JoeCanuck
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 4:30 pm

At a hearing in Seoul into the accident, the NTSB testified that the pilot's failure to monitor airspeed, their lack of understanding of the aircraft's systems, and the complexity of those systems, contributed to the accident.

www.flightglobal.com/news/articles/n...rew-failures-in-asiana-214-400715/

Quote:
NTSB cites autothrottle system, crew failures in Asiana 214 crashHe added that although automation has made aviation safer, the complexity of aircraft systems have created opportunities for new problems that designers never anticipated.

Investigators also noted that the pilots had inadequate understanding of the aircraft's systems and did not effecitvely monitor the aircraft's airspeed.

While I understand that complex systems can be difficult to understand, i'm still of the camp that regardless of that complexity, it was a clear day with great visibility and a perfectly airworthy aircraft with 3 well trained and experienced pilots in the cockpit....and the root cause of the accident was bad flying.

It was a VFR landing and nobody was looking out the window, monitoring airspeed or both, and the complexity of the automatic systems didn't prevent the pilots from pushing the thrust levers forward, or hitting the TOGA button, (or whatever it is), or otherwise actually controlling the aircraft.

Pilots are supposed to the the last and best line of defense in case of problems...these guys weren't.

Sure, the auto throttles could have had one more mode added to them....but these guys are supposed to know how to fly the plane in case the automation fails...and it actually didn't even fail.....nothing did except the pilots.

No matter how much automation goes into the cockpit, there is always a chance of misunderstanding or failure. The number one job of the pilot is to fly the aircraft. If you can't concentrate for the 15 minutes it takes to fly final and land an aircraft filled with hundreds of people, (each of which is counting on you not to kill them), every single time, then you really shouldn''t be in the cockpit.

I would rather come up with solutions than apportion blame....usually....but this one goes right on the pilots. Maybe the airline let them slip by with inadequate training or Boeing didn't put the right sound on their warning buzzer...but at some point, pilots have nobody else to blame but themselves.

This is one of those times.
What the...?
 
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chrisnh
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 4:45 pm

I'm sure this is going to bring out the chorus, "Ohhh! Boeing is at fault, too! I KNEW it!!"

But the crew is supposed to know these systems...know the plane...know when the flight envelope doesn't quite feel right. That's why airliners have pilots and aren't autonomous drones...the human factor is important. So I would lay more of the blame on Asiana for its training practices than anywhere else. The pilots themselves might indeed be the last line of defense, but who put them in those two seats to begin with? Asiana.
 
silentbob
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 5:12 pm

Quoting JoeCanuck (Thread starter):
with 3 well trained and experienced pilots in the cockpit

Evidently they weren't that well trained if they didn't understand the systems on the aircraft.

Quoting JoeCanuck (Thread starter):
No matter how much automation goes into the cockpit, there is always a chance of misunderstanding or failure. The number one job of the pilot is to fly the aircraft.

Additional automation seems like a bad idea if the complexity of the aircraft was part of the problem.

Quoting ChrisNH (Reply 1):
So I would lay more of the blame on Asiana for its training practices than anywhere else.

Perhaps mandating more training time or requiring a pilot to spend some time in the aircraft as a first officer before operating as a captain in a new type would be an appropriate course of action.
 
kaitak
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 5:17 pm

Quoting JoeCanuck (Thread starter):
Sure, the auto throttles could have had one more mode added to them....but these guys are supposed to know how to fly the plane in case the automation fails...and it actually didn't even fail.....nothing did except the pilots.

It's the same with any piece of automation of electronics; you need to understand what they do and why to get the best out of them. There are 1,200 777s flying today, so roughly 15-20,000 pilots who have gone through training processes, line checks and sim checks, studied all the modes for their oral tests ... and they could do - and still do - the flying just fine. It's a great airplane, but like all great machinery, there is complexity to it. This complexity has a logic to it. They should have understood it.

Quoting ChrisNH (Reply 1):
But the crew is supposed to know these systems...know the plane...know when the flight envelope doesn't quite feel right. That's why airliners have pilots and aren't autonomous drones...the human factor is important. So I would lay more of the blame on Asiana for its training practices than anywhere else. The pilots themselves might indeed be the last line of defense, but who put them in those two seats to begin with? Asiana.

My feelings exactly, Chris. It's down to the airline. And it probably would have helped if the check captain had more experience and the safety pilot was keeping a closer eye on things. There are so many reasons that this accident should NOT have happened.
 
777222
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 5:23 pm

According to the animation in the USA Today article , they weren't ever stabilized on the approach. At some point (5 miles out?) that becomes an automatic go-around, doesn't it? If they had performed the go-around in time none of this happens.
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bhill
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 6:17 pm

Quoting silentbob (Reply 4):
Evidently they weren't that well trained if they didn't understand the systems on the aircraft

Then how in the HELL did they get rated or certified on that aircraft???!!!
Carpe Pices
 
washingtonflyer
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 6:18 pm

How many flight deck crew members were in that cockpit at the time of the crash?
 
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Finn350
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 6:19 pm

Probable cause according to the NTSB

Quote:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.

Source: http://www.ntsb.gov/news/events/2014/asiana214/abstract.html
 
LH707330
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 6:32 pm

Of of the discussion points that came along after AF447 regarding the systems is the question "will changing it likely improve safety or possibly risk unintended consequences?" As far as the FLCH trap in the 777, it may be worth changing that to make sure similar things are less likely to happen. Every accident has a bunch of factors "anded" together, so taking an honest look at each of them and considering the pros and cons of eliminating it is a worthwhile endeavor.
 
