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Showing posts with label ntsb. Show all posts
Showing posts with label ntsb. Show all posts

14 May 2015

Why the Amtrak train crash in Philadelphia is like a plane crash

The crash of Amtrak Northeast Regional Train 188 in Philadelphia, PA on May 12, 2015 involved an Amtrak passenger train, but in many ways this train crash was like a plane crash, specifically in the ways that the major US media outlets responded to the event. It is extremely rare for train crashes to generate intense media interest, but this kind of attention is routine for airline crashes. Upon closer review, the media response to the Amtrak crash is not so surprising.

Although it has only been a couple of days since the crash, the NTSB accident investigation team has revealed key details of the events that led to the crash. In short, it looks like the train was traveling just over 100 mph (161 kph), and derailed after entering a curve that had a 50 mph speed limit.

There were five crew members and about 240 passengers on board. Seven of those passengers were killed, and several dozen passengers and crew members were injured.



NTSB Board Member Robert Sumwalt at crash site

Amtrak accidents are common
While this accident has received the kind of attention usually given a major plane crash (for example, continuous coverage from major news networks that includes having news anchors at the crash site), Amtrak accidents are actually quite common. According to the Federal Railroad Administration, over the last decade, Amtrak has been involved with accidents and incidents that have resulted in over 1,000 deaths.



(Click to enlarge)

In the last three years, Amtrak has been involved in over 50 accidents per year, with 21 in the first two months of 2015.



(Click to enlarge)

Why this crash stands out
The circumstances around the Philadelphia crash that have led to an intense amount of media attention include where it happened, who was on the train, and perhaps more importantly, who is likely to travel by train on that route.

The crash took place on not only the most heavily traveled route in the Amtrak system, with over 12 million riders in 2011, it is also a route that connects New York City with Washington, DC, two metropolitan areas where many members of the US financial, political, and media elite live and work.

Many of the elite members of US society, even if they don't live or work in New York or Washington, have either traveled on that route on many occasions, or know friends, colleagues, or family members who do. A quick review of some of those killed in the crash can give you an insight into the kinds of people who regularly travel on this route. The dead include:

  • A tech company CEO
  • A software architect for a major news media organization
  • A US Naval Academy midshipman
  • A university dean
  • A senior vice president of a Fortune 100 company

Given the ongoing media coverage, it is very likely that the most influential business, political, and media decision makers throughout the US are not only keenly aware of the accident, but can also imagine circumstances where they could have been on that train that night. If it had been a jet airliner traveling between major cities in the northeast US, the airliner's passenger list would have likely reflected the profile of the people on that Amtrak train.

These are the reasons why the traveling public, especially the more influential members of the traveling public, may feel about this train crash the same way they would perceive a plane crash, as something that could happen to them.

Additional resources
Amtrak Northeast Corridor overview 2011

Graphics:
Federal Railroad Administration
National Transportation Safety Board

04 November 2014

NTSB provides timeline of SpaceShipTwo mishap

The following is an overview of the preliminary findings presented by the NTSB on the third day of their investigation.

During the fourth media briefing on the third day of the on site portion of the NTSB investigation of the crash of SpaceShipTwo, the most significant information provided by acting NTSB chair Christopher A. Hart was a general timeline of the events between the release of SpaceShipTwo from its mothership WhiteKnightTwo, and the loss of telemetry from SpaceShipTwo. In that roughly fifteen second span, a number of events occurred inside SpaceShipTwo:

  • SpaceShipTwo released from mothership WhiteKnightTwo at 10:07:19 PDT (17:07:19 UTC)
  • The rocket engine was ignited about two seconds later.
  • About eight seconds later, and 10 seconds after release, SpaceShipTwo was traveling at about Mach 0.94
  • Sometime during the next two seconds, the feather lock handle was moved from the locked to the unlock position by the person sitting in the right seat.
  • At about 12 seconds after release, the vehicle was traveling at Mach 1.02
  • The feathers began to deploy at about 13 seconds after release.
  • Telemetry and video data was lost about two seconds later, roughly 15 seconds after release.

In addition to the timeline, the NTSB stated that lightweight debris was recovered about 30-35 miles northeast of the main wreckage area, and it was not clear what role wind may have played in the distribution of that wreckage. Also, while there was clear evidence that the pilot in the right seat moved the feather lock handle, during the media briefing, Hart was not clear if it was the pilot or the copilot who did so.

Shortly after the media briefing, NTSB clarified its position on Twitter, stating that the copilot, who did not survive the mishap, was the person in the right seat who moved the lock/unlock handle into the unlocked position.

Additional resources
Initial NTSB SpaceShipTwo accident investigation
Review of first two NTSB briefings on 1 November 2014
Review of third NTSB briefing on 2 November 2014
Review of fourth NTSB briefing on 3 November 2014

03 November 2014

NTSB hints that SpaceShipTwo breakup was not related to an engine failure

The following is an overview of the factual data presented by the NTSB on the second day of their investigation.

During the media briefing on the second day of the NTSB investigation of the crash of SpaceShipTwo, acting NTSB chair Christopher A. Hart, reported on some of their early findings that implied that there was no fire, explosion, or other kind of breach or failure involving the engine, fuel tank, or oxidizer tank. Early evidence instead points to an un uncommanded deployment of the feathering system just prior to the loss of telemetry from SpaceShipTwo.

The feathering system on SpaceShipTwo allows the twin booms on the vehicle, referred to as the feathers, to rotate upward in order to provide more aerodynamic drag on reentry. They are intended to be deployed after the engine has shut down and prior to reentry. According the information provided at the briefing, deploying the feathers takes two actions from the flight crew. The feathering system has to first be unlocked before they can be deployed by moving the feather handle into the feathered position.

There is a feathering handle that moves the feathers into the feathered position. Based on video evidence from inside SpaceShipTwo, the copilot unlocked the system, but the system deployed without any crew input.


Model of SpaceShipTwo in unfeathered position

Model of SpaceShipTwo in feathered position


The sequence of events was roughly as follows:

  • After being released from its carrier aircraft, the crew of SpaceShipTwo ignited the rocket engine.
  • About nine seconds after engine ignition, telemetry data showed that the feather parameters changed from locked to unlocked.
  • Video from the cockpit showed that the copilot had unlocked the feathering system, and is consistent with the telemetry data.
  • About two seconds later, the feathers moved toward the deployed position even though the feather handle had not been moved into the feather position.
  • The feather deployment occurred at a speed just above Mach 1.
  • Shortly after feathering occurred, video data and telemetry data terminated.
  • The engine burn was normal prior to the deployment of the feathers.
  • Normal procedures would have had the crew unlocking the feathering system at a speed of about Mach 1.4.
  • Unlocking the feathering system alone should not have allowed the feathers to deploy.
  • The inflight breakup of the vehicle began sometime after telemetry ceased.
  • The NTSB has not determined if the inflight breakup was caused by aerodynamic forces or from some other cause.
  • The rocket engine, fuel tank, or oxidizer tank showed no evidence of a breach or burn through consistent with some sort of fire, explosion or structural failure affecting those components.

The NTSB emphasized that their statements were statements of fact rather than a determination of a cause of the mishap. Below is a video of the third media briefing.

Additional resources
Initial NTSB SpaceShipTwo accident investigation
Review of first two NTSB briefings on 1 November 2014
Review of third NTSB briefing on 2 November 2014

Note: An earlier version of this story inadvertently stated that there was evidence of a breach or burn on some components.

01 November 2014

Virgin Galactic SpaceShipTwo NTSB accident investigation

The NTSB is leading the investigation into yesterday's crash of Scaled Composites SpaceShipTwo north of Mojave, CA. Saturday November 1st was the first day of the investigation, and the NTSB has already had one one media briefing with a second planned for late in the evening.

The following is an overview of the crash and comments on the early media briefings.

31 October 2014; Scaled Composites; Model 339 (SpaceShipTwo); N339SS; near Cantil, CA: The vehicle, which is designed to fly into the lower reaches of space (above 100 km above Earth) was on its first powered test flight with a new engine fuel and oxidizer combination (nylon and nitrous oxide). SpaceShipTwo was dropped from its carrier vehicle at about 45,000 feet, and ignited its engine.

