NTSB update on Asiana 214
BOAC, as a fare paying pax, I must say that I have no time for pilots who, when twenty knots slow on final approach with a full plane of pax, remain in the "pull on their own yokes" mode rather than make a correction to their approach.
If you were ever 20 knots slow on final would you have passed the check ride?
No. Why?
At the risk of boring our audience here, the pilot's check ride is executed to determine if you are fit to be in charge of flying the airplane (and nowadays, making sure your many systems fly the airplane in support of your efforts), in accordance with standards.
30+ knots slow in final (37, IIRC from the report) is so far beyond standards as to begger belief. It amazes me that apologists are still cropping up on a Professional Pilot's forum, and where professional pilots contribute, professional pilots who day in and day out bring people safely to their destinations by flying to standards.
As fare paying pax, it is not too much to ask that the pilots fly to standards, and that the company offering the seats for a payment of money ensures same.
If you were ever 20 knots slow on final would you have passed the check ride?
No. Why?
At the risk of boring our audience here, the pilot's check ride is executed to determine if you are fit to be in charge of flying the airplane (and nowadays, making sure your many systems fly the airplane in support of your efforts), in accordance with standards.
30+ knots slow in final (37, IIRC from the report) is so far beyond standards as to begger belief. It amazes me that apologists are still cropping up on a Professional Pilot's forum, and where professional pilots contribute, professional pilots who day in and day out bring people safely to their destinations by flying to standards.
As fare paying pax, it is not too much to ask that the pilots fly to standards, and that the company offering the seats for a payment of money ensures same.
Thread Starter
This comes down to not knowing how the systems works (A/P and A/T), not following your own company's SOP, having a check pilot obviously not doing his job properly and ultimately a Captain trained on the B777 that can't fly his aircraft on a VFR day on a visual approach to a runway without the assistance of auto flight, in other words, manually.
@ DaveReidUK...
Oh pleeease!
Yes Boeing could have made their understanding of the system better in their manuals and did a better job at it on the 787...
However the fact remains and the bottom line is that this crew (3 of them in the cockpit) and in particular the PF/captain screwed up big time.
- He may have thought the A/T would "save" him but he did not understand the system and it came back and bit him.
- Fact, they did not even follow company SOPs
- Fact, he selected a higher altitude in the preselect which in FLC mode will try to climb (and add power) to that selected altitude. This is not a B777 only FLC mode of operation, it works that way in many aircrafts.
- Fact, even after A/T and A/P disconnect he couldn't fly the aircraft of a prescribed track, laterally and most importantly vertically.
Fact, the PF did not even notice the increase in pitch attitude while looking outside.
Fact, when the speed bleed way below the calculated Vref and was heading towards a stall, he did not even notice the increase in back pressure required to keep the aircraft from continuing its descent below G/S, up to 100 lbs back pressure at one point!
Some of you guys would like to blame SFO ATC, some of you guys would like to blame Boeing (and yes their manual should be better written), but in the end it was the PF's responsibility to get that aircraft down safely and he did not to his job.
Yes Boeing could have made their understanding of the system better in their manuals and did a better job at it on the 787...
However the fact remains and the bottom line is that this crew (3 of them in the cockpit) and in particular the PF/captain screwed up big time.
- He may have thought the A/T would "save" him but he did not understand the system and it came back and bit him.
- Fact, they did not even follow company SOPs
- Fact, he selected a higher altitude in the preselect which in FLC mode will try to climb (and add power) to that selected altitude. This is not a B777 only FLC mode of operation, it works that way in many aircrafts.
- Fact, even after A/T and A/P disconnect he couldn't fly the aircraft of a prescribed track, laterally and most importantly vertically.
Fact, the PF did not even notice the increase in pitch attitude while looking outside.
Fact, when the speed bleed way below the calculated Vref and was heading towards a stall, he did not even notice the increase in back pressure required to keep the aircraft from continuing its descent below G/S, up to 100 lbs back pressure at one point!
Some of you guys would like to blame SFO ATC, some of you guys would like to blame Boeing (and yes their manual should be better written), but in the end it was the PF's responsibility to get that aircraft down safely and he did not to his job.
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Fact, the PF did not even notice the increase in pitch attitude while looking outside.
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I agree with fast cruiser and others who share the view.
