NTSB update on Asiana 214
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Originally Posted by fox niner
That would be a pity, if true. It would put all the blame on that single snippet of information. My gut feeling is that there is much more to this accident. It really can't be that simple. Asiana would really love that,as it would (almost) clear their name entirely.
I have been saying for a while now, that I wouldn’t be surprised to learn that some sort of “cheat-sheet answer” issue may have been involved. I have seen more than my fair share of such “activity” that I’ve become “spring loaded” to the “suspicious position.” When I describe “cheat sheet activity” I mean learning some kind of deliberately contrived “set of numbers” or a “sequencing” of doing something” i.e., setting flaps, flying airspeeds, setting throttles, making control inputs or control reversals, etc., some of which are “held” for a given time and then something else may be done … and it all depends on what the effort was supposed to provide. The justification from most of those who practice such idiocy is that it either looks successful or actually is somewhat successful – and most of it was derived in a simulator – and, therefore, we’re back to the inherent problems with simulation accuracy. I have this “bias” because of the numbers of times I’ve seen, and my colleagues have seen, that precise form of “flying” that has proven to be “successful” enough times that otherwise lacking aviators use it to “get by” when they are being observed. If the “cheat sheet” approach is accurate enough and the lacking aviator performs it discretely enough, it all looks good enough that we only find out about it through careful observation of a simulator session or after sifting through the wreckage.
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A live report of all what is being said during the NTSB hearing can be read here.
NTSB HEARING - DAY 2 - 9AM -5PM - Recapd
NTSB HEARING - DAY 2 - 9AM -5PM - Recapd
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Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.
So no sign of the above rumour in the hearing so far.
I can't help but note how often they appear to be switching language. Being an ignorant Englishman and this only speaking assuredly non-technical French, how much extra distraction or workload is switching between languages causing?
I can't help but see a lot of Korean after the "speak English" command.
I know all of us worship at the One True Brief of our current employers, but that seems a fairly confused and perfunctory brief for a bloke on line training too.
I can't help but see a lot of Korean after the "speak English" command.
I know all of us worship at the One True Brief of our current employers, but that seems a fairly confused and perfunctory brief for a bloke on line training too.
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80 pounds of backpressure to maintain gs?
Excerpt from NTSB, Dr. Bramble senior human performance investigator at the NTSB questions CAPT John Cashman, former 777 test pilot...
">> A FOLLOW-UP TO THE LINE OF QUESTIONING CAPTAIN COX IS ASKED GETTING ABOUT WITH RESPECT TO THE FEEL. THERE IS FEEDBACK, CORRECT, ON THE YOKE AT THE ANGLE THEY WERE AT, HOW MANY POUNDS OF PRESSURE WOULD YOU HAVE EXPECTED TO BE APPLIED TO THE OAK TO ACHIEVE THAT?
>> AT WHICH POINT?
>> IN THE ACCIDENT FLIGHT.
>> WHEN THEY WERE DECELERATING, ALL THE TIME IT WOULD HAVE BEEN A GRADUALLY INCREASING FORCE.
>> CULMINATING WITH A MAXIMUM?
>> I'M TRYING SURE MEMBER WHAT THE FLIGHT RECORDER SHOWED, BUT I THINK IT WAS TOWARD 80 POUNDS.
>> 80 POUNDS?
>> YES. THE AIRPLANE, FROM WHAT THE DATA SHOWS, WAS NOT TRIMMED AFTER THE AUTOPILOT WAS DISCONNECTED. IT COULD HAVE BEEN DOWN TO THE TOP OF THE AMBER BAND TO THE FORCE COULD HAVE BEEN ZERO. ONCE THEY ENTER THE AMBER BAND, THE FORCE OF THE STICK GOES UP BY A FACTOR OF FIVE FOR EVERY 10 KNOTS OF SPEED."
I'm a bugsmasher, but if I am pulling until I've got 80lbs on the yoke with the a/c nose up in the air and still seeing all red PAPIs...maybe something is wrong?
">> A FOLLOW-UP TO THE LINE OF QUESTIONING CAPTAIN COX IS ASKED GETTING ABOUT WITH RESPECT TO THE FEEL. THERE IS FEEDBACK, CORRECT, ON THE YOKE AT THE ANGLE THEY WERE AT, HOW MANY POUNDS OF PRESSURE WOULD YOU HAVE EXPECTED TO BE APPLIED TO THE OAK TO ACHIEVE THAT?
