Asiana flight crash at San Francisco

[deagles007]

from: suninmyeyes
"
In the scenario described with V/S of 1500 fpm the autothrottle would have maintained the speed at Vref plus 5 knots once the speed had come back to that point. So at some later stage the mode must have been changed to one where the autothrottle stayed in "hold" and maintained idle thrust. FLCH or VNAV SPD would do this. Or as has been mentioned earlier if the handling pilot is resting his hands heavily on the thrust levers this death grip could prevent the thrust levers from opening up.
"

Exactly. Since they disabled the autopilot at 1600 ft according to Hersman/.NTSB, it would seem VNAV SPD was not active. Perhaps it was still in VNAV SPD and the pilots were confused? From the B777 Systems Summary [Automatic Flight] manual by Boeing:

With the autothrottle armed, the autothrottle automatically activates if:
-no autopilot or flight director active, or
-an autopilot or flight director is in VNAV XXX, FPA, ALT, V/S, or G/S
AND
-speed less than FMC calculated value for one second
-thrust below reference thrust
-airplane altitude above 100 feet RA on approach or airplane barometric altitude 400 ft above airport on takeoff
Note: During a descent in VNAV SPD, the autothrottle may activate in HOLD mode and will not support stall protection

In particular the last two items are of importance, if they were in VNAV SPD mode (autopilot on), then A/T would be put in HOLD mode.
Or if the CDU thinks it is in takeoff, then the 400 ft elevation may apply and autothrottle is not active . It seems that it was when below 500 ft when the speed dropped more and more below their programmed SPD (137). Also from the Boeing manual:

Autothrottle (A/T) Switch
Push - above 400 feet, with the autothrottle armed, activates the appropriate autothrottle mode for the selected AFDS pitch mode, or if no pitch mode, in the speed (SPD) mode.

[Knot Apilot]

Originally Posted by wiggy

Maybe..I think on current "evidence" crew performance will be at the top of the list (no surprise there) but.....

Once upon a time when I was converting to the 777 a wise trainer said to me " great aircraft, but because of the full time auto-throttle you really have to work at keeping the speed from your scan and watch out for the FLCH trap"....

Now he was aware of the FLCH trap, many people in this place knew of the FLCH trap (and can cope FCOM 2 chapter and verse) ..it was a "known, known".

Thank you. I completely agree about crew performance! I'm just trying to put a little balance in and perhaps find 'extenuating circumstances.' And maybe justifiable ones at that.

Also, you raise great points. The questions are:

• Did the crew have the benefit of a 'wise trainer'?
• Was the issue a "known-known" to them? Since, as gathered from this thread, Boeing does not address the issue in their official manuals!
• Did they receive adequate training and instruction as to the performance limits of the auto-throttles?

You had a great instructor that saw the reality of automation and thought "outside-the-box". In other words, he was a real pilot! This seems to be whats sorely lacking in modern airline training in some companies.

[King on a Wing]

Autothrottle..

Quote from FCOM :

"When the pitch mode is FLCH or TOGA, or the airplane is below 400 feet above the airport on takeoff, or below 100 feet radio altitude on approach, the autothrottle will not automatically activate."

Hmmm...

[JPJP]

The bridge is at 6nm, and if you believe in 300ft per NM, then the "correct" height at the bridge is 1800ft, not much difference. The base of class B goes to 1500 feet at 7nm and 2500ft at 10nm. The plate does say "recommended", not "required"

You're almost correct. 6NM is from the SFO VOR. The VOR is located at the crossing point of the runways. Not at the threshold. So you essentially lose another mile. Therefore 1500 feet at the bridge would equate to a 3 degree glide slope.

I know it's a small point, perhaps even nitpicking. I've seen FOs cross the bridge at the 1900 foot recommended altitude and they're one dot high on the GS (when there was a glide slope). Do you think the Korean crew would see that 1900 altitude as a 'recommend' or would they consider it a restriction ? I think they'd consider the latter.

[Back at NH]

Interesting, especially since a search on Asiana fleet aircraft types do not correlate. There are no A-320 aircraft listed in their fleet. They list A-330 and future delivery of A-380 in 2014.

Besides, how could he fly an A-320 to SFO from Korea or China? The distance is almost twice as far as the aircraft range.