747WanSui
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 7:56 pm

I hope Mayday/Air Crash Investigation will produce an episode that discusses this particular accident in detail, especially since they mentioned it briefly in a special episode produced recently. If they do decide to go ahead and produce an episode on this accident, I hope that it airs no later than 2016.
Long live the Boeing 747!
 
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TWA772LR
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 7:58 pm

So its partly the aircrafts fault that the pilots crashed it on a beautiful summers day?
When wasn't America great?


The thoughts and opinions shared under this username are mine and are not influenced by my employer.
 
Max Q
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 7:59 pm

Quoting LH707330 (Reply 8):
As far as the FLCH trap in the 777, it may be worth changing that to make sure similar things are less likely to happen

Not a single other accident has been caused by this 'trap'


If you are aware about what is going on and are a competent, careful pilot you simply wouldn't allow this to happen.
This crew did not meet that standard.
The best contribution to safety is a competent Pilot.


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UALWN
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:19 pm

Quoting Max Q (Reply 11):
Not a single other accident has been caused by this 'trap'

Not a single other accident has been caused by this crew either...
AT7/111/146/Avro/CRJ/CR9/EMB/ERJ/E75/F50/100/L15/DC9/D10/M8X/717/727/737/747/757/767/777/787/AB6/310/32X/330/340/350/380
 
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zeke
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:36 pm

Quoting 777222 (Reply 4):
According to the animation in the USA Today article , they weren't ever stabilized on the approach. At some point (5 miles out?) that becomes an automatic go-around, doesn't it? If they had performed the go-around in time none of this happens.

"stabilized on the approach" is a company standard, I do not know what they use. Where I work it is 1500 ft, I know a lot of US carriers use 500 ft for VMC conditions. The were stable (on profile and on speed) at 500 ft. The newspaper got that wrong.

Quoting bhill (Reply 5):
Then how in the HELL did they get rated or certified on that aircraft???!!!

I have spoken to 777 captains that had over 10 years experience on type, they were unaware that the system would not wake up.

Quoting Max Q (Reply 11):
Not a single other accident has been caused by this 'trap'

However many incidents, including during the 787 certification when being flown by a FAA test pilot prompting the FAA to demand that Boeing change the documentation.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
JoeCanuck
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:41 pm

They didn't need to understand why the plane was to slow and to low. .. They only had to recognize that it was and push the levers forward. ... That's it.

The plane, in no way, tried to prevent them from seeing what was happening or from correcting the problem.

The trap was overconfidence and complacency. .. Not an automation mode.

As for airline training, it's still up to the pilots to make sure they are at least competent at basic airmanship before sitting in the pointy end of the plane.


This was negligence pure and simple. ... And people died. If I take my eyes of off the road and kill 3 people, I go to jail. Maybe I didn't understand how the cruise control worked. ...I still go to jail.

I'm starting to think the Italians may be right.

If I was a family member of one of those who died, I would be bloody upset to hear about lame excuses.
What the...?
 
YYZYYT
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:46 pm

Quoting TWA772LR (Reply 10):
So its partly the aircrafts fault that the pilots crashed it on a beautiful summers day?

No, not according to the NTSB (see the probable cause cited in reply 7).

It would seem that Boeing's sole contribution* was that the complexities were inadequately described in manuals... but that is only one of the contributing causes (and even then, only part of one - since Asiana's manuals are also mentioned).

All of the rest of the causes are related to the airline (training and scheduling) and pilots (more or less as the a.net investigation panel pronounced, on day 1).



* By the way, not "fault"
 
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speedbored
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:47 pm

Before this thread descends into another fanboy vs fanboy sparring match, let's just look at what the NTSB actually said:

Probably cause of the crash:
1) Crew mismanagement of descent during visual approach.
2) Inadequate monitoring by crew of airspeed, and delayed call for go-around.
3) Pilot's unintended de-activation of air speed control.

So, it is the NTSB's judgement that the accident was probably caused by pilot error, pilot error or pilot error.

But, the NTSB say that the pilots were assisted in erring by the following contributory factors:
1) Inadequate description by Boeing of aircraft system complexities.
2) Inadequate flight system training by Asiana.
3) Inadequate visual approach training by Asiana.
4) Inadequate supervision of pilot flying by pilot monitoring. [which IMO equates to pilot error]
5) Crew fatigue.

So the pilots were helped to screw up this landing by Boeing's inadequate documentation, Asiana's inadequate training and by being tired.

For those people who continue to assert that the pilots were incompetent, it is worth noting that one of the NTSB board members is on record as saying:
‘“I personally do not believe this is a case of crew competency,” says board member Robert Sumwalt. “I think this is a case of the pilot flying the airplane expecting the airplane would do something… that it wasn’t designed to do.”

And finally, for those people who continue to assert that the aircraft was faultless, it is also worth noting that among the 10 NTSB recommendations, mostly about improving documentation and training, there is also this recommendation to Boeing:
Modify 777 systems to expand conditions under which autothrottle protects speed.
 
av757
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:48 pm

Automation is anulling basic flying skills and airmanship in pilots.
Training and standard operating procedures (SOP's) require pilots to use and rely on automation thus making them too dependant on the use of automation.
Thus not permiting when conditions permit to manually fly and operate the airplane allowing them to maintain their airmanship skills sharp and proficient.

