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Asiana flight crash at San Francisco

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Asiana flight crash at San Francisco

Old 10th Jul 2013, 05:07
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paulftw:


What I find funny around here is the total lack of any input from any Korean pilot, want to be pilot or what ever, to add anything in defense or against standards or what happened. “ The Korean mindset bashing “ that has been going on for pages and pages; I would have thought maybe a Korean post? Looking at History, if it's a bent plane say in India, we get posts form Indians either defending the standards or against, same for accidents in Russia etc., we get the locals involved.

With no input from any one in Korea on this issue over the last 60 odd pages leaves me to think, maybe if they ignore it the problem will go away. I just find it a little strange. Maybe they can Photoshop out the bent metal at SFO and all will be forgotten over time.
I don't know, maybe they find some of the racist-tinged comments sprinkled throughout this thread a bit off-putting?

I'm not a pilot, nor am I in the aviation industry. I am a journo and I happened to be on duty this weekend when the plane went down. It also happened in my hometown so I have been following this case closely and stumbled on to this forum via an external link.

It took me three days to go through every single post on here. At times it was insightful and at times, it was painful.

Even though I am on the other side of the cockpit door and have none of your expertise, I do know some things that may help to steer the conversation in the right direction.

Several of you speculated about the "cultural" dynamics among the pilots and whether the instructor pilot was junior to the pilot who was flying the jet. I would like to direct your attention to the following article:

The co-pilot, Mr. Lee, born in 1967, was attempting his first 777 landing at SFO, and his ninth landing overall with that model. He had previously landed the 777 at Narita in Tokyo, London Heathrow and Los Angeles. Between 1999 and 2004, Mr. Lee landed other models of passenger planes at the same airport in San Francisco.
A Korean transport ministry spokesman said Mr. Lee had been at the controls for five hours before landing. He has 43 hours of real, non-simulated experience flying 777s, roughly the equivalent of three to four trans-Pacific flights.
Few details emerged Monday about Mr. Lee, who joined Asiana as a trainee in 1994 and gained his pilot's license in 2001. He has just under 10,000 hours of flying time.

The captain on board, Lee Jeong-min (THIS IS THE INSTRUCTOR), has a 12,387 hour flight record. Born in 1964, Mr. Lee Jeong-min has 3,220 hours of flight experience in the 777 model.


As you can see, seniority was not an issue here so perhaps we can put that speculation to rest.
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Old 10th Jul 2013, 05:09
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Two points….of the two non operating pilots, the guy sat in the jumpseat behind the operating FO can see next to nothing of the flight instruments…his view is almost totally blocked. The guy sat on the jumpseat behind the centre console is another matter however….

If the LHS pilot was just onto the 777 from Airbus, is there a possibility that he wasn't used to the feel of the engine thrust levers moving to spool up since as far as I am aware (never having flown the Airbus) the levers are fixed so he 'may' have reverted to type at a critical moment and not even realised the engines were not doing what he thought they should have been? There is a different position and 'feel' to when the thrust levers are at idle and when they are spooled….if your not used to that difference it won't set mental alarm bells ringing.

I like the tactile feedback the thrust levers give…another situational awareness clue the Boeing gives…..If your used to it of course

Last edited by felixthecat; 10th Jul 2013 at 05:14.
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Old 10th Jul 2013, 05:19
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The FO sitting in the jump seat was probably too scared to speak up about the
loss of Airspeed if he indeed even noticed it.

Lets imagine he did speak up and saved the day, how do you think the two Captains would have reacted later on? I think the FO might have been told off and probably this would have effected his career later on. So he probably saw the low Airspeed and "thought" they had it under control.
It was incredibly unprofessional of him not to say something if he spotted it, which he should have. He claims that he couldn't see the runway which is understandable from a jump seat on late finals even if they had been on the correct profile. Therefore what else did he have to look at apart from the instruments?

This looks like a classic and massive failure of CRM.
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Old 10th Jul 2013, 05:19
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1900ft at 5nm to touch, just because of Class B airspace? Get real you lot.
The bridge is at 6nm, and if you believe in 300ft per NM, then the "correct" height at the bridge is 1800ft, not much difference. The base of class B goes to 1500 feet at 7nm and 2500ft at 10nm. The plate does say "recommended", not "required"
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Old 10th Jul 2013, 05:22
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Plenty of FO's around the world have sat there and said nothing while the Captain proceeded to kill them.

