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Fatigue, inexperience may have contributed to Asiana crash

By Martha Mendoza & Paul Elias

Associated Press

LAST UPDATED: 02:12 p.m. HST, Jul 08, 2013

SAN FRANCISCO » Investigators trying to understand why Asiana Airlines Flight 214 crash landed focused today on decisions made in the cockpit of the giant jet, where an experienced pilot was learning his way around a new aircraft and fellow pilots were supposed to be monitoring his actions.

Authorities also reviewed the initial rescue efforts after fire officials acknowledged that one of their trucks may have run over one of the two Chinese teenagers killed in the crash at San Francisco International Airport. The students were the accident's only two fatalities.

National Transportation Safety Board Chairman Deborah Hersman said investigators watched airport surveillance video to determine whether an emergency vehicle ran over one of students. But they have not reached any firm conclusions.

The students had been seated in the rear of the aircraft, where many of the most seriously injured passengers were seated, Hersman said.

The NTSB also said part of the jet's tail section was found in San Francisco Bay, and debris from the seawall was carried several hundred feet down the runway, indicating the plane hit the seawall on its approach.

Investigators have said Flight 214 was flying "significantly below" its target speed during approach when the crew tried to abort the landing just before the plane smashed onto the runway. Authorities do not know yet whether the pilot's inexperience with the Boeing 777 and landing it at San Francisco's airport played a role.

The airline acknowledged today in Seoul that the pilot at the controls had little experience flying that type of plane and was landing one for the first time at that airport.

Asiana spokeswoman Lee Hyomin said pilot Lee Gang-guk had logged nearly 10,000 hours operating other planes but had only 43 hours in the 777, a plane she said he still was getting used to flying.

It's not unusual for veteran pilots to learn about new aircraft by flying with more experienced colleagues. Another pilot on the flight, Lee Jeong-min, had about 12,390 hours of flying experience, including 3,220 hours on the 777, according to the Ministry of Land, Infrastructure and Transport in South Korea.

Lee Jeong-min was the deputy pilot, tasked with helping Lee Gang-guk get accustomed to the 777, according to Asiana Airlines.

It was unclear whether the other two pilots were in the cockpit, which seats four. But that would be standard procedure at the end of a long international flight.

NTSB lead investigator Bill English said pilot interviews were going slowly because of the need for translation. The interviews began only after agents from the Korean Aviation and Rail Accident Investigation Board arrived from South Korea.

New details of the investigation have also raised questions about whether the pilots may have been so reliant on automated cockpit systems that they failed to notice the plane's airspeed had dropped dangerous low, aviation safety experts and other airline pilots said.

Information gleaned from the Boeing 777's flight-data recorders revealed a jet that appeared to be descending normally until the last half-minute before impact.

The autopilot was switched off at about 1,600 feet as the plane began its final descent, according to an account of the last 82 seconds of flight provided by Hersman.

Over the next 42 seconds, the plane appeared to descend normally, reaching about 500 feet and slowing to 134 knots (154 mph), a 777 pilot for a major airline familiar with Hersman's description told The Associated Press. The pilot spoke on the condition of anonymity because his company had not approved him speaking publicly.

But something went wrong during the following 18 seconds. The plane continued slowing to 118 knots (136 mph), well below its target speed of 137 knots (158 mph) that is typical for crossing the runway threshold. By that time, the plane had descended to just 200 feet.

Eight seconds later, with the speed still falling, Hersman said, the throttles were moved forward, an apparent attempt by the pilot to increase speed. But it was too little, too late.

Five seconds later, at 50 percent power, speed began to increase.

A key question raised by the NTSB's account is why two experienced pilots — the pilot flying the plane and another supervising pilot in the other seat — apparently didn't notice the plane's airspeed problem.

Part of the answer to that question may lie in whether the pilot flying, after switching off the autopilot, still had the plane's autothrottle engaged during the descent.

