If the George Zimmerman trial wasn’t enough to feed a media frenzy, a major airplane crash at one of the country’s busiest airports filled the remaining void. When I was contacted by a national TV network to validate a specific nuance of the 777 automation system, I actually considered that maybe this time the media would get it right — well, at least in the ballpark, anyhow. After viewing a YouTube video of an Oakland newscaster reading the now infamously fake names of the pilots, I knew all glory for accuracy had faded. In that regard, I felt compelled to enter the speculation fray of the Asiana Airlines Flight 214 crash.
Although the general public is certainly fascinated by the sensational aspect of an airplane crash, we as pilots are fascinated more by an accident’s relevance to our own personal aviation experiences. The popularity of the Aftermath column in this magazine is a reflection of that fascination. If the accident involves an airplane we have flown, we take a keen interest. Put my name on that list. But before I discuss some of the pertinent aspects of Asiana 214, afford me the opportunity to explain the process of a major National Transportation Safety Board investigation. Having donned a blue Tyvek suit and shuffled around a crash site after my airline had one of its worst days, I have a unique perspective. It was a life experience that I would care not to repeat. A full year passed before the smell dissipated from my nostrils.
The Go Team, with its gold-embroidered NTSB windbreakers, is the most familiar and identifiable ingredient in the process. These folks are employed by the government full time and are chosen by the NTSB for their knowledge in certain areas of accident investigation. With the Asiana crash, these areas are Structures, Powerplants, Systems, Performance, ATC, DFDR (Digital Flight Data Recorder), CVR (Cockpit Voice Recorder), Flight Crew Ops and Survival Factors. Each Go Team member is designated a group chairman according to their area of expertise.
Accident investigators approach the wreckage of Asiana Airlines Flight 214. As in every investigation, the aftermath of the crash demanded a highly coordinated effort.|
The NTSB employs a party system, with it always being the first party in the investigation. The FAA is the second party. At the discretion of the Investigator In Charge (IIC), entities with an interest in the investigation are included as third parties. For the Asiana investigation, the major entities are the airline, Boeing, Pratt & Whitney and KARAIB (Korean Aviation and Railway Accident Investigation Board). The NTSB has limited people resources. It relies on these entities to provide an individual expert in at least one or more of the participating groups.
After the NTSB conducts an organizational meeting at the command center, the group chairmen outline the tasks to be accomplished during the on-scene field phase of the investigation. Each group examines the wreckage as it pertains to its area of expertise. When the day’s tasks are completed and the group chairmen have assembled the collected data, they report to the IIC at the end-of-the-day progress meeting. After the progress meeting, a press briefing is given.
Once the on-scene activities are complete, the groups prepare drafts of their factual reports. When all the reports have been submitted and distributed to the parties and NTSB members, a public hearing is convened. About 90 days later, at the discretion of the IIC, a technical review meeting is conducted. The technical review allows all the investigative groups to compare notes.
The analysis phase begins when all parties are given the opportunity to submit their interpretation of the factual data. The interpretation includes safety recommendations. With the party submissions presented, the NTSB convenes a Sunshine Meet-ing, during which the board members reach a conclusion based on the factual data. An official probable cause is issued with recommendations to the parties involved. Soon after, the Blue Cover Report is entered into public record, concluding the investigation. If one or more of the interested parties disagree with the findings, perhaps after discovery of additional evidence, a petition for reconsideration can be filed. The sole purpose of the entire process is not to place blame but to find a cause so that the same accident never occurs again.
The NTSB, in Chairman Deborah Hersman’s words, has been very transparent with the factual data of Asiana Flight 214. That’s good and bad. It’s good that a government organization is showing its cards. It’s bad because the release of information allows the misinformed to reach biased conclusions without all the factual data. It is strict NTSB policy that releasing any factual data without approval risks losing investigative party status. I’ll weigh in using only the data presented at the press briefings and my own experience with flying the 777.
