Asiana 777 crashed on landing at SFO

[BEfly]

Who wants to bet the industry will learn nothing from this, save for maybe the actual professional pilots who understand this stuff?

I know it's still too early to speculate but the NTSB is putting out information about this accident faster than I've ever seen via twitter and other means so I think it's fair to at least start considering what may have occurred. My observations thus far:

- not surprising, Asian cockpit techniques... over-reliance on automation. Inability to actually fly an airplane. Volumes have been written about this issue. Yet the Asians quite regularly tell us Westerners to mind our business when we try to suggest they change their ways. I have personally seen this in India, Japan and Korea. Lots of trivial "make-work" cockpit stuff they do which takes attention away from flying the aircraft. If I had a nickel for every time I heard "You Americans think you know everything... " when working for various carriers in these countries.

- IOE. I've always thought IOE was a pretty risky event as it is. I recall years ago when a check-airman literally talked to me all the way across the Atlantic... all night long. Unreal. How much aviation crap do you have to cover? I was worn out before we even got to TOD. The approach was a blur. In fact I recall my neck being kinked from turning towards him as if to show I'm interested. If I knew then what I know now I would've told him enough is enough. It's impossible to cover it all in 25-40 hrs of IOE. Just show the student how to land and shoot approaches. It will take him or her another 300-1000 hrs to get comfortable with the airplane. That's just the way it is. Someone needs to start telling checkairman that it doesn't make them a bad instructor if they don't talk the whole flight. Cover a few items, yes. Maybe give some pointers on the arrival, approach and landing. But enough with the "let me show you how much I know" technique. Then again, maybe it's 180 degrees different in this case. Maybe the checkairman wasn't giving enough input, clearly not at the critical moments, if this Captain was elder and senior to him.

50% power when you're 35 kts below target speed? Are you kidding me?

- The dumbing down of aviation. Both Boeing and Airbus have strived to make today's aircraft dummy-proof. Which is why you see certain people hired into this profession because of who they know, rather than on their skills and competence. The conventional wisdom has become, "anyone can be trained to fly these things". Well, apparently not when things step outside of one's comfort zone. Even at my airline I see a few of pilots who lack basic airmanship skills. Look at all the posts on all the web-boards talking about what to do if the A/T does this or that. Who cares? Turn the auto-throttles off and fly the airplane. IMO, this should be a requirement. But I know that will never happen.

-Fatigue. These guys were landing a jet after a grueling 11 hr flight at their WOCL. No doubt they were probably awake for 16-18 hrs save for maybe a short nap on the airplane. They were sleep deprived and fatigued. No doubt about it. The fatigue issue was probably amplified if excessive instruction was being conducted across the Pacific. All of the contributing factors to fatigue will be probably be brushed under the rug.

At the end of the day, the so-called "experts" like that talking parrot Schiavo, or the annoying "aviation buff" Richard Quest, and the whole host of non-pilots who have zero idea about how we do our jobs will push for recommendations of further automation, more IOE, whatever.

The reality seems pretty simple, barring any MAJOR engine anomalies, these guys forgot how to fly an airplane likely due to a career defined by automation in the cockpit. Pretty stupid if you ask me. This and the Asian hierarchy variables has always been pretty well known and those of us who have witnessed it have always warned of it's dire consequences.

Good post

 

[gutshotdraw]

As with most accidents, I'm guessing we'll discover an error chain combining numerous factors that resulted in all the holes lining up.

Long flight and possible fatigue.
Non-Standard ILS due to glide slope OTS.
Low experience level in type.
Lack of understanding or inappropriate use of automation.
Cultural distortion of CRM.
Training deficiencies in basic airmanship.

Accidents are rarely born of one monumental screw up. After three days of information, this unfortunate incident strikes me as a classic compounded error chain.

 

[IBNAV8R]

An excellent point. The flight began in Shanghai, stopped in Seoul and ended in San Francisco. It was a four man crew, nevertheless that's a very long time to spend with a check airmen giving you the beady eye.

Not to mention they were landing about 0330 on the home clock.

 

[waveflyer]

Good posts Dan roman and why me worry.

The trend in the industry has been less hand-flying and more automation. Solo time reduced in exchange for dual on the initial level. (Judgement development hindered.) looking for technical solutions instead of pilot ability solutions. AB initio programs. I got my commercial license with well over 200 hours- flight instructed at a school pumping them out with 130. Less and less required. Now Garmin 1000's from day one. Less and less focus on stick and rudder-sight picture- and feeling the plane in your ass.

How many of us fly with pilots right here in america that would struggle taking the jet and spot landing it w/ no papi and instruments covered? When did we begin to believe that was acceptable?

