Asiana crash to reopen sensitive questions on etiquette, automation
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                                                                  Asiana crash to reopen sensitive questions on etiquette, automation         
     On a seemingly routine visual approach on clear late morning over 
San Francisco, a 
Boeing 777-200ER flown by 
Asiana Airlines  started an approach that began too high, descended too low, swerved off  the centreline and, in the final, crucial moments, slowed to nearly a  stall.
 The resulting crash on runway 28L that killed two  passengers and sent more than 180 to the hospital triggered a US safety  investigation that promises to reopen sensitive questions over crew  resources management, automation, air traffic management and culture.
 The  experience and working dynamic between the pilot flying, captain Lee  Gang-guk, and the pilot monitoring (but still in command), Lee  Jeong-min, is already a major focus for investigators. Lee Gang-guk had  recently transitioned to the 
777 from the 
Airbus A320, while Lee Jeong-min was flying as an instructor in the 
777 for the first time.
 Perhaps  reviving distant memories of South Korean pilots and a culture of  deference to authority, the US National Transportation Safety Board  (NTSB) also wants to know whether Lee Jeong-min and the relief first  officer present on the flightdeck suppressed voicing any concerns to Lee  Gang-guk.
 "We are certainly interested to see if there are any  issues where are any challenges to crew communication," says Deborah  Hersman, NTSB chairman. "We will be looking at those relationships as we  move forward."
 Investigators will also look at a series of  complications with the automated systems designed to make the pilots'  job easier, but appeared, in this case, to flummox and confuse the crew.
 First,  a deactivated glideslope indicator - due to construction at the airport  - forced the crew to fly a non-instrumented approach, which appeared to  make them uncomfortable. According to Hersman, the pilot monitoring -  and not the pilot flying - realised they were coming in too high on the  glideslope as the aircraft passed through 4,000ft (1,220m). 
 In  an attempt to correct the mistake, the crew - working in vertical speed  mode - set a descent rate of 1,500ft in the flight director, which  corresponds to an unusually steep descent rate.
 The next  automation problem appeared after the steep descent from 4,000ft put the  aircraft too low on the glidepath. Neither the pilot flying nor the  pilot monitoring noticed that they were too low until passing through  500ft and approximately 35s away from a normal landing. The pilot flying  said in interviews with the NTSB that he was temporarily blinded by a  flash of light from the ground, which Hersman says is being  investigated.
 "We really don't know what it could have been," she adds.
 The  pilots however were already flirting with disaster. Many airlines  require pilots to be in final landing configuration and on the  glideslope as the aircraft passes through 1,000ft. The Asiana 777 had  already passed through 500ft and was low on the glideslope, but the crew  did not break off the approach.
 As the crew attempted to pull  the nose up and regain altitude, the aircraft also yawed off the  centerline of the runway, forcing the pilot flying to make quick lateral  corrections at the same time as he was trying to ascend.
 At this  point, another automated tool caught the crew off-guard. As Lee  Gang-guk, the pilot flying, raised the nose up, the pilot monitoring  later told the NTSB that he assumed the auto-throttles were still  engaged.
 The auto-throttles were either inhibited as a result of  the selected operating mode, turned off unknowingly by one of the crew  members or had somehow failed. Neither pilot advanced the throttles to  compensate for the vertical corrections, which appeared to cause the  aircraft to bleed off speed from 137kt (254km/h) down to a low of 103kt  within 3s from impact with the seawall. 
 The NTSB is still trying  to understand the complexities involving how the autothrottle operates  in the different operating modes of the 777. 
 "In the last 2.5  minutes in the flight, we see multiple autopilot modes, and we see  multiple autothrottle modes," Hersman says. "We need to understand what  those modes were - if they were commanded by the pilots, if they were  activated inadvertently, if the pilots understood what the mode was  doing."
 The status of the autothrottle system, however, may not  relieve the pilots of blame for losing track of the airspeed as it  departed from the reference of 137kt. Moreover, some 777 pilots are  trained in simulators to catch inoperative auto-throttles on approach  and successfully execute the approach or go-around. 
 The lack of a  glideslope indicator to enable a stabilised approach is also not likely  to be a probable cause, as airline pilots are expected to be able to  hand-fly a routine visual approach to an 11,000ft runway.
 Like  the automation issue with the auto-throttles, however, the NTSB wants to  understand what role - if any - the air traffic management tools played  in the crew's decisions that morning. The NTSB has asked the US Federal  Aviation Administration to provide data on all of the missed approaches  to runway 28L since 1 June, when the glidescope indicator was  deactivated to begin the three-month construction project.
 It is  still early in the investigation, but so far, neither the Asiana crew  nor the NTSB has found any reason to blame the Pratt & Whitney  PW4090 engines on the seven-year-old aircraft for failing to maintain  the aircraft at the reference airspeed. The crew had plenty of power  available, but it was not summoned until it was already too late.
 Unless a fault is detected upon further analysis, that likely means that the incident is not a repeat of the 
British Airways Flight 38, which crashed landed short of the runway at 
London Heathrow  airport in 2008. In that non-fatal incident, an unusually large number  of ice crystals that formed in the fuel clogged a heat-exchanger on a 
Rolls-Royce Trent 800 engine.
 As  the Asiana crew faces questions about actions before the crash, they  are also under scrutiny for the decisions made immediately afterwards.  Despite a crash that ripped off the tail of the aircraft and spun it in a  violent 360 degree circle that cracked a rib of the reserve first  officer in the jump seat, the flightdeck initially told the lead flight  attendant to keep passengers seated rather than immediately evacuate,  Hersman says.
 The order from the flightdeck was rescinded only  after a flight attendant came forward from the middle section of the  cabin to report that the No. 2 engine was on fire. But the passengers  and crew lost 90s of evacuation time before video reviewed by the NTSB  showed the cabin doors finally opening and the slides deploying. 
 "The  pilots indicated [to the lead cabin attendant] that they were working  with air traffic control," Hersman says, adding that the flightcrew was  not fully aware of the fuselage damage when they gave the order to keep  the passengers seated.
 Another key subject of the investigation  will be the crashworthiness of the seats and the integrity of the escape  slides. Although the fuselage sustained two massive impacts and stayed  mostly intact, two of the escape slides somehow deployed inside the  cabin. One of the slides pinned down a flight attendant, who was the  last person on the aircraft to be rescued as flames began to consume the  interior of the fuselage sidewall, Hersman says.