NTSB update on Asiana 214

[bubbers44]

Excuse me, but -
"...raised the possibility that a key device that ASSISTS THE PILOT IN CONTROLLING the Boeing 777’s speed may have malfunctioned."

I would agree on that statement and that would be the brain.

[flarepilot]

if you had a pilot directed to manipulate the thrust levers to maintain Vref plus 5 and a proper descent rate, and he or she DID NOT MAINTAIN SPEED, at least we would hope the OTHER PILOT would notice and do something about it (other than crash).

so too the automation...direct it to hold speed and if it doesn't do so, DO SOMETHING ABOUT IT other than let it crash.

[Desert185]

if you had a pilot directed to manipulate the thrust levers to maintain Vref plus 5 and a proper descent rate, and he or she DID NOT MAINTAIN SPEED, at least we would hope the OTHER PILOT would notice and do something about it (other than crash).

so too the automation...direct it to hold speed and if it doesn't do so, DO SOMETHING ABOUT IT other than let it crash.

There are some days you just have to be a pilot. On that day, the redundancy of having two (in reality three) pilots in the cockpit/flightdeck/whatever failed. Really incredible failure points, considering that level of the profession.

[sandiego89]

rottenray, bravo for your efforts in post #23 of (hopefully) curtailing a harmfull poster. Agree 100%. Well put.

[220mph]

Originally Posted by Sir Richard

This appears to be pure speculation by the "ambulance chaser" acting for the family. I wonder where he gets his "information" from?

Quote:
"Fire department personnel knew she was on the ground, yet they didn't carry her to safety, Tarricone said. Her injuries and her position on the ground show it was unlikely she was ejected from the plane, and her family believes another firefighter carried her off the jet and then left her on the ground, he said.

"We know that several firefighters saw her and knew she was there before she was covered with foam," Tarricone said. "They inexplicably abandoned her."

I suggest you, and others, do a little research before making these kind of attacks. Those comments are directly from a number of different sources and media reports made at the time of the incident.

I did a detailed review of media comments and available photos etc., along with a detailed review and analysis of the amateur video that captured the incident from almost the moment the aircraft came to rest, thru the next 20 minutes or so.

I noted the possibility of a casualty before it was getting much media - based on evidence in the early scene photos, which speculation sadly turned out to be true.

I was highly critical of the emergency response - which was disjointed and uncoordinated ... with firefighters seemingly unprepared for a major incident response. The equipment was poorly positioned, and key equipment (ie: foam booms) either unused or unworkable.

The firefighters clearly had no plan on fighting a fire in a round fuselage - instead of deploying booms (several clearly broken) to spray down into the fire they simply - and ineffectively - emptied whole tankers of foam shooting OVER the top of the fuselage.

The tapes and photos show the girl run over was NOT in that location during the evacuation. She was not placed there until long after the evacuation. They also show firefighters were on scene - the same truck - for many minutes - with a clear view of the spot the girl was placed - and that there was no significant amount of foam deployed there, other than on the isolated engine pylon area, until many minutes later - after the pax evaced and the fuselage became fully involved in fire.

Media and other reports showed the firefighter who ran over the girl had been picking up lunch when the crash occurred, and that she jumped into a truck solo - with no spotter, proceeded to the incident and ran over the girl.

Other reports indicated firefighters had placed the girl there, and for some reason they had determined she was deceased - which was clearly not true. Whether accurate or not, there is NO excuse for abandoning a victim - deceased or not - in harms way, as here.

Helmet cams on firefighters confirmed many of these facts. The SFO Fire Dept responded by banning personal video devices, despite that this incident was well on its way to being covered up before the personal video surfaced.

My opinion, based on hours of review of the video, the photos and numerous reports - is that had their been fire onboard earlier the majority of pax would have perished - in large part a result of the fire response.

Keep in mind as well that nearly 20 minutes after the crash survivors who had run toward approach end of runway, and found the seriously injured crew along the way, had to repeatedly call 911 and beg for emergency responders.

