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NTSB releases Asiana 214 CVR Transcript

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PDF of the transcript of the cockpit voice recorder for Asiana 214 (dms.ntsb.gov) Daha Fazlası...

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TXCAVU
They got way behind the plane and couldn't recover for a go around. Unfortunate.
preacher1
preacher1 12
Exactly. Even putting the cultural issues aside, the training pilot is as much at fault as the trainee for not monitoring the airspeed. As a trainer, he should have had enough savvy to make sure the Auto Throttles were activated. Everybody talks about the different modes but the 777 has been around a long time with that same cockpit and avionics setup and other 121's, both U.S. or foreign carriers aren't crashing them. They screwed up. To admit that will be total disgrace in their culture but that is what they need to do and save the rest of us a lot of grief and bother.
TXCAVU
And the pissing talk about the captain who went to another carrier...droning on and on withing last 30 minutes of flight.
preacher1
preacher1 4
Seems to me that's what happened to the UPS A330 at BHM; they were yakking rather than monitoring the approach.
TXCAVU
Didn't catch the CVR on that one (UPS A330/BHM). Still wondering how they were found outside the plane.
preacher1
preacher1 3
I don't think I heard that officially. I think it was a comment on here, in that somebody posted they heard the transcripts. NTSB didn't put out much on that one and it's actually been kinda quiet.
isppilot
Victor Tango 1
The chatter about the other captain happened above 10,000 ft. Sterile cockpit rules are no irrelevant conversations below 10,000 ft. When they were cleared to descend to 9000, there was no further nonsense chatter.
preacher1
preacher1 1
I guess that is true, but what in the sam hill were they doing during that time?
gearup328
Peter Steitz 1
Amen, Preacher1
smoki
smoki 4
Amidst all the inputs by the right seat Check / Training Captain that "...it looks high..." during the approach there's never any mention by either one of them (left seat Captain PF or the Check Captain) as to the altitude they should be at according to distance. With a negligible correction for touchdown zone altitude at SFO, the basic rule of thumb that's been around forever for a 3 degree glideslope of 300ft per mile could easily have been cross checked during the approach. Assuming there's DME provided on the localizer the distance would have been measured essentially from the touchdown zone otherwise GPS distance could have been used and in a worst case the SFO VORTAC with correction.

These two weren't pilots at all, they were switch flippers, button pushers and knob twisters as if they were playing a video game with no instrument scan to catch the fact that the all important number, i.e. airspeed, was decaying to stall, thus the stick shaker stall warning just prior to impact. What a surprise given the throttles were resting on the flight idle stops throughout the approach. Putting complete trust in a computer or several of them on a flying machine is a perfect setup for disaster. The crash of AF 447 a few years ago is another such example with the final words spoken on the CVR ("damn it, we're going to crash") reflective of the realization too late that the computer was wrong after all.
dupre
roberto dupre 1
Dear Paul,
Donald is correct. All systems on the Airbus performed OK till the impact...At the moment the A/P disengage, pilot control inputs (right seat) stayed erratic till it hit the ocean....A clear case of pilot(s) error.
donallen
Donald Allen 0
Your last sentence is just wrong, absolutely wrong. Have you read the publicly available account of AF447? I don't think so. The computer wasn't involved in that accident at all. It had switched to "alternate law", handing control of the aircraft to the pilots, because it had no reliable airspeed indications, due to Pitot tube icing. The pilot in the right seat was flying the airplane and no idea what he was doing. In fact, the only thing they did right was to turn on the Pitot tube heaters, which cleared the problem and resulted in many stall warnings. Which the PF and the fellow in the left seat ignored. So, in fact, the computer was right and they ignored it, killing themselves and a lot of innocent people.
donallen
Donald Allen 0
In that last sentence, you don't know what you are talking about. Have you read the publicly available accounts of the AF447 accident? I don't think so. If you have, you didn't understand them.

