Asiana Flights between ICN and SFO Banned.

Asiana Airlines, South Korea’s second-largest carrier, was ordered to halt its daily flights to San Francisco after the crash while landing at the city’s airport in July last year killed three passengers.

The airline won’t be allowed to fly to the city for 45 days from Seoul- Incheon airport, the Ministry of Land, Infrastructure and Transport said today. Investigations by the US National Transportation Safety Board found pilot error, inadequate training on automation system of the B777 aircraft led to the fatal accident.

Asiana strengthened pilot training, appointed a new chief executive officer and hired an official to oversee safety after Flight 214 struck a seawall short of the San Francisco airport on July 6 last year. The carrier violated US law by not promptly helping victims and family members immediately after the crash, which also injured 49 people, the Department of Transportation said in February.

“The government plans to implement additional measures to ensure proper pilot training at Asiana,” the ministry said.

The government reduced the penalty from the maximum of 90 days because of the crew’s efforts to evacuate passengers, the ministry said in the statement. Asiana has six months to comply with the ruling. The order will be finalized if the airline doesn’t object within the next 15 days.

Asiana will consider legal steps against the government’s decision, the Seoul-based airline said in an e-mailed statement after the government pronounced its verdict. The carrier’s shares gained 3.4% to 4,630 won as of 2.21pm in the city.

IATA’s support
Since the San Francisco crash, the South Korean government has stepped up regulations to improve airline safety standards, including steeper penalties for accidents involving casualties.

The International Air Transport Association had sent a letter to the South Korean transport ministry last month that the airline shouldn’t be sanctioned over the crash. A carrier already suffers significant financial loss from life and equipment, legal liability and damage to image, the group said.

The pilots on Flight 214 mismanaged their approach to the airport, failed to
notice the deteriorating speed and lights near the runway showing they were too low, and then didn’t abort the touchdown, which they were trained to do, according to the NTSB. The two pilots also didn’t communicate as they each made changes to the cockpit automation, the board found.

Source: Bloomberg News
Photo: Reuters

Asiana Flight 214 Crash – NTSB Animation

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.

On July 6, 2013, about 1128 Pacific daylight time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, was on approach to runway 28L when it struck a seawall at San Francisco International Airport (SFO), San Francisco, California. Three of the 291 passengers were fatally injured; 40 passengers, 8 of the 12 flight attendants, and 1 of the 4 flight crewmembers received serious injuries. The other 248 passengers, 4 flight attendants, and 3 flight crewmembers received minor injuries or were not injured. The airplane was destroyed by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport, Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations Part 129. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed.

The flight was vectored for a visual approach to runway 28L and intercepted the final approach course about 14 nautical miles (nm) from the threshold at an altitude slightly above the desired 3° glidepath. This set the flight crew up for a straight-in visual approach; however, after the flight crew accepted an air traffic control instruction to maintain 180 knots to 5 nm from the runway, the flight crew mismanaged the airplane’s descent, which resulted in the airplane being well above the desired 3° glidepath when it reached the 5 nm point. The flight crew’s difficulty in managing the airplane’s descent continued as the approach continued. In an attempt to increase the airplane’s descent rate and capture the desired glidepath, the pilot flying (PF) selected an autopilot (A/P) mode (flight level change speed [FLCH SPD]) that instead resulted in the autoflight system initiating a climb because the airplane was below the selected altitude. The PF disconnected the A/P and moved the thrust levers to idle, which caused the autothrottle (A/T) to change to the HOLD mode, a mode in which the A/T does not control airspeed. The PF then pitched the airplane down and increased the descent rate. Neither the PF, the pilot monitoring (PM), nor the observer noted the change in A/T mode to HOLD.

As the airplane reached 500 ft above airport elevation, the point at which Asiana’s procedures dictated that the approach must be stabilized, the precision approach path indicator (PAPI) would have shown the flight crew that the airplane was slightly above the desired glidepath. Also, the airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 knots. However, the thrust levers were still at idle, and the descent rate was about 1,200 ft per minute, well above the descent rate of about 700 fpm needed to maintain the desired glidepath; these were two indications that the approach was not stabilized. Based on these two indications, the flight crew should have determined that the approach was unstabilized and initiated a go-around, but they did not do so. As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath; the PAPI displayed three and then four red lights, indicating the continuing descent below the glidepath. The decreasing trend in airspeed continued, and about 200 ft, the flight crew became aware of the low airspeed and low path conditions but did not initiate a go-around until the airplane was below 100 ft, at which point the airplane did not have the performance capability to accomplish a go-around. The flight crew’s insufficient monitoring of airspeed indications during the approach resulted from expectancy, increased workload, fatigue, and automation reliance.

Public information from NTSB Docket DCA13MA120

Asiana Recruits ANA Veteran to Manage Safety Program

Asiana Airline’s new chief safety officer vowed yesterday to improve safety at the nation’s second-largest air carrier after a fatal accident in San Francisco in July.

