Crash at San Francisco

[stu7708 244]

Just a horrible sight to see those images.. and just imagine how much worse the situation would have been if they had hit that plane passing in the opposite direction..

 

This CNN video with comments on the data on the FDR does point even more in the direction of Pilot error and a Controlled flight in to ground as the cause of the accident...

 

http://edition.cnn.com/video/data/2.0/video/us/2013/07/07/black-box-sheds-light-on-flight-214-.cnn.html

 

 

[allardjd 1,853]

The other AC was at the hold short line to the over-run area.  A few seconds earlier the tower had offered him a "line up and wait" and he declined, saying they needed another few minutes to be ready.  If he'd taken that, he'd have been square in the impact area.  They must have had a ring-side seat, if they had their heads up and were looking, but may have been busy, heads-down in the cockpit.  Haven't heard any statements by them.

 

They deplaned them there and bussed them back to the terminal, later using a tug to move the plane back.

 

John

[allardjd 1,853]

It boggles the mind how a trained, certified, licensed, type-rated crew can screw up a 13+ NM, daylight, straight-in visual approach to an 11,000 foot runway in clear WX, light winds and good visibility, but they did.  No credible indication yet that there was anything wrong with the airplane.

 

The NTSB has said that the PAPI lighting system was on - there had been some disagreement earlier about that.  Also, the localizer was on, but not the glide slope.  NTSB also said something to the effect that they were below Vref and "...not just a few knots..."

[britfrog 180]

It has now been announced that the ILS on 28L was inop, and that the plane was conducting a manual approach, and sadly therein lies the problem. Nowadays pilots carry out too few manual approaches as the automatic systems can in most cases carry out a better landing. Some airlines demand that pilots carry out a manual landing at least once a month others have no rules at all.

The 777 engines  were at idle 7 seconds before the crash when a pilot discovered they were below their target approach speed, the engines should have been at least at 35% to stop speed erosion with flaps out, because turbines take a lot of time to spool up if needed, also in case they need to overshoot for whatever reason. The stick shaker also was activated indicating they were on the edge of stall, It all looks very much that the crew were not monitoring systems as they should have been as they are so used to doing it in autoland , I think they still shouldd have had the autothrottles engaged until the flare if they had done at least this they wouldnt have stalled, Sadly it looks like 3 pilots heads are on the chopping block, plus the airline for not insisting on manual landing recency. No doubt it will all come out in the wash, sadly two died but it could have been a lot worse if he had stalled 5 seconds before and run head on into the harbour wall.

[stu7708 244]

I saw a report in a Swedish newspaper that the Pilot Flying (and according to other sources that would be the Captain) wasn't certified on the 777 yet, the flight was part of his certification process.. he was an experienced pilot with over 10.000 hours in the 747 and other airliners though, but had only 43 hours in the 777.

 

Not sure how reliable the source is but that's what they claim...

[britfrog 180]

yeah it appears that the training captain wasnt keeping as good an eye on things as he should have been, still no excuse for P2 to be sitting on his thumbs as well.

[allardjd 1,853]

_{I'm reading that many of the injuries are pretty severe, including some cases of paralysis.  It appears that the AC more or less ground looped while skidding out and ALMOST flipped over, going 40 or 50 degrees off horizontal at one point.  If it had gone over the number of fatalities would certainly have been much higher, if not 100%.}

 

_{I'm also seeing that SFO approaches often require some fairly severe step-downs that can be a challenge getting a big airliner down and which delay being able to establish a stabilized descent until fairly close in.  While that is almost certainly a contributor to a mis-managed approach, there's simply no excuse for letting the airspeed get so dangerously low and for not initiating a go-around earlier, i.e. while it was still possible.}

 

_John

 

_{EDIT:  In this case they were at 4,200 at about 14 NM, which doesn't seem that severe but I'm not sure at what point they were able to come lower.  If too close in, that might still be challenging.  Three degrees is roughly 300' per NM.}

 

_JDA

 

 

[brett 2,316]

There has also been scuttlebutt about the pilots for that airline having more ego than experience and the CoPilot knows not to question the Captains, lest they be admonished. Is this true ya think?  

[allardjd 1,853]

Very true in some Asian cultures, Korea possibly the most prevalent in that respect. They have a very high degree of respect for and deference to their elders and those above them in chains of command.  Going the other way, it is often seen as a right by those in "left seat" situations and they are not too accepting of questioning, implied criticism, etc.  It has been a factor in several past crashes of Korean airliners. 

 

I should note that this is cultural, not racial before someone gets their knickers in a knot.

 

John

[brett 2,316]

That's almost criminal behavior for professionals.

[icudan 5]

Hi, Flightradar24 have analyzed the last 150 seconds of data from the flight. as you can see in the below picture. According to their analysis it looks like the ADS-B transponder continued to transmit data for about 10 seconds after the first impact. You can also see that the altitude increased after the first impact, when the aircraft bounced up in the air. The ground speed in the last seconds of the flight was only 112 knots.

 

[icudan 5]

Sorry there is also a kml file they have done if you want to watch the last 150 seconds on Google Earth. http://ge.tt/45Z3VGl/v/0?c

[allardjd 1,853]

Correction of what I said in an earlier post - only one of the two fatalities was found in the debris field back near the runway threshold.  The other was found only 30 feet from the aircraft.  That is the one that they suspect may have been struck by a responding emergency vehicle. 

