NTSB update on Asiana 214
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Sir Richard
There we will have to disagree, my argument being that the absence of an EICAS warning contributed to this accident and other incidents as well.
Hempy
I doubt anyone would disagree with you regarding the responsibilities of the PIC. However, the discussion here is about a design flaw, a know trap which has contributed to a fatal accident.
It would be interesting to know if the trap remains on the 787?
I guess that any EICAS caution, without bells and whistles (or cricket bats), would have been ignored on that sunny day in SFO.
Hempy
If the PIC of an aircraft, with all of the responsibilities designated to that role, does not know the operation of the basic systems of the aircraft (e.g the fkn autopilot!) he is in Command of, he has no right being there. And is fully responsible for any outcomes resulting from said failings..
It would be interesting to know if the trap remains on the 787?
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However, the discussion here is about a design flaw, a know trap which has contributed to a fatal accident.
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If it contributed to the crew awareness and safety - YES.
FLCH No so much a design flaw, but a design weakness which can catch the unwary. Also, consider that this accident could represent a difference between what the regulators expected from pilots (acceptable for certification) and that which actually occurred, which reflects on the overall situation including high workload, training flight, demanding ATC scenario, etc.
Thus the weakness represents a series of assumptions, first by the manufacturer, then the regulator, and finally the operator and crew; all of whom had opportunity to consider the system, provide warnings or mitigations or just by understanding the assumptions.
Thus the safety message is that we need to identify the assumptions in operations, and if these have weaknesses take action;- don’t use FLCH during approach (why not use manual thrust), don’t remove all approach aids simultaneously or use ‘unnecessary’ noise / traffic restricted approach profiles, don’t train in these demanding circumstances (cf AMS 737 accident), and beware situations where there may be little spare mental capacity to cope with failures or system weaknesses.
How many other 777 pilots have been caught by this, how was the situation detected, and what is now done to avoid the weakness … and did anyone tell the manufacturer / regulator / operator so that they might reconsider the situation?
Thus the weakness represents a series of assumptions, first by the manufacturer, then the regulator, and finally the operator and crew; all of whom had opportunity to consider the system, provide warnings or mitigations or just by understanding the assumptions.
Thus the safety message is that we need to identify the assumptions in operations, and if these have weaknesses take action;- don’t use FLCH during approach (why not use manual thrust), don’t remove all approach aids simultaneously or use ‘unnecessary’ noise / traffic restricted approach profiles, don’t train in these demanding circumstances (cf AMS 737 accident), and beware situations where there may be little spare mental capacity to cope with failures or system weaknesses.
How many other 777 pilots have been caught by this, how was the situation detected, and what is now done to avoid the weakness … and did anyone tell the manufacturer / regulator / operator so that they might reconsider the situation?
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FLCH No so much a design flaw, but a design weakness which can catch the unwary. Also, consider that this accident could represent a difference between what the regulators expected from pilots (acceptable for certification) and that which actually occurred, which reflects on the overall situation including high workload, training flight, demanding ATC scenario, etc.
Thus the weakness represents a series of assumptions, first by the manufacturer, then the regulator, and finally the operator and crew; all of whom had opportunity to consider the system, provide warnings or mitigations or just by understanding the assumptions.
Thus the safety message is that we need to identify the assumptions in operations, and if these have weaknesses take action;- don’t use FLCH during approach (why not use manual thrust), don’t remove all approach aids simultaneously or use ‘unnecessary’ noise / traffic restricted approach profiles, don’t train in these demanding circumstances (cf AMS 737 accident), and beware situations where there may be little spare mental capacity to cope with failures or system weaknesses.
How many other 777 pilots have been caught by this, how was the situation detected, and what is now done to avoid the weakness … and did anyone tell the manufacturer / regulator / operator so that they might reconsider the situation?
Thus the weakness represents a series of assumptions, first by the manufacturer, then the regulator, and finally the operator and crew; all of whom had opportunity to consider the system, provide warnings or mitigations or just by understanding the assumptions.
Thus the safety message is that we need to identify the assumptions in operations, and if these have weaknesses take action;- don’t use FLCH during approach (why not use manual thrust), don’t remove all approach aids simultaneously or use ‘unnecessary’ noise / traffic restricted approach profiles, don’t train in these demanding circumstances (cf AMS 737 accident), and beware situations where there may be little spare mental capacity to cope with failures or system weaknesses.
How many other 777 pilots have been caught by this, how was the situation detected, and what is now done to avoid the weakness … and did anyone tell the manufacturer / regulator / operator so that they might reconsider the situation?
