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Asiana 777 San Francisco crash NTSB hearing

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I just read this interesting article which releases some information the NTSB has learned so far in it's investigation into the July 6th crash landing of a Asiana 777-300 at KSFO. 

 

http://www.washingtonpost.com/politics/pilot-who-crashed-at-sfo-worried-about-landing/2013/12/11/26aa659c-62cc-11e3-af0d-4bb80d704888_story.html

 

One big takeaway for me is the value of ample simulator time.   The training pilot at fault admits he was uncomfortable with his level of experience with the 777's autoflight systems, and the article specifically brings attention to the pilot's confusion about the supposed ability of the autothrottle to "wake" itself from the hold function if the systems sense a drop below safe minimum speeds.  Just my opinion, but his testimony reads like someone posting a bug report on the PMDG forum because they did not read the manual.   Imagine if this fellow had the PMDG 777 at his disposal, say on his laptop at the hotel or training center, since he admits he was very unprepared and did not study the systems well.   His unfamiliarity was probably a symptom of ineffective classroom training, or lack of access to the simulator because of cost concerns, but I can't help but think how PMDG can tap an under served market for a cost effective, easily accessible training/practice medium like the PMDG study quality sims.   I know if I was training, I would always be practicing in the FSX environment in my spare time to learn as much as possible. 

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From the article... "Junior officers’ reluctance to speak up has been an issue in past accidents, though industry training has tried to emphasize that safety should come first."

 

This s#^t needs to STOP!  How many more lives are we going to lose because of this nonsense? 

I wonder what really goes on behind the scenes in this profession?  I know there is a hierarchy with employees in aviation, but what would cause "junior officers" and first officers to stay quiet when they clearly know something is wrong or feel they're not capable yet?  I doubt they're going to get a sucker punch from the PIC for speaking up.

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Interesting read this.   I have to say that a number of things seemed to conspire against the pilot here.   Firstly, his misunderstanding of the "wake-up" function of the auto throttles, and because of the stress he must have been under knowing that he is inexperienced and then attempting a manual landing on an aircraft in which he has so little experience.  

 

He was already intimidated by the machine and by his own insecurities and then piled on top of that the fact that it seems to me that the crew failed to observe proper CRM procedures, and worse still, it seems as though the crew was not properly briefed on how to handle certain situations if and when they occur.   The fact that the pilot thought only the instructor pilot can issue the command to abandon the approach and landing is a bit shocking.  

 

What should have been the case is that the pilot flying should always know that if he is in command of the aircraft at that stage, he is the one making the decisions and if he is uncomfortable with the approach, he should abandon it and shoot another one.   It is his call, not the instructor.

 

It also seems that there is a cockpit gradient problem here.   We may love or hate the Aussies ( :P ), but one thing that no-one can accuse them of is this very issue.   Qantas is the one airline where (if I understand it correctly), the FO is encouraged to challenge the Captain's decisions if he believes that the flight is in danger by virtue of the Captain's actions.   An environment is created where pilots are encouraged to speak up, no matter how junior you are.  

 

 

 


One big takeaway for me is the value of ample simulator time.

 

I agree with you there.   It doesn't really matter how many hours you have on other aircraft, it is the one that you are flying at that moment which counts.   Basic airmanship alone is not enough when you are not familiar with the aircraft and it's systems and a simulator is invaluable to teach you the basics.

 

Another troubling aspect is the fact that it seems the pilot had been distressed about it prior to this particular flight, but did not speak up about his fears.   This is where the British have created a masterful system, called CHIRP.   Here pilots can anonymously raise concerns that are taken seriously and addressed.   This way they don't have to fear for getting into trouble and they can be sure that their concerns enjoy priority and are being addressed.  

 

All things considered as the NTSB stated, it is never just a single cause, it is a number of things that conspire and leads to the accident.   I believe the airline and their procedures may be the ones who carry the most of the burden here and it may be where the NTSB places the most weight.

 

Kind regards

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I don't mean to be "Monday Night Quarterbacking" and I do understand that this investigation is far from over but let me point out some things;

 

1- Basic flying skills. You cannot just rely on an ILS, every single airline pilot needs to be able to shoot a visual. I don't care what airplane, how familiar or unfamiliar with the aircraft the pilot is. You need to be able to recognize when you're below glide path.