>> AT WHICH POINT?
>> IN THE ACCIDENT FLIGHT.
>> WHEN THEY WERE DECELERATING, ALL THE TIME IT WOULD HAVE BEEN A GRADUALLY INCREASING FORCE.
>> CULMINATING WITH A MAXIMUM?
>> I'M TRYING SURE MEMBER WHAT THE FLIGHT RECORDER SHOWED, BUT I THINK IT WAS TOWARD 80 POUNDS.
>> 80 POUNDS?
>> YES. THE AIRPLANE, FROM WHAT THE DATA SHOWS, WAS NOT TRIMMED AFTER THE AUTOPILOT WAS DISCONNECTED. IT COULD HAVE BEEN DOWN TO THE TOP OF THE AMBER BAND TO THE FORCE COULD HAVE BEEN ZERO. ONCE THEY ENTER THE AMBER BAND, THE FORCE OF THE STICK GOES UP BY A FACTOR OF FIVE FOR EVERY 10 KNOTS OF SPEED."
I'm a bugsmasher, but if I am pulling until I've got 80lbs on the yoke with the a/c nose up in the air and still seeing all red PAPIs...maybe something is wrong?
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reading the transcript of the cvr is amazing...lots of talk about vision, sunglasses and lasix!
bamboo...much can be read and understood...the use of sir can be understood to be an admonishment instead of a respectful agreement.
yes, the autothrottles were perfect, but even if they were not (and this is not the case), it would still be up to the pilot to FLY THE PLANE.
I think we do agree bamboo
it seems that ATC might have been slow in clearing the plane to land.
no discussion of the three to one method of checking a visual approach or a method of five times groundspeed to equal descent rate in feet per minute to make good a glideslope!
bamboo...much can be read and understood...the use of sir can be understood to be an admonishment instead of a respectful agreement.
yes, the autothrottles were perfect, but even if they were not (and this is not the case), it would still be up to the pilot to FLY THE PLANE.
I think we do agree bamboo
it seems that ATC might have been slow in clearing the plane to land.
no discussion of the three to one method of checking a visual approach or a method of five times groundspeed to equal descent rate in feet per minute to make good a glideslope!
Sawbones, you're not giving Mr. Cashman quite enough credit - he was the CHIEF test pilot for the 777, starting with the very first test flight in 1994. I think he was the Chief test pilot for the whole company when he retired.
I flew with John many, many times - heck of a pilot (most of the Boeing test pilots fall into that category). My understanding was that he was an engineer before he became a pilot - and it showed - he really understood the airplane and how it worked.
I wish I had the time to listen it, it sounds like the proceeding are rather interesting
I flew with John many, many times - heck of a pilot (most of the Boeing test pilots fall into that category). My understanding was that he was an engineer before he became a pilot - and it showed - he really understood the airplane and how it worked.
I wish I had the time to listen it, it sounds like the proceeding are rather interesting
Thanks for the link to the ntsb cvr transcript.
As to the latest video ... grateful there were no more fatalities.
As to the latest video ... grateful there were no more fatalities.
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For the love of God
Did a pilot with thousands of hours behind the stick actually say that, on a perfect day with unlimited visibility, no winds of any importance and no other distractions than having to actually fly the plane, "it was very difficult to perform a visual approach with a heavy airplane"? Perhaps, and that's a perhaps, with the amendment "at KSFO" unspoken, but still???
If so then someone needs a reality check. And so does anyone dreaming up any some sort of excuse for what happened. Yes, let the investigations continue. Let the lessons be learned.
But this plain and simple should not have happened. Period.
And if any professional pilot says otherwise then I'd much rather hitch a ride across the Atlantic on a container vessel than be seated in the back of a modern airliner flown by a child of the magenta line.
If so then someone needs a reality check. And so does anyone dreaming up any some sort of excuse for what happened. Yes, let the investigations continue. Let the lessons be learned.
But this plain and simple should not have happened. Period.
And if any professional pilot says otherwise then I'd much rather hitch a ride across the Atlantic on a container vessel than be seated in the back of a modern airliner flown by a child of the magenta line.
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you're not giving Mr. Cashman quite enough credit
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The "very difficult" quote comes from a Fox News article - best get a more reliable source before taking it as read.