AV757
 
Chaostheory
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 8:51 pm

Quoting JoeCanuck (Reply 14):
The trap was overconfidence and complacency. .. Not an automation mode.

When interviewed, the pilot flying said he thought (mistakenly) that the autothrottle would still respond. It would seem he didn't fully understand the automation. See below:

The PF was informed that the FDR indicated that speed dropped from 135 to 118 between 500
and 200 feet. Asked whether there was anything from a human factors standpoint that could help
investigators understand how he and the PM might have missed the decrease in speed, such as
being fixated on the runway or assuming that the autothrottle would maintain the appropriate
speed, he said that they should have maintained the speed manually in that case. He said he did
not know. He would have to think about it. He said he believed the autothrottle should have
come out of the idle position to prevent the airplane going below the minimum speed. That was the theory at least, as he understood it.


Taken from the NTSB accident docket Operations 2 - Exhibit 2B, Interview Summaries.
 
Chaostheory
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 9:03 pm

Quoting av757 (Reply 17):
Training and standard operating procedures (SOP's) require pilots to use and rely on automation thus making them too dependant on the use of automation.

777 training is similar no matter where it takes place. SOPs however can be vastly different.

Many US and many EU (LH, AF, IB) airlines encourage manual flight. By manual flight I mean A/P off, F/D off and ATHR off.

In this instance, Asiana did not allow ATHR off.
 
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airmagnac
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 9:41 pm

Quoting JoeCanuck (Thread starter):
it was a clear day with great visibility and a perfectly airworthy aircraft with 3 well trained and experienced pilots in the cockpit

Yes, all was easy and routine...then again, a large proportion of road accidents happen on straight roads, in good weather, and in the vicinity of home or work on roads which drivers know quite well.
So maybe the fact that the conditions were good is not so relevant after all.

Quoting JoeCanuck (Thread starter):
the root cause of the accident was bad flying.

One could call that a tautology  
And as such, it is quite useless statement, as the devil is in the details hidding behind the notion of "flying". This notion covers a complex interaction between aircraft systems and human systems, aka "pilots", this interaction being influenced by external factors such as weather, training, ATC instructions, airline ops SOPs, maintenance status of the aircraft, etc...As in any other accident, the point is to understand how all these things affected each other up to the breaking point. Simply isolating the pilots on one side and the aircraft on the other is useless, as it does not reflect the reality of the situation.

Quoting JoeCanuck (Thread starter):
prevent the pilots from pushing the thrust levers forward, or hitting the TOGA button,

Umm...they did. As one can see quite clearly from the FDR data available on the NTSB website, by the way...

Quoting JoeCanuck (Thread starter):
but these guys are supposed to know how to fly the plane in case the automation fails...and it actually didn't even fail

As you say yourself, it's not an issue of automation failure.
It's an issue of properly transitioning flight control tasks between the automation and the humans. This transition involves both parties, working together. Again, automation and pilots cannot be separated.

Quoting JoeCanuck (Thread starter):
I would rather come up with solutions than apportion blame....usually....but this one goes right on the pilots. Maybe the airline let them slip by with inadequate training or Boeing didn't put the right sound on their warning buzzer...but at some point, pilots have nobody else to blame but themselves.

Who cares ? We all know they screwed up. What I am interested in is not seeing this happen again. If it can be proven that no other pilot ever forgets to check his FMA, an no other pilot ever overlooks airspeed for 10 seconds, then yes, sure, let's blame these guys and move on.
I am however quite sceptical about the validity of those hypotheses I just made. And thus I'd rather have ressources spent on a more in-depth investigation looking at all involved entities, and all potential solutions to prevent a repeat, rather then watch a bunch of grown-ups point fingers at each other and yell "he did it - no he did" like a bunch of 3 year-olds in a sandbox.

Quoting ChrisNH (Reply 1):
But the crew is supposed to know these systems...know the plane

There are lots of systems on an airliner, each different from the others, and every single one of them is complicated. It is not surprising that among all the pilots out there, some can forget about a specific aspect during a period of high workload, even if it is important.

Quoting ChrisNH (Reply 1):
So I would lay more of the blame on Asiana for its training practices than anywhere else

Expanding on what I just said, do you think the problem is exclusive to the training methods used for Asiana personnel ? Or could it be a wider issue with training techniques in general, which have to prioritize the knowledge provided to air crew due to the immensly large amount of information that must be passed on ? Maybe all training organisations are doing this wrong.

Quoting bhill (Reply 5):
Then how in the HELL did they get rated or certified on that aircraft???!!!

Same point as above. Rating and certification do not imply 100% safe and under control, nor does it mean knowing about every last detail of an aicraft. Those thingsz only mean compliance to a set of regulations, which may or may not be adequate.

Quoting LH707330 (Reply 8):
regarding the systems is the question "will changing it likely improve safety or possibly risk unintended consequences?

Yes but as the Boeing person says in the article, and as for AF447 and other accidents, the difficulty with a design change is that there is far more risk of breaking something else, then there is of preventing the same accident from happening again. So it takes lots of time to do such modiications, supposing they are even feasible.

Quoting Max Q (Reply 11):
This crew did not meet that standard.