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Or instead pilots could be trained to monitor speed and power on the approach like most good pilots already do
Actually remove absolutely all automation, make it a simple stick& rudder aircraft and all "weaknesses" are gone. Additional safeguards and other "warnings" only compound the problem by making pilot more dependent on them. More warnings, more audio sounds, more flashing lights don't necessarily make it safer, basic fact known to anybody who studied human factors in the cockpit. Therefore it has been recognized long time ago that absolutely nothing can replace monitoring such basic things like speed, power and attitude. These guys failed to monitor all 3 of them which is pretty astounding if you think about it.
It's a well known human characteristic that, during high workload situations, aural inputs often get filtered out. In other words, when highly focused, we tend not to hear things or use 'selective hearing'. There was a documented case of a wheels up landing where both pilots swore the aural alert never sounded - until they listened to the CVR playback
That's why the stall warning is a 'stick shaker', yoke forces go up, etc. An aural alert saying 'low airspeed' may not get through.
Perhaps the cricket/baseball bat isn't such a bad idea.
That's why the stall warning is a 'stick shaker', yoke forces go up, etc. An aural alert saying 'low airspeed' may not get through.
Perhaps the cricket/baseball bat isn't such a bad idea.
In some very high workload situations the majority of perceptual inputs could degrade as might the mental ability to understand the situation, including monitoring and other alerts. A key aspect of safety is being able to identify these situations beforehand, as early as possible; thus manufacturer, regulator, and operator involvement – not leave it to the crew who might be overloaded. The industry must stop relying on the crew to detect everybody else’s lack of foresight; crews are human and they are the ones attempting to manage all of these factors at the critical moment.
Automation is very useful, but if misused then problems might occur. The skill in design, regulation, and operation is to foresee possible misuses and mitigate the effects. Documentation, SOPs and warnings are the least effective, as might be training; thus every effort should be made to ensure that the system is as tolerant to misuse as possible. Without knowing the 777 in detail, the AT system appears less resilient than other AT systems; it might be more capable, but is it as safe – you should not trade one for the other.
Automation is very useful, but if misused then problems might occur. The skill in design, regulation, and operation is to foresee possible misuses and mitigate the effects. Documentation, SOPs and warnings are the least effective, as might be training; thus every effort should be made to ensure that the system is as tolerant to misuse as possible. Without knowing the 777 in detail, the AT system appears less resilient than other AT systems; it might be more capable, but is it as safe – you should not trade one for the other.
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not leave it to the crew who might be overloaded. The industry must stop relying on the crew to detect everybody else’s lack of foresight;
I also claim that this crew was far from "overloaded", they had good weather and perfectly well functioning aircraft. They were not dealing with multiple emergencies, malfunctioning equipment, smoke in the cabin, etc. and/or substandard weather. It is really a travesty to call it an 'overload' considering that many rookie pilots shoot similar approaches in much less capable aircraft every day and they don't enjoy benefit of additional sets of eyes in the cockpit.
Last edited by olasek; 16th Apr 2014 at 01:44.
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It sounds like Asiana won't be taking their medicine. Not until they modify their SOPs, training, standards & checking will they ever be a safe airline. Their face-saving, ignorant attitude will prove me right when they have their next crash.
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safetypee:
Very high workload ...
... such as a manual, day VFR approach to a long runway, good equipment, normal traffic and sequencing?
In a well-liked 20-year-old design type, proven by millions of landings?
Really?
In some very high workload situations the majority of perceptual inputs could degrade as might the mental ability to understand the situation, including monitoring and other alerts...
... such as a manual, day VFR approach to a long runway, good equipment, normal traffic and sequencing?
In a well-liked 20-year-old design type, proven by millions of landings?
Really?
I wholeheartedly agree with the sentiments re "they should have done/known better" but why would somebody deliberately design an ATS that would not stop the speed reducing below the bottom foot/Vref, regardless of the mode it was in? I can't see any logical reason.
Originally Posted by MarcK
Well, at some point they have to land. Or would you like them to run off the end of the runway at Vref?
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Twit. All ATS close the power to Idle at 50-30ft for the flare. What jet do you fly again
Twit...not the 'Bus..it calls "retard" the pilots closes the thrust levers..
Twit...not the 'Bus..it calls "retard" the pilots closes the thrust levers..
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Capn Bloggs:
Very well - it's such an excellent idea let's petition to make it a universal cert requirement (like throttles fwd for TO, etc.). And write AD's for retrofit too.
why would somebody deliberately design an ATS that would not stop the speed reducing below the bottom foot/Vref, regardless of the mode it was in? I can't see any logical reason.