Asiana Crash Landing At Sfo Saturday

[Don Hudson]

From Curt Lewis' Newsletter this morning:

Asiana Airlines Flight 214 crashed during landing at San Francisco International Airport in July, resulting in three deaths and injuring more than 180.

Investigators will release new information this week highlighting that excessive reliance on cockpit computers, combined with pilot confusion about automated thrust settings, led to the crash of an Asiana Airline Co. jet trying to land at San Francisco in July, people familiar with the probe said.

The crash resulted in three deaths and more than 180 injuries after the tail of the widebody jetliner, arriving after an overnight flight from Seoul, slammed into a sea wall. The aircraft broke apart and eventually was engulfed by fire.

The National Transportation Safety Board public hearing that kicks off Tuesday, while stopping short of formally identifying the cause, also will focus on broad safety concerns about potential downsides of automation and the need to adjust pilot training in light of increasingly computerized cockpits.

The NTSB is expected to answer the biggest puzzle surrounding the crash of Asiana Flight 214, according to people briefed on the details, by revealing that the veteran pilots misunderstood precisely how the Boeing Co. 777's automated speed-control features were designed to function. Partly as a result of that confusion and the flight crew's undue trust in the system, investigators have found the pilots failed to properly monitor the jetliner's speed and trajectory.

Previously, the NTSB didn't disclose whether the pilots failed to turn on the plane's auto-throttles-intended to maintain designated airspeed-or somehow disconnected them during the late phase of the approach to San Francisco International Airport. On Tuesday, the board is slated to spell out a sequence of events showing the pilots weren't aware that the auto-throttle system was inadvertently shifted into an inactive mode shortly before the crash, according to people familiar with the board's findings.

NTSB investigators and others view the high-profile crash as a prime example of a trend some have dubbed "automation addiction," which safety experts believe poses the greatest hazards to airline passengers world-wide.

Advances in cockpit automation over the decades have contributed greatly to making flying safer than ever in the U.S. and globally. But various studies have shown that both manual flying skills and situational awareness in the cockpit tend to erode as airline pilots depend more extensively on computerized flight-control systems. When those built-in safeguards suddenly malfunction or switch off, according to experts, startled or confused crews may react improperly.

Descending over water toward the San Francisco runway in good weather on July 6, the Asiana pilots engaged the Boeing 777's auto-throttles to maintain safe speed during the visual approach. But after the twin-engine jet passed through roughly 3,000 feet, according to people briefed on the details, the pilots didn't realize computerized speed controls had become inactive after they changed a setting to computers and eased back the throttles, not recognizing that meant auto-thrust wouldn't work. They failed to notice or react to a specific cockpit alert about the status of the auto-throttles, according to these people and others familiar with data investigators collected.

With airspeed dropping quickly and dangerously below a predetermined level while the descent rate increased to about 1,200 feet per minute-or more than twice the normal rate-the crew failed to react until it was too late. Throttles weren't manually advanced to increase engine thrust and try to climb away from the strip until about two seconds before impact, based on earlier safety board statements.

Asiana, the NTSB and the Federal Aviation Administration all declined to comment in advance of the hearing. Boeing, which provides simulator training for all of the airline's 777 pilots, also declined to comment. In the past, Asiana has said the pilots were properly trained, met all regulatory requirements and had the necessary experience for their tasks.

The dynamics inside the cockpit were complicated because the pilot flying the approach, who had recently been upgraded to a 777 captain, was still under the supervision of a training captain sitting in what is usually the co-pilot's seat. The pilot trainee was making his first approach to San Francisco at the controls of a 777 and the training pilot was in the midst of his first trip overseeing a newly-minted 777 captain. A more-junior co-pilot, sitting in the cockpit to help monitor the approach, apparently gave the initial verbal warning of a problem.

The board is expected to delve into communication and authority issues that might have hampered teamwork between the trainee pilot and the training captain, based on earlier safety board statements. The runway's instrument landing system was out for maintenance at the time, according to the NTSB.

On Wednesday, the hearing will feature testimony from leaders of an industry-government panel that issued a study last month spelling out the potential hazards of pilots who become so dependent on automation that "they may be reluctant to intervene" in an emergency; or lack adequate training or "sufficient in-depth knowledge and skills" to properly control an airliner's trajectory under certain circumstances.

