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Asiana flight crash at San Francisco

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Asiana flight crash at San Francisco

Old 8th Jul 2013, 23:17
  #981 (permalink)  
 
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Quote:
Be very interested if anyone has a copy of the SFO Notam for July 6 prior to the accident.
Ref post #535

SFO 06/011 SFO NAV ILS RWY 28R IM OTS TIL 1308222359
SFO 06/010 SFO NAV LDA RWY 28R GP OTS WEF 1306011400-1308222359
SFO 06/009 SFO NAV ILS RWY 28R CAT 2/3 NA WEF 1306011400-1308222359
SFO 06/008 SFO RWY 28R RVRT OTS WEF 1306011400-1308222359
SFO 06/005 SFO NAV ILS RWY 28L GP OTS WEF 1306011400-1308222359
SFO 06/004 SFO NAV ILS RWY 28R GP OTS WEF 1306011400-1308222359
SFO 06/003 SFO RWY 28R ALS OTS WEF 1306011400-1308222359


When will the aviation industry wake up and start issuing NOTAMS in normal plain English. Do you think non native with English as a second language really can get to grip with the NOTAM gobbledygook we face everyday?

If this accident investigation concludes that basic flying skills were the biggest contributor to this accident it should be a huge wake up call for this industry.
This type of accident will statistically increase as basic flying skills are reduced due to the airline cadet transition straight to complex jet population increases.
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Old 8th Jul 2013, 23:19
  #982 (permalink)  
 
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Harking back to the comments on observation of an aircraft's flightpath and speed, if I ever had a pilot on the jump seat, I would always give them a headset and ask them to be my 3rd pair of eyes and ears. On at least 2 occasions this 3rd, supplementary pilot helped to sort out a couple of unclear ATC transmissions.

Also, if I flew with a new F/O, straight out of Line Training, once I'd completed my departure brief I would say:

"There's one important thing I need to add which is this. The reason I'm in this left-hand seat is because I've been doing this job longer than you. It doesn't mean that I'm incapable of making mistakes. So if you see or hear anything which you don't understand or appears to be not right, please speak up and tell me."

My company had excellent CRM training, but I still felt that it was important to give a new and maybe nervous young F/O full permission and encouragement to say something if they weren't comfortable. There is absolutely no room for pride in the flight deck; the important thing is that the day's flying is accomplished safely, and hopefully enjoyably as well.

And back to the posts on unserviceable ILS at LHR, I do remember a day, maybe 15 years ago, when the ILS for 09L was out and pilots were invited to make NDB approaches. What ATC had not appreciated was that company policy of some airlines was for the approach to be flown at approach speed from the final descent point. Some 10 miles at maybe a Vref of 125 knots rather than 160 knots, sure slowed the landing rate down! I seem to remember that the 4 holds were well used that day!
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Old 8th Jul 2013, 23:25
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Definition Operational;

Fit for proper functioning; ready for use
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Old 8th Jul 2013, 23:28
  #984 (permalink)  
 
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A Squared.

I thought as much.
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Old 8th Jul 2013, 23:40
  #985 (permalink)  
 
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Reading this thread reminds me why I don't come on here much anymore. Apart from a large number of armchair experts posting a lot of drivel, it seems the majority have made up their mind this accident was caused by pilot error, and a sizeable majority of them that this is most likely because the crew were all Korean. It may indeed have been pilot error, but until the CVR and FDR have been analysed no one knows what really happened.

Personally I find it pretty unlikely that a speed 18 knots below Vref 16 seconds before impact (plus the resulting high attitude) would have not elicited a reaction from the handling pilot, ie pushing the throttles forward, or failing that a reaction from the pilot in the right-hand seat (who after all was a training captain, who, by job description, is expected, and expects to have to be to be, more vigilant than a line captain). If the relief crew were also on the flight-deck then the idea that they would just sit there and let the operating crew crash the aircraft is even more absurd. I find it highly unlikely that the auto-throttle would have been disconnected, it's standard practice to have it always engaged, and it would have woken up long before impact if those speeds quoted are accurate.

It seems all the "experts" here have it all worked out. As a current B777 skipper, I am very interested in knowing what caused this accident, but, personally, I'll wait for more information before jumping to conclusions. But hey, if it turns out they screwed the pooch (which btw I am not discounting as a possibility), you can all have a good sneer and say you told me so.

