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Asiana flight crash at San Francisco

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Old 8th Jul 2013, 13:54
  #841 (permalink)  
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Originally Posted by overthewing
I'm surprised the flight crew weren't interviewed immediately.
- it is readily apparent that they had spoken to the airline fairly quickly or the CEO would not have issued his statement so soon before NTSB arrived..
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Old 8th Jul 2013, 13:54
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There appears to be a worrying trend here. Taking the Turkish AMS accident and this one (while not, of course, prejudging the NTSB findings) it would seem that the performance of trainers is falling, both in attention and actions that are required.
The factories are still ramping up their deliveries...

Re said sector LGW-BLV... KBLV?

robertbartsch
I cannot remember the NTSB making statements on TV this early after a crash and which seems to indict the crew for their poor performance.
Which is a step back in culture.

YIKES! I suppose if this happened in France and not in the USA, the crew would be immediately arrested and held criminally liable. Maybe that is a good system.
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Old 8th Jul 2013, 13:56
  #843 (permalink)  
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In our mob generally speaking all crew members sit in the cockpit for T/O and LDG unless other circumstances are needed. Indeed the relief crew take an active part in both pre flight and post flight setups.
We (mostly) fly the 777F as a four-man crew. One relief FO does walk around/courier compartment/catering/hazmat, the other helps with ETOPS/MEL/clearance issues, the F/O sets up the EFB and the captain works the FMS. We can prep for a 15-hour leg in 30-40 minutes.

All four are up front for takeoff and landing. All on headsets, and RFO's do interject when necessary. A go-around can be called from any seat.

It's funny to hear about speculation regarding single-pilot ops. In our newest plane we're trending the other way....
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Old 8th Jul 2013, 13:56
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Possibly a automation modes issue? On the aircraft I instruct on, there's a trap we've known about since we started. If you are on autopilot and autothrottle, descending in FLCH (Flight Level Change) mode, the speed is controlled by pitch, and the autothrottles go to a passive mode, called "speed on elevator". If you change autopilot modes to a different pitch mode (VS, Alt Hold, etc, or if the autopilot captures another mode, like ALT CAPTURE, GS, etc), the autothrottles revert to controlling the speed ("speed on thrust" mode). HOWEVER, (this is the trap) as I said, if you are descending on autopilot and autothrottle in FLCH, AND DISCONNECT THE AUTOPILOT, the autothrottle does NOT revert to "speed on thrust". but stays in "speed on elevator". The pilot must SELECT another pitch mode, to get the autothrottles to control speed again...if not, the autothrottles stay at idle when the pilot, say, levels off and, he expects the autothrottles to advance the throttles to maintain speed. He must either control the throttles manually, or choose another pitch mode. This sounds like the classic autothrotlle TRAP we teach about on day one of FPT, and day one of simulator. It seems he was unstable on approach; if he were in FLCH, and decided to level off, he disconnects the autopilot, levels off; he expects the throttles to maintain speed with authrottle, but they stay at idle. It seems he leveled off pretty late, and may not have had time to realize his danger, concentrating on the runway, PAPI, etc, whilst the speed bled off. Purely Speculation. Does the 777 behave this way?
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Old 8th Jul 2013, 14:03
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And, of course, such an incident could NEVER happen in The USA?

That's American exceptionism??
The point is, it used to be more common in the USA. The industry noted that it was a mistake to have a hierarchy in the cockpit that would degrade communication. That lead to CRM Crew resource management - Wikipedia, the free encyclopedia

As a result, accidents in the USA went down substantially. Other cultures that still have been unable to break down the hierarchy struggle with a higher accident rate. I've read here that FOQA data in Korea can be used against a pilot in a punitive way. If this is indeed true, then that should be addressed too.

So many in this thread are fixated on the idea of "racism" but it's really human factors we're talking about. Culture does play a role in that.

