744 Forum

Apron => Hangar 7 => Topic started by: Phil Bunch on Sat, 6 Jul 2013 23:28

Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Sat, 6 Jul 2013 23:28
A video is available here:

http://www.cnn.com/2013/07/06/us/california-plane-incident/index.html?hpt=hp_t1

Basic news story here:

http://www.guardian.co.uk/world/2013/jul/06/san-francisco-airport-plane-crash-boeing

At the moment (623pm, KJFK time zone), there isn't much info about injuries, but apparently there are at least 2 dead and 70 injured, per CNN TV news.  A large fireball was reported and the airliner looks pretty badly burned from a helicopter TV video stream - large holes in the roof with a burned out interior visible.  323 were reported as souls on board by one news story.

Allegedly, no distress calls by the crew were made.  One pilot on the TV news said the plane landed short, but the TV video feed was too close-up for me to see that.  It is sitting on the ground next to the runway on TV news, with its tail assembly completely missing and not visible in the fairly close-up TV video stream.  Runway 28L is allegedly their intended runway.  They allegedly clipped the seawall on the way to a landing.  Many pieces of the tail assembly are visible near the end of the runway.  A pilot on TV speculates that the pilot tried to pull up once he realized they were too low and speculates that this caused the tail to impact near the end of the runway where many tail assembly parts including both horizontal stabilizers are now visible.

Still photos on TV show a number of people walking away from the crash site, so apparently many or most were able to evacuate in an emergency procedure - the inflatable slides are visible.

Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sat, 6 Jul 2013 23:33
As always, better coverage here:

www.avherald.com
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Sun, 7 Jul 2013 00:54
An infographic by the NY Times is linked below.  Not sure that it adds much info:

http://www.nytimes.com/interactive/2013/07/06/us/where-asiana-flight-214-came-to-rest.html?smid=fb-nytimes&WT.z_sma=US_WAF_20130706&_r=1&

The associated news article is here, with some additional information and comments:

http://www.nytimes.com/2013/07/07/us/san-francisco-plane-crash.html

Here's an excerpt, discussing the displaced threshold, and speculation that the captain may have forgotten about this detail if he used a visual approach, etc:

"Arnold Reiner, a retired airline captain and the former director of flight safety at Pan Am, said that it appeared from television images that the jetliner had touched down far earlier than the normal landing point, which is about 1,000 feet down the runway. That runway, 28 Left, has a "displaced threshold," he said, meaning that the runway's usable area does not begin at the start of the pavement. The Instrument Landing System would normally guide the pilot to the proper touchdown point, but in clear weather, pilots will sometimes fly a visual approach. "
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 7 Jul 2013 00:59
ILS is inop due to upgrade. Everybody flies visual. The displaced threshold isn't very long at 28L and even then you rather clearly see where the water ends and the concrete begins. This wasn't a simple misjudgement, I fear.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: torrence on Sun, 7 Jul 2013 09:09
Hypothetical, Jeoren,

What would happen if you didn't remember the ILS INOP and programed an autoland with incorrect threshold? What alerts/alarms would go off first?

Another random thing that occurred to me was what if one entered a totally bad Vref and the throttles followed that cue and stalled you early.  Any warning before the stick shaker? I know there are multiple checks to prevent a low and slow approach, but it appears that's what may have happened.  

Seems clear they were below glide path, stalled and dropped way early, but WHY?

Thank God the evac and other stuff worked as well as it did.

Torrence

Edit:  Agree about the visual - even as pax, on a clear day it's hard to miss the fact you're touching down just after crossing to dry land!
T
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 7 Jul 2013 12:48
(speculation)

It will totally depend on whether the ILS glideslope had been turned off, or had been misaligned. In principle a glideslope beacon turned off would have prevented the aircraft from locking on and should have kept it at the 2000 ft GS intercept height. If however the GS beacon had been misaligned, it could potentially have been set up at an approach angle lower than 3 degrees which could have caused a lower than usual approach and potentially the crash as it happened.

However this is not very likely. The seawall was impacted off centerline, suggesting that the pilots flew manual. But this misalignment may have been caused by last minute (second) panic and pullup without thrust and other fumbling. If indeed the aircraft had been following a, say, two degree GS (I did not do the math), the indications would have been a way-off GS intercept (far further out than usual, many miles), higher pitch angle, lower vertical speed, and higher engine thrust on approach. The radar altimeter would have directed the autothrottles to go idle at the usual 20-30 ft over the sea, which now means way before the seawall.

It would be a 'nice' experiment to set the GS to 2 degrees and run the sim and see what happens.

We will have to be patient.

But ... an operative GS combined with a GS misalign and a tired crew still flying the ILS may explain things. It goes sort of okay until the A/T pulls the power off before the seawall and then you are too low to do anything. And tower people may not warn you as they expect you are flying visual and 'anything goes'. Don't forget that a two-degree glideslope actually will bring the ILS antenna (in the 744 these are on the nose gear door for finals; 777 may have the same setup) correctly to the touchdown point. It is the lower-hanging parts of the aircraft that hit ground before the touchdown point. Pilots are high up. There definitely is a different view, you are 1/3 lower than usual, but if you are tired...

It's a rainy Sunday. I may actually do the math. If somebody else starts it earlier, please post here.


Hoppie
(end of speculation)
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 7 Jul 2013 14:07
Somebody plotted the FlightAware data against Google Earth.

https://twitter.com/sbaker/status/353611787750494208/photo/1

Although this isn't officially confirmed data, it does suggest a higher and steeper than usual approach if anything. Definitely not a low approach angle.

Near-flat segment on short final, followed by steep descent into the seawall. Could mean anything.


Hoppie



(http://www.hoppie.nl/tmp/OZ214-bb.jpg)
Picking up the replay boxes probably was easy this time...
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 7 Jul 2013 22:47
Apparently the NTSB guys have already played back most of the stuff (which should be easy given the pristine condition of the boxes).

From AVHerald.com:

QuoteOn Jul 7th the NTSB reported in a press conference at San Francisco Airport, the crew was cleared for a visual approach to runway 28L, the crew acknowledged, flaps were set at 30 degrees, gear was down, Vapp was 137 knots, a normal approach commenced, no anomalies or concerns were raised within the cockpit, 7 seconds prior to impact a crew member called for speed, 4 seconds prior to impact the stick shaker activated, a call to go-around happened 1.5 seconds prior to impact, this data based on a first read out of the cockpit voice recorder. According to flight data recorder the throttles were at idle, the speed significantly decayed below target of 137 knots - the exact value not yet determined -, the thrust levers were advanced and the engines appeared to respond normally. The NTSB confirmed the PAPIs runway 28L were available to the approaching aircraft before the accident, however were damaged in the accident and thus went out of service again. The localizer was available, the glideslope was out of service, according NOTAMs were in effect. There were no reports of windshear and no adverse weather conditions. The air traffic controller was operating normal, no anomaly was effective, until the controller noticed the aircraft had hit the sea wall. The controller declared emergency for the aircraft and initiated emergency response. ARAIB and Asiana personnel have arrived on scene and have joined the investigation. The Mayor of San Francisco reported runway 10L/28R was cleared for service.


Given the observed but not yet confirmed steep approach, I sincerely hope this wasn't a simple "oops" where the crew forgot to add thrust once the PAPI glide slope was captured.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 7 Jul 2013 23:06
There nowadays always is somebody filming anything.

http://www.youtube.com/watch?v=sEDZerwU7uE
Title: Asiana 777 crashes in San Francisco
Post by: G-CIVA on Mon, 8 Jul 2013 01:53
NTSB press conference:

http://youtu.be/XLYeUbeyfOg

NTSB Twitter page (for more info & pictures):

https://twitter.com/NTSB
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Mon, 8 Jul 2013 04:22
The Wall Street Journal is reporting what I would call "apparent pilot error", informally:

http://online.wsj.com/article/SB10001424127887323823004578592152181919438.html

Here's an excerpt:
--------------------------------------------------

Pilots of the Asiana Airlines jet that crashed at San Francisco International Airport over the weekend allowed the Boeing 777's speed to dip dangerously low, and then apparently ran out of time to correct their landing approach, according to preliminary data released by investigators.

While stopping short of pinpointing pilot error as the likely cause of the fiery crash that killed two teenage passengers and injured dozens of others, National Transportation Safety Board Chairman Deborah Hersman indicated Sunday that investigators already are focused primarily on understanding why the crew allowed speed to decay to such an extent—and failed to take decisive action until the wide-body jet was less than two seconds from impact.

In the first on-scene briefing by the NTSB, Ms. Hersman said a preliminary readout of the plane's flight-data and cockpit-voice recorders indicates that everything was normal—with no discussion of any onboard problems or concerns about the visual approach in good weather—until just seven seconds before impact.

At that point, she told reporters, the crew realized the plane arriving on an overnight flight from Seoul was flying too slowly. "The speed was significantly below" the designated approach speed of roughly 130 miles an hour.

Three seconds later, a stall-warning activated, indicating the Boeing 777 carrying 307 passengers was losing aerodynamic lift. The crew didn't act to sharply increase engine thrust and try to climb away from the strip—conducting what is called a "go-around"—until 1.5 seconds before impact.

The safety board believes "the engines appear to respond normally" to those commands, Ms. Hersman said, but by then it was too late to recover, and portions of the lumbering jet slammed into the seawall in front of the strip.

Taken together, the preliminary data and Ms. Hersman's early description of the sequence of events strongly suggest investigators are leaning away from mechanical or other system failures as the likely culprit.

During the media briefing, Ms. Hersman stressed that there was "no prior distress call" from the cockpit crew, which should have been able to rely on both ground-based and onboard landing aids to "establish an approach path" to safely reach the beginning of the runway. The jet slammed down roughly 1,000 feet short of that point, leaving some parts on the seawall separating the runway from San Francisco Bay. Other parts were recovered from the nearby water.

Because the jet was on a visual approach in excellent weather, "you don't need instruments to get into the airport" safely, Ms. Hersman said.

In another significant disclosure, she said investigators "haven't identified any specific similarities" between Saturday's Asiana crash and the 2008 belly landing of another Boeing 777, operated by British Airways, on final approach to London's Heathrow International Airport. Investigators determined the British jet's engines were starved of fuel after chunks of ice blocked its fuel system.
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Mon, 8 Jul 2013 09:59
In the ATC recording released, you can hear radio comm between the acft and tower for some time after impact - so the comm system (i guess VHF) was still working after the crash? Perhaps power switched to the batt buses automatically?
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Mon, 8 Jul 2013 10:24
Quote from: Jeroen HoppenbrouwersGiven the observed but not yet confirmed steep approach, I sincerely hope this wasn't a simple "oops" where the crew forgot to add thrust once the PAPI glide slope was captured.

