Asiana Crash Landing At Sfo Saturday

[J.O.]

I've heard many stories from colleagues who have worked in that part of the world, speaking of a general fear among the locals of manual flying and visual approaches. If even half of them are true, then something needs to change.

[csteacy]

While I agree to all of the challenges at SFO playing a part I think it was quite possibly a simple misunderstanding of the a/p and a/t modes. If he was high, likely he was in level change to capture whatever path he had set up. If the autopilot was subsequently disconnected and he pitched up manually when he regained the path, the auto throttles would have still been in arm and commanding idle thrust. They did not notice it in time and subsequently got way too slow. They may have had the right speed selected the whole time but with the incorrect mode. Not sure what altitude criteria Asiana has for stable approach, but it sounds like it needs revamping or retraining.

[Guest ACSideStick]

Malcolm, I am in agreement with you.

Years ago I was an instructor, and taught many pilots (some who I now work with) to fly. During a Private Pilot course, by far the most difficult part was teaching a student how to land. This was only done visually and it took a great deal of time for the students to learn "The Picture". During the PPL, so as to not confuse the matter, the VOR/ILS would be off. You didn't want the student to have even know it was there. The whole point of the course was learning to read the map while flying, and then land anywhere by looking out the window.

Once a student was about to complete the PPL, you might reward them with a little familiarization with the ILS, but still stress to leave it alone until your commercial IFR. It was all about teach how to fly.

Sadly, this isn't the case everywhere anymore. The trend is to turn out low-time pilots who are ready to push buttons, but not have a clue how to really fly.

As to Mitch's point, this trend is entirely MBA, not safety, driven.

[rudder]

I agree, and this could be a major contributing factor.

Contributing factor to creating the opportunity for an unstable approach? Perhaps. Contributing factor to continuing an unstable approach and therefore flying a perfectly serviceable aircraft into the ground short of an 11,000' runway on a clear day? No way.

Airline pilots are left in situations quite often where meeting the criteria for a stable approach (including appropriate normal thrust setting for aircraft configuration) is a challenge. And in any company with a proper safety culture, it is recognized that the appropriate response to that scenario is to go-around and meet the stable approach criteria on the subsequent approach and landing (and that go-around would happen at either 500' AGL/VMC or 1000' AGL/IMC not 50'AGL)

Therefore the investigation will have to include Asiana's policy on stable approach criteria and why this crew continued rather than initiate a go-around much sooner.

[J.O.]

Unless they are polar opposite to their major competitor, they will have a very strict stable approach criteria. But a strict policy on its own is not enough to make pilots aware of their aircraft's energy throughout an approach. That comes with experience and good, solid training.

[blues deville]

Sure, it's a chain but in the end it comes down to basic flying skills. t.

That's my point. Another trainee with better basic flying skills encountering all of the same events on that flight might have resulted in a non-event. Or a different training Captain.

One thing....

[DEFCON]

In an earlier post I speculated on the aircraft's being too slow and too low. It's now clear; the aircraft was 'really low and way too slow'. In short; this crash appears to represent the early and complete loss of situational awareness by whomever was in command of the flight.

Good point JL.

How do we know this was a Captain upgrade versus a promo from CR pilot to F/O?

All in all, with each of these peculiar crashes it becomes ever clearer; there's too much dependency on the magic toys today; an agenda created by the MBA who continues to place unqualified pilots in seats in which they don't belong. Why do Cadets wear three bars anyway and isn't this a slap in the face to the properly qualified F/O?

[rudder]

Unless they are polar opposite to their major competitor, they will have a very strict stable approach criteria. But a strict policy on its own is not enough to make pilots aware of their aircraft's energy throughout an approach. That comes with experience and good, solid training.

Not later than 500' AGL (VMC):

- aircraft configured for landing (gear and land flaps)

- speed within Vref +10 to -5

- on profile (nominal 3 degree path verified by either or a combination of VNAV, GS, or VASIS) and descent rate less than 1000 fpm

- engines spooled (thrust setting appropriate for aircraft configuration)

Note than none of these speak to A/P or A/T operation or status. These are basic criteria that apply in ALL cases and are easily verified using checklists and basic flight instruments/visual clues. If any one condition is not met by 500' AGL (VMC) then the proper call by either crew member is "unstable......go around".

If all of the stable approach criteria are met then aircraft energy is not a factor. It is only a factor when trying to salvage a landing from an unstable approach (not a good idea and prohibited in most commercial air operations). These rules are in place to protect both experienced and inexperienced pilots/crews.

There is a suggestion on another forum that perhaps they were using FL CH mode due to no ILS G/S - assumed that the A/T system would manage speed while the PF managed the pitch of the aircraft - and that in fact the A/T at some point reverted to THR HLD and did not become active again either because the A/P was disconnected or due to parameters being met for landing (below 100' RA).

Boeing does not require A/T disconnect coincident with A/P disconnect but there are several operators that have this policy, perhaps to avoid what happened yesterday in SFO.

[J.O.]

