Update on 2013 article, 777 crash San Fransisco

Posted: June 25, 2014 by tchannon in Accountability, Analysis

Since I posted on the crash, an update when the primary crash report is published is reasonable even though this is off the blog normal fare. Engineering types tend to have wide interests

Reuters report

U.S. investigators propose review of flight controls after Asiana crash

By Alwyn Scott and Annika McGinnis

WASHINGTON Tue Jun 24, 2014 10:14pm BST

(Reuters) – U.S. investigators on Tuesday said Boeing Co should consider modifying flight controls on the 777 jetliner in response to an Asiana Airlines crash in San Francisco last July that killed three people and injured more than 180.

The National Transportation Safety Board accepted 30 findings following an 11-month investigation into the July 6, 2013 crash, and made more than two dozen recommendations to the Federal Aviation Administration, the Seoul-based airline, Boeing, firefighters and San Francisco city and county.

Original Talkshop article, expired on allowing comments.

Boing’s response looks like climatology response

Boeing said it “respectfully disagrees” with the NTSB’s finding that the automated system on the 777 contributed to the accident. “We do not believe (it) is supported by the evidence,” spokesman Doug Alder said in a statement. “We note that the 777 has an extraordinary record of safety – a record established over decades of safe operation.”

Denial mode. Safe operation = we got away with it, not the same thing as actually so.

One of the things about Airbus is the consistent flight deck. Know one, know them all, at least so I understand. This begs the question of the extent to which manual override should be allowed, does it for example trip an audible alarm? (not that alarms prevent anything as I recall from air accident voice tapes, alarm sounding, panic, ground con


So, lets see, after reproducing bullet feature lists from Airbus and Boing, from page 6 of

Chapter 9
Human Factors Engineering and Flight
Deck Design
Kathy H. Abbott
Federal Aviation Administration

One of the significant differences between the design philosophies of the two manufacturers [Airbus / Boing] is in the area of envelope protection. Airbus’ philosophy has led to the implementation of what has been described as “hard” limits, where the pilot can provide whatever control inputs he or she desires, but the airplane will not exceed the flight envelope. In contrast, Boeing has “soft” limits, where the pilot will meet increasing resistance to control inputs that will take the airplane beyond the normal flight envelope, but can do so if he or she chooses. In either case, it is important for the pilot to understand what the design philosophy is for the airplane being flown.

An ouch follows 😦

But responders did not adequately verify their belief that one passenger – 16-year-old Ye Meng Yuan – had died. She was run over by two firefighting vehicles about a half an hour after the crash, the NTSB said.

Post by Tim

  1. Jerry says:

    I was trained as a Commercial pilot in the 1950s. When flying IFR, as this airliner was by definition, the sacred rule was to check the three A’s every five seconds — Airspeed, Altitude, Attitude.

    The pilots of this airplane clearly forgot about the first A, as it was more than 30 knots too slow. There are limits in airplane design for designing precautions against inattention. A certain level of competency is assumed by all airplane manufacturers and actually demonstrated for the controlling government agencies.

  2. JohnM says:

    We disagree with the comment that the 777 control systems contributed because we have a good safety record? That’s a non-sequitur. The latter part has nothing to do with the former part.

    One thing that really bothers me about the Asiana accident is the gaping hole in the roof of the plane. Does the plane have a vulnerability to fire near that point and if so did it contribute the Malaysian Airlines MH370 disaster, that plane also being a 777 and reported to be on fire?

  3. Wayne Job says:

    I spent many hours in the pointy end of boeing aircraft over many years. Their engineering is usually reliable and easy to use. All aircraft are inherently dangerous and it is crew training that makes them less so. Somewhat like modern cars , with all their safety features, it dumbs down the drivers. Thus making aircraft with all the bells and whistles, in an effort to make them Murphy proof, the crew know less and less about what makes them tick. Thus they are dumbed down and less attentive. The next generation of airliners will probably be crew less, talk about fly by wire.

  4. Konrad. says:

    No, it won’t do. Boeing is not to blame.

    I have a PPL, and what is painfully obvious it those piloting the aircraft had no understanding of aerodynamics, let alone the 100+ tonnes of aluminium they were supposed to be in control of.

    I’ve been dumped behind the controls of a turboprop and landed and escaped in soft mud. You know what you are doing or you do not. (soft mud short field take off instructions with additional cows/roos avoidance for free on receipt of self addressed post card)

    No good blaming Boeing. The pilots were idiots who wouldn’t have qualified in the “west”.

    Seriously, my instructor would have failed these flakes well before they could ever killed anyone.

