An expensive reminder of the basics

July 10, 2013 by Bruce Landsberg

airplaneThe Asiana Boeing 777 accident at San Francisco is the news happening of the week. Pundits, bloggers, and all manner of experts/pseudo experts—present company included—are holding forth on what happened or might have happened. This accident serves as an expensive and tragic reminder about the importance of basics and why things are done in certain ways regarding aviation safety. My sense is that there will be very little new that comes out of this that we didn’t already know years before!

I’ll confine my observations to the more salient points. Feel free to comment, as I know you will. The usual disclaimer: Until the accident is completely investigated my comments must be regarded as speculative and subject to error.

At this writing the facts appear to be that the aircraft stalled/mushed into the sea wall just short of the runway at a high angle of attack and low airspeed. Why?

  • Transitioning pilots are often not “one” with the aircraft until they have acquired significantly more time to learn its nuances. Even though the captain was highly experienced in heavy jet aircraft, he was a newbie to the B777.
  • The instructor pilot was also new to his role and, unless some significant mechanical problem is discovered, will likely have a contributing role for failing to properly supervise the new captain.
  • One of the biggest possible factors is complacency: “I’ve done this a thousand times. How hard could it be?”
  • The pilots reported to the NTSB that the auto-throttle failed to respond. Automation (auto-throttles in this case) must always be treated with caution. It’s typically more reliable than we are but must be programmed correctly and the programming should always be verified and monitored. “Set it and forget it” is a recipe for surprise and occasional disaster.
  • The culture in many countries defers to authority and experience. Even when the senior person is wrong it’s tough and may be career-limiting to say that the emperor is wearing no clothes. Some senior pilots and organizations are unenlightened that they just might be subject to the occasional human failing.
  • The pilot monitoring needs to monitor the main thing. In this case that would be airspeed, configuration, and alignment. If it’s not working, speak up, and if it’s not corrected, take appropriate corrective action. A bruised ego is far better than a busted aircraft!
  • Stabilized approaches are always a good idea, and the bigger the aircraft, the more important it becomes. For light aircraft we recommend that everything be stable at no later than 500 feet agl.
  • Finally, if something looks funny or weird it probably is, and that might be a great time to do something different rather than waiting to see how it plays out.

I welcome your comments!

Bruce Landsberg
President, AOPA Foundation

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22 Responses to “An expensive reminder of the basics”

  1. John Lowe Says:

    Apparantly, the PNF (the Instructor) was not calling out airspeed and altitude. Thought that was key in CRM with multiple pilot crews. What happened to the mantra “High / Low, Fast or Slow”?

  2. Brian Turrisi Says:

    With the advanced age of automation, as pilots we cannot forget that basic fundamentals still matter most and that the pilot is the final monitor and over sight of all the automated systems.
    On any landing in any sized aircraft, a key element to monitor is airspeed. regardless of what “auto mode” a plane is in, the pilot(s) still must not assume the auto system is so good that looking at the airspeed is not necessary.
    There was a long period of time (at least 34 seconds) between the time airspeed fell below 137 and when it hit the sea wall. Plenty of time to react but they did not until the last 1-3 seconds when too late. Why?……

  3. Wael Hassan Says:

    I am a newbie private pilot , does heavy aircraft pilots have to choose a PGP like we do in a single engine aircraft? Or do they totally rely on the autoland advanced avionics in a VFR approach? I was in a flight between Alex and Cairo in an A380 and I can swear that the pilot landed in the second third of the runway that he had to push the breaks to hard to get the plane to stop. And of course he missed all the taxi ways and had to do a 180 on the runway that proved my theory.

  4. Bruce Landsberg Says:

    Wael….

    To my knowledge, the guidance is the same. On long runways they have “the touchdown zone” which is marked appropriately along with a 1000′ fixed distance marker. That’s the target point. Go much beyond and obviously the energy wasn’t being managed properly.

