Asiana flight crash at San Francisco

[BOAC]

tilnextime - the reference to PPRune was, I hope you realise, a red herring, meant to highlight the vast range of wildly differing opinions from those qualified and those not

My post was in fact to support your post, but to point out the difficulty of finding the right basis for 'normal' and 'acceptable' - and this is the major task as you can see on PPRune.

Returning to this SFO "180 to 5" - I consider that if flown EXACTLY that way it is un-doable (I await the 'aces' cries). Most manufacturers' FCOM do not encourage using flaps as 'speedbrakes' which is what is necessary here.

I would guess that if the Asiana crew had KNOWN they were 'expected' by ATC to begin slowing at 7, a lot of the pressure would have been removed. Hence my call for some sort of clarity in speed control.

nitpicker - no - it transpires that ATC 'wanted' 180 to 7 with a tolerance of 2 miles to reduce speed (based on an earlier post). I feel Asiana were totally unaware of this aspect (too).

[Trackdiamond]

Visual approach principles

Am new here so please bear with me if I come across naively as I have read some quite robust and even philosophical posts on this wonderful thread..very inspiring I should add.

I feel the onus was on the TC to accept the potentially unstabilising approach clearance they accepted, however multi pilot cockpit golden rules:back each other up, if you don't like what the automation is doing..take over manually(and that applies to auto throttle too ).In any case if visual and unstabilized by 500ft ..Go Around!

Visual approach does mean beyond flying with the naked eye and seat of the pants in my humble opinion. PAPI was operational at the time was it not?were the PAPIS fully operational?3 rows for high cockpit jets (if first two rows followed would bring the touchdown much closer than the normal glideslope and undershoot with lowered gear clearance height).CNN NTSB report on the handling pilot interview that he was temprarily blinded during approach might be related to Papi visualization??

How about CDFA method of approaching visually?

CDFA was designed to replace the old dive and drive NPA profiles common in old USA culture..but not limited to just NPA but could be also utilised in visual approach ezpecially with VNAV assistance calculated or FMC assisted.

Visual approach doesn't mean both crew heads up and ignore all flight and nav instrument indications and alerts..the pre stall threshold hash marks on the PFD for instance!

Finally when you hear whoop whoop pull up..you usually have less than 10 seconds to get out of the hell hole.as most accident CVRs have miserably demonstrated.

[JW411]

I did a lot of flying in the USA (including being based at JFK for three years). There only ever seemed to be three speeds to remember:

250 Knots below 10,000 ft.

210 Knots intermediate approach and,

180 Knots to the marker/5 nms.

That's what everybody did and it was certainly not difficult in a DC-10 (mind you, we could put 35 Flap down at 185 Knots).

So what has changed since I hung my boots up to make it so bl**dy difficult to do nowadays?

[Dolfin]

Originally Posted by "MPN11

It appears from earlier posts that is "accepted" that an early speed reduction from 180/5 to 180/7 is OK. Would the Asiana crew have that perspective? Especially when the PF is 'under training'? What would be the IP's opinion if the deceleration started 2 miles earlier than instructed? Would the PF not try to comply with 180/5?

I call it CRM:

ATC:"Maintain 180 to 5 miles"
Crew:"Wilco."
Captain to IP:"I don't think I can maintain the speed restriction, I will start reducing at 7NM, inform ATC."
Crew:"Radar, we are unable to maintain 180 to 5NM, we start reducing at 7NM."

Where is the problem?
The problem is not to communicate when a situation develops in a way, a pilot does not like it.
It seems as if there was no communication inside the crew about the unstable approach, and there was definately no communication to ATC about that or about being unable to comply to the speed restriction.

[bobcat4]

BOAC wrote:

yes, we know that - you are not reading the posts!

The only thing that might be unusual is that “180 to 5” means “180 to 5, but if you want to slow down at 7, that’s fine”. That is, unusual to Korean pilots who might be interpreting “180 to 5” as “do not go slower than 180 knots until 5 nm, that’s an order!”

They seemed to maintain 180 to 5 (DME) more or less exactly. Oh, and "180 to 5 DME" means 180 to 4 nm from threshold in SFO. Correct me if I'm wrong. But that means you have 2 nm to get stable, and that is 45 seconds at 160 knots.

[Dolfin]

Originally Posted by "JW411

So what has changed since I hung my boots up to make it so bl**dy difficult to do nowadays?

Let me take a guess: Nothing has really changed at all! The physics of flight is still the same as with the Wilbur bro's.
If one knows what to do and can fly the ship, it's a piece of cake, but if not, it's kinda mystic magic and things start falling out of the sky.

[aterpster]

JW411:

I did a lot of flying in the USA (including being based at JFK for three years). There only ever seemed to be three speeds to remember:

250 Knots below 10,000 ft.

210 Knots intermediate approach and,

180 Knots to the marker/5 nms.

That's what everybody did and it was certainly not difficult in a DC-10 (mind you, we could put 35 Flap down at 185 Knots).

So what has changed since I hung my boots up to make it so bl**dy difficult to do nowadays?

