Incidente 777 Asiana a SFO


Asiana Airlines acknowledged for the first time that the "probable cause" of the fatal crash in San Francisco last July was its pilot flying too slow, according to documents federal investigators released today.

However, the airline also said "inconsistencies" in the Boeing 777-200ER's autothrottle contributed to the crash. The airline's positions submitted earlier this month were part of hundreds of pages of documents the National Transportation Safety Board will consider while investigating the crash that killed three passengers and injured more than 200.

Asiana said the plane's navigation equipment "led the crew to believe that the autothrottle was maintaining the airspeed set by the crew" and instead the equipment "disabled the aircraft's minimum airspeed protection." The airline also said test pilots had trouble landing under the same conditions in simulators.

But Boeing, in its submission to NTSB, said the plane and all its systems were functioning as expected before the crash and "did not contribute to the accident." The 39-page Boeing filing said Asiana pilots should have aborted their landing 500 feet off the ground as stated by the airline's own policy because of numerous cues that the plane's speed was lowering, the thrust setting was incorrect and the plane was flying too low.

"This accident occurred due to the flight crew's failure to monitor and control airspeed, thrust level and glide path on short final approach," said the filing from Michelle Bernson, Boeing's chief engineer for air-safety investigations.

The Asiana and Boeing documents are just two parts of what the NTSB will consider as it determines the probable cause of the crash and any recommendations resulting from it. Investigators hope to finish the case before the anniversary of the crash July 6.

Asiana Flight 214 slammed into a seawall at the end of the runway in San Francisco before spinning around, breaking into pieces and burning. Three passengers died in the incident, one of whom was run over by a fire truck, and more than 200 were sent to hospitals.

NTSB investigators earlier revealed that the plane was traveling lower and slower than intended when it struck the seawall. The plane was traveling about 119 mph, despite a goal of 158 mph.

But NTSB Chairman Deborah Hersman has said generally that even if there was confusion about how equipment worked, pilots are obligated to monitor their equipment and pay attention to their surroundings, to prevent crashes. She drew no conclusions yet about the Asiana incident.

At a December hearing of the NTSB, investigators said the flying pilot, Lee Kang Kuk, was landing for the first time at San Francisco. He had spent just 43 hours flying the 777, although he had clocked 9,684 hours on a variety of other jets. Another pilot serving as an instructor on the flight, Lee Jung Min, had spent 3,208 hours flying 777s out of 12,307 total flying hours.

"It's not a lack of pilot training," said Thomas Haueter, a former director of NTSB's Office of Aviation Safety, who is consulting for Asiana. "These guys were extraordinarily well-trained. They get very specific training about flying into San Francisco."

In the latest documents, Asiana said the plane's autopilot changed "for an unknown reason" as the plane was about 1,600 feet off the ground approaching the runway. The autopilot changed from so-called "pitch" mode to "flight-level change" mode, which commanded the plane to climb back to 3,000 feet as if it had missed its targeted approach, and raised its speed and height.

In interviews after the accident, none of the three pilots in the cockpit recalled the flying pilot "or anyone else pressing the (flight-level change) button," according to Asiana.

But in Boeing's filing, the manufacturer said the click of the button being pushed at 1,600 feet can be heard on the cockpit voice recorder.

Within three seconds, flying pilot Lee Kang Kuk disconnected the autopilot, called out "manual flight" and moved throttles to idle, according to Asiana. But doing that put the engines in "hold" mode that kept them idling, which effectively disconnected the autothrottle so that it wouldn't maintain a minimum speed, the airline said.

A noise alarm sounds if the autothrottle is disconnected, but not when it is in "hold" mode, the airline said.

"The flight crew believed that the autothrottle system would maintain the commanded airspeed through the final approach," the airline said.

The FAA had "strongly" encouraged Boeing to enhance its software so that the autothrottle would "wake up" during large changes in air speed, after an FAA test pilot raised the same concern while flying the manufacturer's 787 for certification in 2010.

But Boeing hasn't done so. At the December hearing, Robert Myers, Boeing's chief engineer of flight-deck engineering, said if pilots are surprised by the automation, they are expected to use basic skills and manually fly the plane.

"If the airplane is not doing what they expect it to do, that they can disconnect the automation altogether and fly manually," Myers said.

NTSB conducted simulator tests in January with crews of 777 pilots from Boeing and the FAA that found they had trouble with an approach similar to Asiana's, according to the airline.

