- 7 months ago
Category
📺
TVTranscript
00:00A final approach goes horribly wrong.
00:10Just wandering heights on the end.
00:13The dramatic rescue in San Francisco is caught on camera.
00:17They use the terms mass casualty event.
00:21The search for a cause.
00:22Bingo.
00:23Divides air safety experts.
00:25The worst mode possible.
00:27I disagree.
00:28Was it the pilots, the plane, or something else that doomed Asiana Flight 214?
00:35The hard part is to say, which one is the straw that broke the camel's back?
00:58Ladies and gentlemen, this is your captain speaking.
01:08We hope you had a pleasant flight.
01:10We'll be on the ground in about 30 minutes.
01:13Enjoy your stay in San Francisco and hope to see you again soon.
01:18Asiana Flight 214 is nearing the end of an overnight flight from Seoul, Korea to San
01:23Francisco.
01:26Ben Levy is a frequent flyer, returning home.
01:31I fly pretty often for business or visiting my family.
01:34I'm originally from France, and so I fly long distance a lot.
01:38I fly in and out of SFO a lot.
01:40So I know the airport very well.
01:43Many of the other 291 passengers are Chinese, including a group of teenagers on their way
01:49to summer camp in the United States.
01:51I think they were all pretty excited about the trip.
01:54I think they were all having a good time and excited to be in that plane and going
01:59to the US.
02:02Is that the Golden Gate?
02:03Captain Lee Kong-Cook takes in the sights as he guides the plane towards the airport.
02:09Golden Gate's over there.
02:11That bridge goes to Oakland.
02:13Ah, okay.
02:15Lee Chung-Min, also a captain, is serving as first officer today.
02:19Yeah, I remember it being a gorgeous day, as good as it can be.
02:24No wind, beautiful sunny day, not a single cloud in the sky.
02:29The arrival into San Francisco is a very scenic approach.
02:33From the Sierra Mountains all the way into the San Francisco Bay Area, it's a very pretty
02:39arrival.
02:40Runway in sight.
02:41Asiana 214 heavy, turn left 310 degrees.
02:42Cleared visual approach.
02:43Controllers clear the crew for their final turn to the runway.
02:54It is a busy piece of airspace.
02:56You do have to listen on the frequency and you do have to anticipate what the controller
03:00is going to give you.
03:02In addition, experience really counts flying into San Francisco.
03:06Cleared visual approach, Asiana 214.
03:10Okay, gear down, sir.
03:14Gear down.
03:18The way we put on the brakes in an airplane is by putting our trailing edge flaps down,
03:23our leading edge devices down, and even the gear, that's our brake.
03:29They then enter an altitude to climb to in case of a missed approach.
03:33Missed approach 3,000 feet.
03:40In the cabin, the flight attendants prepare passengers for landing.
03:44Asiana 214 heavy, runway 28 left, cleared to land.
03:53Landing checklist complete, cleared to land.
03:56On glide path.
03:57The pilots check a set of lights beside the runway that can help guide them to a safe
04:02landing.
04:05Check.
04:09The plane is less than a minute from the runway when Ben Levy realizes something is
04:15wrong.
04:18I remember noticing that there's a small pier that extends out of the runway.
04:23And I'm like, wow, we're very low.
04:27And I dismissed the thought thinking, well, what can go wrong?
04:30There's all the technology on board to make sure that those guys don't mess up.
04:35In the cockpit, a crisis hits.
04:50In that fraction of a second, I feel the thrust of the engine re-engaging full throttle.
04:56The captain pulls up the nose and tries to climb.
05:01But it may be too late.
05:02Hang on.
05:03Looks like we're not going to make it on the wall.
05:04At that point, I'm thinking, we're going to hit the water.
05:05The plane was very violent.
05:06Just wondering how it's going to end, how it's going to stop and when it's going to
05:07stop.
05:08I'm just wondering how it's going to end, how it's going to stop and when it's going
05:09to stop.
05:10I'm just wondering how it's going to end, how it's going to stop and when it's going to
05:11stop.
05:12I'm just wondering how it's going to end, how it's going to stop.
05:13I'm just wondering how it's going to end, how it's going to stop.
05:14I'm just wondering how it's going to end, how it's going to stop.
05:15I'm just wondering how it's going to end, how it's going to stop.
05:17I'm just wondering how it's going to end, how it's going to stop.
05:18I'm just wondering how it's going to end, how it's going to stop.
05:19I'm just wondering how it's going to end, how it's going to stop.
