An investigation into the crash of an AirAsia flight last year has found pilot error in breaking protocol by pulling circuit-breakers on part of the aircraft’s control system — which turned off the autopilot — was partly to blame for the crash, reports the Australian Broadcasting Corporation.

The investigation summarized its findings as follows:

  • Both crew error and a rudder system problem had contributed to the crash
  • The same rudder system problem occurred at least 23 times in the 12 months prior to the crash


The investigation also found there had a maintenance problem with the aircraft that had been left unresolved by AirAsia for 12 months.

A more detailed hour long report on the state of Indonesian civil aviation and that of AirAsia Indonesia and by implication AirAsia itself can be viewed on the ABC (Australia’s) Foreign Correspondent programme.

The programme which aired on 3 May 2016 in Australia is available for download online from 4 May 2016 onwards. The programme offers compelling and compulsory viewing for those who fly or intend to fly AirAsia or any of Indonesia’s many airlines in future.


For whatever it is worth, the Indonesian arm of AirAsia claims it has now upgraded its systems to prevent such occurrences (as the events that led to the tragedy of AirAsia QZ8501) in the future.

Tony Fernandez the Airline’s CEO issued an apology to relatives of the victims of Air Asia QZ8501 a few days after the crash. We called his actions a mistake. The outcomes of the Indonesian National Transportation Safety Commission findings into the cause of the crash likely vindicates our position in this respect.


A fault with the rudder control system and poor attempts to repair the fault were major factors contributing to the crash according to Indonesian investigators of the National Transportation Safety Commission.

The Indonesian National Transportation Safety Commission claims that although the rudder problem was  a major contributing factor, it was the poor maintenance of the aircraft that created the problem that caused confusion in the cockpit and corrective actions by the pilot and co-pilot that led to the crash.


Repeated problems with the system led to the pilots disengaging the autopilot in stormy weather in a bid to fix the situation, and then losing control of the Airbus A320-200, Indonesia’s official National Transportation Safety Committee (KNKT) said”.

On three occasions the report found the pilot and co-pilot reacted according to the guidelines to the warning alarm”.

Investigators also  say that when the crew received the fourth warning, they (the pilots) pulled circuit-breakers on part of the aircraft’s control system in a bid to reset the system to stop the alarm sounding”. This resulted in them turning off the autopilot, causing the plane then to roll out of control.

The report also indicates that the flight data recorders did not implicate the weather in the crash. Critically the report says the AirAsia plane the problem with its rudder system was a recurring problem occurring 23 times in the 12 months prior to the crash.

Cold comfort for the passengers of the ill fated flight, their friends and family and more important for the travelling public of a low cost, now low safety airline.


A list of the most dangerous airlines in the world has been released and while AirAsia Indonesia is included, Malaysia Airlines is not.

The list of the most dangerous airlines of the world was published in the Daily Mail (Australia edition) recently. The following is extracted from the Daily Mail Australia 4 May 2016.

“The Malaysian carrier MAS scored five out of a possible seven stars for its safety record, as opposed to five airlines which just manage one star.

Three AirAsia subsidiaries – in Indonesia, Malaysia and the Philippines – were included on the list, scoring just two, three and three stars respectively.

Indonesia’s AirAsia Flight QZ8501 crashed into the Java Sea on December 28, killing all 162 people on board.” 


  1. IT.Scheiss says:

    This finding of gross negligence on Air Asia Indonesia’s part, which resulted in many deaths, is something which should shut all those adoring Tony Fernandez and Air Asia fanboys and fangirls up, and also fanboys and fangirls of other budget airline operators around the world, some of which charge for using the aircraft toilet and perhaps even for every sheet of toilet paper used.

    Bloomberg reported:-

    “A crack in the soldering of the rudder system caused the plane to exit autopilot, then start rolling sideways and upward, according to a report released on Tuesday by Indonesia’s National Transportation Safety Committee.”

    I am an electronics engineer who installed and maintained minicomputers back in the 1980s and this crack in a soldered joint is called a “dry joint” in our jargon.

    I recall many sleepless nights trying to fix a problem in the electronic circuitry of one of those filing-cabinet sized removal hard disk drives. Worse still, the occurrence of this problem was intermittent and a nightmare for maintenance engineers, since intermittent problems can cause the minicomputer to hang once every few hours which is very difficult for maintenance engineers to identify.