I probably go back further than you. I don't recall speed assignments being quite that simple. I do know asking someone to do 180 knots to the FAF, or similar point, is sacrificing a staple final approach for the sake of "moving the medal."

Fairly early in my career, probably 1969 or perhaps 1970, I clearly recall the Airman's Information Manual in those days stated that ATC speed assignments would be discontinued not later than 3 miles prior to the outer marker. One day a Los Angeles controller was adamant that I give him 170 to the outer marker. I refused whereupon he got quite huffy. The frequency wasn't that busy so I told him I was based there and suggest he discuss it with my chief pilot.

Well, they did call him and a note was waiting for me to see him. We chatted about it, and I showed him the AIM passage. His response was sort of like Rodney King; i.e., "We've all got to get along."

In the years after that ATC continued to just get ever more aggressive.

I suspect the 180 knot assignment to Asiana until 5 miles is going to result in the FAA picking up part of the bill for the accident.

[RAT 5]

When ATC asked for 'silly' speeds to be flown, so as to help out their traffic flow, even when there was no traffic, I used to suggest having the gear down 1nm early so that when you reduced thrust to configure and slow down the drag was immediate. That was a medium/heavy. These large/heavy a/c might have more trouble. If you start the complete slowing down 1nm early the inertia will likely allow you to slip through the hoop un-noticed. Understanding your a/c & engines' behaviour is always primary. A little more drag earlier means you don't have to go to idle in a bums rush to slow & configure.Might this be true of these heavier slippery types? The engines are bigger than my old CF-6's

[ExecClubPax]

Never run out of altitude, speed and ideas at the same time. On the face of the evidence to date, it appears this crew did just that. It doesn't create much confidence in those, like myself, who pay pilots to get them from A to B safely. When all you professionals have done swapping your pet theories, please remember the folks in the paying seats have a vested interest in ensuring appropriate skills and standards are maintained.

[JW411]

Aterpster:

I thank you for your response. I've just had a look in my old Jepps for JFK and LAX and I cannot find any strict laid down speed limitations apart from the 250 Knots at 10,000 feet.

However, I did find in the Introduction section under Speed Adjustment that ATC expect aircraft to maintain +/- 10 knots of any speed restriction given.

Therefore, 180 to 5 could be 170 to 5 or 190 to 5 as I read it?

[BOAC]

Originally Posted by JW

However, I did find in the Introduction section under Speed Adjustment that ATC expect aircraft to maintain +/- 10 knots of any speed restriction given.

- I have a feeling that is ICAO?

[JW411]

You might well be right. I gave nearly all of my FAA stuff including the AIM and How to Pass the ATPL exams to a young man who was making his way in American aviation a long time ago, so I don't have that many references left to hand in my seriously retired state!

[suninmyeyes]

Conf iture

You quoted me as saying

The biggest clue that things were about to go wrong was most likely the word "HOLD " at the top left of the primary flight display that indicates to those in the know that the autothrottle although engaged will not increase the thrust. Had the word at the top left been SPD (Speed) the accident would not have happened.

You asked

In this eventuality, would it be enough or necessary to deselect the second FD to get back to SPD ?

The answer is yes. If the second flight director had been switched off the autothrottle would have engaged in speed mode and the accident would not have happened.

Like someone else I wondered if the speedbrake had been pulled out earlier. The 777 is extremely slippery and frequently needs use of speedbrake on approach. If the speedbrake is left out for more than about 20 seconds without someone's hand on it it is extremely easy to forget it. The 777 warns you if you have left the speedbrake out but only when the power comes back up from idle, in this case the power did not come back up from idle until too late so there would not have been a warning. If the speedbrake had been left extended below 1000 feet the speed reduction would have happened even more quickly and it would have been one more unstabilised approach criteria item that had not been complied with.

[tilnextime]

BOAC

My post was in fact to support your post, but to point out the difficulty of finding the right basis for 'normal' and 'acceptable' - and this is the major task as you can see on PPRuNe.

Sorry I missed that.

It's a major task, and if referred to a "committee of the whole", it ain't gonna get done right. It's going to take some serious leadership, and the results are still not going to please everybody. But the objective is not pleasing everyone, but establishing sound, safe standards covering all of aviation, not just one aircraft, one crew. Flying is only one part of commercial aviation. Many of the other integral part:, maintenance, ATC, logistics, POL, crash rescue, etc are all essential elements to getting the job done in a safe, orderly and expeditious manner, and these elements are not rooted in flying skill. Few, pilots have a clue as to how to get fuel from the distributor to the wing tanks, nor the quality assurance involved. Without that uncontaminated fuel, flying would be seriously less safe.

While commanding an airfield, I overheard my operations officer tell a transient pilot who was a flight school classmate, "You know, up until now, I considered things like ATC, POL, crash rescue, restricted airspace management and the like PFM (Pure F--ing Magic). Now I find that I am Mandrake the Magician, and a simple wave of a wand does not provide those services at all. I'm learning what Aviation is all about, and it ain't just flying."

