NTSB update on Asiana 214
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LW_50 - Indeed not - it is, I think, simply designed to allow altitude change, but we know the crew was well confused with modes etc. as shown by the selection of it with a higher altitude selected BUT I still argue that msr would be a good idea whatever it is being used for.
No the function is as it says there for Flight Level Change. This was used several times in the NTSB questions.
(NTSB): Captain Cashman, why no auto thrust protection in flight level change mode?
(NTSB): Given that, the situation when the flight level changes and the autothrottle is on hold, do you consider that to be an error-tolerant design?
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Are we missing something?
What I miss in the NTSB report are remarks about the stall protection feature of the 777. Did it in this case work for them or against them?
If I am not mistaken the 777 has a feature that the closer you are to te stall speed the harder you have to pull the yoke. I think it stops trimming at a certain speed.
YES ik know they should have made a GA at 500ft and YES more things went wrong. BUT when I read this:
I have the feeling we are missing something.
I see the following scenario:
- Long flight, tired, wrong timezone, "your head says night, your eyes say way to bright".........recognize that feeling?
- Two pilots not comfortable with a visual. (NOT GOOD at ALL, but we all know those guys DO exist)
- Just before 500ft instead of adding the necessary power or making a GA the poor guy starts pulling the yoke. BUT why did he not notice the drop in airspeed?
Was it just:
Or was there more? Why was he not suffently monitoring the airspeed? And why did it take him so long to start doing that. Could it be that the protective system distracted him? He pulls. The speeds drops. He has to pull harder, this distracts him even further. Tunnel vision on the yoke..........situation out of control even further?
YES I know, without the feature he might have stalled the aircraft, but do we know that for sure? Was this optimal protection?
If I am not mistaken the 777 has a feature that the closer you are to te stall speed the harder you have to pull the yoke. I think it stops trimming at a certain speed.
YES ik know they should have made a GA at 500ft and YES more things went wrong. BUT when I read this:
As the airplane reached 500 ft above airport elevation, the point at which Asiana’s procedures dictated that the approach must be stabilized, the precision approach path indicator (PAPI) would have shown the flight crew that the airplane was slightly above the desired glidepath. Also, the airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 knots. However, the thrust levers were still at idle, and the descent rate was about 1,200 ft per minute, well above the descent rate of about 700 fpm needed to maintain the desired glidepath; these were two indications that the approach was not stabilized. Based on these two indications, the flight crew should have determined that the approach was unstabilized and initiated a go-around, but they did not do so. As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath; the PAPI displayed three and then four red lights, indicating the continuing descent below the glidepath. The decreasing trend in airspeed continued, and about 200 ft, the flight crew became aware of the low airspeed and low path conditions but did not initiate a go-around until the airplane was below 100 ft, at which point the airplane did not have the performance capability to accomplish a go-around. The flight crew’s insufficient monitoring of airspeed indications during the approach resulted from expectancy, increased workload, fatigue, and automation reliance.
I see the following scenario:
- Long flight, tired, wrong timezone, "your head says night, your eyes say way to bright".........recognize that feeling?
- Two pilots not comfortable with a visual. (NOT GOOD at ALL, but we all know those guys DO exist)
- Just before 500ft instead of adding the necessary power or making a GA the poor guy starts pulling the yoke. BUT why did he not notice the drop in airspeed?
Was it just:
The flight crew’s insufficient monitoring of airspeed indications during the approach resulted from expectancy, increased workload, fatigue, and automation reliance.
YES I know, without the feature he might have stalled the aircraft, but do we know that for sure? Was this optimal protection?
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SFO firefighters missed 'window of opportunity' to save girl - SFGate
A true tragedy and a miracle not a whole lot more people died. The pilots were not up to speed on that aircraft with anything out of the ordinary. The fire fighters should have removed the young girl from where she was, even if they thought she was dead, and brought her to a location where she could not be run over. Not once but twice. Even if they thought saving those who were alive were more important at that point in time.
Well meaning people (crew and firefighters) doing their job, but they mucked it up. They were not up to the task at hand.
A true tragedy and a miracle not a whole lot more people died. The pilots were not up to speed on that aircraft with anything out of the ordinary. The fire fighters should have removed the young girl from where she was, even if they thought she was dead, and brought her to a location where she could not be run over. Not once but twice. Even if they thought saving those who were alive were more important at that point in time.
Well meaning people (crew and firefighters) doing their job, but they mucked it up. They were not up to the task at hand.
