NTSB update on Asiana 214

[DaveReidUK]

October 25, 2013

WASHINGTON - The National Transportation Safety Board is convening a 2-day investigative hearing to discuss the ongoing investigation into the crash of Asiana Airlines Flight 214 and to gather additional factual information. The hearing, which will be held December 10–11, 2013, at the NTSB’s Board Room and Conference Center in Washington, DC, will focus on pilot awareness in highly automated aircraft, emergency response, and cabin safety. Parties participating in the investigative hearing will be announced at a later time.

Below is an update of the ongoing investigation. This is a factual update only and no interviews are being conducted.

• The investigator-in-charge and investigators from the Operations and Human Performance Group traveled to Korea and met with officials from Asiana Airlines and the KARAIB. While in Korea, investigators conducted numerous interviews with Asiana management and training personnel, observed Asiana procedures in a simulator and an exemplar aircraft, and gathered further documentation on airline training and policies.

• NTSB investigators from the Maintenance Group also traveled to Korea and reviewed the records for the accident airplane, including the maintenance that had been performed on the evacuation slides.

• The Survival Factors Group conducted an examination of the evacuation slide/raft systems at the manufacturer’s facility in New Jersey and is planning future testing of the systems. The group also re-examined the wreckage to gather additional information about the fire propagation and structural damage. Following that examination, the wreckage was sectioned and moved to a secure storage facility.

• Investigators and party members met in Seattle to examine the recorded flight data and compare it to the expected airplane systems operation. The Systems Group is currently developing a test plan for the mode control panel and the Vehicle Performance Group is finalizing the event simulation match.

[WHBM]

Well none of those four bullet points listed above, unfortunately, lists investigating if gung-ho fire truck drivers ran over and killed survivors from the accident, so I presume that's been airbrushed out.

[underfire]

observed Asiana procedures in a simulator and an exemplar aircraft, exemplar is an odd choice of wording...


"While in Korea, the NTSB investigators interviewed Asiana personnel, observed company procedures in a simulator and a similar aircraft, gathered further documentation on airline training and policies, and reviewed records of the plane that crashed."

[talkpedlar]

pr eshemplow ..from the Korean word for emasculated management, fickle leadership etc.. :=

[Airbubba]

exemplar is an odd choice of wording...

Standard NTSB speak, see 7:48 in one of Captain Sumwalt's briefings about the recent BHM A306 crash:

Member Robert Sumwalt holds final media brieifing on UPS flight 1354 crash - YouTube

[J.O.]

Well none of those four bullet points listed above, unfortunately, lists investigating if gung-ho fire truck drivers ran over and killed survivors from the accident, so I presume that's been airbrushed out.

And just what exactly do you suppose this statement means? :rolleyes:

The hearing, which will be held December 10–11, 2013, at the NTSB’s Board Room and Conference Center in Washington, DC, will focus on pilot awareness in highly automated aircraft, emergency response, and cabin safety.

[ironbutt57]

WHBM.....the "gung ho" fire truck driver couldnt see the victim as foam from another vehicle had covered her apparently....before you open your stupid trap and criticise people think about it and put yourself in their place....and anyway why would it be airbrushed out?? it's been all over the news...

[flatfootsam]

exemplar
ɪgˈzɛmplə,ɛg-/
noun
1.
a person or thing serving as a typical example or appropriate model.

It' English....

[His dudeness]

WHBM.....the "gung ho" fire truck driver couldnt see the victim as foam from another vehicle had covered her apparently....before you open your stupid trap and criticise people think about it and put yourself in their place....and anyway why would it be airbrushed out?? it's been all over the news...

+ 1.

WHBM, your remark is - IMHO - grossly unfair. Please remove it.

[paully]

In defence of WHBM, they have a point. In the course of this tragedy people lost their lives, in a road accident, as a result of an air accident. It is, therefore, an intrinsic part of this investigation. It cannot be anything else. I would think that NTSB would delegate that part of the investigation to local Police but, the findings, would have to be included in the final report.

I do accept that the posters words could have been a tad more diplomatic

[DaveReidUK]

gung-ho
unthinkingly enthusiastic and eager, especially about taking part in fighting or warfare

A tad harsh to use about a rescue professional who was doing his job i.e. attempting to save lives.

[mikkojuha]

"rescue professional who was doing his job i.e. attempting to save lives"
If the original video of the US rescue professionals at work was the best example they can do, I dont´t want to know how the unprofessionals do their job.

Is it right method to squirt the foam from the maximum distance? How did they manage to burn the hull as a whole? No wonder that the poor girl instead of the aircraft was covered with the foam.

[Hotelpresident]

Fire fighter job is really a complicate job. Misunderstanding or confusion is always possible during those moments. It is not surprise they have to constantly train to reach the best maximum performance.


Is it right method to squirt the foam from the maximum distance?


I suppose they did just in case the tanks with fuel were going to explode.

[J.O.]

"rescue professional who was doing his job i.e. attempting to save lives"
If the original video of the US rescue professionals at work was the best example they can do, I dont´t want to know how the unprofessionals do their job.

Is it right method to squirt the foam from the maximum distance? How did they manage to burn the hull as a whole? No wonder that the poor girl instead of the aircraft was covered with the foam.

Since you obviously have no idea what the SOP is for dealing with such situations, it would be best if you left it to those who do to pass comment. The goal is not to save the aircraft, it is to save the passengers. Given the survival rate from this accident, that goal was achieved. That success is because they met their goal by protecting the exit paths. Period. They stayed back because it gave them a wider view of the scene and they could better react as a highly dynamic situation evolved.

The death of the young passenger is highly tragic and you can bet your last sheckle that the operator involved hasn't had a good night's sleep since that day. They'd rather have died on the scene than accidentally hit one of the victims. One may also wish to remember that in spite of lots of training, few airport firefighters ever get to respond to a real accident of this magnitude. There's no textbook case either. All of the planning and preparation is based on past experience and a best guess as to what they will face on the scene. This experience will be used to study current procedures and make changes for the future. Much like the work the NTSB is doing for the accident itself, which by the way is the real reason that young girl died in the first place.

[westhawk]

The NTSB investigation of the Asiana 214 crash will of course include survivability factors and ARFF response. However, I would expect that the final report will be somewhat limited with respect to the ARFF response. Nor is the report likely to contradict the investigative findings of the San Mateo county coroner or district attorneys office. The main focus of the investigation will rightfully be centered on what led to the crash. After all, without the crash, none of the rest of it would be at issue. I would be very surprised if recommendations regarding fire department training and policy aren't included though.

The DA has stated that no charges are to be filed against anyone because their investigation revealed that there is no evidence that any criminal act was committed. The coroner has ruled the death of the girl run over to be accidental. The girl's parents are suing the city of San Fransisco. In a nutshell, the case of the girl's death will be contested in civil court.

BTW, the use of the word "he" in describing the gender of the driver of the ARFF vehicle in question appears to be in error. Among the multitude of news reports regarding this story, there is an article (http://www.mercurynews.com/san-mateo-county-times/ci_24338780/asiana-crash-no-charges-firefighter-run-over-death) by the San Mateo County Times/San Jose Mercury News which summarizes the situation as local officials see it as of last week.

[Tomspur]

Just as an aside, according to the LVRJ the driver of the emergency vehicle will not be charged.

Here is the article

Firefighter who ran over crash survivor won't be charged | Las Vegas Review-Journal (http://www.reviewjournal.com/news/firefighter-who-ran-over-crash-survivor-wont-be-charged)

[NG_Kaptain]

"But the plane’s pilots, as well as the airline, have raised the possibility that a key device that controls the Boeing 777’s speed may have malfunctioned."
Firefighter who ran over crash survivor won't be charged | Las Vegas Review-Journal (http://www.reviewjournal.com/news/firefighter-who-ran-over-crash-survivor-wont-be-charged)

What was the device called? The pilot?

[deSitter]

"Fire department personnel knew she was on the ground, yet they didn't carry her to safety, Tarricone said. Her injuries and her position on the ground show it was unlikely she was ejected from the plane, and her family believes another firefighter carried her off the jet and then left her on the ground, he said.

"We know that several firefighters saw her and knew she was there before she was covered with foam," Tarricone said. "They inexplicably abandoned her."


Very bad, charges were merited. Let's hope the family take a mountain of cash from the city of SF. The rule in the US is - being in uniform more or less guarantees the miscreant a free pass for any level of incompetence.

[Sir Richard]

This appears to be pure speculation by the "ambulance chaser" acting for the family. I wonder where he gets his "information" from?

"Fire department personnel knew she was on the ground, yet they didn't carry her to safety, Tarricone said. Her injuries and her position on the ground show it was unlikely she was ejected from the plane, and her family believes another firefighter carried her off the jet and then left her on the ground, he said.

"We know that several firefighters saw her and knew she was there before she was covered with foam," Tarricone said. "They inexplicably abandoned her."

p.s. does than include the Asiana crew? :E

The rule in the US is - being in uniform more or less guarantees the miscreant a free pass for any level of incompetence.

[Lonewolf_50]

Very bad, charges were merited. Let's hope the family take a mountain of cash from the city of SF. The rule in the US is - being in uniform more or less guarantees the miscreant a free pass for any level of incompetence.
You attempt at a wind up is so full of crap it isn't funny.
Try telling that free pass BS to the two generals who just got relieved over Afghanistan. See the thread in Mil Aircrew.
other recent examples: See the cop who is charged with his dumbacity in the biker assault case.

If you don't know WTF you are talking about, which you do not, you are better off keeping your lying trap shut.

[Desert185]

Now there is talk about revisiting Age 65 after the age 63 United captain had a heart attack inflight.

Given the facts involved in Asiana, I guess we could conclude Asian males shouldn't be pilots, autothrottles cause landing accidents, women shouldn't drive fire trucks and all visual approaches should be made with an operating ILS. At least a flight plan was filed (one of the first things mentioned by the press in the US). Simple...and ridiculous.

Do we really need another mandated rule and procedure that would have contributed to the prevention of this tragedy? Lawyers need not respond. :rolleyes:

[PA-28-180]

" Do we really need another mandated rule and procedure..."

Unfortunately, Desert185, this IS the usual guvmint response....have a problem....create ANOTHER government program, as in "I'm from the government. I'm here to help you" :ugh::ugh:

[rottenray]

deSitter writes:
The rule in the US is - being in uniform more or less guarantees the miscreant a free pass for any level of incompetence.I cannot even begin to describe how deeply offensive and incorrect this statement is.

We (in the US) have so many dedicated emergency personnel who have already proved this wrong by giving their lives trying to save others that I really shouldn't even have to reply to this.

But I will, and I am going to go against rules and "play the man" instead of "playing the ball."

I took the time to look through a lot of your posts in other topics.

Many statements you have made here and in other threads lead me to believe that you are here to derive pleasure from aggravating others, rather than contributing to a productive discussion.

If you'd like to call me out on this, be prepared for a lot of embarrassment. I have done my homework and can prove, beyond doubt, that you are what we call a "troll."

Your credibility on this site is at a solid zero. I don't know for sure if you participate in other aviation fora, but I think I recognize your trolling, antagonistic posting style in a few other places.

My advice, which you don't have to listen to, is to post less and read more - perhaps you'll eventually become nearly as wise as you think you are.


In less words - shut up and stop interfering with the intelligent discussion going on, you have nothing to say that any of us want to hear/read.

[Ranger One]

I was based out of… a small town in the north-east of the USA for many years.

For several of those years I was an active and well-trained member of an extremely professional combo (i.e. mostly volunteer with some paid guys too) fire department.

Reading the language some of my so-called fellow professionals are using towards fire and rescue personnel quite frankly makes me want to puke.

Do you think those men and women aren't every whit as professional as you are? Do you really feel it's your place to be Monday morning quarterbacking them? Especially when it's a profession you know bugger all about?

It's not even just one of you; there are several culprits. Some seem borderline obsessional about it.

You should be ashamed.

I'm surprised the moderators are letting this go on.

fuming.

[flarepilot]

ranger1

you have my respect and agreement.

[neila83]

I can see why some people are upset by the tone of some others about the fire crew, but there is a valid point here - and it should be properly investigated as a full third of the deaths in this accident are likely due to the fireservice response. So just brushing it aside as 'unfortunate' doesn't really wash. It is the fire service's job to save people, if someone died due to their actions, are they not as culpable as the air crew? The situation may be confusing, difficult, fast moving etc but is this not what they are trained for? Just like landing is what the air crew are trained for, and we keep hearing how an air crew that coudn't make the landing shouldn't be flying a plane - couldn't the same be said for a fire crew that can't do their job without killing someone?

Sadly there is a tendency for posters to form their opinion according to the nationality of those involved. My extremely strong suspicion is that if the nationalities were reversed and this had happened in the reciprocal country, it would be the fire service getting all the flak with demands for their heads, and excuses left right and centre for the flight crew.

For consideration, maybe ask yourself whether you are too quick to blame one group and defend another without rational basis?

[cwatters]

Rescue efforts and actions normally are covered in the final report. No reason to suspect they won't be this time?

[Ranger One]

neila83, I assure you the fire service will be debriefing and analyzing exactly as we would. And of course the whole thing will be part of the NTSB investigation. No-one is suggesting it should be brushed aside.

Unfortunately some people aren't interested in letting facts get in the way of a good rant; they already know exactly what happened, they don't need any damn investigation, facts or analysis, they just want to be abusive and offensive. Trolls, as someone else put it, quite rightly IMHO.

[DH_call]

@Ranger One

Thank you. Let's not forget that had those "professional" pilots not bungle a routine landing (allegedly), those rescue personnel would not have been there.

[Rick777]

Pilots commenting on the professionalism and procedures and techniques of firefighters makes about as much sense and firefighters commenting on pilots and how they do their job.

[stilton]

It's terribly tragic what happened to this passenger, but it was an accident. I think that even the possibility of this firefighter having to face charges for an accident while doing their utmost to save passengers lives was obscene.


There are only two people to blame in this accident and resulting deaths, they were in the left and right seats of that B777.

[Cows getting bigger]

Stepping back from the accountability argument, both occurrences need investigating. Pilots don't intentionally set out to crash aeroplanes, just as much as firefighters don't aim to kill the people they are meant to rescue.

If there have been failures (system, equipment or human), then once these have been identified they can be addressed such to minimise the risk to future passengers. Sure, if the final results of the investigation then hint at some form of negligence then let the lawyers have their moment.

Jumping on the 'hang em high' wagon isn't particularly helpful and does little to promote flight safety.

[suninmyeyes]

"But the plane’s pilots, as well as the airline, have raised the possibility that a key device that controls the Boeing 777’s speed may have malfunctioned."

I think Boeing would have been aware in the first week of the investigation if the autothrottle had malfunctioned, just as they were aware in the Turkish accident at Schipol. There has been no mention from Boeing of any autothrottle malfunction.

If the quote at the top is recent then it would imply that the pilots and the airline are still not aware of how the 777 autothrottle works. Although the autothrottle arm switches are engaged, and the autothrottle is engaged the autothrottle will not maintain the target speed in certain modes such as Flight Level Change if one flight director is off, the other is on and the autopilot is out and the flight director commands are not being followed. The warning is at the top left of the PFD where the thrust flight mode annunciation has gone to HOLD.

777 pilots (well most) have always been aware of how one can inadvertently get low and slow in this situation. The interesting thing will be if Boeing change the logic system of the autothrottle to make it easier for those who lack the basic skills. However by doing that they may be laying themselves open to the accusation that the system is not ideal and was contributory to the accident. The system does work well and if both flight directors had been off the autothrottle would have maintained the target speed and the accident would not have happened.

[vilas]

suninmyeyes
It is very similar to an Airbus fatal accident of Indian Airlines in the 90s. There also one FD was off and as a result the Auto Thrust did not change to speed mode. Pilots fail to realize what was happening and by the time they decided to go around the aircraft was too low and hit the ground killing everyone.

[olasek]

that the system is not ideal
Because there is no such thing as an ideal system.
These pilots weren't even facing a truly malfunctioning system and they still botched a landing in a 100% working aircraft. These pilots are supposed to be trained to handle landing with malfunctioning systems, malfunctioning throttle, engines out, degraded electrics/hydraulics, etc. This is what makes this crash so appalling and so rare.

[ExSp33db1rd]

Coupled to the fact that the 'handling pilot' under supervision was fresh off Airbus flying, and mightn't have been concerned that the throttles were stationary?

No excuse, in any aircraft, for not having hands on and if the speed is low overriding any auto system and giving it a handful of power and if the gadget fights you then turn the barsteward off ?

The 'supervising' pilot allegedly 'admits' seeing 3 red PAPI's at 500 ft. which isn't too serious, although somewhat lower than desired, at least one knows that one is still in 'the funnel', but to sit there and watch the 4th red light appear, at which time one loses all guidance as to how far outside the 'the funnel' one is, is well .............. ! But then we weren't there, so conjecture is useless.

An instructor once told me " when in doubt, lash out, everything forward for speed " and of course he was referring to power, pitch, mixture, carb.heat, flaps, cowl flaps etc. that we had to cope with, not just one lever !!

[barit1]

"...raised the possibility that a key device that controls the Boeing 777’s speed may have malfunctioned."