Roughly two minutes after release from the carrier aircraft White Knight Two, the SpaceShipTwo vehicle experienced an inflight breakup. One of the two crew members was killed, and the other was able to bail out of the vehicle and was injured.

Prior to the accident flight, there had been the 54 test flights of SpaceShipTwo, of which 34 involved a release from the carrier aircraft, including three powered flights.

Scaled Composites, which conducted the flight test, is a partner of Virgin Galactic, which had planned on using SpaceShipTwo to take passengers on suborbital trips into space in the near future.


Summary of first two NTSB briefings on 1 November 2014
Both NTSB briefing were given by acting NTSB chair Christopher A. Hart, was short, and provided the following preliminary information about the accident:

  • While the NTSB has previously participated in the investigations of the Challenger and Columbia Space Shuttle accidents, this will be the first time it has taken the lead role in the investigation of a crewed space launch vehicle accident.
  • The NTSB team consists of about 13-15 investigators and specialists in the areas of structures, including systems, engines, vehicle, performance, and operations.
  • The parties to the investigation are the FAA, Scaled Composites, and Virgin Galactic
  • The vehicle was flying in a southwesterly direction, and the wreckage field is about five miles (8 km) long, and is oriented from the northeast to the southwest.
  • The wreckage pattern indicates that an inflight breakup occurred, but the NTSB has not yet determined why this happened.
  • The left and right tail booms were near the beginning of the wreckage trail, followed by the fuselage, fuel and oxidizer tanks, cockpit, and the rocket engine.
  • There were a total of three tanks in the vehicle, a fuel tank, an oxidizer tank, and a methane tank.
  • The NTSB was unaware of the altitude of the mishap.
  • There was extensive video data available from the flight, including six cameras on SpaceShipTwo, another three on White Knight Two, one in a chase aircraft, and one on the Edwards AFB test range.
  • The NTSB does not know if the six cameras on board SpaceShipTwo have been recovered.
  • There were six data sources on SpaceShipTwo and about 1000 parameters of telemetry available from the flight. There was also a radar on the chase aircraft.
  • Interviews have been conducted, but NTSB will not reveal what has been discovered until later in the investigation.
  • The surviving pilot has not yet been interviewed because his doctors recommended against doing so at this time.
  • The NTSB does not know how the surviving pilot exited the vehicle.
  • The on scene portion of the investigation will continue for another four to seven days, and the full investigation will take about a year.
  • Scaled Composites can continue operations during the investigation.
  • News and updates to the investigation will be available at the NTSB's web site (www.ntsb.gov) Twitter feed (@NTSB).

Initial SpaceShipTwo NTSB briefings


Initial NTSB SpaceShipTwo briefings 1 November 2014

25 June 2014

NTSB report on July 2013 crash of an Asiana Airlines 777 in San Francisco

On 24 June 2014, NTSB Board members met to determine the probable cause of the July 2013 crash of Asiana Airlines flight 214 in San Francisco, CA, which resulted in the deaths of there passengers. The Board concluded that there were a number of probable and contributory causes for the accident, with many of them revolving around the crew's understanding of the aircraft's automated systems.

Synopsis
On July 6, 2013, about 11:28 am local time, a Asiana Airlines flight 214, a Boeing 777-200ER (HL7742), struck a seawall while attempting to land on runway 28L at San Francisco International Airport (SFO). Three of the 291 passengers were killed, and 40 passengers were serious injured. All 16 crew members survived, but nine were seriously injured.



Aprroach sequence
Although air traffic control (ATC) allowed the aircraft to attempt a landing under visual flight rules, the flight crew used both the autopilot and autothrottle system during the landing. The sequence of events shortly before the crash featured a number of changes in the flight control system, and according to the NTSB the flight crew's understanding of how the aircraft performed in various autopilot and autothrottle modes led to the crash.

The following is a synopsis of the portion of the NTSB report on the crash of flight 214 that focused on the landing approach:

  • The flight was vectored for a visual approach to runway 28L, and intercepted the final approach course about 14 nautical miles from the threshold at an altitude that put the aircraft slightly above the desired three degree glide path.

  • The flight crew accepted an ATC instruction to maintain 180 knots until five nautical miles from the runway, but mismanaged the airplane’s descent, which resulted in the airplane still being above the desired three degree glide path when it reached the five nautical mile point.

  • In an attempt to increase the airplane’s descent rate and capture the desired glide path, the pilot flying (PF) selected an autopilot mode that resulted in the autoflight system initiating a climb. The chosen autopilot mode, 'flight level change,' attempted to bring the aircraft to the selected altitude, which was above the aircraft's altitude at that point of the approach.

  • The PF disconnected the autopilot, moved the thrust levers to idle, and then pitched the aircraft down, which increased the decent rate.

  • When the PF disconnected the autopilot, that action caused the autothrottle to change to the 'hold' mode, which is a mode where the autothrottle does not control airspeed. Neither the PF or the other two pilots in the cockpit noted this change in the autothrottle mode.

  • Asiana’s procedures dictated that the approach must be stabilized by the time the aircraft descends to 500 feet above the airport elevation. The approach was not stabilized, and the crew should have initiated a go-around, but instead continued the approach.

  • As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath.

  • Airspeed continued to decrease, and at about 200 feet, the flight crew became aware of both a low airspeed and low glide path condition, but still did not initiate a go-around.

  • The crew finally initiated a go-around when the airplane was at less then 100 feet of altitude. However, at that point the airplane did not have the performance capability to accomplish a go-around.


NTSB animation of the final approach


Crash sequence
The following information was in the NTSB report synopsis released on 24 June 2014, and from two NTSB media briefings given shortly after the accident.

  • The main landing gear hit the sea wall first, followed by the tail section.

  • The main landing gear sheared away from the aircraft as designed, and the wing fuel tanks were not punctured by the gear separation or during the rest of the crash sequence.

  • The tail section broke off after the aircraft contacted the sea wall. Cabin flooring and galley components were found on the chevrons in the runway overrun area between the sea wall and the runway threshold.

  • Two passengers and four flight attendants were ejected from the aircraft. All four flight attendants were seriously injured, and both passengers were killed.

  • Neither of the ejected passengers were wearing seat belts at the time of the crash, and one of these passengers was later run over by two of the responding firefighting vehicles. The NTSB noted that had the passengers been wearing their seat belts, they would have likely remained in the aircraft and survived.

  • One of the flight attendants initiated an evacuation after became aware of a post-crash fire. All but five of the passengers were able to evacuate on their own. Firefighters rescued five passengers, one of whom later died.

NTSB probable and contributing causes
The NTSB determined that the probable causes of this accident was due to a combination of flight crew actions:

  • Mismanagment of the airplane’s descent during the visual approach,

  • Unintended deactivation of the automatic airspeed control system,

  • Inadequate monitoring of airspeed, and

  • Delayed execution of a go-around after they became aware that the airplane was below acceptable glide path and airspeed tolerances.

The NTSB found that there were also several contributing causes:

  • Complex autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training,

  • The flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot systems,

  • Inadequate training on the planning and executing of visual approaches;

  • Inadequate supervision of the pilot flying by the instructor pilot; and

  • Flight crew fatigue.


Key NTSB Asiana investigation resources
Abstract of NTSB accident report
Asiana flight 214 investigation main page
Asiana flight 214 accident docket
Asiana flight 214 investigative hearing transcript (11 December 2013 hearing archived by AirSafeNews.com)

Related AirSafeNews.com articles

21 February 2014

Advice on how to prevent injuries from inflight turbulence

Turbulence happens on just about every flight, but most of the time the amount of turbulence is very small, and the level of risk is very low. Two turbulence events that happened earlier this week, one involving a Cathay Pacific 747 and the second a United Airlines 737 both led to injuries, and also received quite a bit of media attention.

These two events served as a reminder reminders of just how serious students can be, and the need for passengers to be aware of the potential danger.The following insights and advice should keep you from becoming one of those statistics.

