SFO- Asiana 777 crash

[KevinAu 441]

Just out of curiosity.....why is it that ATC uses this "slam dunk" approach procedure at KSFO? Is it something to do with noise abatement? I have only ever arrived at KSFO once in my life (in a BA 747-200 back in October 1995), and I remember the engines being extremely quiet as we approached over San Pablo Bay, and then San Francisco Bay. We were approaching from the north and east, and the plane turned right to get on final approach for one of the 28 runways (I can't remember which one, but I assume it was 28R). To be honest, that 747 felt like a huge glider!

Noise abatement. Yes you were gliding in. It can be fun or challenging for the pilot, depending on their comfort and experience, but definitely less safe than a normal approach.

[KevinAu 441]

He said Asiana's level of airmanship not 'Asian' ;) Look, I don't think anyone is disagreeing with the fact that approach tends to keep you high when operating into KSFO, you can see the same thing happening on many arrivals globally. I have spoken to many flight crew that like to call it a slam dunk approach, my old man used to operate the 744 into KSFO with Singapore cargo and says the same thing. That is just how it is, everyone deals it with safely, it's part of the job.

 

You can go on about it till you are blue in the face, I doubt anyone here is going to agree with you that ATC was at fault, and the people that matter' NTSB' certainly disagree with you.

 

Regarding culture - Not sure where you live or who you fly for? Do you have any experience with how things operate in the Middle East & Far East? I can tell you that issues most definitely exist in Asia when it comes to CRM.

 

I mentioned that 10 years ago in the Middle East the exact same problems existed, Captains treated like gods, you did not question them, CRM was very poor & first officers afraid to speak up.

 

It took a number of incident's to change things out here, one of the worse being this crash - (If anything just read the CVR transcript) The captain treated the F/O like a child.

 

http://www.bea.aero/docspa/2000/a40-ek000823a/htm/a40-ek000823a.html

 

It is no secret that that the same culture still exists within many Asian airlines. I have spoken to guy's directly and heard nightmare stories of flying with Captains that have huge ego's and do not like to be questioned.

 

I have a lot of respect for many aspects of Asian culture, very disciplined, very respectful of seniority. However in many cases it doesn't translate well into the flight deck when you are working as a team. Yes the Captain has the final say, that doesn't mean keep your mouth shut because the Captain always knows best.

And neither does the NTSB seem to think there was a culture issue here either.

 

They may be the only opinion that matters but it does not mean they call out everything or haven't been influenced by any of the parties.

 

I won't turn blue because I don't expect anybody here on this board to agree with what I say because my perspective after 12000 hours in the air is probably a lot different than the simmers here standing outside the fence. Those of us who do fly airliners can instantly see the main threat here was the high energy approach handed them by the controller. All the problems and exposed weaknesses in airmanship that ensue are a result of the controller's one action.

 

Yes it is poor airmanship but that does not mean controllers should be excused either for their piece.

[Tom Allensworth 1,532]

Those of us who do fly airliners can instantly see the main threat here was the high energy approach handed them by the controller. All the problems and exposed weaknesses in airmanship that ensue are a result of the controller's one action.

 

I don't get your desire to hang out the ATC. Noise abatement is a regulatory imposed requirement. ATC is not regulatory. It simply follows the regulations imposed in its airspace. So, if you want to place blame for the "high energy approach", blame the FAA.

[Great Ozzie 101]

Noise abatement is a regulatory imposed requirement.

 

A slam dunk approach is not always for noise abatement.  Could be based on traffic into the airport.  Also... as well as the system works, things on both ends (for pilots and controllers) don't always work out as planned (weather, personal problems, mistakes etc.)

 

 

ATC is not regulatory.

 

§91.123   Compliance with ATC clearances and instructions.

 

(a) When an ATC clearance has been obtained, no pilot in command may deviate from that clearance unless an amended clearance is obtained, an emergency exists, or the deviation is in response to a traffic alert and collision avoidance system resolution advisory. However, except in Class A airspace, a pilot may cancel an IFR flight plan if the operation is being conducted in VFR weather conditions. When a pilot is uncertain of an ATC clearance, that pilot shall immediately request clarification from ATC.

 

b. Except in an emergency, no person may operate an aircraft contrary to an ATC instruction in an area in which air traffic control is exercised.

[Tom Allensworth 1,532]

 

 

§91.123 Compliance with ATC clearances and instructions.

 

Rob, you are quoting to me FAR's. FAR's are not created by ATC, thus my statement. In other words ATC doesn't write regulations, the FAA does. ATC manages the airspace in accordance with the FAR's.

[Mickel 42]

Disregard. Clarified above.

[Tom Allensworth 1,532]

I think what Tom was getting at is that ATC don't make the rules (eg the imposition of noise abatement), they just have to work within them, like everyone else.

Exactly.