Many B777 operators have the policy to have them both disconnected because it carries over from earlier Boeings in their fleets where this was a requirement. The B777, much like the A320, has an autothrust system that is more sophisticated than earlier generations, but also like the A320, when used in the wrong vertical mode, it won't always do what you expect it to do. The FLCH mode issue could certainly put them in that state if they let it.

[blues deville]

How do we know this was a Captain upgrade versus a promo from CR pilot to F/O?

NTSB have advised the media that the trainee was a Captain transitioning to the 777. His previous aircraft may have been Airbus 319/320.

[CanadaEH]

Footage of Asiana crashing:

http://www.youtube.com/watch?v=lBi8zR44OsU

[Mitch Cronin]

The B777, much like the A320, has an autothrust system

emmm .... that'll be "auto throttle" on the Boeing beastie, sir.

[J.O.]

Same **bleep**, different day, mister!

[rudder]

Selecting FL CH while on approach would have exposed the crew to the potential A/T 'sleep mode' trap. If the A/T system was in fact in THR HLD and the A/P had been subsequently selected off in an attempt to manually recover the aircraft profile to the VASIS at a low altitude, then the speed decay could have gone unnoticed by both pilots while looking out the window and nobody watching the ASI's as they were trying to land off an unstable approach. The string of events may have started with possibly being left high by the arrival controller and accepting the visual approach clearance to a runway without ILS G/S guidance, but the fate of the flight wasn't sealed until a very bad decision at 500' AGL to continue.

I would like to think that most airline pilots would be comfortable turning off the automation and conducting a hand flown visual approach to landing without any undue speed/altitude/profile excursions. I would also expect that all airline pilots would be able to recognize and understand the dangers of continuing an unstable approach and would appreciate that the expected response without any risk of discipline or retribution is to go-around. Perhaps that expectation is not realistic in today's rapidly expanding global commercial aviation industry.

Also, latest from NTSB briefing:

NTSB: Briefing Prelim Data
82 secs before impact - AP off - 1600 ft alt
73 secs - 173kts
54 secs - 149kts
34 secs - 134kts - 500 ft
16 secs - 118kts - 200 ft
8 secs - 112kts - 125 ft
3 secs - 103kts
Impact - 106kts

[JL]

An additional factor to consider in this accident is the lack of visual cues the fligth crew would have had while flying over water vs a built up area. A seemingly uniform background such as water makes for a poor reference for judging aircraft height and speed; glassy water being the ultimate condition.

[Guest rozar s'macco]

They had a PAPI, and likely a virtual VNAV path. Glassy water is reaching. It wasn't a slam dunk approach, I believe they were at 4000 feet 13 miles back. SFO and controllers elsewhere usually have a bit of a feel for who they can push, performance-wise. North American carriers into SFO (and LAX, SAN, LAS, MIA, LGA etc) will be pushed (my experience), foreign ones are usually given a bit more leeway to sort themselves out it seems. No blaming the controllers here, in my view.

[Guest ACSideStick]

Rich, you may have hit on a clue to all this when you talked about training with a failure and follows by an ILS coupled.

Where I work, the only ILS in training I see is the mandatory cat3 or Cat 2. The rest of it is failures followed by a non precision approach, and at least one hand flown approach from downwind WITH a engine failure etc.

We don't do ILSs at all, except if a loft scenario calls for it as part of a script.

ILS Luxery ( in my best Monty python voice)

[Trader]

Well, it appears that it comes down to one of two types of approaches.

1. VNAV/RNAV - SFO has significant RNAV approaches up to including the SOIA approaches for parallel runways.

2. Visual approach.

In VNAV the AP and AT are active and, if you discoonect the AP aiutothrust remains active and will control speed.

If the conducted a visual approach the 777 procedure is to turn BOTH flight directors OFF and then the PNF flight director back on. This ensures that the AT is in an ACTIVE mode (not HOLD) where is will control speed or 'wake up' if speed decays. (to be fair this is not well understood by many 777 pilots)

So, if they were flying a visual app, they either did not follow this procedure OR they somehow ended up flying visually from some other approach and missed this.

In the end though it is unacceptable for any professional pilots to miss something like this!!!! I still don't understand how they managed to get so low as well without realizing something was wrong?

[mo32a]

I'm afraid that this may result in more automation and less pilot involvement in the future. I can also foresee the time when your aircraft is monitored and controlled by the "home office". Rather than just receiving ACARS messages they will be able to intervene to correct the situation. With this and AF incidents showing the public that it is the pilots who are the problem the demand for less pilot involvement may increase.

Remember when bad weather was the enemy of aviation causing accidents and delays? Sadly, now it is good weather that seemingly is the enemy of safety.

