NTSB update on Asiana 214
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Olasek?
In a world run by lawyers, when there is a system that allows supposedly trained and responsible people to effectively commit suicide, and potentially take hundreds of paying customers with them, it seems within the realms of product liability experience to insist that the manufacture takes some action.
Perhaps insist that the machine at the very least asks politely whether suicide is indeed the captain's intent this afternoon (beyond displaying the perilous airspeed and height), or perhaps that the manufacturer takes a hand in checking the competence of the drivers.
It's a sad turn of events, but perhaps lawsuits will affect the situation? Is a plane a car, where the manufacturers are generally shielded, or does the manufacturer potentially face lawsuits from victims?
Perhaps insist that the machine at the very least asks politely whether suicide is indeed the captain's intent this afternoon (beyond displaying the perilous airspeed and height), or perhaps that the manufacturer takes a hand in checking the competence of the drivers.
It's a sad turn of events, but perhaps lawsuits will affect the situation? Is a plane a car, where the manufacturers are generally shielded, or does the manufacturer potentially face lawsuits from victims?
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but perhaps lawsuits will affect the situation?
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Perhaps insist that the machine at the very least asks politely
BTW, never heard about car manufacturers being shielded from lawsuits.
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Car manufacturers shielded?
Perhaps not by legislation, but by practice.
Insurance companies seem to go after drivers, and not manufacturers - although there was that relatively recent fuss about Toyota software that seemed to turn out to be due to a mix of badly-secured floor mats and a lack of regard for the switch-off instructions in the manual for a keyless car.
If car accidents happened only once every two years, then I guess that might change.
Insurance companies seem to go after drivers, and not manufacturers - although there was that relatively recent fuss about Toyota software that seemed to turn out to be due to a mix of badly-secured floor mats and a lack of regard for the switch-off instructions in the manual for a keyless car.
If car accidents happened only once every two years, then I guess that might change.
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Insurance companies seem to go after drivers, and not manufacturers
But if car design is in question you bet - victims sue.
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777's must have done many tens of thousands of visual approaches without mishap. It wasn't the airplanes fault, that much is clear.
Political correctnes will not prevent this type of accident happening again. We cannot have pilots that are scared of flying the airplane on a nice clear day. If they are worried/scared is because even they themselves have serious doubts about their ability (or currency). On top of that we cannot have a cultural mindset where a high probability of a crash is preferable to loosing face or speaking out of turn.
A pilot that cannot look out of the window and land an airplane visually on a suitable runway is not a pilot, it does not belong in an airliner. This has to be an absolutely minimum requirement. What would this crew have done if they had to land flaps up? Or gear up? Or in a strong crosswind? Or with unreliable airspeed? Or in many of hundreds of other more demanding scenarios than a visual approach?
The cultural issues are not new and they are well understood, they still need to be addressed. The systems manager versus pilot debate has taken us the wrong path. We have to be pilots AND systems managers. We are droping the pilot bit because it costs money to train and maintain. Accidents cost money too.
Political correctnes will not prevent this type of accident happening again. We cannot have pilots that are scared of flying the airplane on a nice clear day. If they are worried/scared is because even they themselves have serious doubts about their ability (or currency). On top of that we cannot have a cultural mindset where a high probability of a crash is preferable to loosing face or speaking out of turn.
A pilot that cannot look out of the window and land an airplane visually on a suitable runway is not a pilot, it does not belong in an airliner. This has to be an absolutely minimum requirement. What would this crew have done if they had to land flaps up? Or gear up? Or in a strong crosswind? Or with unreliable airspeed? Or in many of hundreds of other more demanding scenarios than a visual approach?
The cultural issues are not new and they are well understood, they still need to be addressed. The systems manager versus pilot debate has taken us the wrong path. We have to be pilots AND systems managers. We are droping the pilot bit because it costs money to train and maintain. Accidents cost money too.
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There's always a problem, post-crash, with lawsuits. Part of this is the fact that cases usually go before a jury of non-specialists who may be told stuff that makes any pilot worth his salt roll his eyes, because the jury often buys nonsense.
I particularly remember a case where a light aircraft pilot made what looked like a typical undershoot with CFIT, followed by a post-crash fire. His family found a shyster who put it about that, no, the aircraft had caught fire on short final, that that was the cause of the crash! Of course the aircraft wreckage had been destroyed by fire, so that it was impossible to say that this very unlikely scenario had not played out, and then there was the bereaved family up against the big, rich, aircraft manufacturer, when the jury came down on the side of the family.
