Asiana 777 crashes in San Francisco

[evaamo]

This is a very interesting post I read elsewhere today, and I think it helps to understand how a tragedy like this came to pass:
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After I retired from UAL as a Standards Captain on the –400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it's a minefield of a work environment ... for them and for us expats.

One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don't think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all "got it" and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.

We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.

This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce "normal" standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this Asiana crew, it didnt' compute that you needed to be a 1000' AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn't pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.

Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested "Radar Vectors" to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then "Cleared for the approach" and he could have selected "Exit Hold" and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to "Extend the FAF" and he couldn't understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was "Hold at XYZ." Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).

This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141's in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!

The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can't change 3000 years of culture.

The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It's actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don't trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don't get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!

Finally, I'll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.

Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250' after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800' after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real "flight time" or real experience did he get. Minutes! Of course, on the 777 or 747, it's the same only they get more inflated logbooks.

So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.

[martin1006]

First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots.

This is exactly the same issue deciding me to avoid any Chinese airliner if it's possible.

They also are trained robots and follow the leader.

I told the Chinese and other expats in China many times. Asian airlines are not safe to fly with.

Their mentality simply obstructs them to ensure a safe cockpit crew.

[martin]

Moi,

what worries me about the whole ongoing huge "discussion" of the crash is the matter of timing.

Essentially (and simplified), two groups of causal factors could be involved :

I. "human factors", such as the professional CV and background of the pilots, seniority matters, CRM, and of course those much-talked-about "cultural" issues.

II. "technical" factors, such as weather, bird strike, aircraft systems or components breaking or not working as they should, ice in the fuel lines (as in another 777 accident), etc. Also potential cockpit/instrument design weaknesses (e.g. "FLCH trap"), even though this is on the borderline to group I.

Both groups of factors are of course valid "suspects" as causes for the crash, thus both must and will be investigated.

However, the "timing problem" is this:

The group I factors are quickly and easily accessible to the discussion (more precisely, they are perceived to be so). And they can be understood by everyone (at least that's what everyone thinks).

So, once some basic facts of this group are known (usually within hours, thanks to the media), not only aviation professionals, but also media "experts", and the public in general feel free to start a vast debate about the impact these factors may have had on the crash. This is what is currently going on.

Not so with the group II factors, however: Figuring them out may easily take  months of work by highly specialized personnel (NTSB), and even then understanding them will require a lot of technical knowledge.
[size=8](The readers of this forum certainly represent a group far more knowledgeable about this stuff than the "general public", but have you by now fully understood the nature of the 777 "FLCH trap"?).[/size]

So, at this point there simply can be no meaningful discussion of group II factors, simply because the necessary facts are not yet known (for months to come probably). And once they are known, far less people than are currently discussing away will understand them.

The conclusion can therefore only be: While it is in principle perfectly legitimate (and indeed necessary) to discuss the group I factors, that must not lead to "focussing bias", with the group II factors simply being skipped.

And strong restraint ought to be exercised until we really have a full picture.

Discussion of possibilities is one thing (necessary and useful), but drawing conclusions is quite another, and for the Asiana crash, simply not possible at this point.

Unfortunately it seems the line between the two is being increasingly blurred in the ongoing public "exchange of opinions", which somewhat goes along the lines of "It must have been , because we can [size=8](discuss those)[/size]".

Human factors are a very valid concern in this accident, but they are not the whole picture.

Cheers.
Martin

[Hardy Heinlin]

This is a very good comment, in my opinion.


Cheers,

|-|ardy

[Phil Bunch]

The FAA has announced that it will require the co-pilot to have 1500 hours, as a reaction to the Asiana crash:

http://www.bloomberg.com/video/faa-new-co-pilot-rules-after-asiana-crash-py6aH4o5TyyeicCarSnElA.html

[Jeroen Hoppenbrouwers]

500 hours more bush flying? Phew!

[John Golin]

This is a very good comment, in my opinion.


Cheers,

|-|ardy

Yes, and the NTSB are generally fantastic at  ensuring all avenues are investigated to their conclusion for any contributing factors - if there are 'human factors', what put the pilots in the position where that error or mistake could happen and cause an accident? Sort those out and safety increases again...

[martin]

500 hours more bush flying

Actually, going from 250 to 1500 hours, it appears (600% !).

M

[Jeroen Hoppenbrouwers]

Wow. I wonder where you can get 1500 hours without being F/O. Nobody can pay for thay himself; so will we see everybody moving to Africa for a few years to build hours?