No they did not, and nobody (not even Asiana) is denying that. However this was not a couple of teenage PPLs, but three pilots with quite a few hours in their logbooks. So once again, can we afford to take the easy route, and just shrug it off as incompetence while supposing that no other pilot in the world will make similar mistakes ? Or do we consider the risk that there may be a more systemic issue here ?
My goal as an engineer is to fill my soul with coffee and become immortal
 
Chaostheory
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 10:02 pm

Quoting airmagnac (Reply 20):
while supposing that no other pilot in the world will make similar mistakes ?

Almost a mirror crash of the TK 737 at AMS.
 
trex8
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 10:12 pm

Quoting UALWN (Reply 12):
Quoting Max Q (Reply 11):
Not a single other accident has been caused by this 'trap'

Not a single other accident has been caused by this crew either...

  
 
Utah744
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 10:42 pm

I always thought of the ATs working just like I if I were moving them. You are very high on approach and you nose over to get back on GS so you'd idle the engines. But as you neared the GS would advance the power levers to allow those huge engines to spin up. With Boeing the power levers actually move so you can anticipate what will happen. I question the pilot flying skills (sorry to be so harsh, but that is the way it is.) As far as IOE goes this would have been a great time for the IP to brief somewhere in that 10 hour flight about setting up a Vnav approach. That way he could have had a pseudo glide slope and the ATs would never been put in a position of trying to slow the plane down near the ground. Back to the real approach, it had GO AROUND written all over it.
You are never too old to learn something stupid
 
Scruffer
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 10:45 pm

Quoting UALWN (Reply 12):
Not a single other accident has been caused by this crew either...

Given that this was the only time that this crew combination has been together that is not a ringing endorsement of the crew.
 
Mir
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:02 pm

Quoting ChrisNH (Reply 1):
So I would lay more of the blame on Asiana for its training practices than anywhere else. The pilots themselves might indeed be the last line of defense, but who put them in those two seats to begin with? Asiana.

Which is a bit strange, because if I'm not mistaken, in Asiana's presentation to the NTSB they emphasized several times the the crew had been told about the FLCH function and the protections that it does not provide.

Quoting LH707330 (Reply 8):
As far as the FLCH trap in the 777, it may be worth changing that to make sure similar things are less likely to happen.

You could do that. But you'd be fundamentally changing the principle behind the system, and when you do that you're opening the door to a bunch of unintended consequences. I would argue that the potential pitfalls of the system are now very well understood, and that the likelihood of this sort of thing happening again is incredibly low. And it's not like the crew were using the system in a phase of flight it was designed or intended to be used for either. If they'd used a different mode on the final approach, one that Boeing had listed in its manuals, we wouldn't be talking about this. So I'd say that the risks of changing the system outweigh the risks of leaving things be and emphasizing proper use of the current system.

Quoting Zeke (Reply 13):
"stabilized on the approach" is a company standard, I do not know what they use. Where I work it is 1500 ft, I know a lot of US carriers use 500 ft for VMC conditions. The were stable (on profile and on speed) at 500 ft. The newspaper got that wrong.

It's quite a stretch to say they were stable. They happened to be at the correct altitude and speed at 500 feet, but in order for the approach to be stable that state has to be maintained. You can't be descending faster than normal with the airspeed dropping off and say "oh, we just happened to be on speed and glidepath at a particular altitude, so we're stable". A stable approach means on speed and glidepath, and in such a position that only small corrections are necessary to keep the airplane on speed and glidepath. You can't be in that position on a standard glidepath if the throttles are at idle.

Quoting speedbored (Reply 16):
‘“I personally do not believe this is a case of crew competency,” says board member Robert Sumwalt. “I think this is a case of the pilot flying the airplane expecting the airplane would do something… that it wasn’t designed to do.”

There was certainly that, but I don't think you can ignore the failure of the crew to monitor the airplane. Expecting the airplane to do something is fine, but when you don't keep your eye on the airplane to make sure it's doing what you expect, that is in my mind an issue of competence. Not competence in the sense of physically flying the plane (I fully believe that if the crew had been told they had to do the approach with no autopilot and no autothrottle they could have done it with no problem), but in the sense of being able to properly manage the automation. We're not talking about anything advanced when discussing the need to monitor the flight path on an approach - that's very basic stuff.

-Mir
7 billion, one nation, imagination...it's a beautiful day
 
LH707330
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:08 pm

Quoting airmagnac (Reply 20):

Quoting LH707330 (Reply 8):
regarding the systems is the question "will changing it likely improve safety or possibly risk unintended consequences?

Yes but as the Boeing person says in the article, and as for AF447 and other accidents, the difficulty with a design change is that there is far more risk of breaking something else, then there is of preventing the same accident from happening again. So it takes lots of time to do such modiications, supposing they are even feasible.

I think we're in violent agreement here, hence my next comment:

Quoting LH707330 (Reply 8):
Every accident has a bunch of factors "anded" together, so taking an honest look at each of them and considering the pros and cons of eliminating it is a worthwhile endeavor.
Quoting airmagnac (Reply 20):
So once again, can we afford to take the easy route, and just shrug it off as incompetence while supposing that no other pilot in the world will make similar mistakes ? Or do we consider the risk that there may be a more systemic issue here ?