 

2- How many hours did this pilot have? He should have spoken sooner about his concerns. In the US it is instilled upon us to speak up. This is no time to be prideful, there are innocent people in the back that depend on you to do your job. Everybody has limits. If you exceed your limitations please speak up.

 

3- This light that he's talking about. Could it have been glare from flying over the water? What is the concern about using sunglasses? It's considered rude? That's plain ignorant.

 

4- The pitfalls of relying too much on automation. See 1. It should have never come to this point. I've seen so many pilots rely way too much on automation to the point of loosing touch with the airplane. Automation is an aid, not a crutch.

 

5-Preflight briefing/approach briefing. What happened to it? If he was the PIC or SIC, Pilot Flying or Pilot Monitoring, he should have been very clear that he could initiate a missed approach and not wait for the instructor to call it. If the article is correct I don't buy his story at all.

 

6- Why wasn't the FO more assertive? To the point of taking over the controls. It isn't all that uncommon here in the US to call out any deviation, especially during critical phases of flight. If the diviation isn't acknowledged and corrected then the Pilot Monitoring can take over the controls. I don't know of any captain that wouldn't thank the first officer for doing that. In this case it would've been an incident report instead of loss of life.

 

I hope this never happens to me or to anybody else. It's sad that at this day in age flightdeck crews can still be intimidated by the fellow next to him just because he has an extra stripe.

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Autothrottle "wakeup":

 

It's supposed to provide a safety margin in case the pilots lose awareness of their airspeed. It's NOT a "set up and forget about airspeed completely" system.

 

Three pilots in the cockpit didn't care a thing about airspeed for a prolonged period. And the authrottles weren't even armed during that stage.

 

Flying the airplane comes first. Not exactly knowing about the A/T wakeup is a lame excuse for three long-term pilots lacking basic airmanship.

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Historically, in Asian countries, there was a reluctance for the junior or second officers to speak up against the pilot in command.

This stemmed from the fact that most pilots were recruited from military sources where obedience was instilled in the co-pilot not to question the actions of the captain.

This lead to accidents in countries like Taiwan and Singapore being commonplace.

 

It seems this culture is still prevalent even now.

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but I can't help but think how PMDG can tap an under served market for a cost effective, easily accessible training/practice medium like the PMDG study quality sims.

Funny you say this, a few years back I got to know former ZOOM airlines chief and check captain Mike Simmons. They flew 757/767 and he told me that all the guys there were issued a copy of the LVD 767 to practice the systems on.

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I just read this interesting article which releases some information the NTSB has learned so far in it's investigation into the July 6th crash landing of a Asiana 777-300 at KSFO. 

Just a quick correction, it was a 777-200ER, not a -300.

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Autothrottle "wakeup":

 

It's supposed to provide a safety margin in case the pilots lose awareness of their airspeed. It's NOT a "set up and forget about airspeed completely" system.

 

Three pilots in the cockpit didn't care a thing about airspeed for a prolonged period. And the authrottles weren't even armed during that stage.

 

Flying the airplane comes first. Not exactly knowing about the A/T wakeup is a lame excuse for three long-term pilots lacking basic airmanship.

 

A/T arm switches were never turned off - here's how I'm understanding what they did:

 

1. They went V/S after the San Mateo bridge and dialed the MCP up to 3000 for the missed approach. (which is the correct thing to do if you want to do this on A/P)

 

2. Apparently due to thinking they were high, they pressed FLCH at 3 miles out. FLCH is not supposed to be used in an approach environment and the fact that they pressed it while the MCP altitude was *above* them indicates they didn't really understand the mode. FLCH will not continue a descent with the missed approach alt set like VNAV PTH, V/S or G/S will.

 

3. After they pressed FLCH the thrust started coming up and the aircraft started to pitch up to climb to 3000. (as it should - FLCH is a simple pitch-for-speed mode and only does what you tell it to with the MCP altitude and speed knobs) At this point they disconnected the A/P and manually held the thrust levers back against the idle stops when the airplane started doing something the PF didn't expect. If you do this for 3 seconds on the 777 the A/T mode goes to HOLD. (this is documented in the manuals) Because they left it in FLCH, the A/T never woke up because it was expecting a climb to 3000, not a continued descent in the other direction. That's where it stayed until a few seconds before impact.

