777 crash at SFO

Carbon fiber composites used in F1 are (most likely) not the same as used in aircraft. Different resin systems can greatly alter the behavior. The design criteria are completely different. Gr/Ep used for (787) primary structure will not buckle like a beer can. I am familiar with the design architecture and material systems used on the 787.

 

I think we are picking nits here.

Cartwheels are vertical rotations (like a cart wheel on a cart) of more than 180 degrees.
Spins are usually horizontal or nearly so.

I witnessed a FULL cartwheel of a Rutan LongEZ in a cow pasture during a crash.
The rotation was vertical (like a cart wheel on a cart), 360 degrees, tearing one wing off in the process.

I helped flipped the airplane over after it came to rest.

Yes, the Asiana lifted off the ground and spun around but the word "cartwheel" is a misnomer.

 

There you go!

Seriously, they should have been scanning their instruments. They teach you that when you first get in a plane, and every moment thereafter. It is what you do all the time.

You should at least know your attitude, airspeed, altitude, and heading. You should know the latest information from those instruments every few seconds for every flight at every moment.

If that crew. If one of four of those guys had looked at the instruments regularly there would have been no accident.

Now, who else doesn't know what to do flying around right now!

Is this ab initio crap...

BTW - were the autothrottles active or not... One report says they started moving "all of sudden" like when the pilot took his hands off them, or were they not, in a mode, actively trying to maintain vref at all.

 

I think a better description was 'pirouette' but it surely wasn't graceful.

>8^)
ER

 

From a flag officer friend of mine.

I received this from a friend who is an ex Naval Aviator and retired airline pilot. He tells it like it is!


Subject: Low-down on Korean pilots

enjoy your flight on Asiana..

After I retired from UAL as a Standards Captain on the –400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it’s a minefield of a work environment ... for them and for us expats.

One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don’t think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all “got it” and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.

We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.

This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce “normal” standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this Asiana crew, it didnt’ compute that you needed to be a 1000’ AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn’t pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.

Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested “Radar Vectors” to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then “Cleared for the approach” and he could have selected “Exit Hold” and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to “Extend the FAF” and he couldn’t understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was “Hold at XYZ.” Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).

This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141’s in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!

The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can’t change 3000 years of culture.

The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It’s actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don’t trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don’t get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!

Finally, I’ll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.

Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250’ after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800’ after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real “flight time” or real experience did he get. Minutes! Of course, on the 777 or 747, it’s the same only they get more inflated logbooks.

So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.

 

Wait a moment. This accident was 100% pilot error.

The genius Air France pilot decided to "show off" at an airshow. He turned off part of the automation so that he could get down to 30' (THIRTY FEET!!!!) off the ground over the runway and fly at the slowest possible speed (highest AOA).

Jet engines take time to "spool up" or deliver max power. Our little "show off" waited too long for his Kodak moment and hit the trees at the end of the runway.

The flight computer wouldn't let him immediately pull up because his airspeed was so low that it felt the plane would stall. Now, the plane didn't know it was going to hit trees. It had no idea the pilots were idiots.

If the plane's engines had time to spool up and increase airspeed, the plane's computers would have allowed it to gain altitude.

With all that said, the scarebus has automation that can't be completely switched off. The pilot switched part off.

If this were a Boeing, they could have switched it all off. And, they may not have hit the trees, but been damn close to stalling which the Boeing would have allowed.

Wouldn't you rather the pilot be able to make 100% of the decisions, since the plane's computer didn't know it was about to hit trees.

Finally, don't be a show-off at 30' off the ground flying as slow as possible with trees at the end of the runway and............. forget to add power before it's too late... Sound familiar?

 

OMG.

I will never fly a South Korean airline...

Kai

 

+1. A common, everyday example of this phenomenon is speed dialing. We remember fewer phone numbers because it's easier to remember a single or double digit speed dial number, or can look it up using the search feature on a smart phone, but if we're stuck using an old fashioned phone, we have trouble remembering the actual numbers to dial.

 

Kind of what I was saying a couple of days ago.

