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Asiana flight crash at San Francisco

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Asiana flight crash at San Francisco

Old 10th Jul 2013, 11:57
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Falcon900

Please do try and keep "up to speed"

Turning off the navigation aids created the possibilty for the failure which seems to have occurred here, and surely cannot be justified other than on cost grounds.
The 28L Localiser was radiating normally, the 28L Glideslope was OFF as the landing threshold is in the process of being moved to the west. PAPIs for the new threshold were working normally and providing the glideslope guidance in severe VMC.
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Old 10th Jul 2013, 11:58
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RetiredF4
The probable obvious cause of this accident seems to be non existent energy management by the crew.

The low speed was the reason for dropping low on the glidepath and for being unable to correct this situation in time. Most information for a visual approach can be found or correlated from outside visual references, speed canīt. It has to be checked with the instruments and managed properly.
There seems to be a overreliance on the AT to do this job at all times and under most circumstances. There is no excuse that the speed decay in that published amount and time was not recognized until it was too late.
Agreed but what if you pushed the thrust levers forward and there was no response from the engines? You would get an event like this or the BA777 at Heathrow.

Not saying it happened this way but it perfectly fits the flight profile.
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Old 10th Jul 2013, 12:17
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From Crewmeal

Quote:
Sources in the country's transport ministry confirmed Bong Dong Won - who was in the cockpit jump seat - repeatedly yelled "sink rate" in the final minute before the crash, it was reported.

If the sink rate - the rate of decrease in altitude - was checked when Mr Bong raised the alarm, it may have prevented the plane from hitting the seawall as it landed at San Francisco Airport, reports said.

But the two pilots at the controls - Lee Kang Kuk and his instructor Lee Jung Min - apparently did not respond to Mr Bong's shouted warnings, the respected Joongang Daily newspaper said.
This from Sky News

It's all coming out in the wash.
IF Sky News is reporting this correctly (that would be a first) and IF the original source is correct and IF this is backed up by the CVR, this is suggestive of several things, both positive and negative

On the positive side:
A) The FO in the jump seat was paying attention
B) He identified the issue (and would appear to have done so well before the two in front - nearly a minute earlier)
C) He had the gumption/guts/training to bring it to the attention of the two far more senior bods in front of him, as he should

On the negative side
D) His (repeated) "sink rate" warnings seem to have been uncrecognised / ignored / otherwise not acted upon for close to a minute, until the PF moved the throttles forward at 7 secs to go. (The LTC is recorded as stating that when he went to move the throttles forward, they had already been moved by the PF)
E) The LTC apparently called for go around at 1.5 seconds before impact. Quite how he thought this was going to be achieved from basically zero altitude at vRef-30 or more is quite another matter!

@aa5bpilot
interesting plots - thanks for these, not least the amount of other arrivals who were way below vref (though possibly in different conditions and, as you say this is GS, not IAS). Another caveat being, of course, that this is FA data

Last edited by NamelessWonder; 10th Jul 2013 at 12:22.
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Old 10th Jul 2013, 12:19
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Captain Bloggs:

That's the problem with discussing this as though pitch and power work in isolation. They don't, they work together, and always have.
P + A = performance. Not just a Navy thing.

Pitch and power together, lead with power if a correction is needed when high and fast or when low and slow.

If Hi and slow, then you'd probably want to lead with pitch, so you can trade alt for a/s and your correction may work. If low and fast, likewise not a bad idea to lead with pitch.

In either case, you'd end up with a pitch correction, and then counter correction when back on the numbers to resume profile. In either case, you may need to adjust power slightly to stay on profile.

As with anything flying, depends on the situation.

When I consider the lead time you need in a heavy, I'd guess that you have to stay well ahead of the aircraft, and lead with power by more time, if you find yourself high and fast or low and slow, which means that you need to lead the counter correction as well by some seconds as your correction gets you back toward your glide path. You still want to "catch" it rather than go through and porpise about the glide path.

Anyway, I don't think the principles differ, what differs is response time and how much you have to lead the aircraft in time to get the corrections you want to regain the profile (performance) that you are looking for.


squawk7700
So either you are managing both, or you manage none. They both go hand in hand, taking one of those out is just opening the door to create bad habits - like not noticing a huge airspeed loss on short final.
That is what I am trying to get at. Thanks for saying it better.

dba7
thanks for your polite and insightful post, error in re AF 447 crew considered.