Early days still, but it would not be the first time.
Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Mon, 8 Jul 2013 11:05
10,000 hour seasoned captain flying, including 747-400 experience, but still training on the new 777 (40 hours under his belt). Supervised by a 3000+ hour 777 training captain. Rats. This should have been about the safest landing ever.

I fear the training department will get a few remarks very soon.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: martin on Mon, 8 Jul 2013 20:02
On PPruNe, someone described a tricky feature of the 777 for the following case:

¤ autopilot (AP) is ON, but not in a "speed" mode
__(FLCH was mentioned in particular, and described as a "trap" in this context);
¤  autothrottle (AT) is ON.
¤ Now AP is disconnected, but
¤ AT is left ON (which seems to be customary on the 777),

In this case (if I understood correctly), the AT while "technically" still ON will actually do nothing any more; you'll have to move the throttle levers manually to change thrust.

Not a problem as long as you are aware of this situation, but if not...
(Note that no one is suggesting this actually played a role in the Asiana crash.)

Is this behaviour the same on the 744?

Martin
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Mon, 8 Jul 2013 20:21
Q: is there a difference in disconnecting the AT from the TQ switch, and disarming the AT from the MCP switches (L&R for the 777)

So lets say 137kts is set in the MCP, AT switches on MCP are armed, and AT is disengaged via the TQ switch, will the AT kick in at any point as the speed trend approaches 137kts, assuming the levers are at idle, without any intervention?

fc
Title: Asiana 777 crashes in San Francisco
Post by: John Golin on Mon, 8 Jul 2013 22:52
(My understanding is no - it will not 'reengage' .  Interestingly VNAV does have some altitude protection with AT disengaged - http://www.youtube.com/watch?v=IJKU19Rn0GA - not what I expected until I saw the clip ).


I've never understood why the AT, by design, can be 'on' and not active in a mode - and why HOLD exists (outside of takeoff for both).
Title: Asiana 777 crashes in San Francisco
Post by: Joe Clark on Tue, 9 Jul 2013 01:11
Quote from: John Golin(My understanding is no - it will not 'reengage' .  Interestingly VNAV does have some altitude protection with AT disengaged - http://www.youtube.com/watch?v=IJKU19Rn0GA - not what I expected until I saw the clip ).


I've never understood why the AT, by design, can be 'on' and not active in a mode - and why HOLD exists (outside of takeoff for both).

Is the AT "on" or is it simply "armed"? To me, when the L/R AT switch is pushed up, the AT is "armed"  When the A/T button is pushed and the light is on, the AT is on.
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Tue, 9 Jul 2013 01:17
Here's a link to a press article on the "FLCH trap", as it's being called here and there.  They make reference to pprune.

http://www.theatlantic.com/national/print/2013/07/professional-pilots-on-the-san-francisco-crash/277563/

PAPI being active until apparently wrecked by the crash itself is yet another factor that makes all of this seem so incomprehensible to this lay person.  

And we thought the Air France high-altitude stall over the Atlantic was an anomaly...in some ways, this seems worse to me.  It's hard to beat setting the throttles to idle and apparently flying the thing into the ground on a clear day.  The stick shaker alarm appears to be a bit late for this specific situation.  

We can't remind ourselves too many times to wait for the final investigation report, but it's also very hard to avoid some degree of informal speculation.
-----------------------------------------------------------

How can the aviation community possibly prevent these very rare events where the crew has some sort of group delusional experience and screws up what seems in retrospect to be an "obvious" problem?  Perhaps we are at an accident rate that is as low as it can practically be?  We don't know how to write perfect software either, so more automation isn't the answer, I personally believe.  Would better training really fix these rare, seemingly inexcusable problems?
Title: Asiana 777 crashes in San Francisco
Post by: John H Watson on Tue, 9 Jul 2013 01:31
QuoteSo lets say 137kts is set in the MCP, AT switches on MCP are armed, and AT is disengaged via the TQ switch, will the AT kick in at any point as the speed trend approaches 137kts, assuming the levers are at idle, without any intervention?

From the 777 Maintenance Manual

QuoteAutomatic Speed Mode Engagement

If the A/T is not engaged, it will automatically engage in the speed (SPD) mode when all these conditions are true:

*At least one A/T ARM switch is in the ARM position
*Radio altitude is more than 100 feet, or more than 400 feet after takeoff
*Engine thrust is below the engine thrust limit
*The autopilot or the flight director are not in a speed-through-elevator mode
*The airspeed is just above stall speed

Without knowing what mode the FD was in, it would be hard to say if the A/T would have engaged.
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Tue, 9 Jul 2013 02:37
Here's a graph of the apparent descent, published by the NY Times:

http://www.nytimes.com/interactive/2013/07/07/us/asiana214-uneven-descent.html?ref=us
Title: Asiana 777 crashes in San Francisco
Post by: John Golin on Tue, 9 Jul 2013 03:06
Quote from: Joe Clark
Quote from: John Golin(My understanding is no - it will not 'reengage' .  Interestingly VNAV does have some altitude protection with AT disengaged - http://www.youtube.com/watch?v=IJKU19Rn0GA - not what I expected until I saw the clip ).


I've never understood why the AT, by design, can be 'on' and not active in a mode - and why HOLD exists (outside of takeoff for both).

Is the AT "on" or is it simply "armed"? To me, when the L/R AT switch is pushed up, the AT is "armed"  When the A/T button is pushed and the light is on, the AT is on.

Armed - yes... my question is probably poorly phrased.  :)

It goes to the entire logic of the AT - why does it need to be armed but not  Active in some active mode (SPD / THR etc)?  The autopilot is not like this - if it is on, you always have a roll and pitch mode (of some description).

QuoteAutomatic Speed Mode Engagement

If the A/T is not engaged, it will automatically engage in the speed (SPD) mode when all these conditions are true:

*At least one A/T ARM switch is in the ARM position
*Radio altitude is more than 100 feet, or more than 400 feet after takeoff
*Engine thrust is below the engine thrust limit
*The autopilot or the flight director are not in a speed-through-elevator mode
*The airspeed is just above stall speed

Thanks Mr Watson!

In the above note, if it was either ON (and engaged in a mode) or OFF, what would we lose?  Yes, things would have to be done differently, but I don't understand what is the advantage of the complexity we have with an 'Armed'  (that couldn't be achieved some other way)?

I have the feeling someone is about to embarrass me with a really obvious reason...  probably to do with interaction with AP modes...?

 :?
 :P
Title: Asiana 777 crashes in San Francisco
Post by: John H Watson on Tue, 9 Jul 2013 03:58
Armed-but-not-engaged allows the pilots to control the thrust manually (as it probably should have been done in this situation). However, if a go-around is needed (think panic & reflex), a TOGA switch is pushed. This not only provides a visual (F/D) cue for manoeuvres, but also GA thrust.

The partial automation gives the pilot a free hand (for other tasks or even an extra hand on the control column for more precise control).

HOLD mode gives the pilot the ability to add extra thrust without pushing buttons/changing modes. e.g. in FLCH descent mode to decrease the descent rate. However, you need to engage the A/P or follow the F/D to maintain selected airspeed.

Hope this makes sense.

Rgds
JHW
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Tue, 9 Jul 2013 04:51
Lot of articles flying around the net on the experience of the captain.

When we were still living in the USA and I was still flying I used to participate in the FAA excellent safety program WINGS. Aimed at GA it's goal is to increase overall safety and reduce accidents.

I remember I went to one of their seminars. Topic was how to reduce fatal accidents in GA. The FAA has a lot of data pertaining on this. The most telling part of their analysis was that there is no correlation between hours flown and fatal accidents rate. Put differently, statistically speaking a new pilot with say 100 hours flying a Cessna 150 has the same statistical chance of being in a fatal accident as the captain of a Learjet with 10.000 hours.

The big differentiator was safety training and awareness. Pilots that engage in constant safey education/training are statistically speaking much less prone to end up in fatal accidents. The WINGS programs is exactly that, it constantly encourages pilots to study, read, be engaged in the broadest sense possible of enhancing your flying skills and your attitude. The latter probably being the most relevant.

There are other safety programs that do exactly the same. For instance Cirrus runs special (safety) programs for their owners. And statistically speaking those that participate crash 50% less then the pilots that don't participate.

This 777 is not part of GA, but I'm sure the same principle applies. Flying safe is first and foremost an attitude.

Not executing a go-around or to late is, unfortunately, something that happens a lot. In itself it is not a particular difficult manoevre. It is considered a "safety manoevre". It gets you out of potential trouble.

I keep reading that they 'requested a go-around'. Not sure what they mean, but you certainly don't request a go around from ATC. When you're not happy with your approach, you just push the TOGA button or firewall the throttles and when you're well established in the climb you tell ATC you're going around.

Nobody will question a pilot that goes around. There is no legal requirement to report anything. At least not with the authorities. I understand some carriers require their pilots to explain why they went around. Not sure if that is a good practice.

Of course, we still need to hear what the real course of this accident is.

Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: John Golin on Tue, 9 Jul 2013 06:22
Quote from: John H WatsonArmed-but-not-engaged allows the pilots to control the thrust manually (as it probably should have been done in this situation). However, if a go-around is needed (think panic & reflex), a TOGA switch is pushed. This not only provides a visual (F/D) cue for manoeuvres, but also GA thrust.

The partial automation gives the pilot a free hand (for other tasks or even an extra hand on the control column for more precise control).

HOLD mode gives the pilot the ability to add extra thrust without pushing buttons/changing modes. e.g. in FLCH descent mode to decrease the descent rate. However, you need to engage the A/P or follow the F/D to maintain selected airspeed.

Hope this makes sense.

Rgds
JHW

It does indeed, thanks  :)

Though I still wonder why couldn't you design a TOGA push alone without AT armed to go to TOGA? And we don't 'half fly' the autopilot - if you want to tweak the throttles, use the thumb switch to disengage, and when you want to give it back to the automation, reengage...

No confusion then :)

Meh... what would I know - I don't fly, and in PS1 leave the A/T on until 100ft anyway (unless Roddez silently turns it off when I'm looking out the window!  :evil:  )
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Tue, 9 Jul 2013 08:41
Just picked this up on aviation Harald:

The aircraft joined a 17nm final, the crew reported the runway in sight before being handed off to tower. The autopilot was disconnected at 1600 feet 82 seconds prior to impact, the aircraft descended through 1400 feet at 170 KIAS 73 seconds prior to impact, descended through 1000 feet at 149 KIAS 54 seconds, 500 feet at 134 KIAS 34 seconds, 200 feet at 118 KIAS 16 seconds prior to impact. At 125 feet and 112 KIAS the thrust levers were advanced and the engines began to spool up 8 seconds prior to impact, the aircraft reached a minimum speed of 103 KIAS 3 seconds prior to impact, the engines were accelerating through 50% engine power at that point, and accelerated to 106 knots. The vertical profile needs to be assessed first. There was debris from the sea wall thrown several hundred feet towards the runway, part of the tailcone is in the sea wall, a significant portion of the tail is ahead of the sea wall in the water.


