Asiana Pilot Set Throttles He Didn’t Understand to Idle

An Asiana Airlines Inc. (020560) captain nervous about making a visual landing in San Francisco inadvertently disabled a speed-control system before the plane crashed into a seawall on July 6, documents show.

Lee Kang Kuk, a veteran with Seoul-based Asiana who was being trained on the Boeing Co. (BA) 777-200ER wide-body, had momentarily adjusted the power without realizing the plane’s computers then assumed he wanted the engines to remain at idle, according to information released yesterday at a U.S. National Transportation Safety Board hearing.

The documents, while showing the pilots made mistakes, raise questions about the design of auto-throttles on Boeing aircraft and whether related training has been adequate. The safety board hasn’t concluded what caused the crash, which killed three teenage girls from China in the first accident in the U.S. with passenger deaths since 2009.

Lee, 45, “believed the auto-throttle should have come out of the idle position to prevent the airplane going below the minimum speed” for landing, the NTSB said in a summary of an interview with him. “That was the theory at least, as he understood it.”

In most modes of operation, the speed-protection system on the 777 and several other Boeing aircraft won’t allow planes to slow too much, safeguarding against accidents such as the Asiana crash. The plane, on the verge of losing lift because it was almost 40 miles (64 kilometers) per hour slower than its target speed, broke apart after hitting the ground.

Photographer: David Paul Morris/Bloomberg

A burned Boeing Co. 777, operated by Asiana Airlines Inc., sits on the runway after it crashed landed at San Francisco International Airport on July 6, 2013. Close

A burned Boeing Co. 777, operated by Asiana Airlines Inc., sits on the runway after it... Read More

Close
Open
Photographer: David Paul Morris/Bloomberg

A burned Boeing Co. 777, operated by Asiana Airlines Inc., sits on the runway after it crashed landed at San Francisco International Airport on July 6, 2013.

Cockpit Confusion

Asiana shares fell 0.1 percent to close at 4,795 won in Seoul today. The stock has dropped 6.3 percent since the crash, compared with a 7.3 percent gain in the benchmark Kospi index.

“The accident has damaged Asiana’s reputation especially in China, one of its biggest markets,” said Kang Dong Jin, an analyst at HMC Investment Securities Co. in Seoul. “It’s also going to be a long-term financial burden because the outcome could mean lawsuits and higher insurance payments.”

In some combinations of auto-throttle and autopilot settings, such as during Asiana Flight 214’s approach to San Francisco, the system becomes dormant, according to NTSB documents.

The three pilots in the cockpit didn’t sense the impending danger until seconds before impact, according to NTSB documents and a voice-recorder transcript made public at the start of the hearing.

Falling Fast

Bong Dong Won, 40, a crew member on board to give the pilots a rest break, said at least twice that the plane was descending too quickly in the final minute, according to the transcript.

Lee and Lee Jung Min, 49, an instructor pilot monitoring the captain as part of his training on the 777, failed to abort the landing after the plane descended below 500 feet (152 meters), as was required under airline rules, according to the documents.

“Asiana is committed to taking necessary steps to ensure such an accident never happens again,” the airline said yesterday in a statement responding to the NTSB hearing.

No one in the cockpit commented immediately after a series of chimes 11 seconds before impact indicated that the plane had reached dangerously low speed, according to the transcript.

“Speed,” Lee Jung Min said three seconds later. An unidentified person said “speed” again 1.2 seconds later.

Late Power

Shortly after the plane descended below 50 feet, the plane’s control column began shaking to warn pilots they were in danger of losing lift, known as an aerodynamic stall, according to the recording.

Only then, 8.5 seconds after the initial speed warning, did Lee Jung Min call for aborting the landing and climbing, according to the transcript.

“Go around,” he said, after uttering an expletive in English. The pilots added power too late to prevent the collision.