It's worth noting that the NTSB said fatigue was related to the accident, as in AF447 and the Colgan crash, inter Alia. There are a high proportion of crashes involving a combination of fatigue, lack of systems knowledge, and improper or delayed reactions to time-sensitive issues. In order to reduce these, it'd be a good start to look at the following:

Fatigue: FAR 117 is starting to fix this, more will hopefully follow

Systems knowledge: not sure if there are simple fixes here, but cleaning up training manuals and human/machine interfaces to simplify user experience would be a start

Improper reactions: more hand flying. David Learmount and others have been crowing about decaying stick-and-rudder skills for quite some time now, and I agree that it's gotten bad, especially among long-haul crews. Although it flies in the face of the "senior crews fly big iron" rule, it might make sense to switch pilots between long-haul and short-haul flying so that the entire pool practices stick-and-rudder skills on a regular basis, and not just a few times a month. Might also make it easier to sub crews, but I confess I've got no experience with that.
 
eastern747
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:13 pm

What!!!! Really??? We knew this at the beginning..Those crews members were not qualified to fly that aircraft. You can't blame Boeing...I just bought a new BMW...so if I drive off and have an accident, do I blame BMW? Hell no! And what about those clowns in the cockpit? They should be arrested, brought to the US and put on trial. How do you crash an aircraft, on a clear day with no weather, perfect day...crew tired! What!!!! Check Captain in the flight deck....But we all know nothing will happen to ANA because of politics. I would say that these crew members should be barred from flying into/from USA.
 
Mir
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:15 pm

Quoting LH707330 (Reply 26):
Although it flies in the face of the "senior crews fly big iron" rule, it might make sense to switch pilots between long-haul and short-haul flying so that the entire pool practices stick-and-rudder skills on a regular basis, and not just a few times a month.

The question is how you do that given the fact that 777s aren't going to be flying short-haul, 737s aren't going to be flying long-haul, and cross-qualifying crews (if you even can do it at all) is both expensive and introduces the potential for other errors to be made. I don't see it working.

-Mir
7 billion, one nation, imagination...it's a beautiful day
 
wjcandee
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:24 pm

Whether or not these fellas "expected" it to wake up, it's absolutely their job to notice that it didn't wake up. Simply having one's hand on the throttle levers would have made that clear.

It's also the PNF's job to be monitoring airspeed.

Critical to me is the fact that these arrogant folks ignored repeated calls of "sink rate" by the human sitting right behind them. But he apparently did not have enough "status" in the cockpit for them to pay attention to him. What counters sink rate? Power. He might as well have been calling out "airspeed".

Yeah. It's the airplane's fault.
 
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flyingturtle
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:46 pm

Quoting EASTERN747 (Reply 27):
What!!!! Really??? We knew this at the beginning..

Well.... really? To me it's the first official confirmation that pilot error was involved. I haven't interviewed the pilots, I haven't documented the wreckage pattern, I haven't looked at the FDR data, so it's quite news to me.

Quoting EASTERN747 (Reply 27):
How do you crash an aircraft, on a clear day with no weather, perfect day...crew tired! What!!!!

Tired people make all kinds of errors. Like me typing "rm -rf /home" and hitting enter in the Linux console. AFAIK we still do not have a published CVR transcript, so I wonder why nobody called out the unstabilized approach. I really wonder about the human factors part of the investigation.

Quoting EASTERN747 (Reply 27):
ANA


O RLY?

 
Quoting EASTERN747 (Reply 27):
because of politics

Which politics? Asiana isn't an airline with a big clout.


David
Reading accident reports is what calms me down
 
sphealey
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:47 pm

Quoting kaitak (Reply 3):
It's the same with any piece of automation of electronics; you need to understand what they do and why to get the best out of them.

Modes are horrifically confusing to human beings, and even the most knowledgeable and capable person with the deepest understanding of the system can get lost in mode confusion and lose situational awareness. That is why all high-performance user interface guidelines recommend reducing modes to an absolute minimum and eliminating them altogether wherever possible.

The arcane terminology and abbreviations - presumably left over from the Dymo days - can't help in this situation either.

sPh
 
N243NW
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Tue Jun 24, 2014 11:50 pm

Quoting ChaosTheory (Reply 21):
Almost a mirror crash of the TK 737 at AMS.

Although the TK crash involved mechanical failure while this one involved a misunderstanding of the aircraft's automation, overall I can see your point about the similarities between these accidents.

I can see Boeing possibly releasing an Alert Service Bulletin for the 777 (just to cover their rears) that is similar to the ASB for the 737 after the TK accident, where the EGPWS triggers an AIRSPEED LOW aural warning well before the stick shaker to help crews notice an impending accident.
B-52s don't take off. They scare the ground away.
 
JoeCanuck
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 12:17 am

Quoting speedbored (Reply 16):

To my mind, expecting the plane to do something it wasn't capable of doing, not recognising that it isn't doing what was exected and not taking control in a timely manner, is the exact definition of incompetency.

Quoting ChaosTheory (Reply 18):

The trap wasn't that the plane didn't do what was expected, it was that the pilots thought that it would always do what was expected..no exceptions, so they were on short final expecting to not have to intervene...ever.

Quoting airmagnac (Reply 20):

Yes, all was easy and routine...then again, a large proportion of road accidents happen on straight roads, in good weather, and in the vicinity of home or work on roads which drivers know quite well.
So maybe the fact that the conditions were good is not so relevant after all.