Aviation safety experts have longed warned that an overreliance on automation is contributing to an erosion in pilots' stick-and-rudder flying skills. It's too soon to say if that was the case in the Asiana crash, but it's something NTSB investigators will be exploring, they said.

"It sounds like they let the airplane get slow and it came out from under them," said John Cox, a former US Airways pilot and former Air Line Pilots Association air crash investigator.

"There are two real big questions here: Why did they let the airplane get that slow, and where was the non-flying pilot, the monitoring pilot, who should have been calling out 'airspeed, airspeed, airspeed,' " Cox said.

More than 180 people aboard the plane went to hospitals with injuries. But remarkably, 305 of 307 passengers and crew survived, and more than a third didn't even require hospitalization. Only a small number were critically injured.

The passengers included 141 Chinese, 77 South Koreans, 64 Americans, three Canadians, three Indians, one Japanese, one Vietnamese and one person from France.

Three firefighters — and two police officers without safety gear — rushed onto the plane to help evacuate trapped passengers, including one who was trapped under a collapsed bulkhead.

They had gotten everyone off the craft except one elderly man, who was in his seat, moaning and unable to move.

"We were running out of time," San Francisco Fire Department Lt. Dave Monteverdi recalled Monday at a news conference. "The smoke was starting to get thicker and thicker. So we had no choice. We stood him up and amazingly, he started shuffling his feet. That was a good sign...we were able to get him out and he was pretty much the last person off the plane."

The two dead passengers were identified as 16-year-old students from China who were scheduled to attend summer camp in California with dozens of classmates.

One of their bodies was found on the tarmac near where the plane's tail broke off when it slammed into the runway, the other was found on the left side of the plane about 30 feet (10 meters) away from where the jetliner came to rest after it skidded down the runway.

The flight originated in Shanghai, China, and stopped over in Seoul, South Korea, before making the nearly 11-hour trip to San Francisco.

NTSB investigators are also sure to examine whether pilot fatigue played a role in the accident, which occurred after a 10-hour nighttime flight. As is typical for long flights, four pilots were aboard, allowing the crew to take turns flying and resting. But pilots who regularly fly long routes say it's difficult to get restful sleep on planes.

The accident occurred in the late morning in San Francisco, but in Seoul it was 3:37 a.m.

"Fatigue is there. It is a factor," said Kevin Hiatt, a former Delta Air Lines chief international pilot. "At the end of a 10-hour flight, regardless of whether you have had a two-hour nap or not, it has been a long flight."

The two teenagers killed in the crash were close friends and top students.

Wang Linjia showed talent in physics and calligraphy; Ye Mengyuan was a champion gymnast who excelled in literature. Both were part of a trend among affluent Chinese families willing to spend thousands of dollars to send their children to the U.S. for a few weeks in the summer to practice English and hopefully boost their chances of attending a U.S. college — considered better than China's alternatives by many Chinese families.

The girls posted their last messages on their microblog accounts Thursday and Friday. The last posting from Wang said simply, "Go."


Lowy reported from Washington.


Associated Press writers Jason Dearen, Terry Collins, Paul Elias, Lisa Leff and Sudhin Thanawala in San Francisco, Gillian Wong and Didi Tang in Beijing, and Hyung-jin Kim in Seoul also contributed to this report.