This should not happen in 2013 in a modern jet operated by a major carrier BUT IT DOES.
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Old 10th Jul 2013, 05:27
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A plausible scenario?

Based on the CBS report:
NTSB: Asiana pilots say they used automatic speed controls for landing that went tragically wrong in San Francisco - CBS News

... which states the position of the FD [PF=on; PM=off], "Looking out of the window" may have been a contributory factor.

A scenario that I have witnessed several times, in high workload, "rushed" approaches, is that following a call for A/P disconnect & "Flight Directors Off", the PM will fail to de-select their FD, because they are cognitively overloaded (visually monitoring a (recovering?) profile, completing checklist & ATC calls).

This simple omission is rarely caught if not acted on at the time of A/P disconnect, and is alone sufficient to prevent A/Throttle wakeup.

This is how the FLCH trap works (in practise) and was well explained during training.

Just to clarify:
With both A/P & both FD off, A/T re-engages in SPD mode (with an FD left on this does't happen).
Despite the A/T switch being in the Armed position (glare-shield), the A/T may not wake-up if certain criteria are met.
Disconnecting the A/T (thrust levers) may result in A/T re-engaging.

Last edited by awair; 10th Jul 2013 at 05:58.
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Old 10th Jul 2013, 05:49
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Is there a link to yesterdays NTSB briefing somewhere? As opposed to CNN highlights…
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Old 10th Jul 2013, 05:57
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Pilots in Asiana crash relied on automatic equipment for airspeed

Pilots in Asiana crash relied on automatic equipment for airspeed

The pilots aboard the Asiana Airlines Boeing 777 that crashed in San Francisco relied on automatic equipment - an auto-throttle system - to maintain airspeed and did not realize the plane was flying too slowly until it was just 200 feet above the ground, the head of the U.S. National Transportation Safety Board said on Tuesday.

In her third detailed briefing on Saturday's crash that killed two Chinese passengers and injured more than 180 other people, NTSB Chairwoman Deborah Hersman also said two flight attendants were ejected from the plane after its tail hit a seawall in front of the runway and was torn off. Both were found injured but alive on the side of the runway.

Hersman said many questions remained about the incident. The South Korean airline's flight crew members were not tested for drugs or alcohol after the crash, a requirement for pilots of U.S.-based carriers involved in accidents, she said.

The accounts given to investigators by the pilots, as relayed by Hersman, confirmed information from the plane's flight data recorder that showed the plane was traveling 25 percent below its target airspeed as it came in for landing.

While she has declined to speculate on the cause of the crash, much of the information released by the NTSB suggests pilot error as a main focus of the investigation.

The pilot in charge of landing the plane on Saturday was in training on the 777 and was roughly halfway through the process, while seated next to him was a co-pilot on his first flight as an instructor. Both were experienced pilots, although they had not flown together before, Hersman said.

"At about 500 feet, he realized that they were low," Hersman told reporters, referring to the instructor pilot's account of the failed last-second attempts to avoid Saturday's disaster. "Between 500 and 200 feet, they had a lateral deviation and they were low. They were trying to correct at that point."

Referring to the instructor pilot, she said it was not until 200 feet that "he recognized the auto-throttles were not maintaining speed" and tried to abort the landing. Hersman had previously said that the plane had been at an altitude of 200 feet 16 seconds before crashing.

Three of the four pilots on board were in the cabin during the landing, although only two could see the runway, Hersman said, citing the interviews by investigators with the crew.

Hersman said an examination of the wreckage showed that the auto-throttle was "armed," but it was not clear if it had been properly engaged or had somehow failed before the plane slowed to a near-stall and hit the ground. "We need to understand a little better" how the auto-throttle is used, she said.

"They had set speed at 137 knots (158 mph), and he assumed that the auto-throttles were maintaining speed," Hersman said of the instructor pilot.

She noted that the pilots were responsible for maintaining airspeed.

"We have a flying pilot and two other pilots in the cockpit and they have a monitoring function," she said. "One of the critical things that needs to be monitored on an approach to landing is speed. So we need to understand what was going on in the cockpit and also what was going on with the aircraft."

