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Asiana Crash Landing At Sfo Saturday

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Flight International has an article commenting on the A/T topic. Wouldn't be surprised if this law firm is using these unofficial reports as a basis for their case?

http://www.flightglobal.com/news/articles/asiana-777-pilot-assumed-autothrottles-engaged-until-seconds-before-impact-388103/?cmpid=NLC%7CFGFG%7CFGFIN-2013-0716-GLOB

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Colbert and Stewart.....comedic genius.

FYI....Colbert lost his father and two brothers on a US Air crash several years ago.

Edited by blues deville

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Just did a LOFT scenario where A/P was failed on descent just below RVSM altitude. Completed an RNAV STAR with many speed and altitude crossing restrictions to a high density terminal (ATC instructions at the most inopportune times). It was surprisingly busy keeping up with the FMS and MCP programming (for the PM), but we landed the simulator safely :biggrin1:

Perhaps Asiana will have to add that exercise to their training syllabus. Perhaps everybody should.

  • Like 1

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visual and hands on or autopilot? :Grin-Nod:

Single engine, eyes closed, in the middle of a thunderstorm. And no, I'm not that good, that's just how big the holes are.

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Finally, some courtesy. There I am, floating in the middle of the lake, and a guy does a circut signalling his intention to land. This time, I have plenty of time to paddle out of the way ( not like last year), and I happily observe the landing from the dock. Now, THAT is a Visual Approach. :)

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And now the pilot is claiming a blinding flash 34 seconds before impact was the problem. Possibly lasered.

This according to the 6PM Global BC newscast.

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We still don't know the status of the autothrust - whether it was engaged or not, and if not, when not? Also, we don't know what the Altitude Select on the MCP was reading. Was it set above the altitude of the aircraft, (set to MA alt, for example), set at zero because they were high and didn't want a capture too early which would bring up the thrust and further de-stabilize the approach. We can almost be sure it wasn't set for something below the aircraft but above airport elevation, unless the autothrust was only armed but not engaged, (and why would that be?, one wonders...it was a training flight after all...when would it have been disconnected - hm).

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Hi Rich;

The Air India Bangalore accident report is very difficult to find. A friend has uploaded it to here. It is a very long report and looks as though it were typed on an old (even at the time!) Underwood. I don't think this is a repeat of IC605 in one sense, but it is in another which led me to ask the questions above. The B777 does not have the same FD system that the A320 did at the time of the accident, (with reversion to "SPEED" 2 knots above Vls...only above 100ft). The setting of the Altitude Select was such that "Idle-Open Descent" would remain the autoflight mode right down to the ground, and it is that fact that caused me to ask the above question.

Re, "What difference does it make whether the autothrottle was engaged or not?"

and,

Re, "Whatever the status of the autothrust (OK, OK... autothrottle for the Boeing diehards) where were the PF's hands?"

I think it makes a lot of difference, :)

The answer to the first question would tell us a possible cause of the accident which the answer to the second question would not.

The second question is a hindsight question and no answer would explain the accident.

The answer to the first question leads us to further examination.

Clearly, the argument for moving throttles keeping pilots informed as to thrust levels now fails in two fatal accidents. Just like the argument for sidesticks vs control columns, (or ram's horns...)

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I think the combination of modes will be a critical issue. Using FLCH (an auto flight/auto thrust mode) for their approach phase of flight may be the issue.

Also, if the trainee's most recent experience was Airbus (where the thrust levers do not move) and the PF did have his hand on both control wheel and thrust levers, perhaps this also will be a factor.

I would like to know what they were using as a reference for the vertical path, electronic or visual, to arrive 1500' short of the desired touch down point.

Edited by blues deville

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Hi Rich;

Re, "But I think my question about where the PF's hands were placed is important because, if his hands were on the 'throttles', it would have given him an indication of what the autothrottle was doing (or not) without having to refer to the FMA."

I think that's a correct statement and could have made the difference but (and my point in my response was), that's a "should have" statement. What we think should have happened does not explain people's behaviour.

