NTSB update on Asiana 214

[Desert185]

Another report:

Asiana Pilot 'Very Concerned' About Landing Visually - AVweb flash Article (http://www.avweb.com/avwebflash/news/Asiana-Pilot-Very-Concerned-About-Landing-Visually221108-1.html)

Absolutely incredible.

[ImbracableCrunk]

IFALPA systematically rejects the notion that pilots are ‘forgetting how to fly.’ “Automated systems actually require the pilot to be more of a pilot, and systems of systems manager. Pilots’ knowledge and skill have actually increased as a result of increased automation,” said Capt. Dave McKenney, Human Factors Chairman for IFALPA.

Ok, Dave.

IFALPA Supports APU at NTSB Investigative Hearing into Asiana Flight 214 | Business Wire (http://www.businesswire.com/news/home/20131211006482/en/IFALPA-Supports-APU-NTSB-Investigative-Hearing-Asiana)

[RAT 5]

If he can't fly an aircraft to a visual approach on a clear and beautiful VFR day then he has no business being in a cockpit of an aeroplane.

I agree completely, and that of course is any aeroplane. And it is very true that this guy is not the only one with an unease about such a manoeuvre. My last few airlines, large, medium & small a/c, included many F/O's who shied away from making visual circuits, even when there was an ILS at the end of it. They might just get away with a base training type level circuit at 1500', but no way could they do a CDA low drag circuit from downwind or passing overhead. There were some who were enthusiastic and good at it. What troubled me was the spread in talent and attitude. The root cause of that might be found in the selection and training process of the various airlines; plus the line operating philosophy and thus that of the captains. It now seems quite a common philosophy that visual approaches are frowned upon.
Most major airports have PAPI backup to ILS or NPA. But what if the approach aid is u/s? Then you have only the PAPI. However, I've flown to airfields where the PAPI's were also having a bad day. Perhaps it was a circle/visual approach to the non instrument runway. One company had the SOP that a finals OM equivalent had to be constructed and a waypoint with speed & altitude inserted to give VNAV guidance. With that philosophy how can pilots be expected to maintain their MK.1 eyeball skills. And there are still needle & dials a/c flying the skies.
What has happened to the world of 25 years ago when visuals in to any airfield was common, even the major ones, traffic permitting. It helped speed up traffic flow and saved time/fuel. It also kept the skills up for when it was necessary into some tiny inhospitable places. If you fly to Africa it is really necessary to have the basic skills. There's no guarantee things will be working correctly, or at all, no matter what the notams said. Then you needed to know the characteristics of your a/c so that you knew when the approach aids were not kosher.
How have skills levels deteriorated so much? I hear some XAA's suggesting they need to be improved and 'go back to basics', great, but how did we get to this mess in the first place. I think we need to know that to be able to correct the problem. There needs to be a thorough analysis of the airline training culture and the checking culture and the associated philosophies.
We've seen the demise of the profession into to robotic button pushing automons and the associated reduction in perceived status and T's & C's. Perhaps there is a link to the dilution of skills. Less skills less status less pay.Perhaps they have been perceived as unnecessary. A/C are more reliable and have more back-ups. There is more radar; more ILS's etc. Runways are longer. The whole infrastructure is much improved. Extensive cover-all SOP's.No longer are Topguns required.
IMHO when there is a hiccup the pilots need to be a reliable insurance policy and sort it out. The pax pay good money & expect it. They get on an a/c with blind faith. They do not want pilots to be the cause of the hiccup, but if they are then they do not want them to exacerbate the problem. Yet that is what we see happening. Take away the crutches of an ideal day and someone stumbles and falls over. It shouldn't happen.
I wonder what mitigating circumstances will be quoted in all these recent inexplicable serviceable a/c prangs. Obviously it was not on purpose, but it happened for reasons that were not evident to the crew. Why? Once we answer that we can address finding a solution. Let's find the WHY first and find a professional long tern solution, not a knee jerk quick fix.

[TeachMe]

Stuart,

"Within the Interview Summaries, in the reports linked by Airbubba, is this snippet from the Captain under training in the left seat, Lee Kang Kuk: Quote:
He began preparing for the flight at 0930. It was a training flight, so he showed up early. The cockpit crew show time was 1510. He spent almost 6 hours preparing for the flight, checking the NOTAMS, the regulations, and the ETOPS
regulations. He first saw the PM (the instructor pilot) around 1440. He briefed everything with him. Pushback time was about 1630 local time.
Turning up at work "almost 6 hours" before report? Dedication ..... or extreme anxiety?

Furthermore, from the Jazz Hands post above, it seems the culture authority gradient idea about who can and cannot instigate/order a go around does not sit well with a safe operation. "

In Korean culture this is basically showing your 'dedication'. It has no bearing on his ability or stress level. As an example, in Korea it is very bad form to go home before the boss. Thus, some of my K friends go to work before the boss (8am), play video games and waste time until 6pm, and then work hard for a few hours and leave after the boss at 10pm. They could do all their work from 10-2pm, sleep in and spend time with their kids, but that would 'look bad'!