    Thankfully, intermittent problems tend to occur increasingly more frequently, until it finally fails altogether and becomes a hard fault, which is much easier to identify and fix.

    I finally traced the problem on the hard disk drive to a dry joint between one of the leads of a connector on backplane into which the hard disk’s control circuit boards were slotted. Once the particular defective joint is identified, then it is a simple matter to remove the old solder and properly resolder it afresh and the hard disk was working fine again.

    Solder is an alloy of lead and tin and it is melted at the point of contact to form a close and secure electrical connection between the metal leads of electronic components, chips and connectors to the metal tracks running between these components, chips and connectors on the circuit board of which they are all part of.

    Now a dry joint can result from a poor soldering job during production in the factory or subsequently by a technician in a workshop during repair. Dry joints can also develop in originally sound solder joints due to the effects of vibration, thermal expansion and contraction, the effects of corrosion over time or from all of these factors together.

    Whilst the circuitry on that hard disk drive was subjected to much vibrational stress and strain, electronic circuity, especially on the exposed extremities of aircraft frequently experience mechanical as well as rather severe thermal stresses and strains as they they go through several extreme variations in temperature each day, between ground-level temperatures especially at airports in hot desert and tropical regions and sub-zero temperatures when in flight.

    Indonesia’s National Transportation Safety Committee’s cited “… the faulty component, the Rudder Travel Limiter, had suffered 23 problems in the past 12 months, citing maintenance records”, according to Channel News Asia.

    An according to the US federal Aviation Authority, the Rudder Travel Limiter on an Airbus A320 is located in its tail fin. Just scroll down to Figure 1 of this PDF document.

    That being so, the tail fin and any electronic equipment in it will experience both mechanical and rather extreme thermal stresses and strains.

    According to Bloomberg, “the interval of occurrence becoming shorter in the last three months, according to the report”.

    Yes it was an intermittent problem but if maintenance records already show that it was a problem with this Rudder Travel Limiter, then it should have been immediately replaced and not left in place and deteriorate further until its problems caused pilot confusion which resulted in the untimely deaths of 162 unfortunate souls.

    Heck! Whenever I was able to identify a problem, intermittent or otherwise, to a particular circuit board, I would just swap it with a working spare and let the computer department carry on with their work.

    If that minicomputer I serviced went down for a day, accounts and payroll processing would have been delayed but nobody died. However, when a plane goes down, quite often, everyone on board dies, so the maintenance and safety of aircraft and its passengers must be taken very much more seriously than problems on a 1970s era office minicomputer.


    • grkumar says:

      You are quite right. However I find cold comfort in the Indonesian authorities assurances of ‘remedial action to prevent further occurrences of this sort of thing in future’. The Indonesian authorities are very much like the Indian authorities of a decade or two ago. Incompetent and corrupted at every level.

      As for the other low budget carriers I think Scoot and Tiger will be more reliable due to their Singapore Airlines links.

      Tony Fernandez grew his airline in a Mahathir era business environment where all things were possible without much effort if you had the right connections but not where responsibility and diligence is required.

      Liked by 1 person

      • IT.Scheiss says:

        Yes Kumar, cold comfort for the wives, children, siblings and relatives of those who perished.

        And yes, agreed that the “remedial action” promised by the Indonesian authorities most probably is just hot air.

        Also, the awareness, discipline and duty of care required to have a strong maintenance culture is not only lacking in Indonesia but also here in Malaysia and many other parts of South East Asia besides Singapore.

        Truly stringent maintenance practices and culture are found in the most developed and matured industrial societies such as Germany, Sweden, Switzerland and Japan, followed by South Korea, other western European countries, North America, Australia, New Zealand and in some industry sectors in Taiwan.

        Besides that, such maintenance culture does not appear to be so strong in Southern European countries and in Eastern Europe, where the manufacturing industry is is not as mature.

        I believe that it will take a while to imbue people emerging from an agrarian culture with the ethics, discipline and duty of care required for a strong maintenance culture.

        Also, as you rightly pointed out, corruption plays a big part in the compromise on safety for profits.