Just because accidents happen on a clear day doesn't mean the clear day contributed to the accident.

Quote:
One could call that a tautology
And as such, it is quite useless statement, as the devil is in the details hidding behind the notion of "flying". This notion covers a complex interaction between aircraft systems and human systems, aka "pilots", this interaction being influenced by external factors such as weather, training, ATC instructions, airline ops SOPs, maintenance status of the aircraft, etc...As in any other accident, the point is to understand how all these things affected each other up to the breaking point. Simply isolating the pilots on one side and the aircraft on the other is useless, as it does not reflect the reality of the situation.

One could call it tautology, but they'd be wrong. Not only is it not a useless statement, but it has a very precise meaning.

The interactions between aircraft and human are taken care of in basic training....rule one, fly the plane and they were doing, or supposed to be doing, very basic flyng. They are pilots....they didn't do rule one.

Quote:
Umm...they did. As one can see quite clearly from the FDR data available on the NTSB website, by the way...

Indeed....only much too late...much like looking both ways AFTER getting hit trying to cross the street.

Quote:
It's an issue of properly transitioning flight control tasks between the automation and the humans. This transition involves both parties, working together. Again, automation and pilots cannot be separated.

...which is called flying an aircrft. Actually, it was an issue of humans not doing the most basic thing in flying....which is flying. Sometimes there isn't any need to delve into complex human interactions with machines...sometimes it's simple....like this time. Just because planes are complex and humans are complex doesn't mean their interactions must be complex. This interaction merely required looking out the window, seeing you are too low and trying to prevent going lower...before it's too late. I've done it plenty of times.

Simple.

Any pilot that needs to be prompted not to overlook airspeed and /or altitude on short final shouldn't be flying.




Quote:
Who cares ? We all know they screwed up. What I am interested in is not seeing this happen again. If it can be proven that no other pilot ever forgets to check his FMA, an no other pilot ever overlooks airspeed for 10 seconds, then yes, sure, let's blame these guys and move on.

I care. Every time there is a CFIT accident, we try our darndest to discover the deep psychological and/or physiological and/or socialogical causes/contributions/excuses. This accident didn't require anybody checking the FMA....just looking out the window...and maybe, for extra measure, checking airspeed. The FMA didn't cause or prevent anything. That the crew's expectations were so out of touch with reality that they insisted on waiting past the last minute to get on with flying the aircraft...without seeing an obvious trend, anticipating a solution and implementing a solution.

All pilot...no FMA. They weren't even aware enough to realise their own lives were in danger...until much too late.

I am not pointing fingers like a 3 year old in a sandbox, thanks very much. I'm merely cutting through the crap to get to the crux of the matter....which is the plane worked fine....the pilots didn't. The cure is to not take your job of flying a bloody plane full of people who are counting on you not to kill them, lightly...and in doing so, prevent yourself from being killed. Heck, you don't even have to give a damn about passengers...if you'r'e only concerned about not killing yourself, everybody still wins.

A pilot has to do that every time...no fatal mistakes...ever. Sorry....that's the job...nobody made you do it...you accepted that responsibility when you signed up. If you can't handle it, stay out of the cockpit.

But, because of this, Boeing is going to have to redesign their FMA to prevent this type of thing from happening again....(even though it wasn't the real problem in this accident)....which will mean every pilot who has been trained on the current system will have to untrain the old system, train the new system and hope his reflexes don't remember the old system at the wrong time...and how many people will that endanger?



With any accident I try to look at cause with respect to prevention of a repeat. This time...I have no idea what can be done. ...and If saving your own life isn't reason enough to not screw up, I really don't think anything is.
What the...?
 
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zeke
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 12:22 am

Quoting Mir (Reply 25):
You can't be descending faster than normal with the airspeed dropping off and say "oh, we just happened to be on speed and glidepath at a particular altitude, so we're stable".

Yes you can, that is the whole point. After that point where I work it the PM is required then to call out excessive sink/speed/ or pitch changes.

Quoting Mir (Reply 25):
A stable approach means on speed and glidepath, and in such a position that only small corrections are necessary to keep the airplane on speed and glidepath.

Not where I work, nothing about "only small corrections", its all about what it appropriate for the conditions and ATC requirements. Stable for us basically means on slope, fully configured, and landing checklist complete. It does not mean we cannot have thrust at idle or MCT, it does not mean we cannot have higher or lower ROD, it all depends on the conditions and what ATC has asked of us.

Quoting Mir (Reply 25):
You can't be in that position on a standard glidepath if the throttles are at idle.

You should try flying a heavy aircraft with 10-30 kts of tailwind down to 500 ft (pushing 1000 fpm), and then go through positive shear at 100 ft.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
Chaostheory
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 12:34 am

Quoting sphealey (Reply 31):
Modes are horrifically confusing to human beings, and even the most knowledgeable and capable person with the deepest understanding of the system can get lost in mode confusion and lose situational awareness. That is why all high-performance user interface guidelines recommend reducing modes to an absolute minimum and eliminating them altogether wherever possible.

Unfortunately, Airbus and Boeing have both gone down the cockpit commonality path which can restrict improvements to the pilot-plane interface.

They would do well to take pointers from Dassault's falcon line up. It's hard to beat.

Quoting JoeCanuck (Reply 33):
sometimes it's simple....like this time.
Quoting JoeCanuck (Reply 33):
Simple.