Making the assumption that readers of this magazine are already versed in the evidence that the airplane got low and slow, I’ll cut to the chase. Below 10,000 feet on the descent, two experienced pilots occupied the flying seats, with the first officer observing from the jumpseat and the relief captain occupying a cabin seat. Although the right seat pilot was a new check airman, he had approx-imately 3,000 hours in the 777 alone. The left seat pilot was more than halfway through his initial operating experience (IOE) with about 25 hours left to go before he was considered fully qualified — a 60-hour requirement for Asiana. (Most U.S. carriers require only 25 hours of IOE for a PIC.) The left seat pilot had been a ground and simulator instructor, transitioning from eight years of flying the A320 — an interesting and perhaps crucial fact.
Asiana Flight 214 was cleared for a visual approach. Although the glide slope was out of service, no untypical procedures were utilized by ATC. The precision approach path indicator (PAPI) was available as a source of glide-path guidance. The autopilot was disconnected at 1,600 feet. The left side flight director switch was in the off position with the right side switch in the on position, an indication that the IOE captain had no electronic guidance. The check airman reported that vertical speed was the flight director mode in operation. The autothrottle switches were in the armed position. A command speed of 137 knots had been determined to be the appropriate approach speed by the crew. At 1,400 feet the airplane had slowed to 170 knots. Seventy-three seconds later, the airplane reached a speed of 103 knots, at which time the tail cone impacted the seawall prior to the threshold of Runway 28L while the crew attempted to execute a go-around. At 500 feet, the check airman had observed three red PAPI lights and one white. And at 200 feet he observed four red PAPI lights.
The 777 autothrottles will maintain current speed or speed selected when vertical speed mode is pressed. But if the autothrottles are disconnected by pressing the button on either power lever, they will not engage unless another vertical mode is selected or the takeoff go-around switch on either power lever is utilized. It appears that the autothrottles were armed, but no information has been forthcoming stating whether they were engaged. If they were not engaged, the thrust levers would only apply power once the computer determined the speed was nearing stick shaker activation, an automatic warning function of an impending stall. Below 100 feet in the approach configuration, the automatic activation system is no longer active. The system assumes the pilot is landing.
Boeing autothrottles have a clutch system. They move, providing a subtle visual cue. Airbus autothrottles do not move. It is a set-and-forget system. Perhaps the IOE captain regressed to his prior Airbus experience. He was in an unfamiliar airplane executing an untypical operation — a visual approach without electronic glide-path guidance. That being said, an LNAV/VNAV approach was available as backup, but it doesn’t appear that it was utilized.
The FlightAware graph reflects the possibility that the approach was never quite stabilized after 4,000 feet. A descent rate at over 1,300 fpm below 600 feet does not qualify for the definition of a stabilized approach.
If the autothrottles were engaged, another possibility exists. They are easily overridden. I made that mistake in the simulator during my initial training, resting the weight of my hand on top of the thrust levers. I allowed the speed to decrease to an uncomfortable level on a single-engine approach before I recovered. Gone unmonitored, it would have the result the world witnessed with the Asiana flight.
In addition to the automation issues, consider some other ingredients as accident factors. No matter how pleasant the individual, flying with a check airman adds a certain measure of stress above and beyond the awkwardness of operating a new airplane. An IOE pilot is under constant performance evaluation. Having been on both sides of the equation, I understand the stress. Add to the mix the fact that the captain in the right seat was new to his check airman position, evaluating an experienced captain who had been an instructor. Perhaps a little intimidation was involved? Or perhaps the check airman had an expectation that the IOE captain would perform to a higher standard?
Utilizing automation for nearly every phase of flight can deteriorate or de-emphasize basic flying skills. As ridiculous as it sounds, a visual approach could prove to be a daunting task, especially if it’s rarely accomplished without electronic guidance.
As a peripheral factor, the IOE captain claimed to have experienced a flash of light at some point during the approach. Although the NTSB will investigate the possibility, it doesn’t appear to give the light much credence. Even the IOE captain admits that it did not obscure his vision inside the cockpit.
Regardless of the above possibilities, why weren’t the power levers shoved through the instrument panel light years earlier? That’s the multimillion-dollar investigation question. I’ll be on the sidelines with you, waiting for the NTSB’s Blue Cover Report.
View photos from the investigation of the Asiana 214 crash in our gallery here.
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