After the study was released, David McKenney, an airline pilot, union official and one of the panel's co-chairs, said the report's conclusions and recommendations were partly aimed at preventing tragedies such as the Asiana crash. "We have basically trained pilots how to interface with the automated systems," he said, "but now we have to go back to make sure they remain mentally engaged and understand that computers are merely tools" pilots can use to control an aircraft's flight path.

The report lays out the dangers of so-called "mode confusion," when pilots lose track of exactly which tasks cockpit computers are supposed to perform. New training approaches are necessary, according to Mr. McKenney, to instill the skills and confidence pilots need "to be prepared to take over and do things manually" in an emergency.

Earlier this year, according to U.S. government and industry officials, Asiana presented the NTSB with arguments that some type of anomaly or malfunction prompted the auto-throttles to stop working. The airline also cited a number of such suspected events on the global 777 fleet. But after interviewing the pilots of Flight 214 and reviewing maintenance and other records, U.S. investigators haven't found any malfunctions that affected the engines, auto-throttles or other onboard systems prior to impact.

The July crash prompted major reassessments inside Asiana as well as its national regulator. The carrier beefed up training efforts, including enhanced simulator sessions and greater emphasis on manual flying and instrument-monitoring skills, according to industry officials. Asiana's recurrent pilot-training programs and supervision of new captains already exceeded FAA and South Korean minimums prior to the crash, these officials said, but now they incorporate elements aimed at providing a more in-depth understanding of computer systems.

Last week, Asiana announced the hiring of a new senior executive vice president to head up safety efforts. Akiyoshi Yamamura, a former safety specialist at Japan's All Nippon Airways, told reporters he plans to take a more proactive approach to training and identifying budding safety problems.

http://online.wsj.com/news/articles/SB10001424052702304744304579246570888527440

[DEFCON]

The investigators can be as polite and politically correct as they feel necessary and there very well may be a problem with 'automation addiction' today, but at least in this case, it appears that the people occupying the pilot seats did not possess anything resembling 'basic' flying skills.

[Trader]

"Earlier this year, according to U.S. government and industry officials, Asiana presented the NTSB with arguments that some type of anomaly or malfunction prompted the auto-throttles to stop working. The airline also cited a number of such suspected events on the global 777 fleet. But after interviewing the pilots of Flight 214 and reviewing maintenance and other records, U.S. investigators haven't found any malfunctions that affected the engines, auto-throttles or other onboard systems prior to impact."

RIght into excuse mode-----doesn't sound like they learned anything!

[Don Hudson]

"RIght into excuse mode-----doesn't sound like they learned anything!"

Denial is a powerful and sometimes-cultural fact of the human psyche. It is, of course, the antithesis of how progress in aviation safety is made and therefore does not demonstrate the ability for change and adaption. This is very disturbing when seen in a major air carrier.

This wasn't an "automation" accident. As with AF447, this was a performance accident in a perfectly serviceable transport aircraft. Asiana is required to find out why their crew's performance caused a fatal accident and make the necessary changes. The above statement (and likely the coming week's presentations) will determine whether such changes have been made, given the knowledge gained through independent investigative means and not from what the airline in question has to say about the matter.

[Guest]

The hearing is live streamed for those interested. I imagine it will be archived?

http://ntsb.capitolconnection.org/live/ntsblive_flv.htm

[Don Hudson]

Canoehead - yes, it's archived and available for three months.

The speech recognition-to-text is pretty good!

[airt]

Analysis: Foreign Airline Crews Had Difficulties With San Francisco Landings

http://online.wsj.com/news/articles/SB10001424052702303330204579251191895420138?mod=WSJ_hppMIDDLENexttoWhatsNewsSecond

[Guest]

Thanks Don

That's a pretty slick webcast, but on my iPad I had to use the Photon browser for video, but it wouldn't roll through the text. With Safari it would scroll the text, but can't play the video (that silly Apple/Flash fight).

This accident investigative outcome will be great new material for the Human Factors departments at many airlines.

[conehead]

That "Culture" issue is pretty serious... I'd say it was a very large contributing factor in the crash...

[Mitch Cronin]

That sounds like an admission that any notion of decent CRM is next to impossible within that culture.

If I was in charge of hiring at that airline, I guess I'd have to start looking elsewhere for a lot of pilots.

[conehead]

<off_topic_observation> ...if my last name was "Dongwon"... and my parents named me "Bong"... I'd shoot 'em!<back_to_topic>

[Don Hudson]

As I've mentioned, this isn't an automation accident, it's a performance accident. More automation is not an appropriate response and would only compound the problem, nor is just more training the answer.