Airline turbulence basics
You can experience turbulence for many reasons, typically due to weather conditions such as thunderstorms. Severe turbulence can happen in any phase of flight, but it's most likely to be hazardous during cruise when passengers and crew may be out of their seats and not belted in. In most cases a passenger experiencing turbulence will feel nothing more than a slight vibration. At the other extreme are those rare events that are severe enough to throw passengers around the cabin.

What causes turbulence?
Turbulence is air movement that normally cannot be seen. While it may sometimes be associated with weather conditions like thunderstorms, it can also happen in the following situations, which could happen even on a clear day.

  1. Thermals - Heat from the sun makes warm air masses rise and cold ones fall.
  2. Jet streams - Fast, high-altitude air currents shift, disturbing the air nearby.
  3. Mountains - Air passing over mountains can lead to turbulence as the air mixes above the air mass on the other downwind side.
  4. Wake turbulence - If an aircraft travels too close to another aircraft, the trailing aircraft may pass through an area of chaotic air currents caused by the lead aircraft.

How bad can it get?
Turbulence effects can range from the barely noticeable to the potentially dangerous. What you may feel can range from feeling a slight strain against your seat belts, to being forced violently against your seat belts, and having unsecured items (including yourself if you are unbuckled) being being tossed about the cabin.

Reducing your risks from turbulence
When the flight crew expects turbulence, they will work with the cabin crew to make sure that passengers are in their seats and belted in, and that serving carts and other loose items are properly secured. Even when turbulence is not expected, you should take a few basics steps before and during the flight to ensure your safety:

  • Follow the instructions of the crew - If the crew suggests that passengers return to their seats, do so as soon as you can.
  • Wear your seat belt at all times - Turbulence events can happen even during a smooth flight on a cloudless day. Turbulence is not always predictable and may arrive without warning.
  • Be aware of your overhead bin - If you are sitting under an overhead bin, make sure that the door is properly closed. Also, avoid sitting under a bin that is heavily packed or that contains one or more heavy items. If you can, move to a seat that is not directly under a bin.

Resources
Turbulence injuries on a United flight out of Denver - 18 Feburary 2014
AirSafe.com turbulence information
Passengers killed by turbulence
FAA turbulence information
How to measure turbulence while you fly
Using child restraints on aircraft
Airline pilot Patrick Smith weighs in on turbulence

Photo credit: Civil Aviation Safety Authority of Australia

18 February 2014

Turbulence injuries on a United flight out of Denver

17 February 2014, United Airlines 737-700, flight 1676, near Billings, MT: Yesterday, several passengers and crew members were injured in a turbulence event involving a United Airlines 737-700 that was en route from Denver, CO to Billings, MT, with at least one passenger hitting the ceiling hard enough to damage a panel. According to the FAA, the captain declared a medical emergency, and the aircraft landed without further incident. The event took place in the early afternoon, and the aircraft was reportedly in clear skies at the time of the incident.


United 737-700 in Billings, MT after turbulence event

The aircraft apparently encountered turbulence during descent that caused several flight attendants and unrestrained passengers to be tossed in the air. Most of the the injuries were minor, and only one victim, a flight attendant, required hospitalization.

Among those tossed in midair was an infant, who landed in a nearby seat and was not injured. According to United, there were 114 passengers and five crew members on board, and three flight attendants and two passengers were injured. Since the 737 has two flight crew members, this implies that all of the flight attendants who were on board were injured.

Turbulence events are not that rare, with the NTSB noting hundreds of such events in their online database. The FAA notes that in the 10-year period from 2002-2011, a total of 110 passengers and 219 crew members were injured by turbulence.

AirSafe.com has extensive background information on inflight turbulence at turbulence.airsafe.com, including advice on how to reduce turbulence risks and a link to a mobile phone app that will allow you to measure turbulence while you fly.

While significant turbulence events that lead to injuries occur several times a year, fatal events are much more infrequent. The last turbulence event that led to a passenger death was in 1997 on a United Airlines 747 that was on a flight from Japan to the US.


Fear of flying and turbulence
Capt. Tom Bunn of the SOAR fear of flying program offers insights into what causes turbulence, and shows passengers a method for controlling the anxiety that turbulence causes some passengers.

Get help NOW from the fear of flying experts at SOAR

Download AirSafe.com's fear of flying resource guide


Resources
AirSafe.com turbulence information
Passengers killed by turbulence
FAA turbulence information
How to measure turbulence while you fly
Using child restraints on aircraft
Airline pilot Patrick Smith weighs in on turbulence

Photo credit: Caleb VanGrinsven

13 December 2013

Review of NTSB Asiana flight 214 investigative hearing

On 11 December 2013, the NTSB conducted a day-long investigative hearing into the 6 July 2013 crash of Asiana flight 214 in San Francisco, featuring public testimony from representatives of Boeing, Asiana Airlines, and other organizations directly involved in the accident and the subsequent investigation. While the NTSB had previously released to the public substantial amounts of information about the accident, there was quite a bit more new material presented at the hearing.


For a summary of the hearing, listen to the Al Jazeera America interview featuring their transportation contributor Dr. Todd Curtis.


The amount of information presented at the hearing was noteworthy, as was the way that it was released. Like it has since the day of the accident, the NTSB has been very innovative in the way that it has used the Internet to get information very quickly to the public. This article describes some of the information presented in the hearing, and also points out some of the areas where the information released could be incomplete or misleading.

The purpose of the investigative hearing
The NTSB holds public hearings during major accident investigations for many reasons, among the most important is making the public aware of the progress of the investigation, and to focus attention on the key areas of the investigation. While the key parties involved in the investigation, most notably Boeing and Asiana airlines, provided testimony and answered detailed questions from NTSB Board members, they have all been closely involved with the investigation from the beginning, and have likely already provided the same information to the investigators.

The public testimony is more of an opportunity for the media and the general public, including accident victims and their families, to learn additional details of the investigation and to get an idea of where the investigation is heading.

What the NTSB discussed
The NTSB investigative hearing focused on five areas:

  1. Boeing 777 flight deck design concepts and characteristics
  2. Asiana pilot training on Boeing 777 automated systems and visual approach procedures
  3. Effects and influence of automation on human performance in the accident sequence
  4. Emergency response
  5. Airplane cabin crashworthiness and occupant protection.

The investigation is far from complete
The investigative hearing is only part of the accident investigation process, focusing on the factual aspects of what happened in the accident and the initial emergency response to the crash, as well as factors that may have played a role in circumstances that led up to the accident or that affected the emergency response.

Hearing testimony provided insights into the "what happened" kind of questions being asked by the NTSB, such as what was the sequence of events that occurred immediately before and after the accident, as well as insights into "why it happened" questions such as the kind of training provided to the flight crew on the accident aircraft. The latter parts of the investigation focuses on answering "why it happened."

Other "why it happened" type of questions may address issues or explain circumstances that happened days, months, or even years before the accident, and that may have led to the situations that allowed the accident to occur and that may have made deaths and injuries either more or less likely once the accident occurred. The hearing didn't fully answer all of the "what happened" and "why it happened" questions. Complete answers to these questions, and well as recommendations for changes and improvements, will likely not happen until the final report is published.

These recommendations, which are answers to "what should be done" questions, typically, but not always, get answered at the time the final report is published because much of the analysis of the accident happens after the NTSB and their investigative partners have had an opportunity to sort through information from a variety of sources. NTSB final reports have a similar organization, and typically have three sections; Findings, Probable Cause, and Recommendations, that are associated with the three kinds of questions mentioned earlier. The "Findings" section would answer the "what happened" questions, the "Probable Cause" section would answer the "why it happened" questions, and the "Recommendations" section would address the "what should be done" questions.

Key implied "what happened" questions
While the investigation is not complete, and other factual information may come to light later, the testimony provided in the hearing implied that the following scenario led to the crash:

  • Although the glideslope portion of the landing runway's instrument landing system was not operational, and the crew was vectored for a visual approach to the landing runway, the Asiana crew decided to used both the autothrottle and autopilot during their landing.
  • The autothrottle was being used to control airspeed, and the autopilot was being used to control the flight path.
  • During the latter part of the landing attempt, the crew disconnected the autopilot and manually adjusted the throttles, and this put the autothrottle in a mode where it was no longer controlling airspeed.
  • The crew continued the landing attempt, and the airspeed was decreasing, but did not take actions to increase the airspeed soon enough to avoid crashing short of the runway.