REUTERS
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Old 10th Jul 2013, 05:59
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Is there a link to yesterdays NTSB briefing somewhere? As opposed to CNN highlights…
NTSB Briefing on Asiana Airline Plane Crash | C-SPAN

Last edited by overthewing; 10th Jul 2013 at 06:00.
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Old 10th Jul 2013, 06:00
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This story has turned from interesting to just plain tragic for everyone involved.
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Old 10th Jul 2013, 06:04
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The NTSB says "South Korean airliner's pilots were not tested for drugs or alcohol after the crash, because they do not fall under US regulations"

Is this true? Isn't potentially "endangering an aircraft", be it passenger or crew, accepted international law?

I'm not suggesting that there is any evidence the pilots were incapacitated in this way, but I had always assumed that all possible evidence is rigorously gathered to establish cause.
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Old 10th Jul 2013, 06:05
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dba7

DBA7...
please do not be surprised if this kind of "TRAINED" pilots you find all over the world today.
Nothing to do with Korea or Asia. But a lot to do with "modern" way of training.
Good you mentioned Air France. Can anybody remember what Air France has CHANGED in training since last year or so?
 
Old 10th Jul 2013, 06:07
  #1333 (permalink)  
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Definitely no monitoring despite automatics as an excuse.

Awair,

Airbus has had similar problems with pilots not switching off both FDs before approach etc. Airbus has now redesigned in A380 and subsequent A350 models have only 1 button FDs on/off in the middle of the Glare shield FCU panel.

But still doesn't explain dropping off the approach path and not correcting or giving it away earlier.

We're the pilots monitoring:
1. the approach path PAPI
2. Airspeed
3. Attitude
4. Runway alignment.

Even if your stabilized at 1000 feet and it all looks fine. Below 1000 feet if any of these parameters are grossly out a GO-AROUND should be accomplished, as soon as its recognized. Automatics or no automatics.
So if they weren't monitoring the approach what were they doing?
CVR may tell.
It was a SKY BLUE DAY! Tantalizing sites San Francisco Bay, one wonders.
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Old 10th Jul 2013, 06:08
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As you can see, seniority was not an issue here so perhaps we can put that speculation to rest.

"Seniority" might more comprehensively be referred to as "rank", and can encompass factors other than chronological age in a hierarchical society.

Hierarchy can have many gradations that may override a slight seniority in age. One pilot may have been with the company longer. He may have held a higher rank in the military. There may have been a socioeconomic class difference in their upbringing. Someone earlier in the thread mentioned the instructor was in a junior class to the PF at technical university.

None of which would matter in the absence of an authoritarian culture with strong social norms of unquestioning deference to those of higher stature, with the potential to impede communication.

I don't know if any of these were factors on the flight deck that day, but in any case it seems flip to point to a 3-year age difference and claim that this puts the seniority issue to rest.

Last edited by tech9803; 10th Jul 2013 at 06:15.
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Old 10th Jul 2013, 06:13
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Partial Paraphrased Transcript of NTSB Brief 7/9/13

I made this quick partial transcript of the NTSB briefing today.

Included only pertinent points for now.

Thought I'd post it here for quick reference.

Enjoy!

Video found here:

(Numbers in parentheses refer to time in video. All emphasis mine.)


Partial Paraphrased Transcript of Third Media Briefing by NTSB Chairman Deborah Hersman on July 9, 2013



(3:13) POSITION OF SWITCHES AS CONFIRMED BY INVESTIGATORS

  • Flight Director was ON for the right seat, OFF for the left seat
  • Auto-throttles armed.
  • All 3 fire handles extended - Both engines and APU
  • Flaps were set to 30.
  • Speed-brake lever was down, indicates that it was not being used.



(5:49) INITIAL IMPACT LOCATION

  • When you get down to the sea wall you can identify where the first strikes took place.
  • First the main landing gear impacted the seawall and then the tail.


(8.55) FLIGHT CREW INTERVIEWS

  • 3 of the 4 flight crew members interviews completed.
  • Information from the interviews has not yet been confirmed with flight data/CVR


(9:55) PERSONNEL IN COCKPIT AT TIME OF CRASH

3 pilots in the cockpit at time of the crash; 1 pilot seated in the cabin.
  • Pilot Flying seated in the left seat.
  • Instructor Pilot seated in the right seat.
  • Relief First Officer sitting in the jump seat.
  • Relief Captain sitting in the cabin.