  5. John Scherer Says:

    For Jumbo aircraft (I flew C-5′s for almost 20 years on and off), the aiming point is 1500 feet (past the fixed turbojet aiming point at 1000 feet) This is for the threshold crossing height. In the C-5, we were requried to cross the threshold at 50 feet. This kept the rear landing gear–which were about 200 feet behind me in the cockpit–safely over the threshhold. On three bar vasi systems, we used the far two vasi’s for aiming to keep the TCH at 50 feet. If you aimed at the threshhold in a C-5, you would be in danger of putting the aft main landing gear in the overrun. In any event, the Air Force mantra was: aviate, navigate, communicate.

  6. Gregg Says:

    Energy management (EM) and situational awareness (SA) always apply. Flying/Crew flight time in the B-777 does not supercede basic EM and SA. What has not been discussed is the cultural paradigm of “saving face”, which needs to be subordinate to EM and SA in crew resource management (CRM). The last time I checked, being “politically correct” does not supercede “Fly the airplane. Collect your wits; maintain aircraft control. Aviate, Navigate, Communicate.”

  7. Alan D. Resnicke Says:

    During my days as an Instructor in the USAF, we worked hard not to schedule ‘new’ with ‘new.’ Most of my early Instructor rides were with experienced crew, not brand new pilots. Conversely, when I gained a few more Instructor hours, I took on newly-minted students or upgrade pilots. A new instructor along with a new captain is a human factors mishap looking for a location (in this case, SFO).

  8. Wayne Padgett Says:

    The Asiana crew simply had too many toos.
    Too low.
    Too Slow.
    Too Late!

  9. Robert Chapin Says:

    Yes, it is likely very little new will be learned. I think one of the main lessons will be recognizing the opportunity for better warning systems. If the approach is not stabilized, the airspeed is too low, and the altitude is too near the TDZE, then the airplane could advise a go-around before it’s too late. The 777 hardware is already capable of it, with probably just a software modification needed.

  10. Eric Says:

    I’m a GA pilot but have never had the privilege of flying professionally; I have, however, been fortunate enough to fly in the jump seat on several corporate maintenance flights in Gulfstream GIV’s and GV’s. I noticed on every flight that the non-flying pilot called altitude and deviation from target airspeed all the way down to touchdown beginning at 1000 or 500 feet – ie “400 minus 2, 300 plus 3″, meaning “400 feet agl, 2 knots under target airspeed, 300 feet agl, 3 knots above target airspeed”. I assumed this was standard practice for all commercial operations and I use it when I flight my small airplanes on final. This practice certainly would have saved Flight 214.

  11. Wayne Padgett Says:

    After learning the details of the approach my question is; why weren’t the 2 highly experienced captains, with many hours in heavy AC, unable to visually determine, in time for correction, that their approach path was too low? Anyone?

  12. Ricardo Says:

    It seems that airline approaches are often flown on autopilot, including auto throttle. If that was normal for this crew, I can imagine that the lack of glide slope info could have caused some confusion. I wonder how much practice crews do get in fully manual approaches.

  13. Bruce M. Curtis AOPA 484898 Says:

    I’d add a few things. First, not all hours are real flight hours; Asiana, like most intercontinental carriers, has as policy, engaging the autopilot as soon after liftoff as practicable, and used until established on final. In such instances, a transpacific pilot may spend 14 hours in the sky, but only 3 minutes hand-flying the aircraft. When crewmembers rotate through the cockpit on long haul flights, an individual pilot may not get even one takeoff and one landing, per flight.

    Boeing 777s are revered as kittens to land, yet as a passenger in a 777 of another Korean Airline, I recall an arrival that would have made a pre-solo student blush. The day was gorgeous wind-calm VFR, yet the flying pilot still managed to set the aircraft down with such ham-handed awkwardness that we blew a tire and nearly departed the runway. Rustiness is a real possibility where hand-flown takeoffs and landings are rare as IRS admirers. A long-haul first officer might have thousands of hours logged, yet have very little actual stick-and-throttle time in low-level turbulent terminal airspace. The way we log hours must be changed to reflect the real-world recurrency benefits they bring, or don’t bring.

    Then there is faith. Not the religious kind, but unquestioned dependence on automated systems and navigation. This is a new-tech sort of dilemma, but it’s safety-critical: trusting misadjusted automation opens up marvelous new ways to end the day in a noisy and destructive manner. New century fault modes between human and mecha, (apologies to the movie, Artificial Intelligence) need to be understood and quantified so they can be fixed and training amended invoke the kind of healthy skepticism that makes pilots frequently monitor the basic vitals; airspeed, altitude and heading. New crew training that highlights likely automation complacency scenarios needs to be integrated in both initial and recurrent crew training.