Well fortunately for the rest of us, safety minded folk at the NTSB and elsewhere don't see this accident as being 'simple'.

Two experienced pilots with incident free records flew a perfectly serviceable aircraft into the ground.

It's not simple.
 
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par13del
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:00 am

Quoting JoeCanuck (Thread starter):
with 3 well trained and experienced pilots in the cockpit....and the root cause of the accident was bad flying.
Quoting Zeke (Reply 13):
I have spoken to 777 captains that had over 10 years experience on type, they were unaware that the system would not wake up.

What can we take away from this:
1. In 10 years they were fortunate never to have a visual approach?
2. In 10 years they never had the need to use that AT mode?

If this mode is so critical that the NTSB and others think it should be modified how is it that other than the 787 test flight that we have not had much discourse about the design? No opinion on how good or bad it is, but if it is / was that important my thought is that it would have been used much more for its complexity to have caused much more problems, or am I being too simple?
 
Mir
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:35 am

Quoting par13del (Reply 36):
What can we take away from this:
1. In 10 years they were fortunate never to have a visual approach?
2. In 10 years they never had the need to use that AT mode?

If you select the proper modes for a visual approach, you'll never run into the issue. So it's conceivable that they never encountered it.

Quoting Zeke (Reply 34):
Stable for us basically means on slope, fully configured, and landing checklist complete.

Then we have different definitions of a stable approach. Mine has all of that, but also the requirement that the descent path is constant and correct for the conditions, and that the speed is stable and correct for the conditions. Various factors can adjust the tolerances for those - on a gusty day you'd accept more speed deviation than you would on a calm day, for instance.

Quoting Zeke (Reply 34):
You should try flying a heavy aircraft with 10-30 kts of tailwind down to 500 ft (pushing 1000 fpm), and then go through positive shear at 100 ft.

If that's correct for the conditions, then it's not a problem. But they didn't have 10-30 knots of tailwind, and there was no shear. On a calm day like they had, the throttles being at idle all the way down the approach is a significant abnormality.

-Mir
7 billion, one nation, imagination...it's a beautiful day
 
ltbewr
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:35 am

I would add CRM - cockpit resource management - was a factor here. You had more than the usual number of pilots in the cockpit, that may have distracted the PF and co-pilot. You have the possible issue of the all or most of the people in the cockpit who were former military pilots, so you may have conflicts where the more senior former officer may have less clock time in civilian than a less senior one, which has been a problem with KAL and other airlines.
 
airtechy
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:39 am

If you go back and read the past accident reports, most have had a failure on the airplane, bad weather, or both. The two most recent being the AMS 737 crash and the AF 330 crash. I can't remember the last time a modern airliner crashed with no precipitating failure, CAVU weather, and negligible wind. Unless I missed something, every plane that has an autopilot/autothrottle has an on/off switch and when things turned pair shaped they clearly should have used it.

Interesting that we have many airline pilots on this forum who have seem fit not to defend the pilots....wise move. The few that have have no recourse but to somehow blame the airplane.

It's clear that Asiana has some work to do regards training/retraining their pilots. If they are really requiring their pilots to use "automation" to the greatest extent possible, they must not have confidence in their basic flying ability and are setting themselves up for future accidents.

People here always post how great the Asian airlines hard and soft products are in comparison to the lowly US airlines. Maybe they should direct some of that money forward in the plane. I'll take getting there safely any day to better food and wine and shapely flight attendants.
 
AR385
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:43 am

About the three people that died. Well, I guess that´s that if a 777 exit door hits you in the head, but the other two passengers were ejected for not wearing their seat belts. Who on earth does not fasten their seatbelt for landing in this day and age? Is this a common occurrence?
 
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zeke
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:51 am

Quoting par13del (Reply 36):
If this mode is so critical that the NTSB and others think it should be modified how is it that other than the 787 test flight that we have not had much discourse about the design?

Probably because the other incidents happened at an altitude where they could recover once the low airspeed caution or stick shaker activated. The other oddball part of the setup was one pilot had his flight director on, the other did not. Every aircraft I have flown, either both on, or both off. This also changes the A/T behavior.

Quoting par13del (Reply 36):
No opinion on how good or bad it is, but if it is / was that important my thought is that it would have been used much more for its complexity to have caused much more problems, or am I being too simple?

The PF was new on type, probably the first high energy approach he had flown in the 777. Working out "how to skin the cat" is all part of line training, simulators and books only go so far. It takes a while to get a "feel" for an aircraft on how quickly you can configure and reduce speed.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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zeke
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 1:56 am

Quoting airtechy (Reply 39):
I can't remember the last time a modern airliner crashed with no precipitating failure, CAVU weather, and negligible wind.

UPS 1354 into Birmingham, about a month after OZ214.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
Chaostheory
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 2:07 am

Quoting ltbewr (Reply 38):
I would add CRM - cockpit resource management - was a factor here. You had more than the usual number of pilots in the cockpit, that may have distracted the PF and co-pilot. You have the possible issue of the all or most of the people in the cockpit who were former military pilots, so you may have conflicts where the more senior former officer may have less clock time in civilian than a less senior one, which has been a problem with KAL and other airlines.

I suggest you read the NTSB accident docket pertaining to this crash.