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I know if I was training, I would always be practicing in the FSX environment in my spare time to learn as much as possible. 

 

Reality is his training is the responsibility of his employer and this situation appears extremely lacking on the employers part. Biggest challenge today is training pilots quickly enough to meet the demand of orders of new aircraft or replacing the retiring seniors.

 

Practicing on FSX or any other way sounds good on your own time however doesn't take responsibility away from the employer to provide a decent training program and sign off on competency. A serious overhaul in the culture at Asiana seems in order here.

 

Some may argue that practicing in FSX alone can be a bad idea because a person can pick up a bad habit when not under supervision of a trainer and repeat that bad habit in the job. Remember FSX or P3D on a home computer or laptop is not certified flight training.

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Ryan,

 

can you post a link to the info that says they had 3000 set in the MCP? It was my understanding they had 0 dialled into the MCP whilst in FLCH hence why thrust went to HOLD.

 

Quite shocking that they would keep the levers back in Idle whilst the A/T is trying to spool up the engines, wouldn't that discredit the fact that they believed the A/T was switched off!?

 

Cheers

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Sorry for my "A/T not even armed" statement: I thought I'd remember earlier crash coverage stating exactly that.

 

Forgetting about the MCP ALT set for the MA is one thing; fighting the aircraft pitching up with idling the throttles is a completely different kind of "airmanship" ...   wacko.png

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Another thing I thought of here.  Wouldn't a HUD have helped on an approach in a case like this? It would make it apparent that you were on course to coming down short if you didn't change something quick. I also agree that increasing simulator and hand flying time for transitioning pilots might help. And for unusual situation-have to think of Air France 447. Ironically, despite all of the automation, when things go wrong it still all comes down to basic piloting skills. Maintaining those in the highly automated environments of today is going to be a real challenge. 

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I don't mean to be "Monday Night Quarterbacking" and I do understand that this investigation is far from over but let me point out some things;

 

1- Basic flying skills. You cannot just rely on an ILS, every single airline pilot needs to be able to shoot a visual. I don't care what airplane, how familiar or unfamiliar with the aircraft the pilot is. You need to be able to recognize when you're below glide path.

 

2- How many hours did this pilot have? He should have spoken sooner about his concerns. In the US it is instilled upon us to speak up. This is no time to be prideful, there are innocent people in the back that depend on you to do your job. Everybody has limits. If you exceed your limitations please speak up.

 

3- This light that he's talking about. Could it have been glare from flying over the water? What is the concern about using sunglasses? It's considered rude? That's plain ignorant.

 

4- The pitfalls of relying too much on automation. See 1. It should have never come to this point. I've seen so many pilots rely way too much on automation to the point of loosing touch with the airplane. Automation is an aid, not a crutch.

 

5-Preflight briefing/approach briefing. What happened to it? If he was the PIC or SIC, Pilot Flying or Pilot Monitoring, he should have been very clear that he could initiate a missed approach and not wait for the instructor to call it. If the article is correct I don't buy his story at all.

 

6- Why wasn't the FO more assertive? To the point of taking over the controls. It isn't all that uncommon here in the US to call out any deviation, especially during critical phases of flight. If the diviation isn't acknowledged and corrected then the Pilot Monitoring can take over the controls. I don't know of any captain that wouldn't thank the first officer for doing that. In this case it would've been an incident report instead of loss of life.

 

I hope this never happens to me or to anybody else. It's sad that at this day in age flightdeck crews can still be intimidated by the fellow next to him just because he has an extra stripe.

So true my dad told me stories of copilots getting there iPods out and reading a news paper as they flew the over pole portion(The captain and co-pilot went to the bunks at this point for rest) of the US to Asia flights. When he'd wake up and go back to the cockpit he'd usually get mad and them and ask where the plane was at, and most of the time they didn't know so he'd make them get a map out and figure it out instead of just looking at the screen. Automation of the cockpit is a bad thing! It promotes complacency which is not something any pilot should have whether flying a c152 or a A380.