6. At the end of the day a very experienced crew crashed an aircraft they were concentrating on flying. Sure they weren't quite stabilised blah blah but there's more to it. If there is a latent trap in the autoflight system I want to know about it so it doesn't bite me in the arse on that one time when I'm not quite on top of my game.
Well said, HPSOV L
The stuff up a visual approach, in visual conditions, is appalling, but I am only surprised it has taken this long. Many carriers around the world are using FOQA data recorders for punishment of their pilots. The result is the CP's and pilots are reluctant to hand fly, or turn the auto-throttles off, ever. While this may reduce the number of exceedences on a daily basis, it destroys pilot proficiency.
This mishap isn't the only one where the above point has been raised.
Deepest respects to the poor souls who lost their lives. They will find NOTHING of any value here!
The departed will find nothing here, of any sort, being no longer among the quick and thus not able to read what's here.
3rd Floor
Is that how you fly an ILS?

If you maintain constant airspeed, your power will be what varies your glide path.
Granted, each time you adjust power you'll tend to adjust pitch to stay on speed.
Correction, counter correction.
It was my impression that the aim is to fly the final stretch of an approach at a chosen approach speed. (in the case under consideration, 137 kts).
If you mess about with using your pitch to find the aim point, you'll change your speed, won't you?

So I have to ask: do you fly with one hand or two?

Why my approach to this "scares you" mystifies me. The principles in question have been successfully putting high performance jets on carrier decks for about sixty years. They work.

They also work very well for flying an ILS or a GCA to touchdown in crap weather.

I do understand that you can lead with your nose and catch up with power. So long as one works power and attitude together, one should get to where one is aiming to land. See Squawk7700's post for a better way of putting that.

Last edited by Lonewolf_50; 10th Jul 2013 at 13:20.
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Old 10th Jul 2013, 12:22
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Originally Posted by speed2height
Agreed but what if you pushed the thrust levers forward and there was no response from the engines? You would get an event like this or the BA777 at Heathrow.

Not saying it happened this way but it perfectly fits the flight profile.
Witnesses and the NTSB all report that it did not happen this way. Engines did power up prior to impact.
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Old 10th Jul 2013, 12:29
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Speed2height

Not saying it happened this way but it perfectly fits the flight profile.
The flight profile was botched already further out. If a step down gate like that at the bridge is already 300 feet high to a standard 3 degree glideslope (the Papis by the way have 2.85 degrees AFAIK), common sense forbids to be another 300 feet above the recommended altitude while being faster than necessary at the same time. From that point on they played "catch up".

The question is, why this visual approach in clear VMC was started that far off the ballpoint speed and vertical profile wise, that it ended short of the runway without being discontinued by the crew.

There might be technical reasons, which nobody has discovered yet, there might be factors contributing to the outcome which the findings will uncover, but for an hands on stick and throttle guy like me its hard to understand.

@Lonewolf
I'm with you on that topic, let me just add one thing: the closer the flown speed and the Vref is to the stall speed, the more this leading the correction with pitch and power is necessary.

Last edited by RetiredF4; 10th Jul 2013 at 12:37.
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Old 10th Jul 2013, 12:31
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In #1409 I thought the CVR and FDR had yet to be analysed, but I see from mickjoebill at #682 they had been, so in fact the comments from Deborah do appear to be 'definitive'.

I see from a previous post by NoD that the 777 bible says
Alpha Floor is a low speed protection (in normal law) which is purely an autothrust mode. When activated, it provides TOGA thrust. As the aircraft decelerates into the alpha protection range, the Alpha Floor is activated, even if the autothrust is disengaged. Activation is roughly proportional to the rate of deceleration.

Alpha Floor is inhibited:
* below 100 feet radio Altitude,
* if autothrust unserviceable,
* following double engine failure on an A340 (or one engine out on the twins),
* following certain system/auto flight failures,
* above Mach 0.53.
- no mention of 'FLCH with 0000 set'.