05:20I'm just wondering how it's going to end, how it's going to stop.
05:21I'm just wondering how it's going to end, how it's going to stop.
05:22I'm just wondering how it's going to end, how it's going to stop.
05:23I'm just wondering how it's going to end, how it's going to stop.
05:24I'm just wondering how it's going to end, how it's going to stop.
05:25I'm just wondering how it's going to end, how it's going to stop.
05:26I'm just wondering how it's going to end, how it's going to stop.
05:27I'm just wondering how it's going to end, how it's going to stop.
05:28I'm just wondering how it's going to end, how it's going to stop.
05:29I'm just wondering how it's going to end, how it's going to stop,
05:30and when it's going to stop.
05:31Hang on!
05:32Hang on!
05:33Hang on!
05:34Hang on!
05:35Hang on!
05:36Hang on!
05:47So the plane comes to a rest.
05:48And nothing moves.
05:54and nothing moves.
05:57And all you hear is mourning
05:58from people that are hurt and injured.
06:02Here, here.
06:05Press hard, it'll stop the bleeding.
06:09In the cockpit, the pilots have survived,
06:12but they have no idea how badly damaged their aircraft is.
06:18The brutal impact has torn the tail
06:20off the body of the plane.
06:22Control, come in.
06:24It's Asiana 214.
06:27Initiating evacuation checklist.
06:30We need help out here.
06:32Asiana 214 heavy, emergency vehicles are responding.
06:41An engine is burning.
06:43If fire spreads to the fuel tanks,
06:45the plane could explode.
06:47Passengers need to find a way out fast.
06:51Let's see if we can open this door.
06:52I remember just going for that big lever
06:55on the right-hand side of this airplane
06:57and just opening this door.
06:58And I was shocked at how easy it was.
07:01But getting down to the ground will not be easy.
07:05I'm expecting at that point to see a slide open.
07:08Right in the hole, like, hey, you open the door,
07:10the slide's gonna open.
07:12And there's no slide.
07:15Whoa.
07:16Okay.
07:18Help each other.
07:20Come on.
07:22Luckily, some crumpled pieces of the fuselage
07:24have formed a makeshift set of stairs.
07:28Ben Levy stays by the door
07:30to help the other passengers climb down.
07:33Come on.
07:34You know, in this whole disaster,
07:35to find that the fuselage actually had crumbled on itself,
07:37almost provided, like, a step
07:40that became probably critical for people to exit that plane.
07:44Oh, my God, that's scary.
07:47Eyewitness video captures the dramatic scene
07:50as thousands of people flee the cabin
07:52from only a few exits.
07:57The 777 has eight exits.
07:59Each is equipped with an emergency escape slide.
08:03The slides are supposed to inflate automatically,
08:06but only two have deployed properly.
08:14Someone, please help me.
08:17What's worse, two of the malfunctioning slides
08:19are located inside the plane.
08:22A flight attendant is trapped.
08:24I can't move.
08:27If you pull, I can try.
08:30No.
08:31Get something sharp.
08:36She couldn't breathe under the slide.
08:39Bill Bramble is an air emergency expert.
08:42He understands the desperation the crew is facing.
08:46They were worried about her suffocating,
08:48so it was a very strong sense of urgency
08:50to try and get her out.
08:51Plus, there was a fire outside of the fuselage as well.
08:54So, yeah, it was a pretty serious situation.
09:02At San Francisco International Airport,
09:04runway 28L is a disaster zone.
09:08Fire crews battle to keep flames
09:10from consuming the fuselage of Asiana Flight 214.
09:15Come on.
09:17Get out.
09:19Inside the burning plane, a flight attendant is still trapped.
09:27The slides are pretty tough.
09:29You need a sharp, strong object to be able to puncture the slide,
09:32and crash acts do the trick.
09:46With rescuers now on board to help the injured,
09:50Ben Levy finally heads to safety.
09:57I think in my head, I was like, I'm alive, it's incredible.
10:00He's soon sharing his harrowing story with the media.
10:04In your head, everything goes into slow motion.
10:06You just don't believe it's happening.
10:07You don't know if you're going to be dead
10:09at the end of the slow motion or not.
10:10And the entire trip,
10:12we were just trying to figure out
10:13if we're going to be dead at the end of the slow motion or not.
10:16And the entire trauma team has come together,
10:18as they would in a trauma,
10:19although this is very large, multi-casualty incident.
10:22Nearly 50 people are seriously injured.
10:25Six were thrown out to the back of the plane
10:27when the tail broke off.