Key unanswered "why it happened" questions
Critical "why it happened" questions that were hinted at in the hearing, but not yet answered, include the following:

  • Why didn't the crew take corrective action sooner in the landing sequence?
  • Why did the crew use the autopilot and other cockpit automation in ways not recommended by Boeing?
  • Why did the Boeing training organization make certain assumptions about how much airline pilots know about how to use cockpit automation?

How this investigation was different
The Asiana crash was a high profile event, not only in the US, but also in South Korea, where Asiana is based, and China, which had a significant number of its citizens on the flight. The NTSB went to great lengths to accommodate the media interest in this investigation; as well as the public interest in the US, South Korea, and China; by doing the following:

  • Providing a streaming online video stream of the entire hearing,
  • Providing a real-time translation of the hearing in Mandarin Chinese and Korean,
  • Providing a simultaneous transcript in English of the proceedings,
  • Using social media, primarily Twitter, Flickr, and YouTube, to provide related photos,videos, and links to additional material.

While the NTSB has historically provided information freely to the public, until the advent of the Internet, it was very difficult for individuals to get access to the final reports or the supporting data behind their investigations. In recent years, and especially during the Asiana investigation, the NTSB has aggressively used social media like Twitter, Flickr, and YouTube to provide more information than ever before, with even fewer delays. While this level of openness has caused some friction in the past between NTSB and other aviation organizations, the amount and types of information provided by the NTSB during this hearing was consistent with their recent communications policies.

Issues with the NTSB's hearing information
While providing a live webcast, a real-time transcript, and simultaneous translations into other languages were very positive actions with respect to providing information, it is important to recognize that there are potential issues with this information that may limit its usefulness or lead to misinterpretations by the media or the public:

  • The transcript of the Asiana hearing was not completely accurate, so if someone requires an accurate transcription, that portion of that transcript should be compared to the appropriate portion of the video.
  • The webcast video of the hearing will be archived, but it is not clear if the original, somewhat flawed, transcript will also be archived, if there will be a revised transcript archived, or if the NTSB will not archive any transcript.
  • The participants in the hearing were provided with simultaneous translations of all the statements made during the hearing, and it is not clear if those translations were completely accurate. Some of the technical information provided in the hearing was both complex and subtle, and may not be completely understood even if the speaker and listener shared the same language. Some of the spoken testimony has accompanying presentation slides that would help understanding, and may be necessary to view those to make sense of the spoken testimony or the information in the transcript.

Dr. Todd Curtis interviewed by Al Jazeera America
Dr. Todd Curtis, transportation contributor for Al Jazeera America, was interviewed by John Seigenthaler about some of the issues discussed during the NTSB hearing.
Listen to the interview

Key NTSB Asiana investigation resources
Asiana flight 214 investigation main page
Asiana flight 214 accident docket
Asiana flight 214 investigative hearing transcript (archived by AirSafeNews.com)

Key NTSB social media resources
NTSB webcast archives
NTSB YouTube channel
NTSB Flickr photos
NTSB Twitter stream
NTSB RSS feeds
NTSB email subscriptions

Related AirSafeNews.com articles


Find out how to help Todd Curtis run the Boston Marathon at marathon.airsafe.com

11 December 2013

NTSB has live webcast of Asiana 214 investigative hearing today

The NTSB's hearing on Asiana flight 214 began this morning and will end this evening. It is notable for its use of technology to get information quickly to the public. There is no only a live webcast, but also also a live written transcript in English combined with options for translations in Korean and Mandarin Chinese.

This hearing was originally scheduled to take place over two days, but the first day was cancelled due to weather in the Washington, DC area. The agenda was revised so that it could be completed today, and the hearing will run until about 8:00 p.m. This hearing will also be archived for several months, making it very easy for the media and especially the general public to come to their own conclusions about the information provided by witnesses.

Finding live comments on Twitter
If you are searching for recent comments on Twitter, helpful hashtags include #NTSB, #Asiana, and #777.

Resources
Asiana flight 214 NTSB investigative hearing information

05 December 2013

NTSB train crash investigation has lessons for future plane crash investigations

Normally, this site focuses on airline related safety and security events, but the NTSB investigation into the 1 December 2013 fatal derailment of a commuter train in New York is an exception because some of the recent developments in the investigation are quite relevant to how the NTSB would investigate future airline accidents.

The NTSB is best known for its investigations of airline accidents, but it also investigates accidents involving other modes of transportation, including rail accidents. NTSB Board Member Earl Weener, who is a former Boeing executive, is heading the investigation of the fatal 1 December 2013 crash of a Metro-North commuter train in New York, and part of that process includes involving relevant parties that provide technical expertise in support of the NTSB's investigation. During the early part of the investigation, the NTSB serves as the primary conduit of information to the media and the public on the progress of the investigation, and sticks primarily to factual information about the accident. Determination of probable causes, and the role of organizations and individuals in the accident typically happens much later in the investigation.

One of the parties invited to participate in this investigation was the Association of Commuter Rail Employees (ACRE), which represents Metro-North several categories of Metro-North employees. However, the NTSB abruptly removed ACRE from the investigation onm3 December 2013 after a representative of the union gave a series of briefings to the media where that representative discussed and interpreted information related to the ongoing investigation.

This is a very rare move for the NTSB, and one that underscores the importance that the NTSB places in adhering to its investigation process. If this had been an airliner accident investigation, the NTSB would have likely taken the same action. While news media organizations and other groups not directly involved in the investigation are free to speculate about the causes of an accident, parties that are part of the NTSB investigation don't have that option. There are many reasons for this, and perhaps the most obvious one is that publicly speculating about the causes of an accident is inappropriate before all of the relevant factual information about the accident has been analyzed.

Below is Earl Weener's NTSB briefing from 3 December 2013.


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30 August 2013

Social media leads to friction between airlines NTSB and FAA

A Wall Street journal article from 26 August 2013 highlighted the increasingly role social media tools like Twitter are playing in recent airline accidents in the US, leading to some friction between airline officials, the NTSB, and the FAA. In the article, Tim Logan, the senior risk management official at Southwest Airlines, expressed frustrations that speed at which information is released after an accident has led to problems like a lack of coordination between the FAA and the NTSB during an accident investigation, specifically the 22 July 2013 Southwest landing accident in New York.

Logan is not the only airline industry voice with concerns about the speed of information flows to the public. On 8 July 2013, just two days after the of an Asiana 777 in San Francisco, the Airline Pilots Association (ALPA) sent out a press release stating that the organization was "stunned by the amount of detailed operational data from on-board recorders released by the National Transportation Safety Board," saying also that the amount of information released during the field portion of the investigation was unprecedented.

NTSB post accident policies on information
The speed at which NTSB releases information is part of their normal policy. On its web site, the NTSB states that after an accident, it strives to conduct two press conferences a day when on scene, where Board's spokespersons discuss factual, documented information about the accident. The NTSB may remain on site for up to a week, and they may also have several public affairs specialist to handle media requests.

Media involvement past and present
While the NTSB's policies with respect to being transparent and providing factual information to the public in the early stages of an investigation has not changed over the last few decades, the media realities are far different from the past. A little as a generation ago, only the largest media organizations had the resources needed to send video to viewers around the world, and most people had to wait until the following day's newspapers to get photos and interviews from those involved in the accident. Because of these kind of limitations, it could take days or weeks before minute details of an accident would be available to the public.

Compare the past with the present, where it takes little more than a YouTube or Twitter account (both available for free) for any individual or group to communicate with the entire world within seconds. Anyone interested in an accident can choose from a wide range of resources for information, and can get plenty of information directly from the investigating authorities unfiltered and without delay.

NTSB and social media
A 23 July 2013 article published by Twitter quoted an NTSB official stated that sending out tweets after an accident is standard NTSB policy because it helps to keep both the media and the public stay informed during an accident investigation.