So they were really slow!!
Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: martin on Tue, 9 Jul 2013 09:06
Here's a reasonable preliminary analysis (http://flyingprofessors.net/what-happened-to-asiana-airlines-flight-214-2/) worth reading (link found on PPRuNe, and recommended by several pro's there).

Based on FlightAware radar data (caveats apply), and restricting itself to technical aspects (as opposed to "company culture", CRM issues, etc.)

Martin

Update:

1. Belated thanks to John Watson for supplying the relevant 777 manual quote (http://aerowinx.de/forum/topic.php?post=13109#post13109) and a good clarification (http://aerowinx.de/forum/topic.php?post=13112#post13112)!

2. Here is  (on PPRuNe) a more detailed description (http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-44.html#post7929151) of the "FLCH trap" I mentioned earlier (http://aerowinx.de/forum/topic.php?post=13092#post13092).
Title: Asiana 777 crashes in San Francisco
Post by: John Golin on Tue, 9 Jul 2013 23:45
Interesting (for me) comment on the Boeing throttle quadrant from PPRuNe...

"The throttles on all Boeing North airplanes have the same force requirements to move - about 2.5 lbs force at the knob. In fact, with the exception of the 787, they all use minor variations on the same friction device for throttle 'feel'. Naturally, the 747 requires twice the force to move all the throttles since it has twice as many throttles to move. The autothrottle servo has plenty of force margin to move the throttles, its the friction devices that slip - as designed - to allow manual override of the A/T. The throttle quadrant on the 747-8 is unchanged from the 747-400.

That's roughly half the force that was required on the pre-FADEC throttle cabled engines - typically about 4.5 lbs at the knob (sometimes as high as 6 lbs.)."
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Wed, 10 Jul 2013 01:29
More via the AV Herald (from NTSB). Sigh.

On Jul 9th 2013 the NTSB reported in their third press conference based on pilot interviews, that at 500 feet AGL the PAPIs were showing three red one white and the pilot began to pull back on the yoke to reduce rate of descent assuming the autothrottles would maintain the speed set to 137 knots. A lateral deviation developed taking the attention of the crew. Descending through 200 feet all PAPIs were red and the speed had decayed into the red/black marked range, the crew realised the autothrottles were not maintaining the target speed, at that point the autothrottles started to move the levers forward.

This pretty much explains what happened. Not yet 100% why. I don't get why the levers started to move forward eventually. Somebody claims that it wasn't the A/T but the P/F that did this.

More NTSB findings:

There were three pilots in the cockpit, the captain under supervision was pilot flying occupying the left hand seat, the training captain was pilot monitoring occupying the right hand seat, the relief first officer was occupying the observer seat, the relief captain was in the cabin at the time of the landing. The captain under supervision, 9700 hours total flying experience, had flown 10 legs for a total of 35 hours on the Boeing 777-200 so far and was about half way through his supervision. The training captain was on his first flight as training captain, the two pilots had never flown together before.

Well . . .

Cabin crew did better. Lot of things went horribly wrong, such a slides inflating inside the cabin and trapping two cabin crew members which then were cut free by pilots while they tried to extinhuish fire aboard etc. etc. and two cabin crew members were actually ejected at impact and survived being bowled out onto the runway at 100 kts.
Title: Asiana 777 crashes in San Francisco
Post by: Hardy Heinlin on Wed, 10 Jul 2013 01:46
Quote from: Jeroen HoppenbrouwersI don't get why the levers started to move forward eventually.


Wouldn't this agree with that?



Quote from: John H Watson
QuoteSo lets say 137kts is set in the MCP, AT switches on MCP are armed, and AT is disengaged via the TQ switch, will the AT kick in at any point as the speed trend approaches 137kts, assuming the levers are at idle, without any intervention?

From the 777 Maintenance Manual

QuoteAutomatic Speed Mode Engagement

If the A/T is not engaged, it will automatically engage in the speed (SPD) mode when all these conditions are true:

*At least one A/T ARM switch is in the ARM position
*Radio altitude is more than 100 feet, or more than 400 feet after takeoff
*Engine thrust is below the engine thrust limit
*The autopilot or the flight director are not in a speed-through-elevator mode
*The airspeed is just above stall speed

Without knowing what mode the FD was in, it would be hard to say if the A/T would have engaged.
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Wed, 10 Jul 2013 01:53
I mean, the A/T wasn't doing much good, probably not designed to do anything. Why would it then suddenly spring to life well below stall speed? It is much more likely that the throttles (were) moved forward by the P/F.

The "777 FLCH trap" would explain why the A/T wasn't doing anything. Unless my memory fails here, I think on the 747-400 the A/T keeps working if you are in FLCH and then disengage the A/P -- it engages in SPD mode, right? The P/F came off the 747-400, likely with many, many hours.

On the -400 it does not retard for the flare, which is the common surprise people have that use the A/T while flying the yoke manually.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: evaamo on Wed, 10 Jul 2013 02:53
From the 777 FCOM, in the flight controls section (Pitch Envelope Protection & Stall Protection):

"The autothrottle can support stall protection if armed and not activated. If speed decreases to near stick shaker activation, the autothrottle automatically activates in the appropriate mode (SPD or THR REF) and advances thrust to maintain minimum maneuvering speed"

I spoke to a friend of mine who flies the 300 variant, and he told me something I also validated in the FCOM:  the EEC enters an "approach idle" mode when certain criteria is met... one of these being using flaps 25 or 30 (which was the case). This prevents "under spooling" the engines in case of a GA or if an engine goes out.

Fact of the matter is: they were flying an unstable approach and should have performed a go-around before reaching 500' AGL.

cheers
-Enrique
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Wed, 10 Jul 2013 03:00
Just for the sake of completeness: the 777 FLCH trap is described as follows.

When flying with both A/P and A/T engaged, and the AFDS working in a speed-on-elevator mode such as FLCH, for a descent the A/T will sit at idle and then HOLD as you expect. If you then disengage the A/P but leave the A/T engaged, the AFDS will keep the A/T in the speed-on-elevator mode -- i.e., it does not activate the throttle servo if your speed drops under the target MCP speed. It simply expects its other half (the now disengaged A/P or the real pilot) to fix the speed by pitch.

It is quite possible there is another protection far lower down the speed tape, just above stall speed, but either that didn't work or it wasn't in time. I can imagine that if you pull up hard enough to get the PAPIs back to two red, two white, you bleed off speed so rapidly that by the time the A/T comes back up, you face spool-up times longer than time to impact.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Wed, 10 Jul 2013 03:10
Question for the pros from an amateur.

If I would have had to fly the 28L as directed (from high and hot) during WorldFlight, I would probably have selected Vertical Speed instead of FLCH. I would have set the speed bug on the flaps schedule and manipulate the V/S wheel to have the speed move slowly but steadily down towards the desired speed. This would not have protected me against running into the bricks either low or high, but it would give the A/T a fair chance of picking up when the speed reached the MCP speed bug. When the PAPI would be captured I'd adjust the V/S to 800 and then prepare for manual takeover.

Would this technique be reasonable, or open all kinds of cans of worms?


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: evaamo on Wed, 10 Jul 2013 04:05
Hoppie,

I agree with your post regarding the FLCH trap... now it would seem that if the A/T was on HOLD mode, the "protections" mentioned in my last post would have been triggered by being near (or below) Vmca, the low altitude, the flap settings and pilot input via the yoke (there's even a tail strike protection, both during takeoff and landing).

-Enrique
Title: Asiana 777 crashes in San Francisco
Post by: evaamo on Wed, 10 Jul 2013 04:50
As a follow up to my last message, here's the next interesting bit (also found on the 777 FCOM):

"below 100 feet radio altitude on approach, the autothrottle will not automatically activate"

-Enrique
Title: Asiana 777 crashes in San Francisco
Post by: martin on Wed, 10 Jul 2013 08:29
Moi,

Quote from: Jeroen Hall kinds of cans of worms?
Most definitely I'm not a pro (I sometimes wonder even about "amateur"), but FWIW: after ploughing through 1360+ posts (the dole lets you do that...) in the "Asiana Crash" thread of PPRuNe, the following consensus regarding the "FLCH trap" seems to emerge:

¤ The "trap" notwithstanding, FLCH is still useful (and popular),
¤ because it provides the fastest way to lose altitude
¤ while still offering automatic overspeed protection.
(V/S, by contrast, may require too much "fiddling" (quote) with setting the rate and/or deploying speedbrakes, in order to keep the speed in check.)

But to avoid the "trap", FLCH is a no-no (per personal rule or company policy) for any or all of the following:
¤ on approach
¤ below 3000 ft
¤ with the MCP altitude set to 0000 (or runway altitude)

If anyone wishes to dig deeper: To spare you the ploughing, here is a list of links to posts from the PPRuNe thread which I found helpful for understanding the issue:
(Disclaimer: subjective selection, FWIW and YMMV apply; in chronological order; no guarantee of completeness or correctness; posts ploughed through up to #1372, 10th Jul 2013, 06:44 GMT)
* asterisks denote posts I personally (!) found especially illuminating

¤ Link01  
¤ Link02  
¤ Link03  
¤ Link04  
¤ Link05*
¤ Link06  
¤ Link07*  
¤ Link08  
¤ Link09  
¤ Link10*
_ but see also Link11 and Link12  
¤ Link13   (picture!)
   
Plus two links recommended by PPRuNe posters:
¤ Cpt. Chesley "Sully" Sullenberger (of Hudson fame) comments (video)
¤ "Wired" article
(yes, that "Wired", but the article has been recommended).

Note that this is all about the 777 (Link 13 above demonstrates that differences do exist to other types).

Now, how would it all look on a 744?

HTH,
Martin
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Wed, 10 Jul 2013 16:34
Not sure this link adds new info, but the NY Times is reporting that the autothrottles were armed:

https://www.nytimes.com/2013/07/10/us/inquiry-suggests-chance-that-mechanical-failure-had-role-in-crash.html?pagewanted=print

Here's an excerpt:
-----------------------------------------------------

Investigators in the cockpit of the wreckage found the auto-throttle switches set to the "armed" position, meaning that the auto-throttle could have been engaged, depending on various other settings, she said. The disclosure is far from conclusive, but raises the clear possibility that there was a mechanical failure or that the crew misunderstood the automated system it was using.