        And yes, unlike the myth held by Tony Fernandez and Air Asia fanboys and fangirls, and reinforced by a fawning media that Air Asia managed to turn around a loss making airline and make it profitable without government assistance or favour is nonsense, when Air Asia did receive the support and generous concessions of some quarters within the government of the day.

        Sure, MAS lost two planes in 2014, MH370 which was clearly flown off course deliberately by persons yet unknown, either onboard or remotely, and MH17 which was shot down in a war zone but in either case, no negligence on the part of the airline is believed to be involved.

        I also tend to suspect sabotage of MH370 by parties who were not onboard the flight.

        I recall reading about a case in October 2003 where wires in the avionics bay of an MAS Airbus were found cut, fortunately rendering the aircraft unable to of take off.

        The Sydney Morning Herald still has its story on this case online.

        “Malaysian police have launched an investigation into a severe security breach on a Perth-bound Malaysia Airlines plane that led to wires being cut in the cockpit in an apparent sabotage attempt.”

        “An airline safety expert suggested the nature of the damage, which was indicative of vandalism and rendered the airliner incapable of take-off, indicated a cleaner or other unskilled worker might have been involved, rather a knowledgeable airline employee.”

        “Engineers conducting standard pre-flight diagnostic checks at Kuala Lumpur International Airport late on Thursday evening discovered the wiring aboard the Airbus A330 which was to operate MH127 departing at 9.30pm for Kuching and Perth.”

        “According to insiders at the airline, seven wire bundles were cut in the avionics bay, which houses the majority of the aircraft’s computer and flight control systems, and is accessible from the flight deck.”

        The fact that MH370 went astray less than 24 hours after the Court of Appeal imposed a guilty verdict on Anwar made me suspect that sabotage similar to the case of MH127 by disgruntled parties was involved in the case of MH370, perhaps with greater sophistication involved.

        It’s also rather coincidental that an international computer security conference had taken place in Kuala Lumpur around the time MH370 went astray.

        The very fact that MH370 mysteriously and systematically diverted from its original flight path and went down in one of the deepest parts of the Indian Ocean strongly suggests a well thought out intent for it to be very hard to find.

        I hope that the remains of MH370 will eventually be found and the mystery of its disappearance solved once and for all and the culprits brought to book.


  2. jitraguy says:

    I remember an African origin airline that also crashed, enroute to Jeddah orr thereabouts, some time ago. same mentality I supposed.


    • IT.Scheiss says:

      I believe you are referring to 11 July 1991 crash of Nigerian Airways 2120 from Jeddah to Sokoto, Nigeria, an aged DC8 aircraft on lease from financially troubled Nationair of Canada which went bankrupt in May 1993.

      “Prior to departure, the lead mechanic had noticed that the “#2 and #4 tyre pressures were below the minimum for flight dispatch” and attempted to inflate them, but no nitrogen gas was readily available, and the project manager, unwilling to accept a delay, disregarded the problem and readied the aircraft for dispatch. As the aircraft was taxiing, the transfer of the load from the under-inflated No. 2 tire to the No. 1 tire on the same portside axle resulted “in overdeflection, over-heating and structural weakening of the No. 1 tyre.” “The No. 1 tyre failed very early on the take-off roll”, followed almost immediately by the No. 2. The latter stopped rotating “for reasons not established”, and the subsequent friction of the wheel assembly with the runway generated sufficient heat to start a self-sustaining fire. The crew realised there was a problem, but not the nature or seriousness of it. The aircraft was not equipped with fire or heat sensors in the wheel assembly. The first officer was recorded remarking, “We gotta flat tire, you figure?” According to Canadian Transportation Safety Board members interviewed for an episode of Mayday about the accident, standard procedures regarding tire failure during the takeoff roll on the DC-8 did not then (and still did not as of the episode’s season 11 airing) include rejecting takeoff for tire or wheel failures, so the captain proceeded with the takeoff.”

      “When the landing gear was retracted, “burning rubber was brought into close proximity with hydraulic and electrical system components”, causing the failure of both hydraulic and pressurisation systems that led to structural damage and loss of control of the aircraft. The Transportation Safety Board later concluded, “had the crew left the landing gear extended, the accident might have been averted”. Fuel, “probably introduced as a result of ‘burn through’ of the centre fuel tank”, intensified the fire, which eventually consumed the cabin floor. People began falling out of the aircraft when their seat harnesses burned through. “Despite the considerable destruction to the airframe, the aircraft appeared to have been controllable until just before the crash.”