10:30Two of them are dead,
10:31including a young teenager run over by an emergency vehicle.
10:36The firetruck did go over the victim, that's a fact.
10:39Now, what caused the death,
10:41whether the victim was deceased before or as a result,
10:44that is what we're trying to figure out.
10:48Like thousands of others,
10:49investigators at the National Transportation Safety Board
10:52in Washington are riveted by the pictures.
10:57They use the terms mass casualty event.
10:59We really didn't know what was going on at the time.
11:01The first things I heard was an airplane cartwheeled,
11:04mass casualties, and we knew it was a 777,
11:08so it was going to be a very significant event.
11:10Senior investigator Bill English
11:12will lead the high-profile investigation.
11:15Everyone's on standby, as of right now.
11:18So the 777 had been in service for about 20 years
11:20at the time of this accident,
11:22and this was the first fatal accident of a 777
11:24in that entire time.
11:26We knew we were going to be launching a very large team,
11:29so we pulled out all the stops.
11:31By the next morning,
11:33there's a full team of investigators on site.
11:36Their first impression is that the media reports must be wrong.
11:41I'd heard the phrase, the airplane cartwheeled,
11:44and the first photos that I saw
11:47showed the airplane right side up, wings still attached,
11:50still looking pretty much like an airplane
11:52sitting next to the runway,
11:54so we thought that couldn't be true.
11:56When a plane cartwheels on touchdown,
11:58the result is usually a catastrophic break-up
12:01that leaves a long trail of debris.
12:04That's what happened in 1989 in Sioux City, Iowa,
12:07where a DC-10 cartwheeled off the runway,
12:10killing 111 people.
12:16The wreckage from Asiana 214 looks nothing like Sioux City.
12:20English and his colleagues
12:23English can hardly believe the 777 cartwheeled
12:26until he spots some telltale evidence.
12:30We noticed the marks on the runway,
12:32scrape marks and everything.
12:34It looked strange.
12:36It looked like the airplane twisted and turned around.
12:39We thought, did the airplane actually turn around?
12:42And then we saw the video.
12:47Airport surveillance cameras leave no doubt
12:50about Flight 214's violent trajectory.
12:54The surveillance video did show the airplane literally pirouetting,
12:58lifting a good 30 degrees into the air,
13:00spinning almost a full circle around before coming to rest.
13:08It's just a miracle in so many ways.
13:10To find that this plane stayed in one piece,
13:13to find that the wing didn't break apart.
13:16I mean, if we had landed back any other way,
13:18we could have been terrible.
13:21Investigators must now determine
13:23why the 777 crashed short of the runway.
13:27But they also face important questions
13:29about the evacuation and rescue.
13:33How did you end up out there?
13:36Investigator Jason Feddock will try to figure out
13:39what happened to the passengers after the impact.
13:43Can you remember where you were sitting?
13:45People who were actually involved in the accident
13:47can give us a wealth of information
13:49that we couldn't otherwise learn
13:51about what happened inside the cabin.
13:53Was she wearing her seatbelt?
13:55In this case, we talked to the seatmates
13:57of one of the ejected passengers
13:59who explained that she was not wearing her seatbelt
14:01at the time of the accident.
14:03This investigation was almost two investigations in one.
14:06We broke it up into the part that got us to the seawall.
14:09How did this airplane impact those rocks
14:11and come to this accident?
14:13After that was a whole other story to be told.
14:17The complex investigation puts the entire team
14:20under enormous pressure.
14:23There could be clues inside the ruined cockpit,
14:26but toxic fumes and scorched debris
14:29make it too dangerous to enter without protective gear.
14:33OK, here we go.
14:36For NTSB investigator Roger Cox,
14:39the hunt for evidence is worth the risk.
14:42It was a tricky accident site.
14:46We had to be properly garbed up
14:48to make sure that we weren't affected
14:50too much by the dangerous wreckage that was there.
14:56If you get out there right away,
14:58before anybody's had time to move anything around,
15:01you can actually reconstruct what went on.
15:04Cox gathers the pilots' charts and personal effects,
15:07hoping to find clues about what they were doing
15:10in the final stages of the flight.
15:12That's everything I could find.
15:15We removed every single document
15:17and then made sure that we photographed
15:20every single page of every single document
15:23in order to see if any of it was of value.
15:26Many of the documents are in Korean.
15:29They'll need to be translated before they can be fully analysed.
15:37The crash zone, on the other hand,
15:39immediately provides investigators with some important details.