TME

[1a sound asleep]

Can somebody explain WHY we let pilots of such low competency land in our countries? I am forever perplexed by the fact that the regulatory body has no audit provisions for foreign airlines :ugh:

[Airbubba]

Can somebody explain WHY we let pilots of such low competency land in our countries? I am forever perplexed by the fact that the regulatory body has no audit provisions for foreign airlines

Well, the FAA certainly does audit foreign carriers, for example:

US regulator to audit DGCA from today - Times Of India (http://articles.timesofindia.indiatimes.com/2013-12-11/india/45077911_1_dgca-faa-team-aviation-ministry)

[tdracer]

I am forever perplexed by the fact that the regulatory body has no audit provisions for foreign airlines :ugh:

They do audit, as airbubba points out. They can also ban operators that don't measure up to their minimum standards (Lion Air comes to mind).

The better question might be, are they auditing enough, and are the standards high enough.

[edmundronald]

Half the big planes in the sky are "officially" made in the US, they are certified in the US, the other half are "officially" made in Europe certfied in Europe, the training procedures are created by the manufacturer, the airport process is largely created by the same supervising authorities, yes?

And then we are regularly told that the fact that quite a few pilots have insufficient hand flying skills is a fault of ... the koreans, the chinese, the brits, the french the whatever; Really? Each of the members of the AF447 crew was current on type, and trained in the country that manufactured the plane. Can each 59 year old ex-USAF captain sitting in the left hand seat look at the whole-bloooded american 200 hour boy-wonder in the right hand seat, and say with confidence that superboy can be absolutely trusted to hand fly better than the Air France or the Asiana guys did?

From the way the NTSB is talking, the Asiana pilots will probably be doing us the greatest favor of all - they can be used to show that something went wrong. Thus they can serve as an alibi to get the system changed - to get more hand-flying hours into the training, and more hand-flying into the everyday experience of airline pilots. They may even serve as an alibi for improving the next generation of glass cockpits, and -one can hope- better training of the SFO fire crew that will take into account the possible presence of supine survivors at a crash scene.

Edmund

[suninmyeyes]

Now there are unconfirmed reports that the LHS pilot (the new guy) was operating on an invalid pilot’s license, issued by a training organization that recently had its authority to conduct training for pilots revoked.

I suspect someone has got confused as the above quote also applies to the Captain of the Russian B737 crash at Kazan.

[flarepilot]

anyone here remember what a chandelle, turn about a point, or lazy 8 is?

I would really like to see a requirement that anyone checking out as a captain on an airliner demonstrate these in the real plane in real life.

I would wager that a 200 hour pilot who came up the hard way or the military way in the USA is probably on his way to being a good pilot. there is a remarkable heritage in general aviation or military flying in the USA.

I do recall reading that the first man on the moon first learned to fly in a piper cub and paid for it himself by working in a kind of menial job.



so edmundronald, yes I think a 200 hour pilot might be pretty good.


BUT

the guy who is a chosen one, who gets a free ride on some cadet program might not be as motivated to really ''sink his teeth'' into our profession.

There are few nations with the real flying bug...Canada might be another one with their ''bush'' pilots and anyone might care to watch the film,

"captain of the clouds" with james cagney for the flavor...I imagine Australia too.


in the USA it used to be that age 16 meant a car...age 16 meant a car to me and then I could drive it to the airport...and I worked my butt off at minimum wage to pay for lessons, and to pay for gas for the car.

[MrSnuggles]

Ok, hilarious only for Swedes.

Lee Kang Kuk has an awesome name - even better than the prank name from TV. "Kuk" is a very rude word in Swedish. Very.

[barit1]

Not to put too fine a point on it:
I do recall reading that the first man on the moon first learned to fly in a piper cub...

Almost. It was an Aeronca Champion, now preserved at the Armstrong Museum (http://www.armstrongmuseum.org/) in Wapakoneta, OH. (Emphasis is on syllables 1 & 4)

[Airbubba]

Lee Kang Kuk has an awesome name - even better than the prank name from TV. "Kuk" is a very rude word in Swedish. Very.

Since there is no universally adopted standard transliteration from Korean to English the name has some unfortunate sounding renderings in normally very politically correct U.S. media, for example:

Lee Kang-kook

Lee Kang-kook, Pilot Of Crashed Plane, Was Making His Maiden Flight To San Francisco (VIDEO/PHOTOS) (http://www.huffingtonpost.com/2013/07/07/lee-kang-kook-pilot-asiana-plane-crash_n_3559084.html)

Lee Kang-gook

Pilot in deadly crash had no experience landing 777 in San Francisco - CNN.com (http://www.cnn.com/2013/07/07/us/plane-crash-main/)

[olasek]

Yes Individual (airlines) training departments should enforce those standards. But today this is still utopia land we all agree....
I don't think I agree. If you look at training standards among say US airlines they are very high, lots of hand-flying, hand flying with crippled equipment, etc.

[DozyWannabe]

If you will permit this non-flyer an attempt at playing an objective Devil's Advocate, I'd like to try taking a step back to review where I'm at.