Excuse me, but -
"...raised the possibility that a key device that ASSISTS THE PILOT IN CONTROLLING the Boeing 777’s speed may have malfunctioned."

[skiingman]

Very bad, charges were merited. Let's hope the family take a mountain of cash from the city of SF. The rule in the US is - being in uniform more or less guarantees the miscreant a free pass for any level of incompetence.
I see you are taking a lot of heat for this factual statement.

You didn't say always, just more or less. In general people in uniforms are held to lower standards than people not in uniforms. Ask the 2012 Ohio Trooper of the Year. No way in hell had I done that I'd be walking around a free man.

[rottenray]

Reading the language some of my so-called fellow professionals are using towards fire and rescue personnel quite frankly makes me want to puke.

I've been feeling the same way, I thought it was because I had the fish...

[rottenray]

The interesting thing will be if Boeing change the logic system of the autothrottle to make it easier for those who lack the basic skills.

Wow.

Greyhound, here I come!

[bubbers44]

Excuse me, but -
"...raised the possibility that a key device that ASSISTS THE PILOT IN CONTROLLING the Boeing 777’s speed may have malfunctioned."

I would agree on that statement and that would be the brain.

[flarepilot]

if you had a pilot directed to manipulate the thrust levers to maintain Vref plus 5 and a proper descent rate, and he or she DID NOT MAINTAIN SPEED, at least we would hope the OTHER PILOT would notice and do something about it (other than crash).

so too the automation...direct it to hold speed and if it doesn't do so, DO SOMETHING ABOUT IT other than let it crash.

[Desert185]

if you had a pilot directed to manipulate the thrust levers to maintain Vref plus 5 and a proper descent rate, and he or she DID NOT MAINTAIN SPEED, at least we would hope the OTHER PILOT would notice and do something about it (other than crash).

so too the automation...direct it to hold speed and if it doesn't do so, DO SOMETHING ABOUT IT other than let it crash.


There are some days you just have to be a pilot. On that day, the redundancy of having two (in reality three) pilots in the cockpit/flightdeck/whatever failed. Really incredible failure points, considering that level of the profession.

[sandiego89]

rottenray, bravo for your efforts in post #23 of (hopefully) curtailing a harmfull poster. Agree 100%. Well put.

[220mph]

This appears to be pure speculation by the "ambulance chaser" acting for the family. I wonder where he gets his "information" from?

Quote:
"Fire department personnel knew she was on the ground, yet they didn't carry her to safety, Tarricone said. Her injuries and her position on the ground show it was unlikely she was ejected from the plane, and her family believes another firefighter carried her off the jet and then left her on the ground, he said.

"We know that several firefighters saw her and knew she was there before she was covered with foam," Tarricone said. "They inexplicably abandoned her."

I suggest you, and others, do a little research before making these kind of attacks. Those comments are directly from a number of different sources and media reports made at the time of the incident.

I did a detailed review of media comments and available photos etc., along with a detailed review and analysis of the amateur video that captured the incident from almost the moment the aircraft came to rest, thru the next 20 minutes or so.

I noted the possibility of a casualty before it was getting much media - based on evidence in the early scene photos, which speculation sadly turned out to be true.

I was highly critical of the emergency response - which was disjointed and uncoordinated ... with firefighters seemingly unprepared for a major incident response. The equipment was poorly positioned, and key equipment (ie: foam booms) either unused or unworkable.

The firefighters clearly had no plan on fighting a fire in a round fuselage - instead of deploying booms (several clearly broken) to spray down into the fire they simply - and ineffectively - emptied whole tankers of foam shooting OVER the top of the fuselage.

The tapes and photos show the girl run over was NOT in that location during the evacuation. She was not placed there until long after the evacuation. They also show firefighters were on scene - the same truck - for many minutes - with a clear view of the spot the girl was placed - and that there was no significant amount of foam deployed there, other than on the isolated engine pylon area, until many minutes later - after the pax evaced and the fuselage became fully involved in fire.

Media and other reports showed the firefighter who ran over the girl had been picking up lunch when the crash occurred, and that she jumped into a truck solo - with no spotter, proceeded to the incident and ran over the girl.

Other reports indicated firefighters had placed the girl there, and for some reason they had determined she was deceased - which was clearly not true. Whether accurate or not, there is NO excuse for abandoning a victim - deceased or not - in harms way, as here.

Helmet cams on firefighters confirmed many of these facts. The SFO Fire Dept responded by banning personal video devices, despite that this incident was well on its way to being covered up before the personal video surfaced.

My opinion, based on hours of review of the video, the photos and numerous reports - is that had their been fire onboard earlier the majority of pax would have perished - in large part a result of the fire response.

Keep in mind as well that nearly 20 minutes after the crash survivors who had run toward approach end of runway, and found the seriously injured crew along the way, had to repeatedly call 911 and beg for emergency responders.

And that we saw media reports that noted ambulances and other responders had been held for a significant time unable to access the field. Which a review of the amateur video confirms - a LARGE contingent of emergency vehicles can be seen to respond in mass, some 15 minutes or so after the crash.

Here are the several posts I wrote originally on this incident including the detailed timeline review and supporting documentation:

http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-96.html#post7937757

http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-101.html#post7939704

http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-118.html#post7951640

http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-118.html#post7951724

http://www.pprune.org/safety-crm-qa-emergency-response-planning/520419-asiana-crash-investigation-5.html#post8001903

http://www.pprune.org/safety-crm-qa-emergency-response-planning/520419-asiana-crash-investigation-5.html#post8001940

Please read these. They show at minimum, the criticism is entirely appropriate. I would also note in direct response to 'Sir Richard' and his ignorant and offensive "ambulance chaser" comment ... that the counsel for the girls family appears to be acting in the highest professional manner. I would note in the LVRJ article on no criminal charges, rather than rhetoric and accusations this same attorney stated: “It’s really not the subject of criminal prosecution ... It’s properly the subject of civil action."

Those are the actions of a professional and ethical attorney -the opposite of those who employ "ambulance chaser" name-calling.

I would also note I am usually a strong supporter of law enforcement and emergency responders, however, this incident demands thorough review and accountability, and the SFO FD officials responses to date have been IMO anything but professional.

[220mph]

WHBM.....the "gung ho" fire truck driver couldnt see the victim as foam from another vehicle had covered her apparently....before you open your stupid trap and criticise people think about it and put yourself in their place...

"Gung ho" is an exactly correct description of the fire truck driver based on what we have heard reported about her actions that day. It is not a personal condemnation of her but an accurate description of her actions.

Just as criticisms of the fire dept response are not personal either - but fair criticism of their actions and the departments plan and training.

And "put yourself in their place" should NEVER be a consideration, or any part of a professional and competent review of these actions.

The Fire departments actions that day clearly IMO failed. It is clear from a myriad of sources and information they failed. They failed to prevent the aircraft from becoming fully engulfed in fire - which did not occur until more than 15 minutes after the crash. They failed to respond to the entire crash scene - failing to reach critically injured people near the tail section for nearly 20 minutes. And they grossly and critically failed to protect the life of a survivor of a major aircraft disaster - directly causing her death.

They did NOT drop her in foam. There was no foam there until very late in the incident. Had they simply insured she got to the safe triage area - not far away, she would have survived. Even if they thought she was deceased that should have been their proper action.

[woodyspooney]

Sorry if I am digressing but every time I discuss this accident with others, the issue of the FLCH trap comes up. I can really tell you what's wrong with Asiana Training. I am retired for some 6 years now but when I was east in kimchiland years ago, the initial training in KAL and OZ were done by Alteon. I had never heard about the FLCH trap from any of the Alteon blokes!

I was only made aware of this FLCH trap during my OE training by a South East Asian Chinese guy who had initial training with actual Boeing factory pilots. During my 5 years over in ICN, I never had anyone re highlighting that! Sure, we did a lot of automation degradation. We had too many non rated Alteon guys who became T7 instructors who became 777 experts after a fortnight of conversion training! 757 guys, MD 11 guys who think that the T7 is a bloated B737. These Alteon blokes are there to satisfy some vague requirements, fail some guys occasionally to put fear ( fear based management technics ) and show that the system is " working "!

I read somewhere that it is only now that OZ is reviewing some of the stuff taught at their Training Center. The word I heard is that they are telling pilots that the T7 autothrottle system is faulty instead of teaching them real understanding of its logic and algorithms. OZ is not training pilots but dunces:ugh:

[Escape Path]

I'm sorry if I come up too "jumpy" on the crew, but this accident is rubbish and IMO any attempt to cover up the crew's blatant mistakes is rubbish too. As others have said, it was properly functioning aircraft, on a visual approach and on a beautiful day. How the hell did they miss so many cues and just basically sitting there and watching the aircraft crash?

I just wonder how did we manage to fly 40 years ago without having a major airliner crash every week! :rolleyes:

[Centaurus]

How the hell did they miss so many cues and just basically sitting there and watching the aircraft crash?


The pilots didn't miss the cues. The cues were obvious all the way down the flight path but were ignored. The answer to your question is in the blind culture of the operator and similar operators in that region, where protection against loss of face is considered a higher priority over airmanship and flight safety common sense. It is not as if this event was just an isolated case.

[roulishollandais]

in that region, where protection against loss of face is considered a higher priority over airmanship and flight safety common sense These pilots lost their faces in SFO! Airmanship would have avoid that shame.

[ratarsedagain]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.

[FullWings]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.
Or, even more accurately, it can happen any time the A/T is not in SPD.

[RAT 5]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.

Or, even more accurately, it can happen any time the A/T is not in SPD.

Or even more importantly it can happen anytime the sharp end jet jockeys are not in PILOT mode.

[Wizofoz]

Or, even more accurately, it can happen any time the A/T is not in SPD.

Not so- A/T wake up is available in any A/T mode (including disengaged) except HOLD.

[Cows getting bigger]

Has the system led pilots up the garden path? From the educated comments on this thread, there seems to be an awful lot of (semi) automated modes in today's airliners. Does it really need to be that complicated in order to meet the Power + Attitude = Performance mantra?

[Al Murdoch]

Can someone remind me - why does Boeing want the A/T left engaged on the 777? I remember this being discussed somewhere but can't find it now.
My personal view is that I feel far more on top of what's happening with it disengaged, but it seems that this has been deemed unacceptable by someone, somewhere. If I'm honest, my speed awareness is definitely degraded as a result of this.

[RAT 5]

But.... if there is a trap here, and it a known trap - at least the trainers who've posted on here know about it - why do not ALL crews know about it? Is it not highlighted in FCOM 2? Have the airline training departments not caught on to it an issued chapter & verse on the trap? And how did the FAA/JAA et all certify it without that information being understood throughout the pilot community? Likely more questions than answers.
And if it is true on B777 is it also true on B787? and any other types of other manufacturers out there? Could this be the hidden trap-door to a smoking hole? They were damn lucky. If this had been an inferno with no survivors I suspect the reaction would have been much more loud and vigorous than it has been up to now. So far it has mostly been about lack of pilot reaction. They all survived the prang, but the inferno outcome would have caused much more technical furore, after not doubt much head scratching.

[Cows getting bigger]

There is a good discussion here (http://www.pprune.org/rotorheads/522069-as332l2-ditching-off-shetland-23rd-august-2013-a.html) about a helicopter which seems to have achieved something remarkably similar to the Asiana. There is also the relatively recent UPS cargo crash at Birmingham and of course AF447.

Call me a bluff old traditionalist, but I'm sort of seeing a trend.

[747newguy]

Those little girls would not have been in that field if the pilots had not put them there. The rescue crews were trying to do the best they could with what they had. I'm sure that driver didn't have two other drivers behind him monitoring his actions and another in 1st class hanging out...

[topgas]

I have the greatest of respect for all the emergency services. When something like the unfortunate running over of a potential survivor happens, it is simplistic to blame it on the driver. I hesitate to talk about Human Factors on a professional pilots forum, but they come into play here
- she was away from the station when the shout came in
- finding the station empty, she took the reserve machine to the scene (presumably with ATC permission)
- she arrived at the incident with little or no situational awareness and presumably without direction from the incident controller
- the incident scene itself sounds like it was still in the initial response stage and had not developed into an organised site (command post, triage area, etc)

All these points have the potential for human factors failings (system failure), like did she have a radio while she was away, was she requested to bring the reserve machine, was there a reporting point at the scene, and I'm sure they will have all been addressed internally. I feel for the driver, she used her initiative in a rapidly evolving scenario, and had it panned out differently, her bringing another machine may well have saved lives.

I've been involved in Major Incidents, and even the best Major Incident plans can't cover every possibility

[misd-agin]

Basic, basic flying on approach/landing is - aimpoint, airspeed.

That's really BASIC flying. It didn't happen.

Watching guys eyes on final below 1000'. Longest interval to glance to at airspeed is typically 5 seconds. It can be as quick as every two seconds. At 500' they were was slow and correction took over 40 seconds, and perhaps 50 seconds? What were they looking at?

NASA has done eye tracking studies. They probably have the data on how often crews look at airspeed on final.

[aterpster]

misd-agin:


NASA has done eye tracking studies. They probably have the data on how often crews look at airspeed on final.

For those who have a modern HUD and know how to use it, they are looking at IAS almost continuously.

The F-18 comes to mind. It came out in the early 1980s with a HUD.

[Tipsy Barossa]

Agree totally with Woody...in my years up in the land of the morning calm, Alteons guys had no clue about the B777 system traps. It is after some reported failures or incidents that they reactively came out pontificating about how great their systems knowledge. I am very wary of the ex 757 guys who are so inept because they know everything because to then the 777 is just a bigger 757!

Now, I think when Woodey talks about FLCH trap he meant other aspects of that mode in addition the A/T being in Hold! Go study your systems guys!

[bubbers44]

Don't know who Woody is but knowing how to fly any airplane would have prevented this incident. Automation is to help you, not fly your aircraft, if you can not.

[yarpos]

I really wonder how many of the armchair critics, who are so strident about the fire crew actions, have ever been in a high stress chaotic situation where they had to save their own life and/or save others?

If they had, and perhaps more than once, they would understand how quickly a situation like that can turn to crap and have a bad ending.

This type of stuff is usually dished up by people with no real experience of anything remotely like the incident they are ranting about.

[Escape Path]

The pilots didn't miss the cues. The cues were obvious all the way down the flight path but were ignored.

I stand corrected. You are absolutely right!

Or even more importantly it can happen anytime the sharp end jet jockeys are not in PILOT mode.

+1! :ugh:

Don't know who Woody is but knowing how to fly any airplane would have prevented this incident. Automation is to help you, not fly your aircraft, if you can not.

Bubbers making sense as usual. :D

[Tipsy Barossa]

Bubbers is just stating the bloody obvious minus the self aggrandizing anecdotes at Toncontin! Sure had they remember to fly blah blah blah...but they didn't because they were fools or fooled into thinking the automation will take care of the shop. With newer generations of planes and manufacturers taking the road to greater autoomation, new pilots have to cope with automation traps because their SOPs predicated full use of automation.

We will never be going to have new generation of planes behaving like the DC3sc, F-27s or B747 classics that we enjoyed years ago. Present airline SOPs, airport architecture and system, ATC, TRACON, PRNAV, arrivals and departures are full of automatics with their inherent concomitant traps. If pilots are not made aware of such traps and only taught to click off everything automatic, we will only have a short term solution. Fine by me as a pilot, but what about future progress.

I don't want to be an old fart reliving and regurgitating my glory days telling everyone to use quill pens and parchment everytime the wireless keyboard runs out of battery ( of course some are not battery powered ). Sigh...........

[fox niner]

Why has this accident caused so much and vivid discussion on Pprune?
Because the probable cause is so damning. The probable cause, being over reliance on automation because of lack of basic flying skills, is an insult to thousands of professional aviators all around the globe. The NTSB will have to come up with a final report which highlights this and at the same time remains "politically correct" at all times.
Re the FLCH trap and THR HOLD mode that's in the 777. Surely Boeing can assume that the pilots that fly their airplanes, can actually fly airplanes! Come on. What has happened? We have to wake up pronto. The NTSB will have to come up with some landmark report about this.
The Before Asiana Era has just ended.
Welcome to the After Asiana Era.

[Molokai]

Tipsy...bravo! Finally we have an experienced oldie who lived the past, shine in the present and appreciate progress for the future. Much as we all love consummate hand flying skills, the future of aviation is going to be dictated by even more automatics.

Oldie skygods leading a boycott of automatics? Wow, without daily practice and yet fly like a bird whenever some auto glich appear due to management of automatics? Good story at the pub for sure but a tad unreal!

In another life, I flew like a bird too island hopping in my old 737 - 200s, 4 to 5 legs a day into places I knew like the back of my hand. I was pretty confident, cocksure at times as I handfly everyday with no company SOP restrictions. Traffic was easily manageable by ATC, we had all the time and space.

In my present life, I probably make a landing every 2 weeks. All PRNAV SIDs and STARS, a draconian FOQA/AIMS program and a multitudes of other SOPs requiring maximum use of automation for efficiency, economy and airspace constraints. Well, what a litany of excuses you may say...well these are facts of life in modern airline flying. I certainly enjoyed my past hand flying and certainly enjoy the handflying during my sim training and checks but I equally look forward to the challenges of flying the automatics and learning of all the traps!