Unlike AF447 which also was a performance accident but extremely rare, (31 other crews lived to write the failure up in the log book), but under the "right" circumstances this kind of accident can occur again.

The discussions surrounding cultural issues began the day of the accident. Those with whom I've spoken, (none of whom post here on AEF, btw), and who know this culture out of long personal experience discussed it in terms of cockpit authority gradient, ie military rank, and military vs civilian background etc. It doesn't matter what the autothrust did or why - knowledge of the airplane was clearly weak but it doesn't take "more training" to watch the two killer-items, altitude and speed, and realize when the airplane is at risk. In fact they were warned by the RP and so knew a minute before the CFIT, but no one did anything about it.

It's very good that this is now coming out but unlike SOPs, cultural behaviours do not change overnight. In fact I recall the early CRM courses around the early 90's. The guys that needed it most were the ones who dismissed it as so much psycho-babble and confused new-age thinking and they weren't pleasant or easy to fly with. They never got the fact that CRM isn't about the dreaded takeover of the captain's authority, nor was/is it a course given by Miss Manners. It was just a way of giving everyone with skin in the game the power (and the authority and responsiblity) to speak up when something wasn't right.

The solution to prevention in this case is necessarily "top-down" because in a strict chain of authority social structure no one raises their head above the trench. The owners, executives, senior management, checkpilots... everyone, all the way down must start a behavioural change to place layers of prevention in between this culturally-high potential for a repeat performance and the circumstances that will inevitably arise again and which for most western crews have become non-events, (except for the stubborn unwillingness to go around from an approach that has become unstabilized - most still continue).

[Trader]

Don-agree completely!

The issue existes throughout Asia and parts of the ME. At Korean many of these captains are ex-military, come from 'important families' and move through their career based on these connections. Aptitude and skill have little bearing. This then transfers into a cockpit where their 'authority' will not be challenged.

Now we have an accident and STILL no accountability! The captain blames the AP and interface, then blames a 'light' (despite TWO calls from the pilot in the back). The airline makes excuses. It goes on.

As I write this my 10 year old is in his room - untill he takes accountability for his actions. Yet here we have an entire culture trying to shift blame and save face. With all due respect to the various cultures-- sorry-- no room in my book for ANY culture that cannot operate safely especially after DECADES of research, experience and CRM.

My hope is that the NTSB lays blame wherever it belongs without regard to whitewashing anything to cover sensitivities and the company/country are FORCED to make changes. I am guessing the civil suit will be interesting!

[boestar]

Hey.....How about we cut back on the pollution and get rid of the smog....just a thought...

[blues deville]

What Beijing (PEK) needs is serious help in the form of re-training from foreign air traffic controllers who know how to manage a complex airspace. PEK has four large (12000') runways and they still cannot handle any kind of reasonable traffic flow. Two or three runways changes while on descent/approach are not uncommon. After landing, crossing at least two active runways to find your gate creates more delay plus fuel burn and smog. Foreign carriers will sit in line waiting to depart while watching an endless parade of domestic and international Chinese airlines get airborne. Again more fuel burn and pollution. Add some deicing to the equation (last time +3 hours) and you never want to see Beijing on your monthly roster again. That would be my Christmas Miracle wish......but it hasn't happened yet and I don't think WS Santa has that one in his blue bag.

China has plans to build 100 more of this size airport across their country. Good grief.

[DEFCON]

Banning an air carrier from operating in your airspace until safety problems receive satisfactory redress really does get everyone's attention and remedial action. On the other hand, doing so creates an international political event and interferes with commerce. This 'problem' has been recognized internationally for a very long time now and nothing apparent has been done to resolve this modern day aviation related shortcoming. Actual practice may indicate the historical policy continues to be well re-entrenched and clearly supported? One has to wonder if at least the Koreans are thumbing the NTSB etc. having decided long ago that their cultural heritage is more valuable to them than the adoption of modern practices may be...at least in aviation.

[Don Hudson]

Hey.....How about we cut back on the pollution and get rid of the smog....just a thought...

And interfere with progress and profit?...

[Maverick]

Not quite on thread but in the same vein:

Pilots must learn to land

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Low visibility in Beijing spurs requirement

Chinese aviation authorities will soon require captains of domestic flights into Beijing to master lowvisibility landings to combat chronic flight delays that have been worsened by heavy smog.

The Associated Press/Files Flight delays at Beijing airport are due to many factors, including China’s wide-ranging weather patterns and smog.