For one thing, if we take KAL's vastly improved safety record since the top-down operational and safety overhaul a little over a decade ago into account, its apparent success certainly appears to clearly indicate that the oft-cited "cultural issues" can be overcome - this also undermines the idea (which has always made uncomfortable reading to me) that Korean/Asian culture as a whole will always be hazardous to this kind of operation.

I heard this snippet of info (Lee Kang Kuk's statement) on the radio news and my mouth hit the floor..!!!

Hi DD - I'm using this comment not to single you out, but as an example of a common thread running through recent comments.

Taken in isolation, that remark certainly is concerning, but as a firm believer in the maxim "context is everything", I felt obliged to have at least a skim-read of the whole document (kindly linked by Airbubba - see below). The first thing I noticed is that Capt. Lee's interviews span 20 pages of the document, and even just the paragraph containing that remark indicates that there was more to what was troubling him than handling the aircraft - he said that visual approaches were stressful "from the planning phase". Also:

Asked whether he was concerned about his ability to perform the visual approach, he said “very concerned, yea”. Asked what aspect he was most concerned about, he said, “the unstable approach”. He added, "exactly controlling the descent profile and the lateral profile, that is very stressful."

Now, that in itself isn't incompatible with the idea that he didn't have confidence in his manual handling skills, but let's hold that thought briefly.

...some interesting observations on Asiana pilot culture viewed though the eyes of a couple of expat captains on pages 128-136 here:

Document 12 Other Pertinent Forms and Reports - 6120.1 Filing Date September 16, 2013 11 page(s) of Image (PDF or TIFF) 0 Photos (http://dms.ntsb.gov/pubdms/search/document.cfm?docID=404970&docketID=55433&mkey=87395)

The scripted approach to training and flying is mentioned. Lack of hand flying skills at OZ is acknowledged to be cultural and also generational, many of us flew thousands of hours on steam driven round dial planes with primitive analog autopilots before going to glass. Younger pilots, not so much anymore.

Thanks for the link, sir - I've kept it in the quote so folks won't have to go back a few pages to get it. Any folks with the time, I'd highly recommend reading the whole thing, as it paints a vivid and complex picture that I reckon will take patience and thoroughness to pick apart.

The retired ex-pat input is largely what one would expect - which is no slight on them as people or, indeed, airmen - however, the tendency for ex-pat veterans to be suspicious of the abilities of their native (usually younger) colleagues definitely seems to be present in those interviews. That said, to give them their due the interviewees explicitly praise aspects of their colleagues at Asiana in terms of competency when it comes to using the training they've had - their concerns tend to revolve around operational matters such as the broadness of training itself and handling practice/currency. As Airbubba says above, the "automation" bugbear is covered - and eloquently so. However, the interviewees make clear that it is a generational aspect - not a specifically cultural one.

What I found especially enlightening was comparing and contrasting the aforementioned ex-pat retirees' interviews with those of the accident flight crew.

Of special note were these points from the former (emphasis mine):

He was asked how visual approaches were conducted at Asiana. He stated that pilots were seldom allowed to practice visual or contact approaches and every time he offered an FO such an approach, they would refuse or be highly resistant to the suggestion because they did not feel comfortable with it and did not have experience doing it in a B777 or other big airplane. He thought they did not feel confident and did not want to make any mistakes.
...
He stated Asiana stressed very controlled environments and was very critical of excessive descent rates
...
[Asiana's] Korean pilots were very smart and diligent within what they were allowed to do. He always knew exactly what was going to be on flight checks. He heard comments from instructors that if they changed the profile and inserted a hydraulic or electrical problem, the pilots would get the scripted problems right, but weren’t prepared for the unexpected.
...
He was asked if his initial written test when he was hired was an Asiana company test. He stated it was a test from the MOT like an ATP written exam in English, but 70% of the test was about penalties, fines or jail, for things done wrong, and these were the things he had to study.


In the B777 most of time crews did precision approaches and visual approaches were not common. Most captains would use the ILS as a backup to a visual approach, but for the accident approach only the localizer was available because glideslope was out of service. They used waypoints for altitude reference. There was no discussion of building a constant descent profile for guidance on the PFD.
...
Asiana pilots knew the approach to SFO is difficult.
At Asiana there was some special information on the company intranet and there was a simulator flight to SFO. Every year they train for a special airport during recurrent simulator training. In 2013 it was JFK. In 2012 it was SFO. The company considered SFO a “special” airport.


And finally, as promised, returning to Capt. Lee:

Asked whether he had discussed that at all with instructors, he said yes. He said that during ground school, they would discuss the approach to SFO during tea time and how it was high.
...
He added, "Normally the instructor pilots are very alert, there is something how can I say, very alertive. Sometimes too much stressful, but he was very natural. Can say it like that way."

Asked whether the PM was fairly relaxed and did not make him feel stressed, he said he did not know because it was the first time they flew together. Asked whether other PMs seemed more “alertive” or “high key” or on top of things, or active, he said yes. They were more active and touching the instruments. Asked what the PM seemed to be doing that was different during the approach, the PF said it was hard to say because PF was flying and it was double workload, so he could not see the PM and check him.
...
Asked whether he had ever had to take the controls away from a captain because they were not seeing something or confused or disoriented, he said “no, no way.” Asked if he could imagine a situation where he would ever do that, he said “no way”.