The chairwoman, Deborah A. P. Hersman, also said that interviews of the three pilots who were in the cockpit at the time of impact showed that the speed indicator on the flat-panel displays in the cockpit had drifted down into a crosshatched area, meaning that the instruments were saying that the plane was moving too slowly.

At the dual controls, the pilot flying the plane was undergoing initial training as he upgraded from a smaller plane, and was supervised by a veteran pilot who was new as an instructor, Ms. Hersman said. The instructor told investigators that between 500 feet and 200 feet in altitude, the crew was also correcting from a "lateral deviation," meaning that the plane was too far to the right or left (she did not specify which) and realized they were too low.

At 200 feet, the instructor pilot told investigators in an interview, he noticed they were too slow. "He recognized that the auto-throttles were not maintaining speed," and began preparing the airplane to go around for another try. But it was too late.
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Wed, 10 Jul 2013 19:04
Not everybody is happy on the 'transparency' the NTSB provides:

http://sanfrancisco.cbslocal.com/2013/07/09/air-line-pilots-union-criticizes-ntsb-handling-of-sfo-crash-probe/


Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: martin1006 on Thu, 11 Jul 2013 00:10
In my believe it must have been a pilot error. How is it possible when you land with a 4 mans crew in the cockpit without noticing the pitch of the plane is to high and the speed is to low?

Unbelievable!

As far as I know the captain gave the flying pilot command to pitch up and at that moment they found out the trust levers where still on idle and the speed already near stall speed.

It means they probably wanted to use auto throttle at landing and they where not aware of the functions of the meaning of the ARM position in a Triple.

I know at Asiana they always land on auto. (in most Asian countries this is the case)

This is the same lack the Turkisch crew had on Amsterdam. Always landing on Auto and not aware of all the functions in a 737.

Resuming, for me the only possible cause of this crash is a crew depending to much on an automatic function and not monitoring the things what they should monitor.

If you land any airplane by hand and you have your hands on the controls and your eye on your PFD and the runway a crash like this is simply not possible.
Title: Asiana 777 crashes in San Francisco
Post by: evaamo on Thu, 11 Jul 2013 02:57
This is a very interesting post I read elsewhere today, and I think it helps to understand how a tragedy like this came to pass:
---
After I retired from UAL as a Standards Captain on the –400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it's a minefield of a work environment ... for them and for us expats.

One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don't think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all "got it" and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.

We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.

This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce "normal" standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this Asiana crew, it didnt' compute that you needed to be a 1000' AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn't pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.

Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested "Radar Vectors" to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then "Cleared for the approach" and he could have selected "Exit Hold" and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to "Extend the FAF" and he couldn't understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was "Hold at XYZ." Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).

This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141's in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!

The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can't change 3000 years of culture.

The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It's actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don't trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don't get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!

Finally, I'll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.

Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250' after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800' after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real "flight time" or real experience did he get. Minutes! Of course, on the 777 or 747, it's the same only they get more inflated logbooks.

So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.
Title: Asiana 777 crashes in San Francisco
Post by: martin1006 on Thu, 11 Jul 2013 04:50
Quote from: evaamoFirst off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots.

This is exactly the same issue deciding me to avoid any Chinese airliner if it's possible.

They also are trained robots and follow the leader.

I told the Chinese and other expats in China many times. Asian airlines are not safe to fly with.

Their mentality simply obstructs them to ensure a safe cockpit crew.
Title: Asiana 777 crashes in San Francisco
Post by: martin on Thu, 11 Jul 2013 08:00
Moi,

what worries me about the whole ongoing huge "discussion" of the crash is the matter of timing.

Essentially (and simplified), two groups of causal factors could be involved :

I. "human factors", such as the professional CV and background of the pilots, seniority matters, CRM, and of course those much-talked-about "cultural" issues.

II. "technical" factors, such as weather, bird strike, aircraft systems or components breaking or not working as they should, ice in the fuel lines (as in another 777 accident), etc. Also potential cockpit/instrument design weaknesses (e.g. "FLCH trap"), even though this is on the borderline to group I.

Both groups of factors are of course valid "suspects" as causes for the crash, thus both must and will be investigated.

However, the "timing problem" is this:

The group I factors are quickly and easily accessible to the discussion (more precisely, they are perceived to be so). And they can be understood by everyone (at least that's what everyone thinks).

So, once some basic facts of this group are known (usually within hours, thanks to the media), not only aviation professionals, but also media "experts", and the public in general feel free to start a vast debate about the impact these factors may have had on the crash. This is what is currently going on.

Not so with the group II factors, however: Figuring them out may easily take  months of work by highly specialized personnel (NTSB), and even then understanding them will require a lot of technical knowledge.
[size=8](The readers of this forum certainly represent a group far more knowledgeable about this stuff than the "general public", but have you by now fully understood the nature of the 777 "FLCH trap"?).[/size]

So, at this point there simply can be no meaningful discussion of group II factors, simply because the necessary facts are not yet known (for months to come probably). And once they are known, far less people than are currently discussing away will understand them.

The conclusion can therefore only be: While it is in principle perfectly legitimate (and indeed necessary) to discuss the group I factors, that must not lead to "focussing bias", with the group II factors simply being skipped.

And strong restraint ought to be exercised until we really have a full picture.

Discussion of possibilities is one thing (necessary and useful), but drawing conclusions is quite another, and for the Asiana crash, simply not possible at this point.

Unfortunately it seems the line between the two is being increasingly blurred in the ongoing public "exchange of opinions", which somewhat goes along the lines of "It must have been , because we can [size=8](discuss those)[/size]".

Human factors are a very valid concern in this accident, but they are not the whole picture.

Cheers.
Martin
Title: Asiana 777 crashes in San Francisco
Post by: Hardy Heinlin on Thu, 11 Jul 2013 08:20
This (http://aerowinx.com/forum/topic.php?post=13164#post13164) is a very good comment, in my opinion.


Cheers,

|-|ardy
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Thu, 11 Jul 2013 19:01
The FAA has announced that it will require the co-pilot to have 1500 hours, as a reaction to the Asiana crash:

http://www.bloomberg.com/video/faa-new-co-pilot-rules-after-asiana-crash-py6aH4o5TyyeicCarSnElA.html
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Fri, 12 Jul 2013 01:45
500 hours more bush flying? Phew!
Title: Asiana 777 crashes in San Francisco
Post by: John Golin on Fri, 12 Jul 2013 04:31
Quote from: Hardy HeinlinThis is a very good comment, in my opinion.


Cheers,

|-|ardy

Yes, and the NTSB are generally fantastic at  ensuring all avenues are investigated to their conclusion for any contributing factors - if there are 'human factors', what put the pilots in the position where that error or mistake could happen and cause an accident? Sort those out and safety increases again...
Title: Asiana 777 crashes in San Francisco
Post by: martin on Fri, 12 Jul 2013 06:06
Quote from: Jeroen Hoppenbrouwers500 hours more bush flying
Actually, going from 250 to 1500 hours, it appears (600% !).

M
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Fri, 12 Jul 2013 10:59
Wow. I wonder where you can get 1500 hours without being F/O. Nobody can pay for thay himself; so will we see everybody moving to Africa for a few years to build hours?


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Shiv Mathur on Fri, 12 Jul 2013 11:10
I was also wondering how this works ... every time there is a new aircraft type, there exist only pilots with 0 hours on that aircraft.
Are hours in the sim counted?
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Fri, 12 Jul 2013 17:11
Here's a follow-up reply to the NY TImes article I cited previously:

http://www.nytimes.com/2013/07/12/opinion/the-asiana-jet-crash.html?ref=todayspaper

This brief reply is listed below:
----------------------------------------------------------------------------------------------

 To the Editor

Re "Inquiry Suggests Chance That Mechanical Failure Had Role in Crash" (news article, July 10):

If it is found that the pilots needed to manually activate or set the minimum speed on the auto-throttles of the Asiana jet, that means that the design was totally unacceptable. Auto-throttle should be fully automatic, period.

It should automatically prevent the landing speed from dropping below a safe limit. It should never need manual activation, and in fact, the pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.

Similarly, to protect against mechanical failure, full backup should always be provided.

BÉLA LIPTÁK
Stamford, Conn., July 10, 2013

The writer is an automation and safety consultant and the editor of the Instrument and Automation Engineers' Handbook.
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Fri, 12 Jul 2013 17:32
Quotethe pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.
Won't happen.
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Fri, 12 Jul 2013 17:52
Quote from: Jeroen Hoppenbrouwers
Quotethe pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.
Won't happen.

I wondered about the assertion in this article - the pilot(s) have to have very wide latitude to rescue the airliner from a pending disaster.   Disasters have a way of showing up under unusual situations with very stressful options being the only ones available.  There are many examples from recent decades of aviation history - the Sioux City crash landing being but one example - the pilots had to fly and land the airliner mostly using only the throttles.  

I suppose some of the Airbus controls in particular may limit a pilots' options under some circumstances.  

Interestingly, my Volvo S60 also does this - the computerized anti-lock brakes may engage and override my driving, too, under certain circumstances.  This happened once while I mistakenly applied the brakes in an irrational fashion.  The computers took over and stopped the car much faster than I knew it could stop - I thought my eyeballs were going to be pulled out!  Fortunately, there was no real hazard present, and fortunately no one was following me closely!  No harm was done by my car's "FMC".  The newer versions of my car use radar and do such things even more aggressively.

Hopefully soon Google will automate our cars and we can revert to being passengers in our cars most of the time!
Title: Asiana 777 crashes in San Francisco
Post by: Mariano on Sat, 13 Jul 2013 17:26
Another interesting video:

http://www.huffingtonpost.com/2013/07/12/plane-crash-animation-video_n_3587554.html?ncid=edlinkusaolp00000009

Mariano
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Thu, 18 Jul 2013 02:27
And  a very different development yet!

http://edition.cnn.com/2013/07/17/us/asiana-name-blunder-race/index.html?hpt=hp_c4


Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: mabe54 on Sat, 20 Jul 2013 02:24
That's sad.

http://www.cnn.com/2013/07/19/travel/asiana-airlines-crash/index.html?hpt=hp_c2
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Tue, 1 Apr 2014 10:18
It's been a while since I saw any updates on this one. Just came across this on CNN:

http://edition.cnn.com/2014/04/01/us/south-korea-us-asiana-crash/index.html?iref=allsearch

The Captain states:

QuoteFlight 214's pilot, Capt. Lee Kang Kuk, told the National Transportation Safety Board last year that he found it "very stressful, very difficult" to land without the glideslope indicator that helps pilots determine whether the plane is too high or too low during approach.

I wonder what our resident (wide body) pilots think about that statement. On the day of this incident, if I remember correctly, weather and visibillity were fine. Should a pilot not be able to land in VFR conditions without a glideslope indication?

Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: jtsjc1 on Wed, 2 Apr 2014 00:51
I would think someone who is type rated on a T7 should be able to do that!  If he can't accomplish that how would he handle losing an engine on takeoff!?
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Wed, 2 Apr 2014 03:48
Quote from: jtsjc1I would think someone who is type rated on a T7 should be able to do that!  If he can't accomplish that how would he handle losing an engine on takeoff!?

My sentiments exactly, although I don't fly these planes for a living. But I can certainly land my little Cessna or Cirrus without a glide slope indication. I can well imagine that landing a 777 in this fashion is more difficult than a C172, but still.

Again, no expert by any stretch of the imagination but I would have thought that executing a landing, without glideslope indication, would be basic hand flyling skills.

There was a PAPI available and I always felt that was very usefull.

Here is some more detail:

http://avherald.com/h?article=464ef64f&opt=0

Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: torrence on Wed, 2 Apr 2014 20:16
Way back in my PS1 and 747 documentation I seem to recall seeing that the proper touch-down target for the 747 meant that you had to be high with respect to the PAPI indications. 777 the same?  Any real pilots with the answer?

Cheers,
Torrence
Title: Asiana 777 crashes in San Francisco
Post by: stekeller on Thu, 3 Apr 2014 16:37
torrence:

I believe the recommendation to be high on the PAPI was specific to the 747 because of the height of the cockpit. Now the 777-300ER is longer than the 747 so the effect may be similar. Asiana was the shorter 777-200ER, but the pilots would have been trained on the proper aiming point for their aircraft. An interesting note is that the captain in the left seat (being evaluated) was transitioning from the 747-400.

- Stekeller
KORD
Title: Asiana 777 crashes in San Francisco
Post by: torrence on Thu, 3 Apr 2014 19:06
Makes sense, thanks.

In any event, from what I've seen in the public reports, it appears that the pilots were not very comfortable with flying a normal visual approach in good conditions.  Along with the Air France crash this may be another example of failures due to not training in basics of manual flight techniques, resulting in over-reliance on and/or misunderstanding of the limits of automatic modes.

Cheers,
Torrence
Title: Asiana 777 crashes in San Francisco
Post by: IefCooreman on Thu, 3 Apr 2014 20:35
Sorry for the late reply, but it took me quite some time to write down a "relevant" answer. On the PAPI: 777 is normal as any jet, 2 reds, 2 whites. It's not a double decker.

Do I understand the reaction of the pilot? Yes. Do I understand the reaction of people flying Cessna's? Yes. But it's a completely different world and the cause of the crash is not really clear yet (I think there is still a full report to be published), and the case itself (together with the AF A330, and the recent UPS 767) is still discussed everyday, even on flightdecks. Some thoughts...

1) it was a training flight. Every pilot is nervous for those flights (some exceptions exist). A guy with plenty of experience on 747 transfers to 777. Different for him? Yes. 777 actually has to be flown completely different (pilots in some companies with 744's, who got 748's, complained about the "itchy-ness" of the bird, which is nothing more than fly-by-wire than needs a different approach in stick movements) and the 777 is also much more of a glider than the 747. The hot-and-high situation on the approach is either caused by this, or is caused by ATC and makes the situation only worse. If you have the experience flying a 777, any approach is easier on the 777 than on 747. If you don't have the experience it's the other way around. It's about "getting to know the bird", and even after simulator, it takes a couple of takeoff and landings in extreme situations considering the big difference in weights widebodies are subject to. One can question the training captain yes, but asian culture might have an influence here.

2) autothrottle use: when you transfer from one aircraft type to another, you have to leave some of the stuff from previous types behind because it might be bad on your next. Initially this was the case with the autothrottle: we for instance (Boeing training), never disconnected it during training. The 777 has been flying around for years and it has proven it's reliability. When I asked it to my company, we were allowed to do "autothrottle off" approaches, and have done so in the simulator as well. But it's a matter of training. The captain will probably have received the same simulator training and will have been exposed for a very long time to an environment where you never hardly questioned autothrottle. The fact that there is no autothrottle wake-up below 100ft, is a detail in the book. It never happens because in theory you are supposed to be stable at 1000ft/500ft. And that was not true here (swiss cheese model in aviation safety if it rings a bell...). That same stress might have pushed them to continue anyway (swiss cheese again). This point is now the center of a VERY hot and ongoing discussion in aviation: are we making pilots to depending on automation? I am fortunate enough to fly for a company that allows a lot of manual flying, but not all companies are like that. The more you go east from my home, the more you will be forced into automation. The discussion is not about automation itself though, because automation is a good thing and has improved the safety of aviation.

3) Visual approach. Still acceptable? Well, on a cessna it perfectly is. But long haul is a world where pilots sit in a metal tube for hours and hours and hours and do 2,3 landings a month, flying between busy airports with prescribed procedures that usually end in radar vectors for an ILS, or an RNAV exception. I've done 2 "visuals" in 3 years so far. The first one after 8 hours of flight, where takeoff was at 3 in the morning, the second one after 9 hours of flight with takeoff at 8 in the morning local, but midnight at home (8 hours time difference), at max landing weight. Now the idea of doing a visual is a bit thrilling for me, so adrenaline helps a hand. If on the other hand you are flying for an Asian carrier where automation is the way to go, you will not feel at ease at all. The world you work in is not one that contains visual approaches. On top, the Asiana crew (in the pilots's local time) had done pure nightflight and landed 3 in the morning (if I calculate correctly), which is about as bad as it can get for your body. So a visual approach is an acceptable approach, but it has to be one where the pilot has the choice to do so or not. It's too "of-standard" to bluntly to state that we should always be able to carry one out.

4) ATC using visual approaches standard. Many people who know me will probably know that I consider USA ATC the worst in the world for long haul. The world improves itself every day, USA ATC on the other hand seems to think they are the best of the world and use that to deny any reason to improve their way of working. While their way of working is perfect to allow for a fantastic VFR experience, and their controllers are pretty damn good in "peak times" to get everyone in- and out, their idea that everything in VFR should be applicable to IFR is simply dangerous. I consider New York dangerous for this, I have no experience with Los Angeles airport itself, but some with "Socal" radar. Many collegues - me included - have a standard "protection" that we never tell American ATC we have "traffic in sight", because doing so gives them the freedom to handover separation to us and give us a landing clearance, which is ridiculous. A heavy jet is flown (and monitored by the second pilot) eyes inside up to very low height, except for specific cases like ie TCAS alerts. You have too quickly deviations from altitude that are dangerous. I've had one encounter in JFK airspace with a VFR traffic 500ft above. Nobody seems to realize how quickly a 777 flying at 250kts can climb that altitude if you don't watch INSIDE. You can, with enough experience, start to "fly outside", but again, it requires experience because you are never trained to do so. Only once when doing touch&go's in a simulator, but a simulator is still not very reliable for visual work.

I'm only writing this because I hope it makes people understand how we are trained. I personally love to fly with minimum automation. But the Asiana crash is not really about that only, and I'm actually happy the captain has made that statement about his "stress level", especially because he flies for an Asian carrier. I was actually surprised as well how "easy-going" people were discussing the UPS 767 crash in Birmingham, where (if true), pilots simply busted long going basic rules, where in the case of the Asiana, the trainee (because that's what he was) was tricked by training and a small detail in autothrottle functionality. Sometimes I even think the case would have never happened if he was looking inside to his instruments, instead of outside to a PAPI... (oh yes, on the second visual approach I did, on the ground both the captain and I discussed how poor the visibility of the PAPI was indicating both red and white on the same spot)

There's a lot I could add, but I think this short message should be sufficient... :-)
Title: Asiana 777 crashes in San Francisco
Post by: IefCooreman on Thu, 3 Apr 2014 21:53
One note to add, after re-reading my message: when transitioning to 777 from any other Boeing type (except for 787), the autothrottle magic is one of the most "deep" changes you go through in your flying habits, together with the speed trim. Previously you disconnected autopilot and autothrottle simultaneously, this time you are learned to keep the autothrottle all the way and never disconnect. It is exactly this "change" that is one of the main causes it seems. A pilot going through a full training course where autothrottle is never questioned, is here all of a sudden confronted with a small "exception" (that should never have happened if they were stable, of course). But to think that the pilot - who is looking outside - is going to catch that is difficult to tell. I admit as well, that one of the results of the autothrottle system is, you monitor less your speed. This changes when you start to feel comfortable again in your new environment (the 777 flightdeck), but it takes time. You learn step by step.
Title: Asiana 777 crashes in San Francisco
Post by: Richard McDonald Woods on Fri, 4 Apr 2014 09:34
Very, very interesting, Ief. Thanks for your thoughts.
I have found myself more and more flying heads down on final approaches in recent months.
Regards, Richard
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Fri, 4 Apr 2014 17:41
Thanks Ief for that detailed explanation.

Could you elaborate some more on why US ATC is so bad for long haul? Also, your comments about "traffic in sight". I'm familiar with that having flown in the USA, but does it work differently in say Europe compared to the US?

Thanks

Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: stekeller on Fri, 4 Apr 2014 17:52
Hi Ief:

Thanks for all of that valuable input. Nobody wishes to rush to judgment, but this crash is so puzzling because the pilots were experienced, the flight conditions were mild, AND the aircraft appears to have been functioning normally.

My big question is this - I am puzzled by the statements that the pilot flying was unaware or surprised at the autothrottle being disengaged because of 3 things:

1. The mode annunciation for the A/T on the PFD, which he was presumably watching. Or maybe not, because speed was decaying and he did not react in time.
2. The movement (or lack thereof) of the throttles themselves. On the 777 I believe they move (unlike on Airbus FBW aircraft)
3. The sound of the engines - you can hear the power being applied and decreased on approach (at least in the cabin)

In my view, if the pilot flying was looking outside, the sight picture and PAPIs would have helped him. If he was looking inside, the PFD indications, speed tape trend vector, and V/S would have helped him. Back of the clock issues that you mention may explain some mental "paralysis" but it is still quite confounding for me.

- Stekeller
KORD
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sat, 5 Apr 2014 00:39
Don't forget they came in hot and high, engines at flight idle... Nothing will have moved while the aircraft tried to slow down. It went wrong only very late in the descent/approach.

