Asiana flight crash at San Francisco
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asiana 214
1. voice speed is not such a problem as you might think. even in this accident I have'nt heard anyone ask for a repeat. once pilots start flying into these high density airports they would get used to it. obviously laymen cant understand what is being said and that is probably frustrating. tip, just keep running the videos one word at a time, you will soon get the message.
2. the voice saying go around was heard in the background to the controllers voice. it suggests to me that "go around" either came into the Tower from United on another frequency ( taxy/groundcontrol?)and was picked up by the controllers mic or even that it came from another controller alongside him watching events unfold . simultaneous transmissions on the SAME frequency cause interference with each other and usually result in nothing understandable being heard by anyone. hence the rapidity of speech, you have to get off the air pronto in order to allow others to speak. controllers are bound to speak faster than pilots because they have a lot more transmissions to make than an individual pilot.
3. stand to be corrected but it seems logical that everyone must be off the aircraft before fire trucks start filling it with foam etc. the running over is a terrible tragedy and ought not to have happened.
2. the voice saying go around was heard in the background to the controllers voice. it suggests to me that "go around" either came into the Tower from United on another frequency ( taxy/groundcontrol?)and was picked up by the controllers mic or even that it came from another controller alongside him watching events unfold . simultaneous transmissions on the SAME frequency cause interference with each other and usually result in nothing understandable being heard by anyone. hence the rapidity of speech, you have to get off the air pronto in order to allow others to speak. controllers are bound to speak faster than pilots because they have a lot more transmissions to make than an individual pilot.
3. stand to be corrected but it seems logical that everyone must be off the aircraft before fire trucks start filling it with foam etc. the running over is a terrible tragedy and ought not to have happened.
In the case of the SFO Asiana crash, the pilot flying either forgot, that he put the engines in idle, when he needed to drop down quickly, to make an approach, and when he realized he was going too slow, instead of thinking, "Wait, let me think ... Oh yeah, I forgot that I turned the engines to idle a few minutes ago, to drop down, since I was too high, so I'll turn them back up", or he thought they automatically came back on, after being turned down, in which case he should have thought "Well my speed is too slow, maybe I was wrong about the throttle going back to automatic, automatically, and need to push them forward myself". Instead he doesn't think. He just continues to go in for an all but dead stick landing, after his speed was siphoned off from coming in low and flat at the end of his approach. I've studied how people think my entire life, and there's two kinds of people. The ones, who actively think most of the time (unless they are very tired), and people who only think when called upon to think. These pilots were the latter. In order for them to think, someone has to ask them a question. Maybe that's the answer for culturally challenged CRM. Instead of the telling the pilot flying to increase thrust, ask him "Are the throttles still at idle?" or for a little less thinking, the more immediate "Do you think we should push the throttles forward?". It's the Socratic method, where the teacher asks the students questions to make them think, and come to their own conclusions, but using it for non-ego-threatening or non-mutinous sounding CRM. Now that I think about it, this should be incorporated in training at risk for culturally challenged CRM crews.
coastalpilot,
I think you are being a little to narrow in your analysis.
YES an IP should have detected, called, and ultimately corrected the low-speed situate=ion, but, then so should any competent FO- AND, new to type or not, the LHS pilot was not a cadet- he was an experienced commander changing types, who already held a Type Rating on the Aircraft. Maintaining airspeed on approach would not seem to be an unreasonable expectation.
While you are quick to find an individual to blame, you miss asking an important question- WHY would an IP, even an inexperienced one, not monitor and correct a low airspeed situation?
THAT is where a deeper investigation into attitude, training and culture may reveal problems we can fix.
Simply saying "It was His fault" does nothing to prevent things like this happening again.
I think you are being a little to narrow in your analysis.
YES an IP should have detected, called, and ultimately corrected the low-speed situate=ion, but, then so should any competent FO- AND, new to type or not, the LHS pilot was not a cadet- he was an experienced commander changing types, who already held a Type Rating on the Aircraft. Maintaining airspeed on approach would not seem to be an unreasonable expectation.
While you are quick to find an individual to blame, you miss asking an important question- WHY would an IP, even an inexperienced one, not monitor and correct a low airspeed situation?
THAT is where a deeper investigation into attitude, training and culture may reveal problems we can fix.
Simply saying "It was His fault" does nothing to prevent things like this happening again.
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Suddenly, this voice came up and said:
"Army Ninety Twelve; ya'll follow the United Fluff."
My captain looked at me in some amazement and looked sceptical when I told him to get after the United 737 right-to-left ASAP.
"Army Ninety Twelve; ya'll follow the United Fluff."
My captain looked at me in some amazement and looked sceptical when I told him to get after the United 737 right-to-left ASAP.
The controller asked 'Are you carrying a sick parrot?'
It was NATO jargon for an inoperative transponder.