These extracts suggest to me that, putting the manual handling/automation aspect to one side, there's a glaring disconnect in terms of joined-up thinking when it comes to CRM if this crew's experience is to be considered indicative of Asiana's practices.

They also indicate that the potential warning signs that heralded the accident go way beyond being able to put it down to a simple manual handling error and/or ethnic cultural issues.

Going back to that statement from Capt. Kim that caused so much consternation, it becomes clear that confidence in manual handling and visual approaches are only one facet of what he found "stressful". He'd been fed information that SFO was a difficult proposition back in ground school and works for an airline that seems to have a troubling emphasis on punishing any kind of performance issues - especially regarding descent rates. The check Captain states that even veteran Asiana PICs use ILS as a backup when shooting visuals at SFO.

It's a truism that even the best pilots can make horrific errors in judgment when under stress. For his upgrade checkride (a situation more stressful than usual to begin with) Capt. Kim drew a landing at an airport he'd been conditioned to think was a tough assignment, then shooting a visual approach without any ILS backup. I'm not surprised he was nervous!

[RatherBeFlying]

Put pilot in glider on half decent day and tell him he has to land at least 50 km away -- without damaging glider or upsetting ATC.

You can even give him a 5000' tow:E

[bubbers44]

We simply need to get back to the time that pilots were taught how to do a visual approach first because it is so simple, then gradually let them use automation at different levels but can back up to basic hand flying with full confidence they can do it with no problem.

The new way of teaching automation first as we can see is not working very well.

[Chronic Snoozer]

I'm not sure there is a role as devils advocate to play. The facts speak for themselves. If you have a seat in the cockpit then you should be damn well sure you know what you're doing. Landing an airliner on a gin clear day from a visual approach would have to be number one on the list of responsibilities of being a pilot. If you are PIC monitoring someone making a hash of it, it's your responsibility to fix it. Let's not understate this, it was a c*ck up of monumental proportions and a failure in responsibility to the passengers above all.

These guys will cop it from all sides over the next decade but let's move on from that. Let's not adopt the apologists tone looking for excuses. What the investigation seems to have uncovered is that there still exist pockets of resistance to safety culture, airmanship, and CRM.

[RetiredF4]

It is necessary that every contributing factor gets uncovered, all the discussions about cultural things and manual handling of approaches have their value.

But if a crew is not able to monitor airspeed, recognize a dangerous or even only unplanned deviation and take proper action there is no sense to teach manual approaches to them. Get this kind of crew a different job in the two dimensional environment.

[Intruder]

There was no discussion of building a constant descent profile for guidance on the PFD.
And there was no need. An RNAV approach that overlies the ILS/LOC approach to 28L is published. All he had to do was load that. Further, even without the G/S, VNAV guidance would be available for the ILS approach if VNAV was used.

That should have been covered in training ad nauseum!

[chuks]

What seems strange to me is, if this visual approach at San Francisco is considered to be so difficult, why did the accident crew not use a GPS back-up?

It only takes a few minutes to create something that will give you some magenta lines to follow that look the same as an ILS, for a back-up if you are worried about not being able to eyeball a visual approach. It's just a matter of picking information off the approach plate to make up a pseudo-ILS using the GPS. Of course you would not use this as a primary approach aid, but where's the problem with using this as a back-up in visual conditions?

Even with the naked eye one would hope to be able to make a very close guess at losing 300 feet per nautical mile on final, which equals a 3º gradient. The rest of it would seem to be having the aircraft configured and on-speed prior to starting the final approach at a pre-determined altitude and distance, so that I don't understand where the difficulty lies.

On the other hand, not to notice that the speed is unwinding... that reads like a real lack of basic handling skill, as if there were a total dependence on automation to take care of one of the basics, speed control: the auto-throttle in this case that was, unfortunately, not engaged. Or in cultural terms, perhaps someone noticed that the speed was unwinding but felt himself unable to point that out.

I am not familiar with SFO. Is the visual to that runway steeper than 3º, and if so, why?

[fox niner]

Hmm. This is a "lose face" situation that they were specifically trying to avoid. Culturally speaking.

[A Squared]

I am not familiar with SFO. Is the visual to that runway steeper than 3º, and if so, why?

The charted visual has an altitude at about 6 nm that places an aircraft slightly above a normal 3 degree GS. Not enough to throw it in the crazy difficulty category

[RAT 5]

In 80's B732 in the Greek islands it was common to hand fly an arrival onto a shortish runway with no aids except, perhaps a VASI. Considering the sun angle it was also common not to see the VASI's until very short finals. It was also the norm to fly a CDA to such a runway.
In base training it was necessary to fly approaches without VASI or G/S.

