KSFO 777 incident

[Ed Cesnalis]

We still have to get back to the fact that the Pilot In Command was NOT minding the store...

 

These pilots were not failing to mind the store they failed to realize that they were relying on auto throttles what were set to neutral. The pilots were busy but were failing time and again to notice that they were getting lower and slower, lower than glide path and slower than Vref. They didn't figure out that no power was being applied or if they did figure it out they were reluctant to embarrass the captain who felt he had to fly the approach in spite of his concern that he would fail.

 

At a minimum the captain should have the skills to approach and land and his instructor should have the skills to call a go-around if he isn't going to make the runway.

[Top Cat]

These pilots were not failing to mind the store they failed to realize that they were relying on auto throttles what were set to neutral. The pilots were busy but were failing time and again to notice that they were getting lower and slower, lower than glide path and slower than Vref. They didn't figure out that no power was being applied or if they did figure it out they were reluctant to embarrass the captain who felt he had to fly the approach in spite of his concern that he would fail.

 

At a minimum the captain should have the skills to approach and land and his instructor should have the skills to call a go-around if he isn't going to make the runway.

 

I flew for a major airline. I completed the type rating school for the B767/757. Basically, you walk out of the rating ride qualified on both types, never having actually flown the live airplane, which is normal for airline pilots. The next phase is to complete the LOE or Line Orientated Experience under the supervision of the Check Airman, an FAA Designee.

To those who have not undergone this experience, the pilot goes out on the line to complete the 'checkout'. At my airline it was 25 hours minimum but at some it can extend to months depending on their training structure and philosophy. Even when complete the crew's IFR minimums are reduced for a further period based on the Capt's experience in the type.

 

For me, having done ILS Cat 1, 2, 3a/b, VOR, NDB, ASR, ILS-Loc, ILS-BC, approaches for hours on end it can be quite difficult when presented with a 'visual approach' whereby you require the ability to know when and how to handle energy management, flaps, gear etc without the 'easier' cues you get on an instrument approach. For example, for me, my first landing was a visual approach at San Juan PR to runway 8. Typically, we were vectored onto the extended localizer for the diverging runway 10 ILS as we joined the Lagoon Visual approach. During this we're slowing, adding flaps, then gear, following noise abatement, avoiding the traffic pattern at the small GA field on final, keeping it smooth for the passengers, and looking for traffic whilst keeping enough speed to allow for traffic ahead and behind. Company procedures require the CKA in the right seat to be the pilot not flying (PNF) who monitors the approach and who will intervene in order to maintain safety even in straining environment.

During this visual approach, we're descending within company procedures and by 500' VFR we have to be established in the 'slot' regarding airspeed, flap and gear configuration, height and descent rate. The CKA as PNF will call out anytime parameters are exceeded above/below limits and crew will go around.

Flying pilot will handle the controls and call out as automation is clicked off and other pilot will acknowledge. PNF will have his hand behind the throttles ready to push them up on a GA. PNF is also monitoring speed, descent rate and performance.

At San Juan on the Lagoon Visual to runway 8, the PF has to maneuver the plane late on the approach from descending towards runway 10 to turn left to land on 8, and shift to the PAPI lights on 8 and shifting crosswind, whilst maintaining the same 'in the slot' parameters he had established descending towards runway 10. Usually, the auto-throttles were turned off, and called out as being off, at a higher altitude as it's easier for the PF to finesse the subtle power changes required to complete the approach.

Even though you've flown this same Lagoon Visual before in say a B727, or a DC10, it still requires tuning your skills in order to do it in a new type.

It's not difficult but it's demanding and it requires all your ability, skill and experience to complete it successfully. It's much harder when brand new on type and it demands full crew interaction, with no time for worrying about hurting anyone's feelings. San Juan is typically partly cloudy/sunny and 86F year round, but add night time, a strong crosswind or tropical rain showers and the level of difficulty increases.

It's humbling. As a brand new type rated pilot you wonder why it's hard figuring out just when to start slowing, how much power to usem just when to add flaps etc…hey, you just did a Cat 3b ILS in the sim ride to RVR 600/600/600 with auto throttles and three autopilots engaged!! How hard could it be? Actually, most times it's actually harder.