To the comment about the Colgan Air crash and the skill level of Anglo pilots, that is what lead to the new rule in the States requiring 1500 hours before a pilot can be employed in the industry. I think a better solution would have been allowing ab initio training such as the European airlines use or a program the military uses.
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Old 8th Jul 2013, 14:05
  #846 (permalink)  
 
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What I find incredibly interesting in following you guys through this thread, is that the very systems designed to DECREASE your workload appear to INCREASE your workload because FEW of you (largely dependent upon training and experience) trust the damn things...apparently for good reason.

To my mind, it puts the aircrew in the position of always flying with a student pilot; not knowing EXACTLY what he or she is going to do, you're "forced" to follow them through with light hands until you're satisfied. Thus, some of you are ready, willing, and able to intervene because you're essentially flying the plane mentally anyway; and then there are some of you for whom the workload is greatly reduced because you just accept the automation as it is because thats what you're company tells you to do. IOW, it's working until you bend it.

As an aerospace engineer and manager, I'm not sure what is scarier: automated systems that are so complex that no one understands their decision logic; automated systems that may not be completely reliable if modes selected are inappropriate for the flight regime; a cockpit and/or corporate culture that disrupts CRM; or pilots that might not have the skills to land a bloody sailplane without an ILS.

This has been VERY educational, but man, it's a bit frightening to think that I might want to ask the Captain if he or she can shoot a VFR approach when I'm boarding.
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Old 8th Jul 2013, 14:10
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@DavidHoul52

I disagree with your last comment. I have flown with numerous Chinese FO's who say their love flying with expats/foreigners because they can ask questions and learn a thing or two. They do not ask ANY question during their simulator or line training when the instructor is Chinese, for fear of making the trainer lose face should he not know the answer. They will not challenge any unusual setup during flight for the same reasons, and also because of lack of experience from previous types, so they may not always recognise a situation when it arises.

But give them the chance to shine and many will do their best to please and to show they enjoy learning more tricks.

Unfortunately, the majority of them will loose this eagerness and build the so much discussed high power gradient when they turn captains. And will fly then (for the Chinese at least) only with other Chinese crew. They won't speak again English in the cockpit for the rest of their career.

You say there is no evidence of cultural differences on this event. Likewise there is no evidence that there wasn't any. Live a few years in China or Korea , go by the local rules, learn how people interact and the picture you see so well might turn out a bit different.

Of course the WHY has yet to be defined and presented by NTSB.

Either this or loss of SA of both (if they were only 2 in the cockpit) pilots simultaneously, should it be confirmed that no defects or outside elements could be thrown into the equation.

I make as many mistakes as any other pilot, or more, but especially when flying with crew from different parts of the world, I brief them to voice out anything, even if they think it may be trivial, and ask questions as much as you like. This is the cultural difference that I try to iron out a bit with my own, limited means, not because I think they should forget where they come from, but in the interest of safety.

Last edited by FLEXPWR; 8th Jul 2013 at 14:17.
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Old 8th Jul 2013, 14:14
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rdr: you mentioned the sun in their eyes after a long flight. Look at the time of the mishap, and the direction of the runway: west.
Could there be a respect issue with the FO telling the Captain to go around, thereby delaying the call until it was too late?
If so, there's a possible culture issue, organizational at the least, and not based upon the shape of anyone's eyes. That considered, if it's two rated captains in the same airline, then why was the "A/S off by five knots" call not made sooner? That speaks to a different organizational and cultural issue.
Five knots slow, half-dot low. Standard callouts everywhere I've ever worked. Could've saved them. This approach got messed up long before the 7 seconds before impact call-out.
Scan: inside, outside, inside, outside, rinse and repeat ...
On one occasion I elected to fly a visual approach to 31L in JFK instead of going to 31R, this saved a lot of taxi time after landing). I was called to the office to explain why I flew a visual approach and did not use the ILS! FOQA data was designed to be used as a trend indicator, however Korean used it for punitive measures so it is not surprising that local pilots would take whatever measures were required to avoid exceeding the laid down parameters.
cdogg: Read the bolded part I extracted from one of the posts earlier. That addresses a matter of culture, not "race." I suggest that you learn how to read for comprehension, doctor.