Yamamura Akiyoshi, who spent more than 40 years at Japan’s All Nippon Airways (ANA) as a pilot, safety officer and auditor, began his new job as senior executive vice president of safety and security management at Asiana this week.

It is the first time Asiana has given the top safety job to a foreigner. Akiyoshi, who also worked as a safety auditor for the International Air Transport Association (IATA), said that although there are many differences between Korea and Japan’s airline businesses, safety is the highest priority in any country.

“I assure you that we at Asiana Airlines will continuously improve and enhance our aviation safety by strengthening independent oversight,” Akiyoshi told a press conference at the company’s headquarters in western Seoul. “I will apply the know-how I have acquired during my career in aviation safety at ANA and IATA to identify and mitigate risks and construct an improved systematic safety management suited to Asiana Airlines.”

Akiyoshi said he was positive about working here after experiencing the warm culture of the country as an ANA pilot flying Boeing 767 planes between Korea and Japan.

The 65-year-old is reviewing and analyzing Asiana’s safety management system and hinted there could be some changes. He emphasized that safety is something not only one person or division can achieve, but every team – maintenance and engineering, cabin,  airport services and cargo should be involved.

The Meiji University graduate said he was in Shanghai when Asiana Flight 214 crashed during landing at San Francisco International Airport, resulting in the deaths of three Chinese and injuring more than 180 passengers. Akiyoshi said he felt deeply sorry for the victims and their families.

He declined to comment on the ongoing investigation by the U.S. National Transportation Safety Board, saying he would inspect Asian’s safety system again when the accident report is released. He is scheduled to attend an NTSB hearing on the crash next week in Washington.

 “Every airline has its own safety culture, and we will abandon unnecessary things and collect good things from others,” Akiyoshi said. “I want to help Asiana create its own safety culture.”

Source:  Korea JoonAng Daily

Asiana Crash Response to Families Triggers Review by U.S. Agency

Asiana Airlines is under review by the U.S. Transportation Department on whether the South Korean carrier met its legal obligation to assist passengers’ families after a July crash in San Francisco.

The review, prompted by the National Transportation Safety Board, is the first time the board has raised concerns with the department over an airline’s assistance, said Keith Holloway, an NTSB spokesman. A 1996 law requires airlines to provide aid such as posting toll-free numbers and providing lodging and transportation for family members after an accident.

“We didn’t feel that Asiana was providing that information in a timely fashion to the families as they should have, so we notified the DOT about that,” Holloway said in a telephone interview yesterday. Bill Mosley, a DOT spokesman, confirmed that the department is conducting a review.

The July 6 crash occurred when one of Seoul-based Asiana’s planes, carrying 291 passengers and 16 crew members, struck a seawall short of the San Francisco airport, resulting in three deaths and dozens of injuries. The pilots’ manual flying skills and cockpit teamwork are part of an NTSB investigation into the cause of crash, which has prompted the carrier to increase pilot training and begin an outside review of safety standards.

Kiwon Suh, an Asiana spokesman in South Korea, didn’t respond to a call and an e-mail outside regular business hours seeking comment about the U.S. review.

The NTSB raised its concerns with the department immediately after the crash, Holloway said. Asiana’s aid plan, filed with the Transportation Department, was last updated in 2004, he said.

Source:  AP

Korean Pilots Unions criticize the handling of the investigation by the NTSB

The Asiana B777 accident last July 6 at San Francisco airport continues making noise in the worldwide aviation community. 

This time the Korean’s Pilots Unions, representing the flight crew of Asiana 214, issued an statement criticizing the handling of the accident investigation by the NTSB.

The Asiana Pilots Association and the Airline Pilots Association of Korea expressed their concern that the final result of the investigation will not reflect accurately the several factors involved in the accident, since the NTSB has slipped publicly its position on pilot error as the main cause of the accident.

“We have conveyed our concerns about the possibility of inaccurately identifying the cause of the accident, due to NTSB’s press conferences which only give prominence to the possibility of a pilot error and unprecedented speed in disclosure of related materials to the public,” the unions said in a statement.

In several media briefings, the NTSB released information to the public obtained from FDR’s – Flight Data Recorders, meanwhile while the serious fact that one of the victims of the accident survived the same and was hit by one of the fire trucks, is kept concealed.

The autopsy determined that Ye Meng Yuan died crushed by at least one of the rescue vehicles meanwhile she was lying on the runway covered by firefighting foam.

The crash resulted in the deaths of three teenagers, Liu Yipeng died at hospital six days after the accident, meanwhile Wang Linjia died on impact with the seawall of runway 28L at San Francisco Airport.  The three girls were on a group of 34 students travelling to USA.

Asiana 214 Victims

Capt. Ivan

 

Retired Senior Boeing Flight Instructor blames on the Auto-throttle System

The B777 activated auto-throttle system is under close investigation by the NTSB after has been determined that the Asiana aircraft was flying too slowly before impacting the seawall at runway 28L at San Francisco airport last July 6.