BUT for those who insist the gadgets are to blame, a question: We depend on gadgets like engines to keep planes flying, but we train for engine failure and can handle it. Even an ALL Engine failure we can handle. ARE WE SAYING that we (the pilots of asiana have already proven they can't) can't handle a failure of a gadget like an autothrottle?
If the pilots were the president of the united states, I would be calling for impeachment.
BUT for those who insist the gadgets are to blame, a question: We depend on gadgets like engines to keep planes flying, but we train for engine failure and can handle it. Even an ALL Engine failure we can handle. ARE WE SAYING that we (the pilots of asiana have already proven they can't) can't handle a failure of a gadget like an autothrottle?
If the pilots were the president of the united states, I would be calling for impeachment.
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I'm really not quite sure what fault 'all the above' are finding in my recent posts. I am on record here for considering the TC and the Line Captain (u/t) incompetent and the F/O of unknown questionable competence. I am not arguing against that.
The question I asked in #758 has not been answered, apart from Capt B who posed further questions.
I will re-phrase in the hope we can get some sensible answers.
Why, when we know that pilot skills are at probably the lowest point for decades, does a manufacturer take away a 'protection' - so as not to 'spoil' the 'choices' of a crew to crash an aircraft? What would have been wrong if the A/T had cut in and applied power as they sank into oblivion?
'All the above' (well, most) are calling for 'better pilots' as the solution. Wake up. Smell that coffee. You are NOT going to get that solution quickly or easily. Best come up with a different solution?
For glendalegoon
- heard of THY at AMS maybe?
The question I asked in #758 has not been answered, apart from Capt B who posed further questions.
I will re-phrase in the hope we can get some sensible answers.
Why, when we know that pilot skills are at probably the lowest point for decades, does a manufacturer take away a 'protection' - so as not to 'spoil' the 'choices' of a crew to crash an aircraft? What would have been wrong if the A/T had cut in and applied power as they sank into oblivion?
'All the above' (well, most) are calling for 'better pilots' as the solution. Wake up. Smell that coffee. You are NOT going to get that solution quickly or easily. Best come up with a different solution?
For glendalegoon
can't handle a failure of a gadget like an autothrottle?
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does a manufacturer take away a 'protection' -
As to your original question I suggest you google "Pilot Authority and Aircraft Protections", an elaborate 50+ pages analysis of what aircraft envelope protection should and shouldn't be written by some captain who is on a certification committee and prepared by ALPA. If this fails I suggest you go directly to Boeing.
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From the information that has been published and discussed over many months given it does seem an accident contributed to by a crew not monitoring the performance of the ac/; assuming that an automatic system would safe-guard the performance and not being ready/aware to take over manually when the performance was compromised.
I have not read the NTSB report, but some here seem to suggest they have a slightly different slant on the event. Hm! I remember when AA stuffed a B757 into the mountains near Cali with the speed brake still deployed during an EGPWS escape manoeuvre. They blamed Boeing for not having an auto-retract on the speed brakes when TOGA is pushed in the air. (Has it ever been rectified? as per the NTSB recommendation?) They blamed Jepesson for having the wrong 'R' wpt as the first on the FMC legs page. That seemed like another slam-dunk crew screw up for multiple reasons. Why is it so difficult to say so?
OK, they can try to learn from the screw ups and redesign the a/c & SOP's etc to mitigate against a repeat, but ultimately if the human at the coal face screws up as the primary cause then why not say so? It could be engineering, ATC, the company attitude or the pilots' actions (or lack of), but is it not better to be honest with the root cause and then the best solution for future prevention can be found? If there is a technical hidden gotcha, as there seems to be here, then OK, let them design it better, but surely the predominant root cause should always be front and centre and not brushed under the carpet.
Maybe, having not read the NTSB comments, I stand to be corrected. if so, then I accept it.
I have not read the NTSB report, but some here seem to suggest they have a slightly different slant on the event. Hm! I remember when AA stuffed a B757 into the mountains near Cali with the speed brake still deployed during an EGPWS escape manoeuvre. They blamed Boeing for not having an auto-retract on the speed brakes when TOGA is pushed in the air. (Has it ever been rectified? as per the NTSB recommendation?) They blamed Jepesson for having the wrong 'R' wpt as the first on the FMC legs page. That seemed like another slam-dunk crew screw up for multiple reasons. Why is it so difficult to say so?