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Originally Posted by Ian W
No the function is as it says there for Flight Level Change
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BOAC,
If you have not read it, here is an Australian investigation and report on a triple seven involving FLCH during approach to landing.
http://www.skybrary.aero/bookshelf/books/2298.pdf
If you have not read it, here is an Australian investigation and report on a triple seven involving FLCH during approach to landing.
http://www.skybrary.aero/bookshelf/books/2298.pdf
Turbine D, from the linked (and well presented) Australian report:
As our old NATOPS officer used to preach:
You have to know your systems inside and out.
This imperative is doubly true, IMO, when you are flying the trusting and paying public from one place to another.
One's ignorance can cost their lives as well as one's own.
Worldwide, errors associated with the use and management of automatic flight systems have been identified as causal factors in more than 20% of approach and landing accidents.
You have to know your systems inside and out.
This imperative is doubly true, IMO, when you are flying the trusting and paying public from one place to another.
One's ignorance can cost their lives as well as one's own.
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On the 737NG, FLCH is fine to use on approach. You can use it to descend to the platform altitude you capture the G/S from!
You usually find you can't get adequate descent while slowing down while vectoring towards an approach in VNAV PATH, so LVL CH is ideal to simplify things. It is indeed a pitch mode, the logic is that when you select it you get an aircraft that either descends on closed throttles or goes up in N1 climb.
It does not take much mental idea to work out what is going on. Simple types would have an IAS button and you move the levers to go up or down.
It works just the same.
In this mode, you have the speed window open so altering the speed alters pitch. slowing a 737NG down near up speed and it really doesn't go down much without the "Stick of Shame".
No idea about the 777, but common Boeing philosophy should apply to a mode so easy to use like this.
Why in god's sake these pilots were using this mode to descend on a final approach though is a different matter. Then again I can't grasp why airlines don't let pilots use the damn thrust levers either.
You usually find you can't get adequate descent while slowing down while vectoring towards an approach in VNAV PATH, so LVL CH is ideal to simplify things. It is indeed a pitch mode, the logic is that when you select it you get an aircraft that either descends on closed throttles or goes up in N1 climb.
It does not take much mental idea to work out what is going on. Simple types would have an IAS button and you move the levers to go up or down.
It works just the same.
In this mode, you have the speed window open so altering the speed alters pitch. slowing a 737NG down near up speed and it really doesn't go down much without the "Stick of Shame".
No idea about the 777, but common Boeing philosophy should apply to a mode so easy to use like this.
Why in god's sake these pilots were using this mode to descend on a final approach though is a different matter. Then again I can't grasp why airlines don't let pilots use the damn thrust levers either.
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TD - thanks but not relevant to my query. This was totally differnt 'event'. They were using A/P in FLCH, Asiana were not (at the end) and there was no mention of speed as it was never a problem.
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If I am not mistaken the 777 has a feature that the closer you are to te stall speed the harder you have to pull the yoke
Why was he not suffently monitoring the airspeed?
Did it in this case work for them or against them?
Last edited by porterhouse; 25th Jun 2014 at 19:08.
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Hello Porterhouse,
Your are probably right that I am missing some points on all that fly by wire stuff. I am flying the old lady with her old fashion cables.
And YES I ment THEY in stead of HE.
BUT is it an academic exercise?
When I look at the NTSB video. I see at 560 an aircraft on centre-line, on speed and on glide-path, with not enough thrust with a high rate of descent (although not dramatic). I dare to say this happens many times a day in the world, for several reasons. Most of those flights increase power and land normally. Some of them probably do that while knowing that the should have made GO-ARROUND because they were not stabilized at 500ft. A few of them might even have the same problem as the ASIANA guys but were saved by an AT, because that time they made other MCP selections.
I think it's quite interesting to try to find out WHY the Asiana guys did not increase power earlier.
Do you agree that the system must have kicked in?
I am not saying it was a contributing factor........I am just keeping the option open.
I don't agree with your remark about the weather. Weather we can't control........we can however control system design.
Your are probably right that I am missing some points on all that fly by wire stuff. I am flying the old lady with her old fashion cables.
And YES I ment THEY in stead of HE.
BUT is it an academic exercise?