Anthony Keyter, a retired senior Boeing flight instructor said on Friday that the B777 auto-throttle system has a design flaw in its speed control system, suggesting that it may be the culprit of the accident.

“There is an inconsistent functioning of auto-throttle and stall protection systems in the Boeing 777 aircraft. This weak point has been discussed with grave concern among some B777 pilots,” said Keyter in a statement.

The flaw becomes evident when the aircraft is descending with autopilot in the – FLIGHT LEVEL CHANGE MODE.  If the autopilot is disconnected and the auto-throttle is left in – ARMED – position, the throttles will remain in IDLE position and would not automatically increase thrust to maintain the target speed”

“If a speed decrease is not noticed and corrected manually by the pilot, it would continue to bleed off to the point of – STICK SHAKER”, as it was the case of Asiana 214.

“Pilots rely on the auto-throttle system as a last resort to keep the aircraft speed safe under all circumstances.  Then the design flaw in the auto-throttle can thus be considered a contributing factor to the causes of the accident”, he mentioned.

Keyter added that Boeing should address the problem through changes to flight procedures, or an express note in the manual.

Capt. Ivan

Asiana 214 – Accident Animation

This is a very accurate reconstruction of the crash of Asiana flight 214 at San Francisco Airport on July 6, 2013 with the exception of the post impact fire. It is now reported that the fire did not break out until 90 seconds after the aircraft came to rest. That adjustment will be made and re-posted this evening.

All times, speeds, distances and scaling contained are accurate to the data available as of July 10, 2013. There is also included in the segment a blue transparent exemplar aircraft programmed to follow the correct 3 degree glide slope to the intended touchdown point 1,000 ft down the marked runway. This is the path and altitude the Asiana flight should have been flying during the approach. Please note that the blue exemplar aircraft is not programmed to fly at the correct approach speed, only the correct altitude. If it were programmed to fly the correct approach speed it would very quickly pass the Asiana aircraft and disappear off screen. The reconstruction also contains the actual SFO tower communications with flight 214 although the actual timing of the communications may not be absolutely synchronized to the animation since the data necessary to precisely synch won’t be available until it is released by the FAA or NTSB in the coming weeks.

This reconstruction will continue to be further refined and re-posted as new data becomes available.

If you have any questions regarding this animated reconstruction feel free to call Eyewitness Animations at (954) 941-2356 and ask for John. www.eyewitnessanimations.com

 

Pilot’s View

Question of the moment: What lessons do you think can we learn from the Asiana 214 accident?

As investigation progresses we are learning that interaction between human factors and automatism played an important role in the Asiana 214 accident.

  • What do you think aviation community can do to avoid this type of accident in the future ?

 

We welcome your comments.  Please spam free.  All comments may be re-published by Cockpit Chatter.

Flight Attendants, much more than just a pretty for customer service

Asiana 214 Flight Attendants

Today, while reading the news, I found this picture, seeing their faces, I could not do anything than think about the terrible moments these young people lived days ago when the Asiana B777 impacted the runway 28L seawall at San Francisco airport.

The Asiana Flight 214 cabin crew consisted of 11 women and one man, ranging in age from 21 to 42.  Heroes, is the common word I saw on the news all over the world and I think there is no better description to their actions.

On July 6 crash, three flight attendants were ejected while still strapped to their seats from the aircraft’s sheared off tail section.  One of the items among the investigation of the crash will be the emergency evacuation and find a reason why the pilots of Asiana Flight 214 told the flight attendants to delay it for 90 seconds after the crash landing, giving the order only after a flight attendant spotted flames outside.  For sure this will raise inquiries about flight attendant authority during an emergency.  Those who were able, meanwhile, oversaw the emergency evacuation of nearly 300 passengers – using knives to slash seatbelts, slinging axes to free two colleagues trapped by malfunctioning slides, fighting flames and bringing out frightened children.

“I wasn’t really thinking, but my body started carrying out the steps needed for an evacuation,” head attendant Lee Yoon-hye, 40, said during a news conference Sunday.

“In the face of tremendous adversity and obstacles, they did their job and evacuated an entire wide-bodied aircraft in a very short period of time,” said Veda Shook, international president of the Association of Flight Attendants and an Alaska Airlines flight attendant.

“It’s such a shining reflection, not just of the crew, but of the importance of flight attendants in their roles as first responders,” Shook said.

Next time you see that pretty girl serving your dinner or that handsome boy walking on the aisle, think they can also save your life…

Capt. Ivan

Photo Credits:

– Kim Hong-Ji/AFP/Getty Im

– Jeff Chiu

…a colleague as a first row witness and his story

Interesting read…..

Here is an email from a United crew holding short of the runway as the Asiana B-777 approached:

On July 6, 2013 at approximately 1827Z I was the 747-400 relief F/O on flt 885, ID326/06 SFO-KIX. 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.

Source:  email published on Fb by Capt. Alan Carter

  •   GDL 39