15:45Where it impacted on the rocks of the seawall
15:48pretty much tells us it was too low.
15:50It landed well short of where it should have.
15:53The scenario reminds English of another very similar accident.
15:57One of the things we initially thought about
16:00was a previous 777 accident that happened in London, England,
16:03where both engines rolled back
16:05and the crew didn't have any power at all on final approach.
16:08The 777 has one of the best safety records of any plane in the sky.
16:14But in 2008, British Airways Flight 38
16:17slammed to the ground short of the runway at Heathrow Airport
16:21after losing power in both engines.
16:26Investigators determined that ice in the fuel lines
16:29had caused dual-engine failure.
16:32Is that what happened to Asiana 214?
16:37A close look at the engines tells Bill English the answer is no.
16:43He sees clear evidence that they were working normally.
16:47There are certain signatures in the metal, in the blades of the engine,
16:50that show us that they were developing power and hadn't failed.
16:55For now, English has no solid leads to explain
16:58why a plane that seemed about to land safely
17:01crashed just seconds from the runway.
17:06We knew the weather was good, winds were calm, visibility was good.
17:10There was no distress call from the airplane that we'd heard of.
17:13So there was nothing really obvious as to why this would have occurred.
17:22Runway crews assess the damage at San Francisco International Airport
17:27while investigators search for a lead in the crash of Asiana 214.
17:33Air traffic controllers provide some answers.
17:37They could see it on radar and of course visually see it from the tower.
17:40Visibility was 10 miles, a few clouds, not an issue.
17:46Controllers tell investigators that it was a normal day,
17:50except for the fact that some runway equipment was not in operation.
17:56And that runway's glide slope was out of service.
18:00Electronic equipment installed on runways can send signals to a plane's autopilot.
18:06The signals can help guide the plane down at a precise angle.
18:13But the main runway at the airport is under construction
18:16and the equipment is switched off.
18:19It's a revealing discovery.
18:22A combination of high traffic and compact runways
18:26have earned San Francisco Airport a reputation for difficult landings.
18:31To manage the high traffic, controllers often ask pilots to come in fast and steep,
18:37leaving lower altitudes open for departing planes to climb out.
18:42Very often we are given what we call the slam-dunk approach,
18:47where we're high and we have to get down quickly.
18:50And it does create a little bit of a challenge.
18:57All right. So there's San Francisco Airport.
19:01Palo Alto's down here, you know.
19:03Roger Cox knows firsthand how challenging landing at San Francisco Airport can be.
19:10I can say from my own personal experience landing there many, many times
19:13that it's very easy to get high and hot,
19:15and you have to really stay on top of the airplane.
19:18Isiana 214 heavy, runway 28 left, cleared to land.
19:22It all leads to some troubling questions.
19:26Were the Asiana pilots flying into danger?
19:29Did they face an extraordinary risk at an airport notorious for difficult landings?
19:36So he'd be coming in from this direction, straight across the bay.
19:40Roger Cox studies airport radar records.
19:43He wants to know if controllers assigned Asiana Flight 214 an approach
19:48that was too fast and steep to fly safely.
19:52Cleared to land.
19:53There were some complaints initially from the operator
19:56that this crew was being asked to do something that was unreasonable.
19:58So we wanted to spend quite a bit of time looking at whether that was true.
20:03Same instructions.
20:05Same approach.
20:07No one else had a problem.
20:09Airport records reveal controllers gave two other planes the same instructions
20:14just before Asiana touched down.
20:18Both landed safely.
20:20You can't fault the controller.
20:24They managed to land 777s safely without any difficulty.
20:29So although it is a somewhat challenging environment,
20:33we found that nothing that ATC did really caused the accident.
20:39It's another dead end.
20:41For now, what brought down Asiana 214 remains a mystery.
20:47Along with the cause of the accident,
20:50investigators are grappling with another troubling question.
20:54Escape slides are engineered to withstand the forces of aviation accidents.
20:59Why did so many fail during the crash of Flight 214?
21:05Only two of them did what they were supposed to do.
21:08Six of the eight slides didn't deploy properly,
21:12potentially causing deadly delays in the evacuation.
21:16The fire took some time to get into the cabin.
21:19That's a good thing.
21:21But had a fuel tank been punctured or some obstacle been in the way
21:25and we had a much more rapid fire, things could have been very different.
21:30They'll have to search for answers without the help of the plane's flight data recorder.
21:37The recorder is located in the tail section
21:40and stopped recording when the tail smashed into the sea wall.
