The National Transportation Safety Board is holding a daylong hearing into last July’s Asiana Airlines crash at San Francisco International Airport. Here’s the link to live video streaming page for the hearing: Investigative Hearing: Crash of Asiana Flight 214.
The day began with a brief review of the SFO incident on July 6, 2013, and the rest of the day has been devoted mostly to a painstaking examination of the design and performance of the autopilot technology used on Boeing 777s like the one involved in the crash. Those systems are of concern because Flight 214′s speed had fallen far below the speed the crew reportedly believed it had set for the approach — to 103 knots from the commanded 137 knots. The crew didn’t detect the loss of speed until the crash was imminent.
Among a large number of documents released in connection with today’s hearing is a 139-page summary of crew interviews following the crash. The pilot at the controls of the flight, Captain Lee Kang Kuk, told investigators he was “very concerned” about having to land the airliner using a visual approach to the airport. The visual approach was necessary because an airport glide-slope indicator, a system that helps pilots monitor their descent to the runway, was not operating because of construction work at SFO. Lee, a 19-year veteran with Asiana, was training to fly the 777 and making his first landing attempt at SFO at the controls of one of the Boeing jumbo jets. He’s quoted as telling investigators he found everything about landing at the airport difficult, “even landing and taxiing to the gate was stressful, because it was very busy and the controllers were very busy and spoke quickly.”
As to his concern for the approach, the interview summary says:
[Lee] was asked whether he found the accident approach easy or difficult or in the middle. He said it was very stressful, very difficult to perform a visual approach with a heavy airplane, always. From the planning phase it was very stressful because the glideslope was very, very helpful to making an approach. He knew the NOTAMs [Notices to Airmen] said it was out of service, but everyone else had been doing the visual approach, so he could not say he could not do the visual approach. That had been “a very stressful factor”. Asked whether he was concerned about his ability to perform the visual approach, he said “very concerned, yea”. Asked what aspect he was most concerned about, he said, “the unstable approach”. He added, “exactly controlling the descent profile and the lateral profile, that is very stressful.”
Asiana’s chief 777 pilot, Lee Sung-kil, was asked at today’s NTSB hearing if he could explain why Lee Kang Kuk would have felt stressed at the prospect of a visual landing at SFO without the glideslope system. Through a translator, the chief pilot said he was at a loss to explain those statements and emphasized Lee Kang Kuk’s nearly 10,000 hours of flying experience with Asiana.
In his post-crash interview with the safety board investigators, Lee Kang Kuk suggested he was reluctant to initiate an emergency “go around” in deference to the instructor pilot monitoring his handling of the flight, Capt. Lee Jungmin. The instructor pilot, also referred to as the “pilot monitoring,” or PM, was senior to the trainee pilot. In an exchange that illustrates a possible language barrier between the Korean pilot and the accident investigators, he tried to explain why it was “a hard thing” for him to take control of the plane for the “go around” even as the crash was near:
… Normally only in our Korean culture, the one step higher level, the final decision people, he did, he decide the going-around thing. It’s very important thing. As a first officer or the low level people, they dare to think about the go around thing. It’s very hard.
Q. (Investigator): In your mind, then, and I don’t want to put words in your mouth, you tell me, did you feel that as the pilot in the left seat flying the airplane that you had the authority to do, commence a go around yourself?
A. (Lee Kang Kuk): Go around thing. That is very important thing. But the instructor pilot got the authority. Even I am on the left seat [in the command pilot's position], that is very hard to explain, that is our culture. …
Lee Kang Kuk told investigators he was briefly blinded by an unidentified bright light in front of the plane as it neared the runway. That prompted investigators to ask in a follow-up interview whether he wore sunglasses in the cockpit. Lee told the investigators no, “because it would have been considered impolite for him to wear them when he was flying with his PM. He said it was very important in their culture.”
Flight 214 was Lee Kang Kuk’s fifth training trip aboard a 777, but he told investigators he was not sure he was prepared to fly the jet:
Asked how confident he felt about his knowledge of the B777 autoflight system just prior to the accident, he said he was not so confident because he felt he should study more. Asked whether he had been studying and did not feel confident or he had not had enough time to study sufficiently, he said he did not know if he had studied a proper amount, he had just followed the company program. Asked if he felt he was still learning how the system worked, he said every pilot should study every day.
Here’s the Associated Press story on the pilot interviews and what they reveal about the events leading to the Asiana Flight 214 crash:
By Martha Mendoza and Stephen Braun Associated Press
WASHINGTON — The pilot whose Boeing 777 crashed last summer at the San Francisco airport told investigators he was “very concerned” about attempting a visual approach without the runway’s instrument landing aids, which were out of service because of construction, according to an investigative report released Wednesday.