[RAT 5]

No answer yet to my VNAVPTH question. As the ILS was U/S I assumed a competent crew would have programmed a VNAV approach before TOD. This then would have given vertical deviation guidance. As has been said: after a long-haul tiring flight no short slam dunkers but a stable autopilot/autothrottle approach similar to an ILS = VNAVPTH. Was this done? Was the PF flying hands ON = covering the controls? Why allow ATC to suck you into a cup-de-sac you don;t want to be? Who's in charge?

The scenarios that make me nervous: I can understand some crews getting disorientated and in bad weather slamming into a hillside; but a multi crew on a clear day slamming a perfectly good a/c into the ground when looking at the crash point strikes dread into me for the future of the profession. It is happening too often and the authorities need to wake up. So do the operators and sure as hell do the pax.

[Lonewolf_50]

To follow up with wiggy and KnotAPilot:

Even if the gent newer to this type may not have had that systems knowledge embedded in his brain deeply enough (possibly having been through a "drinking with a fire hose" conversion course), his training pilot with much more experience on type would certainly be aware of that feature, would he not? And being the training pilot, would he not be aware of how that systems feature had to be accounted for when operating on the line?

Guessing here, and following what appears to be a productive line of HF and CRM thought ...

[ricfly744]

I fly wide bodies to and from the USA. Landing off a visual at the end of a 10-11 hour flight is not easy, period. That's part of why we earn biggish salaries. US ATC do often instruct STUPID 180 to 5 requirements. I simply don't comply and slow down to approach speed by 4 miles at latest, to ensure a stable approach. English is my mother tongue, and I find the US staccato and non-standard communication difficult to understand. And they do not like to take no (negative) for an answer. Which for the Korean guys cannot have been easy. The command gradient at Asiana sounds over-steep as I have already written. And the lack of provision of a fully functioningl localizer sounds like someone at SFO and the authorities have a lot to answer for.

There has been a lot of nonsense written by people who do not fly wide bodies long-haul for a living. It is sometimes excruciatingly tiring and technically difficult. Even for the most accomplished of us. Sadly the public perception of this type of work is based on ignorance and media hype.

I am sure this accident was avoidable, whether or not the A/T was functioning. However the margins are slimmer than many of you would wish to believe.:

The above, posted a page back by a wise colleague, has to be repeated as it is very true, and I agree totally. Long haul just cannot be compared with a 6 sector short haul duty, even if the second seams more trying or demanding, it may not be the case. And, US ATC is really non standard. Other places in the word can keep a good flow and manage a lot of traffic keeping a good standard. High flow is no excuse.

[joelnthailand]

Mr. Aileron Drag wrote:

You have so hit the nail on the head. Flying manually in the sim was a breeze, because you were wide awake and living on adrenaline. But for a major airport to offer only a visual approach to a dog-tired crew is dreadful.

If you are telling me that ILS is always available, never fails, and is at every airport then, then a visual should never be done.
If you are saying that even flying the G/S you never ever transition to a visual landing then again, a visual should never be done.
Unfortunately - none of these are true. Competency in flying a visual approach is required. On top of that, not sure it's particularly more effort (unless one has completely lost to skill to fly the thing by hand). Also, no evidence that the folks at the wheel were anywhere near dog-tired.

[Aileron Drag]

joelnthailand

If you are telling me that ILS is always available, never fails, and is at every airport then, then a visual should never be done.
If you are saying that even flying the G/S you never ever transition to a visual landing then again, a visual should never be done.
Unfortunately - none of these are true. Competency in flying a visual approach is required. On top of that, not sure it's particularly more effort (unless one has completely lost to skill to fly the thing by hand). Also, no evidence that the folks at the wheel were anywhere near dog-tired.

I'm saying that a crew should use every aid available if they are at the end of a longhaul flight. Yes, if it's LHR-JFK, with a quick flight time, and you've all had a good, restful couple of days off, then sure - go for the visual. But flying from London to LA in January, in continuous turbulence, when you were all up at 4am local............man, by the time (14 hours later) you are at ToD LA, you are shot, dead, knackered.

Under those conditions, you seriously think the crew would be wise to 'practice' a manual, no F/D approach? Are you Mad?

You say there is no evidence that those people were "anywhere near dog-tired".

I can only say - you must - must be a 100 hour PPL.

[Knot Apilot]

Originally Posted by Lonewolf_50

His training pilot with much more experience on type would certainly be aware of that feature, would he not? And being the training pilot, would he not be aware of how that systems feature had to be accounted for when operating on the line?

This is what we don't know yet. And I'm sure NTSB are asking the same questions.