Hoppie

[Shiv Mathur]

I was also wondering how this works ... every time there is a new aircraft type, there exist only pilots with 0 hours on that aircraft.
Are hours in the sim counted?

[Phil Bunch]

Here's a follow-up reply to the NY TImes article I cited previously:

http://www.nytimes.com/2013/07/12/opinion/the-asiana-jet-crash.html?ref=todayspaper

This brief reply is listed below:
----------------------------------------------------------------------------------------------

 To the Editor

Re "Inquiry Suggests Chance That Mechanical Failure Had Role in Crash" (news article, July 10):

If it is found that the pilots needed to manually activate or set the minimum speed on the auto-throttles of the Asiana jet, that means that the design was totally unacceptable. Auto-throttle should be fully automatic, period.

It should automatically prevent the landing speed from dropping below a safe limit. It should never need manual activation, and in fact, the pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.

Similarly, to protect against mechanical failure, full backup should always be provided.

BÉLA LIPTÁK
Stamford, Conn., July 10, 2013

The writer is an automation and safety consultant and the editor of the Instrument and Automation Engineers' Handbook.

[Jeroen Hoppenbrouwers]

the pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.

Won't happen.

[Phil Bunch]

the pilot should only be allowed to increase the safety margin, but not to decrease it or to disable the system.

Won't happen.

I wondered about the assertion in this article - the pilot(s) have to have very wide latitude to rescue the airliner from a pending disaster.   Disasters have a way of showing up under unusual situations with very stressful options being the only ones available.  There are many examples from recent decades of aviation history - the Sioux City crash landing being but one example - the pilots had to fly and land the airliner mostly using only the throttles.  

I suppose some of the Airbus controls in particular may limit a pilots' options under some circumstances.  

Interestingly, my Volvo S60 also does this - the computerized anti-lock brakes may engage and override my driving, too, under certain circumstances.  This happened once while I mistakenly applied the brakes in an irrational fashion.  The computers took over and stopped the car much faster than I knew it could stop - I thought my eyeballs were going to be pulled out!  Fortunately, there was no real hazard present, and fortunately no one was following me closely!  No harm was done by my car's "FMC".  The newer versions of my car use radar and do such things even more aggressively.

Hopefully soon Google will automate our cars and we can revert to being passengers in our cars most of the time!

[Mariano]

Another interesting video:

http://www.huffingtonpost.com/2013/07/12/plane-crash-animation-video_n_3587554.html?ncid=edlinkusaolp00000009

Mariano

[Jeroen D]

And  a very different development yet!

http://edition.cnn.com/2013/07/17/us/asiana-name-blunder-race/index.html?hpt=hp_c4


Jeroen

[mabe54]

That's sad.

http://www.cnn.com/2013/07/19/travel/asiana-airlines-crash/index.html?hpt=hp_c2

[Jeroen D]

It's been a while since I saw any updates on this one. Just came across this on CNN:

http://edition.cnn.com/2014/04/01/us/south-korea-us-asiana-crash/index.html?iref=allsearch

The Captain states:

Flight 214's pilot, Capt. Lee Kang Kuk, told the National Transportation Safety Board last year that he found it "very stressful, very difficult" to land without the glideslope indicator that helps pilots determine whether the plane is too high or too low during approach.

I wonder what our resident (wide body) pilots think about that statement. On the day of this incident, if I remember correctly, weather and visibillity were fine. Should a pilot not be able to land in VFR conditions without a glideslope indication?

Jeroen

[jtsjc1]

I would think someone who is type rated on a T7 should be able to do that!  If he can't accomplish that how would he handle losing an engine on takeoff!?

[Jeroen D]

I would think someone who is type rated on a T7 should be able to do that!  If he can't accomplish that how would he handle losing an engine on takeoff!?

My sentiments exactly, although I don't fly these planes for a living. But I can certainly land my little Cessna or Cirrus without a glide slope indication. I can well imagine that landing a 777 in this fashion is more difficult than a C172, but still.

Again, no expert by any stretch of the imagination but I would have thought that executing a landing, without glideslope indication, would be basic hand flyling skills.

There was a PAPI available and I always felt that was very usefull.

Here is some more detail:

http://avherald.com/h?article=464ef64f&opt=0

Jeroen

[torrence]

Way back in my PS1 and 747 documentation I seem to recall seeing that the proper touch-down target for the 747 meant that you had to be high with respect to the PAPI indications. 777 the same?  Any real pilots with the answer?

Cheers,
Torrence