And that we saw media reports that noted ambulances and other responders had been held for a significant time unable to access the field. Which a review of the amateur video confirms - a LARGE contingent of emergency vehicles can be seen to respond in mass, some 15 minutes or so after the crash.

Here are the several posts I wrote originally on this incident including the detailed timeline review and supporting documentation:

http://www.pprune.org/rumours-news/5...ml#post7937757

http://www.pprune.org/rumours-news/5...ml#post7939704

http://www.pprune.org/rumours-news/5...ml#post7951640

http://www.pprune.org/rumours-news/5...ml#post7951724

http://www.pprune.org/safety-crm-qa-...ml#post8001903

http://www.pprune.org/safety-crm-qa-...ml#post8001940

Please read these. They show at minimum, the criticism is entirely appropriate. I would also note in direct response to 'Sir Richard' and his ignorant and offensive "ambulance chaser" comment ... that the counsel for the girls family appears to be acting in the highest professional manner. I would note in the LVRJ article on no criminal charges, rather than rhetoric and accusations this same attorney stated: “It’s really not the subject of criminal prosecution ... It’s properly the subject of civil action."

Those are the actions of a professional and ethical attorney -the opposite of those who employ "ambulance chaser" name-calling.

I would also note I am usually a strong supporter of law enforcement and emergency responders, however, this incident demands thorough review and accountability, and the SFO FD officials responses to date have been IMO anything but professional.

[220mph]

Originally Posted by ironbutt57

WHBM.....the "gung ho" fire truck driver couldnt see the victim as foam from another vehicle had covered her apparently....before you open your stupid trap and criticise people think about it and put yourself in their place...

"Gung ho" is an exactly correct description of the fire truck driver based on what we have heard reported about her actions that day. It is not a personal condemnation of her but an accurate description of her actions.

Just as criticisms of the fire dept response are not personal either - but fair criticism of their actions and the departments plan and training.

And "put yourself in their place" should NEVER be a consideration, or any part of a professional and competent review of these actions.

The Fire departments actions that day clearly IMO failed. It is clear from a myriad of sources and information they failed. They failed to prevent the aircraft from becoming fully engulfed in fire - which did not occur until more than 15 minutes after the crash. They failed to respond to the entire crash scene - failing to reach critically injured people near the tail section for nearly 20 minutes. And they grossly and critically failed to protect the life of a survivor of a major aircraft disaster - directly causing her death.

They did NOT drop her in foam. There was no foam there until very late in the incident. Had they simply insured she got to the safe triage area - not far away, she would have survived. Even if they thought she was deceased that should have been their proper action.

[woodyspooney]

Sorry if I am digressing but every time I discuss this accident with others, the issue of the FLCH trap comes up. I can really tell you what's wrong with Asiana Training. I am retired for some 6 years now but when I was east in kimchiland years ago, the initial training in KAL and OZ were done by Alteon. I had never heard about the FLCH trap from any of the Alteon blokes!

I was only made aware of this FLCH trap during my OE training by a South East Asian Chinese guy who had initial training with actual Boeing factory pilots. During my 5 years over in ICN, I never had anyone re highlighting that! Sure, we did a lot of automation degradation. We had too many non rated Alteon guys who became T7 instructors who became 777 experts after a fortnight of conversion training! 757 guys, MD 11 guys who think that the T7 is a bloated B737. These Alteon blokes are there to satisfy some vague requirements, fail some guys occasionally to put fear ( fear based management technics ) and show that the system is " working "!

I read somewhere that it is only now that OZ is reviewing some of the stuff taught at their Training Center. The word I heard is that they are telling pilots that the T7 autothrottle system is faulty instead of teaching them real understanding of its logic and algorithms. OZ is not training pilots but dunces

[Escape Path]

I'm sorry if I come up too "jumpy" on the crew, but this accident is rubbish and IMO any attempt to cover up the crew's blatant mistakes is rubbish too. As others have said, it was properly functioning aircraft, on a visual approach and on a beautiful day. How the hell did they miss so many cues and just basically sitting there and watching the aircraft crash?

