Asiana
Crash Puts Focus On Training, Automation
Airspeed
eroded, despite six eyes on the Asiana 777 flight deck
Complications
and distractions aside, over-reliance on automation systems appears to have
trumped basic flying skills and crew resource management in the crash of Asiana
Airlines Flight 214 at San Francisco International Airport on July
6.
The
accident will put additional pressure on an industry already grappling with
implementing training and human-factors lessons learned from recent high-profile
pilot-error-related accidents such as the 2009 Colgan Air Q400 loss-of-control
crash in Buffalo, N.Y., and the Air France A330 accident off the coast of
Brazil. In response to the Colgan accident , the FAA will soon publish a final
rule requiring first-officer hires to have at least 1,500 hr. of flight time and
an air transport pilot certificate and type rating, a six-fold increase compared
to the 250 hr. and commercial pilot certificate minimums today.
Meanwhile,
avionics manufacturers are making headway on research to simplify the complex
and often confusing human-machine interfaces that hinder rather than help
pilots. Rockwell Collins is working on a project to reduce the number of
federated automatic flight control (auto-flight) modes added to the flight deck.
By aligning auto-flight modes with pilot "goals"-arriving at a certain point at
a certain time with a given amount of fuel-researchers were able to design a
prototype mode manager that effectively gives pilots seven auto-flight mode
choices rather than as many as 38.
Adding
to the confusion are multiple modes for autothrottle systems that link to
complex auto-flight and autopilot systems. Autothrottles provide automatic speed
or vertical speed control, including stall prevention in some modes, allowing
pilots to focus on other tasks. According to Boeing documentation, the 777's
autopilot has five operating modes.
Mode
confusion could have played a role in the Asiana crash -the pilot-in-command of
the highly automated 777-200ER expected that the Boeing 's autothrottle system
would hold the aircraft's approach speed to a preset value of 137 kt. as the
aircraft, high on the initial approach, descended to capture a visual or
electronic glideslope.
The
system did not maintain the speed, leaving the engines at flight idle through
the final portions of the approach and placing the aircraft very near an
aerodynamic stall less than 200 ft. above San Francisco Bay in a high-drag state
with landing gear and flaps deployed to 30 deg. before pilots detected the
error.
The
crew attempted a full-thrust go-around, but the call came too late, as the
twinjet's main landing gear and tail clipped a seawall ahead of Runway 28L 1.5
sec. later. The impact removed the landing gear and the empennage, leaving
everything forward of the aft pressure bulkhead to skid and spin uncontrolled on
its belly down the runway. Despite the violent conclusion, the airframe and
cabin largely held together, allowing 123 of the 307 passengers and crew on
board to walk away unassisted (see article below).
While
the NTSB 's final analysis will likely take a year or more to complete,
preliminary information from the cockpit voice and flight data recorders and
pilot interviews indicate that distractions and automation surprises appeared to
cause the pilots to lose altitude and airspeed awareness.
"I
don't know how the whole crew could take their eyes off the speed," a 777 fleet
captain for a major carrier tells Aviation Week. "One of the basic tenets of a
stabilized approach is speed."
Internationally
accepted guidelines call for airspeed and thrust to be stable and the aircraft
on the proper glide path by 1,000 ft. above ground level for an instrument
approach and 500 ft. for a visual approach. The 777 captain's airline recommends
that pilots have the landing gear down by 2,000 ft. altitude and final flaps no
lower than 1,500 ft. If the approach becomes unstable at any time below the
entry altitude, pilots are advised to perform a go-around.
Complicating
the arrival for the Asiana crew was an air traffic control request to maintain
180 kt. until 5 nm from the airport during the final leg of the visual approach,
requiring pilots to bleed off 20 kt. airspeed before lowering the flaps to 30
deg. The tower later cleared Flight 214 to land when it was 1.5 nm from the
runway. Some carriers allow for pilots to land with 25 deg. flaps, which can be
deployed at 185 kt. or below.
The
left-seat pilot, the "pilot-flying," was not officially the pilot-in-command as
he was roughly midway through the airline's initial operating experience phase
for 777 checkout. The instructor pilot in the right seat was pilot-in-command,
on his first flight as an instructor pilot. He had never been paired with the
left-seat pilot, who himself had never flown a 777 into San Francisco. At press
time , it was not clear what roles the two front-seat pilots and a relief first
officer in the jump seat had set in terms of crew resource
management.
Though
GPS-based vertical guidance was likely available to replace Runway 28L's
inoperative instrument landing system glideslope, the Asiana crew may have
elected to fly a visual approach using the four-light precision approach path
indicator (PAPI) located near the touchdown point on the runway . When centered
in the PAPI's 2.85-deg. glideslope, pilots will see two white and two red
lights. All red indicates a position significantly below the glideslope, while
all white lights indicates one well above the reference
glideslope.
The
instructor pilot told investigators that at 500 ft. altitude, he realized the
aircraft was below the PAPI's visual glideslope and told the left seat pilot to
"pull back" on the control yoke. "He had set the speed at 137 kt. and assumed
the autothrottles were maintaining the speed," the NTSB says. Depending on the
auto-flight mode selected, autothrottles, if armed and turned on, should
automatically control engine thrust to maintain a preset speed, in this case 137
kt., the reference landing speed for the 777-200ER that day.
There
are caveats, however. In the takeoff/go-around or flight-level change (FLCH)
auto-flight modes, the autothrottle will not automatically activate to maintain
the selected speed. FLCH is pitch mode used to climb or descend at a constant
airspeed using the elevator for pitch control . There are also "mode surprises,"
certain conditions in which modes will transition without the pilot's knowledge,
potentially putting the automation into a mode like FLCH without the pilot's
knowledge.
By
late last week, the NTSB had not said whether the pilots had purposefully or
mistakenly entered a mode that inhibited the autothrottles, or if the
autothrottle system failed. During interviews, the instructor pilot told
officials the aircraft was "slightly high" when it descended through 4,000 ft.
on the approach and he set the auto-flight system 's vertical speed mode for a
1,500 ft./min. descent rate. NTSB Chairman Deborah Hersman said July 10 that
during the final 2.5 min. of flight, the flight data recorder shows transition
to "multiple autopilot modes and multiple autothrottle modes." "We need to
understand what those modes were, if they were commanded by pilots, commanded
inadvertently, and if the pilots understood what the mode was doing," she says.
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