I was taught by my mentors to hand-fly one leg a trip from mid teens descent to landing INTO the busiest airport you got. No FD, no ILS, as appropriate- have your partner up on all that - but practice the basics where you actually get work- 10,000' decel, decel to flap speeds, config changes and multiple vectors, level offs and descents- if you're comfortable doing this easily- ie: nuts on and could have a conversation- then you're good- if you'd been a bit lazy w/ it and its challenging HAND FLY MORE.

I've had two airlines that were having ASAP issues blowing through altitudes while hand-flying. The response? Memos to keep the autopilot on. "Dont be a hero" Have had captains tell me to put it on bc Having it off increases their workload.
That's the exact backwards thing to do IMO. Hand fly more- just use your judgement on where until you're back mentally miles ahead of the jet.

The powers that be are trying to move to single pilot ops, as a step to no pilot ops, and ab-initio/MPL programs- This accident seems to be the danger of that-

Handfly more guys. Voluntarily take away your glideslope help. Spot land w/o the help. Encourage your peers to do so wisely as well.

That's a good reminder regardless of final outcome here-

But I do hold out hope that the pilots were dealing with something greater than it appears like now- there will be lessons here no doubt.

 

[HA25]

I'm surprised no one has made the observation that perhaps fatigue was a major issue? A 10 hour flight is pretty grueling, 10 hours of IOE? These guys could have just flat worn themselves out. Even worse, from what I hear about Asian carriers, the training can be anal overkill with not enough focus on common sense and tremendous focus on very strict procedures that are not to be deviated from. Which in turn, makes non standard situations, like no G/S, sidestep approach, and starting the approach high and fast as is common place at SFO, more difficult when you try and replace good airmanship with an overly strict focus on procedures.

Bottom line is though, if (and I emphasize IF) the instructor quizzed and hammered on this guy all the way across the Pacific, he could have set themselves up to try and land when they were at a level of fatigue that was very dangerous.

I'm wondering if the environment in the cockpit may be a big factor. Were they working as team to land the airplane or was the check airman more concerned about judging the IOE candidate and withholding his support?
It may be politically incorrect, but I've heard too many stories of Asian Carrier instructors that are incredible tyrants and have an unhealthy focus on hierarchy in the cockpit. 10 hours of that could wear anyone down to an unsafe level.

Smartest observations in the whole thread.... I'd expect nothing less from you "Dan"!

too much armchair QB from guys who've never flown a leg longer than 5 hours in here... On it's face it looks odd that they got that slow at the end of the approach, especially with a check pilot on board (an assumption)... but wait for the final findings and then you can roast them for incompetence.

 

[humveedriver]

Good posts about the cultural differences at the Asian carriers. I wondering this will put any pressure on those carriers to create a more open environment in the flight deck? Hand flying, should be called hands off flying. Because if you are doing right, you shouldn't look like you are trying to churn butter with the yolk. An airplane on speed, pitch and power flies great with no autopilot or constant pilot input.

 

[Boxboy]

Smartest observations in the whole thread.... I'd expect nothing less from you "Dan"!

too much armchair QB from guys who've never flown a leg longer than 5 hours in here... On it's face it looks odd that they got that slow at the end of the approach, especially with a check pilot on board (an assumption)... but wait for the final findings and then you can roast them for incompetence.

I agree. Pilot error? Likely but we all need to remember that this can happen to ANY one of us. There were other causal factors that none of us here on this forum are aware of. It's pretty damn easy playing Monday morning quarterback.

 

[humveedriver]

I agree. Pilot error? Likely but we all need to remember that this can happen to ANY one of us. There were other causal factors that none of us here on this forum are aware of. It's pretty damn easy playing Monday morning quarterback.

So true. You have several thousands of hours of experience in jets. Made thousands of landings. Then one day, it doesn't work out the way it has every time before. Why? Perfect weather and from mx perspective good airplane. Obviously there is more to the story. They were doing training and tired. Maybe the intstructor said "I got it" from altitude to get down to G/S and then told the new Capt he could have it back. And the message got lost. All we know for sure is the airplane got more than 10 knots slow on short final and no one pushed the throttles up. Maybe they both got into a microsleep, which I think is a possibility.

 

[Capn Butthead]

GutShot I agree with what you said 100%. We are slowly being forced to quit flying the airplane. This is the problem that happens when accountants and lawyers dictate how we fly the plane...until an accident happens, and I'm not just referring to this one.

On the hand flying note...I do it every leg usually to the mid 20s and off at 10000...I'm not doing it to be a hero...I'm doing it because I'm bored and because I still enjoy it (novel idea). But because of that I feel really comfortable if something happens. I just flew with a guy who didn't want to fly into a short strip because the HUD was deferred. So I did it. I understand why he wasn't comfortable..I truly do. But it proves your point. Systems fail and you better be able to fly the thing. And like you I have guys say that I'm increasing their workload by hand flying. My response is if this increases your workload you need to retire...what are you going to do when it all fails and it's up to you???