I think it could be said that keeping one's hands on the throttles would, as you say, have cued the PF as to the state of engine thrust, (and the Bangalore accident report makes this point somewhere after page 254), but even if true that does not fully explain the accident. Why were the throttles at idle at that point in the approach, with an airspeed reducing below Vref?

I think knowing what state the autothrottles were in, (armed, not engaged, armed & engaged) and what the Altitude setting on the MCP was will go a lot further to help us understand why the autothrottles did not respond to the reducing speed.

Re, "It would be interesting to hear more from the B777 guys . . ."

Yes, it certainly would. I have experience on the B767 and I am assuming similarities between the types. There is a "hold" mode in FLCH when descending that I would like to further understand. Having the manuals and AMM (non-updated versions) only go so far.

Edited by Don Hudson

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Doesn't this debate really come down to a single issue; the loss of speed control? Regardless of who's automatic toys& tricks are being used, what kind of 'pilot' sits on his hands and does nothing as the airspeed decays below target? Wouldn't a competent pilot be aware of the target speed and the reality that things aren't happening or looking as they should even before the speed has decayed to target value?

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Hi DEFCON;

The issue is certainly one of aviation basics - maintaining speed. The enigma is why a number of highly-experienced and in most cases, highly-trained crews have brought their aircraft to the point of stalling, crashing and killing people - four in the last four years alone. I can list a dozen others*.

We now have cars that will park themselves, that will maintain a "safe" distance from the car ahead while on autothrottle (speed control) and which may soon drive themselves using GPS resolutions currently only available to specialized industries.

So what do we all think is going to happen to driving and parking skills?

It isn't hard to connect the dots.

* Accidents in which the aircraft lost speed energy and / or stalled 1974 - 2013:

-Asiana 214, B777, SFO, struck threshold due loss of speed, July, 2013

-Lionair, B738, Indonesia, late go-around, crashed short of the runway, April, 2013

-AF447, A330, mid-Atlantic Ocean, stalled in response to UAS, June, 2009
-Turkish Airlines, B737, stalled on approach, Amsterdam, The Netherlands, February, 2009
-Colgan, Q400, stalled during approach, Buffalo, New York, February, 2009
-Fedex, ATR42, stalled on approach, non-fatal, Lubbock, Texas, January, 2009
-Air New Zealand/XL Airways, A320, stalled on test flight, Perpignan, France, November, 2008
-Spanair, MD83, stalled on takeoff due zero-slats/flaps t/o, Madrid, Spain, August, 2008
-One-Two-Go, MD82, stalled due go-around thrust not applied, Phuket, Thailand, September, 2007
-Thomson, B737-3Q8, stall and recovery on approach, Bournemouth, Hampshire, September, 2007
-West Caribbean Airways, MD82, stalled during engine failure/thunderstorm proximity, Venezuela, August, 2005
-MK Airlines, B747, fail to get airborne, Halifax, NS, October, 2004
-Airborne Express, DC8, stall test, Virginia, USA, December, 1996
-Airbus, A330, stalled on test flight, Toulouse, France, June, 1994
-China Airlines, A300, stalled on accidental go-around & loss of control, Nagoya, Japan, April, 1994

-Air France, A320, Mulhouse-Habsheim, stalled on low pass during airshow, June, 1988
-China Airlines, B747, stalled after engine failure, a/p remained engaged, San Francisco, USA, February, 1985
-Air Florida, B737, stalled due wing contamination, Washington DC, January, 1982
-Northwest Orient, B727, stall due UAS event (pitot heat off), Stony Point, New York, December, 1974

Edited by Don Hudson

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I was e-mailed this report. I think the guy is all wrong. I suppose that possibly the pilots may not be as focused as they should be at times but I think the problem is much deeper. I would contend that when things go pear-shaped that pilots are losing the situational awareness that they require to get them out of a hole. I contend that in the AF and Cogan accidents, the pilots simply went brain dead and weren't able to deal with sorting out the inputs and coming up with the corrective action even though the situation wasn't all that complicated. Essentially they were simply passengers.