 

I didn't realize TheMayor was a lawyer. In that case, there is no doubt-- Boeing was at fault, and Samsung as well. The pilots had nothing to do with it.

 

Don't forget that P&W must be sued, the avionics supplier, the windshield manufacturer, the maker of the seats, the company that laid the rock wall, the runway asphalt layer, the City of San Francisco, the State of Calfornia etc...

I owned a plane that the previous owner had killed himself in another of his plane's by flying into the side of a mountain in IMC. 100% his fault for not following the procedure correctly.

The lawyers wanted to look at my aircraft's log books. Fishing. They were suing the plane manufacturer, the engine manufacturer, the avionics manufacturer etc...

I told them to get back to be with a subpoena, which they never did.

 

Sometimes accidents are very mysterious, and it takes years to figure out what happened, if ever. Sometimes, though, it is obvious within a few hours.

This one was obvious to anyone who had an ATP. Heck, it was obvious to most private pilots.

That is not to say that you shouldn't do an investigation, because there are always underlying factors and things we can, and should, all learn from. After all, if these guys had it to do over, they would have done things differently.

At the end of the day, though, these guys had perfect weather and a fully functional airplane. To crash under those circumstances is negligence, pure and simple.

These guys will probably end up in jail for a long time. Personally, I don't agree with that, but that's how it works in their country.

 

If the weather was say 600 ft overcast instead of Cavok, the accident probably wouldn't have happened. Hard to wrap your head around that....

 

Agreed it was pilot error in this case as well. However, I think Direct Law provides complete pilot controlled flight, including throttle. The pilot in this case was in one of the Alt Law modes which detected that due to the proximity to the ground, they were considered in landing mode.

 

+1

They would have landed safely on the northerly runways instead with a functioning ILS and probably on autoland. But, they would still be a ticking time bomb.

 

Human Factors engineering and automation are becoming and have been a very big discussion. When an adult who knows how to drive car goes away on a trip, they rent a car, and there is no question that the person can operate it at least moderately well. That's because of systems conformity. We know that when we step on the left pedal, the reaction of the car is to slow, in proportion to the pressure applied. When we set the shift lever to D, the car will move forward when the right pedal is pushed, and the round thing in front of the seat can be rotated CW to move right, and CCW to move left.

The basics are there for all aircraft as well, and that's why a person flying a Cessna can get in a Piper and fly it effectively with little or no experience in the new system. The systems have a conformity built into them. Systems and operational conformity was the norm in comm aircraft for dozens of years, and also through the change from piston, DC3 right through the modern jet.

Where things break down, is when an operational system is introduced to advance the mechanical or automation advantage, and there is no conformity. Imagine if we had started out with the car where the steering wheel would be moved CW for a turn to the right, and then some mfg decided that it made more sense to reverse it! Or, if some cars the right pedal would make the car stop, and not the left pedal! Madness ensues.

With advancements in aviation control automation the lack of this conformity is presenting a lot of challenges. One of the early places this was learned was an acronym called HOTAS. Hands On Throttle And Stick. Most all modern fighters from the US today use a complex, but conformed(or mostly so) group of controls on the throttle and the stick to do many functions. Before, to arm weapons, to select targets, to change conditions of the flight controls required removing your hand from the stick or the throttle and making an adjustment, then returning your hand to the control. Now, that is all pretty much system conformed, but not fully integrated so there are some differences.

Both Boeing and Airbus have automation problems in some cases because there is no system conformity. Two sets of engineers have taken a unique track to accomplish the same task(s), but moving from the Airbus to the Boeing requires re-familiarization with controls that need to conform. Even within the same family there is a lack of conformity because new systems come along, and new automation efforts are involved and they require a new systems approach to operation. An example from above would be the pressure to override the autothrottle between the 747, 737, and 777. I have no idea what the deltas are for the hand pressure to inhibit autothrottle but I can tell you that it would be best if they were all the same, say 2.3-2.5Lbs of lateral pressure.