 

[jonjuan]

G I just flew with a guy who didn't want to fly into a short strip because the HUD was deferred. So I did it. I understand why he wasn't comfortable..I truly do. But it proves your point. Systems fail and you better be able to fly the thing. And like you I have guys say that I'm increasing their workload by hand flying. My response is if this increases your workload you need to retire...what are you going to do when it all fails and it's up to you???

So, you're saying a SWA plane would have diverted to a longer runway if you hadn't been there to save the day due to the HUD being inop?

 

[dicko]

. I just flew with a guy who didn't want to fly into a short strip because the HUD was deferred. So I did it.

He's going to a stroke out when he sees Key West.

 

[Capn Butthead]

Juan....that's funny! Let me pick myself up off of the floor.

No I'm not saying that. I'm saying he did not like having a HUD...if you're used to having something it sucks when you don't have it. I'm fat and out of shape so I'm used to having a hamburger...if I can't get it, I'm not going to work. I've never used a HUD in my life so it's more my norm than what others are used to. We have to stick with what we are comfortable with...but I think as pilots that's where we get trapped. We are creatures of habit...I know that I am...but that's my point and Gutshots point...we need to mix it up and keep ourselves fresh.

 

[gutshotdraw]

My little corner of the aviation world offers a bit more operational flexibility than many airlines. Even though we have the largest fleet in the corporate/fractional world, for the most part our management doesn't legislate technique (so far, thankfully). That is a luxury many airline pilots do not have.

That means a lot more hand flying (the FUN part of this job) and the right to ignore the magic box, the x-ray vision HUD/EVS, and the other Captain Billy Whizbang gadgetry if it doesn't make sense at the time.

Our greatest challenge is being prepared for 7000 different airports from Aspen to Aruba to Angor Wat. That is also our greatest blessing because it helps prevent the inevitable complacency that can creep into some cockpits.

I do worry about some of the international products of ab initio programs and a single-minded focus on nothing but SOPs, airline operations, and slavish devotion to the magenta line.

Combine that style of training with a steep authority gradient of some foreign cultures and relative lack of "out there on your own in the sky" experience and it becomes apparent how something like this could happen.

Worse yet, there is no easy solution.

 

[Flopgut]

You've got to be able to fly the airplane. You've got to be able to fly the airplane. You've got to be able to fly the airplane. It can not be stressed enough. However, an airport like SFO should have a functioning ILS. On a global level, perhaps it's time we all insist that pilots get ALL the tools we need to do the job. I'm talking correct pitot tubes, functioning ILS approaches, investment in ATC systems, etc. I think we are starting to drift away from some safety issues we used to understand better.

 

[Flyer1015]

The whole reason the glidepaths were OTS was to accomdate a displaced threshold to add a runway safety area as mandated by the FAA.

 

[Flopgut]

The whole reason the glidepaths were OTS was to accomdate a displaced threshold to add a runway safety area as mandated by the FAA.

I hear you. Might make sense to have a runway safety area. Except when you might contribute to an accident in the process of building it.

Time to take a good look at how the FAA, airports, ATC etc are doing business. When your airport CFR runs over a survivor, you need to look at the big picture.

 

[Flyer1015]

I hear you. Might make sense to have a runway safety area. Except when you might contribute to an accident in the process of building it.

Time to take a good look at how the FAA, airports, ATC etc are doing business. When your airport CFR runs over a survivor, you need to look at the big picture.

Agreed. Could you imagine surviving an airplane crash only to be run over to death by a CFR truck? If that's not a 'Final Destination' type death, I don't know what is.

 

[redflyer65]

I hear you. Might make sense to have a runway safety area. Except when you might contribute to an accident in the process of building it.

Time to take a good look at how the FAA, airports, ATC etc are doing business. When your airport CFR runs over a survivor, you need to look at the big picture.

Flop,

You are exactly right. No oversight for actual safety.

 

[Old School 737]

Absolutely pathetic if they came up short with the displaced threshold give me a break the runways plenty long even with the Displacement... No need to land on brick number 1 .., I'm sure Fatigue is going to be huge issue.. As it is training and the ability to actually fly the airplane !! 30knots slow !!!!give me a break..,. It's 2 bad ... Feel bad for the hurt... And deaths ..

 

[Whine Lover]

Just had an event where the Heading Knob jammed up....No big deal, right?

Yup.

Try having the autopilot intercept an ILS when you cant select the Heading.

You wind up with F/D OFF, or erroneous Lateral Nav information which you must ignore, and a lot of hand flying into NYC airspace at a critical time.....after an Atlantic Crossing and a 12-16 hour Duty Day.

It happens. It sucks. It isn't pretty.

BUT, it's "Do-Able" if you hand fly now and then....Or, better yet, spent the first 20 years of your Career doing so.

Ab Initio, Push Button "Pilots" might have some trouble with this....I know I did after the last 10 years of automated Boeings.

Thank God for the first 20 years of having to "Do It For Real".




YKW