The Wall Street Journal article discussed how the NTSB's use of Twitter to communicate with the media and the public after an accident has forced other parties involved in investigations, particularly airlines and the FAA, to speed up their responses both the the investigating authorities and to the public. The following chart was taken fro the article, and shows that NTSB sent out 86 tweets in the days after the 6 July 2013 crash of an Asiana 777 (flight 214) in San Francisco, with the largest number (30) sent the day after the crash.



A search for tweets sent by NTSB (@NTSB) about the crash reveals that many of the tweets contained links to a wealth of information, including photos from the crash site, videos of press conferences, and the number of times the original tweet was retweeted:
Tweets from NTSB containing the word 'Asiana'
Tweets from NTSB containing hashtag #Asiana214
Tweets from NTSB containing the number '214'

Note that the search was conducted on the Twitter search site at search.twitter.com, and as is the case with most search engines, different search terms give different results, so it helps to use various search terms associated with an event.

NTSB uses a variety of social media tools to provide information to the public. In addition to Twitter, NTSB uses Flickr to post high resolution photos from accidents, and also has a YouTube channel where past press conferences can be reviewed at any time. Because all of their published information is in the public domain, anyone can use these photos and interviews without cost, and without first asking permission.

The future has more and not less social media
In spite of the protests about the speed at which the NTSB releases information, it is very likely that the future will see a greater role for social media in accident investigations. In the recent Southwest and Asiana crashes, photos and videos taken by some of the passengers involved in the accidents are being used by the NTSB to help further the investigations.

Perhaps the best description of what the future holds is from a headline from this recent headline from an article from the Airline Passenger Experience Association, "Social media becomes important tool in accident probes whether safety professionals like it or not." The article is about the August 2013 meeting if the International Association of Air Safety Investigators (ISASI), where among other things, an informal poll of the roughly 300 air safety specialists in attendance showed that almost all of them used Twitter. Representatives from the Canadian and German aviation accident investigation agencies, as well as a representative from Southwest Airlines, agreed that information supplied by passengers and other witnesses, and shared online, have helped investigators.

07 August 2013

Second NTSB update on Southwest 737 accident at LaGuardia

Earlier this week, the NTSB released a second update on the 22 July 2013 Southwest Airlines flight 345 landing accident at New York's LaGuardia Airport. The accident, which is being handled by the NTSB's Major Investigations Team, resulted in substantial damage to the aircraft.



Initial press release
The initial NTSB press release on 23 July 2013 stated that the jet's nose landing gear collapsed rearward and upward into the fuselage, damaging the electronics bay. The aircraft was also damaged from sliding over 2,000 feet (610 meters) before coming to rest off to the right side of the runway.

First investigative update
Key findings from the first NTSB investigative update released on 25 July 2013 included the following:

  • Evidence from video and other sources was consistent with the nose landing gear making contact with the runway before the main landing gear (this is the reverse of what happens in a normal landing).
  • Flaps were set from 30 to 40 degrees about 56 seconds prior to touchdown.
  • Altitude was about 32 feet, airspeed was about 134 knots, and pitch attitude was about 2 degrees nose-up approximately 4 seconds prior touchdown.
  • At touchdown, the airspeed was approximately 133 knots and the aircraft was pitched down approximately 3 degrees.
  • After touchdown, the aircraft came to a stop within approximately 19 seconds.

Second investigative update
Key findings from the second NTSB investigative update released on 6 August 2013 revealed additional information about the accident flight:

  • This was the first trip the flight crew had flown together and it was the second leg of the trip.
  • The first officer had previous operational experience at LGA, including six flights in 2013.
  • The captain had one previous flight into LaGuardia.
  • On approach into LaGuardia, the first officer was the pilot flying and the captain was the pilot monitoring.
  • The wind changed direction prior to landing, from an 11-knot tailwind when the aircraft was at 1,000 feet, to an 11-knot headwind at landing.
  • The aircraft had been cleared for an ILS approach on runway 4 (see diagram below).
  • The crew reported the airplane was on speed, course and glideslope down to about 200-400 feet.
  • At some point above 400 feet, there was an exchange of control of the airplane and the captain became the flying pilot and made the landing.
  • The NTSB has so far found no mechanical anomalies or aircraft malfunctions, and that a preliminary examination of the nose landing gear indicated that it failed due to stress overload.
  • The NTSB has collected five videos showing various aspects of the crash landing. The team will be analyzing these recordings as part of the investigation.


Photos: NTSB, Wikipedia

30 July 2013

FAA suggests non-US airline crews lack basic piloting skills

On Sunday 28 July 2013, the FAA issued a recommendation that non-US airlines landing at San Francisco International airport (SFO) use their GPS systems to help guide them during landings operated under visual flight conditions at the airport's longest runways, including runway 28L, which was the one being used by the Asiana 777 that crashed at SFO on 6 July 2013 . This implies that non-US pilots may not have the basic piloting skills needed to consistently land aircraft at SFO under visual flight rules.



Dr. Todd Curtis on new FAA recommendations

An FAA representative stated that the recommendation was a response to concerns that some non-US airline pilots may not have sufficient experience or expertise to land an airliner using visual approach procedures, which don't rely primarily on electronic landing aids.

Neither the FAA or the NTSB has stated that the visual approach procedures were a factor in the crash of Asiana flight 214 on July 6th. However, since that crash, the FAA has revealed that an unspecified number of flights involving Asiana, EVA Air, and other non-US carriers have had more aborted landing attempts than usual at SFO.

Since last week, the FAA has instituted a different landing protocol for visual approaches on runway 28L, the intended landing runway for Asiana flight 214, and the parallel runway 28R. That protocol will have air traffic controllers at SFO requesting that non-US airliners use a GPS-based navigation system to assist those flight crews in landing on either of those runways.

In a visual approach, pilots typically don't rely on a variety of electronic aids like an instrument landing system to align the aircraft with the runway and to keep to the aircraft on the proper glide slope. On runway 28L, the glide slope system was not operable on the day of the accident, and is scheduled to be out of commission until 22 August 2013. During a visual approach, pilots may use the glide slope system, as well as other systems like the precision approach path indicator (PAPI) system, which was used by the crew on Asiana fight 214.

While the FAA did not state when the recommendation for non-US airlines would be lifted, it would likely not be necessary once the glide slope system is back in operation.

Additional information

24 July 2013

NTSB launches investigation of Southwest Airlines LaGuardia accident

22 July 2013;Southwest Airlines 737-700; flight 345; LaGuardia Airport, New York, NY: The airliner, with 145 passengers and five crew members on board, was on a scheduled flight from Nashville, TN to New York, had a problem after landing which led to a collapsed nose landing gear and a runway excursion.



After the aircraft came to a stop in a grassy area adjacent to the runway, the occupants evacuated the aircraft using the emergency slides. Nine of the occupants were treated for minor injuries, and no one was serious injured or killed.

The NTSB has launched a formal investigation of this accident, and has already begun processing the information from the cockpit voice recorder and flight data recorder. While this is not a major investigation on the scale of what is happening with Asiana flight 214, this will be a more extensive investigation than what would normally happen after a typical landing gear accident. This is likely because of the level of damage caused by this event.

As can be seen in the photo below, the nose landing gear not only collapsed, it was also pushed up into the electronics bay beneath the cockpit.

Why so much media attention to this accident? While the response of the NTSB is typical for this kind of accident, the media response is not. While it did not garner the kind of nonstop coverage that happened on major cable news shows after the Asiana crash, it has two qualities that are often associated with high levels of media coverage of airline events:

  • It involved a major US airline, and
  • It occurred in New York, the most influential media market in the US, and arguably in the the entire English-speaking world.

The last point is possibly the most important since not only do many US news and broadcast media organizations have headquarters in New York, many of the people who work at those organizations use the airport where the accident occurred. Had the same event occurred at a US airport that was not in a major media market, it is unlikely that this event would have led to much media coverage.