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atilter wrote:
greater and greater reliance on hi-tech autmation to aide human effort has minimized/diminished practical ability...human action is not perfect but with the proper training and practice, the human will be the ultimate performer especially in the event that any hi-tech aide is momentarily turned off for maintenance...example - students are now so reliant upon computers/calculators, they no longer have the ability to perform simple logic math calulations without them because they don't have to (there is no requirement to learn to do without them)...
on July 8,2013 | 12:34PM
Valleyisle57 wrote:
Wow.....That has got to be one of the longest sentences I have ever seen! Atilter, please learn proper grammar before posting. You lost me after the first line!
on July 8,2013 | 12:59PM
MakaniKai wrote:
me too! Painful read.
on July 8,2013 | 01:22PM
serious wrote:
Where is that invisible hand that cuts off these comments? Say something, spit it out!!! Four pilots in the airplane. On landing two in the seats and another is in the jump seat between the pilots. They were too slow and too low--three pairs of eyes ---- Somebody has to say something---doesn't matter the amount of time in that particular airplane --- if you don't have speed and altitude you CRASH!!!!
on July 8,2013 | 02:09PM
atilter wrote:
ooo- i'm sorry!!!
on July 8,2013 | 05:09PM
808warriorfan wrote:
Take a DEEP BREATH and see if you can say that in one (1) breath w/out having to come up for air.....
on July 8,2013 | 11:13PM
goodday wrote:
Students have to do tests/homework without calculators. There's no way to show all the work by just punching in numbers in a calculator.
on July 8,2013 | 04:20PM
atilter wrote:
wonderful! - or - simply show all the steps in the logic process by using da pencil and paper - not just write down the answer the calculator spits out. first - define and list the given facts in the problem (by reading). second - set up the statement (formula) to arrive at the solution using the factors (varables, dependent and independent) with the equal sign setting off the result (the solution). third - show all the step progressions (calculations) that are used to arrive at the solution (usually after the equal sign). this is one way to show that a person understands every facet of the problem and how to arrive there at the final solution. it'll be all there, shown, self-evident, and irrefutable. then the teacher can show where the thought process went awry, or the calculation mis-step. (capitalizations left off intentionally!) if one cannot understand the thought given then it clearly exemplifies the problem we as a society face. i rest my case. corollary - if any one of the given steps cannot be accomplished, it's obvious that the solution would never be reached. duh!!
on July 8,2013 | 05:07PM
Anonymous wrote:
This is very tragic and I can't help but feel sad for the pilots responsible. What a huge responsibility to be flying all these people with so little rest - it's amazing there aren't more accidents like this one.
on July 8,2013 | 04:08PM
serious wrote:
In all due respect, I have done it, they have bunks to rest. They use autopilot the whole route the problem was the glidepath for the automatic landing was out--same as the Korean Air disaster on Guam---these pilots shouldn't be licensed to drive bikes. Don't fly these airlines.
on July 8,2013 | 04:31PM
engineersoldier wrote:
Correct, there were two flying crews,i.e., 2 captains, 2 copilots--fatigue should not have been a factor.
on July 8,2013 | 05:19PM
engineersoldier wrote:
As Malcolm Gladwell pointed out in 'Outliers', cultural issues may well have been a factor with the more senior but less experienced 'captain' in the driver's seat and the junior but more experienced--and perhaps reluctant--copilot in the next seat. Not good.
on July 8,2013 | 05:11PM
cigaripo wrote:
There was another Korean airliner crash a few years back that one of the cable channels brought to light the circumstance of the causes. There were mechanical failure caused by human failure to follow correct maintenance repair procedures. But the main failure was human error in the chain of command and communication within the cockpit. It was brought to light that in Korean society the leader's decision is not to be questioned by subordinates. In that accident the pilot was a highly respected former military pilot who's words/ commands were supreme. The other crew members knew something wasn't right, but wouldn't dare override the captain, who followed a defective instrument reading. The Korean airline industry were to revamp there cockpit training so the communication between the crew would be open and not restricted to age old custom. In this case, no one knows who was the captain to give the final procedural direction and if anyone recognized a problem. With two captains and more crew members, I feel someone should have recognized the deficient flight approach. Hopefully it doesn't boil down to a captain who's supreme rule of his crew over rode the safety of his passengers, and a crew too scared of losing their jobs and not do anything to correct the error.
on July 8,2013 | 05:15PM
usahwn wrote:
Just thinking out loud, who pays for all the damages and losses ?
on July 8,2013 | 08:31PM
SueH wrote:
Such an astute conclusion!! One thing's for sure: there certainly wasn't anything wrong with the AIRCRAFT, except for the ham-handed idiot at the controls and his "monkey brother" watching from the other seat.
on July 8,2013 | 08:40PM
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