OK, they can try to learn from the screw ups and redesign the a/c & SOP's etc to mitigate against a repeat, but ultimately if the human at the coal face screws up as the primary cause then why not say so? It could be engineering, ATC, the company attitude or the pilots' actions (or lack of), but is it not better to be honest with the root cause and then the best solution for future prevention can be found? If there is a technical hidden gotcha, as there seems to be here, then OK, let them design it better, but surely the predominant root cause should always be front and centre and not brushed under the carpet.
Maybe, having not read the NTSB comments, I stand to be corrected. if so, then I accept it.
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Total Pilot(s) error...
Way beyond pilot error. It applies to every air carrier, and aviation agency world wide on the 6 continents that subvert the requirement of pilots demonstrating the basic four fundamentals of flight with manual flight without any automation whatsoever other than the grey matter between their ears.
Passenger on the jets as well as the innocent people on the ground above the flight path deserve better.
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So, in short, none of the 'experts' here know why min speed reversion in that FLCH mode was not incorporated. That's worrying.
I have looked at all(54) pages in olasek's reference and the author appears to support the option for crew to deliberately stall a 777 on finals if they 'wish'.
God help us all.
I have looked at all(54) pages in olasek's reference and the author appears to support the option for crew to deliberately stall a 777 on finals if they 'wish'.
God help us all.
BOAC, the design is a couple of decades old.
First flight 1994
First used by United Airlines 1995.
You assert something taken away with over twenty years of foresight into the state of pilot hand flying skills / proficiency today. You may wish to compare the date of final design approval for the 777 with the issuance of the lecture/video on The Children of the Magenta Line. I think the former prededed the latter. (IIRC, COTML was produced in 1998)
(Snarky aside: In any event, I doubt if management gave bloodyforkall about such man to machine interface details at various airlines ... )
Even if you didn't mean that, no problem, but t's how it came off.
First flight 1994
First used by United Airlines 1995.
You assert something taken away with over twenty years of foresight into the state of pilot hand flying skills / proficiency today. You may wish to compare the date of final design approval for the 777 with the issuance of the lecture/video on The Children of the Magenta Line. I think the former prededed the latter. (IIRC, COTML was produced in 1998)
(Snarky aside: In any event, I doubt if management gave bloodyforkall about such man to machine interface details at various airlines ... )
Even if you didn't mean that, no problem, but t's how it came off.
BOAC, the A/T was put in HOLD. Since the A/T can't read the pilots mind, it has to assume that was intentional.
Are you really advocating an A/T that can unilaterally apply thrust, even when the pilot has commanded it not to? What if there was an issue with unreliable airspeed (been known to happen), do you want the A/T to firewall the throttles against the pilots wishes to maintain the erroneous airspeed during landing? Boeing design philosophy says the pilot has the final say.
As an aside, I'm not a pilot, but I am a driver - and sometimes a race driver. As an experience driver, coming into corner I can evaluate my speed relative to what would be an 'appropriate' speed for that corner and adjust my speed accordingly (without using a speedometer). Shouldn't an experienced professional pilot be able to do the same thing while landing on a beautiful summer day? Or is that an invalid comparison?
Are you really advocating an A/T that can unilaterally apply thrust, even when the pilot has commanded it not to? What if there was an issue with unreliable airspeed (been known to happen), do you want the A/T to firewall the throttles against the pilots wishes to maintain the erroneous airspeed during landing? Boeing design philosophy says the pilot has the final say.
As an aside, I'm not a pilot, but I am a driver - and sometimes a race driver. As an experience driver, coming into corner I can evaluate my speed relative to what would be an 'appropriate' speed for that corner and adjust my speed accordingly (without using a speedometer). Shouldn't an experienced professional pilot be able to do the same thing while landing on a beautiful summer day? Or is that an invalid comparison?
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I am familiar with the thys at ams.
the animation says it all.
I get mad at myself if I get 5 knots slow. I mean really mad and it doesn't happen often. But this pilot got 34 knots slow. animation is interesting, esp that after full power they accelerated by 2 knots!
dear race car driver. a pilot can perceive speed in many ways, the airspeed indicator is the most important. but sometimes your eyes are not on the airspeed indicator (SHAME ON THEM). There is a gadget called a stick shaker which physically shakes the control wheel to WAKE UP a pilot. Stick shaker at the least should make you LOOK AT THE AIRSPEED INDICATOR and add thrust unless the stick shaker has fired off in error. It is an electric motor mounted eccentrically to vibrate things to wake you up.