Memory of the 737 is fading, but why is there a suggestion that 777 min speed reversion (msr - which would have applied power when the IAS dropped below 1.3Vs) did not kick in above 100'RA? I cannot find the tabulated speeds quickly but I'm sure the speed 'disappeared' well above 100'RA. I can see absolutely no logic in disabling msr in FLCH and if it is so disabled, I would suggest a PDQ revision of this.................................
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Old 10th Jul 2013, 12:33
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That is for Airbus.
The 777 does not have Alpha floor.

Me shakes me head....

Also, for the 100th time THEY WERE NOT IN FLCH.
The NTSB said they were last in VS-1500

Last edited by nitpicker330; 10th Jul 2013 at 12:41.
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Old 10th Jul 2013, 12:49
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Maybe I missed this; if so, sorry. Does SFO Tower have Mode C SSR? If so, both visually and from the SSR height readout it must have been obvious that the a/c was below the G/S. I know some UK towers have an alarm system if an aircraft goes off the localiser but I don't know about G/S.
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Old 10th Jul 2013, 12:52
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The NTSB said in response to a reporter question that SFO ATC do not have the ability to monitor the Aircraft glide slope, that's up to the Pilots she said.
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Old 10th Jul 2013, 12:54
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Also, for the 100th time THEY WERE NOT IN FLCH.
The NTSB said they were last in VS-1500
Not quite- The NTSB said one of the Pilots reported they selected V/S -1500 at an earlier stage of the approach.

They have not said what mode the FDR revealed they were in at the time of the crash.

FLCH with the PFs F/D off would fit the facts very nicely.

If they were in V/S and thus the A/T was is SPD, why didn't A/T wake-up happen?
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Old 10th Jul 2013, 12:56
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Lurking around now for awhile, I've finally come to the point I have to contribute something.

All the comments about how people can't fly anymore, automation dependency, etc, etc.

When a few decades ago the first advanced autopilots where introduced they where a great tool to advance safety! Airspace became busier, airplanes more advanced. Airplanes capable of landing in extreme weather. Reading the book faith is the hunter, holy !! Those guys could really fly!! However, throughout the book, how many crashes where described? Automation has really reduced that. However, automation became so complex that accidents started to happen due to a lack of understanding the automation. Subsequently a lot of time training was spend on understanding the complex systems.

Same can be said about SOP's

Notable accidents, the airbus crash at Zurich I believe where a simple wrong push of a button led to a wrong autopilot mode and subsequent descent into terrain, or Swissair into Halifax, where sticking to SOP's delayed landing!

However, we have now come to the point where we realize there is a negative side to automation, namely dependency!!

Should we now all go back to hand flying?? Into our busy airport with much increased workloads? Will that make aviation safer?

Now, the reality of wide body flying for a major, say, you fly 700 hrs a year. Less than 10 percent of that will be flying in a terminal area where you can practice some of the flying skills, however most of that will be to major airports where you will be vectored into a busy airport with controllers you can hardly understand, hardly ever flying a standard profile, coming there once or maybe twice a year so you are also unfamiliar with the place! Is this the place to practice your manual skills after flying for 10hrs through the night? When most people on your time clock are just getting ready to wake up to go to work! As a wide body FO, I do about 35 to 40 trips a year to some of the busiest airports in the world. Should I, every time make a raw data non precision approach after a 9 to 12 hr flight just to prove I can do it. I can guarantee that that will not improve safety!!

Increase training? Every time I go to the sim, I have to satisfactory show hand flying skills, however, I'm well rested, not flying into busy airspac,e although we do practice going into all the places we fly to, using standard profiles, I can understand the ATC because it's done by a instructor from my own company, etc, etc.This does not accurately represent line flying!!

There is something to be said about increasing training, however we are now dealing with the low cost company's and passengers that demand lower and lower ticket prices! Your company can increase training all they want, but soon they will be out of business because they can't compete!

Now, coming to the mishap flight. I understand that the pilot flying was training, with 43hrs this was probably his 4 or fifth flight, probably still overwhelmed by the new aircraft and faced with a busy airport, with staccato ATC instructions and a inoperative G/S( something he probably practiced in the sim) etc, etc.

He messed up, sure enough!, but I don't think he woke up that morning thinking he was going to do a lousy job, I don't think he thought of himself of being a substandard pilot!

Just maybe, he read on here all the comments about Turkish in Amsterdam and thought, what a wankers, that will never happen to me....

As most people on here do.....