What you describe in the safety arena in your own profession, and its improvement, is also a cultural shift. There is a culture in your profession and in each organization in that profession.

Safety culture in a given organization does not exist in a vacuum. The larger "host" culture will influence it. It has taken "the West" three generations of learning, and many lessons have been written in blood, regarding safety culture, organizational culture, and cockpit gradient. That is in part due to our host culture being one wherein the background conditions are there for change to take place, however clumsily. Your own profession is a fine example. If the base culture does not embrace that form of change, it is harder for the sub elements to do so. (Though as Gladwell points out, not impossible). But in the Korean Air case, there was considerable external motivation to change.
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Old 8th Jul 2013, 14:19
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JARRule

Dear JARRule,

You just exposed why accidents like this will become more and more common.

Do you even understand why?
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Old 8th Jul 2013, 14:25
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I notice that flying skills have generally degraded sine the introduction of the Q.A.R.. People don't like the phone calls from Management about busting a restrictive petty parameter. (Big Brother syndrome ) so visual approaches become unusual & so flight safety is degraded. Blame lies with the management. I wonder if this will be part of the NTSB repot?
But then that would show the FAA & other authorities in a bad light, so proberbly not.
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Old 8th Jul 2013, 14:29
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@FLEXPWR

Thanks for your interesting post. Not wanting someone else to lose face is found in some asian cultures to a lesser or greater extent but I did wish to point out that reluctance of FOs to speak up in the cockpit at critical times is by no means confined to asian flight crews, is it? In the case of the 2010 Polish Air Force Tu-154 crash there was likely to have even been non-pilot interference.

I do think it's much to early even to speculate about the role of this (or any kind) of cultural issue. Do we even know what the culture of this particular operator is? Cultural values can be overridden by operational values, even if the operational values are at variance to that from which most of the members come. What happens if the investigation finds that Asiana in fact takes CRM very seriously? Speculate all you like, but it it worth offending a large part of the aviation community claiming it's in the interest of "truth" even before the FDR and CVR have been opened?

Last edited by DavidHoul52; 8th Jul 2013 at 14:43.
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Old 8th Jul 2013, 14:34
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Quote from the Boeing 777 manual

For those unfamiliar with the Autothrottle system on the B777, here's a quote from the Ops manual:
"With the autothrottle armed, the autothrottle automatically activates if:
• no autopilot or flightdirector active, or
• an autopilot or flightdirector is in VNAVXXX, FPA, ALT, V/S, or G/S,

and:
• speed less than an FMC calculated value for one second
• thrust below reference thrust
• airplane altitude above 100feet RA on approach, or airplane barometric altitude 400 feet above airport on takeoff.
Note: During a descent in VNAV SPD, the autothrottle may activate in HOLD mode and will not support stall protection".
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Old 8th Jul 2013, 14:36
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- it is readily apparent that they had spoken to the airline fairly quickly or the CEO would not have issued his statement so soon before NTSB arrived..
I've heard no evidence from the NTSB that they've had information from the crew. Everything that Deborah Hersman said seemed to refer to what they've acquired from CVR / FDR.

When asked by the press who was flying the plane, she said that she didn't know, but intended to know by Monday. Since that seems a fairly obvious question to ask had the pilots been interviewed, and since the NTSB can presumably tell from the FDR which side of the cockpit was doing the business on the approach, I infer that a) she hadn't spoke to the pilots or b) the pilots had not disclosed who was sitting where.

Within a couple of hours of BA38, we knew exactly who'd been flying the plane.
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Old 8th Jul 2013, 14:45
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Just my two cents worth and maybe something investigators could consider. Criticise all you like but this happened to me when I converted from AirbusA330 to the 777. ( fortunately in the sim) it may be relevant as the trainee on this flight previously flew a320'and may well have been converting from Airbus to Boeing.