The facts are this: AF447 was flown into a high altitude storm, mistake 1, and the Pitot tubes iced up. With no reliable airspeed, the computer went into "alternate law", handing the airplane over to the pilots, neither of them the captain, who had left the cockpit to rest just before entering the storm (mistake 2). The PF was the least experienced of the three and tried to climb over the storm, from 35000', an impossibility (mistake 3). In so doing, he put the airplane into a high altitude stall. The only thing these guys did right was to turn on the Pitot tube heaters. Once the icing condition cleared, the computer got back in the act and issued multiple stall warnings, which the people (I hesitate to use the word 'pilots') in the cockpit ignored, resulting in their deaths and the deaths of hundreds of people who had put their trust in them. The fact is that the computer was RIGHT and was ignored, resulting in hundreds of fatalities.
dbaker
Daniel Baker 4
NTSB / Operations Group Chairman Factual Report - Interview Summaries (139 pages)

http://dms.ntsb.gov/public%2F55000-55499%2F55433%2F543238.pdf
joelwiley
joel wiley 2
thanks for posting.
akayemm
Er.A.K. Mittal 1
Nice bundle of info to go thru.
Great job. ThanX.
mmcleran
Crainium rectum extractus - so preventable
joelwiley
joel wiley 3
Analcephalectomy is another term for it.
VFR is challenging prior to the procedure.
Doobs
Dee Lowry 3
The cockpit equipment is designed offer "Pilot Choices". "Pilot Automation" is to aid the pilot and not to represent the pilot.
sparkie624
sparkie624 1
I would appear that they did not make the recommended "Pilot Choices"
sparkie624
sparkie624 2
Is it just me, or did there seem to be a very short check list and a lot of non-essential conversation on the approach. Those guys had the clues... Ben nice if they had listened to them.
akayemm
Er.A.K. Mittal 1
These pilots did nothing that an average pilot does. None of the basics were followed,as it seems to me,a layman.
No one from ASIANA have any defence. Entire analysis of fact finding has limited but highly important application. What corrections are needed on the part of ASIANA.
Legal claims have nothing to do with the long term safety measures needed at ASIANA as a whole.
A full overhaul is the call of the day.
preacher1
preacher1 2
Asiana, like many other companies, both foreign and domestic, have plenty of policies and SOP's in place that look real good on paper, BUT, no on can have full assurance of what goes on in the cockpit. In this case, CRM and the trainer should rule, not culture or status, as noted by the PF not wanting to ask for the other runway because it would be an embarrassment.
akayemm
Er.A.K. Mittal 1
Pardon the my style. What makes a banana republic so ? They too have good looking set of constitution and laws !
We, in India have laws which can be envy of any civilised but on implementation ? It's all too pathetic ! Sadly .
That's why every where there is cry to discard excessive legislation, and instead bring about better implementation.
Be it a nation or a corporation or a home !
gearup328
Peter Steitz 1
Can you imagine the SFO tower on a balmy, beautiful day watching an aircraft sink below the GP and crash into the approach end of the runway? Must have been a dream awakening. I don't care what all of you post here----pilots need to "fly the airplane". Automation is great but when it comes to eyeballs--we need real pilots. The airplane will fly just right if you guide it.
sparkie624
sparkie624 1
Seeing their distance and the fact that depth perception, they probably knew they were close, but thought the crew knew what they were doing until parts started flying off the plane. Nothing the tower could have or should have done. All on the crew on this one.
eli62
Lee Bolman 1
We know from research back in the 70s that pilots make more errors as stress increases. Reports on the Asiana accident indicate that you had two newbies at the controls: the Captain/pilot flying, who was new to the equipment, and the pilot monitoring/PIC, who was in his first run as an instructor, commanding from the right seat.
The PF told investigators he was feeling a lot of stress, presumably because he wasn’t yet fully comfortable with the plane, didn’t have much experience landing it, and felt some additional pressure from the need to make a visual approach with the glide slope out.
A key question is whether the check pilot (PM) didn’t see trouble coming, or did see it but didn’t know what to do. Could he have been afraid of making a bad situation worse by adding more stress to the PF? It was his first run in an instructor role, and the first time he and the PF had flown together. All that might help to explain why a PM who was active and chatty before things started to heat up got so quiet during a critical phase of flight.