Now, there are airlines that prohibit an approach onto a runway without a glide-slope indicator, except by the captain in daytime. A straight-in approach at night is allowed, but a LNAV/VNAV finals must be inserted in FMC. A circling approach without glide-path indicators is not allowed.
In other words what was quite common years ago is not now allowed, yet the manoeuvres are what any basic pilot should be able to do. Secondly, if there is an outage of aids it is only the captain who can fly it. How does the apprentice learn?
Here might be a clue why skills have deteriorated; because it is an SOP.
Someone said jet flying is taught the wrong way round; first the automatics then a little hand flying. The common SOP's are all orientated around automatics and the SOP envelope is so tight that the boundaries are never approached but more importantly are not even known, (except a stall perhaps). There-in lies a clue as to why serviceable a/c are being stuffed into the ground. A descending visual circuit onto a long runway in CAVOK with little glide-path guidance is so far removed from the everyday operation and skill set of the average pilot that it is too far outside their normal SOP box = comfort zone. It should be a simple exercise to perform, repeatedly, in the sim as RST, but it isn't. It's being disallowed on line and not trained in sim. The only time anything remotely like this happens is base training; and then it is from a level circuit.
It is the training departments who have allowed skills to deteriorate and the XAA's who have allowed them to do it. Training = money. If it can be designed out of the operation by the use of automatics & SOP's then money is saved and the perception is safety is enhanced. That might have been the attitude until the last 2 years. I hope there will be a change to that mind-set, but I do not hold my breath.

[Torquelink]

From FlightGlobal:

Test pilots on the Boeing 787 encountered the dormant throttle phenomenon at the centre of the Asiana 777 crash inquiry, the hearing into the accident has shown.

It has also revealed that the European Aviation Safety Agency had noted the behaviour logic following a series of familiarisation flights on the 787 in May 2011.

Delegates at the National Transportation Safety Board hearing into the Asiana crash, which is exploring automation issues, had heard that the 777’s flight-level change mode – normally only used in cruise – was activated during the final approach to San Francisco.

As a result of the aircraft’s system logic, the mode change effectively left the autothrottle in an unresponsive “hold” state when the pilot disengaged the autopilot and retarded the thrust to idle.

The airspeed of the 777 bled away, with no increase in thrust, and the aircraft sank before colliding with a sea wall short of the runway.

Boeing’s 787 shares a number of cockpit characteristics with the 777 and the two have a common type rating.

US FAA acting assistant manager, transport airplane directorate, Stephen Boyd told the hearing that, during a 787 test flight, an FAA pilot had initiated a flight level change which was then interrupted by a traffic-avoidance event.

Boyd said the autothrottle similarly entered a hold mode and the test pilot, upon realising that airspeed was decaying, let the situation continue to “see what would happen”.

“Our test pilot believed that the autothrottle would ‘wake up’, not realising that the autothrottle…would not ‘wake up’. It was already awake,” added Boyd. The pilot eventually added thrust to bring the airspeed back and continue the flight.

EASA had similarly noted that the autothrottle ‘wake up’, which acts as an airspeed-protection feature, is inoperative during certain automation modes – including flight-level change mode with the autothrottle on hold.

In its debriefing document following six 787 validation flights in May 2011, EASA stated that, while the ‘wake-up’ feature is not required for certification, its absence under certain conditions might be considered an “inconsistency” from the pilot’s perspective.

“Inconsistency in automation behaviour has been in the past a strong contributor to aviation accidents,” it added. “The manufacturer would enhance the safety of the product by avoiding exceptions in the ‘autothrottle wake-up’ mode condition.”

[ironbutt57]

Reading the latest...have questions about the simulator training program this fellow successfully completed during his transition to the 777 from the Airbus...all the ergonomic discussion aside..it is what it is...and must be understood

[Jn14:6]

I think the main problem was a dormant pilot which did not wake up!

[ironbutt57]

well the age old argument.."i was confused because of my former aircraft" doesn't work in this case...the 'Bus would have done the same thing if open descent were pulled with the GA alt set in the window...

[chuks]

Logic suggests that having an auto throttle "wake up" in the flare to landing, for example, might be sub-optimal! In other words, it's probably designed to stay "asleep" under certain conditions.

Even without the auto throttle, there's still the airspeed tape unwinding; that should be a primary flight instrument that's included in your scan. Well, that's how it works for Microsoft Flight Simulator, anyway. Is it different on a Boeing 777?

This is going to be an interesting accident report. Would anyone like to take a guess if the Korean authorities might disagree with whatever the NTSB has to say, as the Egyptians did after that accident they had?

[silverhawk]

First world equipment

Third world mentality.


Shoot me down, but am I wrong?

[StinkyMonkey]

Ironbutt: No it would not... Also, the bus would go into Alpha Floor if attempted be flown this slow...

[ironbutt57]

monkey...think....commence descent inVS mode to attempt to capture the glideslope.they were..set GA altitude at some point.they did..continuing the descent in VS as they did....realize you are not descending fast enough and "pull open descent.the Boeing version a level change button which they did....surprise!!! the airplane climbs to the altitude set in the MCP!!....seen it done by SO many times....the Alpha floor...yes you are right...but i wasn't talking about that...

[AirRabbit]

Here might be a clue why skills have deteriorated; because it is an SOP.
It is the training departments who have allowed skills to deteriorate and the XAA's who have allowed them to do it. Training = money. If it can be designed out of the operation by the use of automatics & SOP's then money is saved and the perception is safety is enhanced. ... I hope there will be a change to that mind-set, but I do not hold my breath.

