Asiana Airlines 777 crash at SFO

[Andyrooc]

I have a theory:

 

"If you weren't there in the cockpit, you probably don't know what happened. If you were there in the cockpit, you probably don't know what happened either."

 

So, the number of theories written on the internets provides roughly zero additional knowledge as to what actually happened, and even less as to why it happened.

[SwissCyul]

There we go:

 

 

Status: Preliminary - official Date: 06 JUL 2013 Time: 11:28

Type:Boeing 777-28EER   

Operator: Asiana Airlines

 

Registration: HL7742 C/n / msn: 29171/553

 

First flight: 2005-02-25 (8 years 4 months)

 

Engines: 2 Pratt & Whitney PW4090

 

Crew: Fatalities: 0 / Occupants: 16 

 

Passengers: Fatalities: 2 / Occupants: 291

 

Total: Fatalities: 2 / Occupants: 307

 

Airplane damage: Destroyed Airplane fate: Written off (damaged beyond repair)

 

Location: San Francisco International Airport, CA (SFO) (United States of America) 

 

Phase: Landing (LDG)

 

Nature: International Scheduled Passenger

 

Departure airport: Seoul-Incheon International Airport (ICN/RKSI), South Korea

 

Destination airport: San Francisco International Airport, CA (SFO/KSFO),United States of America

 

Flightnumber: 214

 

 

Narrative:
A Boeing 777-200 passenger jet, operated by Asiana Airlines, was destroyed in a landing accident at San Francisco International Airport, CA (SFO). There were 291 passengers and 16 crew members on board. Two passengers died and 49 were seriously injured.
Flight OZ-214 originated in Seoul-Incheon International Airport (ICN), South Korea were it departed at 16:35 local Korean time. Destination of the flight was San Francisco, CA. 
The weather at San Francisco was fine with 6-7 knot winds and a visibility of 10+ miles. The pilot undergoing initial operating experience was in the left hand seat as Pilot Flying. An instructor pilot was sitting in the right hand seat. The relief first officer was in the jump seat at the time of the approach.
The pilot flying had logged about 9700 flying hours. Flight 214 was his tenth flight leg on a Boeing 777 while undergoing initial operating experience.
The flight was cleared for an approach to runway 28L, the ILS glidepath of which had been declared unserviceable in the current Notam.
The airplane was configured for landing with 30 degrees of flaps and gear down. Target threshold speed was 137 knots. According to preliminary information from the cockpit voice recorder, the crew did not state and anomalies or concerns during the approach. The throttles were at idle and autothrottle armed. 
At 1600 feet the autopilot was disengaged. The aircaft descended through an altitude of 1400 ft at 170 kts and slowed down to 149 kts at 1000 feet.
At 500 feet altitude, 34 seconds prior to impact, the speed dropped to 134 kts, which was just below the target threshold speed. The airspeed then dropped significantly, reaching 118 knots at 200 feet altitude. The instructor pilot reported that he noticed four red PAPI lights and concluded that the autothrottle had not maintained speed.
Eight seconds prior to impact, the throttles were moved forward. Airspeed according to the FDR, was 112 knots at an altitude of 125 feet. Seven seconds prior to impact, one of the crew members made a call to increase speed. 
The stick shaker sounded 4 seconds prior to impact. One second later the speed was 103 knots, the lowest recorded by the FDR. One of the crew members made a call for go a around at 1.5 seconds before impact. The throttles were advanced and the engines appeared to respond normally. 
The main landing gear and rear fuselage then struck a sea wall, just short of runway 28L. Airspeed was 106 knots. The empennage separated at the rear bulkhead. 
The airplane then ballooned, yawed left and spun 360 degrees before it came to rest to the left of runway 28L, 735 m (2400 ft) from the seawall.
A post impact fire occurred when a fuel tank ruptured inboard of the nr. 2 engine, spilling fuel on the hot engine, causing it to ignite.

Weather at the time of the accident (11:28 LT / 18:28 Z) was reported as:
KSFO 061756Z 21006KT 10SM FEW016 18/10 A2982 RMK AO2 SLP097 T01780100 10183 20128 51005
[10:56 LT: Wind 210 degrees at 6 knots; Visibility: 10 or more miles; few clouds at 1600 feet AGL; Temperature: 18°C, Dew point: 10°C; Pressure 1010 mb]
KSFO 061856Z 21007KT 170V240 10SM FEW016 18/10 A2982 RMK AO2 SLP098 T01830100
[11:56 LT: Wind 210 degrees at 7 knots, varying in direction between 170 and 240 degrees; Visibility: 10 or more miles; few clouds at 1600 feet AGL; Temperature: 18°C, Dew point: 10°C; Pressure 1010 mb]

The ILS glidepath for runway 28L and 28R at SFO had been declared unserviceable from June 1 until August 22.

Sources: 
» NTSB

Edited July 11, 2013 by SwissCyul

[Nicola_M]

It certainly looks like autpilot was disengaged, and with it autothrottle too, as jetjerry said a few posts back.

Could be a basic pilot error, or something mechanical.  I can't believe that mulitple someones with that many hours would make such an elemental error.

 

But at the end of the day, we're all guessing. 

 

"The instructor pilot reported that he noticed four red PAPI lights and concluded that the autothrottle had not maintained speed."

Interesting, considering it's been widely reported the PAPis at SFO were off, and have been for the last two weeks.

Edited July 10, 2013 by Nicola_M

[Andyrooc]

Despite being mentioned in the NOTAMs, the PAPIs were actually working.

[Peter T.]

Maybe Wikipedia isnt a reliable source, but I read that the fire was traced to a post-crash rupture of an oil tank above the right engine, when oil leaking from the ruptured tank fell onto the hot engine and ignited

[Andyrooc]

Indeed, the huge fireball and subsequent fire would seem to indicate something flammable came into contact with something hot. And it definitely wasn't the left engine...