In older planes the controls would shake and you would feel it, but with computers and hydraulics between the wheel and the controls something artificial had to be added.
Clearly, these pilots were not top of their class.
the animation says it all.
I get mad at myself if I get 5 knots slow. I mean really mad and it doesn't happen often. But this pilot got 34 knots slow. animation is interesting, esp that after full power they accelerated by 2 knots!
dear race car driver. a pilot can perceive speed in many ways, the airspeed indicator is the most important. but sometimes your eyes are not on the airspeed indicator (SHAME ON THEM). There is a gadget called a stick shaker which physically shakes the control wheel to WAKE UP a pilot. Stick shaker at the least should make you LOOK AT THE AIRSPEED INDICATOR and add thrust unless the stick shaker has fired off in error. It is an electric motor mounted eccentrically to vibrate things to wake you up.
In older planes the controls would shake and you would feel it, but with computers and hydraulics between the wheel and the controls something artificial had to be added.
Clearly, these pilots were not top of their class.
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Originally Posted by tdracer
Are you really advocating an A/T that can unilaterally apply thrust, even when the pilot has commanded it not to? What if there was an issue with unreliable airspeed (been known to happen), do you want the A/T to firewall the throttles against the pilots wishes to maintain the erroneous airspeed during landing? Boeing design philosophy says the pilot has the final say.
As an aside, I'm not a pilot,
As an aside, I'm not a pilot,
All this anxiety about 'what to do with a rogue A/T" - turn the ***** off!
I'm still waiting for the logic in removing msr from this mode. I hear "the pilots need the choice" - well, they plainly are not up to it, are they?
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"why min speed reversion in that FLCH mode was not incorporated"
Below from the NTSB transcript. Sorry about the all caps and typos, that is how it was transcribed.
DID BOEING CONSIDER PUTTING ON AN AUTOMATIC AUTOTHROTTLE ACTIVATION AT A MINIMUM SPEED, REGARDLESS OF THE STATUS OF THE MODES?
(John Cashman, former Boeing chief test pilot during 777 development): WE CERTAINLY ALWAYS LOOK AT POSSIBILITIES. THE MAIN PROBLEM WITH THAT GOES BACK TO THAT ORIGINAL PHILOSOPHY -- NOT CHANGING MODES AND AUTOPILOT THAT THE PILOT IS NOT COMMAND. WHAT WOULD HAPPEN IF YOU JUST ACTIVATED THE THROTTLE IS YOU WOULD HAVE TWO CONTROLLERS OF ONE PARAMETER. THE AUTOPILOT WOULD BE CONTROLLING SPEED BY PITCHING, AND THE AUTOTHROTTLE WOULD BE CONTROLLING SPEED BY CHANGING THRUST. IT DOES NOT WORK FOR A WELL, SO YOU HAVE TO MAKE A MODE CHANGE, BUT THE AUTOPILOT IN A DIFFERENT CONTROL MODE, AND/OR THE TRUST. IT IS DIFFICULT TO DO, AND IT WAS VIOLATING ONE OF OUR FUNDAMENTAL FIND CONCEPTS.
>> CAPTAIN CASHMAN, YOU TALK ABOUT AUTOTHROTTLE WAKE UP. ISN'T THE ISSUE OF AUTOTHROTTLE FOR PROTECTION?
>> THE ENVELOPE PROTECTION OF THE AUTO ENGAGE OR WAKE-UP FUNCTION IS AN ELEMENT OF THE STALL PROTECTION, BUT IT IS NOT THE STALL PROTECTION SYSTEM. IN OTHER WORDS, IT IS RELATED TO OPERATION WHEN THE AUTOTHROTTLE IS TURNED OFF OR HAS BEEN DISENGAGED INADVERTENTLY OR A FAILURE TO DROP IT OFF, THAT IT WILL ENGAGE ITSELF. IT IS NOT A FUNCTION THAT IF THE AUTOTHROTTLE IS ALREADY IN ANOTHER MODE, IT WILL CHANGE THE MODE AND DO SOMETHING TO CONTROL SPEED. IT WAS REALLY THERE TO COME ALIVE AND ENGAGE ITSELF WHEN A HAD BEEN SELECTED OFF.
>> CAPTAIN CASHMAN, WHY NO AUTO THRUST PROTECTION IN -- MODE?