    Sounding the alarm about automation complacency displacing stick and rudder skill isn’t being Chicken Little; the crash of Air France Flight 447 over the Tropical convergence zone east of Brazil has been linked to faulty hand-flying skills. Investigators believe that when the Airbus A 330 lost airspeed data due to icing, the flight crewmembers weren’t able to synthesize the data they had left to understand and compensate for the failure. Flight recorders indicate the widebody aircraft was held in a stall and rode it from the flight levels to the ocean below.

    Maybe Asiana flight 214 was a timely reminder that every pilot should stay stick-sharp, not just those of use who lovingly caress that yoke, down low, with blue above.

    Bruce Curtis
    ATP/CFI, A, I, ME, Gold Seal

  14. Graeme Smith Says:

    Talking it down worked for these guys:

    04 06 43 06 LMP 700, 21 down, 33 degrees.
    04 06 43 08 CDR Pretty rocky area.
    04 06 43 l0 LMP 600 feet, down to 19; 540 feet, down to 30, down to 15.
    04 06 43 24 CDR Okay.
    04 06 43 25 LMP Okay, 400 feet, down to 9, 58 forward.
    04 06 43 31 LMP 350 feet, down at 4 – 330 – 6-1/2 down. We’re pegged on … velocity.
    04 06 43 44 LMP 300 feet down, 3-1/2, 47 forward. Coming up – 1 a minute, 1-1/2 down. Moving out.
    04 06 43 55 LMP 270.
    04 06 43 57 CDR Okay, how’s the fuel?
    04 06 43 59 _ Wait Just a minute.
    04 06 44 00 CDR Okay, Ed, this looks like a good area here.
    04 06 44 03 _ I got the shadow out there. 250, down at 2-1/2, 19 forward.
    04 06 44 ll LMP Altitude velocity light, 3-1/2 down, 220 feet; 13 forward, ll forward, coming down nicely. 200 feet – -
    04 06 44 23 CDR … – -
    04 06 44 25 LMP 5-1/2 down, 5-1/2 down.
    04 06 44 27 CDR I got to get …
    04 06 44 30 LMP 160 feet, 6-1/2 down – 5-1/2 down, 9 forward.
    Still looks good. 120 feet.
    04 06 44 43 I24P 100 feet, 3-1/2 down, 9 forward. 5 percent – …
    04 06 44 50 CDR Okay.
    04 06 44 53 IAEP Okay, 75 feet. And it’s looking good; down a half. 6 forward; light’s on. 6 – 60 feet down, 2-1/2, 2 forward, 2 forward.
    04 06 45 13 LMP Looks good. 40 feet down, 2-1/2. Picking up
    some dust. 30 feet, 2-1/2 down – straight down; 4 forward, 4 forward, drifting to the right a little.
    04 06 45 26 LMP 20 feet, down a half; drifting forward Just a little bit. Good. Okay.
    04 06 45 41 CDR SHUTDOWN.
    04 06 45 42 LMP Okay. ENGINE STOP; ACA out of DETENT.
    04 06 45 43 CDR Out of DETENT.
    04 06 45 45 LMP AUTO MODE CONTROL, both AUTO; DESCENT ENGINE
    CO_ID OVERRIDE, OFF; ENGINE ARM, OFF; 413 is in.
    04 06 45 52 CDR ENGINE ARM is OFF.
    04 06 45 58 CDR Houston – Tranquility Base here. THE EAGLE HAS
    LANDED.

  15. David Eberhardt Says:

    one of your points: “» Stabilized approaches are always a good idea, and the bigger the aircraft, the more important it becomes. For light aircraft we recommend that everything be stable at no later than 500 feet agl.”