Each crew flew 10 landings — five standard and five representing the higher and faster path that Asiana was following. In the 10 flights mirroring the Asiana approach, crews descended more steeply than the airline's recommended rate of 1,000 feet per minute every time, according to the airline.

In four of those cases they set off the plane's warning for descending too fast. In two other tries they were considered "unstable" for flying too high or too fast, which means the pilot should consider aborting the landing and flying around the airport for another try, according to the airline.

To prevent future crashes, Asiana urged the NTSB to recommend that FAA require Boeing to put better warnings in its training manuals and aboard its aircraft about the autothrottle.

Asiana also suggested a noise alert for low airspeed, like what 737 aircraft have, early enough to allow a pilot to abort a landing and try again. The planes' current low-airspeed alert sounded 11 seconds before the San Francisco crash, which was too late for pilots to circle around.

Asiana said it revised its training thoroughly after the accident, to prevent another occurrence. The airline canceled 80 flights after the crash so that pilots could receive extra training that was already more than the Korean government required.

http://www.usatoday.com/story/trave...sb-san-francisco-boeing-autothrottle/6574165/
 
Asiana Crash Debate Goes Beyond Pilots to Automation

U.S. investigators are debating whether to blame a Boeing Co. (BA) jetliner’s design for helping cause a cascade of pilot mistakes in last year’s Asiana Airlines Inc. (020560) crash that killed three Chinese teenagers.

The sticking point within the U.S. National Transportation Safety Board, in the days before its final decision is due, is over the extent to which Boeing’s automatic throttle contributed to the plane’s loss of speed before it slammed into a seawall in San Francisco on July 6, said three people with knowledge of the discussions. They asked not to be identified because they weren’t authorized to speak.
The safety board tomorrow will decide on the probable cause and other factors leading to Seoul-based Asiana’s crash, the first in the U.S. with passenger deaths in more than four years. While there’s little doubt the pilots made multiple mistakes, a finding that equipment on the 777-200 jet confused them could open Chicago-based Boeing to greater liability in lawsuits and shade public opinion.
“There’s quite a flurry of activity” in the days leading up to the NTSB’s findings in a major accident, Peter Goelz, who served as managing director of the agency during the 1990s, said in an interview.
Such debate is consistent with prior investigations as the NTSB’s five-member board and staff hammer out nuances of what caused tragedies, Goelz said.
The NTSB has several options to address the role of the auto-throttle design. It can include it as part of the cause, list it as a “contributing factor,” or make recommendations for safety improvements that mention the equipment’s role.

il resto dell'articolo qui:

http://www.bloomberg.com/news/2014-06-22/asiana-crash-debate-goes-beyond-pilots-to-automation.html
 
NTSB points to pilot error in Asiana Flight 214 crash

Asiana Airlines Flight 214’s pilots didn’t have a full understanding of the aircraft’s automated systems and “mismanaged” the approach to San Francisco International Airport (SFO), the US National Transportation Safety Board (NTSB) has concluded.
“The crew over-relied on automated systems that they didn’t fully understand,” NTSB acting chairman Christopher Hart said Tuesday during a public hearing releasing the board’s findings on the July 6, 2013 crash. The Asiana Boeing 777-200ER came down short of SFO’s runway 28L, hit a sea wall and crashed on landing. There were three fatalities and 49 serious injuries resulting from the crash, according to NTSB. One of the fatalities occurred when an emergency response vehicle ran over a passenger who had been ejected from the aircraft during the crash sequence.
But most of the 307 passengers and crew aboard survived the accident with no or minor injuries, which Hart said can be attributed to advances in aircraft safety. “In years past, [a similar crash] might have resulted in scores or hundreds of fatalities,” he said, noting that “fire blocking materials” gave passengers and crew the time to escape the fiery aircraft.

The NTSB placed blame for the crash on errors made by pilots Jeong-Min Lee and Gang-Guk Lee, who were at the controls when the aircraft attempted to make the landing on a clear day at SFO. Jeong-Min Lee was the pilot in command, sitting in the right seat and acting as an instructor to Gang-Guk Lee, a veteran pilot in the midst of transitioning to the 777 who was sitting in the left seat and controlling the aircraft.
Speaking of Gang-Guk Lee, NTSB senior air safety investigator Roger Cox said, “Although he was an experienced pilot, he lacked critical manual flying skills.” The pilot flying the aircraft “needed more active coaching,” Cox said. But even though the flying pilot was “showing poor awareness,” the pilot in command “did not intervene in time,” he added.

