The San Francisco airplane accident: was someone negligent?
The tragic crash of an Asiana flight Saturday while landing in San Francisco is a terrifying event despite the fact that “only” two people died.
It’s tragic because two people dying is, of course, too many people—although everyone realizes it could have been much, much worse. It’s tragic because many of the victims (varying numbers have been reported) sustained very serious injuries.
And as more facts emerge, there are extra layers of upset. For example, we learn that one of the two sixteen-year-old girls who died in the crash may have been run over by a fire truck racing to the rescue. The irony of this is deep, although it’s also possible that the girl was already deceased before that (after all, the other girl was not run over and she died as well).
Another shocking fact is that the pilot in charge of the jet—which by all accounts was going far too slowly and flying too low for a proper approach to that particular airport—was piloting that type of plane into San Francisco for the first time:
…[W]ith Asiana insisting there was no mechanical failure, the data from the flight recorders showing the plane far below appropriate speed and the fact that the pilots were controlling the plane in what is called a “visual approach,” the available evidence Sunday suggested the crew was at fault.
On Monday, Asiana spokeswoman Lee Hyomin said that Lee Gang-guk, the pilot in control of the Boeing 777, had little experience flying that kind of plane. She told the Associated Press that it was the pilot’s first time landing in San Francisco and that he had nearly 10,000 hours flying other planes but only 43 hours on the 777.
There’s some question, though, about the accuracy of that “first time landing in San Francisco” statement. According to this report, the pilot had landed planes in San Francisco “several times between 1999 and 2004.” Of course, “several” times is not a great many, and 2004 is almost ten years ago, plus the fact that this was his first time landing a 777 in San Francisco. San Francisco—like Boston, an airport with which I am quite familiar—has a water approach, which is known to be tricky.
But before we get too shocked at the pilot’s inexperience, let’s reflect that at some point pilots have to have a maiden voyage. After all, every airline can’t have training runs with empty planes for each pilot new to that airplane and/or that airport at each of the world’s airports. I read in one article (can’t find it now, so I’m not giving a link) that the other pilot of the Asiana plane was very experienced both with San Francisco and with 777s, and he was supposed to have been closely supervising Lee Gang-guk during the landing. That sounds like a good system, but it’s highly possible it went sadly awry this time.
I’ve also read a while back that (again, can’t find the article right now), with improvements in airplane and instrument design based in part on what we’ve learned from previous accidents, although the airplane accident rate has gone down, a higher percentage of the accidents that do occur tend to be due to pilot error. The preliminary findings in this case point strongly in that direction.
I assume we’ll find out more as time goes on.
I don’t want to be presumptive as there are many days of investigations to go. However, as a retired airline pilot I can make some observations.
Several times in my career, I was either the pilot in training or the pilot who was supervising the training of someone new to the aircraft we were flying. That is a normal procedure with all airlines.
Even though it was a clear day with no strong crosswinds , and they were making a visual approach, it is common practice (in fact required practice at my old airline) to have the ILS tuned and used as a backup to the pilot’s visual clues outside the airplane. Thus, the pilot who was training the new pilot should have been quick to observe that the pilot flying was low and slow. Engines idle (if indeed they were idle) below 500 feet is not normal procedure. At 500 feet if the approach was not on glideslope and on speed with the engines spooled up, as the training pilot I would have ordered a go around. That didn’t happen. I will look forward to seeing why.
J.J.:
I figured you’d be able to offer some insight.
Fortunately, both pilots survived, although we haven’t heard much about whether they were injured. I have read that they have not been interviewed yet, which leads me to believe they are injured. If in fact one or both of them was negligent, it will be a tough road ahead, psychologically and legally.
Someplace, maybe on a note taped to the windshield, in a computer readout, a plaque next to the throttle, in the pilot’s head, was the airspeed for landing.
Say it’s the reported 137kt.
How could the pilot forget to keep the plane at 137kt?
The greenest rookie, hauled out of coach because both pilots got kimchee tummy and were out of action, would not fail to do the simplest thing, which is maintain airspeed. I can see the failure to do the counterintuitive–keep the nose level or down–but not the airspeed. Was something else going on?
In 2008 a 777-200 crash landed in the same manner as this most recent crash. The blame was placed on an engine component (fuel-oil heat exchanger), of the Rolls Royce Trent 895 which was installed on the British Air aircraft. RR says the problem was fixed. The RR Tents are not mounted to all 777-200’s (GE & P&W also power many 772’s), but I dont know if Asiana has them on theirs. Just throwing that out there.