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This NYT article
http://www.nytimes.com/2013/12/12/us...o-airport.html
seems to give a reasonable summary of evidence that emerged at the 12/11 hearing.
Following are key extracts:
The pilots of the Asiana jumbo jet that crashed in San Francisco on July 6 were deeply confused about the plane’s automated control systems, and that is a common problem among airline pilots, according to experts who testified Wednesday in a National Transportation Safety Board hearing on the crash.
In the transcript, no one said that the plane was too low until the last 30 seconds of the flight. Three seconds before impact, Captain Lee made a comment rendered in the transcript as “oh # go around,” indicating an attempt to re-engage the engines and abort the approach.
http://www.nytimes.com/2013/12/12/us...o-airport.html
seems to give a reasonable summary of evidence that emerged at the 12/11 hearing.
Following are key extracts:
The pilots of the Asiana jumbo jet that crashed in San Francisco on July 6 were deeply confused about the plane’s automated control systems, and that is a common problem among airline pilots, according to experts who testified Wednesday in a National Transportation Safety Board hearing on the crash.
“We do have an issue in aviation that needs to be dealt with,” the chairwoman of the safety board, Deborah A. P. Hersman, told reporters during a break in the hearing.
The captain and the supervising pilot in the Asiana crash — in which a Boeing 777 hit a sea wall short of the runway, killing three passengers — said they thought a system that is used to control the plane’s airspeed was running, although it was not. And all three pilots overlooked a prominent display that showed their airspeed was too low.
According to documents released by the board, for 19 seconds leading up to the crash the pilots had a clear view of guidance lights on the field that indicated they were flying too low, but they did not follow company procedure to break off the approach.
The plane’s captain, Lee Kang Kuk, told investigators — although he was wrong — that he believed the protection system in the Boeing was similar to the one in the Airbus A320, which he had substantially more experience flying.
In the Boeing, the throttle levers — one for each of the two engines and located on a center pedestal between the captain and the first officer — will move as the automatic system manipulates the engines. In the Airbus they will not move even when the auto-throttle adjusts the engines’ power.
The captain was supposed to keep a hand on the throttle levers to feel them move, and he did so on and off, he told investigators. Lack of movement in the throttle levers did not trouble him, he told investigators, because he thought the auto-throttle would “wake up” and maintain a safe minimum speed with no sign.
Boeing’s design leaves more discretion to the pilot and does not always ensure that the engines will maintain a minimum speed. Asiana ground school instructors warned the crews that the auto-throttle would be disabled when autopilot was being used by the crew to control the plane’s descent to a certain altitude, according to one safety board document, but the lesson evidently did not stick.
Captain Lee told investigators that any of the three pilots on the plane could have decided to break off the approach, but he said it was “very hard” for him to do so because he was a “low-level” person being supervised by an instructor pilot.
He also said that as the plane approached, he was momentarily blinded by a light on the runway, possibly a reflection of the sun, but that he would not wear sunglasses because that was considered impolite among Koreans.
The pilots did know they were descending too fast. One said so about a minute before impact, in English, which the crew was using on approach, according to a transcript of the flight data recorder. The second mention was also in English, but the third, about nine seconds after the first, was in Korean, a clue in the transcript about the urgency in the cockpit.
The captain and the supervising pilot in the Asiana crash — in which a Boeing 777 hit a sea wall short of the runway, killing three passengers — said they thought a system that is used to control the plane’s airspeed was running, although it was not. And all three pilots overlooked a prominent display that showed their airspeed was too low.
According to documents released by the board, for 19 seconds leading up to the crash the pilots had a clear view of guidance lights on the field that indicated they were flying too low, but they did not follow company procedure to break off the approach.
The plane’s captain, Lee Kang Kuk, told investigators — although he was wrong — that he believed the protection system in the Boeing was similar to the one in the Airbus A320, which he had substantially more experience flying.
In the Boeing, the throttle levers — one for each of the two engines and located on a center pedestal between the captain and the first officer — will move as the automatic system manipulates the engines. In the Airbus they will not move even when the auto-throttle adjusts the engines’ power.
The captain was supposed to keep a hand on the throttle levers to feel them move, and he did so on and off, he told investigators. Lack of movement in the throttle levers did not trouble him, he told investigators, because he thought the auto-throttle would “wake up” and maintain a safe minimum speed with no sign.