For me, I requested a few legs in the B757 with the Check Airman just so I wouldn't be walking up for a scheduled flight on the 757 having never 'actually' flown one before despite being jointly rated on both and having completed the LOE on the 767. They're very similar, but do have important differences. I would have been fully legal if I'd not had the requested B757 legs however! By the way, the rating covered the B767-200, 767-300ER, 757-200, and 757-200ER models. Different weights, engines, displays, and important differences in some systems and procedures. The same airplanes…only different!

 

The NTSB will issue it's finding of probable cause. It obviously didn't go the way it should have and there are obvious issues with the PNF not monitoring the approach, especially if the PF was so new to type and was slow in coming up to speed (no pun intended). The automation is supposed to provide tools to make it' easier' for the crew to fly successfully not for them to become such slaves to it, or so dependent upon it that they assume it's doing something when it isn't and then tragically, not being able to see that and react appropriately and in time to avoid disaster.

[FastEddieB]

I don't think pilots should criticize other pilots, especially if they have never flown anything larger than an LSA. Too many people in this country think they know more than someone else, when in actuality, they don't know shit.

 

What he said.

[Jim]

Nice explanation. My brother was a B757 Captain for Eastern when they folded. I don't think pilots should criticize other pilots, especially if they have never flown anything larger than an LSA. Too many people in this country think they know more than someone else, when in actuality, they don't know shit.

 

I know two professional pilots. One, also my instructor, is a captain for Southwest. He's adamant that anyone that's not comfortable with a VFR approach and landing in perfect daytime weather is incompetent. The other, a pilot for FedEx who flies MD11's, was not so quick to judge.

[Doug G.]

Everything I have heard of the incident points to pilot error. (Even the admission of the pilot.) It doesn't take a ton of experience to see that. Is that being judgemental? (Not saying that I don't make mistakes, or that flying a very complex plane is easy.)

[Ed Cesnalis]

At 500' AGL their speed and altitude numbers where not that bad yet but they were rapidly running out of energy and the throttles remained retarded. If there were similar checks below 500' a timely GA would have been more likely.

 

The pilot admitted to embarrassment as being a factor and I realize that by not ignoring this cultural telltale that I am an American racist.

[Top Cat]

When I learn that the pilot needs to monitor the automation to the point where there isn't any deviation from the intended flight path ( I assume this includes deviation from intended airspeed ) I assume it would be easier to hand fly.

 

This is a good point.

However, there is a range of situations with an automated airliner from full-on Cat3b auto throttle, 3 autopilots, auto brakes, auto spoilers landing on a Cat3b equipped runway (which itself requires a litany of lighting, markings, etc), to an automation off approach to an appropriate runway (the airline still requires lights, markings, width, length, slope, surface limitations even for VFR).

Somewhere in here the crew have to knowhow to brief each other as to what they're intending to do, how they're intending to do it and at what level of automation, if any, they're using to do it. As the level of automation changes, then the PF and PNF need to alert each other as to the change and how it's affecting the approach.

Thus, the old saw, 'just hand fly it', only works if both PF and PNF are aware , and acknowledge, that 'hand flying' is what is actually happening. Usually, this simply means calling 'autopilot off' but you could still have auto-throttle. Calling 'auto-throttle off' still has the ability for the auto throttles to engage in the event of a stall or windshear, in some types and models.

You could still 'hand fly' and have auto-spoilers armed along with auto-brakes. So you still have some combination and a level of automation.

 

It's these multiple levels of types of automation which require the verbal interaction of the crew and the 'crew concept' to be applied. You don't know for sure what the other guy is thinking but you do know something by what he calls out or tells you along with monitoring what he says he's doing.

 

In VFR at 500' (1000' IFR) if you are in the 'slot' (airspeed, sink rate, power, altitude, right runway) the you can continue. The PF and PNF have to agree. The PNF then monitors those same parameters all the way to touchdown and calls out deviations. The GPWS provides additional callouts (sink rate, too low, 50, 40, 30, 20, 10 etc). There are a lot of resources available to monitor the flight path.