 

John

[brett 2,316]

Hmmm, The fire trucks didn't look like they had gotten that close. If that is the case, I feel sorry for the driver.

[allardjd 1,853]

The most amazing fact I've heard so far (from the NTSB briefing video) - the fuel tanks did not rupture and there was no evidence of a fuel-fed fire. More kudos to Boeing for building a very strong airframe.

 

The fire that did occur resulted from a ruptured lube oil tank in the right engine. That engine was broken off the wing and was lodged against the side of the fuselage.

 

John

[allardjd 1,853]

It gets worse...

 

Third Chinese girl dies from injuries in SF crash

 

http://apnews.myway.com/article/20130713/DA7GH1PG2.html

 

John

[GHAO 0]

I read an interesting analysis of this crash, that compared the energy profile (or potential and kinetic energy) against that of a 777 that landed a few minutes before. The Asiana was too high, but then the kinetic energy dropped under the sweet spot as the pilot reduced thrust to idle, and she started to drop below the glideslope - which the pilot did not recognise since the ILS was out. As others have said, it's 7 seconds or so to spool one of those engines up. And my experience on FS with 777 is to do everything early... and not hit the ground close to stall speed, 112 knots.

The same analysis had many comments, including some harrowing ones from pilot trainers over in Korea, talking about the culture there - how they could learn the rule book by rote, but not actually understand any of it. The trainer got fired after failing one captain who mucked something up (can't remember what but it was way over my head!)...

[allardjd 1,853]

Possible smoking gun here. There's an Autopilot mode called FLCH (Flight Level Change) that, if used on an approach, can cause the autothrottles to be out of the loop. It's not certain this is exactly what happened but it's a plausible explanation. I don' think it in any way relieves the crew of responsibility for the accident but may shed some light on how it came about. Good article...

 

http://www.aviationweek.com/Article.aspx?id=/article-xml/AW_07_22_2013_p25-597816.xml&p=1

 

John

[David TRIGGS 0]

Absolutely ... FLCH (flight Level Change) on the autopilot would be very unwise so close to the ground .... but surely in good visibility no commercial jet is going to be landed with the Autopilot, surely? ...... my info on this is that final approach is always taken in manual!

David

[allardjd 1,853]

Off a discussion board! From a retired United Captain.

 

Low-down on Korean pilots

____________________________________________________

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 didn't’ 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.

 

[Name Withheld]

[brett 2,316]

I guess saving face is more important than people's lives. This fellows post is an eye opener that will go nowhere due to ingrained attitudes from the higher ups.  

[Bruce (a.k.a. brian747) 142]

    Thank you, John. Whilst hugely depressing, that account goes a long way to illustrate the seeds from which such an accident might have grown.

 

My own experience was extremely technical albeit not aviation-related, and on a different eastern subcontinent, but a lot of what "Capt Brown" said resonated strongly with me, especially regarding an over-reliance on rote memorization and a disproportionate respect for authority. In my own experience, there was also a widespread culture of cheating in order to acquire meaningless paper qualifications with no actual experience, but that might be inapplicable in Korea.

 

It is hard to see what can be done to improve matters unless international action is taken and independent certification takes place.

 

Cheers,

 

Brian

 

[Andrew Godden 945]

The link below is for a 25 min segment out of an AA training session on "Automation Dependency" posted in Nov 2011.  It's an excellent video with some great moments in the delivery.  The bottom line is simply brilliant or brilliantly simple, "Fly the airplane first.", a message if heeded by Asiana pilots could have possibly avoided the tragedy.

 

There is a section on FLCH and I think it suggested the lag in these command inputs translates to something like 0.23 nm.

 

http://www.youtube.com/watch?feature=player_embedded&v=h3kREPMzMLk

 

Cheers

Andrew

[britfrog 180]

The story of this capt brown is all too familiar to me, my father was originally sent to the caribbean to train the then cpl/ir's which most of the commercial piots were, to atpl standards. like capt brown he came up against a wall after a few years and was eventually railroaded out.

 

I in my last few years of piloting always insisted that me and my f/o carried out a manual landing at least once a week, however this was reported back to the senior jobs worth who banned the practice "as the autopilot always makes a better landing than a human can"

 

BA suggests that pilots should carry out one manual landing every month or so when conditions  are agreable

 

the problem we have now is that the bean counters have already started down the road to single pilot occupancy with a senior member of the cabin staff trained to a level of competency that he should be able to take over the a/c if the pilot becomes disabled,

this increasing level of insanity will have a direct effect on the safety of air travel.

[britfrog 180]

I read an interesting analysis of this crash, that compared the energy profile (or potential and kinetic energy) against that of a 777 that landed a few minutes before. The Asiana was too high, but then the kinetic energy dropped under the sweet spot as the pilot reduced thrust to idle, and she started to drop below the glideslope - which the pilot did not recognise since the ILS was out. As others have said, it's 7 seconds or so to spool one of those engines up. And my experience on FS with 777 is to do everything early... and not hit the ground close to stall speed, 112 knots.

The same analysis had many comments, including some harrowing ones from pilot trainers over in Korea, talking about the culture there - how they could learn the rule book by rote, but not actually understand any of it. The trainer got fired after failing one captain who mucked something up (can't remember what but it was way over my head!)...

 

modern jets are not like small  a/c you have to fly them on cutting power only when above the runway you should try a proper simulator , this is something that comes home  immediately after your first "landing"