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OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 4:44 am

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
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TheRedBaron
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 5:04 am

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
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David L
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 7:23 am

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.
 
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Starlionblue
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 10:09 am

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." - John Ringo
 
Norcal773
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 1:56 pm

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
 
traindoc
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 2:07 pm

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.
 
hivue
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 2:21 pm

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?
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TheRedBaron
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 4:01 pm

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
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David L
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 4:57 pm

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.
 
abba
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 5:43 pm

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!
 
135mech
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 6:10 pm

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
135Mech
 
135mech
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 6:22 pm

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
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Norcal773
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 6:43 pm

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
 
David L
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 6:58 pm

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.
 
abba
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 7:07 pm

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.
 
UA787DEN
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 18, 2013 9:30 pm

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?
 
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glideslope
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 1:37 am

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
 
76er
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 6:35 am

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.
 
Norcal773
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 9:30 am

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
 
wanderlustlax
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 2:03 pm

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'.
 
stlgph
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 5:11 pm

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]
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bioyuki
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 5:45 pm

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
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LTC8K6
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 6:16 pm

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]
 
747megatop
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 6:32 pm

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]
 
nomadd22
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 6:41 pm

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.
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goldenargosy
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 7:35 pm

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

  
 
David L
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 9:22 pm

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.
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 19, 2013 11:16 pm

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
 
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Starlionblue
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 12:56 am

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." - John Ringo
 
BEG2IAH
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 1:00 am

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.
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 1:17 am

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
 
airtechy
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 1:36 am

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
 
WNbob
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 3:16 am

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.
 
David L
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 8:21 am

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.
 
mandala499
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 11:41 am

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 !
 
airtechy
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 7:18 pm

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
 
David L
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 7:44 pm

Quoting airtechy (Reply 35):
Thank you.

You're welcome. Why didn't Mandala499 think of that?   
 
airtechy
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 7:49 pm

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

AT
 
Mir
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 8:03 pm

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
 
Klaus
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 8:31 pm

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.
 
Mir
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 9:17 pm

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
 
cornutt
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 9:36 pm

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?
 
Skydrol
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 9:40 pm

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]
∙ ---{--« ∙ ----{--« ∙ --{-« ∙ ---{--« ∙ --{--« ∙ --{-« ∙ ----{--« ∙
 
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speedbored
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 9:41 pm

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.
Still don't like the look and feel of the site? Look at:http://www.airliners.net/forum/viewtopic.php?f=12&t=1335851
 
Klaus
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 10:05 pm

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.
 
Mr AirNZ
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 11:07 pm

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.
 
BEG2IAH
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 20, 2013 11:10 pm

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.
 
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neutrino
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RE: OZ 777 Crash At SFO Part 10

Sun Jul 21, 2013 5:22 am

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
 
Mir
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RE: OZ 777 Crash At SFO Part 10

Sun Jul 21, 2013 6:08 am

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
 
Max Q
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RE: OZ 777 Crash At SFO Part 10

Sun Jul 21, 2013 6:32 am

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.

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