Boeing’s design leaves more discretion to the pilot and does not always ensure that the engines will maintain a minimum speed. Asiana ground school instructors warned the crews that the auto-throttle would be disabled when autopilot was being used by the crew to control the plane’s descent to a certain altitude, according to one safety board document, but the lesson evidently did not stick.
Captain Lee told investigators that any of the three pilots on the plane could have decided to break off the approach, but he said it was “very hard” for him to do so because he was a “low-level” person being supervised by an instructor pilot.
He also said that as the plane approached, he was momentarily blinded by a light on the runway, possibly a reflection of the sun, but that he would not wear sunglasses because that was considered impolite among Koreans.
The pilots did know they were descending too fast. One said so about a minute before impact, in English, which the crew was using on approach, according to a transcript of the flight data recorder. The second mention was also in English, but the third, about nine seconds after the first, was in Korean, a clue in the transcript about the urgency in the cockpit.
olasek, I was merely nit-picking that:
didn't really give Mr. Cashman enough credit - he's not just a "former 777 test pilot" (there are a lot of those), he was the "Chief 777 Test Pilot" during the aircraft development (and for several years there after).
CAPT John Cashman, former 777 test pilot...
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Illuminating excerpt from the transcript
>> i assume you're referring to a specific issue raised during the 787 program by our test pilot related to the wake-up function of the autothrottle, where they were conducting a flight test, and there was a flight level change initiated, and the flight level change was interrupted by another event, in this case it was a traffic avoidance event, and as a result of the logic of the airplane, the autothrottles went into hold mode. Our pilot was monitoring airspeed and noticed airspeed was decaying, and as part of the test pilot functions, lapierre speed to decay further to see what would happen. -- allowed the test be to decay further to see what would happen. Our test pilot believed that the autothrottle would wake up, not realizing that the autothrottle, since it was on, as mr. Myers explained, the autothrottle was on, the autothrottle would not wake up. It was already awake. So he allowed speeds of decay, and at a save point, he put throttles back in, brought the thrust back up and continued the flight. He raised that as a response item. Basically way for the faa to document a potential concern and to get a response from the applicant, in this case boeing, response to the question about why it works that way, and to determine if it is susceptible. In the process of doing that evaluation, over working with boeing on this one, the pilot determine that the fact that the autothrottle did not wake up without a safety issue, nor was it a regulatory noncompliance. Given those two critical factors, at that point, he believes it was still an area where there could be improvement , and he worked with boeing to include additional information in the flight manual to explain that the autothrottle on the 787 would not wake up from an autothrottle hold.
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TDracer:
No offence meant to CAPT Cashman, indeed his appearance on the panel today means for the NTSB, Boeing etc... he is "the" go-to 777 test pilot!
But 80 lbs of yoke force was quite a revelation for me - that airplane was trying to say something!
No offence meant to CAPT Cashman, indeed his appearance on the panel today means for the NTSB, Boeing etc... he is "the" go-to 777 test pilot!
But 80 lbs of yoke force was quite a revelation for me - that airplane was trying to say something!
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VERY Interesting!!
Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.
Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.
http://dms.ntsb.gov/public%2F55000-5...3%2F543209.pdf
Looks like the information provided to the NTSB is that the licenses were in order.
Several thousand pages of information, plus audio and video files, were released when the docket was made public this morning:
Accident ID DCA13MA120 Mode Aviation occurred on July 06, 2013 in San Francisco, CA United States Last Modified on December 11, 2013 07:12 Public Released on December 11, 2013 08:12 Total 135 document items
As discussed extensively earlier here on PPRuNe, the autothrottle THR HOLD FLCH 'trap' is well known, and is present in all EICAS Boeings from the 757 onward. It looks like Boeing's position is that it is consistent with the original design philosophy of the automation to not intervene too much when the pilot is making manual inputs. If the autothrottles are off, they will 'wake up' to maintain speed but if they are on in THR HOLD mode, they are already 'awake' but intentionally not responding until they change to another mode e.g. SPD.
From NTSB questioning I get the idea that they are going to suggest that this autothrottle behavior be modified or at least covered more specifically in sim training.
I might have got myself into an undesirable situation on approach with some MCP mismanagement somehow but like most people posting here, I can't conceive not immediately reacting to low airspeed, sinkrate calls and red PAPI's below 1000 feet.
Last edited by Airbubba; 12th Dec 2013 at 18:37.