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OZ 777 Crash At SFO Part 10  
User currently offlinemoderators From United States of America, joined Apr 2004, 513 posts, RR: 0
Posted (1 year 3 months 1 week 2 days ago) and read 32894 times:
AIRLINERS.NET CREW
FORUM MODERATOR

Hello All,

Part 9 has become extremely long so we are creating Part 10 in order to make it easier to find new information.

Part 9 can be found here OZ 777 Crash At SFO Part 9 (by moderators Jul 12 2013 in Civil Aviation)

Regards,

The Moderator Crew


Please use moderators@airliners.net to contact us.
153 replies: All unread, showing first 25:
 
User currently offlineTheRedBaron From Mexico, joined Mar 2005, 2259 posts, RR: 9
Reply 1, posted (1 year 3 months 1 week 2 days ago) and read 33077 times:

Holy COW. the pictures

From Rfields post:

Quote:
I should also mention that it is amazing how quickly an approach can go from looking fine to looking horribly dangerous in a low power / behind the power curve aircraft.

EDIT - found this link on another site - http://www.iamajellydoughnut.com/AT/Asiana.pdf

33 photos of the inside and the removal of the wreckage

What a miracle after all this destruction that almost everyone survived!!!

I know everyone of us make mistakes but those pilots deserve to be called morons, if not worse, way to destroy an aircraft and also the lives of the passengers...

The final report will not be kind to those guys...

TRB



The best seat in a Plane is the Jumpseat.
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 2, posted (1 year 3 months 1 week 1 day 22 hours ago) and read 32599 times:

Quoting TheRedBaron (Reply 1):
I know everyone of us make mistakes but those pilots deserve to be called morons, if not worse

Certain combinations of circumstances can make anyone look like a moron. At the moment it looks likely that the report will note errors made by this crew but we don't yet know how those errors came about. Labeling the crew as morons doesn't seem very objective or constructive.


User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 3, posted (1 year 3 months 1 week 1 day 19 hours ago) and read 32265 times:

Quoting David L (Reply 2):
Quoting TheRedBaron (Reply 1):
I know everyone of us make mistakes but those pilots deserve to be called morons, if not worse

Certain combinations of circumstances can make anyone look like a moron. At the moment it looks likely that the report will note errors made by this crew but we don't yet know how those errors came about. Labeling the crew as morons doesn't seem very objective or constructive.

        

It is very easy for us to sit and judge. Certainly a screwup occurred, but at this moment we don't have the exact details. Cockpit dynamics, fatigue, high workload and other factors all add up to make these situations quite complex.

Any pilot will tell you that pitch, power and airspeed is basic stuff, but he will also tell you that when you are tired and stressed you make mistakes. Then you get back on the ground and go "what the heck was I thinking?"

It will be interesting to see what the investigation turns up in this area.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 4, posted (1 year 3 months 1 week 1 day 15 hours ago) and read 31786 times:

Quoting TheRedBaron (Reply 1):

WOOW! I hadn't seen those pics and the damage towards the back even without the fire is bad!



If you're going through hell, keep going
User currently offlinetraindoc From United States of America, joined Mar 2008, 361 posts, RR: 0
Reply 5, posted (1 year 3 months 1 week 1 day 15 hours ago) and read 31710 times:

On some other aviation websites posters are saying that we need even better seats than those on the T7, which can handle 16 G's. They say that better seats will reduce spine injuries. That may be true, but only if you put each pax in some type of shock resistant space shuttle type seat with shoulder harnesses. In reality, any sudden downward force of even 1 or 2 G's is enough to cause spine injuries. My take as an ER physician is that the Asiana T7 did one heck of a job protecting the passengers. The proof is in how few pax actually had debilitating injuries.

User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 6, posted (1 year 3 months 1 week 1 day 15 hours ago) and read 31624 times:

Quoting TheRedBaron (Reply 1):
I know everyone of us make mistakes but those pilots deserve to be called morons, if not worse,

The problem actually is that they are NOT morons but rather a trained and experienced flight crew. Still they crashed a 777 with no mx problems in great weather. Why is that? It's similar to the AF447 situation where a lot of people just wrote the crew off as a bunch of dolts for stalling the plane. Why does a competent, certified flight crew do stuff that, at least superficially, looks really stupid?


User currently offlineTheRedBaron From Mexico, joined Mar 2005, 2259 posts, RR: 9
Reply 7, posted (1 year 3 months 1 week 1 day 13 hours ago) and read 31321 times:

Quoting David L (Reply 2):
Certain combinations of circumstances can make anyone look like a moron. At the moment it looks likely that the report will note errors made by this crew but we don't yet know how those errors came about. Labeling the crew as morons doesn't seem very objective or constructive.
Quoting hivue (Reply 6):
Why does a competent, certified flight crew do stuff that, at least superficially, looks really stupid?

I agree that I am being too harsh on those guys, and God knows they have a huge burden to carry... but back on tops, one thing taht creeps up again and again is the: " too many cooks on the kitchen syndrome " AF 477 is a great example, Turkish crash (that cost the lives of the pilots) and this one too, I really find it hard to believe that (if the 777 did not have any MX problem), they crashed in a clear day, with an experienced crew and another set of eyes and Brain in the cockpit...

God knows I have made some really stupid mistakes, but I have learned that when in doubt ASK, and ask for help, you may look ignorant or nervous or lacking experience, but it avoids even larger mistakes...

I apologize for being too judgmental, and yes it doesnt bring anything constructive to the topic, but I guess the report will not be kind to them, and they have to live with that mistake...a burden I don't want ANYBODY to have....

TRB



The best seat in a Plane is the Jumpseat.
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 8, posted (1 year 3 months 1 week 1 day 12 hours ago) and read 31173 times:

Quoting TheRedBaron (Reply 7):
I have learned that when in doubt ASK, and ask for help, you may look ignorant or nervous or lacking experience, but it avoids even larger mistakes...

To be fair, we don't know much about how the Asiana crew interacted. Maybe the CRM was bad, maybe it was good but bad decisions were made, maybe it was more complicated.

In the case of AF447, the crew did question each other. What was lacking was suitable answers.


User currently offlineabba From Denmark, joined Jun 2005, 1372 posts, RR: 2
Reply 9, posted (1 year 3 months 1 week 1 day 12 hours ago) and read 31004 times:

Norcal773
"I lived in Asia as an expat for 3 years, Manila, Singapore and Hong Kong. I still think parading the FAs in front of camera while they cried had nothing to do with the culture, it was just a dumb move by OZ- period."

Don't be rediculus, please. First: 3 years is nothing but an extended turist stay. And don't speak of Asia and Asian culture as such. It simply makes no sense! The difference between Manila and Seul is - at least! - as big as between Istandbull and London or Cairo and New York. Hey - I have been in Mexico City - now I know American culture!


User currently offline135mech From United States of America, joined Oct 2006, 412 posts, RR: 4
Reply 10, posted (1 year 3 months 1 week 1 day 11 hours ago) and read 30848 times:
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Quoting TheRedBaron (Reply 1):
What a miracle after all this destruction that almost everyone survived!!!

I know everyone of us make mistakes but those pilots deserve to be called morons, if not worse, way to destroy an aircraft and also the lives of the passengers...

The final report will not be kind to those guys...

TRB



I am sorry if I offend anyone (not my intention) but I completely agree with TheRedBaron on this! It was the best of conditions, and this should have never happened, the airline and insurance have to pay out the wazoo for this accident, and the ripple effects of this for them and the others involved; directly and indirectly, will suck for all!

I know that no one wants to ever hear "pilot error"... but call it what it is and don't hide behind politics etc.

RIP to the three!

Regards,
135Mech


User currently offline135mech From United States of America, joined Oct 2006, 412 posts, RR: 4
Reply 11, posted (1 year 3 months 1 week 1 day 11 hours ago) and read 30791 times:
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Quoting David L (Reply 8):
In the case of AF447, the crew did question each other. What was lacking was suitable answers.



AND... the person in the right seat continuously holding back on the control stick saying he didn't understand what was wrong...HE was what was wrong in the end!

135Mech


User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 12, posted (1 year 3 months 1 week 1 day 11 hours ago) and read 30701 times:

Quoting abba (Reply 9):
on't be rediculus, please. First: 3 years is nothing but an extended turist stay. And don't speak of Asia and Asian culture as such. It simply makes no sense! The difference between Manila and Seul is - at least! - as big as between Istandbull and London or Cairo and New York. Hey - I have been in Mexico City - now I know American culture!

Eeh,you obviously didn't care to read my other posts, did you? Hate it when people take bits and pieces and don't bother to follow up on other posts before making as ass out of themselves. Anyways, whatever dude!



If you're going through hell, keep going
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 13, posted (1 year 3 months 1 week 1 day 10 hours ago) and read 30611 times:

Quoting 135mech (Reply 10):
but call it what it is and don't hide behind politics etc.

Saying it might not be "pilot error, end of story" is not hiding behind politics in my view.

Quoting 135mech (Reply 11):
AND... the person in the right seat continuously holding back on the control stick saying he didn't understand what was wrong...HE was what was wrong in the end!

Except he didn't. From the DFDR sidestick traces it seems more likely that he was targeting a memory-item pitch but it was the pitch from the wrong phase of flight. Yes, that was wrong but it was still recoverable for some time. Plenty of other issues played a part. It doesn't alter the point I made in response to the suggestion that the AF447 crew didn't ask questions.


User currently offlineabba From Denmark, joined Jun 2005, 1372 posts, RR: 2
Reply 14, posted (1 year 3 months 1 week 1 day 10 hours ago) and read 30554 times:

Quoting Norcal773 (Reply 12):
Eeh,you obviously didn't care to read my other posts


No - but I read this one and the one from Zeke which was a comment spot on in relation to this issue.


User currently offlineUA787DEN From United States of America, joined Dec 2012, 420 posts, RR: 0
Reply 15, posted (1 year 3 months 1 week 1 day 8 hours ago) and read 28805 times:

If the pilots really didn't want the 777 I would've taken it! 
Quoting David L (Reply 8):
To be fair, we don't know much about how the Asiana crew interacted.

        

I agree that the final report will not be kind to those guys, but it is too early to know exactly who it will ding the most. Any idea if/when we could get a copy of the CVRs?


User currently offlineglideslope From United States of America, joined May 2004, 1621 posts, RR: 0
Reply 16, posted (1 year 3 months 1 week 1 day 4 hours ago) and read 26809 times:

Quoting UA787DEN (Reply 15):
I agree that the final report will not be kind to those guys, but it is too early to know exactly who it will ding the most. Any idea if/when we could get a copy of the CVRs?

IMO, the "Big Ding" will clearly be on the Instructor in the (R) seat. While the AC was not, they were clearly in "Mental Auto Pilot." The AC was flying them (so they thought).

I am very interested in the final report. I want to know when the (R) seat knew there was a problem. I hope he was not aware, and simply waited to long to make the call on a bad approach trying to save face for the (L) seat to get back on the curve.

Asian Culture could become a biggie in this. Hopefully not. I just fine it mind boggling with three on the deck they would attempt to stretch the glide like they did.

Thanks for the images (OP).



To know your Enemy, you must become your Enemy.” Sun Tzu
User currently offline76er From Netherlands, joined Mar 2007, 551 posts, RR: 1
Reply 17, posted (1 year 3 months 1 week 23 hours ago) and read 25477 times:

Quoting glideslope (Reply 16):
I want to know when the (R) seat knew there was a problem.

Didn't he report to investigators seeing three red lights from the PAPI? That would be THE moment for him to notify the PF of this and confirm that corrective action is initiated.


User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 18, posted (1 year 3 months 1 week 20 hours ago) and read 25239 times:

Quoting glideslope (Reply 16):
IMO, the "Big Ding" will clearly be on the Instructor in the (R) seat. While the AC was not, they were clearly in "Mental Auto Pilot." The AC was flying them (so they thought).

I am very interested in the final report. I want to know when the (R) seat knew there was a problem. I hope he was not aware, and simply waited to long to make the call on a bad approach trying to save face for the (L) seat to get back on the curve.

Asian Culture could become a biggie in this. Hopefully not. I just fine it mind boggling with three on the deck they would attempt to stretch the glide like they did.

I agree. He was also the pilot supposed to be monitoring the speed. As for the culture, I am not sure if you're referring to poor CRM. Someone posted a video of a KLM 777 missed approach at SFO in one of the earlier threads (I cannot find it) and they made the call much earlier when they realized they were high instead of bleeding attitude and speed quick like these guys did.

Quoting 76er (Reply 17):
Didn't he report to investigators seeing three red lights from the PAPI? That would be THE moment for him to notify the PF of this and confirm that corrective action is initiated.

He did, yes. He said it was one red at first then 3 red but I guess at that point it was too late.



If you're going through hell, keep going
User currently offlinewanderlustlax From United States of America, joined May 2013, 38 posts, RR: 0
Reply 19, posted (1 year 3 months 1 week 15 hours ago) and read 24921 times:

I don't know if this has been posted yet -- and while I caution is NOT official, all signs seem to point towards the worst possible news about the girl found under the foam outside the plane:

http://gawker.com/asiana-crash-victi...being-hit-by-emergency-v-836295760

Pending the final confirmation of this, I'm sure there will be more heads rolling than just the pilots'.


User currently offlinestlgph From United States of America, joined Oct 2004, 9412 posts, RR: 26
Reply 20, posted (1 year 3 months 1 week 12 hours ago) and read 24576 times:

Quoting wanderlustlax (Reply 19):

Bloomberg is reporting coroner confirmation on this report.


edit: San Francisco Fire Chief at press conference calling the death "a tragic accident."

[Edited 2013-07-19 10:21:26]


if assumptions could fly, airliners.net would be the world's busiest airport
User currently offlinebioyuki From United States of America, joined Nov 2009, 156 posts, RR: 0
Reply 21, posted (1 year 3 months 1 week 11 hours ago) and read 24425 times:

Confirmed by the San Francisco Chronicle...she died due to blunt force injuries sustained when she was hit/run over by the vehicle:

http://www.sfgate.com/bayarea/articl...-survivor-was-run-over-4674928.php



Next flight: UA 726/84 SFO-EWR-TLV
User currently offlineLTC8K6 From United States of America, joined Jun 2009, 1210 posts, RR: 0
Reply 22, posted (1 year 3 months 1 week 11 hours ago) and read 24282 times:

Yeah, and it looks like she was indeed where a few posters speculated...

I hate to think of that happening to her...

[Edited 2013-07-19 11:17:35]

User currently offline747megatop From United States of America, joined May 2007, 716 posts, RR: 0
Reply 23, posted (1 year 3 months 1 week 11 hours ago) and read 24204 times:

Quoting glideslope (Reply 16):
Asian Culture could become a biggie in this. Hopefully not. I just fine it mind boggling with three on the deck they would attempt to stretch the glide like they did.

Folks, i have been a silent observer on this culture thing and i think this is not really relevant to the issue at hand and here is why - because it is not quantifiable and cannot be clearly defined. Every culture in every country including the US has it's positives and negatives, it is very easy to talk about cultural issues of another culture. Other countries perceive the US culture (expecially at work) for example as being too casual and joke about everything [i know people will be up in arms now about this and folks will start defending this and saying this is not true, so let's not go there]. One incident comes to mind where a Northwest jet overshot an airport for quite a distance before they realized; luckily no one got killed as there was no crash - so, someone sitting outside the US can question the "casual culture" [again, i don't want to start an argument here, just putting another perspective of this incident and i haven't bothered to look up the cockpit CVR transcripts if they exist, so I personally don't know if the pilots were snoozing or talking about their most recent vacation etc.].