I just wonder how did we manage to fly 40 years ago without having a major airliner crash every week!

[Centaurus]

How the hell did they miss so many cues and just basically sitting there and watching the aircraft crash?

The pilots didn't miss the cues. The cues were obvious all the way down the flight path but were ignored. The answer to your question is in the blind culture of the operator and similar operators in that region, where protection against loss of face is considered a higher priority over airmanship and flight safety common sense. It is not as if this event was just an isolated case.

[roulishollandais]

Originally Posted by Centaurus

in that region, where protection against loss of face is considered a higher priority over airmanship and flight safety common sense

These pilots lost their faces in SFO! Airmanship would have avoid that shame.

[ratarsedagain]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.

[FullWings]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.

Or, even more accurately, it can happen any time the A/T is not in SPD.

[RAT 5]

"FLCH trap"
More accurately, it is an Autothrottle 'HOLD' trap, as it can happen any time the the A/T goes into HOLD mode, with the A/P disengaged.

Or, even more accurately, it can happen any time the A/T is not in SPD.

Or even more importantly it can happen anytime the sharp end jet jockeys are not in PILOT mode.

[Wizofoz]

Or, even more accurately, it can happen any time the A/T is not in SPD.

Not so- A/T wake up is available in any A/T mode (including disengaged) except HOLD.

[Cows getting bigger]

Has the system led pilots up the garden path? From the educated comments on this thread, there seems to be an awful lot of (semi) automated modes in today's airliners. Does it really need to be that complicated in order to meet the Power + Attitude = Performance mantra?

[Al Murdoch]

Can someone remind me - why does Boeing want the A/T left engaged on the 777? I remember this being discussed somewhere but can't find it now.
My personal view is that I feel far more on top of what's happening with it disengaged, but it seems that this has been deemed unacceptable by someone, somewhere. If I'm honest, my speed awareness is definitely degraded as a result of this.

[RAT 5]

But.... if there is a trap here, and it a known trap - at least the trainers who've posted on here know about it - why do not ALL crews know about it? Is it not highlighted in FCOM 2? Have the airline training departments not caught on to it an issued chapter & verse on the trap? And how did the FAA/JAA et all certify it without that information being understood throughout the pilot community? Likely more questions than answers.
And if it is true on B777 is it also true on B787? and any other types of other manufacturers out there? Could this be the hidden trap-door to a smoking hole? They were damn lucky. If this had been an inferno with no survivors I suspect the reaction would have been much more loud and vigorous than it has been up to now. So far it has mostly been about lack of pilot reaction. They all survived the prang, but the inferno outcome would have caused much more technical furore, after not doubt much head scratching.

[Cows getting bigger]

There is a good discussion here about a helicopter which seems to have achieved something remarkably similar to the Asiana. There is also the relatively recent UPS cargo crash at Birmingham and of course AF447.

Call me a bluff old traditionalist, but I'm sort of seeing a trend.

[747newguy]

Those little girls would not have been in that field if the pilots had not put them there. The rescue crews were trying to do the best they could with what they had. I'm sure that driver didn't have two other drivers behind him monitoring his actions and another in 1st class hanging out...

[topgas]

I have the greatest of respect for all the emergency services. When something like the unfortunate running over of a potential survivor happens, it is simplistic to blame it on the driver. I hesitate to talk about Human Factors on a professional pilots forum, but they come into play here
- she was away from the station when the shout came in
- finding the station empty, she took the reserve machine to the scene (presumably with ATC permission)
- she arrived at the incident with little or no situational awareness and presumably without direction from the incident controller
- the incident scene itself sounds like it was still in the initial response stage and had not developed into an organised site (command post, triage area, etc)

All these points have the potential for human factors failings (system failure), like did she have a radio while she was away, was she requested to bring the reserve machine, was there a reporting point at the scene, and I'm sure they will have all been addressed internally. I feel for the driver, she used her initiative in a rapidly evolving scenario, and had it panned out differently, her bringing another machine may well have saved lives.

I've been involved in Major Incidents, and even the best Major Incident plans can't cover every possibility