[Locked door]

There seems to be the same misunderstanding that only the pilots are to blame for this incident developing as in other threads.

Yes, pilots should be able to fly a visual, non precision or precision approaches. However the recent cargo crash by US pilots at a US field and numerous other accidents and incidents on approach suggest that there are other factors too.

At SFO there are two tightly spaced parallel runways. Switching off the ILS / LOC to either of them is not sensible. This combined with the policy of late runway changes, pairing aircraft on approach and ATC routinely inducing high energy situations increases pilot workload and therefore reduces spare mental capacity and situational awareness.

If the accident aircraft had been on a lazy ten mile final ILS this accident probably wouldn't have happened. The investigating authority has very little influence on the training standards of the airlines that fly to SFO, but a lot of influence on how the ATC and airfield is organised. With a little thought the operating environment could be a lot safer.

I am a regular (every eight weeks or so) visitor to SFO. More often than I'd like I find myself (in a 747) with speedbrakes fully deployed, taking flap near limiting speeds, sometimes gear down way early, using the MCP or hand flying to intercept the visual profile (or if I'm lucky the ILS/LOC) from above with another a/c very close on the parallel approach. How much spare capacity do I and my crew have to deal with an unexpected TCAS RA, an engine failure etc. Contrast that to how much spare capacity I and my crew would have on a lazy ILS with staggered approaches so no other a/c are near.

Don't rely on pilots being skilled to stop them having accidents. It's all about providing the safest possible environment. Do that and you'll have fewer accidents.

remember the age old saying, "a superior pilot uses their superior judgement to avoid using their superior skill"

[potteroomore]

I am geriatric couch potato now and I marvel at exploits of bubbers at TGU. I may or may nothave flown so well...I just don't remember as I started at 16 and after 48 years of pedalling airborne contraptions I called it a day after 5 years on the T7. No I had not heard of the FLCH trap but I always override the ATS as if I am flying manual thrust levers. My f/os at times looked alarmed as they heard the autothrottle servos fighting my manual input ( rarely ), or as I increase thrust anticipating ALT capture or SPD mode activation when in HOLD mode.

To cut it short, I always follow through the thrust levers and override them as I so judge. Of course the company maintenance guy with anal retention on the jumpseat may not to be to happy hearing the ATS servos grinding as I override the automatic retarding of the thrust levers.

I have no wish to recount my manual flying exploits....not many instances as I always preempted any untoward incidences, so I never allowed any chances for any heroism to develop...like a vague memory of rejecting a takeoff at 50 kts when I noticed in the corner of my eye a fuel truck blundering near an active runway. It did careen onto the runway after I vacated through a faraway perpendicular taxiway according to my f/o. Had I waited until it had ventured onto the runway, and rejected I would probably be at above 110 kts requiring superior skills who I might not have had.

Looking back, maybe I was stupid never getting a 3 minutes of fame. In good old Oz, I used to fly lazily on the venerable 727 down the DME steps and tight circled for the runway. No Foqa, no drama just pure joyful flying with the many " after thumping " checks. On the 777, I could probably do that ( but not very well I guess due to " lack of handling " ) but I am sure my f/o would be very overloaded trying to manipulate the MCP settings as per SOPs.

I do not envy modern airline pilots who have all sort of restrictions working against them especially the freedom to choose the level of automation they desire. I certainly see and appreciate Tipsy's and Molokai's contention. A geriatric should look to the future too! Past glories ( real or imagined ) notwithstanding.:bored:: Nap time!:zzz:

[Cool Guys]

I dont want to counter any of the wise words spoken by the very knowledgeable and experienced people posting above but I have another angle from which this issue can be viewed. I have not piloted a fly by wire jet but I have spent many years automating heavy and complex industrial equipment that can also kill people when it fails to work properly.

In my opinion, with good automation many of these problems should not occur. Good automation does not have traps, it is simple, the auto pilot mimics manual control pretty closely. Good automation actually assists the operator/pilot to operate manually rather than hinder it. People tend to over complicate automation. An old fossil I used to work with used to say it is very easy to make automation complicated & difficult to use and very hard to make it simple & easy to use. In my experience any piece of automation can be made simple and user friendly, it just takes experienced people more time to produce and lots of consultation with the end user/pilot. Experienced people tend to make thing simpler.

Another point I have come to realise with automation is it is very easy to get away with producing messy SW. With the more mechanical professions things have to look nice, other wise it will be noticed by everybody. Electrical professions can be a bit rougher, if cabling is not supported evenly no one except for other electrical people or people with access to electrical enclosures notices. SW onthe other hand is hidden away on flash memory and if you have a few unnecessary loops or illogical implementations no one notices apart from other SW engineers.

[aterpster]

Cool guys:

In my opinion, with good automation many of these problems should not occur. Good automation does not have traps, it is simple, the auto pilot mimics manual control pretty closely. Good automation actually assists the operator/pilot to operate manually rather than hinder it. People tend to over complicate automation. An old fossil I used to work with used to say it is very easy to make automation complicated & difficult to use and very hard to make it simple & easy to use.

The automation in a Boeing 777 is not just good, it is outstanding. It is simple to use if the pilot has good training, and really understands the fundamentals of flying a jet transport airplane.

[Dida]

There is no FLCH trap. The trap is using that mode when it is not supposed to be used - close to the the ground. In my current company it is absolutely forbidden to use it to intercept flight path from above during approach phase.

[olasek]

In my opinion, with good automation many of these problems should not occur.
As a pilot I disagree. Modern autopilots are simple to use but they still require training, proficiency, etc. And yes, experienced pilots were extensively consulted during their design. But these are complex devices and flying is far more complex than operating machinery on the ground, this equipment is not idiot-proof. These are not smart-phones or cruise controls in cars that can be operated without even reading a manual.

[barit1]

Cool Guys:
Another point I have come to realise with automation is it is very easy to get away with producing messy SW.

No! You can't be referring to "GLITCHES (http://www.washingtontimes.com/news/2013/nov/4/problems-and-excuses-mount-for-obamacare/?utm_source=RSS_Feed&utm_medium=RSS)", can you?

[Machaca]

Another point I have come to realise with automation is it is very easy to get away with producing messy SW.

No! You can't be referring to "GLITCHES", can you?


Please refrain from conflating the likes of website or factory machinery software with flight control software. They are galaxies apart.

[West Coast]

Popped in to see if there's anything new. Still seeing the there I was in SFO stories none of which is relevant to the accident. That you had the boards and gear out and was descending like a bonanza full of doctors isn't relevent to the Asiana crash.

[Cool Guys]

Thanks for the feed back guys. I am glad to hear I am wrong :)

[Locked door]

West Coast

That comment just goes to show your total lack of understanding of aviation safety, particularly the 'swiss cheese' or 'error chain' models of accident prevention.

[roulishollandais]

In my opinion, with good automation many of these problems should not occur. Good automation does not have traps, it is simple, the auto pilot mimics manual control pretty closeAP mimics manual control (with some improvments), but FBW systems place "protections" and flight laws unknown from pilots.
Testing automation on the ground is much easier than doing it on airliners in the sky at 500 kt. In any case "good automation" requests to stop modifications and to product total description of every detail of the system BEFORE operational use. It seems that aviation industry does not respect these quality minimum rules.

[sheppey]

increases pilot workload and therefore reduces spare mental capacity and situational awareness.


Oh come on now! Don't airline pilots have to undergo all sorts of aptitude tests to prove they are the Right Stuff before being offered a job as a pilot in an airline? What's all this "spare mental capacity" rubbish? They are given hours of training in simulators and that cover all sorts of emergencies on almost every simulator trip. Doesn't that training give them an abundance of "spare mental capacity" to do a straight forward visual approach and landing?

[flarepilot]

I've found that the MORE you exercise your mind and eye / hand flying, you get better and stronger and have more capacity to handle things


using automation all the time is like using an escalator instead of taking the stairs. and the day the escalator goes Tango Uniform, you will be out of breath and have NO spare capacity.

one pilot friend of mine said: you really aren't ready to be an instrument pilot or ATP until you can hand fly an ILS to minimums while eating a hamburger and getting the phone number of a DARN good looking Female Flight Attendant.


All while doing your logbook.

[Ian W]

Bubbers is just stating the bloody obvious minus the self aggrandizing anecdotes at Toncontin! Sure had they remember to fly blah blah blah...but they didn't because they were fools or fooled into thinking the automation will take care of the shop. With newer generations of planes and manufacturers taking the road to greater autoomation, new pilots have to cope with automation traps because their SOPs predicated full use of automation.

We will never be going to have new generation of planes behaving like the DC3sc, F-27s or B747 classics that we enjoyed years ago. Present airline SOPs, airport architecture and system, ATC, TRACON, PRNAV, arrivals and departures are full of automatics with their inherent concomitant traps. If pilots are not made aware of such traps and only taught to click off everything automatic, we will only have a short term solution. Fine by me as a pilot, but what about future progress.

I don't want to be an old fart reliving and regurgitating my glory days telling everyone to use quill pens and parchment everytime the wireless keyboard runs out of battery ( of course some are not battery powered ). Sigh...........

One correction here - traps is not plural - it is singular.

And I think that this is what Bubbers was trying to say. The single trap is - believing that total trust can be placed in automation, leading the pilot to ignore what the aircraft is doing.

Automation should only be trusted as much as the PNF trusts the PF - PNF should continually monitor the safety fundamentals.

This may upset those who believe that automation is to be fully trusted but that is the trap. If automation could be fully trusted there would be no need to have a flight crew there in the first place.

[RAT 5]

We will never be going to have new generation of planes behaving like the DC3sc, F-27s or B747 classics that we enjoyed years ago. Present airline SOPs, airport architecture and system, ATC, TRACON, PRNAV, arrivals and departures are full of automatics with their inherent concomitant traps. If pilots are not made aware of such traps and only taught to click off everything automatic, we will only have a short term solution.

This may upset those who believe that automation is to be fully trusted but that is the trap.

Reflecting on the sentiments above I think we need to consider a couple of points. Regarding the old types of a/c we used to fly... and therein lies a clue..'fly'.. Sure we had to operate them as well, but we knew how to fly them, often had to fly them e.g. Greek islands, and knew their foibles. They had basic automatics and we knew how to operate and monitor those because we knew more about what the a/c should be doing. Did the automatics do what we would do manually? Yes; then watch it carefully, and even we might learn something at the same time. This idea of 'clicking off everything automatic' means they first have to realise there is a problem and then be able to take over manually. Much debate has been made about the lack of ability of modern pilots in that latter regard. We need to be aware when the automatics start to go AWOL and perhaps correct it via the automatics: then, if that proves unsatisfactory takeover ourselves.
I saw over the past 20 years a generation of pilots who did not know the foibles and the basic envelope and thus didn't realise when things were starting to go awry. Their monitoring skills were 'knowledge and understanding deficient'. They trusted too much and fell into traps. Some they had induced by
mis-management of the FMC/AFDS, some had crept up on them via the FMC having a mind if its own. Sometimes they noticed, sometimes not. Sometimes they knew how to correct it or startedg playing the piano in hope.

I now see a new generation who, by their training, is even more removed from the a/c and therefore the understanding of the dark art. The basic flight school training is so diluted from days gone by it's scary. 150hrs and no aeros. The basic jet TQ syllabus is not orientated to learning how to control the beast manually, but how to operate it. There are lots of boxes to be ticked with systems failures and monkey reading QRH's. There are so many back ups that the QRH will always get you home. Many crashes I've read about were not mis- handling of QRH's, but caused by things which did not fit the index of the QRH, and the crew was found deficient.
If you don't fully understand what the a/c should be doing and how you would control it during various phases of flight, how can you be an effective monitor? You are suckered into the TRUST attitude. The SOP's are written so comprehensively that if you stick rigidly to them you might survive your 40 year career. That is what is being drummed into the cadets at TQ school. But still we see serviceable a/c being pranged. You can't write an SOP or QRH for all scenarios. Mother nature is waiting to bite, and that includes human factors from all links in the chain.
Without the basic knowledge and skills we can not be effective monitors, because we don't realise when it's creeping away from us; and we won't be effective last chance saloon when necessary. Those of us who came up the ladder via those basic a/c an onto the LNAV/VNAV/GPS a/c should not have forgotten the basics of earlier lives. The 150hr cadets going straight onto the new wizz-bang all bells & whistles a/c never had, and likely never will have, those in-depth basics.
I still believe TQ school should teach, in depth, how to fly the a/c, avoid the known traps of manual and automatic flight and afterwards learn how to operate the a/c. Given that guys now can get command after 4 years of trained monkey flying the foundations need to be more solid. Otherwise there will be a 'lot of trusting' going on, and hoping reliability, back-ups & SOP's will avoid any piloting skills being needed. The human factors people keep telling us that we are very bad monitors. We make very weak ones if we don't fully understand what we are monitoring, and yet I see technology & SOP's moving ever greater towards the alter of monitoring pilots. The PF is only a button pusher being PM to the automatics, and PM is the monitor to ensure PF pushes the correct buttons. What a life.

[MrDuck]

as others have said, is complete trust in the automation without verify.
Is not the recurring issue here not so much that the airplane misbehaved but that no one was monitoring the basic flight instruments?

[Al Murdoch]

So, does anyone know why Boeing wants the A/T left in for landing or am I just talking to myself?

[Machaca]

The 777 auto-trims for thrust changes.

[West Coast]

Doors

Nice effort. The scenario you described and that I opined on wasn't evident during the Asiana crash. Stay on task, stick to facts, don't stray.

You must be something, I ask we avoid rambling, non pertinent stories and you draw conclusions as to my level of knowledge.

There's lessons to be learned from Asiana, there I was stories do nothing only water it down, distracting from the narrative.

[framer]

Rat 5 is bang on the money..
I'll give a practical example of one of his points.
Many of the younger/newer pilots that I have flown with don't run a 3x profile in their head during descent. To those of us who used to have to run it constantly all the way to touch down this seems absurd. But they have never had to, and nobody ever trains them to do it, so they don't, they just check that the VNAV pip is in the right place and then feel comfortable.
So, as Rat pointed out, when the profile is wrong, when do they pick it up? Passing 20,000ft when they expect to have 70nm to run but only have 55? No, they don't even notice because they have never been controlling it manually. Scary I know but it's true in many cases.

[flarepilot]

Its not their race

Its not their airline

Its simply this...pilots allowed a plane to get low and slow...and not just a sloppy five knots.

I had an uncle...he never flew a plane in his life...anytime he saw me he said: don't get low and slow. He said this to me for over 30 years.


so someone who doesn't have a pilot's lic. knows it.

don't blame fatigue, the only excuse is that everyone ate the fish, or they were not doing their jobs

[Brian Abraham]

A viewpoint from Les Abend, current 777 captain, and author "Flying" magazine.

Jumpseat: Speculation Fascination with the Asiana 214 Crash | Flying Magazine (http://www.flyingmag.com/technique/accidents/jumpseat-speculation-fascination-asiana-214-crash)

[bubbers44]

So, theoretically with a pilots license should in my opinion never get low and slow. One of my favorite FO's when I was on vacation flew with a captain that got low and slow into TGU and took out the fence at the 70 ft cliff landing south.

There is no excuse for that if you are a real pilot and not a button pusher fresh out of school or who never progressed past that. I was in Europe when I read this in the newspaper. Later, I found out it was my friend who was the FO. I thought everybody knew if you are approaching a runway with a cliff on the approach end the air has to spill over the cliff downward if you have a head wind so you get a down draft. He didn't. Stupidity sometimes can not be fixed.

[ATC Watcher]

Les Abend :The NTSB, in Chairman Deborah Hersman’s words, has been very transparent with the factual data of Asiana Flight 214.(....) It’s bad because the release of information allows the misinformed to reach biased conclusions without all the factual data.


How true .

This accident is almost a carbon copy of TK / AMS . This time the crew survived so we might know what went inside their heads and why no-one saw the speed decay. Some good might come out of this in the end.

[RAT 5]

But they have never had to, and nobody ever trains them to do it, so they don't, they just check that the VNAV pip is in the right place and then feel comfortable.
So, as Rat pointed out, when the profile is wrong, when do they pick it up?

Even worse reliance on automatics and VNAV: when adjusting the route during arrival; perhaps with an extended centre line when still flying towards the downwind and needing to make a 180 to the runway, the VNAV vertical error might give >2000' high. What happens is the new generation yanks out the speed brake and dives the a/c to attain 'the path'.
Ask them to look at the ILS DME = direct track miles to the airfield; now add 15nm for the downwind, base turn and finals from 2000'. Are you high or low? Very often the answer is LOW. There is an ah ha moment, the speed brake is retracted and now the question. "How can VNAV show that error?" "It doesn't matter, but it did. Now do you understand that you are in charge and the FMC is a tool to help you, but you have to decide if you trust the info it's giving you and whether to use that info." Your brain needs to be further ahead than the nose of the CDU.
It's like the guys who punch numbers into a calculator with no gross error cross check of the answer expected. They too have some surprises.

[Piltdown Man]

This accident is almost a carbon copy of TK / AMS . This time the crew survived so we might know what went inside their heads and why no-one saw the speed decay.