>> THE AUTOTHROTTLE PROTECTION FEATURE OR WAKE-UP FEATURE IS ONLY WHEN THE AUTOTHROTTLE IS TURNED OFF. IN A FLIGHT LEVEL CHANGE MODE, THE SPEED IS BEING CONTROLLED BY PITCHING THE AIRPLANE, NOT BY MOVING THE THROTTLE.
>> GIVEN THAT, THE SITUATION WHEN THE FLIGHT LEVEL CHANGES IN THE AUTOTHROTTLE IS AN HOLD, DO YOU CONSIDER THAT TO BE AN ERROR-TOLERANT DIVINE? -- DESIGN?
(Bob Myers, Boeing Chief of Flight Deck Engineering): I THINK I SHOULD REITERATE BRIEFLY WHAT CAPTAIN CASHMAN WAS TALKING ABOUT. WE LOOKED AT THIS DESIGN, AND WE WERE FACED WITH A DIVINE CHOICE. -- DESIGN CHOICE. IF WE GET A WAKE-UP OR A MODE TRANSITION OF THE AUTOTHROTTLE FOR A LOW-SPEED CONDITION, SAY, WE WOULD HAVE HAD CONDITION -- IN HOLD MODE FOR A LOW-SPEED CONDITION, WE HAD TO TRANSITION THE PILOTS AUTHORIZING THAT INCOME OWED-- IN COMMAND MODE CHANGE. THEY WOULD HAVE HAD TWO SYSTEMS CONTROLLING SPEED. WE HAD TO RECTIFY THAT SITUATION . IN THAT CASE, WE WOULD END UP WITH TWO MODE CHANGES AND A THRUST INCREASE, AND IF THIS LOW-SPEED CONDITION CAME ABOUT BECAUSE OF AN ENGINE PROBLEM, WE MIGHT ALSO BE PUSHING THRUST UP INTO THE ASYMMETRIC THRUST CONDITIONS. WE WOULD HAVE POTENTIALLY TWO MODE CHANGES UNCOMMITTED BY THE PILOT, A THRUST INCREASE, POSSIBLY ASYMMETRIC THRUST INCREASE, AND WE WOULD BE VIOLATING OUR PHILOSOPHY OF THE PILOT HAVING AUTHORITY. WE THOUGHT THE LESS CONFUSING OF THE SITUATIONS WAS THE DESIGN WE CHOSE.
Below from the NTSB transcript. Sorry about the all caps and typos, that is how it was transcribed.
DID BOEING CONSIDER PUTTING ON AN AUTOMATIC AUTOTHROTTLE ACTIVATION AT A MINIMUM SPEED, REGARDLESS OF THE STATUS OF THE MODES?
(John Cashman, former Boeing chief test pilot during 777 development): WE CERTAINLY ALWAYS LOOK AT POSSIBILITIES. THE MAIN PROBLEM WITH THAT GOES BACK TO THAT ORIGINAL PHILOSOPHY -- NOT CHANGING MODES AND AUTOPILOT THAT THE PILOT IS NOT COMMAND. WHAT WOULD HAPPEN IF YOU JUST ACTIVATED THE THROTTLE IS YOU WOULD HAVE TWO CONTROLLERS OF ONE PARAMETER. THE AUTOPILOT WOULD BE CONTROLLING SPEED BY PITCHING, AND THE AUTOTHROTTLE WOULD BE CONTROLLING SPEED BY CHANGING THRUST. IT DOES NOT WORK FOR A WELL, SO YOU HAVE TO MAKE A MODE CHANGE, BUT THE AUTOPILOT IN A DIFFERENT CONTROL MODE, AND/OR THE TRUST. IT IS DIFFICULT TO DO, AND IT WAS VIOLATING ONE OF OUR FUNDAMENTAL FIND CONCEPTS.
>> CAPTAIN CASHMAN, YOU TALK ABOUT AUTOTHROTTLE WAKE UP. ISN'T THE ISSUE OF AUTOTHROTTLE FOR PROTECTION?
>> THE ENVELOPE PROTECTION OF THE AUTO ENGAGE OR WAKE-UP FUNCTION IS AN ELEMENT OF THE STALL PROTECTION, BUT IT IS NOT THE STALL PROTECTION SYSTEM. IN OTHER WORDS, IT IS RELATED TO OPERATION WHEN THE AUTOTHROTTLE IS TURNED OFF OR HAS BEEN DISENGAGED INADVERTENTLY OR A FAILURE TO DROP IT OFF, THAT IT WILL ENGAGE ITSELF. IT IS NOT A FUNCTION THAT IF THE AUTOTHROTTLE IS ALREADY IN ANOTHER MODE, IT WILL CHANGE THE MODE AND DO SOMETHING TO CONTROL SPEED. IT WAS REALLY THERE TO COME ALIVE AND ENGAGE ITSELF WHEN A HAD BEEN SELECTED OFF.