At least part of the surprise was caused by the long flight idle that was expected, in my opinion. Turkish at EHAM suffered from the same issue. Coming in with engines idle, then dropping through the set Vref instead of picking up. You need explicit awareness and almost literally say to yourself "Here comes the A/T... yes... well... hey... *click click* manual" as the speed decreases quite sharply when you go from (presumably) FLCH descent into glide slope capture with engines at idle.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Will on Sun, 6 Apr 2014 03:22
Interesting perspective, Ief. I suspect the United States' VFR culture goes back to the overall aviation culture in the country. Almost all civilian airline pilots start out as flight instructors in Pipers or Cessnas for a thousand hours or so, and then build time flying night mail, or hauling skydivers, or doing pipeline patrol, or air ambulance, or some other kind of entry-level work in small planes, followed eventually by a transition to turbine aircraft and then maybe a regional airline before flying big jets. I think something like 5000+ hours prior to airline hire would be fairly typical, much of it in airplanes without much automation. Furthermore, most of those thousands of hours will be into small airports where a visual environment is the rule, not the exception.

I don't know how Asiana hires and trains their pilots. But some countries select their pilots on the basis of pre-employment aptitude tests, and then offer them a job without any previous flight experience at all. They then go from something like 250 piston flight hours, all in a dedicated airline training environment, straight to their airline equipment. That's a very different path from novice to airline cockpit than is what is typical here.

Both training systems are reasonable, and I understand that countries like Korea almost certainly don't have the aviation infrastructure to allow pilots to "work their way up" from smaller jobs to airliners. However, I think the differences in the environments explains the comfort level that the American system has with visual maneuvers.
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Sun, 6 Apr 2014 11:18
Ok, this deviates from the thread a bit, but I agree with Will that the US aviation culture is extremely different from at least the European culture.

Case in point: when family or friends from Europe are over, I like to take an unexpected right turn when we pass the airport near our home and drive straight onto the airport. It's KTMB, a simple three-runway 500-craft non-airline training/parking field with tower. Roads, hangars, no food/drink, basically a straightforward industry area. No gate control, always open, just a 30 mph speed limit sign.

As soon as I "crash through the gate", the newbies duck and expect to be shot at. They remain extremely uncomfortable while we tour the airport and repeatedly ask whether this is allowed. I point out that this is just a road, not the flight line, and the flight line is on the other side of that 2 m fence which incidentally has gates that aren't necessarily locked. I have driven my car onto the flight line (i.e. the other side of the hangars) often for work. It's just a car park with wings.

For non-US people, this seems impossible to accept: aircraft are military objects that are defended by people with guns and making photos sends you to jail, or worse.

In such an aviation-averse culture, I can well imagine that pilots don't see any aircraft close up until they are ready to become their F/O, so to say.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Will on Sun, 6 Apr 2014 20:09
And now I'll offer some perspective as a pilot. Most of you know my story, so bear with me as I repeat myself. To explain my perspective and the experience from which I come: I flew for a regional airline in the USA and I had 6000 hours or so when I left for a different career. I didn't fly a heavy aircraft, but our speed in the terminal area was the same as everyone else: 250 knots until close to the airport and then the same speed limit as every other aircraft (about 180 knots) until the final landing phase, followed by a slowdown on final to our Vref of about 135 knots. So things like relative speed between aircraft was similar.

My plane was a high-workload aircraft. We had no autothrottle (!) and no autopilot (!!!) so every approach and landing required one pilot to maintain a scan inside the aircraft at all times. For that matter, every moment of every flight required exactly the same thing: someone had to be flying the plane, constantly. Further, we had old "steam" gauges, so it was a complicated scan. A gust could knock the plane into a climb and then within seconds we would be unacceptably high or low, or a slight bank wouldn't correct itself until we were out of bounds. It required constant attention. The non-flying pilot would operate radios (ATC, company, and guard; we had no ACARS), look outside, and generally assist, but they were expected to monitor the flight instruments as well.

So here are my thoughts about visual approaches, workload, technology, and culture.

1. Visual approaches. Highly preferred, since when navigation is up to us in the cockpit, the plane can get on the ground faster. Also, there's nothing more fun about flying than hearing "cleared for the visual" when about 15 miles from the airport on a high extended downwind or base. That was when flying got to feel like flying again; you could strategize and plan and aviate, and actually be in command of the aircraft instead of letting ATC steer the plane for you with radar vectors. I remember using the Golden Dome of Notre Dame university as a marker for the turn to final at South Bend, Indiana, or just using your mind's eye to paint an extended centerline out into the landscape and planning your turns accordingly. This was aviation: managing your airplane yourself, in four dimensions (the three dimensions of space plus airspeed). Sometimes people ask me what I miss about aviation and it was moments like this. Yes, we would back up the approach with an ILS whenever possible. And it was usually possible. But the ILS was reassurance that your aircraft was on the right path in space, as opposed to the visual picture being reassuring that the ILS is correct. If every moment had been that fun, I wouldn't have quit. (But that's another story for another day.)

2. Workload. I appreciate the challenges of a visual approach at the end of a long trip. Believe me, I do. However, to place my opinion in context, envision a day of nine turnarounds (we had no corporate maximum), with maximum allowable flight hours, and maximum allowable duty hours, then repeat times four. So at the end of a four-day trip, I had worked 16 hours duty time each day, with 8 hours flying time each day, with nine legs each day, all flown completely manually (no autopilot, remember). With this type of schedule, you learn to curse the day you decided to be an airline pilot, but you do get a ton of valuable experience: flying, aviating, looking for traffic, getting used to the terminal environment; situational awareness becomes like a second sense. Situational awareness is the oxygen you breathe. To say that one would prefer that ATC relieve us of the responsibility to look outside the windshield is a (literally) foreign concept to me. Looking outside is what you do. It's part of aviating, it's part of situational awareness, it's part of the job. Even when you're fatigued.

3. Technology. Technology adds complexity but reduces workload. Anyone who thinks technology doesn't reduce workload is invited to step into 747-100, or a 707, or for that matter into my shoes as a regional pilot and enjoy some four-day trips, nine legs each day, in bad weather, without an autopilot, without ACARS, without EICAS. Enough said. Still, the NTSB is full of incidents in which human beings hadn't yet worked out the proper relationship between pilots and their technological tools. Sometimes pilots ignored indicators that should have helped them. Other times, they relied on faulty gadgets that led them to difficulty. Managing the technological challenges of modern automation is not simple. Anyone who thinks a 747-400 or a 777 is "easy" because of the automation is flatly wrong. However, the automation at the end of the day is simply that: automation. No pilot should, in my opinion, ever get into the cockpit with an expectation that the automation replaces basic airmanship. The pilots in the United States love the 777. They don't get into the cockpit thinking that the systems are so complex that things like situational awareness take a back seat to flying the plane. They just don't think that way. Airmanship comes first, and it is honed through experience; operating a complicated piece of equipment comes second.

4. Culture: I said it already. Airmanship comes first; operating a complicated piece of equipment comes second. Recall what I said in my previous post in this thread. Your typical American pilot comes to the game with thousands of hours of flying experience, accomplished without electronics to reduce workload, and achieved in complicated airspace in which the pilots had to be as aware of the situation outside their cockpit as the situation within it. I think that pays off in several ways, one of which is being comfortable with the concept of a visual approach. Statistics back me up on the American way of aviating. Remember the insane workload and fatigue of my airline that I described above? We carried 2,000,000 passengers per year, and so far, no accidents, and no fatalities. The safety record of American aviation as a whole speaks for itself.

One final point, off topic, to Jeroen's last post: I flew sightseeing tours at the Grand Canyon back before it had a fence around the runway. The airport at that time was the busiest airport in terms of takeoffs and landings in the whole USA. (Most planes were small so the airport wasn't very large in terms of passengers flown, but it certainly had lots of takeoffs and landings.) Anyway, they didn't build the fence for security reasons, they built it to keep elk and coyotes off the runway. (The coyotes learned to tunnel under the fence, probably because rabbits learned to live inside the fence. The fence did keep the elk out, though.)
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Sun, 6 Apr 2014 23:52
Will,

Thanks for the most interesting (and well-written) reflections on your aviation career and flying.  I look forward to rereading it many times.

Your essay gives me a new perspective on life as a pilot for a regional airline.  I've flown as a regional airline passenger many times in my former work for a large company (I'm now retired), but I never gave too much thought to what the pilot's life was really like.

Also, I believe these types of considerations and experiences apply in a general sense to many careers besides aviation.
Title: Asiana 777 crashes in San Francisco
Post by: Will on Mon, 7 Apr 2014 03:18
Phil, thanks so much for your comment.

Upon rereading, I feel I should add just a little clarification for context.

Clarification on my career: I was flying a turboprop, the mighty Jetstream 32. I started as F/O, upgraded to Captain, and then finished my career as an Instructor Pilot in our training department. It wasn't always flying in the gentle airspace over South Bend; every single leg was either into, or out of, the crowded airspace of a major international airline hub.

Clarification on how one can do nine legs in an 8-hour flying day: yes, it's totally possible. Our three closest outstations were each between 30 and 45 minutes flying time away from the hub. These routes were very highly traveled and always oversold, since a 35-minute flight could save a business traveller two or three hours by car. Crew Scheduling loved to bunch all of these turns into one trip since the timing worked out so well. So a nine-leg day made practical sense. We also had our share of "long haul" flights, which for us meant about three hours at FL250 or thereabouts.

Clarification on fatigue: back in my day (the 1990's), we had a 16-hour duty day. Those who are good at math will notice that this leaves 8 hours off, and when you factor in time to get to and from the crew hotel, there was significantly less than 8 hours remaining for actual sleep. Trips were four days long, so there were three overnights per trip, and depending on how long it took to get to and from the hotel, actual sleep time varied between about 6.5 hours to an hour or so less than that. And let's not even talk about the dreaded stand-up overnight.

Clarification on the stand-up overnight: Okay, so we'll talk about stand-ups for a moment. The dreaded "stand-up" was a 16-hour flight day that started at 18:00 and ended at at 10:00 the following morning. It would begin with 5 hours of flying time between 18:00 and about 2:00 am, interrupted by two hours in a hotel at an outstation, and then topped off with another 3 hours of flying from 6:00 until 10:00 the next morning. The term "stand-up" comes from the idea that there really isn't any time to get any meaningful sleep, so you might as well just "stand up" in the hotel. Seriously, hitting the sack for only two hours felt worse than not getting any sleep at all. Crew Scheduling was pretty good about putting a month's worth of stand-ups into one bid so you had time to get your body used to flying on the back side of the clock. But now and then, stand-ups were thrown into a regular line bid. I did literally thousands of hours of this kind of thing, which was excellent training for flying a complicated and fast aircraft, with no autopilot, into and out of some of the most complex airspace in the United States, whatever the weather, and staying up to the task all the time, using both instruments and flight crew in smooth coordination to get the ship slotted and on the ground safely.