I haven’t heard the CVR, but I’m guessing the relief pilot in the jump seat was concerned but very polite when he said , “Sink rate, sir” about 50 seconds before impact. The PF acknowledged that input, but the relief pilot repeated it five seconds later, and maybe a third time. (The source isn’t identified on the third one.) So the pilots got a gentle hint from a back seat driver that maybe they were descending too fast, but for the next 40 seconds or so, all we hear from them is routine calls. The first indication that the PM might be concerned is his comment 23 seconds before impact, “It’s low.” The PF responded, “Yeah.” Not until 8 seconds to impact does the PM comment on speed, and he only issued his go-around call at 30 feet and after the stick shaker warning.
So this may be a classic CRM accident, reminiscent of Eastern’s 1011 at MIA where everyone’s attention was riveted on a nose gear light. You’ve got a PF whose bandwidth is severely narrowed by the stress he was feeling, and a PM who was either out of the loop, or so focused on trying to figure out how to be a good coach that he forgot he was in command of the airplane.
gearup328
Peter Steitz 1
Look, guys a 3 degree GS is 3,000 feet AGL at 10 miles. This aircraft had a radar altimeter. They were over open water--the bay. At 3 miles, they should have about 900 feet AGL. One mile and 300 feet AGL. Glide slope or not. This is just not professional piloting. I'll say it again----FLY THE AIRPLANE.
sparkie624
sparkie624 1
You are correct... the Radio Altimeter should have given them at least part of a clue they were too low... I mean really... On the EGPWS... What do they think the phrase "TOO LOW! PULL UP! TOO LOW! PULL UP!" means... That was heard on the CVR... Of course.... The captain did decide to call Go Around (1st right decision so far, about 30 seconds too late).
cblair0608
cblair0608 1
I'm at a loss. I just don't understand how they weren't monitoring the airspeed. Everyone knows your speed is EVERYTHING, how could they not see they were so low?? Regardless of the "mode" your in you monitor the speed. Being a pilot I try to defend the pilot as much as possible, but its hard to do here......ridiculous. So sad...
preacher1
preacher1 4
Flying is unforgiving. They screwd up and to admit they just flatly made a mistake is total shame and disgrace in that culture, not to mention the clear path to lawsuits it would open up straight to Asiana. Last I heard they were both on desk duty.
btweston
btweston 4
I think that trying to cover one's ass is fairly universal.
preacher1
preacher1 1
You are probably correct, LOL
akayemm
Er.A.K. Mittal -1
Dear preacher1, as I understand , orientals ,including us Indians, are God fearing and humble people. Always worried about the after life and/or the next life.
Admission of an error makes a person great, absolves the person partially.
It's a part of penance and hence a pious act .
Why they failed or evaded , is totally beyond me!
As far as legal claims are concerned they can still be raised , and will be raised.
I guess I have made my point. On both counts.
dupre
roberto dupre 3
When a pilot, from any country, takes the controls of either a C-152 or a B-777, he should leave all his cultural, spiritual and personal beliefs behind and just concentrate to fly the aircraft in a safe manner... Once landed and off duty, only then, he can turn his brain waves loose ,on any exotic thoughts, if he wishes to do so.
preacher1
preacher1 1
You are correct, he SHOULD
preacher1
preacher1 2
Well, I sort of disagree on the Oriental culture. We have been down that road many times before. It may be in their personal thinking but not in the culture in which they live daily.
tbpera
Tom Pera 2
please, Mittal, there's been so many, many reports and accidents related to this issue...catch up!
gearup328
Peter Steitz 1
OK, you can speak of the afterlife but we have a duty to preserve life here on Earth.We have a duty to learn to perform as best we can. These Asiana pilots absolutely failed in their duty. I have made hundreds of approaches visually without any outside guidance except the runway touchdown markings. This culture in Asia has no place in aviation.
preacher1
preacher1 1
It may not have place but it is there. It is not as bad at KAL, simply because they are older, but I remember back in the day, spending a weekend in Seoul and talking to a Boeing Driver that was delivering the first of their 747's. He said that cockpit was hallowed ground. They all had to have KAL uniforms to fly and he said it was a bow every time they turned around and that the regular KAL Captains just strutted around like Banty Roosters.
sparkie624
sparkie624 2
Very simple... they were too busy admiring the "Golden Gate Bridge"

11:13:12.3
CAM
-
1
{
ah. that bridge leads to Oakland
.
btweston
btweston 2
That simple, eh? They looked at a bridge fourteen minutes before the crash. Great. Why have an organization like the NTSB when we can just read your internet comments?
PhotoFinish
PhotoFinish 2
They were reportedly asked what they were doing between. 1600 ft and 500 ft and between 500 and 200 (when the flight modes were changed, and when the decaying airspeed was not detected, respectively, and while the plane was swinging wild in both lateral position and dropping from above the glidepath to below the glidepath).

