressive" high speed dashes at low altitudes, partly tailored around the performances of the Dassault Mercure.
As too many false warnings can lead to the system being completly ignored, or worse complicate already risky situations, this decision can be understood. However, new developments in the following decade reduced the number of false warnings, but the facts that Air Inter did not have GPWS and that French rules did not make it mandatory were almost forgotten by regulators. Bureaucratic manoeuvering between various DGAC departments did not help either.
Eventually, I think work started around 1990-1991 on a rule to align France with the rest of the world, with a target date for 1993. But the Mont St Odile crash happened in 1992, and the rule was passed a month later.

But keep this all in context. Its absence in a new airliner cockpit in 1992 is difficult to justify, but GPWS did not cause the plane to end up going down at 3300ft/min over bumpy terrain, which is the main aspect of this accident. That is what has to be prevented in the first place.
Also, the area was known for generating false warnings, and this was written on the Air France maps used by the crew. So it is not certain that the already confused crew would have reacted in time, if at all.

Quoting tribird1011 (Reply 1):
The very simplistic answer to that is that all regulations (and/or) aircraft equipment requirements are written in blood - meaning a rule exists because someone died because that rule did not exist

Any accident must not be repeated, so fatal accidents often results in new or modified regulations. But most regulations are built directly from technological and operational expertise and analysis of ptoentail failure modes, and/or analysis of actual non-catastrophic failures (see 787 batteries....). So some regulations are written in blood, but far from all. Butyou did warn it was a very simplistic answer  .



Quoting tribird1011 (Reply 1):
if it didn't happen, GPWS may still not have been mandatory today

As said above, FAA made a rule in the seventies ; ICAO recommended mandatory installation of GPWS as early as 1978, and most authorities followed. IIRC by 1992, around 95% of the world fleet was equipped.


Quoting tribird1011 (Reply 1):
I'm not sure if this crash was the one that made GPWS mandatory

Yes for France, no in general because it was already the case.



One "oh shit" can erase a thousand "attaboys".
User currently offlinelonghauler From Canada, joined Mar 2004, 4930 posts, RR: 43
Reply 5, posted (1 year 7 months 1 week 3 days 23 hours ago) and read 8133 times:

Quoting airmagnac (Reply 4):
This was especially true for Air Inter operations, which involved very short hops with "aggressive" high speed dashes at low altitudes, partly tailored around the performances of the Dassault Mercure.

I know what you mean, however you also have to understand though the GPWS warnings were doing what they should have. If they aircraft is doing "A high speed dash at low altitudes", then yes the pilots should be warned of a vulnerable condition. Is it a nuisance? Only if the pilot is totally aware why the warning sounded.

It is like our "pilot notes" for YYT and YYJ. Two airports to which we fly that have high terrain, or quickly rising terrain. It said in our notes that GPWS warnings are not uncommon. Then it says in BOLD faced type "These warnings are NOT false!"



Never gonna grow up, never gonna slow down .... Barefoot Blue Jean Night
User currently offlineairmagnac From Germany, joined Apr 2012, 307 posts, RR: 44
Reply 6, posted (1 year 7 months 1 week 3 days 22 hours ago) and read 7972 times:

Quoting longhauler (Reply 5):

Quite right ! Guess I should have been more precise in my choice of words, especially as I was discussing that in the 787 threads      


Going back to the source, the BEA report (sorry, I only found it in french) :
http://www.bea-fr.org/docspa/1992/f-ed920120/htm/f-ed920120.htm

In §118.222 the authors use the expressions "non justified warnings" (alarmes non justifiées) or "warnings not representative of dangerous situations" (alarmes non représentatives de situations dangereuses). And indeed, not "false alarms".


I also came upon this article while looking up the report :
http://legacy.icao.int/anb/humanfact...Investigating_probed_root_1994.pdf

It's written by Jean Pariès, who led the investigation, and in addition to items related to the accident, it contains some more general thoughts about accident investigations. Quite an interesting read !



One "oh shit" can erase a thousand "attaboys".
User currently offlinelonghauler From Canada, joined Mar 2004, 4930 posts, RR: 43
Reply 7, posted (1 year 7 months 1 week 3 days 20 hours ago) and read 7757 times:

Quoting airmagnac (Reply 6):
Quite an interesting read !

Thank you, that is very interesting.

I have always found this accident fascinating, as I remember the time well. With three A320 crashes so near to the introduction to service, a lot of the "old timers" were dead set against it. As a young guy (then), I was thrilled with this new level of automation and found myself defending the Airbus cockpit interface.



Never gonna grow up, never gonna slow down .... Barefoot Blue Jean Night
User currently offlineFI642 From Monaco, joined Mar 2005, 1079 posts, RR: 2
Reply 8, posted (1 year 7 months 1 week 3 days 20 hours ago) and read 7739 times:

Two of my students did reports on this accident. It was shocking there was no GWPS.
Like the F/O stick shaker on the the DC-10 (which initially was an option)- it wasn't
required, so not specified in the aircraft order.



737MAX, Cool Planes for the Worlds Coolest Airline.
User currently offlinecornutt From United States of America, joined Jan 2013, 338 posts, RR: 1
Reply 9, posted (1 year 7 months 1 week 3 days 19 hours ago) and read 7651 times:

Most of the old, pre-GPS ground proximity warning systems weren't that helpful. The ones that just worked off of the radar altimeter often didn't give warning until it was too late to maneuver. There were systems that used forward-looking radar, but they had a lot of problems with false alarms. False alarms when flying approaches led to a lot of crews disabling or just ignoring alarms during approach, which unfortunately is when you most need an effective GPWS system. GPS combined with good terrain data is what made GPWS a useful system.