[SwissCyul]

Maybe Wikipedia isnt a reliable source, but I read that the fire was traced to a post-crash rupture of an oil tank above the right engine, when oil leaking from the ruptured tank fell onto the hot engine and ignited

Why Wikipedia?

 

 

Do you mean another post or mine?

 

I copied the information from the aviation safety network. Thats where the official reports come out.

 

http://aviation-safety.net/index.php

[greggerm]

Indeed, the huge fireball and subsequent fire would seem to indicate something flammable came into contact with something hot. And it definitely wasn't the left engine...

 

Goes to show you the differences of perception. Having watched the videos, I don't see a fireball with the initial crash - just a massive cloud of that brown dust kicked up from the airplane cartwheeling and slamming down in the dirt. Something in/near the remaining engine ignited and it spread slow enough for the passengers to evacuate.

 

The black smoke from the fire is visible in the video footage, emerging from the dust cloud almost immediately after the final slam into the ground. This is consistent with that still-running engine and fuel tank sustaining damage from that phase of the crash. The now famous (*first) passenger evacuation photo speaks to the fire as well, with a moderate plume of black smoke coming from behind the airplane on the #2 engine side of the fuselage. A later passenger photo shows that black plume extinguished by the ARFF as passengers continue to evacuate and mill around, prior to the cabin getting heavily involved.
 

Ultimately, over the history of aviation more experienced pilots have made more egregious mistakes causing far more tragic results. People, like machines, are certainly not infallible and crash after crash have shown how a chain of single, simple mistakes or omissions can end up in a serious incident. I'll be curious to read the reports on the CVR about how the cockpit was being managed during approach.

 

-Greg

[Andyrooc]

You could be right now that I look at it, but I was being a little facetious as well, and exaggeration was added for effect

 

The second photo is remarkable for the guy casually towing his luggage and on his phone - as if he did this every day. In fact it's remarkable the number of people who evacuated with their luggage seeing as you're not supposed to take such things on escape slides - at least on airlines I've been on.

[BWolf7]

In 2-3 hours I will be departing KSFO on a flight to KIAD. Ill see if I can see anything.

[Nicola_M]

Another Chinese girl has died from her injuries, bringing the death toll now to three.

http://www.bbc.co.uk/news/world-us-canada-23296760

[BWolf7]

At SFO, I was lucky enough to be able to take off on the parallel runway. Could clearly see the T7.

[scubajuan_new]

I know this is a sad incident that deserves respect for the victims and their families, but this just cracked me up. 

 

[Nicola_M]

Not funny.

[scubajuan_new]

Sorry Nicola, Should had just post it in the humour section

[sqrt(-1)]

It might have been funny had no one been hurt in the accident, but now it simply shows a lack of respect for those injured and lost.

[Redfisher]

Geez...lighten up ladies.

[sqrt(-1)]

Whatever you say, boss...

[SwissCyul]

Alright. Some new information.

 

I talked to a former 777 captain and he explained a bit what the cause was.

 

So the approach was a noise reduction approach to not disturb the people of San Francisco.

The 777 came in very steep and had to make various turns to get lined up with the runway. 

The approach was full manual except the speed. The instructor armed the auto-throttle at about 1000ft in descent. 

Normally the armed auto-throttle would engage when the plane catches the glideslope. But at this time the ILS system was turned of at KSFO.

Now the pilots didn't look at the speed anymore because they thought that the auto-throttle would control it. They were also too concentrated on

lining up the 777 with the runway. 35 seconds prior to impact they noticed that they were to low and to slow. By that time you could have managed the situation by pushing the throttle levers to full thrust. But again they were not really paying attention that the plane was already under the estimated touchdown speed. By the time they really put in thrust it was already too late to catch the airplane again. Another feature of the 777 is that when the speed

is too low the 777 automatically pushes down the nose when the auto-throttle is not engaged. That caused the airplane to descent even faster and hit the seawall. 
 

So the conclusion is that the pilots had just to push the engage button for the auto-throttle and the problem is solved.

 

Asian airline pilots are trained to fly only with the autopilot. This is a procedure to save time and to save money. But when a lot of little problems come together you can sometimes loose track of something that is very important. 

 

The same thing we saw with the Turkish airlines 737 crash at Amsterdam. Or the lion air crash 2 months ago. 

 

It's still a pilot error but we have also to look at the circumstances the pilots were in.  

 

I hope this is a bit more information then you knew. 

[Andyrooc]

Interesting, and it gels with stuff I have heard/read as well.

 

I talked to a few jet pilots (73/76/74) and one thing I came away with was the importance of airspeed. It's kind of the king of everything when flying because without enough of it, you stop flying and start falling. But it does seem that some airlines almost 'untrain' that rule from their pilots instincts by mandating automation and lowering its importance. So the pilots might have been doing what they had been trained to do, but really, the whole reason behind having a human up the front is to take care of situations that cannot be automated, and in that, it's seems that they and their training have failed rather badly. If indeed that is what happened!

[SwissCyul]

We just have to see what happens with the pilots. I don't know the regulations of the korean juridical system.

It could be that they will be sent to prison for the rest of their life. 

[Nicola_M]

They've got to leave the US first, and if there's any issue of culpability it's gonna be.... a while before Korea gets them back.

[SwissCyul]

And the reputation of Asiana Airlines is ruined. At least in America...

[BWolf7]

And the reputation of Asiana Airlines is ruined. At least in America...

As I departed SFO, on my left was the smoldering remains of an Asiana 777. On the right was a taxiing Asiana 777. The irony was sickening 

[Andyrooc]

Ironic in a Alanis Morrisette kind of way I guess...