I think folks, the cultural issues topic can all together be avoided if we all (NTSB, ICAO etc. included) ask the right questions such as -

- if there is a disagreement on the cockpit; what is the procedure?
- if there is a tie; who breaks the tie? Who takes the final decision and overrules?
- obviously a cockpit is not a parliament or something where they can take their own time and go with the approach of majority rules; in dire emergencies someone has to make the decision and go with it. So again, what is the process? -
a) In a NON Emergency situation if there is a disagreement should the 2 pilots check with the relief pilot if there is one and the majority rules/prevails?
OR
b) in the case of Asiana, where during landing phase if there is disagreement, but there is critical lack of time and splite second decisions are required does senior most crew member overrules and make a split second decision ? [the decision may be to go around if there is time] OR is the defacto procedure to first do a go around and then circle around to sort out the differences?

So, i think more relevant questions about process/procedure need to be asked and answered versus commenting on "cultural issues".

[Edited 2013-07-19 12:23:41]

[Edited 2013-07-19 12:28:54]

User currently offlinenomadd22 From United States of America, joined Feb 2008, 1881 posts, RR: 0
Reply 24, posted (1 year 3 months 1 week 11 hours ago) and read 24138 times:

Quoting glideslope (Reply 16):
Asian Culture could become a biggie in this. Hopefully not. I just fine it mind boggling with three on the deck they would attempt to stretch the glide like they did.

That's getting kind of old. That culture exists all over the world. You should try to contradict the boss when you're working for BP sometimes. There's a reason they have more trouble than just about all the other oil companies in the US put together. You simply don't tell the boss he's wrong in a lot of cultures. Not just Asia by a long shot.



Andy Goetsch
User currently offlinegoldenargosy From United States of America, joined Jun 2005, 124 posts, RR: 0
Reply 25, posted (1 year 3 months 1 week 10 hours ago) and read 24549 times:

I know that no one wants to ever hear "pilot error"... but call it what it is and don't hide behind politics etc.

  


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 26, posted (1 year 3 months 1 week 8 hours ago) and read 24230 times:

Quoting goldenargosy (Reply 25):

A potentially lengthy investigation has just got underway. Do you think the NTSB believes "pilot error" is the obvious conclusion and they'll just go through the motions for the next few months? Has anyone even suggested the crew definitely didn't make any mistakes? I'll say it again...

Quoting David L (Reply 13):
Saying it might not be "pilot error, end of story" is not hiding behind politics in my view.


User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 27, posted (1 year 3 months 1 week 6 hours ago) and read 24976 times:

Quoting Norcal773 (Reply 4):
WOOW! I hadn't seen those pics and the damage towards the back even without the fire is bad!

I am am amazed at the the picture showing the remaining aft cabin crew seat, and how much of the rear galley and toilets are missing.

Quoting goldenargosy (Reply 25):

I know that no one wants to ever hear "pilot error"... but call it what it is and don't hide behind politics etc.

I know we have had a large number of armchair air safety investigators already come to their conclusions on the cause of this event, I would ask them to have a look at the report of the Turkish 737 report into AMS. What to many at the time was a clear case of pilot error, there three crew on another training flight, on and ILS to land, somehow let the aircraft get slow and allow it to stall short of the runway. The report is here http://www.onderzoeksraad.nl/uploads...s-docs/1748/Rapport_TA_ENG_web.pdf

The report goes into a lot of detail of organisations and circumstances outside of the cockpit that contributed to the accident, pilot error was not the main conclusion. And one would have to ask, if the "airspeed low" warning had been added to the 777, like it has started to be rolled out to the 737 was installed on the OZ flight, would the crew had gone around ?

What people will also see from reading the Dutch air safety investigators report is that there were known problems with the autothrottle system on the 737, however these problems were not brought to the attention of the pilots. The report also indicates that the Rockwell autothrottle that was tested (not installed on the aircraft, just widespread in the fleet of 737s) did not even perform as designed.

There is going to be a lot of technical investigation, and as I have stated previously, I am of the view that a number of causal factors that were not in the cockpit at the time will feature in the NTSB report.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 28, posted (1 year 3 months 1 week 4 hours ago) and read 24592 times:

Quoting 747megatop (Reply 23):
b) in the case of Asiana, where during landing phase if there is disagreement, but there is critical lack of time and splite second decisions are required does senior most crew member overrules and make a split second decision ? [the decision may be to go around if there is time] OR is the defacto procedure to first do a go around and then circle around to sort out the differences?

AFAIK, either pilot calling "go-around" means you go around first and ask questions later. This is not the time for discussion and going around will be less risky than landing in almost all cases.

Quoting zeke (Reply 27):
There is going to be a lot of technical investigation, and as I have stated previously, I am of the view that a number of causal factors that were not in the cockpit at the time will feature in the NTSB report.

  

Human factors experts typically don't like to use the term "pilot error" because it is such a blunt instrument, hiding many important nuances behind a seemingly simple expression.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineBEG2IAH From United States of America, joined Apr 2004, 973 posts, RR: 18
Reply 29, posted (1 year 3 months 1 week 4 hours ago) and read 24505 times:
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Quoting zeke (Reply 27):
I know we have had a large number of armchair air safety investigators already come to their conclusions on the cause of this event

How is the above different from this below?

Quoting zeke (Reply 27):
There is going to be a lot of technical investigation, and as I have stated previously, I am of the view that a number of causal factors that were not in the cockpit at the time will feature in the NTSB report.

Aren't you saying, as another armchair air safety investigator, that it's not pilots' but aircraft (design) error? I honestly don't understand what you are trying to achieve.



FAA killed the purpose of my old signature: Use of approved electronic devices is now permitted.
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 30, posted (1 year 3 months 1 week 4 hours ago) and read 24513 times:

Quoting BEG2IAH (Reply 29):
Aren't you saying, as another armchair air safety investigator, that it's not pilots' but aircraft (design) error? I honestly don't understand what you are trying to achieve.

Not at all, I have not said or implied there was a "aircraft (design) error" with this accident. I also have not ruled out pilot error, nor have I already concluded it. I stated it my belief that there are numerous causal factors that were not in the cockpit, this is based on facts released by the NTSB and the FAA.

Let me repeat myself, I have not stated a "smoking gun" or "cause" or "guilty party", all I have been doing is going through the facts as they emerge.

One fact that has not emerged is the cause/determination by the NTSB.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineairtechy From United States of America, joined Dec 2006, 506 posts, RR: 0
Reply 31, posted (1 year 3 months 1 week 4 hours ago) and read 24466 times:

At least in the Turkish Air and the Air France crash a clearly defined and known hardware failure preceded the accident. We can wait for this report, but to this point at least there are no known hardware failures. At least in the Turkish crash, the pilots recognized the problem and initially corrected for it. In the Air France case, the pilots forgot how to fly the airplane.

Back in the 60's and 70's when the cockpits had basic flight controls and a very basic autopilot airplanes crashed a lot more.....and pilots were generally blamed with "causal factors" being weather, non adherence to established procedures, etc. Better automation has clearly helped reduce accidents, but automation has now become more and more one of the "causal factors" in the few remaining.... thankfully... crashes. You can always find a minor issue with any automation implementation especially if it serves as a blame deflector.

When the NTSB releases their report, it would be interesting if the bullet chart of causes had a percent associated with it. Then, a cause that blamed say 5% of the crash on causal effects and 95% on pilot error could be better interpreted .....which in this case is the way I think it would go.

AT


User currently offlinewnbob From United States of America, joined Nov 2007, 169 posts, RR: 0
Reply 32, posted (1 year 3 months 1 week 2 hours ago) and read 24215 times:

Quoting 747megatop (Reply 23):
I hate to think of that happening to her...

I want that NTSB "intern" identified and asked by a reporter if this is funny.


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 33, posted (1 year 3 months 6 days 21 hours ago) and read 23623 times:

Quoting zeke (Reply 30):
Not at all, I have not said or implied there was a "aircraft (design) error" with this accident. I also have not ruled out pilot error, nor have I already concluded it.

    It can be every frustrating to discuss these matters when some people can only see black and white while the rest of us are talking shades of grey. Your comments about the TK accident are a good illustration that "pilot error" is often accompanied by other factors, not just mechanical failure, which need to be considered.


User currently offlinemandala499 From Indonesia, joined Aug 2001, 6926 posts, RR: 76
Reply 34, posted (1 year 3 months 6 days 18 hours ago) and read 23277 times:

Quoting hivue (Reply 6):
Why does a competent, certified flight crew do stuff that, at least superficially, looks really stupid?

I guess it's a lot of this (subconscious) "it wouldn't happen to me" mentality.
I guess many forget that improvements in safety is not, "if I see that happening, I'd do something else instead of what they did"... that's monday morning quarterbacking. Safety improvements is, "What can make me do the same error if I was in their shoes, and what changes is needed so I reduce my risk of making the same error (no matter how small the chance is)"...

Quoting TheRedBaron (Reply 7):
too many cooks on the kitchen syndrome " AF 477 is a great example

I think AF447 was more of a "not enough cooks in the kitchen syndrome", the two guys that were there didn't know that was going on... the captain went in and couldn't figure out... This is one of those unique cases, where in my opinion, if you keep adding people into the cockpit and eventually someone would recognize it or guess it. Unfortunately, reality has no such luxury.

Quoting 135mech (Reply 10):
I know that no one wants to ever hear "pilot error"... but call it what it is and don't hide behind politics etc.

Pilot error, must be accompanied by factors causing the pilot to make an error.
To just stop at pilot error, is not beneficial to safety.

Let's say if AF447 was simple reported as "stall". Well, not much benefit from the investigation there is it?
One can argue, "pilot error? OK, let's just replace the pilots"... So, apply that logic to AF447 with "stall? OK, change the stall warning system and we'll all be OK" would be the outcome of the same process.

Quoting 135mech (Reply 11):
AND... the person in the right seat continuously holding back on the control stick saying he didn't understand what was wrong...HE was what was wrong in the end!

Incorrect. The FDR plot showed that there was no "continuous holding back on the control stick" and combined with the CVR, does not indicate "the right seat continuously holding back on the control stick saying he didn't understand what was wrong".

Besides, the PF doing the stick manipulation was the left seat...

Quoting glideslope (Reply 16):
I am very interested in the final report. I want to know when the (R) seat knew there was a problem. I hope he was not aware, and simply waited to long to make the call on a bad approach trying to save face for the (L) seat to get back on the curve.

So in the "culture is the issue" argument for the failure of the CRM... can someone tell me why would the PIC & instructor that's older, more senior on type, and has a more prestigious career on his CV, would not call the bad approach and trying to safe the face of his junior on the left seat who's younger, has less hours total, less hours on type, is the SIC (not PIC)?

If I'm a "senior autocratic SOB" on the right seat, I'd jump on the opportunity to slap the guy on the left saying, "you imbecile/useless junior, let me show you how we gods do it!", then take over and botching the landing or going around and save the day...

So this culture issue, has a lot more to look into than just "it's a cultural issue"...

Quoting BEG2IAH (Reply 29):
that it's not pilots' but aircraft (design) error?

Systems on the aircraft are expected to work, and expected to give warnings when they do not work... that is why they are certified. And then there are times when it doesn't function as expected, which can be a minor/benign problem, but we've seen again and again, when it works differently to what the crew expects it... the risks for a mishap increase...

Quoting airtechy (Reply 31):
Back in the 60's and 70's when the cockpits had basic flight controls and a very basic autopilot airplanes crashed a lot more.....and pilots were generally blamed with "causal factors" being weather, non adherence to established procedures, etc. Better automation has clearly helped reduce accidents, but automation has now become more and more one of the "causal factors" in the few remaining.... thankfully... crashes. You can always find a minor issue with any automation implementation especially if it serves as a blame deflector.

The goal of zero accidents/mishaps is an elusive one, it's impossible. Some people have blamed "dependence on automation" as a problem. While I agree, I must also throw caution in line with or adding to what you said...
Do we want to make planes less complex than what they are today and risk going back to more accidents? Or do we want to keep the planes as complex or more complex to increase the levels of safety and reliability, but more difficult to land safety in the much reduced likelihood of something going wrong?



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineairtechy From United States of America, joined Dec 2006, 506 posts, RR: 0
Reply 35, posted (1 year 3 months 6 days 10 hours ago) and read 22491 times:

Quoting David L (Reply 33):

The goal of zero accidents/mishaps is an elusive one, it's impossible. Some people have blamed "dependence on automation" as a problem. While I agree, I must also throw caution in line with or adding to what you said...
Do we want to make planes less complex than what they are today and risk going back to more accidents? Or do we want to keep the planes as complex or more complex to increase the levels of safety and reliability, but more difficult to land safety in the much reduced likelihood of something going wrong?

I think that you have described the problem exactly. Thank you.

AT


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 36, posted (1 year 3 months 6 days 9 hours ago) and read 22423 times:

Quoting airtechy (Reply 35):
Thank you.

You're welcome. Why didn't Mandala499 think of that?   


User currently offlineairtechy From United States of America, joined Dec 2006, 506 posts, RR: 0
Reply 37, posted (1 year 3 months 6 days 9 hours ago) and read 22345 times:

Why does the quote selection never work right....  

AT


User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 38, posted (1 year 3 months 6 days 9 hours ago) and read 22333 times:

Quoting Starlionblue (Reply 28):
Human factors experts typically don't like to use the term "pilot error" because it is such a blunt instrument, hiding many important nuances behind a seemingly simple expression.

As I said in another thread, the term "it's pilot error" is one of the most useless phrases in aviation safety.

Quoting David L (Reply 33):
Your comments about the TK accident are a good illustration that "pilot error" is often accompanied by other factors, not just mechanical failure, which need to be considered.

   In fact, I'm going to go out on a limb and say that they're almost always accompanied by other factors that need to be considered.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 39, posted (1 year 3 months 6 days 9 hours ago) and read 22170 times:

Quoting Mir (Reply 38):
As I said in another thread, the term "it's pilot error" is one of the most useless phrases in aviation safety.

It's usually a simplification in isolation, but it can still be the core issue.


User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 40, posted (1 year 3 months 6 days 8 hours ago) and read 22083 times:

Quoting Klaus (Reply 39):
It's usually a simplification in isolation, but it can still be the core issue.

It's so simplified it's useless. How does saying "it's pilot error" prevent future crashes? By inspiring other pilots to be more careful about not making errors? I suppose that might help crews not make intentional errors, but I don't think it's a stretch to say that the overwhelming majority of errors that lead to crashes are inadvertent.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlinecornutt From United States of America, joined Jan 2013, 338 posts, RR: 1
Reply 41, posted (1 year 3 months 6 days 8 hours ago) and read 21983 times:

Quoting Mir (Reply 38):
As I said in another thread, the term "it's pilot error" is one of the most useless phrases in aviation safety.

I agree. Even when it's true, the next step needs to be taken: why did the pilot make that error? Was he inadequately trained? Misled or confused by the instrumentation? Working to incomplete or insufficient procedures? Placed in a situation beyond his capabilities?


User currently offlineSkydrol From Canada, joined Oct 2003, 975 posts, RR: 10
Reply 42, posted (1 year 3 months 6 days 8 hours ago) and read 22086 times:

Quoting zeke (Reply 27):
Quoting Norcal773 (Reply 4):WOOW! I hadn't seen those pics and the damage towards the back even without the fire is bad!I am am amazed at the the picture showing the remaining aft cabin crew seat, and how much of the rear galley and toilets are missing.

The photos posted in the PDF in reply 1 are incredible. Almost no fire or smoke damage to the aft cabin; has anyone seen post-crash photos of the cockpit? Expect since the external appearance was similar to the aft cabin, (in that it seemed to escape fire damage), it may be intact...



