News Asiana 777-200 Crash on landing at SFO

[Urwumpe]

Actually, the funny detail is, that the situation is fully intentional.

• Boeing thinks the pilot is smart enough to know what he is doing.
• It makes sense to have the FLCH mode active, it is just bad practise
• It even makes sense to have the throttle down to idle during some landings
• The FLCH vertical autopilot mode and the autothrottle mode is indicated in every MFD and should be visible to the usual instrument check patterns.
• So, a warning sound would disturb more than it helps

The problem is just: It is far from intuitive, how the behavior of the FBW system is in that situation.

An Airbus aircraft would attempt to know better than the pilot there, with its own number of accidents proving that this concept is also not fail-safe.

The problem is: When do you warn? The case "FLCH mode active during landing gear deployed" would result in pilots disabling the warning when they know better that this is the right mode and the accident happening again.

The only part where you can really improve this situation for the Boeing concept of FBW is the pilot. If training would be adequate and the quirks of the FBW system known, such a situation should not happen that often.

 

[kamaz]

Your DAU is a two-year old randomly mashing buttons.

The Chernobyl accident proves that inventive operators are much more dangerous than two-year-olds. Two-year-olds are too stupid to disable safeties.

---------- Post added at 02:22 AM ---------- Previous post was at 02:15 AM ----------

Actually, the funny detail is, that the situation is fully intentional.

I think this is very similar to AF447.

The aircraft should be impossible to stall. The pilot knows that the aircraft is impossible to stall, so he ignores the warnings. Problem is, the aircraft is actually in the mode where it can stall.

---------- Post added at 03:05 AM ---------- Previous post was at 02:22 AM ----------

An article describing problems with training of Korean pilots: http://directorblue.blogspot.com/2013/07/the-low-down-on-korean-airliner-pilots.html

 

[Melvin]

Wow, you guys are actually willing to blame the aircraft and it's systems for this crash?


Give me a break. Don't you think it would be more productive to streamline the onboard systems and make them less complicated while at the same time boosting the level of pilot training required to fly aluminum cans full of people through the sky at high speeds?

 

[Urwumpe]

Wow, you guys are actually willing to blame the aircraft and it's systems for this crash?

Who made who?

 

[C3PO]

Wow, you guys are actually willing to blame the aircraft and it's systems for this crash?

There's a difference between 'blame' and 'reason'. That's why accident reports use the term 'contributing factor'.

 

[Melvin]

There's a difference between 'blame' and 'reason'. That's why accident reports use the term 'contributing factor'.

The systems should be taken out of the equation.




This accident, as well as the Air France accident, can be chalked up to lack of training.

 

[MattBaker]

This accident, as well as the Air France accident, can be chalked up to lack of training.

Yes, but in the end 90% of pilots can't react in the perfect manner in any kind of wronggoing and for these situations it would be great if the flight systems aree as intuitive as possible.

 

[Urwumpe]

The systems should be taken out of the equation.

That is wrong. If a different system had been the best point to avoid the accident, the system is even significant.

 

[RGClark]

...
The problem is: When do you warn? The case "FLCH mode active during landing gear deployed" would result in pilots disabling the warning when they know better that this is the right mode and the accident happening again.

It doesn't have to be a constant blaring warning. Just a verbal reminder that autothrottle is now disabled and that now throttle MUST be manually controlled. I believe for example there is a verbal reminder when autopilot is disengaged.
Software is smart enough now it could detect when the pilot is not supplying control inputs in the expected fashion and could supply additional reminders to check air speed and control throttle. This should happen well before the plane gets to the stall condition.

Bob Clark

 

[Urwumpe]

It doesn't have to be a constant blaring warning. Just a verbal reminder that autothrottle is now disabled and that now throttle MUST be manually controlled. I believe for example there is a verbal reminder when autopilot is disengaged.

Software is smart enough now it could detect when the pilot is not supplying control inputs in the expected fashion and could supply additional reminders to check air speed and control throttle. This should happen well before the plane gets to the stall condition.