Next, we get into human adaption and human acceptance. Going back to the car example, when we move the steering wheel of a car, there are literally hundreds of components involved in making the car react as we want it to. The wheel is moved by the hand, and then supported by a bearing on a shaft, which is collapsable, which leads to a U joint, and another shaft, and then another U joint, and a rack, with a pinch clamp, sitting on a bearing, in contact with a gear held on with a pin, engaging a toothed rack.... All the way out to the tires, including the pump and valves.

Now, expand this to the systems used to move the throttles on a modern comm plane. No more do we have exclusively hyd pistons, or cables moving things around. We are now, millions of us each day relying on millions of lines of code in thousands of microprocessors to work correctly. Sure, out at the end of the line there's a servo with hyd fluid in it, but the commands are coming from a bunch of silicon chips, and even one small defect in one line of code can wreak major havoc on correct operation. Do we understand it? Not even remotely. Do we trust it? We have to, there is no alternative to operate such a complex set of systems this fast, and this economically. If we still had to rely on hyd servos for this, it would set back automation decades.

Systems overload. This isn't a problem when an operator has time to look something up, or to try successive approaches to solving a problem. Of course, when there's a plane in the air, and it's on final approach, there isn't time to try several different things, and see which works best. You can't stop in the air and test then check each parameter, you need to have a pretty robust understanding of how, when, where, and what is going to happen should you make the systems move by your hand. What does a human do when a flock of birds fly into both engines over a busy city? This is why complete automation will never, ever take over passenger flight. I'm pretty sure that in my lifetime we will see a fully automated flight from taxi to gate. We're not that far away now. However, the humans will be there - as the final check in the sequence and should something like birds happen, for which there is never going to be enough options available, the human has to take over, and manually get it on the ground(or water, as the case may be).

A Brainy New Chip Could Make Computers More Like Humans : 80beats

Finally, all failures, and all mistakes are by reducto ad absurdem operator error. Even if it's not the pilot who would be 100% at fault for operating the system incorrectly, it may be the designer or the engineer, or the technician who worked on it. Airplanes are the product of the mind of man. We forged the metal, we mixed the chemicals, we charged the electrons of all man-made systems. I recall a story about the early training aircraft for WWII. The designer specified that a bolt connecting the ailerons within the wing structure must be put in so that the head was down, and the nut was up with a cotter pin through it. Well, these planes started crashing during training maneuvers, and for the longest time, through 7 crashes and 12 men killed, no one could figure out what was causing it. Finally, one pilot survived and escaped death and said the ailerons locked up tight as he was in a high G maneuver. They went back and inspected the plane, found the bolt was in upside down, and that was binding on a truss member in the wing during flex under G load. After further inspection, they found one old codger at the assembly plant who was sure he knew better than the engineer who designed it, and was putting the bolt in with the head on top, and the nut and cotter pin on bottom. This was the RIGHT way to do it. No one had the heart to tell him he'd killed 12 men by his mistake.

Systems conformity will go a long way to resolving the automation aspect of this current challenge. However, the down side is that automation takes over, the skills needed by the humans become atrophied. I hadn't shot an ILS approach in 20 years, and I did one a few months ago. It was fugly. After four tries, I finally got things lined up so that we were within two bars on both needles. It wasn't easy, and this was just a training flight on a calm day. No way was I going to handle bumps, or a x wind, or a deviation to the standard arrival on the plate. Just no way.

 

^^ great post!

 

That's not what I said at all. Geez.

What I said is to not jump on any preconceived notion of what happened and blame EVERY pilot in the world who had a certain type of training (as some alluded to earlier here) before the facts are in. And, I also said there are usually a variety of factors -- sometimes not the fault of the pilots who eventually made the error -- that could also be the root cause here.

Is that so difficult to understand?