Beijing Capital International Airport, China’s busiest, has the worst record for flight delays of any major international airport, with only 18 per cent of flights departing on time, according to travel industry monitor FlightStats. Thick smog has cancelled or delayed flights at the Beijing airport when the city’s visibility goes down to a few hundred metres — though officials typically blame the delays on weather conditions rather than pollution.

The new requirement will take effect Jan. 1, an official at the Civil Aviation Administration of China said Thursday. The official said the new skills would be required of all captains on Beijing-bound flights from China’s other major airports, including those in Guangzhou, Shanghai, Chengdu and Shenzhen.

The captains will have to learn to land their aircraft with the assistance of precision auto-landing equipment when visibility falls to 400 metres. Currently, planes are diverted to other airports when visibility is that low.

“The administration is promoting the technology to reduce the impact on flights by severe natural conditions,” the aviation official said, adding that it will be up to the airlines to decide whether to use auto-landing in low visibility.

Auto-landing allows a plane to land automatically with the supervision of a human crew. Experts say that the technology improves aviation safety, but that it requires additional pilot training to supervise the precision hardware both on board and on the ground. The system is geared for three levels of visibility: 800 metres, 400 metres and zero visibility.

The new requirement will apply only to domestic flights because China doesn’t have authority over the qualifications of foreign airlines’ pilots.

Many foreign airlines, however, have already been using auto-landing at major Chinese airports equipped with the proper instruments. The Beijing airport, whose officials did not immediately respond to interview requests, is equipped with high-level auto-landing instruments.

Chinese airlines also have fleets of aircraft capable of auto-landing. But aviation authorities previously did not require Chinese pilots to be trained for low-visibility auto-landing because of hefty training costs, said Shu Ping, dean of aviation safety at China Academy of Civil Aviation Science and Technology.

“The training is very expensive, and the low visibility was not a normal condition,” Shu said. “Now with more smoggy days, the probability of landing with low visibility is higher.”

The Beijing airport’s chronic delays are due to an assortment of factors, including a narrow air corridor for commercial aviation because of the powerful military’s tight control over airspace. China’s wide-ranging weather patterns — including fog, snow and sandstorms — also play a role, as does Beijing’s severe pollution. An annual report says weather conditions caused more than 20 per cent of the flight delays last year in China.

How long will it take until there's a smoking hole in a rice paddy? Incredibly bad idea to put a time frame on it but what do I know?

[Kip Powick]

Hey.....How about we cut back on the pollution and get rid of the smog....just a thought...

They are, they are... I mean look at this story and we all know that will help a big heap ........................in a city of 20,693, 000 persons

In order to get to grips with the high pollution in Beijing，The Chinese Remediation destroyed and shut down hundreds of open-air barbecue grills in the city. The raids were part of a three-month operation to supervise the barbecues.

In order to strengthen management of PM2.5 in Beijing，cityurban management joint public security、transportation、 environmental、protection、business、health and other departments, organizations focus on remediation, joint law enforcement, collection of illegal outdoor grill.

[Don Hudson]

malcolm;

From the story

though officials typically blame the delays on weather conditions rather than pollution.

Standard denial behaviour. They've never read or heard of Feynman. We'll see what lies beneath the saving-face, if/when things gradually, quietly change.

I think there are ways of saving face that acknowledge realities while increasing the safety of an operation and still maintain the structure of society.

In the same way we alter behaviours when entering places which our society has deemed "special", (entering a church/synagogue/temple, entering government houses/rooms, entering the boardroom of a corporation, attending cocktail parties, attending funerals, etc., etc.) - our behaviours, our body language, our thought processes, and even the words we use to express "proper" behaviour in relation to the context we find ourselves in, automatically, sub-conciously (culturally) changes. We did this in North America - we collectively re-categorized the cockpit beginning in the late 80s / early 90's.

In China such an example for change will have to come from the top, down. Big risks, as some (ambitious) people will see such alterations as an "opportunity" (for control, domination, etc). There is that risk even today, in the west.

Staying with the idea for a sec, "The Cockpit" can be subtely "re-categorized" as a "place" where certain behaviours are "done" and others are not. Thus, "speaking out" to a superior becomes "required" when something of high risk is occurring.

Not easy! But it is one way, while maintaining cultural values of strict hierarchy. We did it in North America and it took about fifty years to change the original notion of the nuclear family for example. Not judging or commenting here - I'm just observing that all kinds of "taboo" social behaviours and subjects from the 50's are essentially invisible today. Remember Elvis being filmed on the Ed Sullivan Show from the waste up because the censors thought the shaking and other gestures were inappropriate? Transport those censors to any concert involving rap music today.