(10:46) FLIGHT CREW BACKGROUND AND EXPERIENCE

#1 PILOT FLYING [Captain Lee Kang Kuk]
  • 9,700 total flight time, 5,000 hours as Pilot In Command.
  • This was his initial operating experience in the 777.
  • To complete initial operating experience for Asiana he is required to have 20 flights and 60 flight hours.
  • He had completed 10 legs and about 35 hours flying the 777; was about half way through his initial operating experience on the 777.
  • He was hired in 1994.
  • He did his initial training in Florida.
  • Is rated in the 737, 747, A320 and 777.
  • Was ground school instructor and a SIM instructor for the A320/321
  • He was a captain on the A320 from 2005-2013.
  • Immediately prior to his initial operating experience on the 777, he was a captain on the A320.


#2 INSTRUCTOR PILOT (Captain Lee Jung Min)
  • The instructor pilot was seated in the right seat and is also a captain.
  • He reported total flight time as 13,000 hours with an estimated 3,000 in the 777.
  • Total Pilot In Command time was about 10,000 hours.
  • He had been in the Korean Air Force for 10 years
  • He reported this was his first trip as an instructor pilot.
  • The instructor pilot stated he was the PIC and sitting in the right seat.
  • This was the first time that he and the pilot he was instructing had flown together.

#3 RELIEF FIRST OFFICER
  • The Relief First Officer who was sitting in the jump seat reported he had 4,600 hours flight time.
  • He estimated he had 900-1000 flying in the 777.
  • He flew F-5s and F-16s in the Korean Air Force.
  • He had flown to San Francisco 5 or 6 times as the Pilot Monitoring.
  • Suffered a cracked rib. Only one on the flight deck to be treated for injuries.

#4 RELIEF PILOT
  • 4th pilot was the Relief Captain and was not in the cockpit for the approach.


(14:55) OBSERVATIONS FROM FLIGHT CREW (Not yet corroborated by CVR)

  • Approach asked them to maintain 180 knots until they were about 5 miles out.
  • This aircraft has a max of 160 knots to put down the landing flaps for final configuration.
  • The Relief First Officer, sitting in the jump seat, identified that he could not see the runway or the PAPI from his seating position and that the nose was pitched up so he could not see the runway.
  • Instructor Pilot stated that to the best of his recollection they were slightly high when they passed 4000 feet; they set vertical speed mode at about 1500 feet per minute.
  • At about 500 feet he realized that they were low; he reported seeing three red and one white on the PAPI. He told the pilot to pull back.
  • They had set speed at 137 knots and he assumed that the auto-throttles were maintaining speed.
  • Between 500 feet and 200 feet they had a lateral deviation and they were low. They were trying to correct at that point.
  • At 200 feet he noticed the four PAPIs were red, the airspeed was in the hatched(sp?) area on the Speed Tape. He recognized that the auto-throtles were not maintaining speed and he established a GO-AROUND Attitude.
  • He went to push the throttles forward but stated the other pilot had already pushed the throttles forward.

DETAILS ON THE AUTO-THROTTLES (27:11)

Auto-throttles documented in the armed position.

Q: Does 'armed' mean engaged?
A: Armed means that they are available to be engaged but depending on what mode is used, we really need to understand that a little bit better, to understand how they were used and what the expectation was for the auto-throttles.

Q: Is there a back-up system of any kind on the auto-throttles with respect to holding speed?
A: We need to gather a little bit more information and corroborate the data before we understand the issue.

She went on to state:
"But let me be very clear: The crew is required to maintain a safe aircraft. That means that they need to monitor. We have a flying pilot and we have two other pilots that are in the cockpit and they have a monitoring function. One of the very critical things that needs to be monitored on an approach to landing is speed. And so we need to understand what was going on in the cockpit and also what was going on with the aircraft."

Source: Chairman Hersman's third media briefing on Asiana flight 214 crash July 9, 2013 - YouTube

Last edited by Knot Apilot; 10th Jul 2013 at 09:26.
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Old 10th Jul 2013, 06:14
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The Sounds and Feel of 777 at 105 knots

I'd like to ask some triple 7 drivers about the cockpit airflow acoustic sound difference between 140 and 105 knots. But the only triple 7 cockpit crew who have the experience to comment on the sounds heard at near sea level at 105 knots will likely be interviewed soon.