I think the judgment was reversed on appeal, but those initial, multi-million dollar settlements often lead to no win-no pay lawsuits by people who really don't have a leg to stand on. Everyone from the company that built the crash aircraft down to the guy who last serviced its toilet end up having to fight off the sharks.
I particularly remember a case where a light aircraft pilot made what looked like a typical undershoot with CFIT, followed by a post-crash fire. His family found a shyster who put it about that, no, the aircraft had caught fire on short final, that that was the cause of the crash! Of course the aircraft wreckage had been destroyed by fire, so that it was impossible to say that this very unlikely scenario had not played out, and then there was the bereaved family up against the big, rich, aircraft manufacturer, when the jury came down on the side of the family.
I think the judgment was reversed on appeal, but those initial, multi-million dollar settlements often lead to no win-no pay lawsuits by people who really don't have a leg to stand on. Everyone from the company that built the crash aircraft down to the guy who last serviced its toilet end up having to fight off the sharks.
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Regarding training culture and the use of simulators for RST's etc: I heard a story some years ago and ask for verification.
It was said that there was an airline in the far east where sim checks were conducted by computer. The story went that the check ride was loaded in the sim, you checked in with your ID card and when ready pressed the Go button and followed the program. At the end of the session it printed out a pass/fail and grade. You then checked out and went home.
Is this true or was it April 1st?
It was said that there was an airline in the far east where sim checks were conducted by computer. The story went that the check ride was loaded in the sim, you checked in with your ID card and when ready pressed the Go button and followed the program. At the end of the session it printed out a pass/fail and grade. You then checked out and went home.
Is this true or was it April 1st?
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chuks:
I'm a bit surprised at this; fire while airborne leaved a distinctive smoke trail following the airflow. Any decent accredited investigator, acting as a defense witness, would refute the "fire before crash" theory.
His family found a shyster who put it about that, no, the aircraft had caught fire on short final, that that was the cause of the crash!
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What I remember reading was a scenario that went as if the aircraft, a Beechcraft Bonanza, went on fire on short final, distracting the pilot and thus causing the CFIT. Post-crash, the aircraft burnt out completely, leaving nothing to show when the fire had started, whether that was pre- or post-crash.
Of course it was far more likely that the pilot simply made a mistake and did a "duck-under" when he went visual, or perhaps never went visual and just hit obstructions off the approach end with the usual post-crash fire, but the jury bought this other theory about the in-flight fire. After all, it could have happened that way, even if that was rather improbable!
My point is that American lawyers go after the guys with the deep pockets, any way they can. You will see a list of defendants as long as your arm, sometimes: all the major suppliers, of the airframe, the engines, the instruments, the seats, the galleys... you name it. That "scatter gun" approach is the way to go if you don't have to worry about being hit for costs if you lose.
Of course it was far more likely that the pilot simply made a mistake and did a "duck-under" when he went visual, or perhaps never went visual and just hit obstructions off the approach end with the usual post-crash fire, but the jury bought this other theory about the in-flight fire. After all, it could have happened that way, even if that was rather improbable!
My point is that American lawyers go after the guys with the deep pockets, any way they can. You will see a list of defendants as long as your arm, sometimes: all the major suppliers, of the airframe, the engines, the instruments, the seats, the galleys... you name it. That "scatter gun" approach is the way to go if you don't have to worry about being hit for costs if you lose.
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Rat 5:
No I don't think so. There are certainly canned sessions where the instructor selects a pre-programmed scenario and runs it. How could a computer know when to stop, start, close or open doors, fix issues that arise, judge CRM issues, play ground, ATC, company, purser etc. Running the sim is pretty hands on, even with a canned session.
No I don't think so. There are certainly canned sessions where the instructor selects a pre-programmed scenario and runs it. How could a computer know when to stop, start, close or open doors, fix issues that arise, judge CRM issues, play ground, ATC, company, purser etc. Running the sim is pretty hands on, even with a canned session.
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I agree totally. I wonder if it was more a computerised sim check with no input from the examiner, or SFI if a recurrency, other than as you suggest to do the necessary but not to intervene at all.
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That takes me back a couple of decades (at least) to the “old joke” of airliners being destined to have only 1 pilot and 1 dog in the cockpit. The dog is there to keep the pilot from touching anything, and the pilot is there to feed the dog.