21:45There's no information on what was happening at the moment the slides deployed.
21:51OK, let's see what these slides can take.
21:54To get the data they need,
21:56Jason Feddock turns to a crash test facility more often used for testing cars.
22:01This is unlike anything anyone had ever seen before,
22:04so we wanted to figure out how that happened.
22:07He discovers that at low speeds the slides perform well.
22:11But in high-speed impacts like the one on board Flight 214,
22:16the inflation mechanism can fail quite easily.
22:21We made a recommendation to the FAA
22:23to look at the data we produced from this accident
22:26and see if there were improvements that could be made to future slide design
22:30to help make that part more robust.
22:34The violent force of the impact also accounts for the injuries
22:38suffered by the six people thrown from the plane,
22:41including the young teenager who was run over by a fire truck.
22:47Autopsy results confirm she died immediately after the crash impact.
22:53She was already dead by the time her body was run over.
22:57One of the most important lessons here is to always keep your seat belt fastened
23:01whenever possible on an aircraft.
23:03You never know when you're going to have unexpected turbulence
23:06or be in an accident.
23:08Investigators hope Flight 214's flight recorders
23:12will help them answer the other urgent question.
23:15Why did Flight 214 slam into the seawall in the first place?
23:20I don't think we're going to make the runway.
23:26Modern flight recorders capture detailed information
23:29about virtually every system on board,
23:32including the complex automation that helps the pilots fly the plane.
23:36We were able to see all the basic things,
23:38like airspeed, altitude, the configuration of the airplane.
23:42We were also able to see all the inputs that the crew made.
23:46English carefully plots the data.
23:49Most of it looks completely normal.
23:52But then he spots something unexpected.
23:55A little more than a minute away from the runway,
23:58engine power suddenly drops to idle.
24:01Right here.
24:03The sudden change in power settings makes no sense.
24:07Normally, the last moments of flight are when pilots need more power, not less.
24:12They need extra thrust to overcome increased drag
24:15from the landing gear and wing flaps.
24:19The investigation has already determined
24:21that there was nothing wrong with the engines themselves.
24:26We could see that the engines were making proper power
24:28all the way through the approach.
24:30The question now,
24:32what was the crew doing to control engine power
24:35in the critical final moments of flight?
24:37Speed!
24:39So that brought us right back to,
24:41how did the pilots operate the airplane?
24:43Why did they do what they did that got the airplane too low?
24:47What really struck me was,
24:49how could a couple of highly trained, experienced pilots
24:54simply fly an airplane into the ground shore of the runway?
24:57That was the mystery.
25:02The investigation into Asiana 214
25:05now focuses squarely on the actions of the pilots.
25:09Gear down, sir.
25:11Understanding every nuance of the cockpit voice recording becomes crucial.
25:16The CVR is key.
25:18Gear down.
25:20You can tell what the flight crew are doing.
25:22You can tell what they're thinking sometimes,
25:24because they're verbalizing it.
25:26You can tell how they're deciding what to do next.
25:29They listen as the pilots prepare for landing.
25:32Missed approach 3,000 feet.
25:34They combine what they hear with the FDR data
25:38that shows how the pilots were manipulating the controls.
25:41It seems a little high.
25:43As the crew nears the runway,
25:46the recording hints at the first sign of trouble.
25:49I will descend more.
25:51The plane isn't descending fast enough.
25:54The captain flying takes steps to fix the problem,
25:58but he doesn't explain his actions to his co-pilot.
26:02No call-outs.
26:04How's anyone supposed to know what he's doing?
26:06For investigator Bill Bramble, it's a troubling clue.
26:10The pilot flying is supposed to actually select things
26:14with the autoflight system and call out what he's doing,
26:17and the pilot monitoring is supposed to verify
26:19that the change has actually occurred.
26:21In this case, we saw kind of a breakdown
26:24in that standard pattern of communication and coordination.
26:27Flaps 20.
26:30What the recording reveals next is stunning.
26:33Less than 90 seconds before impact,
26:36the captain makes an inexplicable blunder.
26:39He switches the autopilot to an incorrect setting,
26:43flight level change mode.
26:45That interrupts the landing
26:47and instructs the computer to climb
26:49to the go-around altitude of 3,000 feet.
26:53He made an entry to the autopilot
26:56that at first actually made the airplane climb.
27:00Obviously he didn't want to do that.
27:02The autopilot mode switches here.
27:04Starts all the confusion.
27:06To bring his plane back down,
27:08the captain immediately pulls the throttles back to idle,
27:12a move with major repercussions.