If the pilot wants it that way by configuring the aircraft that way, a warning is not what you want to hear - it could be used in a perfectly safe way, when done properly. A warning, that an autopilot or autothrottle mode is disengaged only happens when it happens automatically, for example because of a hardware failure, and not by explicit crew action. And that moding into FLCH was an explicit crew action.

Also, smart software is not for replacing smart pilots, but to be a reliable partner for a smart pilot. If you think that a better software alone can make it possible to lower training standards, you should use more software in your life and despair.

 

[kamaz]

The systems should be taken out of the equation.

This accident, as well as the Air France accident, can be chalked up to lack of training.

It seems to me that the engineers are attempting to create a plane which cannot be crashed. And constantly, someone comes around and manages to crash it.

In AF447 there was indeed a design error which contributed, because the pilot in the left seat did not know that the pilot in the right seat is constantly pitching the nose up. This led to a stall.

Here, we have an aircraft which has been intentionally configured so that it can be stalled... and then it was stalled. Adding a warning will not help here, because the pilot will learn to expect (and ignore) that warning when selecting the mode in question.

 

[garyw]

It doesn't have to be a constant blaring warning. Just a verbal reminder that autothrottle is now disabled and that now throttle MUST be manually controlled. I believe for example there is a verbal reminder when autopilot is disengaged.
Software is smart enough now it could detect when the pilot is not supplying control inputs in the expected fashion and could supply additional reminders to check air speed and control throttle. This should happen well before the plane gets to the stall condition.

Bob Clark

On the left of this graphic is a speed tape.

Below the bottom of the speed tape are amber and red markers. Amber is 5 knots above stall. The box will also flash.

Those are two visual indications that you might want to consider going a bit faster.

If those are not enough the pilot should be removed from the flight deck. Everything you need is RIGHT THERE.

Also, when a plane, even a 777 goes too slow the nose goes up. Anyone who flies should be sitting there going 'The nose is too high, what's going on.... SPEED'.

If they can't fly by the feel of the aircraft they should be doing something else.

 

[Urwumpe]

On the left of this graphic is a speed tape.



Below the bottom of the speed tape are amber and red markers. Amber is 5 knots above stall. The box will also flash.

Those are two visual indications that you might want to consider going a bit faster.

Also, the three boxes on top of the display indicate (from left to right):

Autothrottle: Next state is "Armed" (because the text is shown white)
Roll navigation mode: Heading selection
Pitch navigation mode: Follow path

In this example, the autopilot is not active.

On a 777, the next mode to be selected by automatic transition for each of the three channels will be displayed as white small text label below the current autopilot modes.

http://www.meriweather.com/flightdeck/777/fwd/pfd.html

As I had written somewhere above on the FLCH situation on the PFD, the left most box for the autothrottle should have been showing IDLE instead of SPD - it was visible to the pilot by a short glance on the display, that the autothrottle was not in the mode that he expected. And for anybody else in the cockpit.

 

[garyw]

Plus on this flight deck was the captain, first officer and a training captain. How the hell three pilots missed two visual indicators (the speed tape and the flashing amber box) plus the pitch angle of the plane is beyond me.

 

[Urwumpe]

Correction on the autothrottle mode, I just checked the 777 manual on that:

It should have been showing HOLD before the crash, which means: Manual throttle control, even when autothrottle is armed.

When the pilot pushes FLCH for a descend, the autothrottle goes into THR mode to hold the speed in the MACH/IAS windows until the thrust level drops to IDLE, then the autothrottle becomes HOLD. The speed in the MACH/IAS window is either what is entered in the FMC or what the pilot manually selected, if the FMC data was no valid velocity.

 

[Cosmic Penguin]

Plus on this flight deck was the captain, first officer and a training captain. How the hell three pilots missed two visual indicators (the speed tape and the flashing amber box) plus the pitch angle of the plane is beyond me.

I wonder if the Korean tradition of "obedience to your senior" caused the others in the cockpit not to alert the captain for anything wrong during the approach - you might want to check out 2 Air Crash Investigations episodes for a detailed discussion of this phenomenon (the crash of KAL 8509 at Stansted in 1999 and the crash of KAL 801 at Guam in 1997).