I don't agree. I'll accept that there were similarities in so much that there were three pilots on the flight decks and the ones 'riding shotgun' failed to monitor the airspeed. These were also training flights. And both were flying with inadequate airspeed. But there the similarities end. The TK crew were distracted by a Rad Alt fault but were unaware of the consequences of that fault (but Boeing must have been, but still did nothing about it). It appears that the F/O tried to correct the underspeed, but being unused to autothrottles, was unprepared for them closing again. I believe had the TK crew disengaged the autothrottle they would have landed safely. But not the Asiana crew. An ex-Airbus pilot would probably be unaware of the "Hold" mode. He would rarely use it if always using the highest level of automation and would probably expect the aircraft to look after him. Dial in the pathetic SOP of "always autoland" and you have a crew working well outside their training, experience and comfort levels but more importantly, a crew incapable of manual flight.

[fox niner]

-A crew incapable of manual flight- is a phenomenon that we have to blame on ourselves. The whole airline industry is culpable of having allowed this to creep into existence.
We -the airline industry- must do something about it. NOW.

[Wirbelsturm]

'HOLD' mode means just that, HOLD the thrust levers as your rate of descent, speed and distance to the selected level is under your right hand.

By selecting the thrust you wish (the autothrottles being 'clutch' disengaged to prevent the autothrust messing about with your pilot selected thrust) you have the ability to control your speed and descent thus achieving clearances as requested by ATC. Pretty nice system if you wish to play with it.

The autothrottle will wake up at ALT capture and re-engage, if you disconnect BOTH flight directors the auto throttle will wake up in SPD mode. If you deselect only ONE FD and then level the aircraft before ALT capture mode then you're in trouble of your own making.

It's not a 'trap' per se, it's a 'feature' that is useful as long as you are aware of the limitations and, as has been said here previously, it's not a mode you should be using close to the deck and on finals.

:}

If in doubt, AP off, manual flying, both FD's off then back on again if they are giving you good info otherwise both off and fly the thing like an aeroplane!

[GlueBall]

Les Abend: The NTSB, in Chairman Deborah Hersman’s words, has been very transparent with the factual data of Asiana Flight 214.(....) It’s bad because the release of information allows the misinformed to reach biased conclusions without all the factual data. (ATC Watcher: "How true.")

Public discussions and speculations about an accident is a fact of life. It's impractical reality for the NTSB and its investigators to keep initial findings of facts secret until the investigation is complete, typically 18 months. The "misinformed" are not tasked in assigning probable cause.

[Elephant and Castle]

The underlying cause might be found in the answer to the following question:

What would have been the consequences for the PF if he had gone around earlier?

Obviously he would have avoided the crash but what would have happened to his training record, comand, promotion, etc? I have not flown in Korea but know some that have and acording to them the consequences of messing up (an approach during training for example) can be pretty harsh.

These are lessons that we learned long long ago. Why don't they sink in?

[ExSp33db1rd]

..................and fly the thing like an aeroplane!

"When In Doubt LashOut. Everything Forward For Speed"

It used to be - Throttles, Mixture, Pitch, Carb. Heat, Cowl Flaps etc. etc. now it's only throttles, can't they at least cope with that ?

[ATC Watcher]

Piltdown Man : Re comparing with TK/AMS.
Of course it is not 100% but for me it started and ended the same ;
not ideal ATC vectoring followed by a high and fast profile, resulting in an unstablized approach not interupted, one failure ( or trap) , then not monitoring speed,( or not noticing speed decay ) stall. ( or close to stall ) impact.

I'd like to know what happenend in their heads. This time we have a chance to know.

[Piltdown Man]

ATC - I do see where you are coming from. And I'll also add that neither of the crews were fully aware of the imminent danger they were in until it was too late. Asiana appeared not to notice and therefore did nothing, the TK crew noticed, but didn't follow up. Both tried in vain at the last moment to escape, but failed. It will be interesting to see what the Asiana crew has to say but I believe the biggest revelations in this incident will be in national standards and culture. Unless this very sensitive area is approached, this type of event will be repeated on a regular basis over the next few years.

Personally, the people to take the lead on this are the manufacturers and insurance companies (a rather un-holy alliance). ICAO are unlikely to mandate how an aircraft is to be flown but unless we improve our skill levels as an industry, we'll be parking a few more aircraft in usual places.

[RAT 5]

What would have been the consequences for the PF if he had gone around earlier?
Obviously he would have avoided the crash but what would have happened to his training record, comand, promotion, etc? I have not flown in Korea but know some that have and acording to them the consequences of messing up (an approach during training for example) can be pretty harsh.

Because they didn't go around and instead came damn near to killing >200 people I suspect his command chances have melted away and following consequences will be an a trillion times more severe than if they had. And what of the judgement of the trainer? Is he still a trainer? This a CREW screw up.

Personally, the people to take the lead on this are the manufacturers and insurance companies (a rather un-holy alliance). ICAO are unlikely to mandate how an aircraft is to be flown but unless we improve our skill levels as an industry, we'll be parking a few more aircraft in usual places.

I thought this was the role of a professional and sincere training department: and if they don't do it then the XAA's should be monitoring this and taking the lead. Where do the FAA & EASA stand on this issue? They are very silent. If this crash was found to be of a technical/design nature then whole worldwide fleet would be grounded until he problem was solved. It is a worldwide problem, many cultures and a/c types, and is in the human factors/training category. I don't see/hear the relevant authorities putting energy in finding the antidote. I wonder if they even acknowledge there is a problem. May be I'm wrong: let's hear it.

[ATC Watcher]

Piltdown Man : I agree with you here. ICAO won't change Annex 13 for a while to come, no need to look for help in this direction unfortunately.

Look, the vast majority of accidents we see today ( say last 15 years) are not anymore single human failures (e.g. Pilot error) but Organisational errors.( lot or small errors committed by a multitude or people all around )
Society is also changind and expect 100% safe travel, so when something happens someone must be to blame for negligence.
Add to this the culture ( a big factor in the 2 accidents we compared ) that everybody wants to avoid because of political incorrectness, and we are likely to get stuck in the present accident investigations model focussing on Technical issues and pilot errors.

Unlike Colgan, AF447, TK etc.. the crew this time is available, and if properly debrieffed, could help us a lot to change the current approach.

[Cows getting bigger]

Whilst it may have been dark, can we throw the Birmingham UPS crash into the same melting pot?

[flarepilot]

cows...UPS was an instrument approach in instrument conditions, in the dark and a non precision approach as well.


the asiana crash was a visual approach with the crew reporting the airport 17 miles out..

and I don't recall the UPS getting slow...low perhaps, but slow no.

asiana was low, slow ...in perfect conditions.

[DozyWannabe]

but FBW systems place "protections" and flight laws unknown from pilots.

Unknown - apart from where they are all explicitly specified in the manuals, that is, no?

[bubbers44]

Asiana was totally pilot error because a simple visual approach with no glide slope is a non event for even a student pilot. Three airline pilots couldn't do it?

[roulishollandais]

In my opinion, with good automation many of these problems should not occur. Good automation does not have traps, it is simple, the auto pilot mimics manual control pretty close

AP mimicsmanual control (with some improvments), but FBW systems place "protections" and flight laws unknown from pilots. Testing automation on the ground is much easier than doing it on airliners in the sky at 500 kt. In any case "good automation" requests to stop modifications and to product total description of every detail of the system BEFORE operational use. It seems that aviation industry does not respect these quality minimum rules
DozyWannabe I am surprised that you misunderstood my post concerning mandatory conditions for automation to work or fail (Cool Guys did it too), not how the Asiana crew flew that basic visual approach to SFO. I did not more mix PA and FBW. Are you suggesting that a visual approach depends on AP or FBW on that type of aircraft, on Books instead of basic gestual process? :}

[bubbers44]

What is gestual process, I have never heard of that term.

[RetiredF4]

bubbers44
What is gestual process, I have never heard of that term.


Basic aircraft handling?

[chrisN]

Bubbers wrote: “ Three airline pilots couldn't do it?”

I seem to recall mention of the 3rd guy (relief FO) calling out “descent rate” more than once. Correct? If so, was it a cockpit gradient issue that the two senior guys up front ignored him? Or the old issue of the audio channel being the first to get overloaded?

[A Squared]

If the accident aircraft had been on a lazy ten mile final ILS this accident probably wouldn't have happened.

As a verifiable fact, Asiana was on a "lazy" *14* mile final, below normal descent profile and at an airspeed below the gear and flap extension speed for a 777.

Seriously, why do people keep making this twaddle up about this being some kind of crazy slam dunk approach?

They were not turned in short.

They were not turned in high

They were not turned in fast.

Why do people keep insisting this was a factor?

[DozyWannabe]

DozyWannabe I am surprised that you misunderstood my post concerning mandatory conditions for automation to work or fail ...

I didn't misunderstand your post, in fact I wasn't replying to that part of it at all!

All I was saying was that your assertion that 'FBW systems place "protections" and flight laws unknown from pilots' is false, because the FBW protections and laws - as well as the parameters that trigger them - are right there in the manual.

Are you suggesting that a visual approach depends on AP or FBW on that type of aircraft, on Books instead of basic gestual process? :}

Not at all - I didn't even touch on that part! What I will point out is that you seem to be blurring the lines between FBW flight control systems and flight automation, which on any airliner equipped with both are two completely separate systems and completely different concepts.

At the risk of sounding like I'm trying to teach you to suck eggs, here's my basic interpretation of the concept:


FBW is simply a concept whereby the link between the flight controls and flight surfaces is electronic as opposed to mechanical or pure hydraulic
"Protections" in a FBW system are comparatively basic systems which will in most circumstances keep an aircraft that is already flying within a safe operating envelope
FCS "laws" are simply a shorthand for system configurations that keep the aircraft handling as close to normally as possible in the event of systems failures
FBW systems are *not* automation in the usual sense - they will not fly the aircraft for you, and they certainly won't prevent you from messing up an approach and landing!


As for flight management/autopilot systems - Boeing and Airbus source theirs from the same supplier - Honeywell - and always have, certainly in the last few decades. These systems work in the way yourself and Cool Guys describe.

[haughtney1]

Just imagine for a second, DEP ARR page, line select rwy in use..ext 10 miles.......add 50' to the runway threshold height and hey presto poor mans glideslope.... 3 seconds work :ok:

[RetiredF4]

Bubbers wrote: “ Three airline pilots couldn't do it?”

ChrisN
I seem to recall mention of the 3rd guy (relief FO) calling out “descent rate” more than once. Correct? If so, was it a cockpit gradient issue that the two senior guys up front ignored him? Or the old issue of the audio channel being the first to get overloaded?

The descent rate was a symtom of the primary cause, dropping low on airspeed. Therefore the relief FO should had named the real problem, a speed problem.

I dont´t think, the descent rate call was ignored at all, it may have caused the pilot to increase pitch, which agrevated the speed problem without having any noticable effect on arresting the descent.

I go with bubbers there.

[olasek]

the descent rate call was ignored at all, it may have caused the pilot to increase pitch, which agrevated the speed problem without having any noticable effect on arresting the descent. I would simply call it an energy problem (kinetic + potential energy). At some earlier stage in the approach they had excess energy, they set idle thrust to lose some of that energy but they never returned the thrust to a 'normal' position and they quickly transitioned from having excess energy to being very energy deficient, they could no longer trade altitude for speed (or vice versa), they were short on both. Energy management during approach - this is ABC of flying.

[roulishollandais]

DozyWannabe,
Thus we agree about difference between APand FBW. Probably many will agree : we may mimic the AP (mimicing human pilot the first) with confidence , but when the flight system is doing an autoland we feel very suspicious about aircraft's behaviour unless ceiling and visibility are beyond eyes skills and often we are surprised how it manages the thing! We would not have done that. FBW does not mimic the human pilot and it is really very frustating to share autority with the strange thinking of the missing algorithm maker near of the ground! Near of schyzophreny...

About your most loved manufacturor flight system's too many "laws", modes, sub-laws, and unnamed objects, gums' analysis is built on experience and I find zero good reason to think otherwise.

Being in a manual did never mean "not being unknown. by smart or stupid people.:hmm: Specially if it is not understood and the manual is often modified :ugh:

[roulishollandais]

Sorry to use that gallicism "gestual". I searched how to replace the word "gestual" and explain better what I was wanting to describe behind "basic gestual process". In French we have two words : "gestuel(le) (adjectif)" and "gestuelle (noun)". But I didn't want to focuse only on the "gestuelle". "Basic" and "process" are just so important.

I confirm to bubbers44 there is no such/analog existing official expression. Perhaps somebody will correct that fact and say it already exists with an other name?

"Basic aircraft handling" suggested by RetiredF4 is near from my aim, but I wanted to say that "Basics" is not only "handling" or, worse, "pushing buttons", but a real high performance dynamic system using many skills of human body and brain, in competition with FBW and automation. I understand that the structure of that system is a multiprocessor (IT science would say "multicore") controlled by some gestural algorithms.

I want to remind that the word "process" refers to "procession" (one after the other, it is that simple structure who allowed computors' expansion) , and check-lists and SOPs are "processes". These processes are written in manuals but the most of these piloting and managing flight processes are built with movements and gestures where all the senses are the sensors, and many body parts are the actuators.

All the human processes are interconnected during Basic formation in an actual network , with a great possibility of combinations and adaptation in time, greater of these of synthetic algorithms.

I agree that human pilot is not able to focuse during hours and hours. But he is able to focuse very well - if regularly trained - during shorter periods and transient parts of flight, see aerobatics, air combat for the best of our Dear PPRuNe's eagles. If something new happens the human has a greater capacity of invention that the computers who are known to be stupid like asses.

The AP is enough to help during steady parts of the flight (inter tropical zone is not the best place for meal and other rests). AF447 shows that FBW did NOT protect them.

The human pilot has a greater rate of error in repetition, and we know that if he starts a bad analysis he tends to stay in error unaware of the treat he puted on himself if time is missing to sit, think and try again.

But the human brain has much better performance facing complexity (if well selected and taught). That cockpit tasks' complexity is desserved by the five senses and many gestures done together in learned processes during basic teaching and regular training.

These basic gestural coprocesses conduced Neil Armstrong to put the foot on the Moon. At the same day a sovietic robot crashed not far away.

[DozyWannabe]

FBW does not mimic the human pilot

It doesn't need to - it's merely transmitting the commands given by the human pilot (or the autopilot) to the flight surfaces and engines.

About your most loved manufacturor...

There we go with the ad hominem. I am not partisan in that regard - I'm what a certain subset of geeks would call "Lawful Neutral". By that I mean I favour no manufacturer, but if I see something I'm fairly certain to be based on hearsay rather than fact, I won't be shy to point it out. For example - in your previous post you again refer to "FBW automation", when FBW and automation are two separate things.

Being in a manual did never mean "not being unknown. by smart or stupid people.:hmm: Specially if it is not understood and the manual is often modified

Perhaps if one cannot be bothered to stay current in understanding the manual, one should not be doing the job.

[roulishollandais]

ad hominem NO, ad homines :) Perhaps if one cannot be bothered to stay current in understanding the manual, one should not be doing the job.ad homines again ! Errare humanum est. Our threads are showing all along that understanding the manual is not so easy. And changing systems or only gains would need to have a new name, or version number not just the date to avoid confusions. Changing systems must be very very seldom.

Could you suggest a name for the non human part of systems (FBW and what you call automation in your Country) please? Untill your suggestion I shall call it "butterfly" :p to don't risk to be :mad:

[bubbers44]

Thanks for the clarification because in 50 years of flying have never heard the term. I have used automation as needed but never required it if not required for FAA requirements. It helps you keep up up on current events via newspaper. Level flight is quite boring

[220mph]

It would seem to this lowly PP that the simple solution to the "FLCH trap" is the LOTW manuever or simply follow the FTDA procedure.

That an entire flight deck was unable to Look Out The Window and/or simply Fly The Damn Aircraft remains to this day ... incredible.

This is not an "error", nor a "mistake" ... it is not "accidental" ... nore even simple inattaention ... t is an outright, abject, and in my opinion criminal, failure.

If you lose control of your car and kill someone you are charged with criminal vehicular homicide or a myriad variations of that.

This failure in my opinion was no different. In fact it was worse, far worse.

[IcePack]

Maybe their is more to this accident than the obvious, as the crew are alive to argue their case, maybe waiting for the final report would be prudent!
Let's be honest they are part of the brotherhood so give them a break!

[Capn Bloggs]

Chuck 'em in jail, eh 220mph? Good one.

Better hope you're not on the next aircraft that does the same if all we do is chuck the pilots in jail if they stuff up.

[ATC Watcher]

220mph : This is not an "error", nor a "mistake" ... it is not "accidental" ... nore even simple inattaention ... t is an outright, abject, and in my opinion criminal, failure.
Good grief ! and we ( and I ) spend all this time trying to convince managers, CAAs and Public Prosecutors that we shoudl look at systemic causes and not individual ones !

But fortunately, looking your profile and then reviewing briefly the 8 posts you wrote so far , I'm glad to see that you are obviously not a pilot, and probably not related to aviation either.

[J.O.]

If you lose control of your car and kill someone you are charged with criminal vehicular homicide or a myriad variations of that.

Just because that is how it is done doesn't mean that it's how it should be done. It all depends on what your ultimate interest is in terms of outcome. If all you care about is getting your pound of flesh, then this approach may heal your pain - although I highly doubt it. This approach also fails to do anything substantive in preventing it from happening again, nor does it consider intent.