LD4

[Edited 2013-07-20 14:45:00]


∙ ---{--« ∙ ----{--« ∙ --{-« ∙ ---{--« ∙ --{--« ∙ --{-« ∙ ----{--« ∙
User currently offlineSpeedbored From United Kingdom, joined Jul 2013, 327 posts, RR: 1
Reply 43, posted (1 year 3 months 6 days 8 hours ago) and read 22033 times:

Quoting Mir (Reply 38):
In fact, I'm going to go out on a limb and say that they're almost always accompanied by other factors that need to be considered.
Quoting Mir (Reply 40):
I don't think it's a stretch to say that the overwhelming majority of errors that lead to crashes are inadvertent.

Couldn't agree more. Excepting gross negligence, people rarely make mistakes for no reason. Whenever anyone makes a mistake, in any walk of life, there will almost always be some special set of circumstances or events leading up to it that contribute towards causing that person to make that mistake.

Given the information available to me at present, it's hard to see how a lot of the blame is not going to be given to the pilots but I'd be amazed if the final report doesn't include a whole raft of contributory factors and recommendations, many of which will be completely unrelated to the actions of the pilots during the final approach.

It's a good thing that investigation agencies like the NTSB or AAIB keep their minds open to everything, instead of jumping to quick "the pilots screwed up" conclusions, otherwise aviation would be a whole lot more dangerous these days than it now is.


User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 44, posted (1 year 3 months 6 days 7 hours ago) and read 21940 times:

Quoting Mir (Reply 40):
It's so simplified it's useless. How does saying "it's pilot error" prevent future crashes? By inspiring other pilots to be more careful about not making errors? I suppose that might help crews not make intentional errors, but I don't think it's a stretch to say that the overwhelming majority of errors that lead to crashes are inadvertent.

It prevents future accidents by providing the impetus to improve training, provide adequate working conditions (including sufficient rest) and by pointing out to crews which pitfalls to pay special attention to.

If this was as senseless as you seem to assume, we'd still have the comparably horrible flight safety of bygone decades.

But we don't.

Because the conclusion "pilot error" combined with the associated circumstantial background information in those cases has indeed helped in improving the safety of pilots as well as the safety of their working environments.


User currently offlineMr AirNZ From New Zealand, joined Feb 2002, 872 posts, RR: 1
Reply 45, posted (1 year 3 months 6 days 6 hours ago) and read 21801 times:

Quoting 747megatop (Reply 23):
Folks, i have been a silent observer on this culture thing and i think this is not really relevant to the issue at hand and here is why - because it is not quantifiable and cannot be clearly defined.

I would disagree with that statement. Geert Hofstede would probably be the leading academic on national culture and has conducted vast research and published a great number of peer reviewed papers plus books.

Quoting 747megatop (Reply 23):
So, i think more relevant questions about process/procedure need to be asked and answered versus commenting on "cultural issues".

I am of the view the two can not be separated. Processes within an organisation do not function in a vacuum, they are directly influenced by both national and company culture. Bob Helmreich was another highly respected academic who published much work on such things in the aviation industry.


User currently offlineBEG2IAH From United States of America, joined Apr 2004, 973 posts, RR: 18
Reply 46, posted (1 year 3 months 6 days 6 hours ago) and read 21789 times:
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Quoting zeke (Reply 30):
Not at all, I have not said or implied there was a "aircraft (design) error" with this accident. I also have not ruled out pilot error, nor have I already concluded it. I stated it my belief that there are numerous causal factors that were not in the cockpit, this is based on facts released by the NTSB and the FAA.

Sorry I read it that way. It sounded like you were actively piling up other contributing factors including warnings, auto throttle, etc. and not mentioning a potential pilot error at all. Now I see you haven't excluded it.

Quoting mandala499 (Reply 34):
we've seen again and again, when it works differently to what the crew expects it... the risks for a mishap increase...

I just hope this crew didn't set instruments expecting them to perform whichever way and never monitored them. I hope the investigation figures it out.



FAA killed the purpose of my old signature: Use of approved electronic devices is now permitted.
User currently offlineneutrino From Singapore, joined May 2012, 615 posts, RR: 0
Reply 47, posted (1 year 3 months 6 days ago) and read 21269 times:

Quoting airtechy (Reply 37):

Why does the quote selection never work right....  

That's due to pilot...err poster error.
It happened because the user pressed the wrong button. It should be the "Quote Selected Text" above the nick of the person to be quoted, not the one below the text.



Potestatem obscuri lateris nescitis
User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 48, posted (1 year 3 months 5 days 23 hours ago) and read 21186 times:

Quoting Klaus (Reply 44):
It prevents future accidents by providing the impetus to improve training, provide adequate working conditions (including sufficient rest) and by pointing out to crews which pitfalls to pay special attention to.

Simply blaming pilot error does none of those things. Training improvements come from when training deficiencies are discovered or suspected. Improvements in working conditions come when deficiencies in those conditions are identified as having contributed to an accident or incident. But if the pilots simply screwed up, then there's no need for increased training as they'd gotten what was legally required and that should have been sufficient. And there's no need for better rest regulations because the present ones were clearly sufficient, it's just that the pilots simply screwed up.

Quoting Klaus (Reply 44):
If this was as senseless as you seem to assume, we'd still have the comparably horrible flight safety of bygone decades.

But we don't.

We don't because we've started looking beyond simple "pilot error" and actually started looking at the factors which lead pilots to make errors.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlineMax Q From United States of America, joined May 2001, 4660 posts, RR: 19
Reply 49, posted (1 year 3 months 5 days 23 hours ago) and read 21160 times:

Well I disagree with most and maintain a couple of points.


Asian culture, particularly Korean is a major problem in the cockpit. It inhibits contribution from junior crewmembers, 'face' is seen as more important than communicating safety concerns assertively to the Captain.


This has been a causal factor in numerous KAL accidents over the years.



Furthermore, blaming this accident on the Autothrottles, just as in the Turkish accident is ridiculous and a total cop out, any competent Pilot does not 'need' autothrottles and indeed, if they are not working disconnect them and operate them manually.


If you are not capable of doing that, you don't belong in a cockpit. Lettting your Aircraft get 30 knots slow because you;'re so dependent on them and crashing as a result is beyond belief, criminally negligent and inexcusable.



The best contribution to safety is a competent Pilot.
User currently offlineAirlineCritic From Finland, joined Mar 2009, 728 posts, RR: 1
Reply 50, posted (1 year 3 months 5 days 21 hours ago) and read 20978 times:

Quoting airtechy (Reply 37):
Why does the quote selection never work right....  

Pilot error, accompanied by some user interface shortcomings in the cockpit design. Some of the pilots on this forum are in real life actual posters, and the consensus among these experts is that the FAA may have to add more mandatory simulator training to cut down on these errors.

The anti-A crowd keeps claiming there's a conspiracy to hide defective software from A(.net). Fortunately good CRM from David L saved the day before the thread was run into ground. But you were lucky to be at forum level 10, at a lower level no one might have paid attention early enough to avoid the crash.


User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 51, posted (1 year 3 months 5 days 20 hours ago) and read 20855 times:

Quoting Max Q (Reply 49):
Asian culture, particularly Korean is a major problem in the cockpit.
Quoting Max Q (Reply 49):
any competent Pilot does not 'need' autothrottles

So we should expect the NTSB report to recommend banning Korean pilots and autothrottles? I guess Dutch pilots should have been banned after Tenerife, and French pilots banned after AF447. All flights should be operated by U.S. pilots flying DC-3s ... oh wait, a few of those have gone down ....



Empty vessels make the most noise.
User currently offlinepliersinsight From United States of America, joined May 2008, 496 posts, RR: 0
Reply 52, posted (1 year 3 months 5 days 17 hours ago) and read 20418 times:

Quoting Max Q (Reply 49):
If you are not capable of doing that, you don't belong in a cockpit. Lettting your Aircraft get 30 knots slow because you;'re so dependent on them and crashing as a result is beyond belief, criminally negligent and inexcusable.

Couldn't agree more with the criminally negligent part, but not on those in the cockpit, but their bosses and the airline execs. I think criminal charges against the crew would have a negative effect on future safety investigations and a terrible effect on safety/decision making. I don't want the crew to start second guessing every decision with the thought of a prison cell. Although there are tacky issues with doing it, a congressional inquiry would be a great option. Bring in the Asiana execs, put them in front of a slate of arrogant legislators who ask loaded questions written for them by aviation experts. The embarrassment of that alone might be enough to cause change.

I would be interested to see an analysis of the expense of hiring and training "follow the magenta line" types versus those who not only can, but are not even remotely nervous about, hand flying the aircraft. I worry for the future when these magenta line types end up being the people doing the training and automation dependence becomes a second generation deficiency. I'd say airlines should develop recency and currency rules on hand flying a certain number of arrivals and approaches every month without AA or AT, but I don't know if that would really change anything but punish those skilled at hand flying with an extra workload and perhaps cause another incident.


User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 53, posted (1 year 3 months 5 days 14 hours ago) and read 20095 times:

Quoting Mir (Reply 48):
Simply blaming pilot error does none of those things.

"Simply" and exclusively reducing all conclusions to just that would be nonsensical, and nobody really advocates that either, so I don't see your point.

Quoting Mir (Reply 48):
We don't because we've started looking beyond simple "pilot error" and actually started looking at the factors which lead pilots to make errors.

You seem to try shifting all of the responsibility completely away from the pilots, which is exactly as nonsensical as the extreme opposite.

Pilots have a high level of responsibility, especially when they're transporting passengers. And that responsibility demands a high level of skills, attention and diligence.

They are not merely puppets on the strings of their airplane systems, their operations manuals and their trainers.

They can't shake their own substantial share of responsibility if they contribute to an accident. And that is just as true as mistakes they may have made are often connected to additional circumstances, without nullifying their responsibility through that.

It is a very good thing that accident investigation nowadays mostly dismisses the apportioning of blame and instead prioritizes finding out how the mechanics of an accident actually worked.

That is definitely the correct path to take for accident investigation like the one done by the NTSB right now, but the ethical and possibly legal responsibilities of all the involved persons (not just the pilots!) don't just vanish into thin air just because the neutral NTSB doesn't want to deal with that.

Especially the US legal system is a horror on its own, but legal proceedings have their place, as do ethical questions in the aftermath, depending on the circumstances.

The simplest cases in these respects are the ones where an accident happens due to random, unforeseeable circumstances despite everybody involved acting correctly – but that is not always the case, unfortunately.

We don't know the final outcome of the Asiana crash investigation yet, but it is possible that a very human instant of lacking attention may(!) have been a crucial factor in the accident, which would be impossible to purge from the ethical responsibility of the persons neglecting their responsibilities this way – if that is what indeed happened, which seems plausible but cannot be said for sure before at least the interim report with all the recordings and technical analyses is available.

I guess most of us can't help but feel some compassion towards the cockpit crew of that flight based on what we know; To some degree they have become victims of this crash as well, but as much as they deserve some compassion too, their share of responsibility (if there was any) won't just dissolve and go away. Being captain or just flying / observing pilot just inherently comes with a certain amount of responsibility.


User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 54, posted (1 year 3 months 5 days 14 hours ago) and read 20063 times:

Quoting Klaus (Reply 53):
You seem to try shifting all of the responsibility completely away from the pilots, which is exactly as nonsensical as the extreme opposite.
Quoting Klaus (Reply 53):
We don't know the final outcome of the Asiana crash investigation yet, but it is possible that a very human instant of lacking attention may(!) have been a crucial factor in the accident, which would be impossible to purge from the ethical responsibility of the persons neglecting their responsibilities this way – if that is what indeed happened, which seems plausible but cannot be said for sure before at least the interim report with all the recordings and technical analyses is available.

I guess most of us can't help but feel some compassion towards the cockpit crew of that flight based on what we know; To some degree they have become victims of this crash as well, but as much as they deserve some compassion too, their share of responsibility (if there was any) won't just dissolve and go away. Being captain or just flying / observing pilot just inherently comes with a certain amount of responsibility.

   Very well-said indeed Klaus!



If you're going through hell, keep going
User currently offlinebellancacf From United States of America, joined May 2011, 152 posts, RR: 0
Reply 55, posted (1 year 3 months 5 days 12 hours ago) and read 19703 times:

Things are simple when I'm the only one working at a task and when there's no one pushing me or looking over my shoulder: it's my responsibility, and I'll do it at my own speed and, God willing, I'll get it right.

Now I introduce "automation". Is the automation an assistant, a "third hand", or it is a "surrogate boss"? I am still at least nominally involved in the task, but what is my attitude?

Mode 1) The automation is my assistant, but one which must be watched and monitored,

or

Mode 2) the automation is my active co-worker; both of us work at the task, but I would be hard-pressed to accomplish it without the help,

or

Mode 3) I think that the automation has taken over, and the task is now Somebody Else's Problem.

Mode 2 is not a problem; it is healthy, aware collaboration.

But Modes 1 and 3 can be encountered in any human, and even in the same human at different times and in different circumstances. When we are no longer collaborating, we select one or the other: I watch my own reactions when working in a team, and I see those modes fighting each other.

The trouble is, Mode 3 will get time wasted, money frittered away, or -- worst case -- people killed.

Personally, I think we had a Mode 3 response before this crash. There's no way that the view out that windshield could have looked right for longer than a moment without a change in pitch and so forth.

What can be done to present the gift of almost autonomous automation to a crew and still have the crew operate in Mode 1? To me, it seems like an issue of crew training -- never, never abdicate your responsibility for the task. But perhaps there are user interface tricks that help. Moving throttles are one way of keeping the crew involved. Others?

[Edited 2013-07-21 11:00:27]

User currently offlineWarmNuts From United States of America, joined May 2006, 100 posts, RR: 4
Reply 56, posted (1 year 3 months 5 days 10 hours ago) and read 19519 times:

Quoting 747megatop (Reply 23):
i think more relevant questions about process/procedure need to be asked and answered versus commenting on "cultural issues".

I agree with this senitment in principle, but as someone who has spent 4 1/2 years in Asia working with companies in India, China, S. Korea, and the Philippines, and in the field of process engineering, I can tell you that cultural characteristics most certianly must be taken into consideration with regards to the architectural framework within which processes are designed, implemented, and executed.


User currently offlineTheRedBaron From Mexico, joined Mar 2005, 2259 posts, RR: 9
Reply 57, posted (1 year 3 months 5 days 10 hours ago) and read 19539 times:

Quoting Klaus (Reply 53):
I guess most of us can't help but feel some compassion towards the cockpit crew of that flight based on what we know; To some degree they have become victims of this crash as well, but as much as they deserve some compassion too, their share of responsibility (if there was any) won't just dissolve and go away. Being captain or just flying / observing pilot just inherently comes with a certain amount of responsibility.

Great observation Klaus..!!! Could no agree more.

In the end if culture has to do with CRM and this crash, the FAA, and Asiana will have to make adjustments to avoid these occurrences that had tragic results.

TRB



The best seat in a Plane is the Jumpseat.
User currently offlinemandala499 From Indonesia, joined Aug 2001, 6926 posts, RR: 76
Reply 58, posted (1 year 3 months 5 days 10 hours ago) and read 19461 times:

Quoting David L (Reply 36):
You're welcome. Why didn't Mandala499 think of that?
Quoting airtechy (Reply 37):
Why does the quote selection never work right....

LOL!

Quoting Max Q (Reply 49):
Asian culture, particularly Korean is a major problem in the cockpit. It inhibits contribution from junior crewmembers, 'face' is seen as more important than communicating safety concerns assertively to the Captain.

OK, throw out the FO in the observer seat. Look at the 2 captains on the LHS and RHS... who's PF, who's PIC, who's junior, who's senior, who has a more 'respected' CV? Then... Who is more likely to have made the mistake? PF or PM? Who should have observed the dangerous trend and corrected? In this case. the junior or the senior?

Mandala499



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 59, posted (1 year 3 months 5 days 7 hours ago) and read 18910 times:

Quoting bellancacf (Reply 55):
Now I introduce "automation". Is the automation an assistant, a "third hand", or it is a "surrogate boss"? I am still at least nominally involved in the task, but what is my attitude?