There is a trend on here as well as other boards, Turkish, Colgan, air France, professional pilots branding one another instead of asking why!!

I don't know the answer, but I do know that simply saying he was an incompetent pilot is not going to reduce this kind of accident. If it did, this wouldn't have happened after Turkish!!! Aviation has come a long way, instead of simply saying, he made a mistake, or ' pilot error' it's much more interesting asking, why did he make that mistake!
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Old 10th Jul 2013, 13:00
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We shall see in the course of time.

If the mode with the right F/D on was VS then unless the PF had disconnected the A/T it would have maintained thrust to keep the selected speed of 137 with SPD annunciated. ( unless the rate of descent made it impossible for the Aircraft to slow down )
It should have stopped it from going below 137 kts when later on he pulled the nose up.

If he disconnected the A/T the right F/D would have kept VS -1500 but without SPD mode. I would have thought in this case the A/T would wake up if the speed got low when he pulled the nose up??

Last edited by nitpicker330; 10th Jul 2013 at 13:08.
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Old 10th Jul 2013, 13:25
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737OPR

You have so hit the nail on the head. Flying manually in the sim was a breeze, because you were wide awake and living on adrenaline. But for a major airport to offer only a visual approach to a dog-tired crew is dreadful. If the G/S has to be off, do it on one runway at a time, and give crews an option of doing a full ILS. The hot-shots posting here about flying with 'stick, rudder, and eyeball' can opt for the visual. Me, at the end of a 14 hour day? I'll take the ILS, please.

Regarding the PH being a bit overwhelmed by the 777, you have reminded me of my very first 777 landing. We had a 'zero hour' sim, so base-training was not needed. How the hell they got that authority is beyond me, because the flare in the sim bore no relation to the real aircraft. I made a horrible mess of that first landing, and aged the trainer in the RHS by about ten years.

Also, coming from an 'older' aircraft, the view was all wrong, since the 777 has a very low approach attitude. I feel so sorry for this guy. At least, for my own first go, I had an ILS.
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Old 10th Jul 2013, 13:32
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Aileron Drag:
Regarding the PH being a bit overwhelmed by the 777, you have reminded me of my very first 777 landing. We had a 'zero hour' sim, so base-training was not needed. How the hell they got that authority is beyond me, because the flare in the sim bore no relation to the real aircraft. I made a horrible mess of that first landing, and aged the trainer in the RHS by about ten years.
The system seems to have tried to set you up for failure there.

Just curious: how many times had you seen the sight picture of a landing when not at the controls in the aircraft, versus the sim? From what you shared there, it sounds like "zero" but I may be assuming too much.

Last edited by Lonewolf_50; 10th Jul 2013 at 13:34.
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Old 10th Jul 2013, 13:33
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Looking at the ATC side of things - although it did not affect this flight - asking for '180 to 5' and expecting 3-400 ft high at that point is a bit risky!.
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Old 10th Jul 2013, 13:37
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"The hot-shots posting here about flying with 'stick, rudder, and eyeball' can opt for the visual. Me, at the end of a 14 hour day? I'll take the ILS, please."

I, as a fare paying passenger, will take the hot-shots then. Not a pilot here but can't really understand why your 14-hour day, (10 days a month perhaps?) filled with exciting AP monitoring and if-you're-lucky 10 minutes of actual flying time, can leave you a ragged wreck unable to safely perform the most basic of flight maneuvers in a modern FBW flight deck?
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Old 10th Jul 2013, 13:38
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Aileron drag---Fair enough. stabilized approaches are always the key.

BOAC--- agreed, we couldn't do 180 to 5 ( = 1500' ) in the A330 and meet company stabilized criteria.
Especially if 300' high.

Last edited by nitpicker330; 10th Jul 2013 at 13:39.
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Old 10th Jul 2013, 13:41
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Nitpicker said
Ok. It but it wasn't his first go in the real Aircraft, he'd done around 10 sectors already.
It will be interesting to find out on how many of those sectors he was PF!
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Old 10th Jul 2013, 13:42
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" Can anybody remember what Air France has CHANGED in training since last year or so? "

- Much more hand flying oriented sim sessions...
- SOP now very close to manufacturers policy... (AF was known, even in France, to reinvent the art of flying, not to say teaching birds how to fly )
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