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... am I the only one who is thinking the crew is maybe playing the "culture" card to cover for gross piloting error. Not that they would expect that to completely excuse them, but if the culture card is taken at face value then their crucifictions should become less painful since the "institution" would bare some blame as well.
Two groups of interlinked problems.
Group 1: Currency and culture
What needs fixing?
Stupid flight deck culture and stupid airline punitive monitoring culture.
More manual flying, on the line, of complex airliners.
What won't fix it?
Idiot pilots thinking that throwing these chaps in the bin will do anything other than bury the real problems. Which are closer to home than you may think.
Group 1: Currency and culture
- If you never do a certain type of approach, then you become bad at it.
- If you are monitored to death with a picky and punitive culture, then you never expose yourself by doing something you are bad at.
- Loop the above two round until you can't do it. If you have to do it, you are stressed for two reasons, the punitive culture and the lack of skill.
What needs fixing?
Stupid flight deck culture and stupid airline punitive monitoring culture.
More manual flying, on the line, of complex airliners.
What won't fix it?
Idiot pilots thinking that throwing these chaps in the bin will do anything other than bury the real problems. Which are closer to home than you may think.
However this bit:
Group 2: Tech
- He reverted to A320 methods: call for FD off to get A/T in speed mode, do nothing with the stick, expect no movement from the thrust levers and you will arrive.
- Nothing needs monitoring because the A320 goes "ping" if any of the auto systems fail. No ping, no problem, no need to monitor. A trillion pilots are guilty of this.
- Notwithstanding, stuff goes wrong and "oddly" the a/c is not maintaining the path. Everyone in the west knows that if it goes wrong you simply go around. Here he has to wait for the other chap to call the go-around, due to bizarre culture.
For one thing, I'm certain that moving thrust levers are a red herring here. For another, the A320 will not, as you say, "ping" if the apparent command given by the crew is consistent with the situation - contrary to a lot of received opinion, Airbus automatics are no more "intelligent" than those of other types.
As to the third point, the interviews state that Asiana's rule regarding GAs is that they must be *flown* by the Captain and not the FO. Whether GAs can be *called* by the FO is not stated, but the PF in this case was already a Captain upgrading to long-haul from a short/medium haul position - moreover he was an instructing/check Captain on the short-haul types, so even if he reverted to previous behaviour he should have had no trouble ordering or flying a GA.
What is interesting is that this particular check flight seemed to combine a visual approach without ILS backup (apparently a very rare occurrence for Asiana PICs), an airport which was considered "difficult" among Asiana's line pilots and a check Captain whose technique was more hands-off than seems to normally have been the case. For his part, he seems to have been reticent to directly ask the check Captain whether the latter was happy with his handling of the flight - and the check Captain himself, despite noting that the PIC seemed "nervous" (per the interview), did not make any attempt to find out why, or provide encouragement/direction if necessary. Possibly as a result of the seemingly punitive nature of the airline's culture, these factors appear to have added to the stress levels of the PIC.
If I may be permitted to speculate:
- The airline was known to have a hard-line approach to excessive descent rates - could this have led to the PIC erring on the side of caution and come in fast and high?
- The check Captain (apparently unusually) was content to let the PIC get on with things - did this cause him to avoid corrective action until too late?
- The PIC seems to have been concerned enough to take on PNF/PM tasks on final - did this impression of "double workload" in fact cause him to be task-saturated at a critical phase?
To illustrate the point I was making earlier about stress, we know that a pilot considered the best in his airline was so concerned about duty/time regulations that the distraction may have caused him to attempt take-off without permission. We know that a pilot who was highly spoken of by his colleagues became so concerned about wake turbulence that it may have caused him to overcontrol his aircraft to the point of structural damage. We have countless examples of pilots being so concerned about making schedule that they continued with approaches that they shouldn't have.
Therefore, no matter what anyone's experience or view of "culture" may be, the nature of increased stress and its ability to cause even the best pilots to make mistakes that seem incredible at face value must be considered here.
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What I remember reading was a scenario that went as if the aircraft, a Beechcraft Bonanza, went on fire on short final, distracting the pilot and thus causing the CFIT. Post-crash, the aircraft burnt out completely, leaving nothing to show when the fire had started, whether that was pre- or post-crash.
And I also remember that the evidence that it was an in flight fire was virtually non-existent.
