Further to my previous post there was a further insightful commentary piece from
the Australian's A-Plus section in Friday's edition.
This IMO further highlights some more interesting parallels to the Norfolk ditching ATSB investigation by stealth vs the full and frank highly publicised preliminary investigation by the NTSB.
As a sidenote it will be of extreme interest if the ATSB's preliminary report for AO-2013-100willbe just as full and frank, because there is certainly some disturbing parallels to Norfolk with that one, remember 50:50 opinion on alternate minimas and diversion and BOM WX forecasting reliability??
AS Flight 214 descended over San Francisco Bay, the Asiana Airlines pilots were trying something new.
In the left seat of the cockpit sat Lee Gang-kuk, a 46-year-old pilot with 35 hours' experience flying a Boeing 777 who was landing the big jet for his first time at San Francisco International Airport. To his right was Lee Jeong-min, making his first trip as an instructor pilot for the South Korean carrier.
While the two men had years of aviation experience, this mission involved unfamiliar duties, and it was the first time they had flown together. The flight came to a tragic end when the airliner came in too low and too slow, killing two passengers and injuring many others as it skittered and spun along the ground.
Investigators trying to piece together what went wrong on Sunday are looking at the pairing of the pilots, who were assigned to work together through a tightly regulated system developed after several deadly crashes in the 1980s blamed in part on inexperience in the cockpit.
They will also be examining the men's working relationship, according to US National Transportation Safety Board chairman Deborah Hersman. "We are certainly interested to see if there are issues where there are challenges to crew communication, if there's an authority break in where people won't challenge one another," she said yesterday.
Pilots are trained to communicate their concerns openly, Hersman says, "to make sure that a junior pilot feels comfortable challenging a senior pilot and to make sure the senior pilot welcomes feedback in a cockpit environment from all members of the crew and considers it".
In August 1997, Korean Air Flight 801 crashed into a hill during heavy rain as the captain tried to make an instrument landing on the US territory of Guam. Besides pilot fatigue, the cause of the Boeing 747-300 crash was put down to a cultural issue: respectful subordinate crew declined to challenge the captain's authority.
The NTSB has concluded interviews with all four pilots who were aboard the weekend Asiana Airlines flight. Hersman says the pilot trainee told investigators he was blinded by a light at about 500 feet, which would have been 34 seconds before impact, and the point at which the airliner began to slow and drop precipitously. Lasers had not been ruled out. It is unclear, however, whether the flash might have played a role in the crash.
Hersman also says that a third pilot in the jump seat of the cockpit told investigators he was warning his colleagues as they approached the runway that their speed was too slow.
Hersman added that, once the plane had come to a stop, the pilots told passengers to remain seated while they communicated with the tower as part of a safety procedure. Hersman says this has happened after other accidents and is not necessarily a problem.
People did not begin fleeing the aircraft until 90 seconds later, when a fire was spotted outside the aircraft. "We don't know what the pilots were thinking, though I can tell you in previous accidents there have been crews that don't evacuate, they wait for other vehicles to come to be able to get the passengers out safely," Hersman says.
It is possible the pilots in the cockpit could not see the fire outside the aircraft, she adds. "Certainly, if there is an awareness that there's fire on board an aircraft, that is a very serious issue." The NTSB chief stresses that, while the trainee pilot was flying the plane, the instructor is ultimately responsible, and thus the way that they worked together will be scrutinised.
James Hall, a former NTSB chairman, says: "That's what the airline needs to do, be responsible so that in the cockpit you're matching the best people, especially when you're introducing someone to a new aircraft."
Massachusetts Institute of Technology aeronautics professor Mary Cummings says it is common for two commercial pilots who have never worked together before to be assigned to the same flight.
However, she says that the military typically tries to have crews work together more permanently. "Research would tell you that crew pairing with the same people over longer periods of time is safer," Cummings says.