Lee Kang Kuk, a 46-year-old pilot who was landing the big jet for his first time at San Francisco, “stated it was very difficult to perform a visual approach with a heavy airplane.” The jet came in too low and slow and crash-landed, killing three people and injuring more than 200, according to the National Transportation Safety Board.
A visual approach involves lining the jet up for landing by looking through the windshield and using numerous other cues, rather than relying on a radio-based system that guides aircraft to the runway.
The investigative report was released at the start of a daylong NTSB hearing that was called to answer lingering questions about the crash, not to conclude exactly what went wrong.
Though Lee was an experienced pilot with the Korea-based airline, he was a trainee captain in the 777, with less than 45 hours in the jet. He had not piloted an airliner into San Francisco since 2004, according to NTSB investigator Bill English.
So far, the investigation has not found any mechanical problems with the 777 prior to impact, although testing is ongoing, English said.
Lee told investigators that he realized others had been safely landing at San Francisco without the glide-slope indicator, an array of antennas that transmits a signal into the cockpit to help with the descent. That system was out of service while the runway was expanded. It has since been restored.
In his interview, the trainee said that while privately he was “very concerned” about his ability to do a visual approach, “everyone else had been doing (it), so he could not say he could not do the visual approach.”
There were other indications that a culture of not acknowledging weakness — and of deferring to a higher-ranking colleague — contributed to the crash.
Lee told NTSB investigators that he did not immediately move to abort the landing and perform a “go around” as the plane descended because he felt that only the instructor pilot had the authority to initiate that emergency move.
A reluctance of junior officers to speak up had been an issue in past accidents, though industry training has tried to emphasize that safety should come first.
Lee also conceded that he was worried about his unfamiliarity with the 777′s autoflight systems. He admitted he had not studied the systems well enough and thought that the plane’s autothrottle was supposed to prevent the jet from flying below minimum speed as it drew near the runway.
But two other Asiana pilots who took an instruction class with Lee said that they were told that the throttle hold did not automatically re-engage under certain autopilot modes.
“This pilot should never have taken off,” said attorney Ilyas Akbari, whose firm represents 14 of the passengers. “The fact that the pilot was stressed and nervous is a testament to the inadequate training he received, and those responsible for his training and for certifying his competency bear some of the culpability for the tragedy of this crash.”
Lee told investigators that as he realized his approach was off, he was worried he might “fail his flight and would be embarrassed.”
Another Asiana pilot who recently flew with Lee told investigators that he was not sure if the trainee captain was making normal progress and that he did not perform well during a trip two days before the accident. That captain described Lee as “not well organized or prepared,” according to the investigative report.
Asiana’s chief pilot told investigators that the airline recommended pilots use as much automation “as possible.”
He also said that the airline told its pilots to turn off the 777′s autopilots below 1,000 feet when making visual approaches to airports. But a former Asiana pilot told the board that Asiana pilots were rarely allowed to practice visual approaches on landing and that many trainee pilots “did not feel confident and did not want to make any mistakes.”
The agency did not say whether Asiana’s reliance on automatic landings was greater than the industry norm.
Recordings from the cockpit show Lee took the controls as the autopilot disconnected when the plane was about 1,500 feet above San Francisco Bay.
Lee insisted in interviews that he had been blinded during a critical instant before the botched landing by a piercing light from outside the aircraft. NTSB investigators repeatedly probed him about the light, but he was unable to pinpoint its origin or how it precisely affected him.
The instructor pilot said he never saw a bright light outside the aircraft.
According to a transcript of the Asiana plane’s cockpit voice recorder, the crew did not comment on the jet’s low approach until it reached 200 feet above the ground.
“It’s low,” an unnamed crewman said at 11:27 a.m.
In an instant, the plane began to shake.
At 20 feet, another crewman broke in: “Go around,” he said. But It was too late.
NTSB investigators also raised concerns about a safety certification issue involving the design of Boeing 777′s controls, warning that the plane’s protection against stalling does not always automatically engage.
When the plane’s autothrottle is placed in a “hold” mode, as it was during the Asiana flight, it is supposed to re-engage or “wake up” when the plane slows to its minimum airspeed.
But a pilot who oversaw the Boeing 787 flight tests for the Federal Aviation Administration told the NTSB that both the 787 and the 777 have the same anti-stall protection systems — and that the wake-up system did not always work when tested at minimum speeds.
Boeing’s retired 777 chief pilot, John Cashman, underscored that auto controls are not designed to replace pilots.
“The pilot is the final authority for the operation of the airplane,” he said.