Human error is the likely culprit.
It may have been as simple as some one miskeying the altimeter data into the nav computer, and then not paying attention to the visual cues that the approach lights provide. Or, as J.J. suggests, the ILS system.
Also, turbofan engines have many sterling attributes, but rapid, immediate increase in speed is not one of them. You don’t wait until the last second do do something…
Totally agree with what JJ said. It is not unique for the flying pilot to have limited experience in the airplane, or no experience at a particular airport. However, given the situation there would be a Supervisory, or Instructor Pilot in the other seat. Why he let the situation deteriorate to the point that has been reported, is simply baffling.
Many people have stated that the absence of the electronic glide slope system is not significant. I do not agree. It did not cause the accident, but it could have contributed. JJ is absolutely correct with regard to policy; and in my experience of training foreign pilots they rely on those systems even more than American pilots do. It also appears from the obviously fresh reconfiguration of the runway, that the visual glide slope aid may have been unavailable as well. I assume that the 777 has internal systems that could have compensated for the lack of airport aids, but these systems can add to confusion if they are not well understood, and if the pilot is not thoroughly schooled and comfortable with their use.
Now, I will make a statement that could be controversial. But, I have worked with many foreign, as well as U.S. pilots. In the modern environment, with pilots coming into the system with much less flying experience than in the past, there is a trend to train systems operators more than airplane pilots. In the absence of system components, or if the systems are not properly employed, they have little to fall back on. That is the way it has been for awhile, and the way it will be.
A couple of decades ago, as more automation became available in the cockpit, one well known, and very successful, U.S. airline did not buy all of the automated features. Some people said it was because the airline was cheap; the airline said that they wanted their pilots to interact directly with the airplane and not become detached from it.
Much of the above makes for discussion, but should obscure the bottom line, which to me is the lack of timely intervention by the Supervisory pilot as the situation obviously deteriorated into an awful mess. His explanation will be fascinating.
Richard Aubry. The 777 has auto throttles. Were they engaged? We don’t yet know. If they were, a simple mistake like setting the airspeed bug improperly could be the answer. That would again suggest no feel for the airplane because the system will take care of it. Technology can lead you into an early grave if you are inattentive. Glide slope issues could have distracted from developing airspeed issues as well.
Many questions; few answers as yet. One given is that the crew was almost assuredly a few miles behind the airplane.
Harry, it was stated by the NTSB Chairman that this airplane had P&W engines, and that the operation was normal. But, Rolls Royce would have done some serious modifications to their engine after the Heathrow problem.
Oldflyer: “Harry, it was stated by the NTSB Chairman that this airplane had P&W engines, and that the operation was normal. But, Rolls Royce would have done some serious modifications to their engine after the Heathrow problem.”
There’s something about you Oldflyer that suggests experience in the subject matter, but cant quite put my finger on it….Oh, well. Thanks for the info on the engines. :^)
Here’s an e-mail I received via my airline pilot retiree grapevine that provides an eyewitness account. A bit long, but may be of interest to those interested.
“Here’s an email from one of the United 747 pilots that witnessed the 777 crashed in SFO. They were holding short of runway 28L at the time of the crash.
On July 6, 2013 at approximately 1827Z I was the 747-400 relief F/O on flt 885, ID326/06 SFO-KIX. (Osaka International Airport) I was a witness to the Asiana Flt 214 accident. We had taxied to hold short of runway 28L at SFO on taxiway F, and were waiting to rectify a HAZMAT cargo issue as well as our final weights before we could run our before takeoff checklist and depart. As we waited on taxiway F heading East, just prior to the perpendicular holding area, all three pilots took notice of the Asiana 777 on short final. I noticed the aircraft looked low on glidepath and had a very high deck angle compared to what seemed “normal”. I then noticed at the apparent descent rate and closure to the runway environment the aircraft looked as though it was going to impact the approach lights mounted on piers in the SF Bay. The aircraft made a fairly drastic looking pull up in the last few feet and it appeared and sounded as if they had applied maximum thrust. However the descent path they were on continued and the thrust applied didn’t appear to come soon enough to prevent impact. The tail cone and empennage of the 777 impacted the bulkhead seawall and departed the airplane and the main landing gear sheared off instantly. This created a long debris field along the arrival end of 28L, mostly along the right side of 28L. We saw the fuselage, largely intact, slide down the runway and out of view of our cockpit. We heard much confusion and quick instructions from SFO Tower and a few moments later heard an aircraft go around over the runway 28 complex. We realized within a few moments that we were apparently unharmed so I got on the PA and instructed everyone to remain seated and that we were safe.