>> CAPTAIN CASHMAN, WHY NO AUTO THRUST PROTECTION IN -- MODE?
>> THE AUTOTHROTTLE PROTECTION FEATURE OR WAKE-UP FEATURE IS ONLY WHEN THE AUTOTHROTTLE IS TURNED OFF. IN A FLIGHT LEVEL CHANGE MODE, THE SPEED IS BEING CONTROLLED BY PITCHING THE AIRPLANE, NOT BY MOVING THE THROTTLE.
>> GIVEN THAT, THE SITUATION WHEN THE FLIGHT LEVEL CHANGES IN THE AUTOTHROTTLE IS AN HOLD, DO YOU CONSIDER THAT TO BE AN ERROR-TOLERANT DIVINE? -- DESIGN?
(Bob Myers, Boeing Chief of Flight Deck Engineering): I THINK I SHOULD REITERATE BRIEFLY WHAT CAPTAIN CASHMAN WAS TALKING ABOUT. WE LOOKED AT THIS DESIGN, AND WE WERE FACED WITH A DIVINE CHOICE. -- DESIGN CHOICE. IF WE GET A WAKE-UP OR A MODE TRANSITION OF THE AUTOTHROTTLE FOR A LOW-SPEED CONDITION, SAY, WE WOULD HAVE HAD CONDITION -- IN HOLD MODE FOR A LOW-SPEED CONDITION, WE HAD TO TRANSITION THE PILOTS AUTHORIZING THAT INCOME OWED-- IN COMMAND MODE CHANGE. THEY WOULD HAVE HAD TWO SYSTEMS CONTROLLING SPEED. WE HAD TO RECTIFY THAT SITUATION . IN THAT CASE, WE WOULD END UP WITH TWO MODE CHANGES AND A THRUST INCREASE, AND IF THIS LOW-SPEED CONDITION CAME ABOUT BECAUSE OF AN ENGINE PROBLEM, WE MIGHT ALSO BE PUSHING THRUST UP INTO THE ASYMMETRIC THRUST CONDITIONS. WE WOULD HAVE POTENTIALLY TWO MODE CHANGES UNCOMMITTED BY THE PILOT, A THRUST INCREASE, POSSIBLY ASYMMETRIC THRUST INCREASE, AND WE WOULD BE VIOLATING OUR PHILOSOPHY OF THE PILOT HAVING AUTHORITY. WE THOUGHT THE LESS CONFUSING OF THE SITUATIONS WAS THE DESIGN WE CHOSE.
Oh, and the A/T was not 'put' in HOLD - it put itself there.
I hear "the pilots need the choice" - well, they plainly are not up to it, are they?
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So, in short, none of the 'experts' here know
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I'm perplexed. Nothing in the NTSB's report mentioned use of non standard American R/T being the reason, as was suggested in a previous thread.
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.
Jesus, there doesn't always have to be 'other' contributing factors. This crew screwed things up right royally. There were so many clues during that approach that were all either ignored or badly handled. 'Misunderstanding' a system could be a contributing factor to 99% of crashes or incidents and we ALL have the ultimate tool in our arsenal if we get in too deep...... GO AROUND. At what point was this fool 'stable??'.
I most certainly don't know all the in's and out's of my aircraft's FBW system, I probably know 90% of it but every week I see something new, difference is that when the aircraft does something I don't like or is in an 'undesirable' situation I have no issue disconnecting and hand flying and then if required 'rebuilding' the automation back in. The ironic thing here is that these guys are almost 100% reliant on a system they seem to only have a very basic knowledge of... and that is dangerous.
I most certainly don't know all the in's and out's of my aircraft's FBW system, I probably know 90% of it but every week I see something new, difference is that when the aircraft does something I don't like or is in an 'undesirable' situation I have no issue disconnecting and hand flying and then if required 'rebuilding' the automation back in. The ironic thing here is that these guys are almost 100% reliant on a system they seem to only have a very basic knowledge of... and that is dangerous.