The Asiana Airlines Dropped into San
Francisco last year, as it flipped onshore, like a just hooked fish. I am truly
sorry for those passengers and its three fatalities, as it could have been
avoided. Every time we walk, drive or ride in a conveyance, it is a risk. It is
difficult for anyone to accept blame, because a huge price tag looms on the
NSTB decision hanging above the heads of booth Asiana and Boeing. The airplane
maker has more money, hence, the great escape from blame lays before the one
with the most money to be taken. Below is the decision:
The wreckage of Asiana Flight 214 lies on the ground after it crashed at the San Francisco International Airport, in San Francisco.
IMAGE: MARCIO JOSE SANCHEZ, FILE/ASSOCIATED PRESS Through mashable Link further below:
Bloomberg Report link Below:
Pilot Fatigue
The pilots mismanaged their approach to the airport, failed to notice the deteriorating speed and lights near the runway showing they were too low, and then didn’t abort the touchdown, which they were trained to do, according to the NTSB.
Pilot fatigue on the Seoul-to-San Francisco flight also played a role. The crew on the South Korean airline was landing in San Francisco at 3:30 a.m. Korea time, which probably hurt their performance, the NTSB said.
Pilots whose performance was hindered by fatigue made a series of “cascading errors” that began miles away from the airport, Roger Cox, an NTSB investigator, said at the hearing.
An underlying reason for the accident was that Captain Lee Kang Kuk, a veteran of the airline who was being trained on the Boeing 777 wide-body, didn’t realize he had disabled the jetliner’s automatic speed protection system as he was trying to descend, according to the NTSB.
Lee told investigators after the crash he thought “the auto-throttle should have come out of the idle position to prevent the airplane going below the minimum speed” for landing, the NTSB said.
‘More Widespread’
Another Asiana captain, Lee Jung Min, an instructor, was seated in the co-pilot’s seat.
NTSB board member Robert Sumwalt, a former airline pilot, said he spoke to a senior airline training pilot after the accident to determine whether average flight crews understood how the 777’s speed protection worked.
“He said to be honest with you, ‘I don’t think it was widely known at all.’” Sumwalt said. “I think that the problem was a lot more widespread than we may have thought.”
At the same time, the cockpit display showed that the plane’s air-speed protections had been disabled and the pilots should have seen that, Cox said.
“There are plenty of cues in front of you telling you what you have done, but you have to look at them,” he said.
Boeing Controls
Boeing wasn’t absolved in the investigation. The disconnection of the plane’s speed-protection system was listed as one of the causes of the crash. Complexities of that system, which was “inadequately” described to the flight crew, contributed to the accident, the NTSB found.
Chicago-based Boeing has maintained that crew actions caused the accident.
“The airplane and all airplane systems were functioning as expected prior to impact and did not contribute to the accident,” Boeing said in a March submission to the NTSB on the accident.
The 777, the largest twin-engine jetliner, began commercial service in 1995 and has one of the industry’s best safety records, according to Boeing’s annual aircraft accident summary.
While Seoul-based Asiana said in its submission the pilots were at fault, it urged the NTSB to find that issues with the plane’s automation were also to blame.
Incidents with an almost identical auto-throttle issue arose in certification of the Boeing 787, NTSB documents show.
The FAA required Boeing to add a note to the then-new 787’s documentation warning pilots they could lose speed protection under the same circumstances, according to the documents. An FAA test pilot flying the 787 in 2010 said he was surprised to learn that the plane’s speed protection could be lost in some cases. The changes weren’t required for the 777.
However, a hearing
judge rules today following a slippery slope down to Asiana pilots and Boeing.
In this slippery slope, the Boeing 777 falls onto a runway sea wall. Crew
exhaustion, unfamiliarity of flight systems behavior under certain conditions,
and confusion. Those stated reasons make this 777-200 fly into a stall on
approach. The aircraft hits the sea wall flips and ends upright off the runway
where it then burns. Asiana would like Boeing take the blame with a faulty auto
throttle system under certain or special conditions with the autopilot. Boeing
suggest a properly trained crew would know how to fly the 777 in any condition.
An Asiana Air training pilot is on board this flight said, he was not
aware of any special conditions existing in the flight and throttle system, nor
has ever heard of such condition. Boeing says the 777-200 takes another skill
level for pilots coming from former aircraft and Asiana lacks that knowledge.
So forth goes the logic in the hearing.