      “The aircrash, combined with Nationair’s poor reputation for on-time service and mechanical problems, led to serious problems with public image and reliability among tour operators. These difficulties were compounded when Nationair locked out its unionised flight attendants and proceeded to replace them with strikebreakers on 19 November 1991. The lock-out lasted 15 months and by the time it ended in early 1993, Nationair found itself in severe financial trouble. At the time, Nationair owed the Canadian government millions of dollars in unpaid landing fees. Creditors began seizing aircraft and demanded cash up front for services. The company was declared bankrupt in May 1993, owing CDN$75 million.”

      This reveals the danger of privately owned airlines trying to get by on the cheap, even in a developed, first world country such as Canada and this was before the explosion of budget airlines.

      Indonesia’s Lion Air also has a poor record of safety.

      “Pilot errors, inadequate crew training and lapses in emergency response procedures led to a plane operated by fast-growing budget carrier Lion Air crashing into the sea off Bali in April 2013, according to a final report into the incident.”

      Just yesterday (May 3), a Lion Air Airbus and a Lion Air Boeing clipped wings at the airport.

      “JAKARTA: Two Indonesian passenger planes clipped wings as they were about to take off from Jakarta’s main airport, an airline said Tuesday (May 3), the latest accident in the country’s beleaguered aviation sector.”

      Then a month earlier:-

      “A plane operated by Batik Air – part of the Lion Group along with Lion Air – was taking off from Jakarta’s Halim Perdanakusuma airport when it clipped a TransNusa plane being towed across the runway.”

      According to, the top 10 safest budget airlines as of January 2016 are in alphabetical order, “Aer Lingus, Flybe, HK Express, Jetblue, Jetstar Australia, Thomas Cook, TUI Fly, Virgin America, Volaris and Westjet”.

      The worst – “The 10 airlines with just one star hail from Nepal, Indonesia, or Surinam.”


      “Low-cost carriers get their savings from efficiency and less money spent on customer service rather than by skimping on safety issues,” said Max Leitschuh, a transportation analyst for iJET International. “In places like North America and Europe, where there’s a well-regulated airline industry, they are not going to let any airlines get away with sub-standard safety practices. The major budget carriers have very good safety records. In fact, many of them have never had a crash before.”

      “Asia, where regulatory standards vary widely and low-cost carriers are booming, is not as clear cut. Budget carrier AirAsia, for example, suffered a major crash in January but had a spotless record until then. But Indonesia’s Lion Air — with eight incidents since 2002 — has an atrocious safety rating and has actually been banned by the EU.”

      “Asia is much more of a mixed bag, both in terms of the airlines and the regulatory authorities,” said Leitschuh. Certain authorities like Singapore’s are excellent. Malaysia’s regulatory agency is mediocre, while Indonesia has major problems, he said. “But just because there’s poor regulation still doesn’t mean the carrier is unsafe — it’s just on the carrier to regulate itself.”

      It looks like the regulators in Indonesia are very slack, including due to corruption and Malaysia’s regulators need to tighten up further.


      • grkumar says:

        Shiess your observations and research are very very appropriate and timely. As for your comments about privately owned airlines, I think they are particularly unsafe and dangerous when they are based in a place like Indonesia where rules and regulations are more of a hurdle to private enterprise than a standard for them to follow for common good.
        Many now revert to the old view that health care, public utilities, public transport and infrastructure are really not for the private sector. These are necessities and for everyone to be able to afford and to benefit from. Because they are capital intensive they can only be properly run by the state perhaps with a little help from the private sector (British Airways and Qantas).


    • grkumar says:

      Thank you Jitraguy

      it was a Nigerian operated aging DC 8 I think that belonged to a Canadian company. The aircraft did not meet any country’s flight safety or airworthy standards so they leased it to the Nigerians.

      The aircraft caught fire shortly after leaving Jeddah. Its tyres could not be inflated to a safe level due to a lack of nitrogen at Jeddah. And when taxing along the runway one of the aircraft’s tyres blew, the friction with the ground heated the metal around it, ignited the hot rubber and when the undercarriage was pulled in, the fire grew to spread to gas cylinders in the belly of the plane, burned the electrical and hydraulic cables disabling the aircraft. When the heat became intense it burned through the seat harnesses and bodies began to fall out of the plane.