27:15But once again, he doesn't tell the other pilot what he's doing.
27:20Not calling out one single action
27:23wouldn't necessarily be a fatal flaw,
27:27but in this particular case,
27:29it had a big influence on the conduct of the flight.
27:32It's low.
27:33Investigators now understand how the engines got to idle.
27:37Yeah.
27:38But why would an experienced captain
27:40make the mistake of leaving them there?
27:44Oh, God.
27:45Go around.
27:46And why did the crew not notice they were dangerously low
27:51until it was too late?
27:57It's like they just sat there and watched it happen.
28:02To find answers, Bramble and Cox prepare
28:05for a sensitive and difficult interview
28:07with the pilot who was flying the plane.
28:10I'll try to help if I can.
28:12We wanted to find out, you know,
28:14how much of what happened did they understand?
28:17We wanted to find out when they became aware
28:20that something was amiss.
28:22And so the only way to do that was by asking them.
28:25I was a bit nervous.
28:27The captain explains he was worried about landing in San Francisco
28:31on a day when there was no electronic runway equipment
28:35to help guide him.
28:37I thought that was very unusual coming from an experienced pilot
28:41No one really needs an electronic glideslope on a clear day
28:44to be able to land an airplane.
28:46It's a fundamental skill that you have to learn
28:48from the time you're a private pilot.
28:50Other pilots are making that landing.
28:54I thought I should be able to make it too.
28:57He said everyone else was doing it,
28:59so I could not say I could not do it.
29:01This seems a little high.
29:05I will descend more.
29:07I think he didn't want to show that he was not confident
29:10or that he was not prepared.
29:12But I think...
29:15Why did he not ask the other guy for help?
29:18I think he just didn't want to admit the weakness.
29:21Slow.
29:23The captain tells investigators he doesn't understand
29:26why the plane didn't have enough power on landing.
29:30I know I made some mistakes,
29:32but I was certain that the autothrottle would control the speed.
29:36Like other modern jets,
29:38the 777 can automatically increase or decrease engine power
29:42through a system known as the autothrottle.
29:47Similar to, but much more sophisticated than your cruise control.
29:51He was confident the autothrottle
29:53was actually going to take care of speed for him.
29:56And in his prior experience, they had.
30:00During his 777 flight training,
30:02the captain was taught about the autothrottle's special wake-up feature.
30:07If the plane's speed drops too low,
30:10the autothrottle engages and adds power,
30:13even if it's switched off.
30:15Amazing.
30:16He had seen this demonstration in the simulator
30:19that the autothrottles would wake up even if the autothrottle was off.
30:23So he had this really high level of expectancy
30:26that the autothrottles would wake up,
30:28advance the thrust and keep them safe.
30:31Investigators consider a chilling possibility.
30:35Did a critical automated system on a Boeing 777 fail in flight?
30:40Is that what doomed Asiana 214?
30:46So the autothrottle and autopilot
30:50both change modes here and then again here.
30:54Investigators dig deeper into the flight data from Asiana 214.
31:00They search for any evidence of a failure or malfunction
31:04in the plane's automated flight systems.
31:07I think the most important thing that we wanted to know
31:10was what autothrottle and autopilot modes were engaged
31:15during the last 2 or 3 minutes of the flight.
31:19Missed approach 3,000 feet.
31:21An undetected problem with the autopilot or autothrottle
31:25could easily have led the pilots to disaster.
31:30Tracing all the computerized functions is a mammoth task.
31:35English studies every input, every mode change.
31:39The exhaustive analysis leaves no doubt.
31:43None of flight 214's automated systems failed in any way.
31:48But there is evidence of something else
31:50that could finally explain what went wrong.
31:53It was pretty evident that we could see
31:56some strange things happening with automation inputs
31:59while that airplane was on short final.
32:02The analysis reveals that the pilots of Asiana 214
32:06punched in a bizarre sequence of inputs,
32:09a sequence that most pilots would never carry out.
32:13First, choosing an autopilot mode rarely used during descent,
32:18then pulling back on the thrust levers
32:21when that error put the plane into a climb.
32:27Bingo! That does it.
32:30The unusual combination of commands
32:33switches off the 777's built-in speed protection,
32:37leaving the engines at idle.
32:39At that point, he disconnected the autopilot,
32:42so now up, down, left and right was in his hands.
32:45He grabbed the throttles and reduced them,
32:48like taking his foot off the gas.
32:50By doing that, that sent the signal to the autothrottle system
32:54that he wanted control of the power as well.