They went from 1 red PAPI to 2 red and 2 white to 3 red PAPI in those 2 periods. Then went 4 red PAPI below 300 crashing and killing passengers.

Their answer was they were looking outside. What specifically were you looking at.

the runway...
the beginning of the runway...
the end of the runway...

Not once did they mention the bridges, the bay, the city, the skyline.

Did they avert their eyes from the visual splendor that is approaching San Francisco, or was the failure to admit to admiration of the view was just a CYA? You be the judge.
hopskip
There's 2 things you need to look at during a visual approach.

1: The runway
2: The airspeed indicator.

You really should be darting your eyes down to the airspeed indicator once every few seconds to check.
joelwiley
joel wiley 1
Was this transcript edited? It seems rather sparse and just hit the 'highlights'.
Routine checklist comments unposted?
Am curious in view of the interview transcripts.
sparkie624
sparkie624 1
Something was edited... It looks different than the first time I saw it.
joelwiley
joel wiley 1
Great, another conspiracy theorist's starting point.
sparkie624
sparkie624 1
Just stating fact... First time I opened it it was not formatted correctly and had to scroll left and right to read a lot of it... When I opened it this time all the paragraphs and pages were where and how they were supposed to be. The changed could have been as simple as a global format change or a parameter change when they rewrote the data file. Not saying any data was changed..Just the format.
projectabove35000feet
PATFTF PATFTF 1
Thanks I actually did enjoy this.
donimolony
Doni Molony 1
Thank you for the post. I enjoyed reading it.
tbpera
Tom Pera 1
trainee had 33 hours on the 777...what's that 2-3 flights?? 4-6 landings and takeoffs? where WAS the trainer on this?? jeeeeez
preacher1
preacher1 2
Lot's of folks have asked that same question. I think Sr. Pilot, PF, saying "I got this, leave me be". LOL
tbpera
Tom Pera 1
tlehner
Tom Lehner 1
No excuse. Captains ho lee fuk and sum ting wong.
sparkie624
sparkie624 1
You forgot the Observer... We Too Low - He should have been looking at something other than the bridge.
preacher1
preacher1 1
Seems to me he called sink rate warning but nobody listened
PhotoFinish
PhotoFinish 1
Four 'Sink Rate' warnings from the FO wre either completely ignored or dealt with incompetently by the 2 Captans at the controls. Had the relief captain not been sleeping in first class, but on the flight deck for approach, his relief FO's warnings (together with his own) may have carried more weight.

They supposedly have CRM training twice a year. In this case, it seems like it must've gone in one ear, out the other.
sparkie624
sparkie624 1
I thought it came from the Automated Computer from the EGPWS
PhotoFinish
PhotoFinish 2
The FO warned them multiple times before the automation.

He stopped warnin them because it seemed they had dealt with the situation. But in the late stage of flight, he could no longer visualize the ground from the jump seat to visualize the continued sink rate despite the nose pitching up.
Bernie20910
Bernie20910 1
The real problem was that a previously undetected and unsuspected, and very localized, short duration earthquake occurred, precisely at the runway threshold, and precisely at the moment they passed over it (on their otherwise perfect landing approach) which caused the entire end of the runway and the seawall to suddenly rise up and strike the aircraft, then subside back down. Act of God and all that, the crew is blameless and exonerated.

That's the new story, and their lawyers will be sticking to it.
Doobs
Dee Lowry 1
Earthquake or not...I, personally don't think the landing...if you want to call it that, maybe an out of controlled crash?...would have made a difference in the outcome. If the "seawall" wasn't there, they would have most likely put the bird in the bay. Really? There were 4 pilots in the nose with their finger up their butt! No excuses.
joelwiley
joel wiley 1
You forgot to include the USGS coverup regarding the seismograph recordings.
Bernie20910
Bernie20910 1
I thought that went without saying... :)

[This comment was deleted.]

preacher1
preacher1 1
That could happen after the NTSB report is final, but not until.
dupre
roberto dupre 2
Thanks for the info
PhotoFinish
PhotoFinish 1
Might depend on how quickly and credibly they respond to the accident during the 12-18 months until the report comes out (by demonstrably improving their pilot training and flight deck CRM practices).

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