Lee Kang Kuk, asked about his approach to the airport, told safety-board investigators it “was very stressful, very difficult.” He wasn’t accustomed to landing without an instrument-landing system guiding him to the runway, as pilots had to do in San Francisco that day because of airport construction, according to an NTSB summary of his statement.

The captains still work for Asiana though they are not flying, Ki Won Suh, an Asiana spokesman, said in an e-mail. Bong, the relief pilot on Flight 214, has resumed flying.

Asiana since the accident has increased the hours of flight-simulation training its pilots receive and taken other steps to make a “fundamental improvement” in safety, Akiyoshi Yamamura, senior executive vice president of safety and security management, said Dec. 3.

Uncomfortable Pilots

Two former Asiana pilots said in interviews that most of the carrier’s crews were uncomfortable with manual flight maneuvers, according to NTSB documents. The pilots gave a similar account in interviews with Bloomberg News in July.

A Federal Aviation Administration study released last month found that pilots’ growing reliance on automation in the cockpit has led to occasional confusion and new safety risks.

Autopilots, automatic throttles and computerized navigation systems have helped improve safety in recent decades, the FAA study concluded. The price for that is occasional confusion because the systems, which sometimes interact with each other, may be improperly set or act in ways that crews don’t anticipate, it said.

Pilots accustomed to having automation handle mundane flying tasks may also lose basic manual flying skills, the report said.

“Obviously that’s an issue of great interest to the NTSB as well as the entire aviation community,” NTSB Chairman Deborah Hersman said at a press conference.

Autopilot Reliability

The devices are so reliable that pilots tend to assume systems like speed control always work, Captain Dave McKenney, of the International Federation of Air Line Pilots Associations, said in testimony yesterday.

“When it doesn’t, they get caught short,” McKenney said. McKenney was a co-author of the FAA study.

As Flight 214 from Seoul neared San Francisco, Lee Kang Kuk, the training pilot, entered a series of parameters into the flight-management and auto-throttle systems that made the plane think he wanted to accelerate and climb.

To counter the plane’s increase in thrust, he pulled the power back so he could resume his descent, the documents show.

Because of the way the auto-throttle had been set, combined with the fact that he had shut off the autopilot, the throttles stayed in the lowest setting, according to the NTSB.

Crash Landing

The impact sheared off the tail section and engines, according to the NTSB. Besides the three passengers who died, more than 200 people were taken to hospitals. The plane held 291 passengers, 12 flight attendants and four pilots.

All three victims may have been flung from the plane, according to statements of unidentified witnesses who were traveling with them, the NTSB said. At least one girl wasn’t wearing her seatbelt, a student seated nearby said.

A 16-year-old girl traveling with a school group from China was run over twice, not once, by fire trucks responding to the crash, investigators disclosed at the hearing.

An autopsy found that the girl, who wasn’t named by the NTSB, wasn’t dead until she was struck by a fire truck. She was covered in firefighting foam. While investigators after the accident said she was run over once, a review of video found a second truck ran over her 11 minutes later.

Fire Department

“While we definitely regret the additional insult to the deceased, this is not a matter of us being callous or careless, either one,” said Dale Carnes, assistant deputy chief of the San Francisco Fire Department.

Carnes described a chaotic post-crash scene at which firefighters had to extinguish a blaze while freeing trapped flight attendants and evaluating the injured.

Hersman of the NTSB, speaking in her opening statement to families of the dead and those who were injured, said “nothing can replace the loss of your loved ones or repair the trauma of a life-changing injury.”

“But we do have the opportunity today to ensure that the lessons of this tragedy are well learned and that the circumstances are not repeated,” she said.

To contact the reporters on this story: Alan Levin in Washington at alevin24@bloomberg.net; Jeff Plungis in Washington at jplungis@bloomberg.net

To contact the editor responsible for this story: Bernard Kohn at bkohn2@bloomberg.net

Press spacebar to pause and continue. Press esc to stop.

Bloomberg reserves the right to remove comments but is under no obligation to do so, or to explain individual moderation decisions.

Please enable JavaScript to view the comments powered by Disqus.