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Some interesting comments on the last 2 pages: please let me ask some questions.
The thought that an SFO visual profile should be a trained manoeuvre: there are many airports where terrain causes them to be a self-briefed or trained airport due to extenuating circumstances. If SFO visuals falls into that category then so be it.
However, my experience of a visual approach is one requested by me. If granted it means I can manoeuvre my a/c as I see fit onto a final approach path to execute a landing with visual references. If it has an ILS it is usually promulgated that the approach will not be flown below the G.S. and sometimes not to establish below XYZ feet. How is it that ATC can determine the 'visual approach' profile?
If they can, and pilots find it demanding, how come it has not been challenged before? How can ATC impose visual approach criteria? It would suggest they are radar vectoring for a difficult energy management visual approach. How has this been allowed to happen AND continue, if it is the case?
I suspect that once the carpet is lifted there will be much to be found has been swept under it over the years.
The thought that an SFO visual profile should be a trained manoeuvre: there are many airports where terrain causes them to be a self-briefed or trained airport due to extenuating circumstances. If SFO visuals falls into that category then so be it.
However, my experience of a visual approach is one requested by me. If granted it means I can manoeuvre my a/c as I see fit onto a final approach path to execute a landing with visual references. If it has an ILS it is usually promulgated that the approach will not be flown below the G.S. and sometimes not to establish below XYZ feet. How is it that ATC can determine the 'visual approach' profile?
If they can, and pilots find it demanding, how come it has not been challenged before? How can ATC impose visual approach criteria? It would suggest they are radar vectoring for a difficult energy management visual approach. How has this been allowed to happen AND continue, if it is the case?
I suspect that once the carpet is lifted there will be much to be found has been swept under it over the years.
Clayne,
WRT to inhibiting FLC, my point was there are relatively simple ways to inhibit FLC that would prevent it being used inappropriately. A safety standard protocol when addressing a hazard is to engineer a fix that eliminates the hazard from causing an accident. We have numerous protections installed in planes presently that don't need to be there, if the plane were flown properly and are very rarely encountered by the pilots.
GF
WRT to inhibiting FLC, my point was there are relatively simple ways to inhibit FLC that would prevent it being used inappropriately. A safety standard protocol when addressing a hazard is to engineer a fix that eliminates the hazard from causing an accident. We have numerous protections installed in planes presently that don't need to be there, if the plane were flown properly and are very rarely encountered by the pilots.
GF
Last edited by galaxy flyer; 13th Jul 2013 at 19:36.
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coastalpilot,
I think you are being a little to narrow in your analysis.
YES an IP should have detected, called, and ultimately corrected the low-speed situate=ion, but, then so should any competent FO- AND, new to type or not, the LHS pilot was not a cadet- he was an experienced commander changing types, who already held a Type Rating on the Aircraft. Maintaining airspeed on approach would not seem to be an unreasonable expectation.
While you are quick to find an individual to blame, you miss asking an important question- WHY would an IP, even an inexperienced one, not monitor and correct a low airspeed situation?
THAT is where a deeper investigation into attitude, training and culture may reveal problems we can fix.
Simply saying "It was His fault" does nothing to prevent things like this happening again....................................................... .............
sorry I dont know proper way to quote and respond clearly so I just copied your comment..
as to the possibility that someone else could have also made the same mistakes as the IP, I don't see what that has to do with it. His was the ultimate responsibility, not the PF.
as to the reasons why the IP failed, I agree they are more important than the fact. I alluded to them in my comment about "institutional failure." Maybe I wasn't clear enough. Thanks for pointing it out.
The real failure was the certification of an IP that did not do his job. Its a big job.
Its a certification/training problem since the airline certified the IP to do a job he failed at his first time out.
a big one.
imo all the angst about the deterioration of hand flying skills is obscuring the real failure. I think its absolutely understandable, even predictable, that the PF would have problems with that approach...new airplane, special airport,(with a very unique visual approach procedure and requirements), back of the clock fatique...and so on.
but the company certified a IP who didnt do his job.
that was the problem, imo.
I think you are being a little to narrow in your analysis.
YES an IP should have detected, called, and ultimately corrected the low-speed situate=ion, but, then so should any competent FO- AND, new to type or not, the LHS pilot was not a cadet- he was an experienced commander changing types, who already held a Type Rating on the Aircraft. Maintaining airspeed on approach would not seem to be an unreasonable expectation.
While you are quick to find an individual to blame, you miss asking an important question- WHY would an IP, even an inexperienced one, not monitor and correct a low airspeed situation?
THAT is where a deeper investigation into attitude, training and culture may reveal problems we can fix.