I would reduce "assistant" to "tool". An assistant can actually share in responsibility and should provide his/her own good judgment in addition to executing as told, a tool does not provide that.

Quoting bellancacf (Reply 55):
Personally, I think we had a Mode 3 response before this crash. There's no way that the view out that windshield could have looked right for longer than a moment without a change in pitch and so forth.

It just doesn't need to be as simple as damnable complacency – I wouldn't be surprised if the outcome of the investigation was closer to the pilots after a long flight being forced into an unusual working pattern due to the inoperable ILS which didn't let them get their tasks and priorities sorted as cleanly and as quickly as they were used to (with the manual corrections of first altitude, then lateral position added to the mix), ultimately leading to crucial priorities such as monitoring the airspeed falling through the cracks.

Which might still not excuse anything, but I think a lack of capability (for whatever reason) does provide a different perspective to a lack of seriousness and outright irresponsibility.


User currently offlinebellancacf From United States of America, joined May 2011, 152 posts, RR: 0
Reply 60, posted (1 year 3 months 5 days 6 hours ago) and read 18857 times:

Mmmm. Right after posting, I ran across an article about instances in which automation _increases_ workload. Too many things to monitor, I guess. Cases in which it would be simpler to just do it yourself, I guess. If you could. But still, neglecting the Mark 1 Eyeball out the windshield ...

User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 61, posted (1 year 3 months 5 days 6 hours ago) and read 18748 times:

Quoting bellancacf (Reply 60):
Right after posting, I ran across an article about instances in which automation _increases_ workload. Too many things to monitor, I guess. Cases in which it would be simpler to just do it yourself, I guess. If you could.

Automation can be done well, but it can also be done badly... That says little about the principle as such.


User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 62, posted (1 year 3 months 5 days 2 hours ago) and read 18391 times:

Quoting Klaus (Reply 53):
You seem to try shifting all of the responsibility completely away from the pilots

Not at all. It's true that I haven't assigned responsibility to the pilots, but that's because we don't have enough information to do so, not because I think something else was responsible. You'll notice that I have never said it isn't pilot error, only that "pilot error" is a vague and ultimately meaningless term.

Quoting Klaus (Reply 53):
it is possible that a very human instant of lacking attention may(!) have been a crucial factor in the accident

Very possible, in fact. But we can't say that conclusively yet.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 63, posted (1 year 3 months 4 days 21 hours ago) and read 17971 times:

Quoting Mir (Reply 62):
You'll notice that I have never said it isn't pilot error

   I don't think anyone has. However, there are some who have said it was pilot error and/or cultural issues and that any talk of other factors is "hiding behind politics". That's the reason some of us are at pains to point out that we don't have enough information yet to reach such specific conclusions.


User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 64, posted (1 year 3 months 4 days 16 hours ago) and read 17400 times:

Quoting David L (Reply 63):
some of us are at pains to point out that we don't have enough information yet to reach such specific conclusions.

Might get flamed a bit, but I'd better say that my job for many years was 'new town development' - which included design and construction. And that most of our (mercifully-few) investigations into 'incidents' and 'accidents' - a few of which were unfortunately fatal - sort of 'worked back to front' to an extent.

Yes, I and my fellow chief officers carried out exhaustive enquiries over weeks and months, often opening things up to allow the public and the workforce to have their say as the evidence of what had happened was put together; and then published comprehensive reports.

But, given that, between us, we were responsible, day by day, for the lives of the people who worked in our departments, it was common-place, after any accident, for the more senior people to decide, very early on, what had probably happened - usually within 48 hours. And take appropriate action to make sure, as far as possible, that it couldn't happen again.........

Fair to say that, given that we were all experienced people, I can't readily recall any occasion on which the ultimate full-investigation report differed significantly from our initial judgment. Not 'boasting,' in any accident the 'signs' are usually there long before the bureaucrats finish their work.........

I very much hope that the airlines/manufacturers/airport concerned are working along similar lines. This was a very serious accident - three killed so far, and a lot of people injured. The truly vital need is to take the most urgent action to ensure, as far as possible, that nothing like it ever happens again.

In this case my - perhaps premature, but probably highly-relevant - conclusion is that SFO should re-install an Instrument Landing System on the runway concerned as soon as ever possible.........

[Edited 2013-07-22 06:30:03]


"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 65, posted (1 year 3 months 4 days 16 hours ago) and read 17219 times:

Quoting Mir (Reply 62):
You'll notice that I have never said it isn't pilot error, only that "pilot error" is a vague and ultimately meaningless term.

And I must definitely disagree with that.

It simply describes the pilots having committed some errors. Which may or may not be the primary cause of an accident, but that is what additional qualifications are for.

The term is absolutely sensible and necessary to identify situations where that has actually been a factor, or even in determining that pilot error was not a factor.

It is in no way "vague" or "meaningless" – it just needs to be used correctly, just like every other term as well.


User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 66, posted (1 year 3 months 4 days 15 hours ago) and read 17019 times:

Quoting Klaus (Reply 65):
It simply describes the pilots having committed some errors.

Which doesn't tell you anything in terms of improving air transportation safety.

In order for it to be "meaningful", you need to know:

1) Which error(s)?

2) Why - training, previous history, external environment (e.g. ATC, ILS, etc), flight deck environment, instrument/control design and functioning, state of the aircraft (anything MEL'd), effectiveness of SOPs and company directives.

THEN you can begin addressing how to reduce the risk of a similar incident reoccurring. "Pilot error" doesn't tell you what to address - unless you want to blindly ground any pilot who makes an error, which would add nothing to safety because you'd be grounding pilots only after they'd made an error.



Empty vessels make the most noise.
User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 67, posted (1 year 3 months 4 days 14 hours ago) and read 16981 times:

Quoting Kaiarahi (Reply 66):
THEN you can begin addressing how to reduce the risk of a similar incident reoccurring. "Pilot error" doesn't tell you what to address...

Lets not forget that the "pilot error" the evidence is pointing to in this case is not adequately monitoring airspeed during approach and landing. Sure there may have been some exotic AP- A/Th factors involved and some CRM and training issues, but monitoring airspeed during landing is Airplane Flying 101.


User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 68, posted (1 year 3 months 4 days 14 hours ago) and read 16934 times:

Quoting hivue (Reply 67):
Lets not forget that the "pilot error" the evidence is pointing to in this case is not adequately monitoring airspeed during approach and landing. Sure there may have been some exotic AP- A/Th factors involved and some CRM and training issues, but monitoring airspeed during landing is Airplane Flying 101.

Every year there are multiple accidents where cars enter traffic intersections on a green signal and are involved in sometimes fatal accidents. Some of the drivers involved in those accidents would be classified as "professional" drivers (taxis, trucks, buses). Looking out for traffic, and avoiding collisions are something every driver should be doing. Traffic signals occasionally do show a green signal to two different directions at the same time when the controller fails. Cars hit each other as they both have a green signal. Is that really driver fault ? Reliance on automation (the traffic signla controller) ? Why are traffic signals installed in the first place ?

The NTSB has only released very small snippets of information, and they have had hundreds of people looking at literally thousands of parameters at the same time. Despite having had over two weeks, and hundreds of people looking at the data, they still have not been able to understand and determine what happened in the last few minutes of the flight.

Somehow you have already concluded based upon only a small subset information the NTSB has, what the NTSB have not been able to determine with all of their data and resources. You did not have that information presented to you in real time like the pilots did on the day.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 69, posted (1 year 3 months 4 days 13 hours ago) and read 16723 times:

Quoting zeke (Reply 68):
Somehow you have already concluded based upon only a small subset information the NTSB has, what the NTSB have not been able to determine with all of their data and resources.

I did not intend to leave the impression that I have concluded anything at all. The investigation may find that the crew did an exemplary job of monitoring airspeed and another factor or factors caused the crash. I was only pointing out that if the invetigation finds that the primary cause was the crew failing to properly monitor air speed, then it's a case where

Quoting Kaiarahi (Reply 66):
"Pilot error" doesn't tell you what to address

does not apply.


User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 70, posted (1 year 3 months 4 days 13 hours ago) and read 16668 times:

Quoting Kaiarahi (Reply 66):
Which doesn't tell you anything in terms of improving air transportation safety.

The term "pilot error" is a summary term, just like "mechanical failure".

Both terms and others like them are perfectly adequate and necessary to summarize the more detailed findings in a quickly accessible form. That is what summaries are for.

I don't get the attempt to put a complete taboo on the term. That would serve absolutely no sensible purpose whatsoever.


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 71, posted (1 year 3 months 4 days 13 hours ago) and read 16597 times:

Quoting NAV20 (Reply 64):

So, are you confident enough to say, right now, that there were no contributing factors, that there were no flaws in their training or in the company's procedures, that there were no untimely distractions that might seem trivial unless they happen at precisely the wrong moment, that ATC didn't throw them any curveballs, for example? I'm not. Maybe there were and maybe there weren't.

Once again, I don't think anyone is saying the crew did not make any mistakes. I just get a bit annoyed when some of us are accused of hiding behind politics just for considering the possibility that the investigation might go beyond simple pilot error and look at any contributing factors.


User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 72, posted (1 year 3 months 4 days 13 hours ago) and read 16692 times:

Quoting zeke (Reply 68):

  

A couple of examples.

A NZ DC-8 crashed at AKL in 1966 on a training flight when the very senior training captain mistakenly selected reverse thrust on engine 4 shortly after rotation, during an engine out simulation. He pulled the number 4 power lever back very rapidly, and the thrust brake lever jumped up and into reverse idle detent. "Pilot error" - yes. But until that accident, no one realized the risk, and throttles were thereafter modified to require a positive lifting motion to engage reverse thrust. (This accident was very close, as my father was supposed to be the FE on the flight, but was swapped out to other duties at the last minute).

Another, also a DC-8 was AC621 in 1970. The FO mistakenly deployed the spoilers in the flare, engine 4 hit the runway, breaking off the engine, pylon and part of the lower wing. The wing was trailing fuel and on the go around it exploded. "Pilot error" - yes. But the investigation also established that AC's SOPs were unclear on whether the spoilers should be armed in the flare or after the mains were on the ground; the FO preferred to arm in the flare, and the captain on the ground. The captain was flying and when he called for the spoilers to be armed in the flare (contrary to his preference), the surprised FO mistakenly deployed them instead of arming. AC's SOPs were subsequently modified.

The risks that were addressed following the investigations into these two accidents would not have been addressed if the cause was simply stated as "pilot error" and action taken against the pilots (which would have been moot anyway, as they all died), rather than addressing the specific causes of the errors.



Empty vessels make the most noise.
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 73, posted (1 year 3 months 4 days 13 hours ago) and read 16542 times:

Quoting Kaiarahi (Reply 72):
The risks that were addressed following the investigations into these two accidents would not have been addressed if the cause was simply stated as "pilot error" and action taken against the pilots (which would have been moot anyway, as they all died), rather than addressing the specific causes of the errors.

Nobody has ever advocated to completely replace detailed investigations with just a single-phrase summary exclusively.

That would make no sense whatsoever.

It would just also make no sense whatsoever to remove the phrase from the summaries of investigations reports, where it absolutely has its place where applicable.

These are completely different things.


User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 74, posted (1 year 3 months 4 days 12 hours ago) and read 16528 times:

Quoting Klaus (Reply 73):
It would just also make no sense whatsoever to remove the phrase from the summaries of investigations reports, where it absolutely has its place where applicable.

"pilot error" is not something I normally see in the actual investigation report following an accident, they will use terms like contributing causes, causal factors etc. It is something that tends to live in the press articles of the report that try to sell newspapers.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 75, posted (1 year 3 months 4 days 12 hours ago) and read 16503 times:

Quoting Klaus (Reply 73):
Nobody has ever advocated to completely replace detailed investigations with just a single-phrase summary exclusively.

Except half the posters on this thread, who are advocating crucifixion of the OZ pilots on the basis of the single-phrase summary "pilot error".

Quoting Klaus (Reply 73):
It would just also make no sense whatsoever to remove the phrase from the summaries of investigations reports, where it absolutely has its place where applicable.

As long as you read the rest of the report.

The bottom line is that investigation reports are written to improve safety, not to assign blame (contrary to the apparent view of many a.net posters). "Pilot error" tells you next to nothing about how to reduce future risk (just as "mechanical failure" is useless as a guide to a mechanic).



Empty vessels make the most noise.
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 76, posted (1 year 3 months 4 days 12 hours ago) and read 16372 times:

Quoting Kaiarahi (Reply 75):
Except half the posters on this thread, who are advocating crucifixion of the OZ pilots on the basis of the single-phrase summary "pilot error".

Come on – that is a massive exaggeration and very far removed from reality.

The emerging evidence simply continued to point towards the pilots first and foremost. But at least in this thread series I have observed none of what you're speaking of.

Quoting Kaiarahi (Reply 75):
As long as you read the rest of the report.

You will never get absolutely everybody to read the whole thing, and you're lucky if more than half of the rest draw realistic conclusions from it.

Quoting Kaiarahi (Reply 75):
The bottom line is that investigation reports are written to improve safety, not to assign blame (contrary to the apparent view of many a.net posters). "Pilot error" tells you next to nothing about how to reduce future risk (just as "mechanical failure" is useless as a guide to a mechanic).

The purpose of summaries is to present the big picture first and foremost, and to provide a starting point for examination of the more detailed findings coming from there.

And whatever the exact wording is, summarizing the primary causes of an accident is valuable and necessary.

A.net is one of the few places where the details are really discussed at length, but even here the contributions are usually pretty mixed, even with plenty of additional information.

The rest of the world needs summaries, and in those it is relevant to indicate whether technical, weather, circumstantial or human issues played crucial roles. You will not get a hour-long examination of an investigation report in the TV evening news. Which is why making good and concise summaries of complex reports is so difficult, but still necessary.


User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 77, posted (1 year 3 months 4 days 11 hours ago) and read 16446 times:

Quoting Klaus (Reply 76):
But at least in this thread series I have observed none of what you're speaking of.

Then I suggest you look again.

Quoting Klaus (Reply 76):
Quoting Kaiarahi (Reply 75):
As long as you read the rest of the report.

You will never get absolutely everybody to read the whole thing, and you're lucky if more than half of the rest draw realistic conclusions from it.

   That's all well and good for the internet in general but not for an aviation enthusiasts' website. In my view there's no excuse for anyone to post misinformation about AF447, for example, when you consider the depth in which that accident and the resulting report were discussed here... and yet it keeps happening, even in this thread. Blurting out an opinion without bothering to avail oneself of the facts when they're readily available, or not caring about the full facts at all, is poor form on an aviation website, in my opinion.


User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 78, posted (1 year 3 months 4 days 11 hours ago) and read 16329 times:

Quoting David L (Reply 77):
Then I suggest you look again.

I've been here all along since the first thread. What you've claimed simply hasn't happend.

Quoting David L (Reply 77):
That's all well and good for the internet in general but not for an aviation enthusiasts' website.

Everybody is welcome to present differentiated, well-thought-through rebuttals to any oversimplifications (see above).

Quoting David L (Reply 77):
In my view there's no excuse for anyone to post misinformation about AF447, for example, when you consider the depth in which that accident and the resulting report were discussed here... and yet it keeps happening, even in this thread. Blurting out an opinion without bothering to avail oneself of the facts when they're readily available, or not caring about the full facts at all, is poor form on an aviation website, in my opinion.

You're in a mostly open internet forum here. It can't be news to you that there will be absurdities or questionable claims from time to time (or often).

That's just the nature of the beast.