Last edited by CAT1; 9th Jul 2013 at 00:01.
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Old 8th Jul 2013, 23:48
  #986 (permalink)  
 
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It was posted that the Rolls Royce engine control (in the BA Heathrow accident) and the PW4000 engine control are both made by Goodrich (the implication that they both might have the same s/w error) Not true - the Trent 800 engine control was done by Lucas - now part of Goodrich. The PW4000 engine controls were done by Hamilton Standard (now Hamilton Sundstrand).
Nitpicking, but... Both Goodrich ( Heritage BFGoodrich Aerospace as well as the Rohr and Lucas divisions) and Hamilton Sundstrand are now owned by United Technologies... who also own Pratt.

Our Company | UTC Aerospace Systems
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Old 8th Jul 2013, 23:53
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Over 1000 posts. There can't possibly be anything else left to speculate over!
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Old 9th Jul 2013, 00:07
  #988 (permalink)  
 
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UA Cockpit Crew

Apologies if this has been posted. I receieved this from a friend of mine who got it as part of a distribution from one of the cockpit crew of the UA 747. I don't personally know tha UA relief FO but apparently permission had been granted to distribute this email freely.

Here is an email from a United crew holding short of the runway as the Asiana B-777 approached:

On July 6, 2013 at approximately 1827Z I was the 747-400 relief F/O on flt 885, ID326/06 SFO-KIX. I was a witness to the Asiana Flt 214 accident. We had taxied to hold short of runway 28L at SFO on taxiway F, and were waiting to rectify a HAZMAT cargo issue as well as our final weights before we could run our before takeoff checklist and depart. As we waited on taxiway F heading East, just prior to the perpendicular holding area, all three pilots took notice of the Asiana 777 on short final. I noticed the aircraft looked low on glidepath and had a very high deck angle compared to what seemed “normal”. I then noticed at the apparent descent rate and closure to the runway environment the aircraft looked as though it was going to impact the approach lights mounted on piers in the SF Bay. The aircraft made a fairly drastic looking pull up in the last few feet and it appeared and sounded as if they had applied maximum thrust. However the descent path they were on continued and the thrust applied didn't appear to come soon enough to prevent impact. The tail cone and empennage of the 777 impacted the bulkhead seawall and departed the airplane and the main landing gear sheared off instantly. This created a long debris field along the arrival end of 28L, mostly along the right side of 28L. We saw the fuselage, largely intact, slide down the runway and out of view of our cockpit. We heard much confusion and quick instructions from SFO Tower and a few moments later heard an aircraft go around over the runway 28 complex. We realized within a few moments that we were apparently unharmed so I got on the PA and instructed everyone to remain seated and that we were safe.

We all acknowledged if we had been located between Runways 28R and 28L on taxiway F we would have likely suffered damage to the right side aft section of our aircraft from the 777.

Approximately two minutes later I was looking out the left side cockpit windows and noticed movement on the right side of Runway 28L. Two survivors were stumbling but moving abeam the Runway “28L” marking on the North side of the runway. I saw one survivor stand up, walk a few feet, then appear to squat down. The other appeared to be a woman and was walking, then fell off to her side and remained on the ground until rescue personnel arrived. The Captain was on the radio and I told him to tell tower what I had seen, but I ended up taking the microphone instead of relaying through him. I told SFO tower that there appeared to be survivors on the right side of the runway and they needed to send assistance immediately. It seemed to take a very long time for vehicles and assistance to arrive for these victims. The survivors I saw were approximately 1000-1500' away from the fuselage and had apparently been ejected from the fuselage.