As the thrust levers on the bus do not move throughout the approach until you here " retard" , I used to rest my hands on the thrust levers. When I was converting to the 777 I did exactly the same , being a little tense during one of the sims I held the thrust levers a little tight. Therefore not allowing them to move. As we continued the approach I did not " feel" the autothrottle trying to move against my stiff grip , as I was focusing on other things( fortunately my scan.)I was effectively inhibiting the autothrottle by holding the thrust levers in a position. The next thing I noticed was the speed bleeding off below vref+5 . As l took my right hand off the thrust levers to point this out to the instructor the autothrottle immediately advanced the levers ( as I was no longer inhibiting them physically). The instructor pointed out that it was a common mistake he had seen on airbus pilots converting to Boeing. A valid learning point , learnt where it is meant to be learnt , in the sim.

Could it be that our colleague was so loaded by being hi on the approach that he like me , held the thrust levers too tight , and was unable to feel the autothrottle trying to physically override his grip. If you are not familiar with this , force. Would you recognise it ? Remember it only came up in my training as a result of a mistake.

Criticise all you,like , I am happy to share my screw ups if as an industry it helps someone , just a little bit.
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Old 8th Jul 2013, 14:48
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DavidH

Ok, I'll be a bit more specific.

Cultural values come for an infinity of different reasons. Overcoming cultural values with "operational values" is al nice on paper.

I have not said the cultural background IS/WAS a cause for the accident.

You are thinking exactly like a westerner: "I can place operational value above cultural values". This is not the case in many countries. Think for a moment that westerners, as a general rule, have the freedom of speech, the freedom to say they think their president is an idiot, and the right to propest and march down the street. Westerners are born with this.

The story is very different when you consider the same situation in China as an example, but former Russia would do as well, there are many countries you can pick from. You do not protest against your government (even social media will be deleted) you do not challenge authority, only if behind closed doors with friends or family, or you might be prosecuted, harassed, or your career might take a turn for the sour. With this in the cultural background, go tell a Chinese/Korean that he/she can complain freely, and watch their reaction.

The unfortunate events in Poland where from a military flight, with military personnel. As above, you do not challenge authority for fear of undesired consequences. Again, cultural background.

To get back to our horses, I do hope they take CRM seriously, but CRM is not just on paper, it has to be explained and applied at all levels, not just in cockpits.

As a side note, the company I'm in has no CRM course, no CRM documentation, no CRM instructors, and of course no CRM accident/incident review... it is just mentionned on ops manual that good CRM should be applied while on duty... and this is one of the top 5 airlines in China.

And I don't see how I am offending anyone here, except you, maybe, feel offended that I disagree?

Last edited by FLEXPWR; 8th Jul 2013 at 14:55.
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Old 8th Jul 2013, 14:49
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"Just my two cents worth and maybe something investigators could consider. Criticise all you like but this happened to me when I converted from AirbusA330 to the 777. ( fortunately in the sim) it may be relevant as the trainee on this flight previously flew a320'and may well have been converting from Airbus to Boeing."

From what I have read so far I had the impression he was in the transition from B744 to B772. But that are only my 2 cents :-).
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Old 8th Jul 2013, 14:50
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I was an investigator with CTSB. MAny years ago, one of my cases involved a Korean Air 747 that damaged the tail by over-rotating while landing at YVR. I was was shocked to learn that the pilot flying was their "Cruise pilot" and had 150 hours TOTAL TIME and 50 hours (of cruise) on type (747).

The captain decided to give him some pole time but did not monitor closely enough. Over 300 pax with a student pilot at the controls.
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Old 8th Jul 2013, 14:54
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a few pages back it was said that nothing has been heard of from the Cabin attendant side.

form other aviation forums

From NBC:

Flight attendant sensed plane was in trouble, 'felt a bang'
By Jack Chang and Youkyung Lee, Associated Press

The evacuation of Asiana flight 214 began badly.

Even before the mangled jetliner began filling with smoke, two evacuation slides on the doors inflated inside the cabin instead of outside, pinning two flight attendants to the floor.