User currently offlinenomadd22 From United States of America, joined Feb 2008, 1881 posts, RR: 0
Reply 79, posted (1 year 3 months 4 days 10 hours ago) and read 16278 times:

Quoting Kaiarahi (Reply 75):
The bottom line is that investigation reports are written to improve safety, not to assign blame

Failing to hold individuals accountable for negligence isn't going to do much to increase safety. Incidents like this, that require multiple failures and bypass layers of checks and redundancies, aren't usually simple misfortunes. They almost invariably occur at the end of a long chain of ignoring procedures and protocols.



Andy Goetsch
User currently offlineDavid L From United Kingdom, joined May 1999, 9524 posts, RR: 42
Reply 80, posted (1 year 3 months 4 days 10 hours ago) and read 16171 times:

Quoting Klaus (Reply 78):
Everybody is welcome to present differentiated, well-thought-through rebuttals to any oversimplifications (see above).

Unless the possibility of contributing factors is suggested.

Quoting Klaus (Reply 78):
You're in a mostly open internet forum here. It can't be news to you that there will be absurdities or questionable claims from time to time (or often).

So, might as well just join in with the Youtube comments or discuss it in the non-cookery forum of a cookery website, then? I said it was poor form (in my view), not that it doesn't happen.

Quoting Klaus (Reply 78):
What you've claimed simply hasn't happend.

I don't want to quote directly as one poster has since modified his view and others may have had second thoughts but try searching for "moron" and "politics" on this page. There are many more examples in the previous parts.

Anyone had any thoughts on starting a thread about this accident in Tech/Ops, where facts carry a bit more weight?


User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 81, posted (1 year 3 months 4 days 9 hours ago) and read 16026 times:

A lot of people on this thread seem to confuse what the meaning of the word 'cause' is. If it turns out that the pilots didn't monitor speed as they should have...and that's a big IF, the cause of the accident will be 'pilot error' no matter how some of you guys wanna spin it. There will be contributing factors e.g insufficient training, lack of speed warnings on the 777 like some have suggested etc but at the end of the day, the cause of the accident would be pilot error for letting speed drop dramatically.

If the A/T wasn't working as it should have, that's a whole different story and at this point we really don't know. Keep in mind there's a difference between 'working as it should have' and 'working as the pilots thought it would'.

As for the air safety improvements that can be done to prevent such incidents from happening in the future, we'll learn that in time when the NTSB makes recommendations but it doesn't take away from the fact that the pilots screwed up- If in fact that is what the NTSB finds out and at this pint nobody has a clue.



If you're going through hell, keep going
User currently offlineikramerica From United States of America, joined May 2005, 21544 posts, RR: 59
Reply 82, posted (1 year 3 months 4 days 8 hours ago) and read 15870 times:

Quoting Kaiarahi (Reply 72):
The risks that were addressed following the investigations into these two accidents would not have been addressed if the cause was simply stated as "pilot error" and action taken against the pilots (which would have been moot anyway, as they all died), rather than addressing the specific causes of the errors.

Please. Now we are getting into pure pilot defensiveness mode. As Klaus is pointing out, this is a red herring, black or white, no discussion argument point that is NOT being advocated by anyone. Nobody is suggesting that pilot error = no need to investigate, no need to change anything.

In most cases, pilot error is "lack of understanding, familiarity, or recall of systems specific to the aircraft they are flying" and there are obvious lessons to be learned after a pilot makes such an error. And the lesson to be taken away is not that "brave pilots rescued a doomed airliner in a dangerous airport situation" like the Korean press sounds like they are advocating.

Is it harder to land a plane without ILS? Yes. Yet it happens every day all over the world without crashing.
Does a 777 (or any aircraft) have unique features and methods? Yes, yet pilots deal with the quirks every day without crashing.

Does the combination of the two excuse the pilots or shift blame to SFO for daring to not have ILS or Boeing for not making the throttles idiot proof?

No. The pilots should be able to land an aircraft without ILS and they should understand the AT modes and implications on the aircraft they are supposed to be proficient on. It's their job and they get paid handsomely for being in command of an aircraft (and more so for being in command of a large aircraft). If it's too difficult they should choose another line of work. Period.

So what comes out of this accident is that maybe training needs to be beefed up, maybe before arming AT pilots should be required to recite what it means to each other on the specific aircraft they are flying, etc. I don't know. But even if the task is a difficult one (but not impossible and successfully accomplished every day all over the world), if you make a mistake while executing it, it's your error.



Of all the things to worry about... the Wookie has no pants.
User currently offlineKlaus From Germany, joined Jul 2001, 21486 posts, RR: 53
Reply 83, posted (1 year 3 months 4 days 8 hours ago) and read 15764 times:

Quoting David L (Reply 80):
So, might as well just join in with the Youtube comments or discuss it in the non-cookery forum of a cookery website, then? I said it was poor form (in my view), not that it doesn't happen.

Everybody has the choice of being a good example – or not.

Quoting David L (Reply 80):
I don't want to quote directly as one poster has since modified his view and others may have had second thoughts but try searching for "moron" and "politics" on this page. There are many more examples in the previous parts.

You can't link to a section of the discussion which would actually support your claim. Which is okay – some hyperbole is par for the course. But maybe we should move on by now.

Quoting David L (Reply 80):
Anyone had any thoughts on starting a thread about this accident in Tech/Ops, where facts carry a bit more weight?

Has been done.


User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 84, posted (1 year 3 months 4 days 3 hours ago) and read 15407 times:

Quoting nomadd22 (Reply 79):
Failing to hold individuals accountable for negligence isn't going to do much to increase safety.

The regulations regarding accident investigations in much of the world including the USA and Europe are based on ICAO documents. They state specifically that the only purpose on an air accident investigation is to improve safety. Assigning blame is not an objective.

Individuals could be held accountable in an accident investigation, but how does this improve safety? Pilots who in the future will benefit from recommendations made by this investigations don't need the extra "motivation" that they will be held accountable if they crash. They're already doing their best not to crash.

The threat of punishment if there is a crash can easily make things worse. It can make pilots hide evidence or taint testimony. Only if you have complete openness from the pilots and others can you get to the truth.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 85, posted (1 year 3 months 4 days 1 hour ago) and read 15246 times:

Quoting David L (Reply 71):
So, are you confident enough to say, right now, that there were no contributing factors, that there were no flaws in their training or in the company's procedures, that there were no untimely distractions that might seem trivial unless they happen at precisely the wrong moment, that ATC didn't throw them any curveballs, for example?

I'm sure that there were contributing factors, DavidL - especially inadequate training (both the South Korean Government and the airline have already said that they are going urgently to improve training). As for distractions, though, from ATC or anyone else, I think that Deborah Hersman would have mentioned anything like that in her briefings?

In her last briefing she said four things that point directly at 'pilot error' or 'inadequate training' or whatever you want to call it. Firstly that all systems on the aeroplane were working normally; secondly that the airspeed dropped from about 135 knots to not much over 100 between 500 feet and 100 feet; thirdly that no-one on the flight deck said anything about speed during that part of the descent; and fourthly that no-one said or did anything about 'going around' until they were within nine seconds of impact (in other words, far too late)?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineBEG2IAH From United States of America, joined Apr 2004, 973 posts, RR: 18
Reply 86, posted (1 year 3 months 4 days 1 hour ago) and read 15234 times:
Support Airliners.net - become a First Class Member!

Quoting David L (Reply 80):
I don't want to quote directly as one poster has since modified his view
Quoting Klaus (Reply 83):
You can't link to a section of the discussion which would actually support your claim.

That was me in the ALPA thread, response #69, i.e., U.S Pilot Union-ALPA Slams Ntsb Over Asiana Crash (by g500 Jul 18 2013 in Civil Aviation)



FAA killed the purpose of my old signature: Use of approved electronic devices is now permitted.
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 87, posted (1 year 3 months 4 days ago) and read 15070 times:

Turns out that I got the times a bit wrong in my post. '9 seconds' was a call to add power. First mention of going around was apparently only 3 seconds before impact:-

— 35 SECONDS FROM IMPACT: Automated callout in cockpit signals plane is at 500 feet. Speed has dropped to 134 knots, just below the optimal landing speed of 137 knots that the pilots believe has been programmed into the "autothrottle." Lee Jeong-min recognizes the plane is coming in too low and tells Lee Gang-guk to "pull back."

— 18 SECONDS OUT: Automated callout indicating plane has reached 200 feet. Speed is 118 knots. The Precision Approach Path Indicator that uses red and white lights to tell pilots if they are approaching correctly is all red, indicating the plane is too low.

— 8-9 SECONDS OUT: Automated 100-foot callout. Plane is traveling at about 112 knots. One of the pilots calls for more speed and throttles begin moving forward.

— 4 SECONDS OUT: The stick shaker, a yoke the pilots hold, begins vibrating, indicating the plane could stall.

— 3 SECONDS OUT: The plane is traveling at 103 knots, the slowest speed recorded by the flight data recorder. The engines begin increasing power from 50 percent. One pilot calls to abort the landing and go around for another try.

— 1.5 SECONDS OUT: A second pilot calls to abort the landing."


http://abcnews.go.com/US/wireStory/n...ngs-sf-plane-crash-glance-19644069



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineoly720man From United Kingdom, joined May 2004, 6814 posts, RR: 11
Reply 88, posted (1 year 3 months 3 days 20 hours ago) and read 14795 times:

Pilots will know more about this than I do, but this suggests one possible cause of the crash

http://www.aviationweek.com/Article....l/AW_07_22_2013_p25-597816.xml&p=2

Highly experienced Boeing widebody pilots have independently determined that an autoflight mode called Flight Level Change may explain why Asiana Flight 214 hit the sea wall ahead of Runway 28L at San Francisco International Airport July 6.
..
.
.

The 777 experts say the most plausible explanation for what happened next was that the pilots, intentionally or in error, selected the FLCH mode on the MCP with the target altitude set at 0 ft. or the minimum descent altitude. In a descent, FLCH reduces thrust to flight idle. The throttles will typically reengage when the aircraft reaches an altitude selected on the MCP, or if the aircraft's speed nears stall speed at radio altimeter heights greater than 100 ft. If the altitude was selected to zero, however, the throttles would have remained at flight idle as Flight 214's pilots increased pitch to remain on the glideslope, causing airspeed to drop below preset levels.

“Boeing is aware of this shortcoming, which in some circles is known as the FLCH 'trap,' and in its training course demonstrates the danger to pilots,” says one of the 777 experts. “The danger of the FLCH trap is that if the autopilot is disengaged and the aircraft levels off early . . . or the rate of descent is reduced, then the airspeed will decay because the autothrottle is temporarily out of the loop.”




wheat and dairy can screw up your brain
User currently offlinejetsetter1969 From Australia, joined Jul 2013, 50 posts, RR: 0
Reply 89, posted (1 year 3 months 3 days 19 hours ago) and read 14593 times:
Support Airliners.net - become a First Class Member!

Quoting Starlionblue reply84

" Individuals could be held accountable in an accident investigation, but how does this improve safety? Pilots who in the future will benefit from recommendations made by this investigations don't need the extra "motivation" that they will be held accountable if they crash. They're already doing their best not to crash.

The threat of punishment if there is a crash can easily make things worse. It can make pilots hide evidence or taint testimony. Only if you have complete openness from the pilots and others can you get to the truth."

My background is not aviation but rail safety and the principles are the same. Remain open minded , find the evidence and facts of an incident/ accident and it is not the investigators role to apportion blame. If the evidence such as the FDR and CVR recordings show the actions of the pilots were contributing factors then the evidence supporting those finding must be shown. However no investigator i have worked with would say the pilot/ driver/ operator of a machine/ train/ aircraft was to blame. It to my way of thinking be the pilot failed to do x or y and the reasons behind this might be a, b and c.

An investigators report once in the hands of the appropriate authority can i would think be part of the professional assessment/ supporting evidence or similar that an employer or legal professional might use to pursue disciplinary or civil matters against those involved. Bear in mind that that evidence in some cases can exonerate the crew from a climate of assumption and hearsay that can have tragic consequences for them. I cannot think of an aviation one off the top of my head but a railway accident in Australia in the 1970s where the driver was accused of speeding and the media was really pushing the story. The recording device in the locomotive showed he was in fact doing under the speed limit and the subsequent investigation and i believe corners inquest showed the root cause was a track failure.

It is easy as a culture to want a fast answer and point the finger and say pilot error, but even if they did make an error we have to ask why? what contributing factors were there? ergonomics, control and gauge placement, sighting distances (PSA 727 flight that struck a light plane on approach to San Diego i think where their lower seating position hindered their view) warning alarms (the cyprus 737 crash in athens).

Without babbling on there is a reason safety has a heirachy of controls where the second lowest is administrative (this includes training). People by nature can and do fail, quality training can reduce the likelihood of an event and history records many events where pilots overcame mechanical and environmental factors that placed them in harms way (US A320 landing on the hudson, QF32 uncontained engine failure out from Singapore and BA 747 in indonesia due to volcanic ash ingestion). We need to be patient and let the investigators present the facts and their recommendations for corrective actions. a couple of hundred meters earlier and that 777 would not have had only 3 fatalaties so their is some comfort for the majority of passengers and crew in the fact they are alive.

cheers


User currently offlineje89_w From United States of America, joined Mar 2002, 2362 posts, RR: 9
Reply 90, posted (1 year 3 months 3 days 14 hours ago) and read 14152 times:
AIRLINERS.NET CREW
PHOTO SCREENER

First of all, my thoughts are with the family and friends of the victims and all those affected.

It's worth noting these two rather interesting images just added to the database, showing a close up of the wreckage and the location of the nose gear.


View Large View Medium
Click here for bigger photo!

Photo © Bill Nelson
View Large View Medium
Click here for bigger photo!

Photo © Bill Nelson



Await the final report of this tragedy.


User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 91, posted (1 year 3 months 3 days 11 hours ago) and read 13806 times:

Quoting oly720man (Reply 88):
Pilots will know more about this than I do, but this suggests one possible cause of the crash

Aaron747 reported this theory several parts earlier on this thread.


User currently offlineairmagnac From Germany, joined Apr 2012, 316 posts, RR: 52
Reply 92, posted (1 year 3 months 3 days 8 hours ago) and read 13509 times:

Quoting Norcal773 (Reply 81):
A lot of people on this thread seem to confuse what the meaning of the word 'cause' is
Quote:
the cause of the accident

(my bold)

Actually, it seems a lot of people have this idea that there is 1 single cause to a crash - THE cause, as you say.
With maybe a few "contributing factors", whatever that is.

Just like any crash, or any event in the real world, ther are most probably several causes
And each of those causes has several causes. And each of those causes of causes have causes. And so on..

To make matters worse, the causes may be interrelated. For instance, the pilots don't work alone, as the driver of a car mostly is. They rely on data provided by the airplane, by ATC, the airline ops staff, the weather forecasts, the cabin crew.... "Pilot error" could be the consequence of earlier issues, of some distractions, of lots of things. It could be the result of using wrong input data. It could be caused by a wide number of things, all of which are of interest for future safety.

So the investigation will not stop at MAIN CAUSE => CRASH, with a few secondary items
It will look similar to this :



(from "Causal reasoning about aircraft accidents", P Ladkin
http://www.rvs.uni-bielefeld.de/research/WBA/)

A bit more complicated. A lot more useful.  

[Edited 2013-07-23 14:51:31]

[Edited 2013-07-23 14:56:49]


One "oh shit" can erase a thousand "attaboys".
User currently offlineComeAndGo From United States of America, joined Mar 2005, 1041 posts, RR: 0
Reply 93, posted (1 year 3 months 3 days 5 hours ago) and read 13190 times:

Quoting ikramerica (Reply 82):
No. The pilots should be able to land an aircraft without ILS and they should understand the AT modes and implications on the aircraft they are supposed to be proficient on. It's their job and they get paid handsomely for being in command of an aircraft (and more so for being in command of a large aircraft). If it's too difficult they should choose another line of work. Period.