[Great Ozzie 101]

My point was... ATC is about as regulatory as it gets.  ATC in a sense does make the rules.

It is very simple.  Operating instructions within their jurisdiction is compulsory. Either you follow the instructions, declare an Emergency... or get yourself out of the system (which in certain airspace is not possible).

Violation of an ATC instruction is a violation of the FAR(s).
 

 

I don't get your desire to hang out the ATC.

Because why add risk to the system?

Thing is... it generally works.  Like it has been said, "99 times out of a 100" there's not a problem.  Just something to gripe about later ("man you saw what that controller did to me???").  But why add an extra layer of complexity & stress?

A study by the U.S. National Transportation Safety Board said that maintaining a high airspeed to the outer marker (OM) may prevent capture of the glideslope by the autopilot and may prevent aircraft stabilization at the defined stabilization height.

The study concluded that no airspeed restriction should be imposed by air traffic control (ATC) when within three nautical miles (nm) to four nm of the OM, especially in instrument meteorological conditions (IMC).

Flight Safety Foundation ALAR Briefing Note 4.2 -- Energy Management (Flight Safety Digest, Aug-Nov 2000)

[Tom Allensworth 1,532]

 

 

Violation of an ATC instruction is a violation of the FAR(s).

 

And the FARS are set by the FAA, not ATC. To my knowledge, there has never been a previous crash at SFO that had a wide body impact the breakwater and tear off its gear. Ascribing any degree of blame to ATC is simply an attempt to give the ASIANA crew relief from their inept handling of this landing. ATC is not a regulatory body - they manage the airspace they are responsible for in accordance with the FARS, which they do not establish.

[Great Ozzie 101]

To my knowledge, there has never been a previous crash at SFO that had a wide body impact the breakwater and tear off its gear.

 

Really, that is irrelevant Tom.  

 

This argument of why it seems to be ok (to increase landing rates by keeping an aircraft's speed high to the OM) reminds me of the Challenger accident.  NASA's attitude had become a "prove to us why we shouldn't launch".

 

Maintaining a high airspeed to the OM can obviously lead to stabilization problems.  Otherwise the NTSB and FSF would not have studied this (high approach airspeed) causing potential problems / accidents.

 

 

Ascribing any degree of blame to ATC is simply an attempt to give the ASIANA crew relief from their inept handling of this landing.

 

Absolutely not.

 

From a pilot perspective (albeit zero airline pilot hours) I cannot fathom how the PF / IP allowed this to occur.

 

From an accident investigator perspective... what I would be considering would include the ATC instructions.  To ignore the operating environment would be negligence on the part of the investigator(s).

 

If we can do something to break a link in the Accident Chain, then why not break that link.  I think that is the point Kevin is trying to make.  I do not (and I don't believe Kevin either) want to absolve the Asiana crew of their responsibility for this accident.

[evaamo 549]

I don't see how ATC can be hold accountable in this case, let's make a quick review:

 

1) KSFO was under VMC rules, winds calm

2) Glideslope out of service, LOC approach in use

3) ATC instructs 180kts until 5nm out from the threshold, like I'm sure it does for much of the rest of the aicraft flying into the airport

4) Crew fails to stay ahead of the aircraft, enter energy management nightmare due to lack of understanding of the 777 automation modes

5) Four pilots in the cockpit (including a check pilot for the captain who was PF and had only ~50 hours in the type) fail to monitor airspeed and in an evident lack of CRM, never say anything to the senior captain/PF. This is where the culture issue comes into play.

6) 400ft above the ground, with engines underspooled and more than 20kts below Vref, someone from the crew finally decided to G/A.

 

Again, I fail to see ATC direct involvement in the accident.

 

Now if ATC is asking every aircraft flying into KSFO (or any other airport) to perform approaches that could be considered dangerous, then it is up to the FAA to review the case and make any correctives. But I'm sure airlines and other operators will start complaining about such correctives if that translates to vectoring the aircraft further out to give more space for those in sequence for landing, delaying each flight in or out of the airport and consuming more fuel, affecting the amount of flights that can be serviced in/out of KSFO every hour, thus hitting the commercial side of the aviation world. In the end, it will be a business decision and the statistic like the "99 out of 100" mentioned above, while unacceptable in terms of safety to some, will meet blind eyes in some of the higher echelons in power for the sake of keeping the industry profitable.

 

So blaming ATC is like shooting the messenger in this case.

 

In the case of Asiana 214, the crew didn't understand the aircraft nor did they seem to be qualified to land in KSFO, regardless of the amount of times the PF and the rest of the crew had previously flown into that airport (which weren't only a few btw, although flying different aircraft types than the 777).

 

cheers

-E

[Christopher Low 5,358]

I can understand what Kevin and Rob mean, but at the end of the day, any pilot qualified to sit on the flight deck of a real world airliner should be able to handle any of the approach procedures that they are given by ATC.