The final decree from
the NTSB comes from them as they reel off all the counter arguments in a
systematic order. A tired crew, unfamiliar with flight characteristic of 777
auto-throttle and auto-pilot habits, where they did not have enough cognizant
recognition (tired) to do the correct landing procedure after a long flight.
They lack understanding for these conditions, and it falls upon either Asiana
or Boeing through training updates or training procedures. The Asiana
instructor on board didn't have recognition for this vulnerability as he stated
he had never heard of these conditions from other pilots during his career.
Boeing did not broadcast this venerability of a solution in case it
happen. The time frame for this occurrence was in seconds, as it caused
confusion for an unsuspecting or under trained and tired crew. Who claimed,
even if fully trained, they would not have been trained on this condition,
since they were not aware of in the first place. Are you confused yet? I am.
Boeing transfers back at Asiana that intuitively they should be aware of its
flight anomalies from experience and understanding of the aircraft. In other
words, it takes a master pilot to fly the 777 with full competence.
NTSB summarizes, Asiana
fell short in its comprehension of the 777, they were tired and became confused
in seconds and Boeing did not do its due diligence in making sure its customers
were aware of, or trained-up for its systems under all conditions. The
passengers lawyers wonder who pays. After-all that is what is at stake at this
point in time.
Boeing will change its
777 presentation back at the plant, for its customers. They will make systems
work intuitively together in a logical manner preventing a disassociation from
auto pilot from auto throttle. Pilots across the board will have additional
training, and bulletins for this condition. Nothing broke or failed on this
777-200. The crew was confused as often is the case in a "Perfect
Storm". Unaware, tired, and untrained is that perfect storm. Everybody
shares in this mishap equally, including the governing agency's that approved
the aircraft in the first place, since they too failed to detect this
vulnerability in the first place.
Very Good Information
found on Mashable Link:
"NTSB investigators say the flight crew aboard an Asiana Airlines flight that
crashed into a seawall at San Francisco International Airport the morning of July 6, 2013, were to blame for the incident that killed three and left more than 180 injured.
"Automation has unquestionably made aviation safer and more efficient. But the more complex automation becomes, the more challenging it is to ensure that the pilots adequately understand it," NTSB acting chair Christopher Hart said in his
opening remarks. "In this instance, the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway," he said.
The pilot, Operations Group Chairman Roger Cox later added, simply "lacked critical manual flying skills. NTSB investigators announced their findings at a publichearing Tuesday morning, nearly one year after the incident, where they sought to answer the primary question: Why did this airplane crash while landing at SFO on a clear day?
Throughout the hearing NTSB investigators repeatedly returned to the pilot's understanding of automated systems on board the aircraft, with one board member saying the incident wasn't caused by pilot incompetency, but an expectation that the auto-throttle system on board the Boeing 777 “would do something for them that the aircraft was not designed to do.
”The Asiana crash, which occurred on a crystal clear day with light winds, showed that advances in flight deck automation can inadvertently bring down a perfectly healthy airplane. The crash therefore calls into question the layers of automation that are being put into modern aircraft, such as the Boeing 787 and forthcoming Airbus A350 series.
The NTSB found that the pilots had "misconceptions" about the plane's autopilot systems, specifically what the autothrottle would do in the event that the plane's airspeed got too low.
In the setting that the autopilot was in at the time of the accident, the autothrottles that are used to maintain specific airspeeds, much like cruise control in a car, were not programmed to wake up and intervene by adding power if the plane got too slow. The pilots believed otherwise, in part because in other autopilot modes on the Boeing 777, the autothrottles would in fact do this.
The airplane, investigators said, was too high approximately five miles out, and the pilots didn’t effectively monitor its airspeed once the plane dipped below 500 feet on its final approach. Pilots then failed to follow go-around procedure, investigators said, until it was too late — less than four seconds before the plane hit the sea wall.
Despite that rough landing, which was captured on surveillance video as seen above, 99% of the occupants on board the aircraft survived, 98% of the passengers were able to evacuate the airplane and 83% of occupants sustained minor or no injuries, the NTSB said. The plane's frame and seats absorbed the majority of the impact.
Two of those killed were not wearing seat belts and were ejected from the aircraft. One of those ejected, passenger 41E, was run over by fire rigs that had responded to the scene, an incident that "never should have happened," investigators said. Fire fighters initially left that passenger lying on the tarmac believing she was dead — but the NTSB says there was a window of opportunity to perform triage on the passenger.
The NTSB credited the aircraft’s flight attendants for initiating the evacuation, overriding the pilot’s orders to wait.
Senior climate reporter Andrew Freedman contributed to this story.
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