As it has been pointed out a number of times already, Asiana & Korean fly to numerous airports in Asia that don't have ILS. So that's not a factor here. What has been pointed out is that management at Asiana should bare some blame for scheduling a training flight with the first foreign landing on an airfield where it was known that the ILS would be inop that day.


User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 94, posted (1 year 3 months 3 days 3 hours ago) and read 12955 times:

Quoting ComeAndGo (Reply 93):
What has been pointed out is that management at Asiana should bare some blame for scheduling a training flight with the first foreign landing on an airfield where it was known that the ILS would be inop that day.

Any landing (and any flight) has a sort of acceptable "bucket of risk". Things like inop ILS, crew fatigue, newness in type, crosswinds, gusts, low ceiling, unfamiliarity with airport and so forth fill the bucket and increase risk. Other factors like good weather and calm winds empty the bucket and decrease risk. Some risks are bigger than others and some interact. The trick is not to make the bucket of risk overflow.

The fact that it was a training flight perhaps increased risk a bit, as did the ILS. However I have a hard time seeing how the total risk was so great as to make the bucket overflow. Fair day, no big terrain hazards...



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 95, posted (1 year 3 months 3 days 1 hour ago) and read 12859 times:

Quoting oly720man,reply=88 quoting 'Aviation Week';:
The 777 experts say the most plausible explanation for what happened next was that the pilots, intentionally or in error, selected the FLCH mode on the MCP with the target altitude set at 0 ft. or the minimum descent altitude. In a descent, FLCH reduces thrust to flight idle. The throttles will typically reengage when the aircraft reaches an altitude selected on the MCP, or if the aircraft's speed nears stall speed at radio altimeter heights greater than 100 ft. If the altitude was selected to zero, however, the throttles would have remained at flight idle as Flight 214's pilots increased pitch to remain on the glideslope, causing airspeed to drop below preset levels.


This theory is getting a lot of coverage on the Net - and certainly 'fits with the facts' in the sense that it is known that the pilot(s) raised the nose late on, and the aeroplane lost a lot of airspeed. I'd invite everyone to 'read around it':-

http://www.google.com.au/#sclient=ps...=b8a02dcf4dcbb135&biw=1187&bih=542



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 96, posted (1 year 3 months 2 days 23 hours ago) and read 12639 times:

Quoting Starlionblue (Reply 94):
Fair day, no big terrain hazards...

There are close calls on a regular basis, if this aircraft just touched down 20-50m further down the runway in all likely hood we would be discussing a runway excursion, normally we only fly over the runway threshold around 50'. There are a lot of landing related accidents, this month so far far there has been 2 turboprops, 9 narrow body, and 2 wide body aircraft involved in landing related incidents. The geographic distribution of these accidents is very widespread, so is the ethnic background of the pilots. type of aircraft, and licenes held by the pilots etc. More than one of these accidents happened in the US, with FAA licenced pilots (e.g. US Airways B737-400, Southwest 737-700).

I therefore submit a thesis that the ethnic origin of a pilot does not have a predisposition to having accidents/incidents. Interestingly the Australian ATSB also released a report this month to indicate that experience does not have a role either.

People who are involved in the industry know how small a margin we work with on a regular basis, we do not go around criticizing others as we have all had to eat humble pie over the years. Everyone has been caught out by one thing or another, everyone has had many landings that feel like they would be better described as arrivals.

I have stated a number of times, that it is my view that the a number of causal factors for this accident were not in the cockpit, that is based upon factual information released by the NTSB. I am also of the view that like AF447, where there was a history in the industry of pitot tubes that met all certification standards were found to ineffective during some atmospheric conditions (indicating real world conditions can exceed the certification standards), we will find out that there have been numerous similar events in the past, the rest of them just happened further from the ground.

Many people these days live in a "blame" culture, always wanting to blame someone else, need a rule to cover every scenario, everything has to be black and white etc. Aviation is not like that, it is full of shades of grey, we have some rules in place that aim to reduce risk, however the risk has never been "advertised" as zero.

Fair day, no terrain, does not mean it is also a walk in the park.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlinesteinberger45 From United States of America, joined May 2009, 13 posts, RR: 0
Reply 97, posted (1 year 3 months 2 days 23 hours ago) and read 12540 times:

If I am not mistaken wasn't there a Korean air crash in the past with an issue with the crew culture. Could we have an issue here with crew management. A lot of the pilots flying for these Korean airlines are ex- military. In the past the captains judgement was never questioned . Could we have had a 1st officer watch and not act as the Captain crashed the plane.

User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 98, posted (1 year 3 months 2 days 23 hours ago) and read 12471 times:

Quoting zeke (Reply 96):
I have stated a number of times, that it is my view that the a number of causal factors for this accident were not in the cockpit, that is based upon factual information released by the NTSB.

Could you please specify some of said 'factual information,' Zeke?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 99, posted (1 year 3 months 2 days 21 hours ago) and read 12271 times:

Quoting Klaus (Reply 70):
I don't get the attempt to put a complete taboo on the term.

Not trying to put a taboo on it, just trying to get people to evolve the conversation into something more productive.

Quoting Norcal773 (Reply 81):
A lot of people on this thread seem to confuse what the meaning of the word 'cause' is. If it turns out that the pilots didn't monitor speed as they should have...and that's a big IF, the cause of the accident will be 'pilot error' no matter how some of you guys wanna spin it.

Actually, if that's the case then the cause will be "the pilots' failure to monitor speed" (or something to that effect), not "pilot error".

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlinesk909 From Denmark, joined Nov 2005, 261 posts, RR: 0
Reply 100, posted (1 year 3 months 2 days 21 hours ago) and read 12254 times:

Quoting steinberger45 (Reply 97):

If I am not mistaken wasn't there a Korean air crash in the past with an issue with the crew culture. Could we have an issue here with crew management. A lot of the pilots flying for these Korean airlines are ex- military. In the past the captains judgement was never questioned . Could we have had a 1st officer watch and not act as the Captain crashed the plane.

Sure it is possible, but because of the previous accidents, the "culture" has changed. So it would definitely shock me, if it were the case.



Life's for Living!
User currently offlinesk909 From Denmark, joined Nov 2005, 261 posts, RR: 0
Reply 101, posted (1 year 3 months 2 days 21 hours ago) and read 12222 times:

Quoting airmagnac (Reply 92):
It could be caused by a wide number of things, all of which are of interest for future safety.

As you say, there is just never 1 reason for an accident. It is the "swiss cheese hole"-theory. But as far as I have been able to read, the pilots flew a perfectly functioning airplane into the ground. So maybe they didn't understand the A/T or they where focused on other things or the A/T didn't work properly. But all boiled down, they did not fly the plane. Basic airmanship. And the number one thing is always airspeed. No airspeed, no flying. It is true at 35,000 feet and at 100 feet.



Life's for Living!
User currently offlineflyingturtle From Switzerland, joined Oct 2011, 2442 posts, RR: 14
Reply 102, posted (1 year 3 months 2 days 19 hours ago) and read 12297 times:

Quoting airmagnac (Reply 92):

I wanted to post this example, but did not think it was worthy enough for this thread: http://en.wikipedia.org/wiki/Why%E2%80%93because_analysis#Example - it features a nice display of the causes that lead to the sinking of the "Herald of Free Enterprise" in the Channel back in 1987.

Quoting Starlionblue (Reply 94):

That's an extremely important thing that can't be stressed enough. Risks are always there, and we need to decide on both acceptable risks, and acceptable probabilities of an accident. There are many methods of bypassing the human mind (which can mess up things by over- or underestimate risks in various ways) in order to get a less biased, and more down-to-earth picture of the situation.

Quoting NAV20 (Reply 98):
Could you please specify some of said 'factual information,' Zeke?

Not again...    Hello AF447 threads, here we come again! 



David



Keeping calm is terrorism against those who want to live in fear.
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 103, posted (1 year 3 months 2 days 19 hours ago) and read 12233 times:

Quoting NAV20 (Reply 98):
Could you please specify some of said 'factual information,' Zeke?

The factual briefings have been made available to the public.
July 07 http://youtu.be/XLYeUbeyfOg
July 08 http://youtu.be/d9MTLlzf8Co
July 09 http://youtu.be/zZZy_IC06ac
July 10 http://youtu.be/JVQ-F9mcHrM
July 11 http://youtu.be/I1GopE_siVY

B roll
http://youtu.be/OHBhaXJVhbg
Additional B roll
http://youtu.be/D1HGGJ2rrY0



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 104, posted (1 year 3 months 2 days 17 hours ago) and read 11918 times:

Quoting zeke (Reply 103):
The factual briefings have been made available to the public.
Quoting zeke (Reply 96):
I have stated a number of times, that it is my view that the a number of causal factors for this accident were not in the cockpit, that is based upon factual information released by the NTSB.

zeke, I watched all the NTSB briefings you provided links to, and do not recall any 'causal factors.....not in the cockpit' being mentioned/discussed.

Of course, I'm no longer young, my memory could be at fault. But please give us all a few quick examples of the 'non-cockpit causes' to which you refer? Which, to the best of my knowledge, none of the rest of us can recall?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 105, posted (1 year 3 months 2 days 16 hours ago) and read 11845 times:

Quoting NAV20 (Reply 104):
zeke, I watched all the NTSB briefings you provided links

It sounds like you do not understand the methodology used in accident investigation, which is not really the topic of this thread.

The videos provide updates of the NTSB factual information which include all factors that the NTSB became aware of shortly after the accident. The methodology used by air accident investigators follow systems like "events and causal factor analysis". I listened to the briefings with an understanding of the methodology being use to recreate the chain of events that resulted in the accident and subsequent evacuation. Basically everything they mentioned in the briefings is part of the chain of events, in their analysis they will work out what factors were more important than others.

Various causal factors are provided/discussed, the causal factors are all the facts released, plus the ones being still being discovered. If you are unable to understand a particular part of the OZ 777 briefings, please ask. I am not going to drawn into a off topic discussion on accident investigation methodology, that is a topic in itself for tech ops.

P.S. I posted the links about 127 minutes ago for around 218 minutes of video, your post indicating you have watched them would seem to be 91 minutes premature.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineSpeedbored From United Kingdom, joined Jul 2013, 327 posts, RR: 1
Reply 106, posted (1 year 3 months 2 days 16 hours ago) and read 11787 times:

Quoting NAV20 (Reply 104):
zeke, I watched all the NTSB briefings you provided links to, and do not recall any 'causal factors.....not in the cockpit' being mentioned/discussed.

Of course, I'm no longer young, my memory could be at fault. But please give us all a few quick examples of the 'non-cockpit causes' to which you refer? Which, to the best of my knowledge, none of the rest of us can recall?

Well I'm not that young anymore either but please don't attempt to speak for me. I am one of 'the rest of us' and I can clearly recall quite a few of the facts that Zeke alludes to, even without reviewing the videos again. For example, being put into a high and fast position by ATC and having to intercept the glideslope from above, or the inoperative ILS, among many other factors.

Zeke doesn't claim that the NTSB have labelled anything as 'causal factors'. He quite clearly says that this is his opinion based on the facts that have been made public by the NTSB. It would be seriously remiss of the NTSB to label anything as a cause at this stage - they are still gathering facts so it's way too early to be publishing conclusions.

[Edited 2013-07-24 06:35:42]

User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 107, posted (1 year 3 months 2 days 16 hours ago) and read 11790 times:

Quoting zeke (Reply 105):
P.S. I posted the links about 127 minutes ago for around 218 minutes of video, your post indicating you have watched them would seem to be 91 minutes premature.

I watched them 'first time round,' Zeke, when they first came out. And I simply do not recall ANY 'non-cockpit causal factors' of the type you refer to being reported/discussed.

So please specify which 'causal factors' you are referring to?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 108, posted (1 year 3 months 2 days 13 hours ago) and read 11496 times:

Quoting Mir (Reply 99):
Actually, if that's the case then the cause will be "the pilots' failure to monitor speed" (or something to that effect), not "pilot error".

'Failure to monitor speed' is an error for technicality sake  
Quoting zeke (Reply 105):
P.S. I posted the links about 127 minutes ago for around 218 minutes of video, your post indicating you have watched them would seem to be 91 minutes premature.

Did you consider the fact that he might have watched them before thus didn't need to watch them again?



If you're going through hell, keep going
User currently offlinewanderlustlax From United States of America, joined May 2013, 38 posts, RR: 0
Reply 109, posted (1 year 3 months 2 days 13 hours ago) and read 11471 times:

Quoting NAV20 (Reply 104):
But please give us all a few quick examples of the 'non-cockpit causes' to which you refer? Which, to the best of my knowledge, none of the rest of us can recall?
Quoting zeke (Reply 105):
The videos provide updates of the NTSB factual information which include all factors that the NTSB became aware of shortly after the accident. The methodology used by air accident investigators follow systems like "events and causal factor analysis". I listened to the briefings with an understanding of the methodology being use to recreate the chain of events that resulted in the accident and subsequent evacuation. Basically everything they mentioned in the briefings is part of the chain of events, in their analysis they will work out what factors were more important than others.

Various causal factors are provided/discussed, the causal factors are all the facts released, plus the ones being still being discovered. If you are unable to understand a particular part of the OZ 777 briefings, please ask. I am not going to drawn into a off topic discussion on accident investigation methodology, that is a topic in itself for tech ops.


Well, zeke. That's the most descriptive non-answer I've ever read.

You complain about those on here that are too quick to damn the pilots but you seem equally as vociferous about defending them blindly and pleading for people to take into account these out-of-cockpit causes you claim have been mentioned in the NTSB briefings...yet you refuse to list those causes for those us who obviously did not hear them called out in the briefings.

All I'm saying is: making rash calls too quickly works in both directions. At least those who take umbrage with the pilots have *some* supporting evidence in making their (perhaps premature) judgements.


User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 110, posted (1 year 3 months 2 days 8 hours ago) and read 11109 times:

Quoting wanderlustlax (Reply 109):
yet you refuse to list those causes for those us who obviously did not hear them called out in the briefings

I said "causal factor", which is not the same as "cause", the way people misquote me is the reason why I want them to look at those NTSB briefings and extract the data themselves.

The NTSB has provided almost 5 hours of briefings where they have outlined so many causal factors inside and outside the cockpit surrounding the accident. Given that other members can list some of those factors, like in reply 106, I am not generating a Wiki page like post on all the causal factors the NTSB have stated. All of the information is available in the NTSB briefings, it will take a little effort to listen to them and compile their own list of causal factors.

I am also not going to derail this thread into a discussion into accident investigation methodologies. There are many places where one can read up on what the term "causal factor" means, or the topic of accident investigation methodologies can be discussed in Tech Ops.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 111, posted (1 year 3 months 2 days 2 hours ago) and read 10762 times:

Quoting Speedbored (Reply 106):
I am one of 'the rest of us' and I can clearly recall quite a few of the facts that Zeke alludes to, even without reviewing the videos again. For example, being put into a high and fast position by ATC and having to intercept the glideslope from above, or the inoperative ILS, among many other factors.

Fair enough, as far as it goes, Speedbored - but if you look at the links in Posts 88 and 95 above, you'll see that all the evidence is that the autopilot brought them down pretty well in line with the runway, with height to spare and at the right speed (about 140 knots). They then disconnected the autopilot at about 1,200 feet, took manual control, and raised the nose to reduce the rate of descent. But it appears that they either didn't know about, or forgot about, the fact that in a descent using FLCH ('Flight Level Change') mode, the auto-throttle stays at 'idle' unless it is reset. So raising the nose inevitably reduced the speed to the point where the aeroplane virtually 'stalled in' - in fact the stall warning did go off in the last few seconds.