    Not politically correct? Count the bodies. Then STFU.

  5. Tim Hammond says:

    I’m struggling to see how having a good safety record doesn’t mean something is safe? Sure, accidents could have been averted by brilliant piloting each time, but how likely is that?

    B777s have been landed millions of times safely in real life and millions of more times in simulators. They are safe. Or am I missing something here that means something that very, very rarely causes a problem (and then is probably caused by pilot error) is then not safe?

  6. mitigatedsceptic says:

    Boing’s response bodes ill for the future safety of commercial flying – more concerned to fight off litigation than to concede that all engineered systems can be improved.

  7. tchannon says:

    Author replies, a number of commenters mention what some people call “a refrigerator”, referring to a commodity product which has been turned into something soul-less doing all it does, not necessarily particularly well.

    I agree.

    Following is not well written, sorry, as is. Have a chuckle, yet another bird has fallen down our kitchen chimney so I have to go…

    Not everyone is “awake” (with it, technically able, etc.) and sometimes I unintentionally lean on anti blocking brakes, we all do, a slippery slope to sloppy yet our parents only managed to produce us because our forebears avoided the grim reaper. Safety is a tough many-faceted problem including the less obvious such as sending the crew to boredom comatose. A crew is there precisely because of the unexpected. Compromises are everywhere.

    As a retired designer who introduced automation I hate taking away control and particularly crass automatics, don’t actually work because it cannot be done. This flows off into misguided or greedy management. Oh look, we could remove staff but omit to point out this fatally compromises function.
    Life today is riddled with this.

    Safety is layered, primary (not having an accident) and secondary (minimising harm when it happens) and even then there might be more layers. False redundancy is frequent.

    In most cases where something dire has happened, not necessary known about in paperwork [*], there has been a multiple fault or failure.

    * why I picked up on Boing trying the years of perfection trick. How many by good fortune cases did manage to recover and land, not clump a wall? There is no system recording the status of every landing and investigation team looking. Ask Boing for the documentation showing the problem has never occurred, does not exist. All very simple, an identified issue, look at it, don’t do the tail end gripe. I hope that is just a daft PR person and not management or engineering writing. Reuters reporters picked up on this..

    Airbus? Oh I could point out their stupidity.

  8. tchannon says:

    Re: unedited last msg.
    Immature Jackdaw (last year’s I expect) fell down the chimney. It was fine. Awfully large feet and long legs.

    Black out all the windows, open outside door, remove fire, start to remove baffle. This one decided to sit tight so I put my hand in, whoosh. Clean up the mess, not too bad given it is a couple of months since the last one. Why this chimney? I have no idea but it is the tallest chimney pot.
    I hate to think how many bodies lie unnoticed.

  9. Konrad. says:

    sorry for my harsh response up thread. I posted after getting slightly riled by Willis’ “I cant find an 11 solar cycle in 17th century wallpaper designs, so the sun doesn’t effect climate…” game over at WUWT.

    My point was a perfectly good plane was flown into the ground in perfect weather. This has more to do with the adverse authority gradient and the rule dependant training in some airlines.

    JohnM however raises a very important issue, the pattern of the fire after the crash. I had to study the design of the 777 at uni as part of CAD/CAM as it was the first airliner designed in virtual space. The pattern of surface discolouration prior to the fire breaking through the skin exactly matched the primary aircon/pressurisation ducts.

    Given that the fire became the primary risk to passengers after “landing”, this warrants further investigation.

    This is not the first time such a top of cabin fire has occurred after a similar crash, previously with an airbus.

    The possibility of an electrical cause seems remote due to the pattern. Ingestion of burning debris into the pressurisation loop also seems unlikely as the engine pods broke off as designed.

    Photographs taken by passengers showed that the oxygen masks deployed in the impact just as in the airbus incident. The full “rubber jungle”.

    The question now is what happens when chemical oxygen generators are activated at sea level pressure? Could this have caused the cabin roof fires?

    777 discolouration before burn through –

    Air France 358 cabin fire –

  10. tchannon says:

    Gas flow sounds feasible, normally a severe issue for fire safety people.

    There has been a 777 fire incident where a powered seat trapped a passenger lithium battery.

    A fire aft would convect heat along the cabin top given the at rest attitude of the cabin.

    Looking around for images reminds me I never want to fly in a passenger jet again.

  11. Trick says:

    “…chemical oxygen generators are activated at sea level pressure? Could this have caused the cabin roof fires?”