32:57So at that point, in effect, the airplane was basically just gliding.
33:01Investigators finally understand
33:03why the autothrottle did not re-engage
33:06and boost engine thrust on landing.
33:09But puzzling questions remain.
33:11Why was the captain so uncertain about autopilot functions?
33:15And why couldn't the crew react in time to save their plane?
33:2122,000 hours between them.
33:25You'd think they'd notice the speed.
33:29Translated from the original Korean,
33:32the cockpit documents go a long way to providing some answers.
33:36It turned out one of the important things that we recovered
33:39was the pilot's training record,
33:41which had detailed history of what he had accomplished
33:45right up to the time of the accident.
33:47The documents reveal Flight 214 was a critical training flight
33:52for Captain Lee Kong-Kook.
33:54Is that the Golden Gate?
33:56He was transferring to the Boeing 777 after flying the Airbus A320,
34:01an aircraft with a very different style of automation.
34:05Golden Gate's over there. That bridge goes to Oakland.
34:09It's a different philosophy of flying,
34:11and he had flown the Airbus for quite some time,
34:14so the transition may still have been an awkward moment.
34:19It was a training flight.
34:21The training records reveal the captain
34:23had been having trouble making the change.
34:26The instructor was fairly critical.
34:29He indicated he felt that the captain who was in training
34:33wasn't sufficiently diligent and attentive to procedure.
34:36That recent criticism may have been on Lee Kong-Kook's mind
34:40as he headed for San Francisco.
34:43He was a little bit stressed because it was a training flight
34:47and he was being monitored by this more senior pilot
34:51and possibly because of this previous flight
34:54where he hadn't performed so well.
34:59But why were the pilots so slow to recognize the danger?
35:05The question that was on everybody's mind
35:07and carried all the way through this investigation
35:10is what was going on in the pilots' heads.
35:12Clear to land.
35:13Even though the landing system was out of service,
35:16there was another way for the pilots to know their plane was too low.
35:21The runway is equipped with special lights
35:23that change color to alert pilots if the approach angle is off.
35:28The PAPI, Precision Approach Path Indicator,
35:31that also aid pilots in the proper vertical path.
35:34Those were operating and were operating properly
35:37at the time of the accident.
35:38It's low.
35:39The pilots were shown four red lights,
35:41meaning the plane is dangerously low.
35:44We had a lot of data and it pretty much showed us
35:47an airplane that was working exactly as it was designed.
35:50That wasn't difficult.
35:51Getting into the whys of why human beings do what they do
35:55or don't notice things is a lot more difficult
35:59and explaining that can be the hardest task of all.
36:04Especially troubling,
36:05why did the more experienced commander wait until it was too late
36:09before taking control of the plane?
36:12I've got control.
36:13If he had intervened sooner,
36:15he would almost certainly have prevented the accident.
36:19The airplane was perfectly flyable up until really the last minute.
36:23So at any point, there were a number of places
36:26where someone could intervene, someone could take over,
36:29someone could make a small change,
36:31and this would have come out very differently.
36:33Yeah, we're just trying to get a sense of how much experience
36:36your guys would have flying by hand.
36:38Can you get me some numbers on that?
36:40They learned that Asiana has strict policies
36:43encouraging pilots to rely on their aircraft automation
36:46as much as possible.
36:48They rarely practice landing the plane by hand.
36:51We have to go to the company's procedures and training,
36:54and there is where I think we've put our finger on the issue.
36:57Cleared visual approach.
37:00Investigators are shocked to learn that this arrival in San Francisco
37:04was the first time the captain ever attempted to land a 777
37:08with no help from the glide slope signal on the runway.
37:14When it comes to visual landings,
37:17this guy's an absolute beginner.
37:21The vast majority of the time,
37:23he had been flying instrument approaches into airports
37:26even when he was technically flying the visual approach.
37:2910,000 hours, almost no hand flying.
37:34It's a stunning discovery.
37:36Despite nearly 10,000 hours as an airline pilot,
37:40the captain has almost no experience flying his plane by hand.
37:45This seems a little high.
37:47You take away all the time that was on the autopilot,
37:49and if you look at all of the flight hours that they had...
37:52I will descend more.
37:54They actually only had a couple of hundred hours of hand flying the airplane,
37:58maybe even less during the years that they had been flying.
38:02So they hadn't been honing their skills.
38:04Investigators also learned that the commander,
38:07though an experienced pilot,
38:09had never before supervised a training flight like this one.
38:13Slow.
