
Sequence of Events in the Cockpit on Asiana Flight 214 - yurisagalov
http://fearoflanding.com/accidents/sequence-of-events-in-the-cockpit-on-asiana-flight-214/
======
marvin
Is there anyone with airline pilot experience who could come with some
detailed analysis of this? To me, I would hazard a guess that whomever was
controlling the airplane was unaware on short final that the autothrottle had
been deactivated. This is consistent with pulling back on the control column
to maintain altitude, an action which will give in the desired result when the
autothrottle is engaged, but must be accompanied by manually increasing
throttle otherwise. This is an elementary piloting mistake, which I believe is
impossible to do in the Airbus since the fly-by-wire system will prevent you
from placing the aircraft in a stall condition. So this might be consistent
with the information that the captain was transitioning from the Airbus to the
Boeing. However, I would be surprised if the investigation doesn't provide
additional details about the human factors among the flight crew.

I guess the biggest question I'm left with after this is how professional
pilots can make this kind of elementary piloting mistake: Not watching the
airspeed on final approach, and not reacting immediately when the PAPI
indicates that the aircraft is too low. I was left with the same kind of
question after the Air France disaster; this plane was stalled straight into
the ocean from cruising altitude. It's a big mystery to me how three pilots
could overlook this condition for four minutes. Maybe this is just the kind of
fluke accident that will happen sometimes when you have ten thousand airliners
in the sky every day. But it seems like a good idea to investigate whether
pilots rely too much on the computers and forget the basics.

Regardless, let's not draw any conclusions until the investigation has had its
say. It's okay to speculate, but I feel that it doesn't provide a lot of
benefit to go into detailed scenarios when the complete picture is unknown.

~~~
ars_technician
I agree; however, the Air France incident you are referring to is when the
airspeed indicator was locked due to a frozen pitot tube, wasn't it? That
seems like a much less blatant failure on the part of the pilots.

~~~
md224
You may have already read this, but if not, this is an incredibly chilling
reconstruction of the events leading up to that crash:

[http://www.popularmechanics.com/technology/aviation/crashes/...](http://www.popularmechanics.com/technology/aviation/crashes/what-
really-happened-aboard-air-france-447-6611877)

Key excerpt from halfway through:

"Another of the pitot tubes begins to function once more. The cockpit's
avionics are now all functioning normally. The flight crew has all the
information that they need to fly safely, and all the systems are fully
functional. The problems that occur from this point forward are entirely due
to human error."

Really tragic.

~~~
hatbert
Right, but how does the cockpit crew know that they airspeed indicators are
working correctly now? They don't.

------
babesh
The pilot depended on automation to fly the plane. When put into a situation
where it was not available, he crashed it showing insufficient piloting skill.
That someone with this lack of skill was placed in this situation shows
institutional failure.

~~~
mikeash
Agreed. I can't fathom how a person who self-described as "very concerned"
with doing a visual approach got into the cockpit of a 777. That's the sort of
thing I'd expect from a fresh student pilot who spent too much time playing
with the ILS in his flight simulator.

~~~
johnw
Alright, but how do you explain the instructor who had 3,200 hours on the 777
who was sitting beside the pilot not making any mention of a too low airspeed
or incorrect landing configuration right up until it was to late? Makes me
wonder if there was some ambiguity in the instrument display or procedures for
neither pilot to make mention of any problems.

~~~
mikeash
The pilot expressed his concerns about performing a visual approach to his
instructor before the flight. The instructor let him fly anyway instead of
instantaneously grounding him and saying, "WTF? This is Piloting 101, go get
your shit together."

The instructor let this person fly when he was lacking such a basic skill, and
that the instructor came from the same system that allowed this incompetent
pilot to attain command of a large airliner. This to me indicates that the
system is broken and there's no reason to think it couldn't produce an
instructor who was also completely useless at performing a visual approach.

------
JHof
I've spent time conducting basic flight training for international students
(including Korean) and am now an airline pilot. Though I don't have much
experience with international operations, what I saw as an instructor is
freshly minted pilots going back to their home countries and immediately being
put into the right seat of an airliner. Many of these students were very poor
pilots, however, as long as they have the money, the flight training machine
that exists in states like Florida will keep training them, and international
airlines will continue to hire the product. It's a matter of national pride
for many countries to be able to employ their own citizens as pilots. Many
will cease learning as soon as they leave flight school due to the poor
training environments that exist in some places.