What we DO know, based on the NTSB brief yesterday, is this:

From NTSB Brief 7/9/13:

"Instructor Pilot stated that [...] they had set speed at 137 knots and he assumed that the auto-throttles were maintaining speed.

[...]

At 200 feet [...] he recognized that the auto-throtles were not maintaining speed and he established a GO-AROUND Attitude."

So the more experienced trainer pilot assumed the auto-throttles were handling the speed. (!)

[NamelessWonder]

Fraom Aileron Drag

MD80

Well, I'm certainly pleased that you're no customer of mine. Back seat pilots with no stomach for flying - I do not need.

Truly, you are speaking from utter ignorance. If you were as bright as you think you are you would know that humans become tired, and when they become tired they progressively require help to accomplish a complex task. Eventually, they become incapable of completing that task, but happily the law limits a pilot's hours so that the ultimate limit is not reached.
. . .

I don't know what level of 'performance' is required from you in your job if you are tired, but after 39 years of flying aeroplanes, chum, I don't need lectures from passengers.

And that's exactly the same kind of "Command Gradient" that many have been describing as a potential cause of the issues in this incident - arrogant in the extreme - "You don't have my qualifications, therefore you cannot possibly have anything valuable to add"

@Greenlights

all 3 did not check the profile, all 3 did not check the speed, all 3 did not check vertical speed, all 3 did not check high nose up attitude... what else ?

Apart from the relief F/O, who apparently called for the entire last minute "sink rate" from the jump seat. But then I guess you didn't bother reading the whole thread did you? Guess it was "below" you!

[5LY]

An inherit shortcoming of PAPI's and VASI's is their lack of information with respect to the degree of diversion. In other words, how red is it? or how white is it? are not helpful questions. You can know that you're seeing 4 reds and know that a correction is required but they give you no information about the seriousness of your diversion or in other words, how far off from the intended path am I.

Just an observation. An element of the many which might help understand the lack of a timely response.

[c53204]

I am assuming the aircraft had no malfunctions. But as a passenger, I expect a flight crew to be able to land an aircraft visually (in suitable conditions) with no aids used on the aircraft or on the ground.

Scenario - no landing aids on the ground available and no autopilot available. Can we say that a correctly rated crew should be able to land in such a scenario? If not, then as a passenger, that scares me.

[mm43]

@ BOAC

that looks remarkably like the Airbus system as described earlier - is that definitely 777?

Right out of the T7 FCOM and was alluded to in Post #721

[nippysweetie]

Anyone out there had to do a sim check after being kept awake to simulate effects of a long-haul shift? I've done car simulations where alcohol was introduced and the results have stayed with me; and they weren't what I'd expected.

[Al Symers]

I wouldn't worry too much about the crew being fatigued. They would have slept most of the way across, newspapers on the windows, screens turned down, Do Not Disturb on the cockpit door, relying on the 'bing bong' of CPDLC to wake them up. It's SOP.

[Knot Apilot]

On the over-releliance on automation...

At the NTSB brief yesterday, one of the reporters asked if the auto-throttles had a back up system. I yelled at the screen: "YES, THE PILOTS!"

There needs to be a serious re-assessment of the attitude towards automation by the airline trainers on their students; with over-reliance on and even reluctance to turn it off shown by pilots involved in major incidents.

Some pilots being lulled into a flase sense of security, thinking the automation is a safety-net that will catch them if they make a mistake, or that they can trust it to handle things while they divert their attention elsewhere.

AUTOMATION IS A FALSE SAFETY-NET!

YOU, THE PILOT, IS THE SAFETY NET!

You are that last slice of the swiss cheese!

IMO, pilots should look at the automation on their plane with distrust.; as if it were HAL, the computer from the movie "2001". It is actively trying to kill you. And if you don't monitor it closely enough, it WILL kill you!

[Cows getting bigger]

So,

Slam dunk into visual which is somewhat unusual and challenging to some operators?
Fatigue and under-arousal?
Reduction in instrument aids?
Cockpit gradient, culture and wider CRM?
A rather mischievous A/T "option"?

Seems like enough holes to me.

[Lonewolf_50]

Knot, while you or I may agree on that, the competing message to pilots from some (perhaps all?) management is that the auto features fly more fuel efficiently, and therefore in a very competitive business environment those features are to be used to the max extent in order to stay in business ... or something to that effect.

Some of the folks here who have alluded to FOQA being used as a hammer by management are on to something, methinks ...