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Sounds like your dad was pulling your leg on that one :) If not let me know what airline he works for so I can avoid! Sure newspapers and iPods are the norm during cruise, so I take it his F/O wasn't doing fuel burn checks at every waypoint?

 

Anyway, automation of the cockpit isn't a bad thing, it helps to reduce workload if used correctly.

 

Automation dependency is a bad thing, combine that with poor training, poor CRM & fatigued crew members on approach after a longhaul and you have an accident waiting to happen.

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He's retired now but flew for United and the story about the F/O's not knowing where they were is true.

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can you post a link to the info that says they had 3000 set in the MCP? It was my understanding they had 0 dialled into the MCP whilst in FLCH hence why thrust went to HOLD.

 

One of the captains said (according to the interview summaries available at ntsb.gov) that around 1,900 feet the PF set the missed approach altitude to 3,000 in the MCP. The other captain said that when they were approaching 2,000 feet he set 3,000 in the MCP altitude.

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I have read enough information from top US instructors who have trained Korean pilots.  To stay well clear of any Korean airlines..

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So true my dad told me stories of copilots getting there iPods out and reading a news paper as they flew the over pole portion(The captain and co-pilot went to the bunks at this point for rest) of the US to Asia flights. When he'd wake up and go back to the cockpit he'd usually get mad and them and ask where the plane was at, and most of the time they didn't know so he'd make them get a map out and figure it out instead of just looking at the screen. Automation of the cockpit is a bad thing! It promotes complacency which is not something any pilot should have whether flying a c152 or a A380.

I believe you. I have never been in a situation like that but a lot can be avoided by a good preflight brief. Good CRM and the correct use of automation is a very good thing, however if automation is used as a crutch it can be very dangerous. We carry charts for a reason so not knowing where the airplane is or following the flight progress on a chart is just plain lazy and poor airmanship. It all goes back to the basics. As private pilots we always knew where we were because we had no choice, we did our pilotage and dead reckoning, so why not continue with the basics. People make this job harder than what it is.

 

The real problem is inexperienced crew. I don't care if a pilot has 10k hours in a A330/B777if he/she is second guessing himself and is afraid to turn off the AP and just stick to the basics I consider that inexperienced and it's a huge problem an needs to be corrected.

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Maybe I'm mistaken, but isn't the very reason the GA button is on the power lever knob(s) because the pilot flying is expected to have his hand on those levers while landing manually?

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Maybe I'm mistaken, but isn't the very reason the GA button is on the power lever knob(s) because the pilot flying is expected to have his hand on those levers while landing manually?

Well it is in that location for a number of reasons, but yes the pilot flying should have his hand on the levers, doesn't matter if the landing is manual of automated.

 

Regards

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Well it is in that location for a number of reasons, but yes the pilot flying should have his hand on the levers, doesn't matter if the landing is manual of automated.

Thanks for confirming that I'm not totally out in left field, Rob. I've read nothing anywhere about the PF's hand positions, but it appears that he didn't have his hand on the levers, else he'd surely have noticed the 'auto-throttle' wasn't doing anything... :unsure:

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Thanks for confirming that I'm not totally out in left field, Rob. I've read nothing anywhere about the PF's hand positions, but it appears that he didn't have his hand on the levers, else he'd surely have noticed the 'auto-throttle' wasn't doing anything... :unsure:

I would be surprised if he didn't have his hands on the throttle, no reason for him not to.

 

At the end of the day you have to ask yourself why the check captain & pilot flying busted stable approach criteria? Putting aside the claimed automation mode confusion, having to do a visual dive and drive into SFO (I personally know flight crew that have complained about it for years)

 

Asiana, like every other airline has stable approach criteria that is set in stone. In the case of this incident they should have been on path/engines spooled and within five knots of Vref by 500ft If not hit TOGA!

 

Nothing can excuse the fact that they busted that final safety net.

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According to the PM the PF had his hand on the throttle after he disconnected the autopilot. The PF said (I understand in general) that he had his hand on the throttle sometimes and sometimes needed both hands on the yoke to fly the plane. He couldn't remember when his hand was on the throttle during this approach.

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