[rudder]

From another forum:

Here is an email from a United crew holding short of the runway as the Asiana B-777 approached:

On July 6, 2013 at approximately 1827Z I was the 747-400 relief F/O on flt 885, ID326/06 SFO-KIX. I was a witness to the Asiana Flt 214 accident. We had taxied to hold short of runway 28L at SFO on taxiway F, and were waiting to rectify a HAZMAT cargo issue as well as our final weights before we could run our before takeoff checklist and depart. As we waited on taxiway F heading East, just prior to the perpendicular holding area, all three pilots took notice of the Asiana 777 on short final. I noticed the aircraft looked low on glidepath and had a very high deck angle compared to what seemed “normal”. I then noticed at the apparent descent rate and closure to the runway environment the aircraft looked as though it was going to impact the approach lights mounted on piers in the SF Bay. The aircraft made a fairly drastic looking pull up in the last few feet and it appeared and sounded as if they had applied maximum thrust. However the descent path they were on continued and the thrust applied didn't appear to come soon enough to prevent impact. The tail cone and empennage of the 777 impacted the bulkhead seawall and departed the airplane and the main landing gear sheared off instantly. This created a long debris field along the arrival end of 28L, mostly along the right side of 28L. We saw the fuselage, largely intact, slide down the runway and out of view of our cockpit. We heard much confusion and quick instructions from SFO Tower and a few moments later heard an aircraft go around over the runway 28 complex. We realized within a few moments that we were apparently unharmed so I got on the PA and instructed everyone to remain seated and that we were safe.

We all acknowledged if we had been located between Runways 28R and 28L on taxiway F we would have likely suffered damage to the right side aft section of our aircraft from the 777.

Approximately two minutes later I was looking out the left side cockpit windows and noticed movement on the right side of Runway 28L. Two survivors were stumbling but moving abeam the Runway “28L” marking on the North side of the runway. I saw one survivor stand up, walk a few feet, then appear to squat down. The other appeared to be a woman and was walking, then fell off to her side and remained on the ground until rescue personnel arrived. The Captain was on the radio and I told him to tell tower what I had seen, but I ended up taking the microphone instead of relaying through him. I told SFO tower that there appeared to be survivors on the right side of the runway and they needed to send assistance immediately. It seemed to take a very long time for vehicles and assistance to arrive for these victims. The survivors I saw were approximately 1000-1500' away from the fuselage and had apparently been ejected from the fuselage.

We made numerous PAs to the passengers telling them any information we had, which we acknowledged was going to change rapidly, and I left the cockpit to check on the flight attendants and the overall mood of the passengers, as I was the third pilot and not in a control seat. A couple of our flight attendants were shaken up but ALL were doing an outstanding and extremely professional job of handling the passenger's needs and providing calm comfort to them. One of the flight attendants contacted unaccompanied minors' parents to ensure them their children were safe and would be taken care of by our crew. Their demeanor and professionalism during this horrific event was noteworthy. I went to each cabin and spoke to the passengers asking if everyone was OK and if they needed any assistance, and gave them information personally, to include telling them what I saw from the cockpit. I also provided encouragement that we would be OK, we'd tell them everything we learn and to please relax and be patient and expect this is going to be a long wait. The passenger mood was concerned but generally calm. A few individuals were emotional as nearly every passenger on the left side of the aircraft saw the fuselage and debris field going over 100 knots past our aircraft only 300' away. By this point everyone had looked out the windows and could see the smoke plume from the 777. A number of passengers also noticed what I had seen with the survivors out near the end of 28L expressing concern that the rescue effort appeared slow for those individuals that had been separated from the airplane wreckage.

We ultimately had a tug come out and tow us back to the gate, doing a 3 point turn in the hold short area of 28L. We were towed to gate 101 where the passengers deplaned.

[Don Hudson]

A very professional performance and an informative summary.

[blues deville]

Sometimes it political. Sometimes it's based the observation of other pilots. In Canada, you can be appointed to a training pilot position without ever receiving any instructor training, but to become a check pilot, you need to complete a checkride conducted by a TC inspector.

Usually it's another's check pilot, but TC will also conduct random checkrides. The Chief Pilot's role is to ensure that the reguired checkrides have been completed and the results are satisfactory. He would usually step in in the event a check pilot fails a ride and requires a re-check.

.

Political? Perhaps sometimes. I've had pilots walk into my office in the past and ask me when were they going to be appointed as a training pilot because they were "this" and "that". Training pilots that I have worked with usually had some kind of instructional background as welll as having demonstrated an above average level during their training and check rides. Also check pilots in Canada must take an Approved Check Pilot course. My initial course was at Air Canada given by Capt. Dave "Swish" Holland and I attended several more during the years following to maintain my status as a company check pilot. Not sure if its still the same but to receive approval from TC to be a chief pilot, I had to write a lengthy exam and endure a 3 hour interview with my region's head inspector. That wasn't much fun!

So I don't think the selection process is quite as loose as you are describing. At least that's not my experience.

[rudder]

Great AA training video about automation dependancy. It appears to be from the 90's but seems equally relevant today.

https://www.youtube.com/watch?v=h3kREPMzMLk

[Don Hudson]

"Automation dependency" is not the result of a technology, it is a state of mind. Automation has never crashed an aircraft but reliance upon magic has.

[rudder]

Well, FWIW I believe that if both the A/P and the A/T had 'failed' during the descent phase and such failure was acknowledged by the crew and therefore the crew had to fly manually on approach to landing that this event would never have occurred.

Once again, humans and technology can be a disappointing combination. Like the man says "click,click - click,click"