 

[C3PO]

I wonder if the Korean tradition of "obedience to your senior" caused the others in the cockpit not to alert the captain for anything wrong during the approach - you might want to check out 2 Air Crash Investigations episodes for a detailed discussion of this phenomenon (the crash of KAL 8509 at Stansted in 1999 and the crash of KAL 801 at Guam in 1997).

That's a possibility, but since this was part of a training flight shouldn't the Pilot Flying be the least senior crew member?

 

[Andy44]

Plus on this flight deck was the captain, first officer and a training captain. How the hell three pilots missed two visual indicators (the speed tape and the flashing amber box) plus the pitch angle of the plane is beyond me.

I wonder if the Korean tradition of "obedience to your senior" caused the others in the cockpit not to alert the captain for anything wrong during the approach - you might want to check out 2 Air Crash Investigations episodes for a detailed discussion of this phenomenon (the crash of KAL 8509 at Stansted in 1999 and the crash of KAL 801 at Guam in 1997).

My guess is that because there were three people there each must've assumed one of the other guys was keeping an eye on it.

It's like three outfielders standing there watching the ball drop to the ground because they each thought somebody else was going to catch it.

Only a guess.

 

[garyw]

I wonder if the Korean tradition of "obedience to your senior" caused the others in the cockpit not to alert the captain for anything wrong during the approach - you might want to check out 2 Air Crash Investigations episodes for a detailed discussion of this phenomenon (the crash of KAL 8509 at Stansted in 1999 and the crash of KAL 801 at Guam in 1997).

Agreed, I've seen those episodes and I think this did occur on the flight deck.

That's a possibility, but since this was part of a training flight shouldn't the Pilot Flying be the least senior crew member?

Not necessarily. If there is a type conversion going on you could have a junior (in terms of time with the company but not 777 experience) training a senior captain. This coupled with the above 'traditional place' mentality caused a lack of CRM at critical times.

My guess is that because there were three people there each must've assumed one of the other guys was keeping an eye on it.

It's like three outfielders standing there watching the ball drop to the ground because they each thought somebody else was going to catch it.

Only a guess.

Reminds me of Douglas Adams talking about how you make a spacecraft invisible with a SEP field (Somebody Elses Problem). Everyone can see it but the brain ignores it as it's somebody elses problem. In this case the IAS gauge was SEP.
This still goes back to bad CRM though. During the approach the Captain should have briefed for a manual landing into SFO and gone through what he expected each of the crew members to do. The instructor should have added his own comments and talked about how the plane would handle and what to look out for.

Even with all of that missing it still leaves one major question - why didn't anyone notice the excessive pitch angle - a classic sign of a plane going too slow.

 

[Urwumpe]

Even with all of that missing it still leaves one major question - why didn't anyone notice the excessive pitch angle - a classic sign of a plane going too slow.

Did it pitch up at all without similar crew input? The underspeed condition developed very shortly before ground contact. 30 seconds and about one mile before threshold, the aircraft was still a bit high and fast.

Just by the few information available:

TTI (seconds) | Event | Speed (IAS)
82| Autopilot off, throttle to idle|190
35| Crew focusses on a lateral deviation|
16| Last mentioning of the lateral deviation|
8| Speed drops to yellow part of the tape | 112
7| Throttle is advanced from idle|
4| Stick shaker is heard|
3| Engine power reached 50% N1, unknown crew member calls for GA| 103
1.5| Another crew member calls for GA|
0|IMPACT|106

Until 8 seconds, there was no strong warning - but the crew also seemed to be more concerned about various deviations, as you would expect from a crew that has little experience with VFR landings all together. The instructor pilot called out for sink rate during the whole final approach, as you can expect since the aircraft was too high initially.

About the Korean culture and their effects on pilots, here is an report of an accident from 1997, KAL 801, that ended as CFIT when the flying pilot ignored that more veteran flight engineer stated that the signal that the pilot picked up, was not the ILS of the airport and the airport was still out of sight.

http://www.ntsb.gov/doclib/reports/2000/AAR0001.pdf