National Transportation Safety Board member Robert L. Sumwalt said Wednesday at a pilots' conference that an NTSB report finds lapsed monitoring factored in 94 percent of aviation mishaps. He spoke in the wake of the July 6 Asiana Airlines crash in San Francisco.
By JOAN LOWY

WASHINGTON (AP) - Airline pilots spend nearly all their time monitoring automated cockpit systems rather than ''hand-flying'' planes, but their brains aren't wired to continually pay close attention to instruments that rarely fail or show discrepancies.

As a result, pilots may see but not register signs of trouble, a problem that is showing up repeatedly in accidents and may have been a factor in the recent crash landing of a South Korean airliner in San Francisco, industry and government experts say.

Teaching pilots how to effectively monitor instruments has become as important as teaching them basic ''stick-and-rudder'' flying skills, a panel of experts told an annual safety conference of the Air Line Pilots Association, the world's largest pilots union, on Wednesday.

''The human brain just isn't very well designed to monitor for an event that very rarely happens,'' said Key Dismukes, a top NASA human factors scientist.

While people ''do very well'' at actively controlling a plane, ''we're not well designed to monitor for a little alphanumeric (a combination of alphabet letters and numbers) on the panel even if that alphanumeric tells us something important,'' he said. ''We can't just sit there and stare at the instruments.''

The ''sheer volume of monitoring required even on the most routine flights and the diversity'' of systems that must be monitored has increased, he said.

Concern about the problem is great enough that government, union and industry safety officials formed a working group last fall to come up with a blueprint for teaching pilots techniques for how to overcome the brain's natural tendency to sometimes see but disregard important information. For example, if pilots see airspeed indicators showing appropriate speeds landing after landing, their brains may filter out an unexpected low or high speed, they said.

''The human brain filters out information it considers unchanging,'' said Helena Reidemar, an airline pilot and the pilots union's director of human factors.

Asiana Flight 214 crashed short of a runway at San Francisco International Airport on July 6 after a nearly 11-hour flight from Seoul, South Korea. Of the 307 people on board, three have died and dozens of others were injured. One of the issues that have emerged in the National Transportation Safety Board's investigation of the accident is whether the pilots, who were supposed to be watching airspeed indicators, were aware the plane was traveling at speeds so dangerously slow that it was at risk of losing lift and stalling.

The flight's pilots set a target airspeed of 137 knots for crossing the runway's threshold. The plane reached speeds as low as 103 knots just before its landing gear and then its tail collided with a rocky seawall at the end of the runway, shearing off the tail, dumping three flight attendants onto the tarmac and sending the rest of the plane spinning and sliding.

Dismukes cautioned that it's too soon to reach conclusions about whether the three Asiana pilots who were in the Boeing 777's highly-automated cockpit were closely monitoring the plane's airspeed, ''but what was going on there in terms of monitoring systems obviously is going to be a crucial issue.''

Robert Sumwalt, an NTSB board member, said: ''The question is, did the pilots recognize they were slow? And if not, why not?''

The board's investigation hasn't turned up any mechanical or computer problems with the plane, NTSB chairman Deborah Hersman said at briefing last week.

The board has repeatedly investigated accidents in which pilots' failure to closely monitor key systems contributed to the crash, Sumwalt said.

In 2007, after an investigation of a fatal business jet accident in Pueblo, Colo., the board recommended that the Federal Aviation Administration require that pilot training programs be modified to contain segments that teach and emphasize monitoring skills and how to manage multiple tasks, Sumwalt said. Since then, the board has twice repeated the recommendation in response to other accidents, he said.

The FAA, however, hasn't required airlines to change their training programs, Sumwalt said. Instead, the agency suggested airlines revise their procedures to ''promote effective monitoring'' if pilots are found to be inconsistent in their monitoring techniques, he said.

The board doesn't believe the advice goes far enough, and has categorized FAA's response as ''unsatisfactory,'' Sumwalt said.