If on the other hand you are interested in safety and prevention of similar occurrences, then you need to take the approach that is (generally) taken to aviation accidents. This approach takes systemic issues including policies, procedures, training and even cultures into consideration to try to understand why it made sense to them at the time. If such an approach was taken to road accidents, I suspect that we'd see many times more training and changes to vehicle and road design that would ultimately result in a safer system, but that stuff costs money and it seems no one is willing to pay for it. So instead we turn a blind eye to possible improvements until a particular section of road experiences multiple deaths. Then we decide to spend some money, but the people who were treated as criminals for past accidents at those locations never get to go back in front of a judge for reconsideration.

[fg32]

Am I the only one who has closely examined the existing video footage?

One can clearly see the moment this person is crushed. The vehicle manoeuvring, the fireman who discovers the body, looking down appalled…signalling for help, others running over, frantic animated conversation, covering the body.

Correlating this with other viewpoints one can determine with great precision not only that this occurs in exactly the correct position, but, I am sorry to say, that there was no foam covering the body at that time.

I guess no-one really wants to know this.

This is of course, only my personal conclusion, from running the available footage through many times, and correlating with various stills and helicopter footage. But the actual sequence of events, from the long-distance high-power footage from across the bay…well..once you comprehend the fire-crews reactions, it becomes crystal clear.
Find the footage, run it for yourself.

Sadly, I doubt this post will survive long.

PS. Don't bother looking unless you can use the highest available resolution…only then can you read the body language of the tiny figures, see the waving arms and the desperate conference with superiors

[aterpster]

fg32:

I would presume the San Mateo County District Attorney's office reviewed all available evidence, including interviews, before they concluded that a criminal filing was not warranted.

The San Francisco Fire Department may, or may not, have sanctioned the employee in accordance with the employment contract. That would be confidential under California law.

The NTSB will eventually have something to say about the matter.

[LiveryMan]

That an entire flight deck was unable to Look Out The Window and/or simply Fly The Damn Aircraft remains to this day ... incredible.

You might find this (http://preppersuniverse.com/the-ominous-facts-regarding-korean-airline-pilots-by-a-former-instructor/) interesting.

[olasek]

That an entire flight deck was unable to Look Out The Window
We actually don't know where they were looking, maybe in fact they were looking out the window but not looking at their instruments, we simply don't know. Whether they were 'criminally negligent' is another matter, FAA has history of going after pilots whom they find 'criminally negligent' but a bar for this is pretty high, doesn't happen often in airline flying.

[aterpster]

olasek:

We actually don't know where they were looking, maybe in fact they were looking out the window but not looking at their instruments, we simply don't know. Whether they were 'criminally negligent' is another matter, FAA has history of going after pilots whom they find 'criminally negligent' but a bar for this is pretty high, doesn't happen often in airline flying.

If criminal charges are filed against the crew, perhaps it would be by Korea.

[Machaca]

fg32:

This San Francisco Chronicle article (http://www.sfgate.com/default/article/Video-sheds-light-on-Flight-214-passenger-s-death-4706576.php) and its (non-graphic) stills from the helmet cam video will enlighten you on the timeline of events and the presence of significant foam.

[olasek]

If criminal charges are filed against the crew, perhaps it would be by Korea. Correct, FAA doesn't even have jurisdiction over foreign pilots.

[roulishollandais]

in your previous post you again refer to "FBW automation", when FBW and automation are two separate things.
My mistake! Thank you for pointing it. I edited my post #121with that erratum : Please read "FBW and automation" instead "FBW automation".
I hope the December NTSB meeting will add "FBW" to "automation" in his study about airlines, SOPs and pilots "automation" over-addiction.

@LiveryMan
Your joint document explains many things and the danger of robot pilots. It is not only Korean. Fake certifications and licenses exist in many countries opening the door to the "butterfly" lobby.

[jetjackel]

WTF? Just retired. Been listening to this post since it began. Been on pprune since 2000. Know SFO well. Did my initial training and cert. at San Carlos in 71'. WTF? Joined Korean Air in Oct of 97. Got fired Jan 98'. Guys are screwed up. Culture rules the behavior.

The incident is beyond "stupid". 20K hours plus in the cockpit in CAVOK. What else should we train them for? They need to be removed. Period.

Good job Delta. This accident indicates it's even worse then better since Delta. Same old "****" over the years. Need to get out of the culture. It's not only KAL. Worked for Cebu Pacific Airlines, Bouraq Indonesian Airlines, United Airways in Bangladesh, Spirit of Manila Airlines. Culture problems, all of them. "Ain't" going to change until Asian airlines implement changes extending their culture to blend with "aviation culture" to the highest degree than can absorb.

It's only about "communication" and following SOP's in the cockpit. Good luck.

How many expats work in Asia?............

What are "we" professionals doing? Shut this post down. Respect and maintain the professionalism of our occupation. This post isn't worth the words. The accident looks like a Cessna 172 crash.

[roulishollandais]

In order to sell more aircraft , airliner manufacturers , looking for new monopolies on the world, wish to have themselves the authority to prescribe the qualifications of pilots, instead the administration of control, airlines and critical and anxious pilots and their unions.
In countries where the democratic control of aerospace is low , such as South Korea in question , this is already the case .
In countries with strong aviation tradition like France , operations have recently suffered the dictates of manufacturers.
At crashes trials the notion of both criminal and civil liability is questioned by international teams of brilliant lawyers in the service of this ultra -liberal aerospace where the status of the Captain is challenged by the prominence given to systems computer on board as a lever to destabilize the old airmanship,, whatever the cost in human lives concealed by the opaque and corrupting system .

[DozyWannabe]

In order to sell more aircraft , airliner manufacturers ... wish to have themselves the authority to prescribe the qualifications of pilots...

Please elaborate with examples if you could.

To the best of my knowledge, manufacturers don't do anything of the sort, they just supply a demand to their customers.

In countries with strong aviation tradition like France , operations have recently suffered the dictates of manufacturers.

Again, please provide examples if you have them.

If you are referring to recent revelations regarding training and heavy reliance on automation by some airlines, then that is coming from the airlines themselves - not the manufacturers.

[olasek]

whatever the cost in human lives concealed by the opaque and corrupting system .
Sorry, I don't see a corruption here, perhaps the system is imperfect but it isn't corruption yet.

[bubbers44]

DW, I agree the airline and pilot should make sure they can do a simple visual approach.

[DozyWannabe]

@bubs - Quite. Personally I'm not sure where RH is going with the automation talk, as even on the most advanced airliners pilots will be expected to shoot ILS and visual approaches manually on a fairly regular basis.

One thing I would like to see, though, is fostering a culture of "no harm, no foul" co-operation - such that a pilot should be free to admit they're struggling in that situation and hand over/go-around accordingly without the threat of a permanent blot on their record.

[roulishollandais]

I'm not sure where RH is going with the automation talk
A bad neighbor is a misfortune,but a bad flight computerized system is hell and thousand deaths. I already said that A FCS was a bad copy of the Viper.I said too that the Effective FCS had to respect math conditions and rules of observability and controllability. I added some posts ago that human gestural processes constitute a dynamic system. That human gestural algorithm can lead human piloting or human limited by "butterfly" piloting. In any case observability and controlability math rules must be respected finaly. If the bird gets a *butterfly* and IF these rules are not respected we have a bad system no matter A or B :{:mad:.

My ref :
- *butterfly* is a friendly wink to theory of chaos, but I accept an other proposition
- The word "protection" must be replaced by "limitation"

- Freedom does responsibility (civil and criminal). No responsibility of pilots in trials you are claiming requests no freedom of decision of the Captain
- Operator's manual suppressed and replaced by Manufacturer's manual (Radio France-Inter yesterday ~10:20)
- Cf Declaration of Me Daniel Soulez-Larivière
- Lack of sanction against frauding French pilots I already told
- Writing of rules of sound limits in European airports to sell Airbus to ex-sovietic world and pressures on ICAO to get them

[olasek]

Hello Frenchman - the way you write and construct your phrases - I don't have slightest clue what you are trying to say.

[Tipsy Barossa]

L




Problems with Koreans having the heads up from their fellows for their sim pc? Check this out. There is a brig. gen patricia halftrack who can procure alteon checker's sim check operating instruction notes! Scary how corrupt the system has got even amongst the expats after I left!



totempole

Join Date: Jul 2009
Location: Nanaimo
Age: 65
Posts: 24
Parker pen pilot hours...oh, oh, oh you guys must be making fun of brig. Gen patricia halfback of " swiss air/crosshair " fame now holed up in incheon! Not nice, you know because he is such a nice volunteer boyscout! Guys can even get alteon instructors' sim check operating notes from him, small wonder so many newbies ace all the sim checks at jungseok building next ti inha hospital !

[Lonewolf_50]

There we go with the ad hominem. I am not partisan in that regard - I'm what a certain subset of geeks would call "Lawful Neutral". By that I mean I favour no manufacturer, but if I see something I'm fairly certain to be based on hearsay rather than fact, I won't be shy to point it out. For example - in your previous post you again refer to "FBW automation", when FBW and automation are two separate things.
Not quite, DW. FBW is a form of automation. It does things under computer control, often times without direct input from the pilot. A classic case in point is the horizontal stab in the S-70 class of helicopter, or the flight controls on the F-18 Hornet which, without frequent computer sensed and controlled corrections, goes unstable.

Your issue may be the problem of conflating FBW and autopilot far too often. You can have AP functions with or without FBW. (See the coupled SAR or Dip approach in the old SH-3 Sea King for a primative example ... )

[DozyWannabe]

Not quite, DW. FBW is a form of automation. It does things under computer control, often times without direct input from the pilot.

In strict technical terms there's a bit of a grey area, certainly - but not all FBW implementations do that. If you want to go with that definition of automation - i.e. anything that is not directly and consciously controlled by the pilot, then everything from the old cables, cams and counterweights, through hydraulic valves to modern digital FBW could also be considered "a form of automation".

Your issue may be the problem of conflating FBW and autopilot far too often.

Spot on. In a traditional sense, the aviation term "automation" tends to refer to anything which actually commands the flightpath and trajectory of the aircraft with no intervention from the pilot other than the initial setting. By that measure, FBW doesn't qualify because it's simply translating control inputs to the flight surfaces just as the old mechanical connections did. It may be more advanced technologically, and operate in ways that earlier systems could not (e.g. using engine power to assist maneouvering), but it's essentially no different in terms of the task it's performing.

[gleneagles]

L




Problems with Koreans having the heads up from their fellows for their sim pc? Check this out. There is a brig. gen patricia halftrack who can procure alteon checker's sim check operating instruction notes! Scary how corrupt the system has got even amongst the expats after I left!



Quote:
totempole

Join Date: Jul 2009
Location: Nanaimo
Age: 65
Posts: 24
Parker pen pilot hours...oh, oh, oh you guys must be making fun of brig. Gen patricia halfback of " swiss air/crosshair " fame now holed up in incheon! Not nice, you know because he is such a nice volunteer boyscout! Guys can even get alteon instructors' sim check operating notes from him, small wonder so many newbies ace all the sim checks at jungseok building next ti inha hospital !


Cease and Desist! You're opening a Big Vat Of Worms!:=:=:=

[robert f jones]

Thank you for that, I thought for one moment, reading the French gentleman's post, I was losing my sense of understanding plain English.

[Chuck Canuck]

Problems with Koreans having the heads up from their fellows for their sim pc? Check this out. There is a brig. gen patricia halftrack who can procure alteon checker's sim check operating instruction notes! Scary how corrupt the system has got even amongst the expats after I left!

Watch it! " Loose Lips Sink Ships ":}

[220mph]

J.O. - thanks for the reasoned response. My point was not to criminalize all mistakes and errors - I agree that a system that encourages self-reporting in attempt to identify and address potential systemic issues is a clear value.

That said in my personal opinion there needs to be limits. Where do you draw the line? Is there any level of mistake, error, or more important lack of competence which rises to an actionable level then?

If there are minimal or no consequences no matter how egregious the act - what incentive is there to correct behavior?

And I'm not sure it's even the pilots who should be held accountable. From a myriad of commenters here and elsewhere this lack of competence in the most basic skill sets seems fairly well known. Clearly company officials are aware, considering their attempts at new outside blood in training/cert areas.

Obviously those efforts have not been successful. Glaringly serious deficiencies in basic flight competency still exist.

The closest experience I have in transport aircraft is a cptr flight sim. That said I would be fairly certain if you put me or someone similar in that cockpit we would have done at least something at some point during that descent ...

Perhaps we should at least consider a moderated approach - where most actions are protected, but also were gross negligence can cause pilots and perhaps more important their companies at risk of prosecution for true negligence?

[J.O.]

220:

Fair points and some good questions. I believe we will find that culture played a significant role in this accident, but whether the NTSB will raise findings against that in their final report remains to be seen.

A fundamental problem that many have trouble accepting is that what you and I would think to be unacceptable in a cockpit culture - i.e. the Captain must be open to questioning from his underlings - is extremely hard to accept in some cultures.

The challenge is in finding black and white definitions for incompetence or negligence for something that is clouded in myriad shades of grey, particularly when it comes to culture. Our world is full of differences that often pit "ours against theirs" in a never-ending debate that usually fails to be resolved due to cultural differences. Much of the world rails at the ancient hunting practices used by Inuit seal hunters in eastern Canada. In their mind the only solution is an outright ban on those practices. Yet most of those same complainers would think nothing of sitting down to a nice meal of beef or chicken that came from a slaughter house where similarly abhorrent killing practices occur, but they are done behind closed doors. Where are the calls to shut down the hundreds of meat packing plants? Of course there isn't such a call from most people because sitting down to that nice steak dinner is a cultural norm - including how it landed on their plate in the first place. But honestly, which side is right in that debate? Who decides?

If we punish this crew for behaving the way centuries of culture have taught them to behave, are we really acting in the best way to prevent it from happening again? I think not. Cultural change takes generations. Any effort to change culture is usually unsuccessful when it is driven by punishment from a side that claims to "know better". Have Western efforts to curb extremist terrorism been advanced by bombing innocent women and children? I think not. Cultural change is best gained through education and setting positive examples, but at the end of the day those making the change have to "want" to change.

[FlexibleResponse]

Old 19th Nov 2013, 12:13
J.O.

Join Date: Feb 2006
Location: On the dark side of the moon
Posts: 670

220:


...If we punish this crew for behaving the way centuries of culture have taught them to behave, are we really acting in the best way to prevent it from happening again?...

YES, YES and YES again.

It is not acceptable to the modern World to accept the excuse of thousands of years of ancient cultural thinking for killing innocent International passengers in this day and age.

Get with the current expectations, or get out of the business...QED.

[J.O.]

Good luck with that.

[WhatsaLizad?]

You're right J.O.

Maybe us Yanks, Aussies and Kiwis should have stood back and let the Japanese catch Chinese/Korean/Vietnamese/Filipino babies on their bayonets, and use our soldiers for bayonet and Samurai sword execution practice nstead of lighting them up almost 70 years ago.

After all, it would be only 30 years or so until they felt comfortable and learn from gentle guidance that sort of behavior isn't acceptable.

It wasn't long ago when we in the west had the same cockpit culture, but learned to change to stop the bloodletting.

You do illustrate a point in world history as to why the western world has seemed to dominate every other culture in warfare. That would be despite our near barbarian status compared to the early advances of the Islamic world and the Asian cultures going back a couple of thousand years, we seem to adapt to what works best quickly no matter whose idea it is. (not always as Uncle Ho proved, as well as Yamamoto V1.0)

Let me guess as to how long our operations would last in other parts of the world if daily ops splattered their airports with Boeing, Airbus and their citizen's body parts.

Not long I'd guess.:ugh:

[J.O.]

I'm not sure why I bother. Clearly some folks refuse to read my comments in the context they're being delivered. I am not for one minute making excuses. I am simply trying to offer real solutions for change. Punishment won't work. It rarely does. If it did, the first hanging in history should have been enough to prevent all future crimes against our fellow man. How's that going?

Whether you, I or anyone else likes it, we live in a world of different cultures. While you may be right that the "West" is more modern and willing to adapt to change, ours is not the only way things get done this world. In fact, many of our own cultural norms are completely effed up but it's unlikely they'll change any time soon. Gun culture in the USA is one classic example. So is the Walmartization of our economies.

The issue of "save face" and its affect on cockpit culture is hardly new, nor are Western attempts to drive it out of the flight deck. Clearly we have yet to succeed. We can get all huffy and close our doors to foreign cultures who refuse to adapt, but how does that protect our fellow citizens when they are traveling around the world and have no choice but to travel with those outfits? Or we can analyze the issue calmly, rationally and without emotion and offer up constructive solutions and lead by example.

[HeavyMetallist]

@J.O.:

Entirely agree with that post. It's unfortunate that it stands out in contrast to so many largely ignorant and culturally arrogant posts on this accident.

[Lonewolf_50]

In other news, and releted to this crash, the FAA seems to think that there are too many children of the magenta line in cockpits (http://usnews.nbcnews.com/_news/2013/11/19/21537851-airline-pilots-depend-too-much-on-automation-says-panel-commissioned-by-faa?lite)these days ...