Rat 5: This post is probably THE most cogent, articulate, precise, and ACCURATE summary of the situation I’ve read in any document or heard in any discussion so far … particularly your description of the “doorstep” on which the responsibility should be placed – training – and your naming the 2 organizations that are the primary culprits in this travesty – the company training department and the regulator … and, I almost stood IN my chair and punched the air when you put the “icing on the cake” with your comment that the reason this travesty is allowed to continue is that “…money is saved and the perception that safety is enhanced is advocated.” The members of this industry should all recognize the value of your description … but … as you so correctly lament “…I do not hold my breath.” We need someone, someplace, who occupies such a visible or recognizable position that will allow whatever this person says to have such a significant impact on the organizations you named, and/or on the traveling public that buys tickets on airplanes, that this issue will be addressed! This person, where ever he/she is, must be willing to stand up and shout, very loudly, over and over, just exactly what you said, to motivate these 2 organizations to fix this very “fixable” calamity! Failing that, this industry is likely going to continue to suffer these kinds of completely avoidable disasters!

[ironbutt57]

Yes...Rat has hit the nail on the head...any profile not published in an FCOM is beyond the skill set of these "pilots in a can"...

[BaBaBoey]

- silverhawk

I think that's too simplistic.

Bad training is bad training; bad pilots are bad pilots, no matter what your ethnic background/home country ... plenty of 'first world' pilots crash too due to their own errors/inexperience.

[misd-agin]

Dozy -
"For one thing, if we take KAL's vastly improved safety record since the top-down operational and safety overhaul a little over a decade ago into account, its apparent success certainly appears to clearly indicate that the oft-cited "cultural issues" can be overcome"




Read the interviews. Lots of comments about higher and lower status. It's alive and well in their cockpit. The issue is was it, or was it not, part of the cause?


Training checks are scripted.


The investigation needs to look into the statement about 'scripted' check rides. AQP is also somewhat scripted.

[AirRabbit]

Bad training is bad training; bad pilots are bad pilots, no matter what your ethnic background/home country ... plenty of 'first world' pilots crash too due to their own errors.

I’m afraid it’s not this simple. People apply to be pilots. These people aren’t pilots until they are trained. Of course there are some people who are more prone to assimilate the training more completely or more easily, and, of course background, experience, and education, can affect how well a person learns, assimilates, and demonstrates what was taught … but it is still true that training takes a person and makes a pilot – good training takes a person and makes a good pilot, and on occasion it makes a superb pilot. Bad training takes a person and makes … what? a pilot? a good pilot?, a superb pilot? … not hardly! Bad training can produce little else but someone who shouldn’t be IN an airplane cockpit, at all!

[AirRabbit]

WOW! I’m going to have to start paying a lot closer attention to this section of this forum … there are some here who are hitting the nail on the head over and over again!


Training checks are scripted.

The investigation needs to look into the statement about 'scripted' check rides. AQP is also somewhat scripted.

Misd-agin … spot-on accurate, sir. While there are some good points about AQP, the same perceptions described by Rat 5, above (that being that “money is saved while the perception that safety is being enhanced), are also at the heart of AQP. Advocates of AQP cite the “advanced training” precepts used, but the real fact is that “how” a program is structured is a very minor player in the quality of the final product. IF anyone looks closely at an AQP program (of course, that would be very difficult to do, because the AQP-approved airline and the regulator maintain each AQP program as “proprietary” and no one is allowed to obtain a copy) they would see training programs authorizing lesser capabilities in the training equipment used, authorizations to substitute one flight task for one or more other required flight tasks, allowances to set their own standards of performance on all tasks, and they are allowed to adjust recurrent training to much wider intervals … all of which allow substantial cost savings. It was during the investigation into the Colgan accident, outside of Buffalo, New York, a couple of years ago, while focusing on stall training, where it was suspicioned that the accident flight crew were trained on stalls but were trained inadequately … simultaneously, it was recognized that some AQP approvals allowed windshear training to substitute for training and testing on stall recognition and recovery. In other words – the accident crew were trained but inadequately so – and that was wrong – but at least some AQP airlines didn’t train any of their crews on stalls, at all, and they were judged to be products of better training that increased their operational safety … what? After this discovery, each AQP airline was supposed to have been advised that they must begin stall recognition and recovery training.

The same culprits cited by Rat 5, above, are the culprits here – the company training department and the regulator. Anyone recognize a trend?

[DozyWannabe]

Read the interviews. Lots of comments about higher and lower status. It's alive and well in their cockpit. The issue is was it, or was it not, part of the cause?

I did read them! I was talking about the "cultural" issues being overcome at KAL, not Asiana - the latter may require a similar audit. I mentioned KAL as an example of how perceived negative aspects of "culture" are not insurmountable, with the right approach.

Training checks are scripted.

The expat pilots who said that retired from Asiana 2 and 4 years ago respectively. It may still be an issue, but there are other issues at Asiana which warrant attention too - specifically the focus on punitive measures almost as soon as you join, and the disconnect between what the crew of the flight said about strong CRM and the actuality, whereby the command gradient in the flight deck seemed at times uncertain.