 

Applying this to GA…I was quite taken aback during my first hour in a FD CTLS checkout as the CFI spent most of the time talking about, and fiddling with, the Dynon Skyview, Garmin GPS, and the other various displays instead of talking about actually how to 'fly' the airplane.

It was interesting to see how much reliance there was on automation at the LSA level of flying too, especially when you could fly this airplane with a couple of round dials under Light Sport rules.

[Top Cat]

Like I said, and as the long explanation from the experienced guy explained. The PIC was still responsible for noticing the plane was low and slow. From the recorder, it appears the guy was busy chatting, and conjecturing, not acting and anticipating.

 

If these planes are too complex to fly, then they should not be in the air.

Reading the transcript I don't see the chatting or conjecture you mention on final approach.

 

There were calls made for being low and for speed although late in the approach. A call to go-around was extremely late.

 

In this LSA forum there are lessons to take away to your day to day flying. Glass cockpits, GPS, Ads-B etc are no substitute for being a pilot, making command decisions and flying the plane.

 

There is a famous saying:-

Aviation itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.

[Ed Cesnalis]

No question, it was a major clusterfuck. Lots of contributing factors leading up to a tragic accident. However, to start jumping to conclusion and even turning it into a racist rant is so American. No wonder everyone hates Americans.

 

What are these contributing factors? The ILS was out and the approach had to be flown visually? Otherwise it was a 10 mile strait in on a clear blue day with calm winds. Is the fact that the pilot programmed the ATs incorrectly and as a result effectively neutralized them while expecting them to activate a contributing factor or just evidence of the crews lack of competence?

 

You point at me and America and cry racism yet it was the captain that pointed out the deficiency and the need to fly an approach that made him extremely nervous in order to avoid embarrassment. SFO simply published a NOTAM they didn't close the runway because the standard, demonstrated by the many other carriers landing without the ILS does not require ILS in good weather.

 

The hundreds of passengers certainly assumed that their flight crew had the same skill level as the other crews in front of them that were doing normal routine landings in good weather without fear of failure. The passengers didn't know that their pilot was scared and motivated by a 2nd stronger fear, fear of embarrassment. Passengers will not board a plane with the knowledge that the pilot is very nervous and lacks the skills to land their flight but must do so despite the risk to hundreds of lives in order to save face. We have seen 757s deadsticked.

 

Fear of embarrassment in a flight crew is a cultural problem that has been mostly rectified, Japan is an example, that fact that it still exists at Asiana doesn't make me a racist but it does put lives at risk.

 

An American would never be embarrassed. After all, we are so exceptional.

 

The western world has a handle on CRM and the history of crashes resulting from avoiding embarrassment lingers in the East.

[Ed Cesnalis]

... I don't think pilots should criticize other pilots ...

 

Why not? Isn't safety more important than avoiding embarrassment? In this case the captain trainee was senior and the unwillingness to criticize the senior pilot contributes to taking the deficient trainee forward in spite of him lacking progress. The cultural barrier prohibits his instructor who is junior to be honest about the trainee's progress and abilities.

[Top Cat]

" Is the fact that the pilot programmed the ATs incorrectly and as a result effectively neutralized them while expecting them to activate a contributing factor or just evidence of the crews lack of competence?"

 

You can't 'program' the Auto-throttles but the cockpit transcript has a double click at one point indicating they might have been disconnected. No call to that effect. Normally, when engaged, they support the speed of the highest bug, then lower, as flaps are lowered. Finally they support the approach speed bug, which was discussed and set by the crew earlier in the approach.

​ Usually, the PNF has his hand behind the throttles guarding the PF whose hand should remain on the throttles, especially if they were disengaged. Not sure if that was this airline's procedure but…the idea is to follow up the PF and the Check Airman would be responsible for ensuring that the trainee was following procedures.