Clarification on the similarities between the stand-up overnight and a transcontinental flight: they're pretty similar. Think of a long duty "day", with a few hours of sleep in the middle, with maximum attention needed at the start and at the finish. Just throw in the fact that the stand-up had multiple takeoffs and landings at each end, in the same airspace, and in the same weather, at the same airports, without autopilot, etc., etc., etc.

Clarification on the universality of my experience: My experience was completely typical. I didn't have it any worse than any other civilian airline pilot in America. My kind of flying experience is what typical pilot-applicants bring to United Airlines, or American, or Southwest, or any other American carrier. (The other typical experience is to get to an airline through the military, but I can't speak to that first hand.)

Sorry this has grown so long! Thanks for reading this far.
Title: Asiana 777 crashes in San Francisco
Post by: SwissCharles on Mon, 7 Apr 2014 16:13
Back from a rather longish lurking spell  but I am still at it - I plan on being one of the 544 eehhmmm... oddballs, so please count me in Hardy ;)  .  With the exception of the throttle quadrant, I do have most of the parts in stock...

There is really nothing to add to Will's very illustrating and very well written view on the life of the average regional pilot except perhaps trying to illustrate another possible explanation to the various kind of pilots...

Will's and my career are virtually mirroring each others! The things we have in common is that we both did our training in the U.S. (me in California) and flying turboprops (me flying Fairchild Metroliners and Saab SF 340's). And I too gave it up after almost 6'000 hrs to pursuit another career. My active career took place in the late 70ies up to 1985 (shows my age, huh  :shock: ) so a little bit earlier than Will's.

The difference lies in the fact that I did almost all of my productive regional flying in Europe (flew for a well known at the time Swiss regional, who went up in Swiss after the failure of Swissair...). But again there's not that much of a difference.

We didn't have the stand up schedule for one thing and the Swiss FOCA didn't allow for the scariest of rostering wishes, the airline would come up with. But the kind of flying we did, was very similar to what Will so well described. Another exception: European Operators in general did equip their planes a bit more 'posh' than their American counterparts. We had autopilots and in the Saab even autothrust - both having a tremendous effect on lowering the overall workload.

But even then - and that's what I like to point out here since I am not sure if this is just a cultural matter of pilot training (US <-> Non-US), or even more a question of a pilot's personality - you had two clearly discernible and rather different kinds of pilots:
Those leaning rather heavily on automation and those who didn't. When things started to get ... interesting (say due to weather or due to some kind of malfunction) you could differentiate between these two groups very easily: The former (also called the System Managers) kept the automatics on (after having them selected on an eye blink after gear retraction  :roll: ...)  the latter (sometimes also called Aviators) turned them off.

As we now see, this trend somehow grew into the current state of affairs. My take on the reason for this: Airlines are trying to save costs in ever new ways and training system managers is probably (far?) more cheaper than to train aviators. And what you pay is what you get (pay dirt - eat sh!t comes to mind). Nowadays they took this even further, if you look at Pay to Fly schemes and such.

For me it is almost incomprehensible how a crew can fly a perfectly serviceable Triple Seven into the ground in CAVOK at a big airport with a decent runway.
This is not in any way to tell how great a pilot I am or was (had my br#wn trousers moments as well  :shock: ) But being able to judge ones glide angle and approximate hit-point seems soooo very basic that I am appalled at the lack of general airmanship - or the lack of airmanship-instilling training of the airlines - as displayed in this absolutely unnecessary crash. But what  can you expect when a return ticket to even far away destinations can be had for an apple and a song.

Sorry for this long post and for extending the off-topic leg a little further. Turning inbound now  ;)

Charles
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Wed, 9 Apr 2014 18:20
I just came across this article by the NY Times on the Asiana San Francisco crash.

http://www.nytimes.com/2014/04/01/us/asiana-airlines-says-secondary-cause-of-san-francisco-crash-was-bad-software.html

I was surprised to read that the crew was confused/lost and that the airline has filed a complaint with the FAA about how the 777's flight director/autothrottle/whatever operate.  How can a crew not know how to operate the primary controls in their airliner?  They claim they had not been trained on how to properly use the 777's system.  I believe they would have had to demonstrate their ability to handle the 777 under all sorts of stress situations in the simulator, and to know when to abort a landing.

------------------------------------------------
Here's a key excerpt:

In San Francisco, the prime cause was quickly clear; even Asiana faulted its crew for failing to notice that the airplane was flying far too slowly to stay in the air. But it is also blaming "inconsistencies in the aircraft's automation logic."

The carrier said Monday in a filing with the National Transportation Safety Board that bad software design "led to the unexpected disabling of airspeed protection without adequate warning to the flight crew," and that a system to warn the crew of low airspeed did not sound soon enough. The airline also said that the approach ordered by air traffic controllers "led to an excessive pilot workload during the final approach."

Boeing has focused on the crew's failure to maintain proper airspeed, which is expected to be listed by the safety board as the probable cause of the crash. Asiana's filing is an effort by the airline to have the plane's design characteristics listed among the contributing factors. The board's conclusions are not admissible in court, but its ranking of factors often influences how a carrier's insurance company and the plane's builder apportion the damage settlements or court judgments.

In the Asiana crash, the crew believed that an auto-throttle would manipulate the engines to keep the plane's airspeed in the range needed for a safe landing, somewhat like the way the cruise control in a car will adjust the throttle to keep the speed constant. It later became obvious that because of a quirk in two tightly linked systems, the autopilot and the auto-throttle, and because the crew had manually adjusted the throttles at one point, the auto-throttle had gone into sleep mode.

This characteristic is well known, and occurs when the autopilot is in a mode called flight level change, which is abbreviated on the relevant cockpit button as "FLCH." The abbreviation has given rise to a nickname the pilots use for the characteristic, "the flitch trap." After the crash, safety board investigators were told by the specialists who train Asiana pilots that not only were the three men in the cockpit warned about the flitch trap, but that they had also been told that they could expect it while landing in San Francisco because the typical approach at the airport required a fast descent and extensive use of the autopilot in different modes.

But Thomas Haueter, a former director of the office of aviation safety at the board and now a consultant to the airline, said the flitch trap was "a bit of a setup for the unwary."

If the crew had turned off the auto-throttle, he said, a separate system would have kicked in to keep the engines running hard enough to prevent aerodynamic stall. But with the auto-throttle in sleep mode, "there's no protection at all, you've got nothing," Mr. Haueter said.

The Asiana pilots union, in a separate submission to the safety board, said pilots were not trained on this characteristic of the 777.

The airline's submission notes that in 2010, when another Boeing plane with a similar auto-throttle, the 787, was being certified by the Federal Aviation Administration, the F.A.A. raised concerns about the way the throttles went into sleep mode. But Boeing declined to make a change and agreed with the F.A.A. to put a warning into the pilot manuals.

After the crash, when test pilots from the F.A.A. and the airline tried to fly the approach that air traffic controllers had given the Asiana flight, they had severe difficulties doing so while following other rules, according to papers filed with the board.

The airline's submission also acknowledges other errors by the crew. For example, Asiana, like all big carriers, requires that the pilots be on a "stabilized approach," lined up horizontally and vertically, at the proper speed with the flaps extended to the proper degree. If the crew is still making adjustments below a certain altitude, the pilot is supposed to break off the approach and go around for another try. In this case, one of the pilots called out that the plane was too low.

Boeing's submission said that "all airplane systems were functioning as expected prior to impact and did not contribute to the accident." It added that the crew had cues that it should have stopped the approach because of the plane's speed and because the thrust setting was incorrect.
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Wed, 9 Apr 2014 18:48
http://avherald.com/h?article=464ef64f&opt=0

details here -


quote:

QuoteOn Mar 31st 2014 Asiana submitted a 46 page document, looking like and easily confused with an official final investigation report, stating that the crew was conducting a high energy approach (from a high and fast posture). At 1600 feet AGL the flight director/autopilot changed to FLCH, however, none of the pilots recalled pressing that or related button, the automation went into go-around mode accelerating the engines for the go around and the autopilot going to acquire the go-around altitude. The pilot flying disconnected the autopilot, called "manual flight". As the aircraft was still high and fast, he pulled the thrust levers to idle, which changed the autothrust function from thrust to hold disabling airspeed protection and automatic wake up function. At 500 feet AGL the aircraft was on glide (PAPI two red, two white) at 135 KIAS 2 knots below VREF still within stabilized approach criteria. During the next 17 seconds the airspeed decreased to 118 KIAS and the aircraft descended to 200 feet AGL, the PAPI now showed 4 reds (below glide). 7 seconds later a quadruple chime sounded, the pilot flying advanced the thrust levers to go around and called "go-around", pitched the aircraft up by about 10 degrees, the engines however were still at idle and the aircraft continued to lose altitude - the stick shaker activated 4 seconds prior to impact - and impacted the sea wall about 11 seconds later.

Asiana complained: "In almost all situations, the B777's autothrottle system supports stall protection and ensures that the aircraft maintains a safe airspeed. However, if a plane is in FLCH mode, the autothrottle will enter HOLD mode if: (1) the throttles are at the aft stop (i.e., engine is in idle); or (2) the throttles are manually overridden. In HOLD mode, the autothrottle is engaged (on), but it does not provide any input to the throttle levers or engines. The servos are disengaged from the throttle levers. Therefore, while the autothrottle is technically on, it is providing no service to the flight crew. ... Boeing makes clear that the autothrottle is an essential tool, stating that "[a]utothrottle use is recommended during all phases of flight," including "[w]hen in manual flight." ... In contrast to the repeated references to the comprehensive airspeed protection provided by the autothrottle system, the Boeing 777 FCOM contains only a single, one-sentence note which can be read to suggest that autothrottle will not support speed protection when in FLCH mode. The note reads: "When the pitch mode is FLCH or TOGA, or the airplane is below 400 feet above the airport on takeoff, or below 100 feet radio altitude on approach, the autothrottle will not automatically activate."
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Wed, 9 Apr 2014 18:59
actually, this does not make sense to me -

this "filch trap" should only be relevant below 100ft RA on approach - they were already way below  vref at 200 fr RA....    (118kts at 200ft)

What mode selection, or disconnect/disarm combination of the AT system would result in the acft loosing all speed protection?

fc
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Thu, 10 Apr 2014 02:20
QuoteBut Boeing declined to make a change and agreed with the F.A.A. to put a warning into the pilot manuals.

Although this may sound like Boeing simply did not want to put any effort in this "trivial change", mind you that changing the fundamental software in an autothrottle computer means a lot more than changing a line here and there.

This is DO-178 design assurance level A or B software, as far as I know. Touching it means a few man years worth of paperwork to document exactly what you want to change (requirements update and review), an extensive safety assessment, full documentation of expected impact on safety and any other aspect including other documentation, setup of tests to test the effect before and after the change, documentation of required lab and flight tests, a complete planning and then you can submit to the FAA what you intend to do. Note that no software specialist has been involved yet.