I got the distinct impression that the PIC and check Captain were each expecting the other to call Go-Around for some time before they decided to do it themselves.

[Lonewolf_50]

Dozy, you may want to think about this in a different light:

who signed for the aircraft: the check captain or the captain who was being checked?

Put another way, who the hell is in charge of the mission?

[Sorry Dog]

Q: Before you had to do that, when you were still like at 300 feet or something, did you feel you had to go around at that time?

A: That’s very hard because normally only in our Korean culture the one step higher level the final decision people he did he decide the going around thing. It’s very important thing. As a first officer or the low level people they dare to think about the go around thing. It’s very hard.

Q: In your mind, then, and I don’t want to put words in your mouth, you tell me, did you feel that as the pilot in the left seat flying the airplane that you had the authority to do, commence a go around yourself?

A: Go around thing. That is very important thing. But the instructor pilot got the authority. Even I am on the left seat, that is very hard to explain, that is our culture. How can I say, during cruise also, when we met the turbulence condition, things like that, easily, B777 go into the maximum airspeed, so that’s the limitation. In that case, I never ever thought about that I controlled that condition because instructor pilot handled that, that sort of limitation thing. So that is a, they control the autothrottle system, things like that. I was also the company investigation team also, I know the investigation or the QAR thing, so my experience said to me the regulation and authority is very obvious to me. So, uh, yeah.

Q: And when you say the regulation is very obvious to you, you mean that there is a regulation that says only the PIC can do go around.

A: Yeah, that is obvious to me, but up to now I thought the very dangerous condition, now I am a captain position. I can do that, but it is very hard, yeah.

Q: So just to close this one out, did you expect that only the instructor pilot could decide to go around?

A: Basically, and the regulation, yeah.

Maybe they are being 100% honest, yet am I the only one who is thinking the crew is maybe playing the "culture" card to cover for gross piloting error. Not that they would expect that to completely excuse them, but if the culture card is taken at face value then their crucifictions should become less painful since the "institution" would bare some blame as well.

You would think that concept of CRM would be covered enough in company training, so that it becomes hard to say with a straight face that only the most senior of the flight crew can call for a GA... yet here they are saying that.

Contrast that to the CVR transcript where the jump seater felt empowered enough to call out "Sink Rate" in english and korean ... I assume to alert the PF to check that, but nobody says check speed until it's too late.... so there is enough CRM going on to alert the PF about vertical speed and I assume horizontal speed is okay in that case too, but it's just that nobody called that out until too late. I think it's reasonable to assume that speed warnings weren't called out in time is because nobody up there noticed that. I just don't see how one say that it's OK to call out sink rate, but it would be a culture fo-pah to say hey pilot, check our speed, we're 15 below target... but nobody said because... breaking news here : Nobody was checking the speed (at least not when it was crucial to do so)

[RAT 5]

Guys: I did not say anything about 'bad training'. I intimated that the training was perhaps inadequate, in an overall sense. If you write extensive SOP's based on the use of automatics, and then train the pilots to operate the a/c in that manner, it can not be called 'bad training'. My question is whether these people are being trained as 'pilots' or a/c operators in an automatic mode. I suspect more of the latter than former. My philosophy is that this is fine as long as the pilot is aware of and fully cognisant with the limitations of the automatics and the envelope of the a/c. Thus when the automatics do not function as required, or are not available to accomplish the task, the pilot is fully capable of taking over manually.
It is this closing statement that I put forward for discussion. I wonder if the XAA's are interested in being included. I wonder if the airlines give a toss. If the recent prangs of serviceable a/c over the past 2 years are not a wake up call then I fear for the industry and the old adage of air is the safest way to travel. Sadly, as with most things, when it is noticed they are going awry, things get worse before they get better.

[flarepilot]

remember when we had check rides in the sim every six months and someone thought, why not call it AQP and do it every year?


it is about money

it is about culture

our culture is : if anyone can do something to keep a plane from crashing,they should do it, (simply put, not actual words).

At Vref, I would have said, you are at vref and should be vref plus five.

at vref minus 5 I would say: you are slow...add power

at vref minus 10 I would say: I've got the plane and I would add power


I sure wouldn't wait until vref minus 35 or so.


lonewolf makes a good point...who was in charge? sounds like NO ONE WAS...

First World Plane

First World Airport

4th World culture.


It isn't racism, I'm sure there are some darn fine Korean pilots...But the culture or ego has to be checked at the cockpit door.

I would make sure that both the check cp and the guy in the left seat never flew again

I would talk to the third pilot who mentioned speed and put him in charge of culture change at the airline...I would also set up a minimum Decibel level for callouts

[iwrbf]

Not a media monkey nor am I trying to pull some stunt. An honest question:

Still any airlines out there which try to keep their personnel (flying crews, that is) on a non-magenta-addiction level?!

In other words: Will I jeopardize my fate on the next regular flight regardless of the airline I'll be flying with?

No pun, honest conclusion. Maybe a bit shocked and frustrated?!

[barit1]

My background: 30+ years ago I rode jump seat - on worldwide carriers - monitoring engine ops and environments.