Automation dependence. I guess it's here to stay. Make sure your life insurance premiums are paid and up to date.

[RAT 5]

but now even the FAA and the pilots union agree that pilots need to avoid “automation addiction” and keep their manual flying skills fresh.

And that is going to require a MAJOR philosophical change in the Flt Ops of many airlines I'm aware of. How is an XAA going to demand that? If the FLT OPs don't want to incorporate this idea due to the occasional screw up and G/A = money & time, then I suspect they'll stay with the automated approach philosophy. This is perceived to be the more safe attitude on a daily basis. If the poo doesn't hit the fan then those lost or latent skills will never be needed. A bit like why do we still have an appendix? That seems to be the philosophy that has evolved during the massive expansion over the past 15 years. There is no time to train this skill in the beginning. A minimum time TQ and get on the line as quickly & safely as possible.
Previously airlines were more quiet in their expansion, and from a few national bases. The training hens could keep a beady eye on their chicks and on the daily operations. It was easy to have a pilot culture, and indeed many charter airfields demanded it. Now, with rapid expansion with many overseas bases with guys from a multitude of backgrounds, it is not possible to have a live daily oversight and build the pilot culture. Neither, with so many ILS's and radar and VNAV/LNAV NPA's & RNAV/VNAV/GPS approaches the Mark 1 eyeball is no longer a required parameter of the modern 'operator'. Hence rigid trained monkey SOP's especially with the expansions begin serviced by cadets. The FAA might want a career progression via the regionals and commuters onto the airlines, but European airlines want raw cadets into the cockpit. No bad habits to unlearn.
They should change the name of the profession to be honest.

[Gretchenfrage]

In such discussions we should demistify or forget about the modern excess of political correctnes concerning the cultural aspect. It seems that simply raising it today puts you in the racist corner and your point of view is discarded.

There is a cultural component and it should be raised, highlighted and, if possible, tackled.

Take for example Switzerland with its liberal arms law. You can see a 16 years old on his mopeds carrying a gun to the gun-range for training (amunition is only distributed there). Each reserve soldier has his weapon at home (with sealed ammunition). There is no big problem with that law.
The same situation can be observed in Lybia today. It is however illegal and with devastating effect.
Where would you rather be or whom would you rather trust?
The answer is obvious and it is due a huge difference in culture, not to say civilisation. We would all agree that it should not be allowed in Lybia, but can continue in Switzerland.

Ask yourself why.

Extending this comparison to civil aviation, we can conclude that the Western culture, or civilisation has brought us the latest generation of airliners. With it came inseparably the design, layout and philosophy of operation of these machines. If another culture has issues and problems to adopt and adapt to this philosophy, it is not necesseraly that their culture is inferior or wrong. Pretending that is wrong and inappropriate, just as insinuating that raising this issue automatically includes such a pretention. It is stating that people with such cultures should maybe not operate Western designs. Either they should design their own machines and sops, adapted to their cultures, stay away from the other if not willing or able to fully adopt the appropriate “culture” during operation.

Important:
It might be that different technologies and sops could reach similar safety standards. Up to today there have been faint shots at that (Russian or Chinese technology/sops), but they have not proven an equally high safety standard up to now, for whatever reason is not the issue here.

Therefore we are not to be treated as racists or supremacists when asking for adoption of the adequate culture in Western designed airliners.
Experience shows that this is a reasonable and safe demand.

Stop beating around the bush and face the facts. In the end we would do these cultures a better service to address the problem straight on.
And we will do safety a much bigger service.

[WhatsaLizad?]

J.O.

That last post was far more clear to me.

I do agree that there isn't a 'one size fits all' fix that will work with all cultures.

[edmundronald]

Maybe asking the locals if they are happy with the control design and the training would be an interesting and positive first step in cultural awareness :)

One of the impression I get from posts here, especially critique of Airbus is that pilots are presented with controls and procedures that are set in stone tablets dropped from the sky.

Re. safety culture, ask yourselves whether you would prefer to be SLF on a Russian Soyouz, or on board a US Space Shuttle? Was that an issue of technology or of culture?

[Cool Guys]

I agree with JO and the responding posts.

People’s basic personalities are the same everywhere, they do not change depending on the race whether it is Western, Asian or Negro. But cultures are different, cultures are different depending on their history. The history influences the person’s education from the time he is born which results in his different ways of doing things, different importance’s etc. This is not saying any of these differences are right or wrong, they are just different. Any resolution of a difficulty resulting from a differing cultural aspect is generally simple to resolve. Respect the differences, be polite, listen, be interested, try to understand, learn.

I think “saving face” is not particularly understood. Ultimately it is not a cultural issue, it comes from a person’s basic personality but it is exasperated by cultural differences. Perhaps it comes from an underlying self doubt, resulting in a slight embarrassment that the Korean culture is presently behind the West from a technological perspective. This is not helped by a Western tendency to pontificate.

From my experience the Korean people are very smart and as a culture they are very willing to learn. With good training based on respect and understanding, any backwardness in their safety culture I am sure will disappear over a short time.

[A37575]

With good training based on respect and understanding, any backwardness in their safety culture I am sure will disappear over a short time.

You are too kind and too optimistic. To use a modern term, it could be argued by those who fly with Korean pilots that these people have a strong and disciplined culture - quite irrational by Western mores - that is hard wired into their brain from a young age. Blind obedience to authority and a suspicion of all foreigners. No - in flight safety terms this culture will not change, ever.

[Lonewolf_50]

For A37575:
Is this hard wired obedience element of their culture the reason why Koreans are so damned good at competitive video games? I'll point to Starcraft, Starcraft II, and League of Legends as three competitive video games (for money, as in 1 million split five ways for the winning team in the LoL championships this past year) played internationally where the Koreans are the acknowledged best (as USA has been in basketball for ages). My son explained to me how, during this past year, it was the better Korean teams that established a better strategy model that changed how the game is played. Since it is played on 5 man teams, there's an element of CRM (teamwork, team role definition, and team contribution) involved there for success at the highest levels, just as in basketball.

Or is there something else?

Is it that there is a training system that works for that particular kind of cognitive and motor skill combination that works so well in Korea? (Hmmm, cognitive and motor skill combination ... sounds a bit like flying, doesn't it?) Gee, developing a good team (CRM) is Well Within Korean cultural models. The money talks, the rest walks. ;)

Gretchenfrage's point on the culture and cultural assumptions behind aircraft and system design are a point well made.

Look at the cultural assumption made in designing the A330, and the presupposition that no pilots will have the aircraft at 60 knots at altitude. (AoA signal clipped/filtered ... )
That pilots won't stall a passenger liner at 35,000 feet. This cultural assumption leads to how the testing and training are developed and funded. 228 dead ... no Koreans at the helm.

[DozyWannabe]

Look at the cultural assumption made in designing the A330, and the presupposition that no pilots will have the aircraft at 60 knots at altitude. (AoA signal clipped/filtered ... )

No, no, no - the <60kts AoA NCD limitation was nothing to do with an air/ground assumption. It was simply an encoding of the vane manufacturer's specifications - i.e. that the vane could not provide reliable data without 60kts of forward airspeed. The limitation was intended to prevent junk data fouling the FCS calculations, nothing more.

[EDIT : As I said in the 11th AF447 thread, I'd be very interested in seeing how all currently operating commercial airliners' sensory, control and warning systems behave when subjected to a flight profile that extreme - the problem is that no simulator can accurately replicate the conditions, and no test pilot in his right mind would risk flying that profile for real!]

[Piltdown Man]

Therefore the joint objective of all airlines should be to bring the teams skills of playing video games to the airline world. I'll will suggest that the winning Korean team had a very flat command gradient. And if this attribute of a successful team can taken on board so to speak, then they'll be in a position to win in flying operations.

[tdracer]

Investigative Hearing: Crash of Asiana Flight 214, San Francisco, CA, 7/6/2013 (http://www.ntsb.gov/news/events/2013/asiana214_hearing/index.html)

The National Transportation Safety Board is convening a 2-day investigative hearing to discuss the ongoing investigation into the crash of Asiana Airlines Flight 214 and to gather additional factual information. The hearing, which will be held December 10-11, 2013, at the NTSB's Board Room and Conference Center in Washington, DC, will focus on pilot awareness in highly automated aircraft, emergency response, and cabin safety.

NTSB public events are also streamed live via webcast (http://www.capitolconnection.net/capcon/ntsb/ntsb.htm).

[Cool Guys]

@A37575

Blind obedience to authority

This comment almost made me fall out of my chair laughing. The opposite is closer to the truth. Even the previous Korean president commented that the Korean people were a noisy bunch, referring to the high number of noisy protests about various issues. In 1980s most of the population including Buddhist monks protested against the then ruling repressive dictatorship, forcing democratic reforms and freedom of speech. Every year farmers get on their trucks and tractors and take to the roads forcing major delays on the motorways in protest about something. In the streets of Seoul it is not uncommon to see bunch of people with a loud hailer protesting about the government or some conglomerate.

There has gotta be other reasons for this "safty culture" issue.

[manincrz2937]

Whenever I see some “proudly born in western culture” guys are so obsessed with finding cultural problem in this kind of accident. It just makes me wonder.
I am really curious what makes them so proud because his passport is just belong to one of the so called “western countries”
Do they really believe current cockpit culture is so different between western and non-western pilots?

I wonder how many guys (who pointed out cultural problem in OZ214) personally or actually know pilots of oz214.
Is there anybody who has ever met or flown together with those crews?
Is there anybody who can describe each OZ214 crew’s personality enough to pick ancient stubborn Asian attitudes in their everyday flight?

Somebody may be able to satisfy his “so proudly western born self-ego” by criticizing cultural problem, but he should realize that it just makes him ….looks like pervert who can’t be satisfied in his current status.

Don’t Jump on hasty generalization.

I have flown with many guys from many countries.
Each person has his own character.
Not all the western guys are reasonable, not all the asian guys authoritative.
Some of them are…some of them are not.

It is pity to see pointing finger on cultural problem whenever non-western pilot’s aircraft down in somewhere.

Can you blame Dreamlifter landing in wrong airport on cultural problem?
Don’t say it was different because Dreamlifter had no casualty.
More than a decade ago, bunch of Chinese student pilots made one municipal airport closed because they made touch and go with wrong frequency in adjacent airport.

It is easy to blame…..especially in online forum….but criticizing based on wild speculation doesn’t make any progress.

[barit1]

Now THAT speaks for itself.

Volumes.

[ExSp33db1rd]

.............any backwardness in their safety culture I am sure will disappear over a short time.

Define 'short'

They've been having aircraft accidents/incidents for quite awhile now.

[Willie Everlearn]

I can't wait to see how all the new Asian and sub-Continent MPLs make out in this 'brave new world' of fast tracking the much less experienced pilot onto a wide body flight deck. :ugh:
No sir.

This brazen P2F crowd have serious competition now. :eek:

Cultural issues be damned says I.
No siree, I can't wait.

[barit1]

One of these days I've got to compile a MTBC (Mean Time Before Carrr-runch) of aircraft of some various carriers. I have some preconceived idea of how they will rank, but hard data will tell the tale.

[Centaurus]

There is a cultural component and it should be raised, highlighted and, if possible, tackled.


Flight International 12-18 November 2013, has published a letter to the Editor on the subject. Full marks to FI for doing so and risking the wrath of the political correctness brigade. The letter is headed "Political Correctness in Aviation" by Angus W Hogg of Horsham, UK. It is a very good letter indeed. Quote:

"I read with interest Bob Owen's call for political correctness to ensure no 'racial and cultural slurs` are used in matters of flight safety (Flight International, 22-28 October). Such lofty ideals have no place in modern aviation where hard facts are valued more than sacred cows.

The harsh reality is that South Korea has an unenviable flight safety record, and to pretend otherwise would be to guarantee the perpetuation of such a tragic legacy. It is a harsh fact that some parts of the world have a significantly worse safety record than others and cultural factors are very significant in explaining why.

That fact is clearly very distasteful to Mr Owen but, to those more interested in truth than dogma, it is a vital piece of the jigsaw which explains so many of the unintended consequences of poor aviation practice. Here in the West, we have much to learn from other cultures. While we should never be complacent, when it comes to aviation safety we have much to offer the rest of the world.

Our safety record has been built up through the ruthless analysis of numerous tragic aviation accidents down the decades. We have wisely chosen to leave no stone unturned in the pursuit of safety. Any attempt to have no-go areas for air safety investigation for fear of offending a particular race or culture does a huge disservice to the travelling public and condemn thousands of innocent people to die unnecessarily in the future.

Would it not be the brave thing to do to admit that culture is an issue and just address it head-on? Those unwilling to learn the lessons of history are destined to repeat them."
Unquote.

The writer of this letter is to be applauded for what he has written and to Flight International, thank you for publishing it.

[TeachMe]

Cool Guys,

You mention a few points, but fail to understand that the protests you mention were largely the masses following (blindly) a few leaders.

I lived and worked in Korea for 13 years (and married a Korean woman!), so trust me when I say there are CLEAR relationships between this accident (what I have read of it) and cultural 'values' in Korean society, including a lot of 'blindness'.

[jimjim1]

@barit1 mentioned
One of these days I've got to compile a MTBC (Mean Time Before Carrr-runch) of aircraft of some various carriers. I have some preconceived idea of how they will rank, but hard data will tell the tale.

This being the Internet someone has already done the job, more or less.

The web site is still up but the detailed crash rate page is now only available on the wayback machine. Maybe he got a letter?

I'll try the links but I may not get them to work since pprune often seems link-shy.

Airline accident ratings (http://web.archive.org/web/20130115111507/http://planecrashinfo.com/rates.htm) Has detailed stats - wayback machine 15 Jan 2013.

Airline accident ratings (http://www.planecrashinfo.com/accidents.htm) Current page, a bit less info.

Plane Crash Info.com (http://www.planecrashinfo.com/) Home page.

[Cool Guys]

Teach Me,

I understand what you are saying. But it wasn’t “Blind obedience to authority” that “will not change, ever” as what @A37575 was indicating. We gotta analyse this issue a bit more accurately that that.

The article in Flight International that Centaurus posted pretty well hits the nail on the head.

[aterpster]

The FAA has recently released a thorough analysis of automation issues and flight path control. The link below goes to the FAA overview of the report and provides a link to the actual report in PDF format:

Fact Sheet ? Report on the Operational Use of Flight Path Management Systems (http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=15434)

[hptaccv]

Can someone translate the FLCH trap on the 777 to 747 terms? Is it the same system design?
In my understanding they leveled off with FLCH (A/T in HOLD), which would change to SPD / ALT mode, or would it not? Intercepting GS would give them SPD & G/S.
thanks..

[Wizofoz]

It would change to SPD/ALT IF they captured the altitude in the MCP.

If they were already below that altitude, or if they had put 0 in the MCP, it would not have changed from HOLD/FLCH.

Yes, intercepting the G/S would have given then SPD/G/S, but the ILS was not radiating.

[hptaccv]

..not that I advocate 'flying' that way...

What's the idea behind using FLCH in that situation? Even if I wanted to keep in the autopilot without ILS radiating (thanks), wouldn't the mode of choice be SPD / V/S ?

[Lonewolf_50]

My first reply went into the aether ...
Therefore the joint objective of all airlines should be to bring the teams skills of playing video games to the airline world.
Hasn't that already begun? :confused: FWIW, video game skills in competition require an intense alert state, which is about the opposite of monitoring an aircraft being flown by HAL. The interactive natures of the processes are different.
I'll will suggest that the winning Korean team had a very flat command gradient.
Yes. This suggests to me that the CRM one would prefer to see in a cockpit is not beyond the reach of our Korean friends.
And if this attribute of a successful team can taken on board so to speak, then they'll be in a position to win in flying operations. Yes, as true there as anywhere. Teamwork wins. :ok:

[misd-agin]

Some carriers, or pilots, are against using V/S.

Not uncommon to hear "use FLCH in the arrival area." *If* that thinking is followed blindly this crash shows the problem that could occur.

[No Fly Zone]

Idle speculation about the principal causes of this and most other aviation incidents steams my blood. When our own NTSB feeds that fire and contributes to the speculation IMO that is even worse. In the case of Asiana 214 it is probably fair to suggest that a very thorough examination of the items listed below be conducted; they are normal parts of a complete investigation. But some of the 'official' remarks made by NTSB officials seem to fuel the fire without offering any significant facts - yet. IMO, everyone at NTSB should take a hefty dose of their own medication and just Shut Up! It may well be 18-24 months until a final report is issued. Short of a major, interim finding that could affect other flights, we have to wait for their report and they should Shut Up until they are ready to issue that report.
IMO, some of the items that require extremely thorough investigation are:

Human factors (CRM practices and appropriate and correct use of automation) and
Automation functions - whether the gizmos worked as expected.
I can wait. Why can the NTSB not wait?:ugh::ugh:

[lomapaseo]

everyone at NTSB should take a hefty dose of their own medication and just Shut Up

Please don't confuse the technical investigating arm from the political appointees approved by congress.

One is political and expected to stimulate the publics interest that someting will be done when all is said and done. That is the purpose of the hearing.