"When two people fly together all the time, you get into a routine that's more efficient. You have experience communicating."
Jeff Skiles, a US Airways first officer, says that with the right training it should not matter if a pilot new to a plane is paired with a pilot making his first trip as a training captain. "Everybody had to have their first time," Skiles says. "You can't show up and have 500 hours experience in an aircraft."
Skiles was the co-pilot of the "Miracle on Hudson" jet that lost thrust in both engines after colliding with a flock of geese in January 2009 taking off from New York's LaGuardia Airport.
The skilful flying of captain Chesley "Sully" Sullenberger and teamwork between Skiles and Sullenberger was credited for a water landing on the Hudson River that saved the lives of all aboard. That accident happened after the pilots had been paired together for only four days.
Details emerging from the Asiana Airlines pilot interviews, cockpit recorders and control-tower communications indicate that Lee Gang-kuk, who was halfway through his certification training for the Boeing 777, and his co-pilot and instructor thought the airliner's speed was being controlled by an autothrottle set at 157mp/h.
Inspectors found that the auto-throttle had been "armed" or made ready for activation, Hersman says. However, investigators are still determining whether it had been engaged. In the final two minutes, there was a lot of use of autopilot and auto-thrusters, and investigators intend to look into whether pilots made the appropriate commands and if they knew what they were doing.
When the pilots realised the plane was approaching the waterfront runway too low and too slow, they both reached for the throttle. Passengers heard a roar as the plane revved up in a last-minute attempt to abort the landing.
The two pilots at the controls during the accident had also been in the cockpit for take-off. Then they rested during the flight while a second pair of pilots took over. The two pairs swapped places again about 90 minutes before landing, giving the trainee a chance to fly during the more challenging approach phase.
With the investigation continuing, Hersman is cautioning against speculating about the cause of the crash. However, she stresses that, even if the auto-throttle did malfunction, the pilots were still ultimately responsible for control of the airliner.
"There are two pilots in the cockpit for a reason," she says. "They're there to fly, to navigate, to communicate, and if they're using automation (then) a big key is to monitor." As the trainee pilot flew, she says, the instructor captain, who is ultimately responsible for flight safety, was tasked with monitoring. The third pilot was in the cockpit jumpseat also to monitor the landing. The Asiana Airlines flight originated in Shanghai and stopped over in Seoul before making the almost 11-hour trip to San Francisco.
A dozen survivors were still in hospital yesterday, half of them flight attendants, including three thrown from the airliner during the accident. One has been identified as 25-year-old Maneenat Tinnakul, whose father told the Thairath newspaper in Thailand that she suffered a minor backache. Another flight attendant, Sirithip Singhakarn, was reported to be in intensive care.
Meanwhile, fire officials are continuing their investigation into whether one of their trucks might have run over one of the two Chinese teenagers headed for a US summer camp, Wang Linjia and Ye Mengyuan, who were killed in the crash.
Citing similarities to a February 2009 fatal US airline crash near Buffalo, New York state, Democrat senator Charles Schumer yesterday called on the Federal Aviation Administration to issue long-delayed safety regulations that would require pilots to undergo more extensive training on how to avoid stalling accidents.
"While the (Asiana) investigation is still ongoing, one thing is clear, this crash and the other recent crashes like Flight 3407 demonstrate a troubling pattern in which pilots are mishandling air speed, which can lead to fatal stalls," Schumer said.
Whatever everyone's opinion on the different methodologies to handling/managing an investigation, NTSB vs ATSB, it is obvious that the NTSB approach will certainly provide all worldwide aviation stakeholders with a source of valuable lessons probably for many years to come! Something sadly lacking in the Norfolk ditching 'Final Report'
Lefty I guess it is implying that both pilots were 'green on green', hence the relevance to this thread Tinny, not to mention the references to reliance on automation which was also relevant to the Pilot Training Inquiry.