Flying the approach in the 777, the throttles move forwards and backwards with power requirements. I say this because Airbus philosophy is that the throttles themselves don't move physically as much, if at all, beyond take-off setting. I find it hard to fathom why the throttles would be retarded allowing for speed to diminish and the PNF not push them up. Unless the PNF, the check pilot, had not realised the auto-throttle was disengaged and carelessly assumed that the approach bug was 'protected' (the a/t would push the power up to fly the bug speed.)

 

There is no sound of the EGPWS sounding 'too low' or 'sink rate' and no call from the PNF for the same reason, which makes you wonder what he was thinking or doing at this point as PIC. He certainly wasn't calling out the declining airspeed or the, presumably, indications of being too low on the PAPI lights.

The most he said to the trainee Captain was regarding turning off the runway and making different taxi-ways.

[Ed Cesnalis]

Asiana Pilot Set Throttles He Didn’t Understand to Idle

http://www.bloomberg...html?cmpid=yhoo

 

As Flight 214 from Seoul neared San Francisco, it was being flown by Lee Kang Kuk. While descending near the runway, the training pilot entered a series of parameters into the flight-management and auto-throttle systems that made the plane think he wanted to accelerate and climb.

 

To counter the plane’s increase in thrust, he pulled the power back so he could resume his descent, the documents show.

 

Because of the way the auto-throttle had been set, combined with the fact that he had shut off the autopilot, the throttles stayed in the lowest setting, according to the NTSB.

[Top Cat]

Asiana Pilot Set Throttles He Didn’t Understand to Idle

http://www.bloomberg...html?cmpid=yhoo

 

As Flight 214 from Seoul neared San Francisco, it was being flown by Lee Kang Kuk. While descending near the runway, the training pilot entered a series of parameters into the flight-management and auto-throttle systems that made the plane think he wanted to accelerate and climb.

 

To counter the plane’s increase in thrust, he pulled the power back so he could resume his descent, the documents show.

 

Because of the way the auto-throttle had been set, combined with the fact that he had shut off the autopilot, the throttles stayed in the lowest setting, according to the NTSB.

 

If the pilot selected N1/EPR instead of speed (to follow the final approach bug) then it's possible the throttles would be moving forward. You can override the auto-throttle by forcibly retarding them but then, to me, this only exaggerates the lack of input from the PNF (PIC check airman) who should have seen that the trainee was retarding throttles in a decreasing speed/increasing descent situation and pushed them up. Perhaps he inadvertently hit the TOGA (go around) button instead of switching the AT off? Nothing on transcript suggests that though.

In any case,the PNF should also been making the settings the PF required to the speed/power, especially if the auto-pilot was off. The PF should be calling for what he wanted, and the PNF complying, in accordance with crew concept style of flying. The cockpit was instead, quiet.

The PNF should have looking for deviations of a few knots from approach speed, sink rate and monitoring the PAPI lights. In fact they must have been low on the slope and, incredibly, 34 knots below approach sped suggesting that the AT were off, throttles at idle with no inclination of either pilot to increase power to resume and maintain approach speed. At this point the PNF should have taken over and called for a go around, in my view.

 

The article you quoted is a newspaper which says it's own source was the NTSB so things can and do get lost in translation. A 'series of parameters'? Do they mean a number of inputs? The FMS at this point is set for the approach and the missed approach.In any case, the autopilot is off, so you can program the FMS all day long, but unless you or the autopilot fly what you've inputted then nothing changes. The PNF should have been talking to him about not fiddling with the FMS (if this is indeed what happened).

The auto-throttles are either on or off, in N1/EPR or speed. The only thing that would have made it want to accelerate and climb is if the TOGA button was hit, or the auto throttles were adding power because the approach speed was too low. If the PF realizes he's done that, then retards the throttles to idle, and leaves them there, with his hand off, then again the PNF isn't doing his job.

The NTSB said early that the actual sped was considerably below the approach bug speed.

If this was happening, what was the check pilot doing about it?

[Ed Cesnalis]

http://www.cnbc.com/id/101404305

 

Asiana Airlines changing pilot training after US crash

 

...A U.S. hearing into the crash revealed one of the pilots said he did not feel he had the authority to abort a low-speed landing as individuals at a "higher level" had to make that decision,..