When I look at the NTSB video. I see at 560 an aircraft on centre-line, on speed and on glide-path, with not enough thrust with a high rate of descent (although not dramatic). I dare to say this happens many times a day in the world, for several reasons. Most of those flights increase power and land normally. Some of them probably do that while knowing that the should have made GO-ARROUND because they were not stabilized at 500ft. A few of them might even have the same problem as the ASIANA guys but were saved by an AT, because that time they made other MCP selections.
I think it's quite interesting to try to find out WHY the Asiana guys did not increase power earlier.
Do you agree that the system must have kicked in?
I am not saying it was a contributing factor........I am just keeping the option open.
I don't agree with your remark about the weather. Weather we can't control........we can however control system design.
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Do you agree that the system must have kicked in?
If you fly an 'old lady with cables' nobody is pushing throttle for you, you must do it.
If you fly with AT it is your basic duty to monitor what AT is doing - if it is not doing what's supposed to do (say it is broken or failed or computer failed, etc) you must do it manually. Pilots must be able to handle adverse scenarios, if a pilot is surprised that AT did not do something for him and he crashed - that's epitome of stupidity and dereliction of duty. Reagan used to say during nuclear arms negotiation with USSR his famous "trust and verify", it applies to flying too.
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@porterhouse
I am not talking about the AT.
Did you read my post?
I am talking about the steering column.
You need to pull harder the closer you get to the stall speed.
I understand this is a feature of the 777.
I think it stops/adjusts the trim(rate) at a certain speed.
Any 777 pilots around?
I am not talking about the AT.
Did you read my post?
I am talking about the steering column.
You need to pull harder the closer you get to the stall speed.
I understand this is a feature of the 777.
I think it stops/adjusts the trim(rate) at a certain speed.
Any 777 pilots around?
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You need to pull harder the closer you get to the stall speed.
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@olasek
Do you have link of the post?
Was also discussed what happens to your brain, when you are pulling 40kg?
Specially when this al happens in matter of seconds? From 560 ft to the ground in 30seconds?
Do you have link of the post?
Was also discussed what happens to your brain, when you are pulling 40kg?
Specially when this al happens in matter of seconds? From 560 ft to the ground in 30seconds?
Pilot error … Automation Dependency or Pilot Dependency
‘it is not required for certification’; correct, but any installed system has to operate as intended (described, trained for, and operational expectation), and must enable the crew to manage errors resulting from interactions that can be reasonably expected in service. CS25.1302 and CS AMC.1302, which is one of the few requirements where the FAA and EASA did not initially use similar (same) text; however both the FAA and Boeing were significant contributors to the drafting of CS25.1302
‘… qualified flight-crew members trained in its use can safely perform their tasks associated with its intended function by meeting the following requirements:
… enable flight crew awareness, if awareness is required for safe operation, of the effects on the aeroplane or systems resulting from flight crew actions.
Operationally-relevant behaviour of the installed equipment must be:
Predictable and unambiguous, and
Designed to enable the flight crew to intervene in a manner appropriate to the task.
To the extent practicable, installed equipment must enable the flight crew to manage errors resulting from the kinds of flight crew interactions with the equipment that can be reasonably expected in service, assuming the flight crew is acting in good faith.’
Thus as much as some posts wish to cite pilot error, consider where the error originated?
The NTSB’s Probable Cause wording has been chosen carefully. Although aspects of the flight were mismanaged there is no explanation of how or why the automatic speed system was ‘unintentionally deactivated’ – unintentional is one view of error. Neither is there any consideration of the airspeed display being adequate for monitoring in these circumstances – cf many other poor speed awareness incidents.
The references to system description and training bias judgement of CS25.1302 in this accident towards the expectation that will pilots are expected to detect errors (cf other 777 incidents). This pilot dependency could a significant problem where automation is assumed to reduced training requirements, - less ability to detect error, reduced system knowledge / experience, and particularly so where automation is used in increasing complex operational environments.
The alternative interpretation is that manufacturers and regulators (and the industry at large) should improve equipment tolerance to error and balance the assumptions made about crew interface with automation in the changing operational and social environment; this assumes that automation weaknesses cannot be rectified in a suitable timescale.
The issue here is the balanced judgement of the requirements, who makes the judgement, what assumptions are in the judgement, and if these assumptions are published for operator / crew awareness.
‘… qualified flight-crew members trained in its use can safely perform their tasks associated with its intended function by meeting the following requirements:
… enable flight crew awareness, if awareness is required for safe operation, of the effects on the aeroplane or systems resulting from flight crew actions.