Perhaps this
Avweb article is a better example of the relevancy to this thread (and ironically to the other Senate thread):
I do it. You do it. We all do it.
As pilots, in the wake of an accident like Asiana 214 last Saturday in San Francisco, we crank up our piety and discipline and decline public comment until the investigators are done. But amongst ourselves, there’s no such restraint and there’s not much in the e-mail I’ve been getting, either, the tone of which is to flat out ask how this crew could have flown such an unstable, off-speed approach. Might as well come right out and say it, even if it will be months before the NTSB puts the puzzle together and learns why the pilots appeared to be so far off acceptable airmanship, much less an A-game. I’ve seen a few unkind student pilot analogies posted and not all of them are from the aviation illiterate masses.
If the current fact pattern is sustained, I’m sure the NTSB will get around to finding out how large looms the human factors aspect of this accident. And at that juncture, a certain déjà vu settles in; a couple of correspondents think they’ve seen this movie before. One of the things investigators will probably examine is how the flying pilots worked both the automation and the CRM. That may cause the surprise appearance of a large elephant long thought dead: the bad old days of Korean air safety when KAL and related companies had 16 hull losses between 1970 and 1999. Two of the worst were KAL 801 in Guam and KAL 8509, both of which occurred within two years of each other in 1997 and 1999.
In KAL 801, the Captain failed to brief the 747 crew on the approach then followed erroneous glideslope signals, crashing into a hill and killing 228. Investigators determined that a contributing cause was a fundamental aspect of Korean culture in which subordinates don’t question their superiors--filial piety woven into the base societal structure in a way that deifies the left seat occupant. In the west, you'll sometimes hear the term "five-striper" applied to such a situation . The FO and engineer on 801 failed to question the Captain’s actions and decision-making, the very thing that modern CRM is supposed to prevent.
The circumstances were different for 8509, a 747 freighter, but the outcome was the same.The Captain’s INU/ADI had proven faulty on the inbound flight and wasn’t repaired properly. When the Captain overbanked on a night takeoff from London’s Stansted Airport, the FO rode through the subsequent departure and crash without uttering a word, even though his ADI was functioning normally. That accident proved to be a watershed for KAL, serving as a wakeup call to improve training and CRM in a way that eventually elevated the airline to among the safest in the world. But human perfectibility being what it is, changing a thousand years of culture might not be as easy as that, and I’m sure investigators will consider it during their interviews and CVR analysis.
Some have seen in the 214 accident an eerie echo of another more recent crash: Air France 447 in 2009. In that accident, three crew members mushed a perfectly recoverable aircraft into the ocean because of confusion over instrument and automation indications and a baffling inability to interpret stall indications. Could flight 214’s crew have suffered similar confusion over the arming of but the failure to engage the autothrottles? Did that even matter? Is there a human interface issue with the automation that’s a design flaw or a training lapse in the airline’s program? I’m sure that’s another lead that will have to be pursued in explaining why the approach went so wrong.
The Asiana crash reminds me of another accident I remembered, but I had to call my friend John Eakin at Air Data Research to pin down the details. It was Continental 1713, which crashed on departure in a raging snow storm from the then-Stapleton Airport in Denver in November, 1987. The investigation revealed that the airline had paired two inexperienced in-type crew members, one with 166 hours, the other with 26 hours. And the relatively green Captain assigned the takeoff to the FO who over rotated on takeoff and lost control of the DC-9.
After 1713, the NTSB recommended—and the FAA adopted—not pairing two low-time crew members on the same flight. I suspect the NTSB will consider if Asiana repeated that mistake. Although both pilots had plenty of total time, the Captain was 43 hours into his IOE and, according to Asiana, the check airman training him was on his first flight as an instructor. Could that, coupled with whatever remnants of Korean culture that persist despite CRM training, have been a factor?
I’m sure that question will come up, too. And given the language and culture barriers, I don’t envy the NTSB figuring it out.
I rest my case your Honour??