Cabin manager Lee Yoon-hye, apparently the last person to leave the burning plane, said crew members deflated the slides with axes to rescue their colleagues, one of whom seemed to be choking beneath the weight of a slide.

It was just one of the moments of drama described Sunday by Lee of a remarkable evacuation that saved 305 of the 307 people on the plane that crashed Saturday while landing in San Francisco.

One flight attendant put a scared elementary schoolboy on her back and slid down a slide, said Lee, in the first comments by a crew member since the crash of the Boeing 777.

A pilot helped another injured flight attendant off the plane after the passengers had escaped. Lee herself worked to put out fires and usher passengers to safety despite a broken tailbone that kept her standing throughout a news briefing with mostly South Korean reporters at a San Francisco hotel. She said she didn't know how bad she was hurt until a doctor at a San Francisco hospital later treated her.

It was still unclear if the pilot's inexperience with the aircraft and airport played a role, and officials were also investigating whether the airport's or plane's equipment could have malfunctioned.

Aviation and airline officials said although the pilot had previously flown a Boeing 777 nine times - for a modest 43 hours in total - it was the first time he was landing that wide-bodied jet into San Francisco. Investigators have said he tried to abort the landing and go back up in the air after realizing he was flying too slow and too low but failed.

Lee, 40, who has nearly 20 years' experience with Asiana, said she knew seconds before impact that something was wrong with the plane.

"Right before touchdown, I felt like the plane was trying to take off. I was thinking 'what's happening?' and then I felt a bang," Lee said. "That bang felt harder than a normal landing. It was a very big shock. Afterward, there was another shock and the plane swayed to the right and to the left."

After the captain ordered an evacuation, Lee said she knew what to do. "I wasn't really thinking, but my body started carrying out the steps needed for an evacuation," Lee said. "I was only thinking about rescuing the next passenger."

When Lee saw that the plane was burning after the crash, she was calm. "I was only thinking that I should put it out quickly. I didn't have time to feel that this fire was going to hurt me," she said.

Lee said she was the last person off the plane and that she tried to approach the back of the aircraft before she left to make sure that no one was left inside. But when she moved to the back of the plane, a cloud of black, toxic smoke made it impossible. "It looked like the ceiling had fallen down," she said.

More than a third of the people onboard didn't require hospitalization, and only a small number were critically injured.
The San Francisco fire chief, Joanne Hayes-White, praised the cabin manager, who she talked to just after the evacuation.

"She was so composed I thought she had come from the terminal," Hayes-White told reporters in a clip posted to YouTube. "She wanted to make sure that everyone was off. ... She was a hero."
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Old 8th Jul 2013, 14:54
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Scan: inside, outside, inside, outside, rinse and repeat ...
Since the thread highlights training deficiencies, I'd like to highlight the above comment as something that lends itself to very little. I'm not having a pop at the poster, however I'm having pop at the commentary which I have experienced from GA right across to simulator and line training in a commercial jet. I've heard it bellowed by line trainers and TRI/TREs for years. Having instructed myself, both in GA and in the simulator of a medium jet transport I have come to the conclusion that the pattering of 'outside, inside' means shag all to bloggs who, in general, hasn't the foggiest what he's meant to be scanning. It's one of these terms that are banded about at a critical flight phase when trainee capacity is close to if not at it's edge. I've even witnessed an instructor being asked what he meant by his 'outside, inside' repeat to fade during an IPC debrief. The answer was rewarded with the most staggering amount of B.S. I have ever heard in aviation training.
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Old 8th Jul 2013, 14:55
  #860 (permalink)  
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Four golds

Excellent post. Thanks for being so candid. That's the type of post that adds to the debate. A potential gotcha I'd never have thought of. That's the type of minute detail that the NTSB will look for.

Flexpwr

You're describing a Chinese airline and this one was from Korea. Sorry I don't get the connection. If I follow your "logic" the culture in BA is the same as AF as LH etc etc.
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