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sk909
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 8:02 am

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.
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sk909
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 8:15 am

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.
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flyingturtle
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 9:45 am

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! 



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zeke
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 10:33 am

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
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NAV20
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 12:39 pm

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?
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zeke
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 1:28 pm

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.
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speedbored
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 1:31 pm

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]
 
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 1:35 pm

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?
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Norcal773
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 4:21 pm

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?
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wanderlustlax
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 4:29 pm

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.
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Wed Jul 24, 2013 9:33 pm

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.
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NAV20
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 3:22 am

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?
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Tommy525
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 8:36 am

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.
 
NAV20
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 12:54 pm

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]
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 3:20 pm

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.
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76er
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 3:24 pm

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'.
 
2175301
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 3:41 pm

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.

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hivue
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 4:04 pm

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."
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dakota123
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 6:32 pm

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]
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Mir
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RE: OZ 777 Crash At SFO Part 10

Thu Jul 25, 2013 7:49 pm

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.

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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 12:53 am

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)
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NAV20
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 3:09 am

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]
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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 4:58 am

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.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
wanderlustlax
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:17 am

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.
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 6:57 am

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."
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
NAV20
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 6:59 am

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
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 7:43 am

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.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 7:52 am

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?
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76er
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 8:37 am

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?
 
2175301
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 10:25 am

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,
 
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speedbored
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 10:45 am

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.
 
Kaiarahi
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 11:05 am

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.
 
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zeke
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 11:53 am

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.
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NAV20
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 12:29 pm

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
 
dakota123
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 4:00 pm

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.
“And If I claim to be a wise man, well surely it means that I don’t know”
 
NAV20
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 4:29 pm

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
 
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speedbored
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 4:37 pm

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.
 
NAV20
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:11 pm

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
 
rfields5421
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:18 pm

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.
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speedbored
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:19 pm

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.
 
dakota123
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:27 pm

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]
“And If I claim to be a wise man, well surely it means that I don’t know”
 
SonomaFlyer
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 5:39 pm

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.
 
B757capt
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RE: OZ 777 Crash At SFO Part 10

Fri Jul 26, 2013 11:51 pm

Any ideas where the wreckage was moved to?
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NAV20
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 27, 2013 5:05 am

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
 
Mir
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 27, 2013 6:45 am

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
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mandala499
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 27, 2013 9:01 am

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 !
 
Kaiarahi
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RE: OZ 777 Crash At SFO Part 10

Sat Jul 27, 2013 12:52 pm

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.
 
hoons90
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RE: OZ 777 Crash At SFO Part 10

Mon Jul 29, 2013 12:51 pm

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.
Flown: 2L 7C 9E 9L AA AB AC AF AY AZ BA BR BX B6 CA CO CP CX DL EK EY JL KE KL LA LH LX MQ NW OZ PD RW SQ TG TP TR TS US WG WN WS XE XJ
 
Alias1024
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RE: OZ 777 Crash At SFO Part 10

Mon Jul 29, 2013 4:37 pm

Quoting b757capt (Reply 142):

Any ideas where the wreckage was moved to?


North side of the 28s, over by the Signature ramp
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n471wn
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RE: OZ 777 Crash At SFO Part 10

Mon Jul 29, 2013 5:55 pm

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

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