    I’ve taught students in T-38s in the Air Force and fly Piper Cherokees and Cessna 172s these days. I can’t imagine student pilots having “everything” stabilized at 500 feet AGL. Besides, light single engine aircraft are constantly changing flap settings during a typical rectangular traffic pattern. A better idea is to have some safe tolerances built in; such as airspeed +15 and no lower than -5 from target approach. I would use about 100-200 feet as a go-around altitude if airplane is not stable for VFR SEL training. CFI need to let their students learn BUT not go too far ! Always has been a difficult gray line to draw.

  16. James Thurber Says:

    I’m a former Navy pilot / Natops officer and my opinion about Asiana Airlines 214 is unprintable. Leave it for me to say the flight deck crew should have been arrested and charged with three counts of homicide and multiple counts of assault. Alas, these cockpit criminals have already fled to Korea and will get away with it. Sorry to be blunt but if you can’t master basic aviation what in the living daylights are you doing at the controls of a 777?

  17. Bruce Landsberg Says:

    David…

    Thanks very much for your comments. The gray line in instruction ( and that was happening in this case) has to have a red line below it that will not put the aircraft in any jeopardy, especially when there are other than essential flight crew on board.

    I absolutely agree that students will be working it all the way down and that is part of their learning what “good” is but there’s that judgment thing on teaching when an approach has become unsalvageable. Not so good to allow them to “attempt to save it” when the risk is rising rapidly.

    Would love to hear some other thoughts – pro and con.

    Many thanks

  18. Robert Ellis Says:

    I had a young student this morning on her 2nd supervised solo say on the radio during the third circuit that she was making a go-around. I could see that she was too high (not unusual on a rare calm day in Kansas). Out grass strip is 2600 feet long with power lines at both ends so there is not a lot of room for “slop”. After she landed I complemented her on making a wise decision and not trying to “get it down” just to save face. As you know there have been many accidents by pilots that think they “have to land” after every approach. I had given her a print-out on stabilised approaches just two days ago. When we were getting the plane out she asked what I thought happened to flight 214 and I said it looked to me like “too low and too slow” and no stabilised approach.

  19. Dan McCarthy Says:

    I find it hard to imagine a flight instructor sitting idly by while a student pilot screws up an approach, in VFR no less, with a full load of trusting passengers. If ‘saving face’ were the issue, and I were doing my job, I’d get around that by saying, “why don’t I make this landing due to the unforeseen complications, lack of glide slope, and high speed request from ATC”. Or, ‘le’me bring in some power (the engines were heard, too late, at full power, a few seconds prior to the crash) since we have the flaps all the way down and we are getting behind ‘the power curve’ very low out here over the water’. What ever happened to basic ‘stick and rudder’, God forbid, we ever get inverted.
    I have heard-thru the aviation grapevine- of ex-pat flight instructor, simulator operators, being fired for flunking foreign -one being the Chief pilot- pilots on the six-month checks.
    But wait, there’s more: Southwest, landing LaGuardia today, 7/23/13, pranged a nose wheel. It looked, to me, on the video, that they drove into the runway without flaring out. Some bystander was heard to say, “it looks like their first landing”. I’m sad for all of them, especially for the dead and maimed.

  20. Pranesh Dey Says:

    There is a lot of alarm over rusting stick-and-rudder skills as pilots become over-reliant on automation. My case is, the allegation doesn’t apply to the Asiana crew. The 777 was in the landing phase, when crews are accustomed to handflying the aircraft. The general perception now is, pilots depend too much on automation and don’t want to handfly. Nothing could be further from the truth. I believe airline policy promotes automation dependance because it improves aircraft ‘performance’ in a complex technical environment and boosts bottomlines.

  21. Robert Chapin Says:

    Bruce, David, I have some thoughts about your comments on, “working it all the way down”. I typed them up on my blog. In a nutshell, neither 500 feet nor 100 feet works for every situation.

  22. Richard Weil Says:

    With less than 300 hours I’m certainly no expert, but our glider club has several heavy jet pilots who say they joined to enjoy “real flying.” I know it’s not always possible, and maybe not necessary, but if folks who flew just heavy jets were encouraged to do an occasional dual in a sailplane, or a simple GA ship, maybe this would give them a good reminder of the basics. This would have to be presented in a very positive way so no one felt insulted. But perhaps it would help as a fun review, especially for those who weren’t CFIs. Don’t see how it could hurt.

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