      It was a horrible example of the extent of negligence for the sake of a buck. Lets hope that Tony Fernandez takes heed of his airlines present status of one of the world’s most unsafe airlines as reported by the Daily Mail.

      Thankfully for all its perceived faults, Malaysian Airlines continues to be regarded as a very safe airline.


  3. IT.Scheiss says:


    Since we’ve run out of “Reply” buttons I have to reply here.

    You wrote.
    “Shiess your observations and research are very very appropriate and timely. ……”

    Thanks for your compliments, GR Kumar.

    When I was a teenager I was rather fascinated with aircraft.

    I have been following Wee Choo Keong’s blog posts criticising Air Asia on several issues, including complaints over misleading advertisements, the proposed merger with MAS, the AIr Asia Indonesia crash and other safety issues and so forth and my prior layman’s general knowledge of airliners and fascination with them kind of gets me more interested in airliner-related issues.

    And, as a student in the UK in the 1970s, when Britain still was still very much a social democratic welfare state, I am and remain today a committed leftist, totally opposed to capitalism, especially of the unfettered, neo-liberal, globalist kind with open borders to trade and flow of capital (but in most cases, not workers) which became prominent again with Margaret Thatcher in Britain and Ronald Reagan in the US, and which has become the norm worldwide and I am also strongly opposed to privatisation, especially of key industries, public infrastructure, facilities and services such as roads, railways, national airlines, national shipping lines, public healthcare, public education, public housing and so forth.

    The common complaint in Malaysia is that government services such as government hospitals are affordable but involve long waiting times, service is slow and so forth, which is true, so they turn to neo-liberal “solutions” such as profit-oriented private hospitals – when the solution shuold be for the government to streamline and improve the quality, efficiency and standards of service in government hospitals.

    It was Mahathir who introduced privatisation to Malaysia in 1980, though I feel that state entities such as Malaysian Airlines, Malayan Railways, Malaysian International Shipping Corporation, local authorities’ maintenance crew, etc all worked better when they were state entities.

    When they first began running in the late 1990s and early 2000s, the STAR and Putra LRT (light rail transit) and KL Monorail lines were built and operated by private consortia but lost money, so the government had buy them up and put them and a bus line under one state-owned transport company Prasarana and now the lines have been extended further to serve areas such as Puchong and Subang Jaya in Klang Valley.

    And, I find the quality of the rolling stock, cleanliness, punctuality and quality of customer service on Prasarana trains to be superior to that on KTM Komuter lines, which shows that the quality of service provided by a state owned entity can be good or even excellent and what it requires is an enlightened, professional, no-nonsense management and a happy, motivated workforce.

    For example, Jalan Utara, Timur, Sultan and Barat in Petaling Jaya were turned into a loop with one-way counter-clockwise traffic flow in October 2014 and until today, the civil work to renovate and re-orientate the road dividers, entry and exit lanes and so forth is still ongoing, I understand because the Petaling Jaya City Council has been having a series of issues with the private contractor engaged to implement these renovations.

    As far as I can remember from my younger days, if these civil works were undertaken by the MBPJ’s own works teams or by the Public Works Department (JKR), these renovations would have been completed very much sooner and with better quality.

    And, the MBPJ comes under the Selangor State Government which has been in Pakatan hands for seven years now and I see no difference in Petaling Jaya between when Selangor was under the BN and under Pakatan today.

    It’s not that I support the BN but it has become pretty apparent to me now that the Pakatan has not done any better to solve the problem of potholes, acutely uneven roads, the ongoing high-rise building craze, etc in Petaling Jaya where I have been living since 1971.

    To be fair though, much traffic disruption on Petaling Jaya roads and beyond has been caused by digging work to lay an underground sewerage reticulation network which is a Federal Government project.

    I wrote about the effects of the construction in my neighbourhood in July 2014.

    Also, I have posted a recent blog on the rape of greenery in Selangor on my blog Selangor Scheiss. (I later learned that the clearing on the hilltop is for the construction of a highway, whilst condos are to be built on the land in the other picture.)


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