    US NTSB Asiana Flight 214 accident report summary:

    “After the airplane came to a stop, a fire initiated within the separated right engine, which came to rest adjacent to the right side of the fuselage. When one of the flight attendants became aware of the fire, he initiated an evacuation, and 98% of the passengers successfully self-evacuated. As the fire spread into the fuselage, firefighters entered the airplane and extricated five passengers (one of whom later died) who were injured and unable to evacuate.”

    “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.”

    “I never want to fly in a passenger jet again.”

    When you do, rec. keep your seat belt fastened when in your seat:

    “18. Passengers 41B and 41E were unrestrained for landing and ejected through the ruptured tail of the airplane at different times during the impact sequence. It is likely that these passengers would have remained in the cabin and survived if they had been wearing their seatbelts.”

    Rec.s To Boeing:

    Using the guidance developed by the low-energy alerting system panel created in accordance with recommendation [7], develop and evaluate a modification to Boeing wide-body automatic flight control systems to help ensure that the aircraft energy state remains at or above the minimum desired energy condition during any portion of the flight. (A-14-XX)

    Revise your 777 Flight Crew Operating Manual to include a specific statement that when the autopilot is off and both flight director switches are turned off, the autothrottle mode goes to speed (SPD) mode and maintains the mode control panel-selected speed. (A-14-XX)


  12. Konrad. says:

    Trick says:
    June 26, 2014 at 2:58 am
    Fire ingress from the engine doesn’t match the discolouration prior to burn through. There is a distinct separation fore and aft of the crossover ducts.

    If it had been fire ingress from the engine trapped against the fuselage, primary burn would have been been forward of crossover. However greatest discolouration is aft and on the opposite side.

  13. Konrad. says:

    “Rec.s To Boeing”?

    No. Wrong.

    Full manual control in such circumstances. If you can’t fly without the assists, you shouldn’t be flying. Even auto brake should have been disengaged.

    There is a reason we keep humans in the loop. Humans who don’t understand that reason shouldn’t be in the loop.

    There is a problem with people who grew up in a house without a light switch flying jets. Pointing this out is not racism, just realism.

  14. Trick says:

    Konrad please note: “1. The following were not factors in the accident: flight crew certification and qualification; flight crew behavioral or medical conditions or the use of alcohol or drugs; airplane certification and maintenance; preimpact structural, engine, or system failures; or the air traffic controllers’ handling of the flight.

    28. Although no additional injuries or loss of life were attributed to the fire attack supervisor’s lack of aircraft rescue and firefighting (ARFF) knowledge and training…”

  15. Konrad. says:

    tchannon says:
    June 26, 2014 at 2:31 am
    “Looking around for images reminds me I never want to fly in a passenger jet again”

    While what starts as a pleasant flight could end in hideous terror…

    you can always chose to fly Pam Ann –

    They don’t make the same mistake more than three times…
    … well, maybe four… 😉

  16. Konrad. says:

    Trick says:
    June 26, 2014 at 4:10 am
    They flew a perfectly good aircraft into the ground in prefect landing conditions. All because they couldn’t fly without automatic systems. The ILS was down at the airfield and they couldn’t land without it. They should have been able to land without it with less than 5 km of slant visibility and 20 knt crosswind if they were in that seat.

    They were not “Gimli Glider” material. No if. No but. No maybe.

    Boeing is not at fault. No bit of paper can ever change that.

  17. Trick says:

    Konrad: “They were not “Gimli Glider” material.”

    Definitely. While the ILS glideslope was out of service for Asiana 214, it was legal to land w/o it. Those Gimli guys ignored an instrument panel indication the fuel gauges were inop. which meant it was illegal to fly the A/C. Which ran out of fuel. For which there was no training. Since it was illegal.

    I remember looking into the cockpit of an ancient DC-10-30 or maybe even was a -10 while boarding and seeing couple little white sticky notes stuck to the I/P instruments with arrows: “Add xx to this one, subtract xx from this one.” Difference between engineering & science.

  18. Konrad says:

    Trick says:
    June 26, 2014 at 4:56 am
    “While the ILS glideslope was out of service for Asiana 214, it was legal to land w/o it.”

    Legal? Is this more of your “iso certified kitchen” tripe?

    They lost ILS and they flew a perfectly good aircraft into the turf. They were incompetent.

    You can even see it from the altitude plot. After stuffing up, they wasted the flare and ground effect cushion before the sea wall. Serious lack of “The right stuff”.

    This was not piston or turboprop with pitch control. This was turbofan. You need to be well ahead of the aircraft all the way. They were well behind the curve all the way down.

    No amount of black squid juice on dead pressed tree pulp will ever change that.

    Despite the sackings, this is the most accurate assessment of the crash –