We all acknowledged if we had been located between Runways 28R and 28L on taxiway F we would have likely suffered damage to the right side aft section of our aircraft from the 777.
Approximately two minutes later I was looking out the left side cockpit windows and noticed movement on the right side of Runway 28L. Two survivors were stumbling but moving abeam the Runway “28L” marking on the North side of the runway. I saw one survivor stand up, walk a few feet, then appear to squat down. The other appeared to be a woman and was walking, then fell off to her side and remained on the ground until rescue personnel arrived. The Captain was on the radio and I told him to tell tower what I had seen, but I ended up taking the microphone instead of relaying through him. I told SFO tower that there appeared to be survivors on the right side of the runway and they needed to send assistance immediately. It seemed to take a very long time for vehicles and assistance to arrive for these victims. The survivors I saw were approximately 1000-1500′ away from the fuselage and had apparently been ejected from the fuselage.
We made numerous PAs to the passengers telling them any information we had, which we acknowledged was going to change rapidly, and I left the cockpit to check on the flight attendants and the overall mood of the passengers, as I was the third pilot and not in a control seat. A couple of our flight attendants were shaken up but ALL were doing an outstanding and extremely professional job of handling the passenger’s needs and providing calm comfort to them. One of the flight attendants contacted unaccompanied minors’ parents to ensure them their children were safe and would be taken care of by our crew. Their demeanor and professionalism during this horrific event was noteworthy. I went to each cabin and spoke to the passengers asking if everyone was OK and if they needed any assistance, and gave them information personally, to include telling them what I saw from the cockpit. I also provided encouragement that we would be OK, we’d tell them everything we learn and to please relax and be patient and expect this is going to be a long wait. The passenger mood was concerned but generally calm. A few individuals were emotional as nearly every passenger on the left side of the aircraft saw the fuselage and debris field going over 100 knots past our aircraft only 300′ away. By this point everyone had looked out the windows and could see the smoke plume from the 777. A number of passengers also noticed what I had seen with the survivors out near the end of 28L expressing concern that the rescue effort appeared slow for those individuals that had been separated from the airplane wreckage.
We ultimately had a tug come out and tow us back to the gate, doing a 3 point turn in the hold short area of 28L. We were towed to gate 101 where the passengers deplaned. Captain Jim Abel met us at the aircraft and gave us information he had and asked if we needed any assistance or hotel rooms for the evening. Captain Herlihy and F/O Ishikawa went to hotels and I went to my home an hour away in the East Bay.”
This pilot’s eyewitness account will become a part of the investigation, IMHO.
When money gets tight and people cut off training funds, human error increases.
After all, if the money is primarily going into somebody’s pockets, then obviously it isn’t being used effectively.
America used to be a society that didn’t cut corners because even if the boss wasn’t looking, individuals had heart, pride, and soul enough to motivate themselves to do the work to quality standards anyway.
As the basic spirit and soul is corrupted in America, so the same affects its people.
It’s not really about proving it one way or another. It just is.
Thanks, J. J. I got the impression he was coming in high and steep: over 1300 fpm with the engines on idle, and well below reasonable airspeed. That’s no way to fly a heavy jet.
It would be interesting to know the flap and spoiler settings. If they were having mechanical issues, they would have announced it. Were they incapable of flying the aircraft without the full ILS system to guide them in?
Oldflyer. All I know about airplanes is that they are complicated systems mostly run right by trained professionals.
So if a “bug” is set on the autothrottle for the wrong air speed, I presume there’s one of those speedometer thingies to tell you true.
Right?
Now what?
KBK asked, “Were they incapable of flying the aircraft without the full ILS system to guide them in?
No, they should be able to make a safe landing with no ILS or visual glide slope indicator in such clear weather conditions. Just sight, sound, and feel with constant cross referencing of the airspeed, vertical speed indicator, altitude and runway alignment. In the simulator it was a normal part of training (at least in my day) to learn to do approaches and landings with no ILS system or visual glide slope system to reference.