The captains will have to learn to land their aircraft with the assistance of precision auto-landing equipment when visibility falls to 400 metres.

IIRC from "the old days, (pre-dot days, for Kip ! )", 400m is about 1200 and that's where CATII requirements begin. One can do CATII using autoflight, or hand-flying the HUD - no question what it's going to be in this particular case. I see this as an increase in the risk of CFIT accidents until the basics are addressed and cultural behaviours are re-calibrated for well-known and established standards for flight safety.

The system is geared for three levels of visibility: 800 metres, 400 metres and zero visibility.

These are just CAT I, CAT II, CAT III limits, although the 'zero' visibillty remark in this case is just blather until the other factors change first.

Such Plug 'n Play fixes as are being suggested in the article above and from some of the comments heard in the NTSB hearings on the Asiana accident are not connected to reality. The sooner that approach is dumped the sooner they can get on with discussions concerning automatic landings in such weather conditions. I'm sure most comprehend the basics of airspeed, altitude and aircraft energy management, because that's not the problem and is not the primary cause of the Asiana accident.

[DEFCON]

The introduction of pilot charm school (CRM) was a big game changer in that regard in our world. Have they even considered the westernized version of the concept in that part of the world?

[Don Hudson]

Have they even considered the westernized version of the concept in that part of the world?

Doesn't look like it to me. Certainly the "easternized" version of CRM doesn't work...

Precisely when CRM (and paying attention to the airspeed) would have saved lives and preserved the airplane and perhaps Asiana's (and by association, other Asian carriers') reputation, they allowed the airplane to stall and people died.

One can understand a predisposition to believe that the throttles behaved like the trainee's former airplane, (A320). But training, simulator work and check work are first defences against such understanding. SOPs and CRM, (and a strong instinct for self-preservation), are all different, standard layers of defence. I doubt very much whether CRM is even mentioned, let alone taught as a formal part of an airline pilot's training in Asia.

I wonder how they're going to come to terms with this?

[rudder]

I wonder how they're going to come to terms with this?

Asiana will agree to implement 'improved pilot training' - knowledge of automation - manual flight - CRM - better delineation of Training Captain responsibilities, etc and perhaps consent to some form of ongoing audit to confirm effectiveness of said training otherwise risks being refused access to American airspace. It would appear that Asiana is as screwed up culturally as another Korean carrier was several years ago.

Boeing will probably modify the FCTM to recommend A/T disengage when A/P is disconnected on approach (not sure this is a valid safety improvement but the NTSB will be looking for some visible indication that the manufacturer is being responsive since one of those "never will happen" events actually happened).

Bottom line is the testimony from this accident crew is so damning that the lawyers that are representing parties suing Asiana are going to have a field day. Everybody else involved is going to be trying to distance themselves from this mess.

Anybody who claims that experienced, well trained, and well tested pilots are not a valuable commodity isn't paying attention. Just ask yourself what the price of one accident will be. This is what it looks like.

[Don Hudson]

rudder;

Re your last observation: Precisely.

We'll see about the first observations, but I hope you're seeing something I'm probably not yet seeing.

Experience and the sixth sense cannot be taught and expertise cannot occur in a 250hr simulator/line-indoc course for MCPLs. The expectation has been, at some carriers and some parts of the world, that automation actually flies the airplane and guards against crashing and that one can hire off-the-street to teach the necessary button-pushing to pass the rides.

Smart, like a streetcar. It needs to change.

I do realize what the tone of these posts must sound like (unpleasant, and unhappy), but these kinds of accidents are entirely preventable and are therefore inexcusable. The industry has largely solved weather, navigation, mechanical, mid-air collision and collision with terrain as major causes of fatal accidents. Today, it is more likely that a perfectly serviceable aircraft involved in an accident will have primary causes in human factors such as this one, than any of the above primary causal areas.

It is extremely disappointing to see the profession and the business degrade to such low standards that those with 250hrs are considered sufficiently competent to get jobs flying large transport aircraft or that people who see something terribly wrong in the cockpit can't, out of fear of retribution, even talk to one another to prevent an accident.

[Boney]

The "got ya" in turning off the A/T is not having alpha protection, unless of course, you brief your winger on that.

One can deselect speed, where arm is showing on the PFD, to have "A" protection, while at the same time having full control of the throttle.

Just a thought