I would think that the noise difference would be obvious. However the very high AOA near "touchdown" may have resulted in the same sounds at 105 as at 140 knots. My impression was that the AF cockpit sounds might have added to the confusion by giving an impression of adequate speed when in fact the acoustic signature was due to mushing through the air instead of going where the nose was pointing.

I am wondering if the NTSB will tease some acoustic clues out of the voice recorder by comparison with other landing at normal approach speeds.
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Old 10th Jul 2013, 06:17
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Originally Posted by Marck
The bridge is at 6nm, and if you believe in 300ft per NM, then the "correct" height at the bridge is 1800ft, not much difference. The base of class B goes to 1500 feet at 7nm and 2500ft at 10nm. The plate does say "recommended", not "required"
1/ Have a look at the location of SFO DME. Then tell me the distance to the runway when you're at 1900ft/6DME SFO.

2/ Unless you have local knowledge about the actual VFR traffic levels below, you'd be a clown to say "oh it only says recommended, let's ignore it". Why do you think the authorities put that recommendation there in the first place?

Originally Posted by SierraFoxtrotOscar
He has 43 hours of real, non-simulated experience flying 777s, roughly the equivalent of three to four trans-Pacific flights....
Few details emerged Monday about Mr. Lee, who joined Asiana as a trainee in 1994 and gained his pilot's license in 2001. He has just under 10,000 hours of flying time.

The captain on board, Lee Jeong-min (THIS IS THE INSTRUCTOR), has a 12,387 hour flight record. Born in 1964, Mr. Lee Jeong-min has 3,220 hours of flight experience in the 777 model.


As you can see, seniority was not an issue here so perhaps we can put that speculation to rest.
Sorry, you're out of your depth here. Firstly, 43 hours flying three times over the Pacific is worthless as far as experience for this approach/accident goes. Do you actually know what goes on above 10,000ft in a airliner cockpit? As far as stick and rudder skills or approach practice goes, nothing. Do some research about average flight time, numbers of total landings, numbers of landings the autoland system does, and numbers of landings each pilot does, and then the numbers of landings without ILS. You'll be surprised at how little "experience" these guys had.

As far as the seniority thing goes, I think the theories put up here are entirely reasonable.

Last edited by Capn Bloggs; 10th Jul 2013 at 06:19.
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Old 10th Jul 2013, 06:28
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Bamboo 30 said
Many times seen first hand how the so called oldtimers with self professed stick and rudder skills simply disc AP and AT during descent cos the descend spd in vnav wasnt what they wanted. didnt prog in the spd in vnav of course spd is different. Simple case of not understanding the automatics and assuming auto fails.
It's called flying the aircraft (FTFA).When the automatics are not doing what you don't want them to do or can't understand what's going you you FTFA and that includes disconnecting the automatics.

Felix wrote
Two points….of the two non operating pilots, the guy sat in the jumpseat behind the operating FO can see next to nothing of the flight instruments…his view is almost totally blocked. The guy sat on the jumpseat behind the centre console is another matter however….
Almost true. From the second observers seat you can see the captains instrument panel and if you lean a bit to the left you can see the centre console including thrust levers and EFIS panel with engine indication. I spent a lot of time in that seat. If there was only one of the relief crew in the flight deck I expect that s/he was on the first observers seat with a view of everything.

To say you thought the A/T was taking care of speed does not absolve you from the responsibility of FTFA. The automatics will only do what you tell it to do.
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Old 10th Jul 2013, 06:29
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Breakthrough: Insight from the Media

At last some new information about the possible cause of the accident...

Many media are now carrying a story attributed to Associated Press that includes this gem regarding KSFO:

"In a news conference Tuesday, NTSB officials didn't explain fully why the plane approached the notoriously difficult landing strip too low and slow, likely causing the crash..."

Landing strip? 28L? 200 feet wide and 11381 feet long?
Notoriously difficult? No terrain, CAVU, over water approach?

And I thought TGU was an interesting approach - but not rising to the level of being notoriously difficult.
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Old 10th Jul 2013, 06:32
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777 CRASH

is it compulsory for relief pilots to be in the flt deck during the approach??
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