[porterhouse]

and they should Shut Up until they are ready to issue that report.I disagree.
There is public demand for basic information, however fragmentary, specially in high profile cases, they understand it. The transparency of their investigation is in their status. Would you want to wait a year for the final report to find out that the train operator in NY crash was asleep at controls, I would not. Also whatever info they release is done in fairly deliberate fashion, no name calling, no gloating, no journalistic hyperbole so common in the media, etc. I think they handled situation quite well and the final report will come.

[flarepilot]

agree with porterhouse


it is quite possible that the mere mention of the speeds in the popular media may have prevented another crash and some pilots to wake up and pay attention.

there was a tragic crash near paso robles...and the reason was so obvious on the cvr that it had to be released early.

perhaps porterhouse knows!

[porterhouse]

there was a tragic crash near paso robles...and the reason was so obvious on the cvr. perhaps porterhouse knows! No, there were quite a few GA crashes around Paso but I am not aware of a single one in which an aircraft was carrying a cvr. I searched through the NTSB database to jolt my memory but could not find anything of a kind either. Perhaps it wasn't exactly in the Paso neighbourhood. EDIT: you probably meant the PSA's crash - about 12 miles away.

flarepilot - you raise another excellent point - preliminary results may prevent other accidents by sensitizing pilots/operators to possible breaches of safety.

[flarepilot]

yes porterhouse, PSA...when someone shoots the pilots you know pretty much why a plane crashed.


been to Paso Robles many times via car, only twice via plane but have flown over it many times.

and yes, if you have an inkling, you have to get the word out pretty darn fast to make sure another crash isn't right around the corner.

[bubbers44]

Yes the fired employee at PSA shot the pilots so crashed near Paso Robles. He was able to bypass security at LAX because he had an airline ID, I believe, to do in his supervisor who fired him. I was flying to SFO that day. About that time out of LAX my FO asked me what is that ID you are wearing and realized I was wearing my Mission Viejo Lake Pass and still got through security.

[bubbers44]

The Asiana crash shows something needs to be done now about how some pilots fly, not in two years. Three supposedly qualified pilots could not do a visual approach in clear conditions and we want to wait two years to fix this? Fix it now. Please don't make us have more dead people before we can fix it. Obviously there is a problem now.

[bamboo30]

Maybe would be good to tell pilots to use the appropriate mode in different phases of flight. Using FLCH at that phase of flight definitely has a smell of sop violation at some point, also to clearly underrstand the automation and what mode does what. For this asiana case, automation didnt fail it did as advertised.

[ExSp33db1rd]

.........realized I was wearing my Mission Viejo Lake Pass and still got through security.

In the early days of compulsory photo I.D.s one of my colleagues substituted a photo of his dog.

Wore it for a long time, he did. ( pre- 9/11 of course )

Sorry - back to topic.............

[RetiredF4]

bamboo30
Maybe would be good to tell pilots to use the appropriate mode in different phases of flight. Using FLCH at that phase of flight definitely has a smell of sop violation at some point, also to clearly underrstand the automation and what mode does what. For this asiana case, automation didnt fail it did as advertised.


How about monitoring speed and attitude in all modes and regardles where you intend to point the aircraft?

[Schnowzer]

RF4,

I think that would be the view of 90% of pilots worldwide. Sadly the other 10% believe an aircraft is flown by manipulating automation to make sure the magenta line is followed as accurately as possible rather than by positioning the pilots body in the right place relative to the earth. After all this is not a small error, aiming 400m short is the same as landing in the middle of the terminal laterally without noticing

I used to think training made the difference but what I see more and more often, as perfectly Servicable aircraft are "killed" by their crews, is that the pilots involved do not have the basic aptitude to do their job. Anyone can wear a uniform and with enough practice jump through hoops but then pretty much everyone can pass a driving test.

One issue from HF I do agree with is the impact of culture. Any culture that views a person gains respect by existing for a long time or passing a course rather than by displaying basic competence is screwed! Importantly though culture is really a component of 'national aptitude' as Einstein said "Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions." So even if you have the underlying aptitude it will never be expressed fully irrespective of the amount of training given if everything else in your national experience suppresses it. As the aircraft is pointed at the sea wall many pilots will not see it as part of their job to interfere with the incompetent pilot's meanderings or even if they do have the ability to fix it.

Thinking ahead and making sure the trajectory of the aircraft is coincident with the runway; admitting mistakes and fixing them both seem to be lost arts to some of those sitting on a flight deck but should be a basic pre-requisite!

[Lonewolf_50]

Whenever I see some “proudly born in western culture” guys are so obsessed with finding cultural problem in this kind of accident. It just makes me wonder.
Wonder no longer. Western Culture has evolved to become a learning culture.

Just culture, CRM, and the impressive advances in aviation safety didn't "just happen one day" in Western Culture.

It happened because some people were able to get out of an authoritarian and deference mind set (remember, a lot of airline pilots in the great boom of air travel were former military pilots, whose military cultural norms were also laced with deference to authority) and through millions of man hours of work, effort, and finding out "what works better" created a philosophy of operation that is better no matter where you are from. It took a base culture of challenging conventional wisdom, of challenging institutional bias, of challenging authority, and of being humble as a virtue to get there.

As I said, it didn't happen overnight, and along the way a lot of people died and a lot of wreckage was pored over by accident investigators. You may wish to consider why Korean Air came to Delta (a company that had learned about the better culture through the process describe above) to help out with their desire to improve their operational safety posture.

Having found the better way the hard way, you should not be surprised to hear those in that culture to be deeply disappointed to see cultural resistance to breaking down the barriers that, in our culture, were broken down over the past two generations in aviation. It hurts because of the dead bodies, not the language someone speaks nor where they were born.

Best wishes in the Enlightenment spreading beyond Western Culture.

[Airbubba]

The NTSB hearing scheduled for today has been postponed:

Asiana Flight 214 Investigative Hearing Postponed

December 10

The National Transportation Safety Board's Investigative Hearing into the crash landing of Asiana Airlines Flight 214 originally scheduled for today, December 10, has been postponed due the government closing because of inclement weather in the Washington DC area.

Press Release December 10, 2013 (http://www.ntsb.gov/news/2013/131210.html)

The NTSB hearing will be streamed live online in English, Korean and Mandarin.

[safetypee]

What have we learned, and how much of that was from the misfortunes of others, or from ourselves.
Start at Chapter 1 - 'learning' is towards the bottom of the page (http://en.wikiquote.org/wiki/Confucius)

"Rather than justify ourselves and blame others, we should look into ourselves".

While we wait for the report, which might only explain why 'this accident' occurred, and on inspection ‘this would not apply to me’, there is opportunity to learn by exploring the situation as currently known and considering how we might avoid this – and why.

[flarepilot]

in my view the systems of an airplane are all subject to failure and a good pilot should be ready to correct or act in a way to save the people aboard and innocents on the ground.

perhaps wings falling off, complete control failure or onboard cabin fire might be good reasons to excuse a pilot from the above.

But even if the autothrotle system failed, there is no excuse to allow an otherwise properly working airplane to get too slow and too low.

[Airbubba]

The OZ 214 NTSB hearing has been rescheduled for 8:30 am tomorrow, December 11, 2013 and will now be only one day lasting until 8 pm Washington time (UTC-5).

NTSB ‏@NTSB 1h
Asiana flight 214 investigative hearing rescheduled for Dec. 11 from 8:30am-8:00pm.


https://twitter.com/NTSB

Links to the video streams here:

Investigative Hearing: Crash of Asiana Flight 214, San Francisco, CA, 7/6/2013 (http://www.ntsb.gov/news/events/2013/asiana214_hearing/index.html)

[bamboo30]

Flarepilot totally agree with you humans must take over if systems fail. However in this case the AT did not fail. It did as published sir

[barit1]

bamboo30 is correct. The only failure was between the trainee captain's ears.

One has to wonder, in fact, why he chose to use a/t while flying a manual approach. :uhoh:

[Hogger60]

Many airlines flying the 777 mandate Autothrottle use for all approaches.

[flarepilot]

bamboo

if the pilot allowed the copilot to fly plane too slowly for safety, is it the copilot's fault?

or is it the captain's fault?

so too with any aircraft system...if the pilot allows the autothrottles to maintain speed, but the authothrottles do not maintain speed, who is at fault?

and if the pilot has asked the autothrottles to maintain speed incorrectly, who is at fault?

[bubbers44]

Bamboo said if you hit FL change and the plane crashes it is because he hit the wrong button. No one is required to look out the window and manually adjust the throttles.

Something has to be done now to change this mentality. Not two years from now.

[ATC Watcher]

Farepilot and others here,
We seem to concentrate on who is at fault and not on the multiple other reasons behind this crash, which bears similiaraties with many other accidents/incidents we saw in the past.

We keep telling ourselves here, it is cultural, pilot errors , lack of CRM, ATHR malfunction or whatever we know best, mainly to ease ourselves in the belief that since we are not Koreans, know how to use automation and have a sound CRM and just culture in place in our own environment , such thing could not happen to us.

If you want to prevent reccurrence and improve Safety today we should be looking as systemic issues to improve that system , just not apportion blame ( or fault) to a few individuals and move on .

For me, just looking at the facts list so far, training ( in broad sense), ability to maintain hand flyings skills , crew pairing, airline SOP , ATC , Crew briefings, Notams redaction and decoding, etc..should also be looked at carefully in addition ,and then get a broader view as to why a basic task such as monitoring airspeed was not performed.
Then instead of blaming individuals, and identifying the probable causes, also propose how to correct all those issues.

Then we need to have a strong regulator who will enforce those recommendations.
Maybe then we will start to see these kinds of accidents disappear.

[safetypee]

ATC Watcher :ok:
“… instead of blaming individuals, and identifying the probable causes, also propose how to correct all those issues.
Then we need to have a strong regulator who will enforce those recommendations.” :ok:

In all countries, but are they able (willing) to learn?

[lomapaseo]

safetypee etal

ATC Watcher http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif
“… instead of blaming individuals, and identifying the probable causes, also propose how to correct all those issues.
Then we need to have a strong regulator who will enforce those recommendations.” http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif

In all countries, but are they able (willing) to learn?

This isn't a deficiency in just a few select countries. A strong regulator doesn't solve the problem unless their is a standard to regulate against.

Just who is expected to write such a standard?

Individual airline training departments ?

[1stspotter]

News which was released at the start of a daylong National Transportation Safety Board hearing into the accident.

"The Asiana Airlines captain who crashed a Boeing 777 at San Francisco International Airport in July told investigators he was stressed out and "very concerned" about attempting a visual approach because the runway's automatic warning systems were out of service due to construction, according to an investigative report released Wednesday.

Lee Kang Kuk, a 46-year-old pilot who was landing the big jet for his first time at San Francisco, "stated it was very difficult to perform a visual approach with a heavy airplane." The jet crash landed after approaching low and slow in an accident that left three dead and more than 150 injured.
"

NTSB says Asiana captain worried about visual landing | Fox News (http://www.foxnews.com/us/2013/12/11/ntsb-to-review-asiana-crash-at-hearing/?cmpid=cmty_twitter_fn)

A Tweet of John Croft which is Senior Editor - Avionics and Safety for Aviation Week says:
"Asiana 214 in FLCH mode on shrt final.Crew added pitch;autothrottles did not respond due to FLCH, speed dropped"

Live Tweets from @ABCaviation:
"automation is a tool to aid the pilot, not replace the pilot"

cockpit voice recorder transcript from @AsianaAirlines 214 crash reveals two calls for a go-around seconds before crash

pilots of @AsianaAirlines 214 received an audible alert of low speed 11 seconds before impacting sea wall at SFO
via web

a go-around was called for seconds before Asiana flt 214 crashed at SFO

[1stspotter]

The hearing on the Asiana B777 crash at SFO can be followed live with video and audio here. The hearing will take the whole day till 8 PM ET.

National Transportation Safety Board (http://ntsb.capitolconnection.org/)

What is being said is live written in the window next to the video. At the moment the pilot who did test flights on B777 prototype is being heared.

[bubbers44]

If the captain didn't feel competent to do a visual approach like everybody else can why didn't he learn how?

[flarepilot]

it is about blame

captain worried? first off, which guy was captain, the check pilot or the newly type rated guy?

wrong mode? who selects right mode?

if this captain was in a department store, taking an escalator from second floor to the third floor and the escalator stopped moving...would he just stand there?

or would he climb the stairs before him...or even turn around about face and go down to the second floor?


ATC watcher, how can it be crew pairing? It was a check ride.

training, crm, culture? come on.


hand flying skills...who is to blame on faulty hand flying skills? is it the korean licensing body? is it the airline? is it the guy who is driving the plane?

certainly those big things sticking up in the console of the airplane had to be noticed by the pilots at some time in their careers.

indeed, how could they make the plane takeoff without moving the throttles forward, even while clicking on the auto throttles?

should we blame someone for not having a memory item checklist: if slow, push throttles forward manually?


maybe we need a checklist to make sure we put on our pants before we put on our shoes?


oh, thanks for posting the link to the live feed...interesting, hope you all can watch it...may even be an archive to watch it later.

testimony said that the crew did push throttles forward

but

obviously too late to do anything.

and no attempt to change flightpath/glidepath with controls.

and then three seconds later bam

so, the crew did know how to move throttles, they just didn't do it in time to make a difference.

even though papi would show them low

even though airpseed indicator would show them slow.


some people would call this: behind the plane

[1stspotter]

The transcript of the cockpit voice recorder of the Asiana flight that crashed at SFO has been released by the NTSB


http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F544904.pdf

[bamboo30]

Flarepilot
Can you read again what i said. AT did as published did as what the pilot selected. If you want to find fault, yes of course its the pilots fault by selecting inappropriate mode at that particular phase of flight and also pilots failure to understand the modes he was using. Of course sir if you do fly 777 you would be in SPD LNAV VS or FPA. Why didnt these modes used at that phase? Only the pilot involved knows.

Bubbers
Look out the window yes sir above and beyond.

[Marty33]

The BLOODY AIRSPEED INDICATOR! For the love of God..

[tdracer]

Lee Kang Kuk, a 46-year-old pilot who was landing the big jet for his first time at San Francisco, "stated it was very difficult to perform a visual approach with a heavy airplane."
http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gifhttp://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gifhttp://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gifhttp://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gifhttp://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gifhttp://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/eek.gif


Sorry, but anyone who thinks performing a visual approach on a beautiful summer day is "very difficult" has absolutely no business sitting in the pointy end of a commercial jet. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/censored.gif

[ATC Watcher]

lomapaseo :
Just who is expected to write such a standard?
Individual airline training departments ?

Standards are defined by ICAO and the National regulating agencies. (although nowadays it starts to be more the other way around )

Yes Individual (airlines) training departments should enforce those standards.
Then the Regulator should check and do a quality audit at regular intervals.
If deficiencies are registered, the National regulator should have authority to take action .
But today this is still utopia land we all agree... :sad:

flarepilot:
how can it be crew pairing? It was a check ride.

training, crm, culture? come on.

hand flying skills...who is to blame on faulty hand flying skills? is it the korean licensing body? is it the airline? is it the guy who is driving the plane?


Pairing a newly promoted check Capt on one of his first check-rides with someone himself on one of its first 777 flights is not exactly a very good idea I would argue.

Training : absolutely ! on performing regularly visual apps for instance.

Maintaining hand flying skills responsibility ?: all the 3 you mentionned. Yes.

Was lsitening to the NTSB debate the last hour before their lunch .Interesting. One comment from the Boeing Chief test pilot : " When we design an airplane we asume crews are very good at monitoring airspseed "
That put a smile on some faces . :E

[AirRabbit]

Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked. :eek:

[fox niner]

Air Rabbit:

That would be a pity, if true. It would put all the blame on that single snippet of information. My gut feeling is that there is much more to this accident. It really can't be that simple. Asiana would really love that,as it would (almost) clear their name entirely.

[porterhouse]

Asiana would really love that,as it would (almost) clear their name entirely. I think such conclusion is highly premature.

[AirRabbit]

That would be a pity, if true. It would put all the blame on that single snippet of information. My gut feeling is that there is much more to this accident. It really can't be that simple. Asiana would really love that,as it would (almost) clear their name entirely.

Of course there would be all sorts of directions that the industry and the media would run if there turns out to be any truth to that report. BUT, I don’t think the airline would be able to side-step ALL of the criticisms … simply due to the fact that, presumably anyway, the airline would have had to “train” that pilot in accordance to whatever training program(s) were/are required by their regulating agency. AND that still doesn’t explain how a training captain in the other seat would have, could have, sat on his hands long enough to have this particular situation develop to the degree that it did.

I have been saying for a while now, that I wouldn’t be surprised to learn that some sort of “cheat-sheet answer” issue may have been involved. I have seen more than my fair share of such “activity” that I’ve become “spring loaded” to the “suspicious position.” When I describe “cheat sheet activity” I mean learning some kind of deliberately contrived “set of numbers” or a “sequencing” of doing something” i.e., setting flaps, flying airspeeds, setting throttles, making control inputs or control reversals, etc., some of which are “held” for a given time and then something else may be done … and it all depends on what the effort was supposed to provide. The justification from most of those who practice such idiocy is that it either looks successful or actually is somewhat successful – and most of it was derived in a simulator – and, therefore, we’re back to the inherent problems with simulation accuracy. I have this “bias” because of the numbers of times I’ve seen, and my colleagues have seen, that precise form of “flying” that has proven to be “successful” enough times that otherwise lacking aviators use it to “get by” when they are being observed. If the “cheat sheet” approach is accurate enough and the lacking aviator performs it discretely enough, it all looks good enough that we only find out about it through careful observation of a simulator session or after sifting through the wreckage.