According to NTSB, the aircraft’s autopilot system was disconnected and the auto-throttles were in hold mode in the final portion of the approach when the aircraft’s speed became too slow. NTSB board member Robert Sumwalt, a former airline pilot, said the Asiana 214 flying pilot expected the auto-throttles would “wake up” if the 777’s speed became too slow.

“I personally don’t think this was a problem with crew competency,” Sumwalt said. “I think this is a case of the pilot thinking the airplane would do something for him that it was not designed to do.”
Sumwalt added that “it was not just this pilot who misunderstood” how the 777’s auto-throttles worked. He said that before the Asiana 214 crash, there was a “widespread” lack of understanding among 777 pilots about how the auto-throttles would respond in a similar situation.
“I think the expectation of the [Asiana 214] pilot was that the auto-throttles would take care of” flight speed, Sumwalt said, adding that the pilot “was astonished” the auto-throttles didn’t “wake up” when the aircraft’s speed became too slow.

Nevertheless, Cox pointed out that the flight’s 14 mile-approach to SFO was troubled throughout. “There are a lot of things the crew could have done to manage the approach much more smoothly,” he said.

NTSB concluded the flight crew “did not follow” standard operating procedures during the approach. During interviews with NTSB investigators following the crash, neither pilot recalled being aware of low airspeed until well below 500 feet, the board reported. NTSB cited the pilots’ “increased workload” and “fatigue” as possible factors in the crash.
NTSB was also critical of the emergency response to the crash at SFO. “There were numerous problems with communication during the emergency response,” the board said, noting the “lack of a common radio frequency” for emergency responders.

http://atwonline.com/safety/ntsb-points-pilot-error-asiana-flight-214-crash
 
Trovo interessante e piuttosto triste questa parte del report: "The NTSB reported that 6 occupants were ejected from the aircraft during the accident sequence, 2 passengers and 4 cabin crew. The cabin crew were wearing their constraints however were ejected due to the destruction of the aft galley. The two ejected passengers were not wearing their seat belts and could still be alive. One of these two passengers were rolled over by two fire trucks. The NTSB said that had these two passengers worn their seat belts, they would likely have remained within the cabin and survived the accident."

Porcazozza gente, le cinture!!!!
 
June 30, 2014, 4:15 PM
Asiana Airlines released a statement on June 24 closely following the NTSB’s finding of probable cause for the July 6, 2013 crash of Flight 214 at San Francisco International Airport. The South Korean airline said, “The NTSB made four training recommendations to Asiana, all of which Asiana has already implemented. We believe the NTSB has properly recognized the multiple factors that contributed to the accident, including the complexities of the autothrottle and autopilot systems, which the agency found were inadequately described by Boeing in its training and operational manuals.”
 
Updated: 2014-11-14 22:03:40 (KST)


The Korean government has penalized Asiana Airlines with a 45-day suspension of its daily flights to San Francisco.
This is for breaking the safety rules when one of its jets crash-landed at San Francisco International Airport in July of last year.
The government says the decision was based on the civil aeronautics law, as well as the loss of life and property that resulted because of the accident.
The standard penalty of 90 days however, was cut in half for the company, as it is currently suffering management issues.
The transport ministry also took into consideration the crew members' level of professionalism and efforts to help passengers after the crash.
Still, the airline stands to lose over 13-and-a-half million U.S. dollars during the suspension period.

Asiana Airlines says it's appealing the decision, highlighting a potential inconvenience for its passengers, given the high traffic on the route.
The company also said that incidents like this usually result in a fine, not a flight ban.
The decision is separate from the earlier penalty of 5-hundred thousand dollars issued to the airline by U.S. federal transportation officials.
Earlier this year, the National Transportation Safety Board concluded that pilot error and an over-reliance on automated systems were to blame for the crash, which left three passengers dead and more than 180 injured.
Shin Se-min, Arirang News.

Reporter : ashin@arirang.co.kr



Luca chiedi la messa in moto ....
 
Ma che tipo di sanzione sarebbe? Utilità?

L'avesse presa un tribunale californiano, avrebbe ancora potuto avere un senso. Avendola presa il Giudice coreano, invece, sfugge totalmente la logica che ci possa stare dietro. Andrebbe letta la sentenza, per come è riportata la notizia (condanna per inadeguato training ai piloti) non si capisce il motivo per il quale impedisci di volare su quella specifica destinazione ma glielo consenti in casa tua. Totalmente illogico.