One of the accidents that led NTSB to renew its recommendation was the February 2009 crash of a regional airliner near Buffalo, N.Y. In that case, the two Colgan Air pilots weren't closely monitoring the Bombardier Q-400's airspeed and so failed to notice that the plane's speed had rapidly dropped about 50 knots, Sumwalt said. The startled captain responded incorrectly to an automated warning of an impending stall, sending the plane plunging into a house below. Fifty people, including a man on the ground, were killed.Continued...

''This is an area that is really ripe for improving safety,'' he said. ''It's time for a paradigm shift. ... It used to be pilots were judged on their stick-and-rudder skills. They also should have to have good monitoring skills.''

Some airlines are incorporating those techniques for improving monitoring skills in their training, experts said.

''We understand there is a threat. We understand there is a need to do things better,'' said Christopher Reed, a JetBlue Airways captain and pilot training manager who was a member of the panel.

JetBlue is trying to give pilots more time flying planes without relying on automated systems in part ''because the mental habit patterns you are following by practicing those skills can help you be a better monitor,'' he said.

Several panel members emphasized the importance of ''actively monitoring'' versus ''passively monitoring'' cockpit systems. Pilots who are flying without automated systems are mentally engaged in flying, and they need to bring that same awareness to monitoring, experts said.

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DEFCON, PMFJI...if I may:

Rich;

"And after a long flight to a busy airport with a non-normal approach, stress and fatigue would most certainly play a role.", yes indeed.

"but it's certainly not as simple as saying the pilots were incompetent.", again, yes indeed, and it may not even default to the now-familiar notions of the "organizational accident". This kind of accident (a sort-of CFIT - LOC) has occurred many times (comparatively speaking), to competent, high-time, well-trained pilots.

A bit different tack - from a website entitled, "Macroresilience":

People Make Poor Monitors for Computers

Airplane automation systems are not the first to discover the truth in the comment made by David Jenkins that “computers make great monitors for people, but people make poor monitors for computers.” As James Reason observes in his seminal book ‘Human Error’:

We have thus traced a progression from where the human is the prime mover and the computer the slave to one in which the roles are very largely reversed. For most of the time, the operator’s task is reduced to that of monitoring the system to ensure that it continues to function within normal limits. The advantages of such a system are obvious; the operator’s workload is substantially reduced, and the [system] performs tasks that the human can specify but cannot actually do. However, the main reason for the human operator’s continued presence is to use his still unique powers of knowledge-based reasoning to cope with system emergencies. And this is a task peculiarly ill-suited to the particular strengths and weaknesses of human cognition…..most operator errors arise from a mismatch between the properties of the system as a whole and the characteristics of human information processing.
System designers have unwittingly created a work situation in which many of the normally adaptive characteristics of human cognition (its natural heuristics and biases) are transformed into dangerous liabilities.

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If they had set a target speed of 137k, shouldn't there be some annunciation if you fall below it?

Basically they had 2 jobs, monitor airspeed and altitude.

Fail.

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If they had set a target speed of 137k, shouldn't there be some annunciation if you fall below it?

Basically they had 2 jobs, monitor airspeed and altitude.

Fail.

The aircraft crashed so obviously there was a "fail" somewhere but there were a lot more than 2 things to monitor. You're an FA right? Even on a "simple" approach in visual conditions there are dozens of things to be doing and monitoring.

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The enigma is why a number of highly-experienced and in most cases, highly-trained crews have brought their aircraft to the point of stalling, crashing and killing people - four in the last four years alone. I can list a dozen others*.

Apart from a mechanical/technical/system fault (?), I believe letting the automation overwhelm your pilot skills and judgement to be the biggest culprit. Remember the acronym CAMI? (Confirm, Activate, Monitor, Intervene).

There is no faulty automation that can't be overridden, but you have to see it for what it is.

Edited by Gumbi

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Fly the airplane first...That's the number one rule.

Then apply the basic rules...Avigate, Navigate, Automate, Communicate.

Edited by Boney

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Fly the airplane first...That's the number one rule.

Then apply the basic rules...Avigate, Navigate, Automate, Communicate.

Isn't there a 'g' missing?

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