Going from a small prop plane to an airliner is perfectly acceptable. It's
been going on for a long time and can produce safe pilots, but those pilots
need to understand basic stick and rudder flying and continue to hone their
skills. Unfortunately, many get started using the automation and allow their
flying skills to atrophy. This is true for long-time airline pilots as well.

In the US, by the time a pilot has reached the cockpit of something like a
777, they've gained quite a bit of experience flying smaller prop planes and
regional jets, which require a little more work on the part of the pilot. The
visual approach assigned to Asiana Flight 214 is a non-issue to US airlines.
It's a routine, every day occurrence that doesn't cause one to become "very
concerned", however, many countries choose to focus their pilot training more
on managing automation than flying the aircraft, and I think that cultural
difference played a big part in this crash.

Talk to a US airline pilot who has worked with a training department
internationally. The stories you'll hear are pretty eye opening.

~~~
js2
[http://philip.greenspun.com/flying/foreign-airline-
safety](http://philip.greenspun.com/flying/foreign-airline-safety)

~~~
JHof
Good article. In the US and some other places around the world, you'll find
pilots who are equally capable of flying automated Airbus type aircraft as
they are 1960's style cockpits using old fashioned radio navigational aids. I
take pride in my skills and ability to operate an aircraft safely.
Unfortunately, what I know seems to be becoming a lost art, and the state of
the piloting profession internationally will likely speed the process of
automating pilots out of the cockpit. It's sad, and I've become pretty keen on
learning a new skill in preparation for the demise of my job.

------
squirrel
If you found this article interesting you might also want to read Normal
Accidents
[http://en.wikipedia.org/wiki/Normal_Accidents](http://en.wikipedia.org/wiki/Normal_Accidents)
which details many similar accidents in planes, ships, nuclear power plants,
and more. The author proposes a model for identifying complex, tightly coupled
systems in which operators have little chance of avoiding error. The parallels
to operational failure in complex, tightly coupled software are evident (at
least they seem so to me).

------
mmaunder
[http://www.reddit.com/r/flying/comments/1srp6a/cockpit_voice...](http://www.reddit.com/r/flying/comments/1srp6a/cockpit_voice_recording_of_asiana_214_released/)

~~~
trimbo
"captain @, @ had too much herb medicine and his liver numbers are too high"

and then

"It's absurd it works at Air Busan, but not in my company"

Note to self, never flying Air Busan.

------
ash
"Due to the potentially disturbing nature of the surveillance video we are
about to show, we will pause for a moment to let [people?] exit the room if
they choose." (9:22)

Is it the standard warning for these hearings?

~~~
lukeholder
I assume family could be present?

------
gilgoomesh
The insistence of aviation and naval industries to continue using knots for
speeds is infuriating.

I can forgive the fact that the article uses U.S. customary units instead of
SI but the article gives distances in miles and altitudes in feet and needing
to convert knots into feet per second or miles per hour as you read is awful.

~~~
ubernostrum
The knot is now defined in terms of an SI unit (1 knot = 1 nautical mile/hour,
1 nautical mile = 1852 meters), and the nautical mile is accepted for use
internationally by BIPM.

Its continued use is due to the fact that the nautical mile is the average
length of one minute of arc along a meridian, which allows easy correction,
when measuring distances in nautical miles, for the distortions of
representing the non-flat Earth on flat charts.

Or, more simply: there are sometimes good reasons for using a unit other than
"look how easy it is to move decimal points".

~~~
hudibras
Or to put it another way: a nautical mile is equal to one minute of latitude
and 60 nautical miles equals one degree of latitude.

I've seen many people become amazed when it's explained to them that a
nautical mile is not just an archaic, arbitrary unit of measure, like a
hogshead or furlong. Part Two of this explanation is to tell them that the
metric system unit of distance, the meter, was also originally based on the
earth's size. Ten million meters (or 10,000 km) is the distance from the
equator to one of the poles.