We made numerous PAs to the passengers telling them any information we had, which we acknowledged was going to change rapidly, and I left the cockpit to check on the flight attendants and the overall mood of the passengers, as I was the third pilot and not in a control seat. A couple of our flight attendants were shaken up but ALL were doing an outstanding and extremely professional job of handling the passenger's needs and providing calm comfort to them. One of the flight attendants contacted unaccompanied minors' parents to ensure them their children were safe and would be taken care of by our crew. Their demeanor and professionalism during this horrific event was noteworthy. I went to each cabin and spoke to the passengers asking if everyone was OK and if they needed any assistance, and gave them information personally, to include telling them what I saw from the cockpit. I also provided encouragement that we would be OK, we'd tell them everything we learn and to please relax and be patient and expect this is going to be a long wait. The passenger mood was concerned but generally calm. A few individuals were emotional as nearly every passenger on the left side of the aircraft saw the fuselage and debris field going over 100 knots past our aircraft only 300' away. By this point everyone had looked out the windows and could see the smoke plume from the 777. A number of passengers also noticed what I had seen with the survivors out near the end of 28L expressing concern that the rescue effort appeared slow for those individuals that had been separated from the airplane wreckage.

We ultimately had a tug come out and tow us back to the gate, doing a 3 point turn in the hold short area of 28L. We were towed to gate 101 where the passengers deplaned.

Last edited by Island-Flyer; 9th Jul 2013 at 00:38.
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Old 9th Jul 2013, 00:09
  #989 (permalink)  
 
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CRM don't forget...which people do.
With a capital "C".

All credit to the "lead" in the back.
She seems to have done a fantastic job given the tough situation.
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Old 9th Jul 2013, 00:10
  #990 (permalink)  
 
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Ref the third or fourth crew members in the flight deck - is it a safer operation to have a the extra crew members in the flight deck? If the answer is yes then it must be less safe to operate with the standard two pilots and if airlines are concerned about flight safety then surely they would operate with three pilots - as it is safer?? Hell if three pilots makes it safer then 4 pilots makes it still safer!!

Modern airliners are two pilot operations - not three or four - the extra crew members are there to extend duty time.

With out having trawled through all the pages I wonder what mode they where in on final descent - if they where high and they where in FLCH mode - the Auto thrust would be in HLD . From what I can remember about this mode is that as the speed goes below the selected speed the A/T remains in Hld and will allow the speed to decay.
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Old 9th Jul 2013, 00:14
  #991 (permalink)  
 
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JimNTexas - v. good insight on power distance, gradient in the Korean Air Force - major factor in some of the national carrier's human factor problems around the time of Guam - because of their hiring of ex military pilots.
Which brings to mind another point - which delinks the issue of authority gradients from race.
There is a type of pilot that more enlightened airlines will look at very carefully before hiring - particularly from a CRM, human factors point of view.
These pilots are prone to over confidence, aggression, making very rapid decisions by themselves with no consultation or checking with others.
Sometimes - they are flat out obnoxious and cocky.
The organisations they work for are hierarchical, often (but not always) with a steep authority gradient.
They sometimes find it difficult to integrate into multi engine, multi-crew air transport operations.
And they come in all skin colours, and speak many different languages.
They're called fighter pilots.
Who knows whether authority gradients will be an issue here - but it's interesting nonetheless.
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Old 9th Jul 2013, 00:15
  #992 (permalink)  
 
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Undershoot in SFO

Can anyone explain what, if anything, the other pilot's function is during an approach to landing ? I understand PF must have had a guy in the other seat monitoring the parameters and why in hell did this guy not take over in time to avert entering into slower than normal approach speed and height ! The clues were all there ! Instructors earn their living taking over well before a student exceeds the aircraft's limitations ! Was it cockpit culture or laissez faire familiarity?
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Old 9th Jul 2013, 00:15
  #993 (permalink)  
 
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possible CRM issue

let my try to shed some light on possible CRM issue in this terrible accident based on insider information I got yesterday although I do not work for Asiana (I work for KAL in training department as instructor..)

I discussed the crash with one of the older KAL captains who is my colleague in training department and who knew the crew and immediately he pointed out that main issue might be that left seat pilot PF Mr.Lee,Kang Kook was senior to instructor doing PM duties from right seat....by senior I mean they both are graduates from Korea Aerospace University and PF Mr.Lee was senior class in University to instructor...

People not familiar how Korean society works will say "so what?" but people working and living in Korea will say: "Ahhh that explains why instructor allowed for situation to deteriorate that bad that it became unrecoverable.."