Most accidents do indeed turn out to be caused by an accumulation of small problems which eventually 'merge' into a big one. But, on what we know so far, this one does look as everything went well until the last thirty seconds - and had a single cause, failure either to reset the auto-throttle after the FLCH descent or to notice the loss of speed and switch to manual throttle control?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinetommy525 From United States of America, joined Nov 2012, 67 posts, RR: 0
Reply 112, posted (1 year 3 months 1 day 21 hours ago) and read 10512 times:

KTVU producers fired for on air gaff:

http://www.sfgate.com/bayarea/matier...ver-Asiana-pilots-fake-4685627.php

It was NOT taken lightly to say the least.


User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 113, posted (1 year 3 months 1 day 16 hours ago) and read 10210 times:

Did a bit more googling and discovered that 'Flight Level Change' mode works the elevators, NOT the throttles. In the climb, one can assume that the pilots set 'climb' power or whatever, and FLCH then applies as much 'up elevator' as the available power will support, while maintaining flying speed.

Not sure what happens in a descent - my best guess is that the engines go to 'idle' and FLCH then raises or lowers the nose as necessary to maintain whatever speed is set on the auto-throttle? That view appears to be supported by the fact that Asiana 214 held about 140 knots through the descent, until it got close in, the autopilot was turned off, and the nose was raised?

Can any of the professional pilots on here please confirm whether all that's right or wrong?

[Edited 2013-07-25 06:13:12]


"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 114, posted (1 year 3 months 1 day 14 hours ago) and read 10010 times:

Quoting NAV20 (Reply 113):
my best guess is that the engines go to 'idle' and FLCH then raises or lowers the nose as necessary to maintain whatever speed is set on the auto-throttle?

OZ214's AP was disengaged (turned off at about 1500 ft). The pilot was doing any nose raising and lowering manually (and LNAV too). It sounds like he thought the A/Th was taking care of the speed when it wasn't.


User currently offline76er From Netherlands, joined Mar 2007, 551 posts, RR: 1
Reply 115, posted (1 year 3 months 1 day 14 hours ago) and read 9985 times:

Sort of right.
When selecting FLCH with a lower altitude set in the MCP thrust will be reduced to idle, while elevators will maintain the selected speed. After a short while the A/T mode changes to HOLD (=armed) and will engage again in SPD mode when the selected altitude is captured.

I suggest googling 'FLCH trap'.


User currently offline2175301 From United States of America, joined May 2007, 1074 posts, RR: 0
Reply 116, posted (1 year 3 months 1 day 14 hours ago) and read 9933 times:

Quoting zeke (Reply 110):
I said "causal factor", which is not the same as "cause", the way people misquote me is the reason why I want them to look at those NTSB briefings and extract the data themselves.

Zeke: In part I understand what you are saying; but, I think you are confusing "facts" with "Causal factors" - as an example; the ILS system was shut down for maintenance is a fact. I would not consider it a Causal Factor as it should not have affected how the crew planned and executed the landing of the plane as this is not an uncommon occurrence, nor did it fail midway during the landing.

My take is that the NTSB briefings contain a lot of facts - and only a few things I would consider Casual Factors (and a few others I would label as a possible Casual Factor). Please note that I am a Root Cause Investigator in the Nuclear Power Industry (one of a handful at our plant); and I know what its like to spend 1-2.5 months in a root cause investigation as I seem to do that every year or so. I have built many event and causal factor charts, and determined root causes (although in one case we could not find one); and its my signature on the cover of the report as the Qualified Root Cause Investigator (and I am the one the NRC comes back to with any questions).

To me the likely Casual Factors that will be most important in this case relate to crew training, procedures, management expectations, culture, etc. Items which the NTSB has said nothing so far (nor would I expect them too). I look forward to reviewing the final report - and I am sure that I will in fact see this incident in our training down the road.

Perry


User currently offlinehivue From United States of America, joined Feb 2013, 1097 posts, RR: 0
Reply 117, posted (1 year 3 months 1 day 13 hours ago) and read 9856 times:

Quoting 76er (Reply 115):
and will engage again in SPD mode when the selected altitude is captured.

And thus will never engage if the selected altitude is set to 0. This, as I understand it, is the essence of the "trap."


User currently offlinedakota123 From United States of America, joined Aug 2006, 116 posts, RR: 0
Reply 118, posted (1 year 3 months 1 day 11 hours ago) and read 9627 times:

Quoting NAV20 (Reply 113):
Did a bit more googling and discovered that 'Flight Level Change' mode works the elevators, NOT the throttles. In the climb, one can assume that the pilots set 'climb' power or whatever, and FLCH then applies as much 'up elevator' as the available power will support, while maintaining flying speed.

Not sure what happens in a descent - my best guess is that the engines go to 'idle' and FLCH then raises or lowers the nose as necessary to maintain whatever speed is set on the auto-throttle? That view appears to be supported by the fact that Asiana 214 held about 140 knots through the descent, until it got close in, the autopilot was turned off, and the nose was raised?

Basically yes. Throttles will trend towards idle but it's a maneuver coordinated with the AP. The maneuver reportedly uses 125 seconds as its time base. Idle may be the result but it's not a given.

If AP is engaged AT will wake up and will provide stall protection regardless of the above. If AP is disengaged but FD is on and speed-through-elevator mode is selected (e.g. FLCH) AT will not wake up and will not provide stall protection but FD will direct nose down and nose-up column force cannot be trimmed out. The system is expecting the pilot to do what the AP would have done, drop the nose. If FDs are off AT will provide stall protection regardless. Makes sense; the FD can't give any direction since it's off so the AT will do what it can to provide envelope protection.

Quoting hivue (Reply 117):
And thus will never engage if the selected altitude is set to 0. This, as I understand it, is the essence of the "trap."

And then 100' is reached and AT inhibited in FLCH regardless.







[Edited 2013-07-25 12:13:49]

User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 119, posted (1 year 3 months 1 day 9 hours ago) and read 9512 times:

Quoting NAV20 (Reply 113):
Not sure what happens in a descent - my best guess is that the engines go to 'idle' and FLCH then raises or lowers the nose as necessary to maintain whatever speed is set on the auto-throttle?

Basically correct.

Quoting hivue (Reply 114):
The pilot was doing any nose raising and lowering manually (and LNAV too). It sounds like he thought the A/Th was taking care of the speed when it wasn't.

The PM stated that he though the A/TH was taking care of speed, so it would appear that at least one person in the cockpit had that mentality.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 120, posted (1 year 3 months 1 day 4 hours ago) and read 9177 times:

Quoting 2175301 (Reply 116):
Zeke: In part I understand what you are saying; but, I think you are confusing "facts" with "Causal factors" - as an example; the ILS system was shut down for maintenance is a fact. I would not consider it a Causal Factor as it should not have affected how the crew planned and executed the landing of the plane as this is not an uncommon occurrence, nor did it fail midway during the landing.

I am not, at the early stage, every fact is a causal factor, techniques like root cause analysis to determine the relative merit or weighting of various factors are done at a later stage. Nothing is dismissed as being a causal factor during the preliminary investigation.

SFO see what I consider to be a higher rate of go-arounds per month compared to a number of other international airports. To dismiss the environment so early in the process without careful analysis I think would not be wise.

If it is not a factor, events like this should not happen so soon after the OZ indecent, EVA Descended Below Safe Height At SFO 28L (by musapapaya Jul 25 2013 in Civil Aviation)



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 121, posted (1 year 3 months 1 day 2 hours ago) and read 9021 times:

Quoting Mir (Reply 119):
Quoting hivue (Reply 114):The pilot was doing any nose raising and lowering manually (and LNAV too). It sounds like he thought the A/Th was taking care of the speed when it wasn't.
The PM stated that he thought the A/TH was taking care of speed, so it would appear that at least one person in the cockpit had that mentality.

Turns out that Deborah Hersman has already made public mention of that fact. And that they had one flight director on and one off - thus 'ensuring' that even if they'd reset the auto-throttle it STILL wouldn't have worked:-

"At about 500 feet," said Hersman, "he realized that they were low. He told the pilot to pull back."

The flight data recorder indicates the plane was traveling 40 mph slower than it should have been for landing -- so slow it triggered a warning system that shook the flight controls in the pilots' hands -- an alert the plane was losing lift and about to stall.

Just 1.5 seconds before the crash, the pilot attempted to abort the landing. The engine started speeding up, but it was too late to get them to full power.

In the interviews, the pilots said that they had set the auto throttle at 137 knots. That's the typical landing speed for the 777. What the NTSB has to confirm now is whether or not those controls were working.

Auto-throttles typically have three settings — off, on and armed. An auto-throttle that is armed but not on will remain at its previous speed, which was probably near idle, said Doug Moss, a pilot for a major U.S. airline and an aviation safety consultant in Torrance, Calif. Pilots will frequently shift to idle off and on when preparing to land in order to descend faster.

The pilot flying the plane had turned off his flight director, while the training captain had his flight director on, Hersman said. The flight director computes and displays the proper pitch and bank angles required in order for the aircraft to follow a selected path.

In most airliners, an autothrottle will not turn on if one flight director is off and one on because it has to work in harmony with the flight directors — both need to be either on or off, Moss said."


http://www.cbsnews.com/8301-201_162-...tragically-wrong-in-san-francisco/

Wouldn't mind betting that the South Korean Government and Asiana saying that they are stepping up training did so because Ms. Hersman has already told them in pretty definite terms why they should?

[Edited 2013-07-25 20:19:58]


"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 122, posted (1 year 3 months 1 day ago) and read 8814 times:

Quoting NAV20 (Reply 121):
Turns out that Deborah Hersman has already made public mention of that fact

She has mentioned some facts, but not everything you quoted. You have said you have watched all of the briefings, why not quote her directly instead of third party sources ?

Quoting NAV20 (Reply 121):
http://www.cbsnews.com/8301-201_162-...tragically-wrong-in-san-francisco/

The article contains information that has not been supported by the NTSB.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlinewanderlustlax From United States of America, joined May 2013, 38 posts, RR: 0
Reply 123, posted (1 year 3 months 1 day ago) and read 8762 times:

Quoting zeke (Reply 122):
She has mentioned some facts, but not everything you quoted. You have said you have watched all of the briefings, why not quote her directly instead of third party sources ?

And why not quote her directly yourself when referring to these so-called casual factors instead of referring people to hours of online videos.

Seems an easy enough task to mention just one casual factor listed by the NTSB that was out-of-cockpit or not related to CRM.


User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 124, posted (1 year 3 months 22 hours ago) and read 8564 times:

Quoting wanderlustlax (Reply 123):
And why not quote her directly yourself when referring to these so-called casual factors instead of referring people to hours of online videos

Every fact the NTSB at this stage is a causal factor, they will need to do their analysis in due course on all the facts available to determine what was or was not important. They mentioned many causal factors, including the airport, ATC, the work/sleep history, qualifications, the automatics, the evacuation procedure, glare on final etc, too many to mention, you will need to watch them all to get an idea of the amount of information they were dealing with just at the preliminary stage.

By asking me to singe out particular causal factors, you are effectively asking me to come to a conclusion. I do not want to do that, I am keeping an open mind. The NTSB mentioned all those factors as well as they have kept an open mind.

In previous threads where I have referenced the briefings, I provided the time in the briefing where the comments were made, not posting news articles e.g.

"The NTSB briefing in the 30/31 min mark said fire did get in the cabin, cabin crew, pilots, and the ARFF were fighting it internally. Then later when describing the removal of the pinned cabin crew at R2 at the 32 min mark makes a slightly different statement."



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 125, posted (1 year 3 months 22 hours ago) and read 8576 times:

Quoting zeke (Reply 122):
why not quote her directly instead of third party sources ?

Really, Zeke..........  

You probably know better than me that the NTSB's job - and policy - is not to apportion blame? The most that Ms. Hersman will ever be able to do (in the 'public area,' anyway) is probably to recommend 'additional training' etc.? But the fact remains that she did mention one of the flight directors being left on; which, I hope you'll agree, is very possibly the reason why the auto-throttle stayed at 'idle' - in other words, quite likely to turn out to be the main (or even the only) cause of the accident?

I then quoted the CBS article because it provided some additional information from what appears to be an entirely respectable source - ("...a pilot for a major U.S. airline and an aviation safety consultant in Torrance, Calif. ...") - who is no doubt freer than Ms. Hersman to discuss the possible (dare I say 'probable'?) cause of the accident?

Really does begin to look as if you don't want any exploration of possible causes; and instead want all discussion to cease until the NTSB issues its report - in about a year's time? I wish that, for all our sakes - given that you're undoubtedly a very experienced and knowledgeable airline pilot - you'd take a more constructive role in the debate?

[Edited 2013-07-26 00:24:17]


"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 126, posted (1 year 3 months 22 hours ago) and read 8502 times:

Quoting NAV20 (Reply 125):
But the fact remains that she did mention one of the flight directors being left on; which, I hope you'll agree, is very possibly the reason why the auto-throttle stayed at 'idle' - in other words, quite likely to turn out to be the main (or even the only) cause of the accident?

There are a lot of reasons why even if everything was working correctly, and the NTSB has not attempted to determine the cause. I know of another A/T function which also correlates to what the NTSB has said which is unrelated to the FD, and more related to the aircraft the PF was flying previously.

They have not even been able to confirm if the A/T system worked as designed. It was not until the Turkish 737 accident investigation did the Dutch investigator discovered one of the vendors of the A/T did not work as designed. At the end of the last NTSB briefing they had not even been able to verify the contents of the CVR/FDR, and had not completed the bench checking of the various avionics boxes removed.

So no, I am not jumping to the conclusion that it was due to one FD being off.

Quoting NAV20 (Reply 125):
I then quoted the CBS article because it provided some additional information from what appears to be an entirely respectable source - ("...a pilot for a major U.S. airline and an aviation safety consultant in Torrance, Calif. ...") - who is no doubt freer than Ms. Hersman to discuss the possible (dare I say 'probable'?) cause of the accident?

Well lets just get rid of the NTSB, we have our probable cause, case closed, nothing to learn here. Have you not realized there are numerous airline pilots on here that have erred on the side of caution, even those who currently fly the 777.

Quoting NAV20 (Reply 125):
Really does begin to look as if you don't want any exploration of possible causes;

To the contrary, I want a full exploration of all the facts (and more facts are still being learned), that means not discounting anything this early on, or trying to make facts fit an outcome.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 127, posted (1 year 3 months 21 hours ago) and read 8681 times:

Quoting zeke (Reply 126):
I know of another A/T function which also correlates to what the NTSB has said which is unrelated to the FD, and more related to the aircraft the PF was flying previously.
Great, Zeke, much more constructive.  

Please tell us all what the 'other auto-throttle function' is?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offline76er From Netherlands, joined Mar 2007, 551 posts, RR: 1
Reply 128, posted (1 year 3 months 21 hours ago) and read 8584 times:

Quoting zeke (Reply 126):
It was not until the Turkish 737 accident investigation did the Dutch investigator discovered one of the vendors of the A/T did not work as designed

Care to elaborate on that?


User currently offline2175301 From United States of America, joined May 2007, 1074 posts, RR: 0
Reply 129, posted (1 year 3 months 19 hours ago) and read 8429 times:

Quoting zeke (Reply 124):

Every fact the NTSB at this stage is a causal factor,

That is clearly not true - and I say that as a fully qualified root cause investigator who runs such investigations for the nuclear industry. There are very substantive differences between "facts" and "casual factors" - and the determination of what is a fact and what might be (or is) a causal factor is normally made very quickly when building the event timeline.

Have you ever actually been part of a NTSB investigation - or a similar investigation in the other two industries that commonly use the process (Nuclear & Medical). Have you ever worked with (or been trained by) the one private company in the US (and I believe there is another in Europe) who teaches the process and provides people to the NTSB, Nuclear, and Medical industries to be lead investigators of certain Root Cause investigations (or leads in certain sub-sections).