 

This is a great dissertation and that is why Boeing has a Human Factors specialist in PD. It also brings to mind the crash of a Boeing 377 in Puget Sound that was caused by the lack of conformity in flight deck controls. I think that I posted this before but I will add it again. I knew the pilot who put the airplane into the sound when when increasing vibrations after take off made it impossible to maintain a positive climb. The pilot asked the FE if he had closed the cowl flaps and the FE answered that they were closed. Even with max power the airplane was going down so it was landed safely in the Sound with no injuries. When the wreckage was retrieved, inspection of the FE's panel showed that the cowl flap switches were in FULL OPEN position, causing severe turbulence over the tail. The FE had been on DC-7's and had recently transferred to the 377 where the cowl flap switches operated in the opposite direction. Thinking that he was closing the cowl flaps, he was opening them. The cowl flaps on an R4360 installation are huge and are virtual speed brakes when in full open position.

 

By shear coincidence I just landed at SFO on the runway exactly next to the crash. A couple of observations

It's weird seeing every piece untouched and exactly as it ended up. Of course, the investigation is going on but it's sort of like a moment frozen in time. You don't expect to see it all so perfectly preserved. There was no one there this morning when I arrived at 8:30.

A 777 normally looks huge -- but not this one. It looks so much smaller now (and that's not a joke). But without the engines, the tail, and sitting on the ground the plane looks small.

The plane did not make it very far down the runway after the tail hit. It must have had a tremendous loss of momentum. Of course, it spin around 360 and I'm sure that helped but it didn't seem very far from the sea where it finally came to rest.

 

Nobody is blaming every pilot in the world. The blame rests squarely on the pilots in this plane. If the root cause was something else, other pilots would also be crashing perfectly functional planes in perfectly good weather.

Exactly.

Mayor, earlier, you told me to go cry a river, even though the only one whining on this thread and refusing to accept blatantly obvious facts is you. Maybe it was ghosts. Maybe it was a fraying cable due to an invisible bird strike. Or maybe, obviously, it was pilot error. Pilot error due to unfamiliarity, due to not being questioned or challenged by fellow crew members, pilot error due to memorizing the correct answers rather than developing critical skills, pilot error due to a failure to stay ahead of the airplane, whatever...it was pilot error.

Preconceived notions? Really? Geez indeed. Take some flying lessons. You can take off and cruise in your first lesson. Landing takes a lot of tries. See how many times the instructor drums it into you to monitor and call out speeds on each of the legs. When you put your car on cruise control, do you close your eyes? Why would you not monitor airspeed even if you assume that auto-throttle is engaged? It is a basic, basic lesson to monitor your plane's critical indicators at all times, and ESPECIALLY during landing.

 

Here's a case where an effort at conformity failed. The early Beech Bonanza has an Aluminum switch panel along the bottom of the inst panel. All the flight control switches are on there except the key and starter. Most planes have the gear switch in the shape of a wheel and it's closest to the pilots knee. The flap switch is generally further to the right or in the middle. In the old Bo, the gear switch is the same as all the others(conforming), and it's further to the right, and the flap switch again is a polished Al unit just like the gear and it's near the pilots knee. Plenty of gear up landings in the old Bo before Beech started putting a little raised Icon on the switches, and finally moved them where they 'belong' and formed them like the flight control they operate.

Back to the issue at hand, I'm in serious doubt that the autothrottle was not working nominally, it's just that some process flow inhibited them from working(pilot action or inaction). Also, selecting autothrottle on a visual appr when you are hand flying the approach with only the PAPI just seems so wrong. But - I don't fly big iron, so I don't know. I was ultra careful in my little Bo to screw a Hot Wheels cute little wheel on the switch to operate the gear, never had a problem.

 

Please re-read post 29.


As to the complete blame on the pilots, I'm not convinced yet. There may have been a human factors problem in how the autothrottle settings are set. Sure, they should have known better but it is possible that there's an issue here that also led to the crash.

Nothing ever is as easy and simple as it seems.

 

you win

 

Interviews with the pilots, cross-checked with flight data recorder information, shows the pilots thought they had auto-throttle engaged, which they did not, and that airspeed got as low as 103 knots on final approach. Lucky they did not end up with the nose stuffed in the sea wall and a corresponding much greater loss of life.

Do you airline pilots actually use auto-throttle on approaches? Seems like surrendering a lot of control during a critical phase of flight to this old military flyer.