You must understand that seniority pretty much determines everything in Korean society interpersonal relationships.. be it by university class seniority,Air Force class seniority or simply by age

Working here now for 3 years I heard million times Koreans saying "ohh I can not say anything he is my senior in Air Force..or University.." or even if one Korean pilot is introducing me to the other usually first sentence is "this is Mr...so and so he is my senior/junior from so and so"..

So general talk here among instructors is that could be one of the crucial factors in this freak accident...Being here longer time and seeing how things are done between seniors and juniors in cockpit (example: if cpt is Air Force class junior to FO, FO is the boss in cockpit no doubt about it..an same applies to Aerospace University graduates) I agree that this can be the case.

Also to mention that seniority "issue" is MUCH more pronounced if 2 pilots are graduates of same organization such as it was in this case.

Anyways...we shall see what has really happened when CVR transcript becomes available but kind of explains mystery (at least to me) of late instructor reaction to unstable approach..

Last edited by bbratuse; 9th Jul 2013 at 00:22.
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Old 9th Jul 2013, 00:21
  #994 (permalink)  
 
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So, you are assuming it was just an unstable approach.....being the most likely explanation because of your racial prejudices and the make up of thr crew?

Last edited by CAT1; 9th Jul 2013 at 00:23.
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Old 9th Jul 2013, 00:27
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immediately he pointed out that main issue might be that left seat pilot PF Mr.Lee,Kang Kook was senior to instructor doing PM duties from right seat....by senior I mean they both are graduates from Korea Aerospace University and PF Mr.Lee was senior class in University to instructor...
I wondered if this might be the case but having no facts upon which to speculate I said nothing. But if this is true it might go a long way towards explaining why the incident occurred as it did, assuming no mechanical problems.

In CRM theory the training captain should have been superior to the pilot in training but culturally he was not, creating a psychological conundrum when things went haywire.
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Old 9th Jul 2013, 00:30
  #996 (permalink)  
 
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Quote: "When will the aviation industry wake up and start issuing NOTAMS in normal plain English. Do you think non native with English as a second language really can get to grip with the NOTAM gobbledygook we face everyday?"

Great question! This code is left over from the days of 300 baud teletype machines.
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Old 9th Jul 2013, 00:32
  #997 (permalink)  
 
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Korean culture

bbratuse said it much more eloquently.
My Canadian friend was a 777 check pilot and he was one of more than 20 US and Canadian pilots who were KAL captains.

Yes. When was the last time you came in at Vso before the threshold?
Not me. I had a habit of flying too low because I'm a high time helo pilot and low time starch winger. But speed is life and altitude is critical.

Look out the bloody window. If anything he was looking inside and with no glide slope, he was lost. But wait. The 777 has a GPS simulated slope.
Curious how many approaches he shot in the sim?
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Old 9th Jul 2013, 00:38
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AnQrKa said

"Should we compare accident rates from western Europe and Asia? Anybody?"

IATA: 2006-2012 data.

North Asia (which includes Korea) has had lower accident rates than Europe

Europe 0.32 0.29 0.42 0.45 0.45 0.00 0.15
North Asia 0.00 0.88 0.00 0.00 0.34 0.00 0.00
Industry 0.65 0.75 0.81 0.71 0.61 0.37 0.20
IATA Member Airlines 0.48 0.68 0.52 0.62 0.25 0.41 0.00
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Old 9th Jul 2013, 00:44
  #999 (permalink)  
 
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Bet my last dollar the A/T was in hold mode and the thrust levers where being used as what they are always used as - hand rests. And I say this with out spite of venom - 8000 hrs in an Asian carrier gave me this observation.
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Old 9th Jul 2013, 00:47
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Yes, the lights were on

@nigegilb, who wishes to confirm whether PAPIs were operational...

...apart from public announcements (from NTSB, I think?) that they were functioning, we have a first-person account from Locked_door on this forum (following link goes to his post, presently #442):

http://www.pprune.org/rumours-news/5...ml#post7927159

who despite using the word "departed" describes a landing on SFO 28L "in a heavy jet", which if I understood correctly occurred "few hours before this tragic accident." Locked_door's account includes seeing the PAPI lights (and indeed, noting that they indicated that his/her ship was too high).

Perhaps Locked_door will provide more information to clarify approximately what time his/her approach and landing took place, with the aid of visual guidance from the PAPIs.
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