I am also very confident that every bit of information the NTSB has provided came directly from the event timeline - and that the vast majority of that timeline, as it was currently assembled, had already been determined to be either "facts" or "causal factors" - with a few left as questionable.

Yes, everything gets looked at - and a number of people will question everything. But to suggest that all "facts" are "casual factors" - and are considered as such from the very first instant is to misunderstand the process.

Root Cause investigations take considerable time, effort, energy, and stamina and are only successful because there is a virtually instant sorting of the information bits into "facts" and "casual factors/possible casual factors" which allows focus on the pattern and importance of the casual factors.

Have a great day,


User currently offlineSpeedbored From United Kingdom, joined Jul 2013, 327 posts, RR: 1
Reply 130, posted (1 year 3 months 18 hours ago) and read 8395 times:

Quoting 2175301 (Reply 129):
Quoting zeke (Reply 124):

Every fact the NTSB at this stage is a causal factor,

That is clearly not true

I suspect that what zeke actually meant to say was 'every fact is a potential causal factor', which, at this stage, is the reality of the situation, until the NTSB divulge more of their findings and any conclusions they come to.

I don't understand why so many people are giving zeke such a hard time when the gist of what he's saying is just that he's keeping an open mind as to the causes of this crash. Far too many other people seem, in their rush to blame the pilots, to be almost fanatically determined not to keep an open mind.

Personally, I'm also keeping an open mind until we hear more from the NTSB. I'd rather wait for the truth than jump to a potentially incorrect conclusion, and I'm far more interested in what the underlying causes of the crash are than who is to blame.


User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 131, posted (1 year 3 months 18 hours ago) and read 8374 times:

Quoting NAV20 (Reply 125):
Really, Zeke..........

Please!! You derailed many AF447 threads by continuing to quote third- and fourth-hand sources that misreported or distorted the official BEA report. When you were directed to the BEA report, you insisted it was not accessible on your computer, despite everybody else on the thread being able to access it.

Quoting wanderlustlax (Reply 123):
Quoting zeke (Reply 122):
She has mentioned some facts, but not everything you quoted. You have said you have watched all of the briefings, why not quote her directly instead of third party sources ?

And why not quote her directly yourself when referring to these so-called casual factors instead of referring people to hours of online videos.

Because then Zeke would be a second-hand source. He's simply suggesting that people get their facts from the original source. If people are too lazy to do the legwork, they should at least refrain from throwing around uninformed opinions.



Empty vessels make the most noise.
User currently offlinezeke From Hong Kong, joined Dec 2006, 9157 posts, RR: 76
Reply 132, posted (1 year 3 months 17 hours ago) and read 8331 times:

Quoting 76er (Reply 128):
Care to elaborate on that?

In the July 9 briefing at the 3 min mark by the NTSB were describing the switch positions in the cockpit, they stated the A/T was armed. At the 17 min mark they describe the final parts of the approach as described in the interview record with the PM. The PM indicated he "assumed" the A/T was maintaining the selected speed of 137 kts at around 500 ft. At 200' the PM established the G/A attitude however the PF already had pushed the thrust forward.

Double clicking the A/T disconnect switches resets the master caution, and the A/T remains armed. Double clicking the A/T disconnect is the procedure that would be used on the A320 for manual thrust control.

Quoting 2175301 (Reply 129):
That is clearly not true - and I say that as a fully qualified root cause investigator who runs such investigations for the nuclear industry. There are very substantive differences between "facts" and "casual factors" - and the determination of what is a fact and what might be (or is) a causal factor is normally made very quickly when building the event timeline.

You are describing the analyzing the cause-effect relationships around a primary event, as far as I am aware they had not started doing that when they were doing the preliminary investigation. The briefing from what I heard stated they were still in the early stage of of the event and causal factor analysis. I heard nothing to suggest they had made a determination so early to start ruling things out.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 133, posted (1 year 3 months 17 hours ago) and read 8232 times:

Quoting zeke (Reply 132):
Double clicking the A/T disconnect switches resets the master caution, and the A/T remains armed. Double clicking the A/T disconnect is the procedure that would be used on the A320 for manual thrust control.

Thanks, Zeke. Apologies, never flown anything with an auto-throttle myself; but does that mean that a double-click gets you full manual control on an A320, but NOT on a B777?



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinedakota123 From United States of America, joined Aug 2006, 116 posts, RR: 0
Reply 134, posted (1 year 3 months 13 hours ago) and read 7925 times:

Quoting NAV20 (Reply 121):
And that they had one flight director on and one off - thus 'ensuring' that even if they'd reset the auto-throttle it STILL wouldn't have worked:-

Even if both FDs had been on the system would have reacted exactly the same since FLCH was selected as the AP/FD mode. FLCH = no AT wakeup. From your comment ("one flight director on and one off") I'm not sure you got that.

If both FDs had been off, however, then there's no FLCH or any other mode (the AP had been disconnected and FDs off, so hand flown) and the ATs would have woken up.

Quoting NAV20 (Reply 125):

I then quoted the CBS article because it provided some additional information from what appears to be an entirely respectable source - ("...a pilot for a major U.S. airline and an aviation safety consultant in Torrance, Calif. ...") - who is no doubt freer than Ms. Hersman to discuss the possible (dare I say 'probable'?) cause of the accident?

The article is far too general to be of any use. No doubt the consultant interviewed, Doug Moss, is extremely knowledgeable and talented (I envy him!) but looking at his credentials from the publicly available information it isn't clear that he knows the 777 intimately. He flies an A320 for UAL and is also type-rated in the DC-9, MD-80, MD-90, MD-11. Not a Boeing in the bunch apparently. He very possibly got the phone call and spoke off the top of his head -- no research.

All several of us are saying is that there are far better sources than a CBS story. That and it's just not certain yet exactly what transpired.


User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 135, posted (1 year 3 months 13 hours ago) and read 7855 times:

Quoting dakota123 (Reply 134):
All several of us are saying is that there are far better sources than a CBS story.

Sure that there may well be, pal..........BUT...........

Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident? Haven't seen anything factual except the CBS outline, so far?

[Edited 2013-07-26 09:34:04]


"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineSpeedbored From United Kingdom, joined Jul 2013, 327 posts, RR: 1
Reply 136, posted (1 year 3 months 13 hours ago) and read 7838 times:

Quoting NAV20 (Reply 135):
Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident?

Given that the CBS article is mostly journalistic supposition, just about any other source is likely to be as-good or better. The best source, of course is the NTSB but, if you're not satisfied with the information they've released so far, you'll just have to wait until they release an interim report.

Quoting NAV20 (Reply 135):
Haven't seen anything factual except the CBS outline, so far?

Maybe that's because other sources are waiting for more facts before saying anything, rather than making things up.


User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 137, posted (1 year 3 months 12 hours ago) and read 7817 times:

Quoting dakota123 (Reply 134):
All several of us are saying is that there are far better sources than a CBS story.
Quoting NAV20 (Reply 135):
Sure that there may well be, pal..........BUT...........

Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident? Haven't seen anything factual except the CBS outline, so far?

Looks like a bit of stalemate really, friend - my source isn't saying much, yours isn't saying anything!  

My guess is that, in respect of this accident, we may not get much more 'solid' information for some months. The stakes are high - on the one hand some people lost their lives, on the other hand the aeroplane, faced with an emergency, did pretty well compared to other makes, in terms of lives lost........



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 138, posted (1 year 3 months 12 hours ago) and read 7797 times:

Quoting NAV20 (Reply 137):
The stakes are high

Yes they are.

Quoting NAV20 (Reply 137):
we may not get much more 'solid' information for some months.

And quoting speculative, uninformed opinion rather than factual or solid information - more likely than not caused damage and injury to innocent people.

Leads to false impressions like we still hear about AF447, etc.

The new media place great value on "the journalistic record" - which is actually more fiction than fact in many cases.

In the case of this crash and AF447 - the journalistic record is largely fiction.


User currently offlineSpeedbored From United Kingdom, joined Jul 2013, 327 posts, RR: 1
Reply 139, posted (1 year 3 months 12 hours ago) and read 7819 times:

Quoting NAV20 (Reply 137):
on the other hand the aeroplane, faced with an emergency, did pretty well compared to other makes, in terms of lives lost........

Really? Completely unnecessary.


User currently offlinedakota123 From United States of America, joined Aug 2006, 116 posts, RR: 0
Reply 140, posted (1 year 3 months 12 hours ago) and read 7775 times:

Quoting NAV20 (Reply 135):

Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident? Haven't seen anything factual except the CBS outline, so far?

I meant 'far better sources' in the context of information for our armchair efforts. (And don't kid yourself, that's all it is.) Not 'sources' in the context of the media. The CBS article is 'factual' -- but is so full generalities that may or may not apply to the 777 and/or may or may not apply to the situation of interest that it's useless.

[Edited 2013-07-26 10:28:25]

User currently offlinesonomaflyer From United States of America, joined Apr 2010, 1846 posts, RR: 0
Reply 141, posted (1 year 3 months 12 hours ago) and read 7753 times:
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Quoting NAV20 (Reply 135):
Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident? Haven't seen anything factual except the CBS outline, so far?

We will know the likely causes of this accident once the final NTSB report is released. We have bits and pieces of the overall puzzle from the information released by the NTSB, that does not add up to causation.

Quoting CBS, CNN or any of the news organizations in a crash investigation is silly. They in turn were relying on speculation from some dude they claim is an expert. Whether that person is or is not is unknown.


User currently offlineb757capt From United States of America, joined Feb 2004, 1392 posts, RR: 0
Reply 142, posted (1 year 3 months 5 hours ago) and read 7419 times:

Any ideas where the wreckage was moved to?


The views written by this user are in no manner the views of my employer and should not be thought as such.
User currently offlineNAV20 From Australia, joined Nov 2003, 9909 posts, RR: 36
Reply 143, posted (1 year 3 months ago) and read 7272 times:

According to this report, b757capt, it's been stored in a 'remote area.' Sounds as if the NTSB has finished with it:-

"The debris will be stored for the next week or so at a remote area of the airport. Asiana will ultimately determine what they want to do with it."

http://www.nbcbayarea.com/news/natio...sit-Wreckage-at-SFO-215026871.html



"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci
User currently offlineMir From United States of America, joined Jan 2004, 21681 posts, RR: 55
Reply 144, posted (1 year 2 months 4 weeks 1 day 22 hours ago) and read 7110 times:

Quoting dakota123 (Reply 134):
. No doubt the consultant interviewed, Doug Moss, is extremely knowledgeable and talented (I envy him!) but looking at his credentials from the publicly available information it isn't clear that he knows the 777 intimately. He flies an A320 for UAL and is also type-rated in the DC-9, MD-80, MD-90, MD-11. Not a Boeing in the bunch apparently. He very possibly got the phone call and spoke off the top of his head -- no research.

   I've learned that a lot of aviation safety consultants are quite ignorant of the particularities of a particular aircraft if they don't have experience with it. They can speak generally about certain things, but I wouldn't trust their systems knowledge at all without more knowledge of their credentials.

-Mir



7 billion, one nation, imagination...it's a beautiful day
User currently offlinemandala499 From Indonesia, joined Aug 2001, 6926 posts, RR: 76
Reply 145, posted (1 year 2 months 4 weeks 1 day 20 hours ago) and read 7014 times:

Quoting dakota123 (Reply 134):
The article is far too general to be of any use. No doubt the consultant interviewed, Doug Moss, is extremely knowledgeable and talented (I envy him!) but looking at his credentials from the publicly available information it isn't clear that he knows the 777 intimately. He flies an A320 for UAL and is also type-rated in the DC-9, MD-80, MD-90, MD-11. Not a Boeing in the bunch apparently. He very possibly got the phone call and spoke off the top of his head -- no research.

Absolutely. I have received such calls for other accidents. A lot of the times, the journo would ask, "well how would it work on your plane or on a plane you know?"

Quoting NAV20 (Reply 135):
Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident? Haven't seen anything factual except the CBS outline, so far?

If you cannot disect between facts and opinions in what the media says, then I suggest you stick with what the NTSB is saying... seriously mate...



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineKaiarahi From Canada, joined Jul 2009, 3033 posts, RR: 28
Reply 146, posted (1 year 2 months 4 weeks 1 day 16 hours ago) and read 6898 times:

Quoting NAV20 (Reply 135):
Please inform us all - ASAP - what said 'far better sources' are saying about the likely causes of this dreadful accident?

My cousin's wife's brother's mother-in-law, who once took a flight from IVC to CHC, says it's because the pilot pushed the thingamijig instead of pulling on the whatchamecallit.



Empty vessels make the most noise.
User currently offlineHOONS90 From Canada, joined Aug 2001, 3036 posts, RR: 52
Reply 147, posted (1 year 2 months 3 weeks 6 days 16 hours ago) and read 5950 times:
AIRLINERS.NET CREW
CHAT OPERATOR

As of August 12th, Asiana flight 214 will no longer exist as it is being renumbered to Asiana flight 212. The return flight will be renumbered to 211.


The biggest mistake made by most human beings: Listening to only half, understanding just a quarter and telling double.
User currently offlineAlias1024 From United States of America, joined Oct 2004, 2778 posts, RR: 2
Reply 148, posted (1 year 2 months 3 weeks 6 days 13 hours ago) and read 5651 times:

Quoting b757capt (Reply 142):

Any ideas where the wreckage was moved to?


North side of the 28s, over by the Signature ramp



It is a mistake to think you can solve any major problems with just potatoes.
User currently offlinen471wn From United States of America, joined Dec 2003, 1563 posts, RR: 2
Reply 149, posted (1 year 2 months 3 weeks 6 days 11 hours ago) and read 5508 times:
Support Airliners.net - become a First Class Member!

Quoting Alias1024 (Reply 148):
North side of the 28s, over by the Signature ramp

And regardless of the stuff they put on the fence you can see it well and especially if you are in a high profile vehicle--Prius owners might as well stay home but I saw it yesterday clearly in my Lincoln Navigator


User currently offlineNorcal773 From United States of America, joined Feb 2007, 1448 posts, RR: 12
Reply 150, posted (1 year 2 months 3 weeks 6 days 11 hours ago) and read 5479 times:

Quoting HOONS90 (Reply 147):
As of August 12th, Asiana flight 214 will no longer exist as it is being renumbered to Asiana flight 212. The return flight will be renumbered to 211.

That's interesting, Thanks for the update. I don't blame them for scrubbing flight # 214.



If you're going through hell, keep going
User currently offlineshrike From United States of America, joined Jul 2013, 54 posts, RR: 0
Reply 151, posted (1 year 2 months 3 weeks 4 days 22 hours ago) and read 4691 times:

Well this is an interesting FAA response (reported by many media sites), especially given the amount of "uncertainty until we get the report" that has been debated here! The FAA must have a different speculation tolerance level...

http://www.mercurynews.com/business/...-told-rely-instruments-land-at-sfo


User currently offlinelegacyins From United States of America, joined Aug 2003, 2091 posts, RR: 0
Reply 152, posted (1 year 2 months 3 weeks 4 days 21 hours ago) and read 4621 times:

Quoting shrike (Reply 151):

Already being discussed here:

FAA Advises All Foreign Carriers To Use GPS At SFO (by bioyuki Jul 28 2013 in Civil Aviation)



John@SFO
User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 153, posted (1 year 2 months 3 weeks 4 days 16 hours ago) and read 4241 times:

Quoting shrike (Reply 151):
The FAA must have a different speculation tolerance level...

The FAA and the NTSB are different agencies with different responsibilities and duties.

The NTSB and FAA will often disagree on the proper course of action on the lessons learned from a crash.

This isn't the first time, and won't be the last time, the FAA issued a change in procedure before the NTSB completes the crash investigation.


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