Additional resources
Previous Southwest events

Photo: NTSB; Video: Bobby Abtahi

18 July 2013

AAIB releases bulletin on 787 fire plus additional 777 crash interviews

On 18 July 2013, the UK's Air Accidents Investigation Branch (AAIB) released a special bulletin related to the 12 July 2013 fire on an Ethiopian Airlines 787 at London's Heathrow airport. The AAIB made two safety recommendations, the first was to advise the FAA to initiate action to have 787 operators deactivate the emergency locator transmitter (ELT), and the second was to have the FAA conduct a safety review of the installation of ELTs in other aircraft where the ELTs are also powered by lithium batteries.

While the AAIB does not have any authority to implement these recommendations, it is very likely that the FAA, Boeing, and all of the 787 operators will respond relatively quickly to the recommendations.

AAIB summary of the fire
The AAIB special bulletin contained the following key information about the events leading up to the fire:

  • The Ethiopian Airlines 787 landed at Heathrow at 0527 hours on 12 July 2013 after an uneventful flight, with no technical problems reported by the crew.

  • After it was towed to a parking area, external power was turned off, and the aircraft was left unpowered.

  • An employee in the air traffic control tower noticed smoke coming from the aircraft at 1534 hours, and fire fighters arrived about one minute later.

  • After a fire crew entered the aircraft, they observed indications of fire above the ceiling panels, and had to move a ceiling panel in order to put out the fire.

  • A later examination revealed extensive heat damage in the rear fuselage in the crown area, just to the left of the centerline, an area which coincided with the location of the ELT.

  • The ELT, which was powered by a set of chemical batteries containing a Lithium-Manganese Dioxide composition, was the only aircraft system in that area that had the potential to initiate a fire when the aircraft was unpowered.

About emergency locator transmitters
ELTs are battery-powered radio transmitters that are carried aboard airliners, other civil aircraft, and most military aircraft. Thay are designed to survive most accidents, and to transmit a signal that can be used by rescue crews and even satellite-based monitors to locate a crash site. The FAA requires the use of ELTs on commercial airliners.

According to the AAIB, the manufacturer of the ELT associated with the recent 787 fire (Honeywell) has produced about 6,000 ELTs for use in a wide range of aircraft, and this the first time the manufacturer has what the AAIB calls a 'thermal event.'

The ELTs used by Boeing in the 787 are all made by Honeywell, and they are powered by a set of five non-rechargeable batteries, each of which is roughly the size of a common household "D" cell battery.

What's next for the 787
There are currently 68 787 aircraft flying with 13 operators around the world. Although the FAA has not made a formal request for airlines to implement the AAIB recommendations, it is likely that Boeing and the airlines will take action relatively quickly. If the recommended actions are taken, in the short term 787s may be flying without ELTs.

While flying without ELTs may make it harder to find an aircraft that has an emergency in an unpopulated area, the FAA can allow airliners to fly for short periods of time without a working ELT, so implementing these AAIB recommendations will likely not cause the FAA to ground the 787. Other regulatory bodies around the world typically follow the actions of the FAA in situations such as this one.


Media interviews with Dr. Todd Curtis about the Asiana 777 crash
The following three interviews with Dr. Curtis were made in the days immediately following the crash of Asiana flight 214

- WGN radio - The Dean Richards show on 8 July 2013
- Bloomberg television interview 8 July 2013

CCTV America 8 July 2013

Additional information

17 July 2013

Update on 787 fire in London plus radio interview on 777 crash

Update on the 12 July 2013 787 fire in London
On 12 July 2013, an Ethiopian Airlines 787 caught fire while parked on an apron at London's Heathrow Airport. There were no passengers on the aircraft at the time of the fire, and no one was injured or killed.

The initial witness and physical evidence shows that this event resulted in smoke throughout the fuselage and extensive heat damage in the upper portion of the rear fuselage. The photo below shows that the fire burned through the top of the fuselage in the rear of the aircraft between the two rear doors and near the base of the vertical fin.


(click to enlarge)

The British Air Accidents Investigation Branch (AAIB) is investigating the fire, and has not yet released any statement about the likely causes of the fire. However, several things are known about the investigation:

  • The aircraft had arrived from Addis Ababa, Ethiopia about nine hours before the fire was discovered.

  • In addition to the AAIB, participants in the investigation include the FAA, NTSB, the Civil Aviation Authority of Ethiopia, Boeing, Ethiopian Airlines, and Honeywell International.

  • Honeywell is the manufacturer of the emergency locator transmitter (ELT) used in the 787.

  • The battery in the ELT is based on a lithium manganese-dioxide technology and not on the lithium-ion technology associated with the batteries that caught fire on two different 787 aircraft in January 2013.

  • The fire was in the rear of the fuselage, and was remote from the areas of the aircraft containing the main battery and the auxiliary power unit batteries, the batteries associated with the grounding of the entire 787 fleet earlier this year.

Dr. Todd Curtis interviewed by eFM radio in South Korea
In the following July 15, 2013 interview on the South Korean eFM radio show Prime Time with Henry Shinn, Dr. Todd Curtis discussed several issues associated with the ongoing investigation into the July 6, 2013 crash of an Asiana 777 in San Francisco, CA, including speculation about the cause of the crash, the role of automated systems in the cockpit, and the NTSB investigative process. Many of the issues raised in this interview included questions about the 777 crash answered in a previous article.

Additional information

15 July 2013

Questions about the crash of Asiana flight 214

Over the past week, numerous questions and comments about the Asiana plane crash have been sent to Dr. Todd Curtis at AirSafe.com. Below are answers to some of the more popular questions posed by the public and the news media.

According to international protocol, who will be in charge of the investigation?

According to section five of Annex 13 to the Convention on International Civil Aviation, the state of occurrence of the accident (in this case, the United States) is required to begin an investigation, and has the option of delegating the investigation to another state or to a regional organization. Typically in the US, the NTSB leads airline accident investigations, unless it is determined to be caused by a criminal act. If that is the case, the FBI takes the lead in the investigation. So far, there is no indication that there was a criminal act, so the NTSB will likely lead and complete the investigation.

How long until this investigation is completed?

Typically, an NTSB investigation takes over a year to complete. The NTSB has published 13 reports on aircraft accidents that have occurred since the beginning of 2009. The shortest time until completion was just over nine months, and the longest was just under 27 months.

The information presented so far by the NTSB seems to point to either a case of pilot error or mechanical failure. From what you have seen, is there any way that you can say which one is more probable?

It is too early to focus on any one possible cause since the NTSB is still in the early part of the investigation, and has only processed and released some of the factual data from the investigation. It is also possible that the probable cause (or probable causes) may include something besides pilot error or mechanical failure. As the investigation continues, the NTSB will know more about the causes of the accident.

While Asiana Airlines stated that the pilot who was in control during the landing was an experienced airline pilot, his limited experience with the 777 seems to lend weight to the pilot error argument. What is the appropriate length of time for a pilot to be trained?

That question is beyond my expertise, but I will say that standards for airline pilots are extremely high around the world, and part of that high standard includes extensive training when airline pilots transition to new aircraft. That training includes ground school to familiarize pilots with systems and procedures, as well as training in high-fidelity aircraft simulators, including full motion simulators, that simulate the sights, sounds, and sensations pilots would experience in an actual aircraft. These training programs have often been developed in concert with the manufacturer to ensure that the training reflects the behavior of the aircraft.

The South Korean government as well as the world's largest organization of airline pilots, the nternational Federation of Air Line Pilot's Association, criticized the NTSB for revealing too much from the Asiana flight 214 investigation. What do you think about the press conferences held by the NTSB since the accident?

The press conferences have been an excellent source of information about the investigation. In my opinion, the kind of information the NTSB has provided is similar to what has been provided from past accidents. The biggest differences between this investigation and prior major investigations have been the access provided to the public and the NTSB's use of social media to inform the public of the availability of recorded press conferences, photographs, and other information from the investigation. In short, the NTSB is providing information much more quickly, and in a more accessible manner than before, but the kind of information being released is consistent with what has been released in the past.

The 777 is reportedly one of Boeing's flagship products and has a strong safety record. Why do you think this is the case?

There are many reasons for this record, and one of them are the high certification requirements of the FAA. At the time of its development, the 777 incorporated regulatory requirements of the FAA, and of the equivalent organizations in Europe and elsewhere. One of those requirements was the inclusion of 16G passenger seats.