User currently offlinelonghauler From Canada, joined Mar 2004, 4930 posts, RR: 43
Reply 10, posted (1 year 7 months 1 week 3 days 19 hours ago) and read 7640 times:

Quoting FI642 (Reply 8):
Like the F/O stick shaker on the the DC-10 (which initially was an option)- it wasn't
required, so not specified in the aircraft order.

Whether the stick shaker is mounted on the F/O side or the Captain side, it will be heard and felt by both pilots. The big issue was that there was only one electrical source, not one stick shaker. As a result of this accident, two stick shakers are required, so that there will be two possible electrical sources. (With only one needed).

[Edited 2013-01-20 15:11:08]


Never gonna grow up, never gonna slow down .... Barefoot Blue Jean Night
User currently offlineViscount724 From Switzerland, joined Oct 2006, 25170 posts, RR: 22
Reply 11, posted (1 year 7 months 1 week 3 days 19 hours ago) and read 7590 times:

Quoting longhauler (Reply 5):
t is like our "pilot notes" for YYT and YYJ. Two airports to which we fly that have high terrain, or quickly rising terrain. It said in our notes that GPWS warnings are not uncommon. Then it says in BOLD faced type "These warnings are NOT false!"

A few related Transport Canada occurrence reports near YYJ, all within the past month:

A Jazz DHC-8-102 (operating as JZA8058) on an IFR flight from Victoria (CYYJ) to Vancouver (CYVR) at 3,500 feet in an area with MVA of 3,500 feet, encountered GPWS warniing, climbed, and was cleared to 4,000 feet.

When level at 3,500 feet in a 3,500 MVA, a Jazz DHC-8-102 (operating as JZA8070) on an IFR flight from Victoria (CYYJ) to Vancouver (CYVR) reported a GPWS warning. JZA8070 was instructed to climb to 5,000 feet.

A Pacific Coastal Airlines Saab 340A operating PCO133, IFR from Vancouver (CYVR) to Victoria (CYYJ), cleared RNAV GNSS 09 on approach to CYYJ, received a GPWS warning while executing the approach. Pilot initiated a climb and then continued the approach. While on the approach the pilot advised the CYYJ Tower the aircraft's GPS had failed and they were executing a missed approach.


User currently offlinelonghauler From Canada, joined Mar 2004, 4930 posts, RR: 43
Reply 12, posted (1 year 7 months 1 week 3 days 19 hours ago) and read 7548 times:

Quoting Viscount724 (Reply 11):
A few related Transport Canada occurrence reports near YYJ, all within the past month:

A lot of the issues around YYJ come from the STAR. If you follow the STAR, at one point it has you pointed directly at the rocks. The GPWS will alert if you are flying quickly. If you slow to below 200 kts, then it does not active the GPWS. So ... it is suggested that we fly less than 200 kts for the last 20 track miles or so ... much to the irritation of ATC!

So I find it interesting that the two Jazz flights were on departure.

And this:

Quoting Viscount724 (Reply 11):
While on the approach the pilot advised the CYYJ Tower the aircraft's GPS had failed and they were executing a missed approach.

Is just scary! I am glad they were disciplined enough to do a go-around when they could not determine if the GPWS was in error or not. On an approach where GPWS warnings are common, this is a tough thing to do! Good on them.



Never gonna grow up, never gonna slow down .... Barefoot Blue Jean Night
User currently offlineBOAC911 From United States of America, joined Sep 2004, 452 posts, RR: 0
Reply 13, posted (1 year 7 months 1 week 3 days 15 hours ago) and read 6780 times:

Reminds of a string of accidents that the A320 went through in the early 1990s. The Air Inter accident was one, but also the Indian Airlines A320 crash, and then the Lufthansa A320 in Warsaw. It damaged Airbus' reputation, and threw into doubt the concept of the "glass cockpit" as it was called then.

User currently offlinemaxpower1954 From United States of America, joined Sep 2008, 1090 posts, RR: 7
Reply 14, posted (1 year 7 months 1 week 3 days 4 hours ago) and read 3288 times:

Quoting BOAC911 (Reply 13):
Reminds of a string of accidents that the A320 went through in the early 1990s. The Air Inter accident was one, but also the Indian Airlines A320 crash, and then the Lufthansa A320 in Warsaw. It damaged Airbus' reputation, and threw into doubt the concept of the "glass cockpit" as it was called then.

It was actually the concept of "fly-by-wire", since glass cockpit airplanes like the 757/767 and 747-400 had been flying quite sometime by then.


User currently offlineedina From United Kingdom, joined Jul 2003, 743 posts, RR: 9
Reply 15, posted (1 year 7 months 1 week 3 days 3 hours ago) and read 3074 times:

Air Inter did not fit GPWS to it's aircraft before the Mont St Odile accident for the reasons mentioned earlier, preferring to invest in full autoland capability, including Head Up Displays in the left hand seat (these were also fitted to both left & right hand seats on the Mercure). Punctuality & reliability was a big part of IT's product with Autoland or "Atterissage Tous Temps" frequently featured in advertising.

With reference to the pilots experience....the Captain has just converted from the Caravelle 12 (known as the Super 12 in IT service) and the co pilot had recently come from the Mercure. One had 250 hours on type (the Captain IIRC) and the other had round about 500 hours on the A320.



Worked on - Caravelle Mercure A300 A320 F27 SD3-60 BAe146 747-100/200/400 DC10-30 767 777 737-400 757 A319 A321
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