Simply saying "It was His fault" does nothing to prevent things like this happening again....................................................... .............
sorry I dont know proper way to quote and respond clearly so I just copied your comment..
as to the possibility that someone else could have also made the same mistakes as the IP, I don't see what that has to do with it. His was the ultimate responsibility, not the PF.
as to the reasons why the IP failed, I agree they are more important than the fact. I alluded to them in my comment about "institutional failure." Maybe I wasn't clear enough. Thanks for pointing it out.
The real failure was the certification of an IP that did not do his job. Its a big job.
Its a certification/training problem since the airline certified the IP to do a job he failed at his first time out.
a big one.
imo all the angst about the deterioration of hand flying skills is obscuring the real failure. I think its absolutely understandable, even predictable, that the PF would have problems with that approach...new airplane, special airport,(with a very unique visual approach procedure and requirements), back of the clock fatique...and so on.
but the company certified a IP who didnt do his job.
that was the problem, imo.
Geez, how do we ever land at KORD when 210 or greater to the marker is the request of the day routinely?
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RAT 5
Been a long time since I managed ATC facilities, so my terminology may be a bit imprecise.
ATC is responsible for managing the safe, orderly and expeditious flow of air traffic through a given block of airspace, with specific horizontal and vertical separation requirements. ATC effectively routes you to a given point in space at which the approach is now the pilot's task, be that intercepting a precision instrumented approach fix, a non precision instrumented approach fix, or a visual approach fix. For an instrument approach fix, obviously, you should be at an altitude and speed conducive to flying on your instruments according to the published approach, as the instruments are your only reference until you can take over visually. Since the approach profile has to be able to deliver you, without any visual reference, to DH or MDA in a stable configuration, airspeed and altitude at the point of initiation of the approach is important, so that you have proper control of the aircraft when "breaking out".
The whole concept of a clearance for a visual approach is that you have visual cues to make the approach from the time your are released at the visual approach fix through to touchdown. It is pilot basic skill that is called upon to manage the approach, not instruments. At the risk of sounding impudent, that's why it's called a "visual approach", not an "instrument approach". And yes, for separation and airspace management reasons, you may be expected to work a bit harder on a "visual approach", but it is an approach from which you have visual reference for a considerably greater amount of time and space to execute the maneuver to the touchdown point.
Yes, it's much easier to shoot an approach in VMC using IMC intended automation. But, since, allegedly, all aircrews are capable of flying an aircraft visually, when an airport is VMC and the safe, orderly and expeditious flow of traffic requires the pilots to use these alleged skills, it is, at least to anyone who has managed airspace (not just operate a single aircraft in airspace) reasonable to expect crews to expend the extra effort they are alleged to be certified to possess. Knowing, however, that some pilots may not be as skilled as others, ATC entertains requests for special handling. Keep in mind the phraseology is "cleared", not "ordered" to make a given approach.
If the regularly issued ATC clearances are over taxing aircrews, then the aircrews should report them as such, no less respond, "Unable". The silence of the pilots is their implicit assent to such approach conditions. If you are waiting for the NTSB to investigate a mishap that proves your position that a given approach, about which the pilots remain formally silent, is over taxing, then your failure to come up on the frequency before the fact could quite well be a contributing factor to any mishap that such an ATC procedure may, at least in your eyes, cause.
How can ATC impose visual approach criteria? It would suggest they are radar vectoring for a difficult energy management visual approach.
ATC is responsible for managing the safe, orderly and expeditious flow of air traffic through a given block of airspace, with specific horizontal and vertical separation requirements. ATC effectively routes you to a given point in space at which the approach is now the pilot's task, be that intercepting a precision instrumented approach fix, a non precision instrumented approach fix, or a visual approach fix. For an instrument approach fix, obviously, you should be at an altitude and speed conducive to flying on your instruments according to the published approach, as the instruments are your only reference until you can take over visually. Since the approach profile has to be able to deliver you, without any visual reference, to DH or MDA in a stable configuration, airspeed and altitude at the point of initiation of the approach is important, so that you have proper control of the aircraft when "breaking out".
The whole concept of a clearance for a visual approach is that you have visual cues to make the approach from the time your are released at the visual approach fix through to touchdown. It is pilot basic skill that is called upon to manage the approach, not instruments. At the risk of sounding impudent, that's why it's called a "visual approach", not an "instrument approach". And yes, for separation and airspace management reasons, you may be expected to work a bit harder on a "visual approach", but it is an approach from which you have visual reference for a considerably greater amount of time and space to execute the maneuver to the touchdown point.
Yes, it's much easier to shoot an approach in VMC using IMC intended automation. But, since, allegedly, all aircrews are capable of flying an aircraft visually, when an airport is VMC and the safe, orderly and expeditious flow of traffic requires the pilots to use these alleged skills, it is, at least to anyone who has managed airspace (not just operate a single aircraft in airspace) reasonable to expect crews to expend the extra effort they are alleged to be certified to possess. Knowing, however, that some pilots may not be as skilled as others, ATC entertains requests for special handling. Keep in mind the phraseology is "cleared", not "ordered" to make a given approach.