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I think the judgment was reversed on appeal, but those initial, multi-million dollar settlements
That "scatter gun" approach is the way to go if you don't have to worry about being hit for costs if you lose.
I don't know if this info as been posted before and I'm not sure...
Just how accurate it is but here it is...
It seems to me there was some misuse of the automation on this aircraft that then put them in a bad situation with no one minding the store.
From another aviation web site...
"During hearings on December 11, National Transportation Safety Board officials described the final approach sequence of Asiana Airlines Flight 214, scannerwhich crashed at San Francisco International Airport on July 6. The Boeing 777 was cleared for a visual approach to Runway 28 Left where, as per a Notam, the glideslope was inactive. The left-seat pilot flying had logged fewer than 45 hours in the 777, while the right-seat instructor had 3,200 hours of time on the widebody. On a 15 mile final approach, the Boeing’s airspeed was at 210 knots as it descended with autopilot and flight-level change (FLCH) engaged. Descent altitude was set at 1,800 feet. The aircraft was high on final approach and switching to vertical speed mode did not help this situation. Final approach reference speed was calculated at 137 knots. On a five-mile final the altitude was reset to 3,000 feet in case of a go-around. At 1,600 feet and 3.5 miles from the runway, the FLCH switch was again activated, which changed the auto-throttle mode. [Boeing does not recommend using FLCH inside the final approach fix—Ed.]. When the FLCH was engaged, the autopilot tried to climb the aircraft to 3,000 feet. The pilot reacted by pulling the thrust to idle and disconnecting the autopilot. This put the autothrottles in hold mode at idle. At 1.4 miles from the runway and at 500 feet above the water the aircraft was still descending. With the thrust at idle, the left-seat pilot began to add backpressure to the control wheel to stop the descent and get back on the visual glideslope from the precision approach path indicator. The airspeed continued to decay–now slowing through 120 knots–although neither pilot mentioned it. Eleven seconds before impact a low-speed alert was heard in the cockpit. At eight seconds from impact and with the aircraft 100 feet above the water, the pilots moved the throttles full forward to initiate a go-around. Four seconds later the stick shaker activated and someone in the cockpit called for a go-around. The action was too late and the main gear and aft fuselage struck the seawall. The lowest recorded airspeed was 103 knots, 34 knots below the calculated safe reference speed."
It seems to me there was some misuse of the automation on this aircraft that then put them in a bad situation with no one minding the store.
From another aviation web site...
"During hearings on December 11, National Transportation Safety Board officials described the final approach sequence of Asiana Airlines Flight 214, scannerwhich crashed at San Francisco International Airport on July 6. The Boeing 777 was cleared for a visual approach to Runway 28 Left where, as per a Notam, the glideslope was inactive. The left-seat pilot flying had logged fewer than 45 hours in the 777, while the right-seat instructor had 3,200 hours of time on the widebody. On a 15 mile final approach, the Boeing’s airspeed was at 210 knots as it descended with autopilot and flight-level change (FLCH) engaged. Descent altitude was set at 1,800 feet. The aircraft was high on final approach and switching to vertical speed mode did not help this situation. Final approach reference speed was calculated at 137 knots. On a five-mile final the altitude was reset to 3,000 feet in case of a go-around. At 1,600 feet and 3.5 miles from the runway, the FLCH switch was again activated, which changed the auto-throttle mode. [Boeing does not recommend using FLCH inside the final approach fix—Ed.]. When the FLCH was engaged, the autopilot tried to climb the aircraft to 3,000 feet. The pilot reacted by pulling the thrust to idle and disconnecting the autopilot. This put the autothrottles in hold mode at idle. At 1.4 miles from the runway and at 500 feet above the water the aircraft was still descending. With the thrust at idle, the left-seat pilot began to add backpressure to the control wheel to stop the descent and get back on the visual glideslope from the precision approach path indicator. The airspeed continued to decay–now slowing through 120 knots–although neither pilot mentioned it. Eleven seconds before impact a low-speed alert was heard in the cockpit. At eight seconds from impact and with the aircraft 100 feet above the water, the pilots moved the throttles full forward to initiate a go-around. Four seconds later the stick shaker activated and someone in the cockpit called for a go-around. The action was too late and the main gear and aft fuselage struck the seawall. The lowest recorded airspeed was 103 knots, 34 knots below the calculated safe reference speed."
Thread Starter
During hearings on December 11
National Transportation Safety Board (Flash)
or here:
National Transportation Safety Board (Windows Media Player)