[1stspotter]

A live report of all what is being said during the NTSB hearing can be read here.
NTSB HEARING - DAY 2 - 9AM -5PM - Recapd (http://recapd.com/w-fff39a)

[1stspotter]

Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.

Have searched the live report (NTSB HEARING - DAY 2 - 9AM -5PM - Recapd (http://recapd.com/w-fff39a)) of all what is said at the NTSB hearing. The word license is mentioned once but not in the context as an invalid license.

So no sign of the above rumour in the hearing so far.

[Jwscud]

I can't help but note how often they appear to be switching language. Being an ignorant Englishman and this only speaking assuredly non-technical French, how much extra distraction or workload is switching between languages causing?

I can't help but see a lot of Korean after the "speak English" command.

I know all of us worship at the One True Brief of our current employers, but that seems a fairly confused and perfunctory brief for a bloke on line training too.

[1stspotter]

Today the NTSB released a new video captured by a surveillance camera showing the crash of the Asiana B777.

Asiana passenger jet crash seen on surveillance video - YouTube

[Jazz Hands]

Now there are unconfirmed reports

From where? The inquiry? The press? Some bloke in the pub? :hmm:

[Sawbones62]

Excerpt from NTSB, Dr. Bramble senior human performance investigator at the NTSB questions CAPT John Cashman, former 777 test pilot...

">> A FOLLOW-UP TO THE LINE OF QUESTIONING CAPTAIN COX IS ASKED GETTING ABOUT WITH RESPECT TO THE FEEL. THERE IS FEEDBACK, CORRECT, ON THE YOKE AT THE ANGLE THEY WERE AT, HOW MANY POUNDS OF PRESSURE WOULD YOU HAVE EXPECTED TO BE APPLIED TO THE OAK TO ACHIEVE THAT?

>> AT WHICH POINT?

>> IN THE ACCIDENT FLIGHT.

>> WHEN THEY WERE DECELERATING, ALL THE TIME IT WOULD HAVE BEEN A GRADUALLY INCREASING FORCE.

>> CULMINATING WITH A MAXIMUM?

>> I'M TRYING SURE MEMBER WHAT THE FLIGHT RECORDER SHOWED, BUT I THINK IT WAS TOWARD 80 POUNDS.

>> 80 POUNDS?

>> YES. THE AIRPLANE, FROM WHAT THE DATA SHOWS, WAS NOT TRIMMED AFTER THE AUTOPILOT WAS DISCONNECTED. IT COULD HAVE BEEN DOWN TO THE TOP OF THE AMBER BAND TO THE FORCE COULD HAVE BEEN ZERO. ONCE THEY ENTER THE AMBER BAND, THE FORCE OF THE STICK GOES UP BY A FACTOR OF FIVE FOR EVERY 10 KNOTS OF SPEED."

I'm a bugsmasher, but if I am pulling until I've got 80lbs on the yoke with the a/c nose up in the air and still seeing all red PAPIs...maybe something is wrong? :eek:

[flarepilot]

reading the transcript of the cvr is amazing...lots of talk about vision, sunglasses and lasix!

bamboo...much can be read and understood...the use of sir can be understood to be an admonishment instead of a respectful agreement.

yes, the autothrottles were perfect, but even if they were not (and this is not the case), it would still be up to the pilot to FLY THE PLANE.

I think we do agree bamboo


it seems that ATC might have been slow in clearing the plane to land.

no discussion of the three to one method of checking a visual approach or a method of five times groundspeed to equal descent rate in feet per minute to make good a glideslope!

[tdracer]

Sawbones, you're not giving Mr. Cashman quite enough credit - he was the CHIEF test pilot for the 777, starting with the very first test flight in 1994. I think he was the Chief test pilot for the whole company when he retired.


I flew with John many, many times - heck of a pilot (most of the Boeing test pilots fall into that category). My understanding was that he was an engineer before he became a pilot - and it showed - he really understood the airplane and how it worked.


I wish I had the time to listen it, it sounds like the proceeding are rather interesting http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/puppy_dog_eyes.gif

[Lonewolf_50]

Thanks for the link to the ntsb cvr transcript.
As to the latest video ... grateful there were no more fatalities.

[bubbers44]

tdracer, yes I agree no pilot should be allowed to fly unsupervised unless he can do a visual approach. J3 Cubs to 777's. I don't care what country you live in.

[Backseat Dane]

Did a pilot with thousands of hours behind the stick actually say that, on a perfect day with unlimited visibility, no winds of any importance and no other distractions than having to actually fly the plane, "it was very difficult to perform a visual approach with a heavy airplane"? Perhaps, and that's a perhaps, with the amendment "at KSFO" unspoken, but still???

If so then someone needs a reality check. And so does anyone dreaming up any some sort of excuse for what happened. Yes, let the investigations continue. Let the lessons be learned.

But this plain and simple should not have happened. Period.

And if any professional pilot says otherwise then I'd much rather hitch a ride across the Atlantic on a container vessel than be seated in the back of a modern airliner flown by a child of the magenta line.

[olasek]

you're not giving Mr. Cashman quite enough credit Not sure how you arrived at this, he must be giving him quite a bit of credit by selecting this exchange from the rest of the voluminous data.

[DozyWannabe]

how much extra distraction or workload is switching between languages causing?

Depends how often you use the non-native language - I've seen people switch mid-sentence without batting an eyelid.

The "very difficult" quote comes from a Fox News article - best get a more reliable source before taking it as read.

[Indarra]

This NYT article
http://www.nytimes.com/2013/12/12/us/asiana-airlines-crash-san-francisco-airport.html
seems to give a reasonable summary of evidence that emerged at the 12/11 hearing.

Following are key extracts:

The pilots of the Asiana jumbo jet that crashed in San Francisco on July 6 were deeply confused about the plane’s automated control systems, and that is a common problem among airline pilots, according to experts who testified Wednesday in a National Transportation Safety Board hearing on the crash.
“We do have an issue in aviation that needs to be dealt with,” the chairwoman of the safety board, Deborah A. P. Hersman, told reporters during a break in the hearing.
The captain and the supervising pilot in the Asiana crash — in which a Boeing 777 hit a sea wall short of the runway, killing three passengers — said they thought a system that is used to control the plane’s airspeed was running, although it was not. And all three pilots overlooked a prominent display that showed their airspeed was too low.
According to documents (http://www.ntsb.gov/news/events/2013/asiana214_hearing/index.html%20) released by the board, for 19 seconds leading up to the crash the pilots had a clear view of guidance lights on the field that indicated they were flying too low, but they did not follow company procedure to break off the approach.
The plane’s captain, Lee Kang Kuk, told investigators — although he was wrong — that he believed the protection system in the Boeing was similar to the one in the Airbus A320, which he had substantially more experience flying.
In the Boeing, the throttle levers — one for each of the two engines and located on a center pedestal between the captain and the first officer — will move as the automatic system manipulates the engines. In the Airbus they will not move even when the auto-throttle adjusts the engines’ power.
The captain was supposed to keep a hand on the throttle levers to feel them move, and he did so on and off, he told investigators. Lack of movement in the throttle levers did not trouble him, he told investigators, because he thought the auto-throttle would “wake up” and maintain a safe minimum speed with no sign.
Boeing’s design leaves more discretion to the pilot and does not always ensure that the engines will maintain a minimum speed. Asiana ground school instructors warned the crews that the auto-throttle would be disabled when autopilot was being used by the crew to control the plane’s descent to a certain altitude, according to one safety board document, but the lesson evidently did not stick.
Captain Lee told investigators that any of the three pilots on the plane could have decided to break off the approach, but he said it was “very hard” for him to do so because he was a “low-level” person being supervised by an instructor pilot.
He also said that as the plane approached, he was momentarily blinded by a light on the runway, possibly a reflection of the sun, but that he would not wear sunglasses because that was considered impolite among Koreans.
The pilots did know they were descending too fast. One said so about a minute before impact, in English, which the crew was using on approach, according to a transcript of the flight data recorder. The second mention was also in English, but the third, about nine seconds after the first, was in Korean, a clue in the transcript about the urgency in the cockpit.
In the transcript, no one said that the plane was too low until the last 30 seconds of the flight. Three seconds before impact, Captain Lee made a comment rendered in the transcript as “oh # go around,” indicating an attempt to re-engage the engines and abort the approach.

[tdracer]

olasek, I was merely nit-picking that:
CAPT John Cashman, former 777 test pilot...didn't really give Mr. Cashman enough credit - he's not just a "former 777 test pilot" (there are a lot of those), he was the "Chief 777 Test Pilot" during the aircraft development (and for several years there after).

[edmundronald]

>> i assume you're referring to a specific issue raised during the 787 program by our test pilot related to the wake-up function of the autothrottle, where they were conducting a flight test, and there was a flight level change initiated, and the flight level change was interrupted by another event, in this case it was a traffic avoidance event, and as a result of the logic of the airplane, the autothrottles went into hold mode. Our pilot was monitoring airspeed and noticed airspeed was decaying, and as part of the test pilot functions, lapierre speed to decay further to see what would happen. -- allowed the test be to decay further to see what would happen. Our test pilot believed that the autothrottle would wake up, not realizing that the autothrottle, since it was on, as mr. Myers explained, the autothrottle was on, the autothrottle would not wake up. It was already awake. So he allowed speeds of decay, and at a save point, he put throttles back in, brought the thrust back up and continued the flight. He raised that as a response item. Basically way for the faa to document a potential concern and to get a response from the applicant, in this case boeing, response to the question about why it works that way, and to determine if it is susceptible. In the process of doing that evaluation, over working with boeing on this one, the pilot determine that the fact that the autothrottle did not wake up without a safety issue, nor was it a regulatory noncompliance. Given those two critical factors, at that point, he believes it was still an area where there could be improvement , and he worked with boeing to include additional information in the flight manual to explain that the autothrottle on the 787 would not wake up from an autothrottle hold.

[Sawbones62]

TDracer:

No offence meant to CAPT Cashman, indeed his appearance on the panel today means for the NTSB, Boeing etc... he is "the" go-to 777 test pilot!

But 80 lbs of yoke force was quite a revelation for me - that airplane was trying to say something!

[Airbubba]

VERY Interesting!!

Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.

Here is the information on flight crew certification from the NTSB accident docket:

http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F543209.pdf

Looks like the information provided to the NTSB is that the licenses were in order.

Several thousand pages of information, plus audio and video files, were released when the docket was made public this morning:

Accident ID DCA13MA120 Mode Aviation occurred on July 06, 2013 in San Francisco, CA United States Last Modified on December 11, 2013 07:12 Public Released on December 11, 2013 08:12 Total 135 document items (http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=55433)

As discussed extensively earlier here on PPRuNe, the autothrottle THR HOLD FLCH 'trap' is well known, and is present in all EICAS Boeings from the 757 onward. It looks like Boeing's position is that it is consistent with the original design philosophy of the automation to not intervene too much when the pilot is making manual inputs. If the autothrottles are off, they will 'wake up' to maintain speed but if they are on in THR HOLD mode, they are already 'awake' but intentionally not responding until they change to another mode e.g. SPD.

From NTSB questioning I get the idea that they are going to suggest that this autothrottle behavior be modified or at least covered more specifically in sim training.

I might have got myself into an undesirable situation on approach with some MCP mismanagement somehow but like most people posting here, I can't conceive not immediately reacting to low airspeed, sinkrate calls and red PAPI's below 1000 feet. :eek:

[CDRW]

What has become of the most basic - I say again the most basic - part of flying / operating any type of aeroplane - and that is monitoring of airspeed - it is why the damn thing flies in the first place.
So many non aviation colleagues are asking me - " is it that hard to monitor airspeed"
Man this is not good.

[Airbubba]

Thumbing through the docket, some interesting observations on Asiana pilot culture viewed though the eyes of a couple of expat captains on pages 128-136 here:

Document 12 Other Pertinent Forms and Reports - 6120.1 Filing Date September 16, 2013 11 page(s) of Image (PDF or TIFF) 0 Photos (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=404970&docketID=55433&mkey=87395)

The scripted approach to training and flying is mentioned. Lack of hand flying skills at OZ is acknowledged to be cultural and also generational, many of us flew thousands of hours on steam driven round dial planes with primitive analog autopilots before going to glass. Younger pilots, not so much anymore.

[Cows getting bigger]

CDRW, call me a bluff old traditionalist, but it is AOA combined with a bit of airspeed that "keeps you flying in the first place", not airspeed. Of course, lacking any worthwhile AOA gauge, the ASI is the least worst way of steering clear of the stall. I guess that pilots who only ever go to about +/- 10 deg in pitch and +/- 20 deg in roll can afford to forget the absolute fundamentals. :)

[ExSp33db1rd]

Lee Kang Kuk, a 46-year-old pilot who was landing the big jet for his first time at San Francisco, "stated it was very difficult to perform a visual approach with a heavy airplane."


Sorry, but anyone who thinks performing a visual approach on a beautiful summer day is "very difficult" has absolutely no business sitting in the pointy end of a commercial jet.

Absolutely. No contest.

I actually found it easier in a 747 than presently in a microlight (LSA) due to ........ inertia, I would occasionally, when passing 500 ft, on the centre line, right height,right rate-of-descent, right speed, right power, checks complete, suggest to my hand flying co-pilot that now only he could fcku it up, change nothing until initiating the landing flare ! (unless of course some external factor interferred)

I recall doing hand flying circuits in a 707 - the aircraft, not the simulator, and ATC asked the training captain why he had requested that the VASI's ( pre-PAPI ) be turned off, 'cos these guys have to learn to sort it out for themselves, was the reply, but of course that was before iPads had been invented,or INS, or FMS, or GPS, maybe even before Bill Gates had even been born all we had was a pair of hands and a pair of eyes and an aeroplane - magic, I'd love to be able to have another go !

[Desert Dawg]

@ExSp33db1rd

I could not have said it better myself!

I heard this snippet of info (Lee Kang Kuk's statement) on the radio news and my mouth hit the floor..!!!

Nuff said..!

[Jazz Hands]

This series of comments - the captain of the flight being interviewed - struck me as interesting:


Q: Before you had to do that, when you were still like at 300 feet or something, did you feel you had to go around at that time?

A: That’s very hard because normally only in our Korean culture the one step higher level the final decision people he did he decide the going around thing. It’s very important thing. As a first officer or the low level people they dare to think about the go around thing. It’s very hard.

Q: In your mind, then, and I don’t want to put words in your mouth, you tell me, did you feel that as the pilot in the left seat flying the airplane that you had the authority to do, commence a go around yourself?

A: Go around thing. That is very important thing. But the instructor pilot got the authority. Even I am on the left seat, that is very hard to explain, that is our culture. How can I say, during cruise also, when we met the turbulence condition, things like that, easily, B777 go into the maximum airspeed, so that’s the limitation. In that case, I never ever thought about that I controlled that condition because instructor pilot handled that, that sort of limitation thing. So that is a, they control the autothrottle system, things like that. I was also the company investigation team also, I know the investigation or the QAR thing, so my experience said to me the regulation and authority is very obvious to me. So, uh, yeah.

Q: And when you say the regulation is very obvious to you, you mean that there is a regulation that says only the PIC can do go around.

A: Yeah, that is obvious to me, but up to now I thought the very dangerous condition, now I am a captain position. I can do that, but it is very hard, yeah.

Q: So just to close this one out, did you expect that only the instructor pilot could decide to go around?

A: Basically, and the regulation, yeah.

[Stuart Sutcliffe]

Within the Interview Summaries, in the reports linked by Airbubba, is this snippet from the Captain under training in the left seat, Lee Kang Kuk:He began preparing for the flight at 0930. It was a training flight, so he showed up early. The cockpit crew show time was 1510. He spent almost 6 hours preparing for the flight, checking the NOTAMS, the regulations, and the ETOPS
regulations. He first saw the PM (the instructor pilot) around 1440. He briefed everything with him. Pushback time was about 1630 local time.
Turning up at work "almost 6 hours" before report? Dedication ..... or extreme anxiety?

Furthermore, from the Jazz Hands post above, it seems the culture authority gradient idea about who can and cannot instigate/order a go around does not sit well with a safe operation.

[captplaystation]

BBC News - Asiana crash pilot 'stressed' by landing (http://www.bbc.co.uk/news/world-asia-25335113)



W.T.F ?

[ImbracableCrunk]

Turning up at work "almost 6 hours" before report? Dedication ..... or extreme anxiety?

Culture. You have to be seen to show before your superior.

There's a race of sorts in flying. Punching in transponder codes before the ACARS PDC has finished printing, calling 25% N2 at 23% so you're not late, etcetera.

I mistakenly sent a PDC request before the CA called for it. It was available, of course, but I hid the printout and requested a new PDC at the "correct" time.

[Jet Jockey A4]

WOW! Just WOW!

If he can't fly an aircraft to a visual approach on a clear and beautiful VFR day then he has no business being in a cockpit of an aeroplane.