If the regularly issued ATC clearances are over taxing aircrews, then the aircrews should report them as such, no less respond, "Unable". The silence of the pilots is their implicit assent to such approach conditions. If you are waiting for the NTSB to investigate a mishap that proves your position that a given approach, about which the pilots remain formally silent, is over taxing, then your failure to come up on the frequency before the fact could quite well be a contributing factor to any mishap that such an ATC procedure may, at least in your eyes, cause.
Last edited by tilnextime; 13th Jul 2013 at 20:36.
The point is, that in some "culturally challenged CRM situations" it is impossible to admit that someone is "unable" to do a certain approach.
Last edited by fox niner; 13th Jul 2013 at 20:42.
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San Francisco plane crash's 3rd fatality identified - CBS News
3rd girl who died was a classmate of the two others.
3rd girl who died was a classmate of the two others.
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This is the first definite confirmation that I've seen which states that the girl who was hit by the fire truck was located in front of the wing (relatively near the slide), rather than behind the plane where those who were ejected ended up.
ID emerges of third girl to die of SF plane crash - SFGate
I have to wonder if she came down the slide (perhaps injured) and collapsed/was overcome/passed out. Of course, it's possible someone carried her down the slide.
ID emerges of third girl to die of SF plane crash - SFGate
I have to wonder if she came down the slide (perhaps injured) and collapsed/was overcome/passed out. Of course, it's possible someone carried her down the slide.
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Fox Niner:
By that reasoning, a crew member from any other "culture" should not be bemoaning the visual approach at SFO.
The point is, that in some "culturally challenged CRM situations" it is impossible to admit that someone is "unable" to do a certain approach.
Tilnextime: sorry, I had to look up "bemoaning", despite my LPE level 6 endorsement. 
But you are right. And I don't bemoan the visual approach at SFO, or anywhere else for that matter. It is a routine maneuver.
What's next? The canarsie approach under review? Or the short lineups that I get offered regularly at schiphol? Or the turn towards final at Nice in southern France?
Nah. You must be able to do it otherwise you are simply not worth the salary.
But you are right. And I don't bemoan the visual approach at SFO, or anywhere else for that matter. It is a routine maneuver.
What's next? The canarsie approach under review? Or the short lineups that I get offered regularly at schiphol? Or the turn towards final at Nice in southern France?
Nah. You must be able to do it otherwise you are simply not worth the salary.
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Tilnextime--some very good points about piloting skills needed to execute a visual approach . Pilots of air carrier jets should also have the skills to execute considerably more difficult tasks such as a single engine go around and return for a single engine visual approach.
CL-44 Tilnextime--some very good points about piloting skills needed to execute a visual approach . Pilots of air carrier jets should also have the skills to execute considerably more difficult tasks such as a single engine go around and return for a single engine visual approach.
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Tilnexttime,
Thanks for your well-written post. I have been cringing at all the posters trying to suggest that ATC has a responsibility to spoon feed every aircraft in case they aren't up to FLYING the aircraft within reasonable limits on a CAVU day.
If you can't comply, just SAY SO!
Framer,
Perhaps that is why we are starting to see the results of a generation of flight crews with bare minimum EXPERIENCE of flying anything but an FMC transitioning to commands.
I have always thought that a solid exposure to multiple aircraft types, without sophisticated AFCS is of far more value than 10,000 hours of monitoring.
It's all coming home to roost.
Thanks for your well-written post. I have been cringing at all the posters trying to suggest that ATC has a responsibility to spoon feed every aircraft in case they aren't up to FLYING the aircraft within reasonable limits on a CAVU day.
If you can't comply, just SAY SO!
Framer,
I suspect most do have those skills as both those manoeuvres are practiced regularly in the sim. The visual approach however........
I have always thought that a solid exposure to multiple aircraft types, without sophisticated AFCS is of far more value than 10,000 hours of monitoring.
It's all coming home to roost.
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A video of the last portion of the approach has been produced.
Asiana 214 ver 2 - YouTube
If accurate, it seems the the right lateral offset that developed was the reason this aircraft didn't descend into the approach lighting system.
Also, the exemplar aircraft is only programmed to follow the correct glide path, not the correct speed for the approach.
Asiana 214 ver 2 - YouTube
If accurate, it seems the the right lateral offset that developed was the reason this aircraft didn't descend into the approach lighting system.
Also, the exemplar aircraft is only programmed to follow the correct glide path, not the correct speed for the approach.
Last edited by Capt Kremin; 13th Jul 2013 at 22:50.
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jugofpropwash:
That is in no way confirmation, let alone definite.
This is the first definite confirmation that I've seen which states that the girl who was hit by the fire truck was located in front of the wing...
That is in no way confirmation, let alone definite.