A 16G seat is one that is tested in ways that simulate the loads that could be expected in a survivable accident. These seats must withstand two different accident scenarios, one in which the forces are mostly in the vertical or downward direction, and one in which the forces are predominantly in the forward or longitudinal direction. The highest load factor these seats must withstand is in the forward direction at 16Gs (16 times the force of gravity). It is unclear what kinds of forces were experienced by the seats on flight 214, but the NTSB will determine that as part of the investigation.

All aircraft certified by the FAA after 1988 had to have these seats, and since the 777 was certified after 1988, every 777 was delivered with these kinds of seats. The previous FAA standard for commercial airliners was 9G seats.

There are several other regulatory requirements and industry innovations that were incorporated into the 777, and I will mention just a few:

  • Cabin materials that are more fire resistant and less likely to produce dangerous fumes when burned,
  • Evacuation requirements that include emergency lighting on or near the cabin floor so that they can be more easily seen in a smoke-filled cabin.
  • Ground proximity warning systems to help warn pilots when they are flying too low or flying in an area of rising terrain,
  • Collision avoidance systems that warn pilots when other airliners are on a collision course or about to pass at an unsafe distance,
  • Emergency exit systems that allow a 777 with a full load of passengers to evacuate all passengers in 90 seconds or less while using only half of the eight available exits,
  • Multiply redundant aircraft systems, including a flight control system that will allow differential engine thrust to be used if flight control surfaces are not working,
  • Main landing gear that are designed to break off in a hard or crash landing in such a way that the wing fuel tanks are not punctured, and
  • Communications systems, including radios to communicate with airport personnel and cabin public address systems, that will continue to operate after a crash even if electrical power is no longer available from the engines or auxiliary power unit.

As an aviation safety expert, what do you think made this crash so survivable?

Very likely several of the items mentioned in the previous answer helped to keep the number of fatalities low, particularly the use of fire resistant cabin materials, the design of the emergency evacuation systems, the design of the main landing gear, the availability of aircraft communications systems, and the presence of the emergency exit lighting on or near the floor. Another factor was the prompt response from emergency and medical personnel who were at and near the airport.

According to the NTSB, the pilots ordered the passengers to remain seated for 90 seconds after the plane came to a halt, until the cabin crew noticed a fire when the evacuation was initiated. Were 90 seconds too long?

The decision to evacuate an aircraft after a crash is made by the crew based on the conditions inside and outside the aircraft. According to the NTSB, the crew made the decision to evacuate when fire was seen outside the cabin. The NTSB will review the accident to determine if there were any problems or errors in the timing of the evacuation decision or the execution of the evacuation.

According to international protocol, how are accident victims usually compensated?

Compensation for events involving international flights is covered by the Montreal Convention, and damage sustained by a passenger or a passenger's baggage in the event of an accident is not subject to any financial limit. How the compensation happens can be complex, especially since the accident took place in the United States. Because of the location of the accident, there may be a variety of international, federal, and state of California laws that may be relevant. Typically, the parties involved agree to a settlement without having a trial, and the terms of the settlement are not shared with the public.

Who is responsible for paying for the claims of victims?

Usually, any private company, government organization, or private individual that has some or all of the legal responsibility for the accident may have to pay victim claims. While many different entities may be legally responsible, in the US, typically only private companies end up paying compensation to victims or their families.

Does the NTSB determine who is legally responsible for paying for the claims of victims?

The NTSB investigation is separate from the process for determining legal liability. While the NTSB investigation is typically completed in about a year, legal proceedings involving victim compensation may take much, much longer to complete.

There remains substantial data from Boeing and the airline that must be reviewed. What do you think is the focal point of this ongoing investigation?

I currently don't have an opinion about what the focus will be because the investigation is still in the early stages. The focus of the NTSB investigation is to determine the probable cause or probable causes that led directly to the accident, as well as to identify those contributing causes that indirectly led to the accident. As the NTSB stated in several of their briefings last week, there is still a substantial amount of information that has to be gathered and analyzed before they will be able narrow the focus of the investigation.

As far as safety is concerned, what long-lasting influence will this accident have in the aviation field?

The long term effects will largely be determined by the recommendations that come out of the NTSB investigation, and any additional insights that the industry may gain from this accident. Until the investigation is complete, it is very difficult to predict the long-term influences of this accident.

Additional information
AirSafeNews.com 13 July 2013 summarizing the two prior NTSB press conferences
AirSafeNews.com 10 July 2013 article on the role of the autothrottle
AirSafeNews.com 8 July 2013 article on early findings of the crash investigation
Other Asiana plane crashes
Other 777 plane crashes
Accident details from Aviation Safety Network
Wikipedia page on this accident

The day after the crash, Dr. Curtis of AirSafe.com and Capt. Tom Bunn of the SOAR fear of flying program, who both spent several hours on the day of the crash on cable news programs providing expert commentary, discussed the media's response to the accident and shared their thoughts on the early reports of the crash.

13 July 2013

Summary of final two NTSB briefings on Asiana 777 plane crash in San Francisco

On Wednesday, 10 July 2013 and Thursday, 11 July 2013, NTSB conducted their final two press conferences in San Francisco, and covered a variety of issues around the accident, including the operation of the autopilot and autothrottle, damage to the airplane, injuries to the flight attendants, the evacuation of the aircraft, and other initial factual findings from the investigation.

The NTSB emphasized in both of these press conferences that the information was factual in nature, and in many cases had not yet been confirmed or corroborated. For example, statements received from the flight crew still have to be matched up with information from sources such as the cockpit voice recorder (CVR) and the flight data recorder (FDR).

Cockpit automation and its role in the crash
As mentioned in a previous AirSafeNews.com article, use of the autothrottle by the crew to maintain speed was an issue because although the crew was heard on the CVR stating that the target speed was 137 knots, the aircraft was significantly slower than that speed before the crash. In Wednesday's press conference, the NTSB stated that there were five distinct autothrottle modes used in flight, and in the last 2.5 minutes of flight, there were several autothrottle and autopilot modes used.

As explained by the NTSB, the autopilot helps pilots manage pitch, roll, attitude, and heading; while the autothrottle helps to control speed or thrust. The two systems can work together, and the NTSB has to determine, with the help of Boeing, the following:

  • Whether autopilot and autothrottle modes were commanded by the pilots or activated inadvertently,
  • How the various autopilot and autothrottle modes are designed to work, and
  • What are the ways the systems are expected to respond in the various modes.

Comparison to automobile cruise control
NTSB chair Deborah Hersman used an analogy to a much simpler automated system to illustrate the role that an autothrottle plays. Like in an airliner, a car's cruise control can be set to a specific speed, but it is up to the driver to monitor the speed. Also, cruise control may not engage if the car is in a particular mode, for example below a certain speed. While in cruise control, the driver may be allowed to increase or decrease speed within certain limits. Disengaging cruise control can be done by disarming the system or by hitting the car's brake.

Status of the pilots on flight 214
There were a total of four pilots on board, and they consisted of two crews. The first crew consisted of a training captain going through his initial operating experience (IOE) on the 777 and an instructor pilot (IP) who was a training captain. The relief crew consisted of a captain and a first officer (FO) This first crew performed the takeoff from Seoul and flew for several hours before the relief crew took over, and then the first crew flew approximately the last 1.5 hours of the flight.

Shortly before landing, when the aircraft was at around 10,000 feet, the relief FO entered the cockpit and was in the jumpseat for the rest of the flight. The NTSB provided details on the experience of the three pilots in the cockpit:

  • The training captain was in the left seat at was the pilot flying (PF),
  • The training captain had about 9,700 total hours, including about 5,000 as pilot in command (PIC),
  • The PF was hired by Asiana in 1994, and trained in Florida,
  • The PF was rated to fly the 737, A320, 747, and 777, and from 2005-2013 flew the A320, serving as an A320 captain before moving to the 777,
  • The PF was also a ground school and simulator instructor for the A320 and A321
  • The IP was also a 777 captain who served in the South Korean air force for about 10 years before joining Asiana,
  • The PF's IOE was to consist of 60 flight hours and 20 flight legs, and had gone through 10 flight legs and about 35 flight hours at the time of the crash,
  • The IP had about 13,000 flight hours, including about 3,000 in the 777, and 10,000 as a PIC,
  • The IP served as the PIC on flight 214, and was sitting in the right seat,
  • This flight was the first time that the PF and the PIC had flown together, and it was the PIC's first trip as an instructor pilot
  • The relief FO was a former F-5 and F-16 pilot in the South Korean air force, and had about 4,600 total hours, including 900-1,000 hours in the 777,
  • The relief FO had flown to San Francisco five or six times as an observer.