In all the witness testimonies I've read, none of them have mentioned CRM as a factor. This is further corroborated by statements made by foreign simulator instructors contracted by Boeing for Asiana.

This is what the FAA/EASA had to say during 787 certification regarding the FLCH trap. Emphasis is mine:

The autothrottle wakeup feature has been considered by the certification team as a system improving significantly the safety of the aircraft to be certified. It protects the aircraft not only against stall but also against low energy states, anticipating on the stick shaker triggering. Unfortunately there are on the B787 (as well as some other previous Boeing models) at least two automation modes (FLCH in descent and VNAV speed in descent, with ATHR on HOLD) for which the autothrottle wakeup function is not operative and therefore does not protect the aircraft. Although the certification team accepts that this autothrottle wakeup feature is not required per certification requirements, these two exceptions look from a pilot’s perspective as an inconsistency in the automation behavior of the airplane. Inconsistency in automation behavior has been in the past a strong contributor to aviation accidents. The manufacturer would enhance the safety of the product by avoiding exceptions in the autothrottle wakeup mode condition.

[Edited 2014-06-24 19:15:00]
 
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SuseJ772
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NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 2:20 am

Quoting flyingturtle (Reply 30):
Tired people make all kinds of errors. Like me typing "rm -rf /home" and hitting enter in the Linux console.

Yeah... that would be bad. Especially if sudo is typed in front of it and out of habit you type your password.   

Quoting Zeke (Reply 34):
Stable for us basically means on slope, fully configured, and landing checklist complete.

I would argue you are "not on slope" in this scenario. Just because you "passed through slope" at 500 feet, doesn't not equate to being on slope.

Quoting Zeke (Reply 34):
It does not mean we cannot have thrust at idle or MCT

I think the issue here isn't whether it is at idle at 500 feet, but WHY is it at idle at 500 feet and what the is the outcome of being at idle for 500 feet. If you you are at idle at 500 feet with a 30 kts tail wind with a shear ahead and on slope, that is stabilized. But if you are at 500 feet, and just happen to be on slope, but at idle and sinking fast off of slope, that should by no means be defined as stabilized just because you lucked out to be at slope at the exact right time.

Quoting Mir (Reply 37):
Then we have different definitions of a stable approach. Mine has all of that, but also the requirement that the descent path is constant and correct for the conditions, and that the speed is stable and correct for the conditions.

I agree with Mir here, even though I usually respect Zeke's opinion above just about anyone.

Quoting Zeke (Reply 42):
UPS 1354 into Birmingham, about a month after OZ214.

You are absolutely right on that one. Also due to fatigue.
Currently at PIE, requesting FWA >> >>
 
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kanban
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RE: NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 3:38 am

The odd thing here is the systems were working as designed and they were unable to recognize the problem created by shutting one component off. What would they have done if one of the systems had failed? Circled waiting for instructions?

Having written Boeing documentation for years, I suspect that it was clear and succinct. However many people tend to want cause and effect scenarios written in as well which leads to more confusion.. i.e. the collision avoidance system merely says "PULL UP, PULL UP".. not " there is a object approaching on an intersect course that you will probably meet in mid air terminating your forward motion, so we would recommend changing your altitude upward when convenient" Manuals are not written by lawyers with layers of blah blah and fine print.

So we add some more warnings and an over-ride to prevent the airspeed from dropping and visual sensors that tell the computer what the pilot can plainly see.. and what happens? Well, the old saying that nothing is fool proof because fools are becoming more ingenious all the time.
 
wjcandee
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RE: NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 3:47 am

Quoting ltbewr (Reply 38):
You had more than the usual number of pilots in the cockpit, that may have distracted the PF and co-pilot. You have the possible issue of the all or most of the people in the cockpit who were former military pilots, so you may have conflicts where the more senior former officer may have less clock time in civilian than a less senior one, which has been a problem with KAL and other airlines.

The exact opposite here. The bunkie was yelling "sink rate", and the guys in the front seats ignored him.
 
dank
Posts: 935
Joined: Thu Jul 20, 2006 11:35 am

RE: NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 4:08 am

Quoting Max Q (Reply 11):
Not a single other accident has been caused by this 'trap'

And not a single other A330 crashed due to blockage of the pitot tubes, yet pitot tubes on A330 and A340s were changed.
 
airtechy
Posts: 735
Joined: Sun Dec 24, 2006 7:35 am

RE: NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 4:17 am

Quoting dank (Reply 47):
And not a single other A330 crashed due to blockage of the pitot tubes, yet pitot tubes on A330 and A340s were changed.

The pitots were already being exchanged before the AF accident. The spec they were designed to did not adequately address all icing conditions.
 
asetiadi
Posts: 233
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RE: NTSB: Plane And Pilots Caused Asiana 214 Accident

Wed Jun 25, 2014 4:23 am

Pilot or Plane error, it doesn't matter anymore. It happened. The more important issue now is, how to prevent this for not happening again. Every system has its flaw. No such thing is flawless. We found 1 now in Asiana crash. Boeing must take a look this matter and try to find a way for preventing this accident. The pilot must be re-trained on how to understand thebsystem better and so on to prevent this kind of accident in the future. We fly safer now because we learnt from the past mistakes, and this accident as well. We have to learn from it. There is no use to blame someone here because they didnt intend to put people in harms away, unless of course if you are a evil bad person. I am sure the asiana pilots are putting the passengers' safety number 1 priority.

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