Operationally-relevant behaviour of the installed equipment must be:
Predictable and unambiguous, and
Designed to enable the flight crew to intervene in a manner appropriate to the task.
To the extent practicable, installed equipment must enable the flight crew to manage errors resulting from the kinds of flight crew interactions with the equipment that can be reasonably expected in service, assuming the flight crew is acting in good faith.’
Thus as much as some posts wish to cite pilot error, consider where the error originated?
The NTSB’s Probable Cause wording has been chosen carefully. Although aspects of the flight were mismanaged there is no explanation of how or why the automatic speed system was ‘unintentionally deactivated’ – unintentional is one view of error. Neither is there any consideration of the airspeed display being adequate for monitoring in these circumstances – cf many other poor speed awareness incidents.
The references to system description and training bias judgement of CS25.1302 in this accident towards the expectation that will pilots are expected to detect errors (cf other 777 incidents). This pilot dependency could a significant problem where automation is assumed to reduced training requirements, - less ability to detect error, reduced system knowledge / experience, and particularly so where automation is used in increasing complex operational environments.
The alternative interpretation is that manufacturers and regulators (and the industry at large) should improve equipment tolerance to error and balance the assumptions made about crew interface with automation in the changing operational and social environment; this assumes that automation weaknesses cannot be rectified in a suitable timescale.
The issue here is the balanced judgement of the requirements, who makes the judgement, what assumptions are in the judgement, and if these assumptions are published for operator / crew awareness.
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@olasek
Found it.
Did it cross your mind, that maybe because HE/THEY were eventually pulling 40kg they had zero reaction?
Did the system work for them or against them? Are you sure you can give an answer to that question?
I can't.
Found it.
They had absolutely zero reaction to the fact that they were pulling on the yoke by about 40 kg!!!! and you tell me that a lousy EICAS msg would change their awareness - you are in a dreamland.
Did the system work for them or against them? Are you sure you can give an answer to that question?
I can't.
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that maybe because HE/THEY were eventually pulling 40kg they had zero raction?
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@olasek
How do you know he considered it normal?
I bet he was fighting for his live because for some reason he ended up in situation were he did not wanted to end-up in.
You must be an ace. Lot of aces end up the same way as this guy did.
You did not answer my question.
Did the system work for him or against him?
My bet is that it distracted him more than it did good.
I would love to hear an opinion on this by some smart NTSB guys. Maybe aviation can learn something from it.
How do you know he considered it normal?
I bet he was fighting for his live because for some reason he ended up in situation were he did not wanted to end-up in.
You must be an ace. Lot of aces end up the same way as this guy did.
You did not answer my question.
Did the system work for him or against him?
My bet is that it distracted him more than it did good.
I would love to hear an opinion on this by some smart NTSB guys. Maybe aviation can learn something from it.
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Safetypee
As usual your psychobabble to make excuses for the pilot and how the A/C system let him down. The A/THR hold mode may be a "trap" but as a PILOT you still have to FLY your aircraft.
It was an 8/8 blue day and all he had to do was look out the window and see he was about to land almost a mile short of his aim point and DO something about it. Runway aspect is taught in initial training and practiced many times. If you then cannot recognise you are well below the normal flight path with 4 reds as well, even though you will have monitored the A/P fly an ILS many many times, giving the ideal glidepath, then you have NO place on the flight deck of a commercial aircraft! This was BASIC piloting skills and a complete lack of them was being shown by the PF and the monitoring "Training" Captain.
The excuse of coming from the Airbus with no moving throttles, does not hold out either. If the A/THR in the "bus" does not keep the speed as you would like it, guess what you can MOVE them and many an Airbus pilot has done.
As usual your psychobabble to make excuses for the pilot and how the A/C system let him down. The A/THR hold mode may be a "trap" but as a PILOT you still have to FLY your aircraft.
It was an 8/8 blue day and all he had to do was look out the window and see he was about to land almost a mile short of his aim point and DO something about it. Runway aspect is taught in initial training and practiced many times. If you then cannot recognise you are well below the normal flight path with 4 reds as well, even though you will have monitored the A/P fly an ILS many many times, giving the ideal glidepath, then you have NO place on the flight deck of a commercial aircraft! This was BASIC piloting skills and a complete lack of them was being shown by the PF and the monitoring "Training" Captain.
The excuse of coming from the Airbus with no moving throttles, does not hold out either. If the A/THR in the "bus" does not keep the speed as you would like it, guess what you can MOVE them and many an Airbus pilot has done.