Then you make the change, and painstakingly work through all of your A/T computer code to assure that all your requirements, tested by all your tests, do touch all your code statements, conditions, and modified conditions -- basically all words in your code must have been touched at least once during the full test programme. Oh, detail, the A/T is part of the FMC (I am not sure this is also true on the 777 but it is elsewhere). Oh, so we need to just re-test all of the FMC code.

Then we submit it to the DER for review, and file for flight test requests to put the thing through all possible permutations of modes that may get us to the changed line of code. Just a few dozen hours of flying approaches in a 777 with three experienced test pilots at the helm and a few engineers in the back to log every wink of the autoflight system.

The van to take the resulting paperwork to the FAA needs to be a Super Duty variant. Only senior managers having the right stuff will dare to put their signature on it, both on the FMC manufacturer's side, Boeing's side, and the FAA's side. Expect a bit of politics here. And a few careers at stake. Somebody will delay the project until he retires.

Five years later, you are done and you can propose the FAA to roll out a worldwide FMC code update. It will require a worldwide flight manual update, retraining of flight crew and trainers, reprogramming of simulators which do not use the actual FMC for cost reasons, re-certification of said simulators, etc.

Alternatively, you put a "WATCH OUT!" sign in the manual and call it a day.



Hoppie
just a level D guy, and not anxious to get any higher just yet
Title: Asiana 777 crashes in San Francisco
Post by: CarlBB on Thu, 10 Apr 2014 07:44
Interesting insight, thanks Hoppie.
Title: Asiana 777 crashes in San Francisco
Post by: Phil Bunch on Thu, 10 Apr 2014 15:41
Hoppie,

Your summary was most interesting to read.  Boeing must employ a huge number of people just to manage the review and approval processes for airliners - it's mind-boggling to think about the paperwork required to produce a new airliner!  It must have taken "100,000 person-years" of paper creation to obtain ETOPS approval, for example!

I assume that the intensive approvals for aviation-related hardware and software is a substantial reason why even the simplest airplane part is extremely expensive.  

Would a similar certification process be required for other countries or does every other country just take the FAA's approval as "good enough"?  For example, from distant memory, I *think* regulated medical products can often use an abbreviated or accelerated approval process after they have obtained approval in another major country or region.
-----------------------------------

Some background - I worked in medical imaging systems R&D for a large company for my whole career, and we had to deal with the US Food and Drug Administration (FDA) as well as national and international standards.  However, the products I worked on were not highly regulated, unlike medications or implanted surgical devices.  As long as your products were both low risk and generally similar to long-standing products, there was no need for extensive clinical trials,, etc.  Most of the problems we had to cope with were related to minor but not ignorable problems that slipped through manufacturing QC or that developed under real-world customer use conditions.  Sometimes this caused a very expensive product recall, but this was fortunately a rare event.
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Thu, 10 Apr 2014 21:52
As far as I know, there are two major certification organisations worldwide, FAA and EASA the European equivalent. They do recognize each other's approvals with minimal paperwork and it depends on who wants to certify what, where you go first. If you certify with another organsation it may be more work to get the big guys to accept your material, but it will always help.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: IefCooreman on Tue, 15 Apr 2014 09:08
Took a while, because pretty long :-)

Farrokh747:
The misconception results from people thinking the autothrottle wakeup is the only stall protection on a 777. In a descent, in FLCH and VNAV SPD modes where the autothrottle has changed to HOLD, the autothrottle wakeup will not activate because the philosophy of these modes is that pitch governs the speed. The 777 however also has a "stall protection" in pitch. The fly-by-wire disables the speed trim system once you really slow down into the yellow band. So the pilot is forced into pulling the stick if he really wants the nose high attitude, or the nose will drop down (so, yes, the Asiana pilot was pulling the stick in the end, fixating outside on the runway). The mistake they made is you shouldn't be in FLCH that close to the ground.

To go back to the answers of Will and SwissCharles. I agree up to a certain level (although to me it becomes a question of attitude and thrust, you don't need a speed indicator) however statistics show that the idea that the well trained pilot should be the ultimate last protection is "incomplete" and solely does not allow for safe aviation. The reason is simple: there is hardly any backup for you. And this is where the focus of training has changed. You don't allow anymore for such situations. Murphy never shows up with 1 single problem... And there is one certainty: we are human, we all make mistakes.

Old simulator training habits (at least from my experience): failing as much as possible until the pilot was left with only himself. If he landed, job wel done. Modern training has completely abandoned this approach. In modern training you could call "threat" a keyword. From the moment you enter the crewroom, you look for threats, and you pre-build defences. This allows for mistakes or problems to happen, and you can deal with them in a safe -unrushed- way. The airplanes we fly are very automated, which results in VERY safe normal flights. But there are many many layers in all the systems. Our job becomes one of checking and working with different layers, assessing and reviewing the possibilities if one layer becomes inoperative. Use of automation is one of these layers, because monitoring is much easier than executing (overview vs focussed). Modern simulator checks are filled with "calm" compared to old school checks. The emphasis is about gathering information, showing you know your aircraft capabilities, your own capabilities, creating safety, creating safe options, choosing, reviewing if anything changes,...

Downgraded situations do not make the flight unsafe, it only forces us to review the possibilities the aircraft-crew combination is giving the crew. Is ETOPS still safe? MNPS? RVSM? High altitude destination still an option? A tiny downgrade can have big consequences if you don't consider it. Even in time-critical situations (smoke, fire, low fuel) you need to choose the path of the "least threats for the available time".

This does not stop you from flying manual. But you choose the right circumstances; situations where there are no extra threats. Boeing allows you to cut out automation and continue to fly manual, when you consider the situation acceptable. Boeing officially also recommends standard use of automation for visual approaches as long as feasible. The big thing here is: it is YOU as a pilot who decides. It should NOT be ATC. If you are tired or stressed (threat), Boeing would rather see you create a visual reference point on final in the FMC, and using LNAV/VNAV for the approach. On the long haul, you don't have the chance to do a lot of visuals. When an ILS is inop, the experience of both pilots will be discussed. When one has done a visual recently and feels up for it, a visual is an option. If there is no experience, a visual simply becomes a threat. This way of thinking is more important than just being able to do it. I might as well quote one of my first bosses: "anyone who elects to fly a manual circle-to-land after an engine failure and successfully lands, I will invite personally to my office and it will be the last visit he makes"

Now you could say, more training is required then. Every three months extra simulator sessions with the focus on very basic flying. I agree completely. However, this is a money thing... for the moment regulations define minimum training requirements, and we deal with it. On the other hand, as a pilot I already feel "overly checked", simulator every six months, theory courses, line check, medical,... And I think for the moment we have come a long way in aviation, flying has become extremely safe. And training still evolves as well. We still make mistakes, but we catch them a lot more, earlier, and create options that are much easier to deal with.

The discussion today: crashes like the AF out of Rio, the Asiana in SFO and the Turkish in Amsterdam, show that despite having an extra layer of automation, pilots have difficulty in stressfull situations of interpreting what is happening exactly. The philosophy of the "automation user-interface" today is still one where information is not always clear to the pilots. The pilot of the AF kept pulling the sidestick back, because he was trained to do so for stall recoveries and the real important messages of the aircraft got lost in the overflow of other systems failing as well. The Asiana was in training and unaware of his autothrottle functionality, hence he was not as protected as he probably thought he'd be, and so was the Turkish crew fooled by a failing radio altimeter. And all of them reacted in the end, but too late.

Jeroen:
My "problem" with American ATC (although I admit, it's pretty much "approach" frequencies) is that they have no consideration at all for your situation as a pilot. You should be able to do what they tell you. They are sitting behind a desk, I can accept that at times they have big problems to solve (everybody needs to get in, everybody needs to get out), and therefore they expect you to do exactly as told. But it's a "no errors allowed" environment, so from my viewpoint: unsafe. And they will use the "visual" rules to make their own life easy, but it makes our life harder – more threats. They haven't evolved. There are still too many "chaos" situations you hardly ever find on other major airports. And it's chaos because humans try to do everything too much "anticipating", not "prepared". On the long haul you can offer flexibility, but you require more time to prepare. New York never has time. But that's only my feeling.

Anyway, these are only my own thoughts on the subject(s). Time to go out and face my jetlag now :-)
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Tue, 15 Apr 2014 11:14
Thanks Ief...!
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Tue, 15 Apr 2014 13:06
I can attest that in those couple of cases I found myself up front in a light jet aircraft in the US, ATC has been "interesting" during the final 5-10 minutes. I thought they just liked to drive the sports car hard, but apparently it is more like don't-care? Directing you straight towards the field until 5 nm out at 4000 ft and then declaring you cleared for the visual. It's that we expected it, but else ... barn doors out ... The other fun one was being about 30 nm from Memphis still at FL450 to keep us on top of the heavies and then having us shoot the bull's eye. My ears still hurt.


Hoppie
Title: Asiana 777 crashes in San Francisco
Post by: Richard McDonald Woods on Tue, 15 Apr 2014 15:25
Very interesting how we (don't) learn from all the combined experiences of human-human and human-machine interactions.
Title: Asiana 777 crashes in San Francisco
Post by: Will on Tue, 15 Apr 2014 15:44
I talked to an approach controller who told me once that she loved turboprops, because they could scream in at 250 kts until short final and then slow down to approach speed in something like two miles, whereas the heavies had to make more subtle changes. (Oh, so that's why the ride was always so thrilling...)
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen D on Wed, 16 Apr 2014 04:35
Thanks Ief.

Regards, Jeroen
Title: Asiana 777 crashes in San Francisco
Post by: IefCooreman on Thu, 17 Apr 2014 11:36
Almost out of jetlag... think I need a character counter or limiter in the reply box...
Title: Asiana 777 crashes in San Francisco
Post by: farrokh747 on Mon, 21 Apr 2014 04:54
Visual approach with camouflage'd papi and strip ...

https://www.youtube.com/watch?v=N-KnxDTyGIo
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Fri, 11 Jul 2014 00:13
Report in progress.

http://www.skybrary.aero/index.php/B772,_San_Francisco_CA_USA,_2013_%28LOC_HF_FIRE_AW%29

(http://www.skybrary.aero/images/thumb/B772_KSFO_wp1.jpg/500px-B772_KSFO_wp1.jpg)
Title: Asiana 777 crashes in San Francisco
Post by: jb747 on Fri, 11 Jul 2014 01:00
That'll keep several folks employed for many years to come...
Title: Asiana 777 crashes in San Francisco
Post by: Jeroen Hoppenbrouwers on Fri, 11 Jul 2014 01:20
... to say the least ... what a list!