There is a menu of ways the pilots can select to do any particular approach. Fully automated with the auto-pilot and auto-throttles engaged and locked onto the ILS. Semi auto with the auto-pilot and auto-throttles engaged, but the pilot steering the airplane through the auto-pilot and following the ILS display. Hand flying the airplane (steering it with the yoke and rudders) with the auto-throttles engaged but using the ILS display to guide you to the airport. Hand flying the airplane with neither auto-pilot or auto-throttles engaged (Steering with the yoke, maintaining proper airspeed and descent rate with the throttles.) but using the ILS as a guide to heading and glide slope. Hand flying the aircraft (using yoke and throttles) with no ILS – just a visual contact with the runway and the pilot’s judgment as to being on glideslope.
I’m sure that those who aren’t pilots find this all rather confusing. Let me just reassure you that each mode has its uses. The weather, traffic conditions, runway braking coefficients, and the pilot’s experience normally dictate what mode is used.
The flight recorders and the pilot interviews will tell us more than we can guess at.
Visual contact with water is meaningless: it is impossible to judge the altitude AND velocity visually when flying over water.
Sergey said, “Visual contact with water is meaningless: it is impossible to judge the altitude AND velocity visually when flying over water.”
No pilot of a modern aircraft (high approach speeds) can fly it strictly by sight, sound, and feel. Instruments must constantly be cross referenced. It is possible to make approaches, even over water without any artificial glideslope information, as long as you know your altitude and distance from the runway. If you know the airport well you don’t even need an electronic distance. Certain landmarks (and there are landmarks on the left as you approach 28L at SFO) will provide evidence of your distance and you are constantly solving in your head the altitude you should be at as you pass these landmarks. There are runways at various airports around the world where this is the only approach possible, as they have no electronic aids. Not many are used by modern commercial jets, but a few are.
JJ et al,
The localizer was NOTAM’d out, but I assume the Glide Path indicator was working.
The Captain upgradee was highly experienced and SENIOR to his IP, which I’d bet will be a factor.
The a/c came in above glide path and captured it then started sinking below as a/s bleed off–very significant.
The throttles were not in auto-throttle.
All the info above I got from the NTSB lady on TV, have watched all of them (except this afternoon will have to catch that tonigh).
I spent 30 years in the AF as an A-10/F-16 pilot and went on to fly 73s with Delta. One of my tours in the AF was as an A-10 pilot on a Korean RKAF base called Suwon. While there, I got to know several Korean fighter pilots (F-5s) and learned quite a bit about their culture. One big factor in their culture is “saving face”–a junior officer only corrects a senior officer VERY respectfully. I also noted that they flew very mechanically, by the numbers and procedures. Tended to like automation versus manual systems.
Given the above, my speculation (emphasis on speculation) is that the Upgradee in the left seat was descending to GS with the throttles in idle maintaining A/S with the decent. Upon reaching GS, either assumed the auto throttles were engaged, or forgot to engage them. After that I’m just guessing, but either he started sinking due to lack of A/S or to preserve it and the right seater simply gave him too much rope assuming that a senior pilot would see his error and correct it. As you know the go-around call/throttle up was way too late. NTSB will have to figure that part out, fortunately the pilots survived.
As for the other two pilots on board, I doubt they could see it coming. Never flew the 77, but have non-reved in the jump seats. they’re about 10′ back (it a massive cockpit compared to the 73) and you really can’t see the instruments or out the window in the landing configuration for that matter. But I bet they sucked their seat cushions up you-know-where when the stall warning horn went off on short final!!!
Cheers,
Wired
Yes, never restored power when he went below the glide slope. Medical issue with the senior pilot?
Tater, Thanks for the update. Have been away from TV today.
Fortunately, I never flew an airplane with auto-throttles. Always had the hands on the throttles during an approach. That keeps you more in the loop even on coupled approaches. To avoid getting rusty I made it a practice to alternate between hand flying and using the auto-pilot for approaches. Being able to hand fly comes in handy when you get those quick entries like the “down the Bay” 180 visuals into the 28s at SFO.
Culture can enter into the way pilots conduct themselves. I’m not familiar with Korean culture, but can imagine seniority and “saving face” might enter into it.
Maybe they actually were not capable of landing SFO without ILS.
Rantburg post from flight trainer with Korean experience
Holy Smoke KBK!!
Kinda confirms what I suspected all along, but had no idea the Koreans sucked THAT bad! Great read, thanks for sharing.