------
damian2000
The pilots attempted to go around at the last second, when it was already too
late - if the pilots had not attempted to go around, i.e. not piled on the
throttle at the last second - just wondering - would the crash have been as
severe?

~~~
imsofuture
It would have been worse^. Throttle response is far from instantaneous (jets
spool relatively slowly), and any speed that they did manage to gain
contributed greatly to lift and almost certainly lessened the force of the
impact.

Throttling up a plane for a go around is not at all analogous to stepping on
the gas while crashing into a brick wall.

^ total speculation

------
rckrd
Forgive me if I'm a little behind, but is the official consensus that this was
a human error? That the measurements were presented correctly to the crew and
that a veteran pilot wouldn't have made these mistakes?

~~~
lisper
I don't know if it's the consensus, but that's certainly how it looks to me
(PPIASEL - private pilot instrument airplane single engine land). Complete and
utter incompetence. The Koreans are actually notorious for this.

[http://blog.rongarret.info/2013/07/do-not-fly-asiana-or-
kal....](http://blog.rongarret.info/2013/07/do-not-fly-asiana-or-kal.html)

~~~
dba7dba
wow, stereotype much?

~~~
PhantomGremlin
Why do you glibly dismiss it as a "stereotype"? Did you read the post that
prompted him to write that? It was preserved on HN:
[https://news.ycombinator.com/item?id=6025525](https://news.ycombinator.com/item?id=6025525)

That post discusses in detail exactly what is wrong with the training culture
in Korea. Do you have any knowledge or experience to dispute the post? Can you
come up with something more enlightening than the 3 word reply "wow,
stereotype much?"?

BTW this criticism of flying culture in many foreign airlines isn't just found
in this one post. Read pprune.org and you will find many many similar stories.
Are all those people posting simply making things up?

I don't think so.

~~~
jpatokal
And this post demolishes Gladwell's theory rather thoroughly.

[http://askakorean.blogspot.com.au/2013/07/culturalism-
gladwe...](http://askakorean.blogspot.com.au/2013/07/culturalism-gladwell-and-
airplane.html)

~~~
lisper
So what? Just because some author advanced a flawed argument does not change
the fact that Koreans account for a greater share of aircraft accidents caused
by pilot error than could be reasonably accounted for by random chance. Just
because an argument is flawed doesn't mean the conclusion is false.

~~~
jpatokal
The link I posted notes that 3 of the 7 crashes where Gladwell blames "pilot
error" were actually caused by being shot down by the Soviets (x2) and being
bombed by the North Koreans (x1). Which pretty much removes the statistical
anomaly of Korean airlines having more accidents.

~~~
lisper
Look, we all agree that Malcolm Gladwell is an idiot, so the fact that he
cites bogus data contributes nothing to the discussion. Happily, we don't need
to rely on Gladwell's data. Korean air lines have had so many incidents and
accidents that there's a whole wikipedia page about them:

[http://en.wikipedia.org/wiki/Korean_Air_incidents_and_accide...](http://en.wikipedia.org/wiki/Korean_Air_incidents_and_accidents)

"Korean Air had many fatal accidents between 1970 and 1999, during which time
it wrote off 16 aircraft in serious incidents and accidents with the loss of
700 lives. The last fatal accident, Korean Air Cargo Flight 8509 in December
1999 led to a review of how Korean cultural attitudes had contributed to its
poor crash history."

So for 30 years, KAL was crashing planes at the rate of about one every other
year. The situation did improve after the review, but there was still an
unintended off-runway landing in 2007, and of course the SFO crash (which is
not mentioned in the article at all -- someone needs to go update it).

------
ars_technician
It brings up an interesting conundrum. The more that pilots use autopilot for
approach, the less feel they have for what the controls should feel like at
the correct airspeed. However, if we just outright ban auto-pilot for
approach, there is more room for human error...

~~~
MBCook
I'm not a pilot, but the ability to set the throttle to idle (including all
auto-controls) while the plane is in the air without warnings seems dangerous
to me. It sounds like a better indication that there was no thrust may have
helped the pilots recognize the error sooner.

~~~
imsofuture
It's not unbelievable using idle thrust in the air. It's inexcusable to not
watch your air speed though.

~~~
MBCook
That's my thought. I can think of a few times where it might make sense,
mostly to burn off speed or altitude; but if you're that low and already under
the suggested approach speed it seems like it's almost certainly a mistake.

I'm surprised they had to get so low before the stall warning system kicked in
(given the speed and throttle position).