[evaamo 549]

I can understand what Kevin and Rob mean, but at the end of the day, any pilot qualified to sit on the flight deck of a real world airliner should be able to handle any of the approach procedures that they are given by ATC.

 

Agreed. And when you're responsible for 300+ souls you should at least know when to say "unable" to an ATC instruction that makes you uncomfortable.

[Great Ozzie 101]

 

 

Agreed. And when you're responsible for 300+ souls you should at least know when to say "unable" to an ATC instruction that makes you uncomfortable.

 

It's not as simple as that.

[KevinAu 441]

I don't see how ATC can be hold accountable in this case, let's make a quick review:

 

1) KSFO was under VMC rules, winds calm

2) Glideslope out of service, LOC approach in use

3) ATC instructs 180kts until 5nm out from the threshold, like I'm sure it does for much of the rest of the aicraft flying into the airport

4) Crew fails to stay ahead of the aircraft, enter energy management nightmare due to lack of understanding of the 777 automation modes

5) Four pilots in the cockpit (including a check pilot for the captain who was PF and had only ~50 hours in the type) fail to monitor airspeed and in an evident lack of CRM, never say anything to the senior captain/PF. This is where the culture issue comes into play.

6) 400ft above the ground, with engines underspooled and more than 20kts below Vref, someone from the crew finally decided to G/A.

 

Again, I fail to see ATC direct involvement in the accident.

 

Now if ATC is asking every aircraft flying into KSFO (or any other airport) to perform approaches that could be considered dangerous, then it is up to the FAA to review the case and make any correctives. But I'm sure airlines and other operators will start complaining about such correctives if that translates to vectoring the aircraft further out to give more space for those in sequence for landing, delaying each flight in or out of the airport and consuming more fuel, affecting the amount of flights that can be serviced in/out of KSFO every hour, thus hitting the commercial side of the aviation world. In the end, it will be a business decision and the statistic like the "99 out of 100" mentioned above, while unacceptable in terms of safety to some, will meet blind eyes in some of the higher echelons in power for the sake of keeping the industry profitable.

 

So blaming ATC is like shooting the messenger in this case.

 

In the case of Asiana 214, the crew didn't understand the aircraft nor did they seem to be qualified to land in KSFO, regardless of the amount of times the PF and the rest of the crew had previously flown into that airport (which weren't only a few btw, although flying different aircraft types than the 777).

 

cheers

-E

7)Aircraft was vectored to a point slightly above the glideslope when cleared for approach.

 

Combining 7) with 3) ensured that an aircraft like the 777 would have difficulties getting established in a stabilized approach. That it would be impossible to achieve stabilized criteria was then solidified when the pilot inappropriately selected FLCH with a higher altitude preselected and the aircraft added thrust and tried to climb, putting them well above glideslope. The only safe option at that point was to go around. The pilots pressed the approach and only arrived onslope and approach speed beyond the point of the approach where a go around should have been initiated if stabilized approach had not been achieved yet. Combining this with inadequate system knowledge and inattention to instrument indications caused them to allow the speed to decay to the point of stalling at an altitude too low for recovery. The ATC involvement occurred at the beginning of this chain of events.

 

However you did nail the primary issue on why ATC was left out of the report as contributing to the crash. Economics. You are absolutely right that ignoring the ATC role in setting aircraft on high energy approaches is unacceptable if one was to focus purely on the safety issues at bear. As you have picked up on, there are certainly business influences at work when the NTSB issues their report. Which begs the question of how many must die before these ATC practices can be brought to an end. Perhaps an A380 crash from an unstabilized approach with significant loss of life? That is probably what it will take before the FAA will decide that the safety advantages of vectoring planes out farther will finally outweigh the economic advantages of squeezing planes in tightly and hoping the pilots are up to snuff.

 

Your notion that no matter what, it was the pilots who couldn't hack it, while certainly true, goes against the entire safety philosophy of threat error management. CRM was replaced years ago by TEM at most airlines. While CRM focused on the individual and checkrides focused on individual skills back then, the current focus is based on the acceptance that no matter what, people will make mistakes, and instead rely on layers of safety nets to catch and stop a threat before an undesired state occurs. As such, from this perspective, ATC handling is one of our most common threats. The majority of the threat warnings in our -7s pertain to ATC setting aircraft up for high energy approaches as sop at certain airports. There is no other word for this other than 'threat'. As an identifief threat, why is nothing done to stop it? As you've alluded to of course, money. If ATC was required to avoid high energy setups, then it would cut down on aircraft arrival rates and take an economic toll on the airport and the airline.

 

So you can see now that the NTSB report on this accident is not entirely complete, since they decided to leave one factor of the accident untouched in order to avoid opening a can of worms. Blaming the foreign pilots and Boeing is painless, but identifying and calling out a threat within the system that, if addressed, can economically impact government and business stakeholders is something that the NTSB is apparently not ready to do yet.