38:15His inexperience most likely led him to wait too long
38:18before taking over the controls.
38:20Steep.
38:22As a flight instructor, knowing that critical point,
38:24when to intervene, when a pilot or a student is going a little bit too far,
38:30is one of the hardest tasks to learn as an instructor.
38:33It takes experience, time,
38:36and a little bit of extra knowledge being ahead of the airplane yourself
38:40as the instructor to see these things starting to decay.
38:43Investigators agree the Asiana crew made serious mistakes that caused the crash.
38:49Bottom line, they let their speed drop.
38:51But they don't agree on why the pilots made those mistakes.
38:55I think those modes would confuse most pilots.
38:59But it's their job not to be confused.
39:02Bill Bramble believes technology is to blame.
39:06The way that we design airplanes
39:08and the way that airplane flight decks are evolving
39:11are influencing the ability of flight crews to stay in the loop
39:15and understand what's going on.
39:17But Roger Cox believes the fault lies squarely with the human pilots.
39:22We say pilots use cues to figure out where are we.
39:26So I couldn't quite grasp why professional crew
39:31hadn't picked up on these obvious cues that were right in front of them.
39:36The crash of Asiana 214 sparks a heated discussion
39:40among industry experts working to make aviation safer.
39:45It's an age-old debate of man versus machine.
39:51What's more significant?
39:53Is it more significant that the pilots did not simply take manual control
39:58and fly this airplane to the runway or go around?
40:01Or is it more significant that they were in this environment of automation
40:05that some people think was too complex?
40:08They fluked into it. The worst mode possible.
40:12The more complex automation becomes,
40:14the more difficult it can be for pilots to understand the entire system.
40:19I am not confident that the majority of pilots,
40:22777 pilots at the time, would have been able to predict
40:25the modes that the airplane would end up in.
40:30There have been other deadly accidents in recent years
40:33that underscore Bill Bramble's concern about automation confusion.
40:38Turkish Airways Flight 1951 was carrying 128 passengers
40:43on approach to Amsterdam,
40:45when a faulty altimeter sent incorrect data to the autopilot.
40:50Speed began to drop.
40:52Like the crew of Asiana 214, the Turkish Airways pilots failed to react,
40:58thinking the plane's automation would maintain a safe speed.
41:03Accidents like this are extremely rare.
41:06It's low.
41:08But researchers say that's part of the problem.
41:11Automation fails so rarely that when it does,
41:15pilots aren't able to react as quickly as they should.
41:20To me, this accident shows the inevitable consequences
41:24of the evolution of the modern flight deck.
41:28The increased automation,
41:30which has improved reliability, efficiency and safety in many ways,
41:34but has left us with some unintended consequences
41:37when something anomalous occurs,
41:39and we don't know what it is,
41:41and we don't know what to do about it.
41:44But not everyone agrees that cockpit automation has gone too far.
41:48Bottom line, it's the pilot's responsibility to fly that plane.
41:54Having flown a lot of airliners for well over 30 years in my career,
41:58I always felt it was incumbent on me and other old pilots
42:01to fully and totally understand every aspect of the airplane,
42:04particularly the cockpit automation.
42:07It's the pilots' responsibility to fly that plane.
42:12In their final report on the crash of Asiana 214,
42:16investigators address both sides of the argument.
42:20They list pilot error as the probable cause.
42:24But they also cite the complexities of the automation system
42:28as a contributing factor.
42:30In an unusual move, the reporter says
42:33that pilot error is not the only reason for the crash.
42:38In an unusual move, the report includes statements
42:41from four members of the National Transportation Safety Board,
42:45each emphasizing their own personal views on the crash.
42:51The report calls for better training for pilots,
42:54including more time spent flying without the use of automation.
43:00There's a great movement now in the industry towards going back to basics.
43:04We've talked a lot about over-reliance on automation,
43:07but airplanes still fly pretty much the same way they have for decades.
43:11And we want to get back to making sure that pilots are ahead of the airplane,
43:16aware of what's going on around them,
43:18and able to keep themselves in that loop of flying,
43:22whether the automation is doing it or not.
43:25The report also urges more intuitive designs for aircraft automation
43:31and better alarms in the cockpit to warn pilots if their speed gets too low.
43:37It's hardly ever that we have an accident that's really just one thing.
43:40The hard part is to say, which one is really that critical event?
43:44Which is the straw that broke the camel's back?
43:46If there is any such thing,
43:48sometimes it takes all those little things to make the accident happen.
Be the first to comment