[wingview]

Last accident @ SFO on final

After I read so many things about a "challenging" (visual) approach for 28L at SFO I wanted to know when the last incident/accident was:
It was in 1968! with an JAL DC-8 on the ILS and hit the water 2,5 mls before the TH (quite similair to the Asiana) but without ILS.

So this was 45 years ago and I would think that in the mean time a lot of visuals were flown with an ILS out. Nothing happend in this period, not even an incident.

I don't know what Asiana's SOP is to be stable but this looks very much to the THY crash at Amsterdam. As a result, PNF didn't monitor anything, not being stable, checklist not finished and at least a 3 men cockpit crew running out of speed and CFIT.

Asiana already said that the plane was perfectly Ok and that they'll change theire training to prevent this happening again in the future. All this leads to pilot error said by Asiana.

Those who are saying they would fly with these guy's because they've learnt there lesson are out of wack. This was a totally avoidable crash which cost 3 young girls their life!

[FO Cokebottle]

Bobcat4 is on the money

Bobcat4 has said it all. The culture of rote learning and nil questioning.

In countries with this education system combined with no general aviation sector where by national pilots learn to fly with the absolute minimum of required practical flight hours and the remainder is done in a box to strict company procedures and blind obedience to the written word before finding themselves in the right seat of a heavy jet, has to be questioned.

These questions should be asked of the State regulator for it is they that approve Airline Training Manuals

Combine this with the apect of the fast paced economic growth in formally autocratic countries/cultures with extreme nationalistic tendencies which had these guys on the ropes. Not excusing them at all.

This is my opinion thats all - having seen it and operated in it.

The once Chief of Standards of the Airline I was with, quietly said to me once, "some of our check airman don't even have airmanship". he was resigned to the this fact. That pretty well summed it up for me.

Further to my previous comment re: "180 to 5", it has always been taken to be referenced to the touch down point.

In addition, I have also had the following instruction, many times, from SFO ATC, "XXXX heavy see the jetstream31 at your x o'clock - x miles?" after the affirmative...."do not pass that aircraft!"

Knowing your aircraft and its limits, knowing about energy management and being prepared for any "normal" ATC instruction is required from the professional air transport pilot. In this case "normal" for SFO.

ATC also know your aircraft's limits and instruct accordingly, however, they also assume you have the required handling skills for that aircraft.

As one poster has previously remarked, " never take the aircraft were your brain hasn't been five minutes beforehand" or words to that effect.

[Cows getting bigger]

An interesting read from a couple of years back.

http://www2.icao.int/en/RunwaySafety...iderations.pdf

[ross_M]

After I read so many things about a "challenging" (visual) approach for 28L at SFO I wanted to know when the last incident/accident was:
It was in 1968! with an JAL DC-8 on the ILS and hit the water 2,5 mls before the TH (quite similair to the Asiana) but without ILS.

Interesting. An uncanny similarity (Wiki excerpted):

(1) Captain Asoh was a veteran pilot with roughly 10,000 hours of flight time

(2) His first officer, Captain Joseph Hazen, had similar flight time, but little DC-8 experience.

(3) Captain Asoh attempted an automatic-coupled Instrument Landing System (ILS) approach

They were mighty lucky though (unlike our Asiana): "None of the 96 passengers or 11 crew were injured in the landing."

I only hope Asiana and the flight crew have the moral courage to use the "Asoh defence": Asoh, when asked by the NTSB about the landing, reportedly replied, "As you Americans say, I fu_ck_ed up."

[BBK]

CBE

Thanks for that link. Interesting stuff such as: "Visual approaches can be associated with more pilot errors including performing unstable approaches...."

[MPN11]

Originally Posted by FO Cokebottle

ATC also know your aircraft's limits and instruct accordingly, however, they also assume you have the required handling skills for that aircraft.

Really? In 30 years I had a vague idea about pilot/aircraft limits, but never EVER presumed to know. That is not, and never has been, an ATCO's responsibility. Local procedures, evolved in consultation with aircraft operating authorities, might result in a procedure that (at a certain distance from t/d, above the notional glideslope, at a speed inconsistent with a stabilised approach in a 777 or whatever). However, they are not imposed by ATC, surely? It is the airport operating authority, though promulgated procedures, that tells ATC what to do and to convey those instructions to the pilot. If that places a pilot at the margins of establishing a stabilised approach, please don't blame ATC - we actually do as we are told.

I know my place, as a former ATCO. I did NOT devise terminal procedures in isolation. I did NOT tell pilots how to fly aircraft. And I certainly didn't issue instructions (like 180 to 5) in the expectation that they would be ignored and turned into 180/7 if the pilot chose.

Peripheral to the main arguments? No idea, but the problem started somewhere, and from my professional perspective the 180/5 at 1800 is a hole in the cheese, as you folks like to say. After that, it's your call … and i do understand much of what has been said about automation, switch positions, monitoring, culture, etc etc.

IMO it starts with a badly designed approach plate which is evidently inappropriate, sets the aircraft up at 1800' (i.e. above the notional glideslope), and only works because those in the know ignore 180/5 and play 180/7.

Who authorised that approach plate? The rest is up to you sky-gods.