Landing aids in use at the airport
Air traffic control was allowing pilots to operate under visual flight rules (VFR) when flight 214 was approaching the San Francisco airport (SFO), which means that pilots were not required to use the instrument landing systems at the landing runway (28L) or any automated systems on their aircraft. One of the electronic aids that provide aircraft guidance on their glide slope was inoperable, but this had been published for some time and all flight crews using the airport should have been able to see this information. The NTSB has not stated if this crew were aware of this.

A glide slope aid that was in operation at runway 28L were the precision approach path indicator (PAPI) lights, a set of four lights arranged in a horizontal line that provide pilots with a visual indicator of whether the aircraft on the glide slope, above the glide slope, or below the glide slope.

A pilot who is on the glide slope would see two sets of red lights on the left and two sets of white lights on the right. In the example shown here (not from SFO), the three left indicators are red and the right one is white, indicating that the aircraft is slightly below the glide slope. Four red lights would indicate that the aircraft is well beloe the glides slope, and four white lights is an indicator of being well above the glide slope.

Final approach sequence
Over the last two press conferences, the NTSB discussed the following key parts of the final approach:

  • The approach path took the aircraft directly over SFO, followed by a wide teardrop left turn to line up with the runway (see below),

    (click to enlarge)
  • Air traffic control (ATC) called for a maximum airspeed of 180 knots until the aircraft was five miles out,
  • The IP recalled that the aircraft was above the intended glide path at 4,000 feet, and that vertical speed mode was set at 1,500 feet per minute,
  • ATC gave a landing clearance about 1.5 miles from the runway, about 90 seconds prior to the crash,
  • There was a sink rate callout prior to the aircraft reaching 500 feet,
  • At about 500 feet, the FP noted a blinding flash of light directly in front of the aircraft but not on the runway,
  • The FP stated that he looked away into the cockpit, and was able see the cockpit instruments, including the speed tape,
  • There was no mention of the light on the CVR,
  • The FP believes it may have been a sun reflection, and the NTSB is determining if this could have been the case,
  • There was an automated 500 foot callout about 35 seconds before the crash,
  • Shortly after this callout, the landing checklist was completed,
  • At about 34 seconds prior to impact, the IP noted that the aircraft was below the glide path at 500 feet, and speed was at about 134 knots, with three red PAPI lights showing, and told the PF to pull back
  • Autothrottle was armed and set at 137 knots
  • between 500-200 feet, the IP noted that there was a lateral deviation and that the aircraft was low,
  • At 200 feet, the IP noted four red PAPI lights, that the speed tape was hatched (a visual indicator of an impending stall), and that the autothrottle had not maintained speed,
  • There was an automated 200 foot callout 18 seconds before impact,
  • There was an automated 100 foot callout nine seconds before impact,
  • Almost immediately after this 100 foot callout, a crew member mentioned airspeed (the NTSB noted that there were no mentions of speed heard on the CVR between 500-100 feet),
  • About three seconds before impact, there was a call for a go around,
  • The IP established a go around attitude, and went to push the throttles forward manually, but saw that the FP had already done so,
  • A second call made for a go around was made by a different crew member about 1.5 seconds before impact.

Crash sequence

  • The main landing gear hit the sea wall first, followed by the tail section,
  • The main landing gear sheared away from the aircraft as designed, and the wing fuel tanks were not punctured by the gear separation or during the the rest of the crash sequence,
  • Cabin flooring and galley components were found on the chevrons in the runway overrun area between the sea wall and the runway threshold,
  • The initial impact displaced rocks from the sea wall and some of them were distributed several hundred feet along the debris trail (see photo below),

    (click to enlarge)
  • All passenger seats stayed inside the cabin, but three flight attendant seats were ejected onto the runway,
  • Door 4L detached from the aircraft at some point in the crash sequence
  • Six of the 12 flight attendants were interviewed, and they stated that two of the eight escape slides inflated inside the cabin after a secondary impact (from a witness video, it appears that the aircraft rotated almost 360 degrees counter clockwise, with the rear of the cabin rising up at an angle before hitting the ground at the end of the crash sequence),
  • The right engine had detached from the wing, had rotated about 90 degrees counter clockwise, and was laying alongside the fuselage (see photo below).

(click to enlarge)

Post-crash actions and fire

  • After the aircraft came to a stop, the lead flight attendant (who was near door 1L) went to the cockpit for advice, and was advised not to initiate evacuation (see door layout in photo below),

    (click to enlarge)
  • Fire extinguisher switches were pulled for both engines and the auxiliary power unit,
  • The flight crew was able to communicate with the control tower, and the cabin crew was able to use the public address system to communicate to passengers,
  • A flight attendant who was trained as a lead flight attendant was at door 2L, saw fire outside door 2R near row 10 of the aircraft, and sent the other flight attendant at door 2L to the front of the cabin to inform the rest of the crew about the fire and the need to evacuate (in earlier briefings, the NTSB stated that the source of the fire was a ruptured oil tank that leaked fuel onto hot engine parts from the right engine),
  • Passenger evacuation began about 90 seconds after the aircraft came to a stop, escape slides were first deployed from door 2L and then from door 1L, and passengers also escaped from door 3R,
  • The control tower called for emergency vehicles after the aircraft hit the runway, the first vehicle arrived about two minutes after the crash, and extinguishing agent was first applied about three minutes after the crash,
  • Cabin emergency exit lighting came on during the evacuation,
  • There were six flight attendants who were injured and hospitalized: three seated in the rear of the plane who were ejected out onto the runway, another flight attendant in the rear who was injured, and two who were injured by the slides that deployed inside the cabin including one at door 1R and a second at door 2R,
  • The remaining six flight attendants had evacuated most of the passengers by the time the fire had spread to the cabin,
  • Aiport fire crews entered the cabin with a fire hose to help fight the fire,
  • Flight attendants helped to fight the fire with fire extinguishers, and also used the extinguishers to help extract the two flight attendants who were trapped by the two escape slides that deployed inside the cabin.

Cabin damage
Prior to the cabin fire, a firefighter entered door 2L and turned right to walk toward the rear of the cabin, and along the way observed that seats in that section were almost pristine, with minimal damage detectable, and that one could just fluff the pillows to get that section ready for the next flight. As he walked toward the rear, he observed more cabin damage, with a sharp contrast between the front and back of the passenger cabin. The photo below shows the pristine area of the cabin that was later damaged by fire.


(click to enlarge)

The NTSB structures team noted that from the cockpit to rear spar of the center wing box, the cabin floor was structurally sound. Aft from the rear spar to doors 3R and 3L, in the passenger seating compartment, support structure were compromised on the right side (flayed out from the aircraft), but still sound on the left side. Between doors 3 and 4, the floor was canted down at an angle, with damage progressively worse towards the back, and there was no cabin floor behind door 4.

Dr. Curtis and Capt. Tom Bunn discuss the crash
The day after the crash, Dr. Curtis of AirSafe.com and Capt. Tom Bunn of the SOAR fear of flying program, who both spent several hours on the day of the crash on cable news programs providing expert commentary, discussed the media's response to the accident and shared their thoughts on the early reports of the crash.

Additional information
AirSafeNews.com 10 July 2013 article on the role of the autothrottle
AirSafeNews.com 8 July 2013 article on early findings of the crash investigation
Other Asiana plane crashes
Other 777 plane crashes
Accident details from Aviation Safety Network
Wikipedia page on this accident

Photos: Wikipedia, NTSB