At that time there was a training focus on Specific Behavioral Objectives (SBOs): i.e. When this happens, the proper response is that. Thus you handled single failures successfully, but not necessarily multiple failures. I see this as like the "scripted" checks many have mentioned here. And the old-timers - going back to WWII is some cases - saw this SBO training as "lightweight".

My question: Now I'm sure a few on this thread were SBO trained, and individually have progressed far since those days. What parallels and what distinctions can you make?

[Willie Nelson]

There has been a subtle yet important change at my outfit (primarily Airbus) recently when the company changed the wording of our SOP's to state then when all factors had been considered the practice of autopilot and auto thrust off is encouraged.

Thankfully, all the go arounds that I have ever conducted have been reported, acknowledged by a simple "thank you for your report" response and that has been the end of it. Unfortunately, very few of my offsiders ever take the opportunity to take this opportunity. I can only conclude that the cultural change needs to spread through all levels of the company.

[bubbers44]

Flare pilot, sounds about right to me. That is what I have always done. That is why we have two pilots, both thinking, and both responsible for the safe operation of your flight.

[bubbers44]

Reports from Zite and other reports confirm nobody was flying the airplane and since they couldn't hand fly well used automation incorrectly so crashed. This will continue until pilot skills are restored.

[AerocatS2A]

remember when we had check rides in the sim every six months and someone thought, why not call it AQP and do it every year?
Are you saying you only do sim checks once a year?

[RAT 5]

A discussion point: There has been much opinion-ating here, me as well, on basic handling skills being lost. I suspect it's come mostly from old farts. I flew much GA and then started in the glamour life on B732. In those days the infrastructure was very primitive, relatively, even in some european areas, and definitely in Africa. The a/c were primitive, relatively. Thus the pilots had to be much sharper about everything in their environment, AND they had to be able to fly the a/c to a high standard. If you couldn't then there were some airports that were just damn dangerous. They were bad enough anyway, but if you couldn't handle the a/c you were in dire straits. You couldn't write extensive trained monkey SOP's for these places. You trained to a high standard of manual flying and operational skills, trusted your crews, especially the captains, and relied upon them to make airmanship judgements. When that didn't happen you ended up on Air Crash investigation.
Going into the major, relatively, airports you could be more relaxed as radar led you by the nose, or let you go visual onto a nice big runway with all the bells and whistles and much flat ground around. BUT, the basics of monitoring what was happening never stopped. It was natural. You didn't switch ON in the greek islands and OFF in London. You were ON all the time because that was your attitude. The a/c were basic and sometimes broke.
Nowadays, with better reliability, multiple backups, FBW a/c full of automatic this and that, and a training belief that the a/c automatics are the best way to fly, they are infallible, will not let you go outside the envelope, is it any wonder that pilots sit there expecting it all to happen for them. If it goes wrong the a/c will either tell them with messages, wailers, bells etc. or it will take over and protect itself.
Even back in B757 days I had instructors from the old B732/727's howling at students to "fly the FD." They didn't emphasise that you also needed to maintain a good instrument scan to ensure the FD was being your friend; NO, it was, "it is always correct so follow it". You can stall with a beautifully centred FD, or equally fly into the ground. This attitude followed on when the autopilot was in charge; punch the MCP and watch the FMA and then relax.

I wonder: has the technological advance run away so much that the a complacency has seeped into the profession? What is sure is that the training philosophies have not kept pace in parallel with technology; nor the checking methods & standards. There is also something in the financial management attitudes. Why are we paying all these people so much money to sit there & push buttons exactly as our SOP tells them to do, monkey fashion, and nothing ever goes wrong. It's child's play. With these opinions at the top is it no wonder standards have slipped. Perhaps it is not perceived necessary any longer to have high standards, only adequate standards. The technology will take care of the odd deficiency. Punch the buttons, navigate onto the ILS and let it do its thing. No crashes = the highest standards. Hm?
Some chickens are coming home to the roost.

But back to the question: has the advent and rapid spread of FBW a/c and almost fail-safe automatics led to the dilution in handling skills and the rather casual attitude found in some flight decks? Especially considering that many pilots no start on this generation of a/c.

[BOAC]

http://www.pprune.org/safety-crm-qa-emergency-response-planning/379780-computers-cockpit-safety-aviation.html

[Airbubba]

remember when we had check rides in the sim every six months and someone thought, why not call it AQP and do it every year?

Are you saying you only do sim checks once a year?

Yep, under most AQP programs, you go to the sim only once a year. This stuff has been around for well over a decade at many carriers.

AQP was initially more relaxed with train to proficiency in my observation but over the years as more check boxes were added it has morphed into a continuous checkride with little or no training accomplished. Many AQP programs only require a line check every two years.

I remember years ago a QF pilot telling me that their command training was so good that only about half the pilots pass it on the first try. That would not be considered good training in the U.S.

Almost everyone passes command training in the U.S., although some might need extra sims or OE legs.

[Centaurus]

Perhaps it is not perceived necessary any longer to have high standards, only adequate standards. The technology will take care of the odd deficiency

You have hit the nail right on the head - especially with that last sentence.:ok:

[flarepilot]

rat5

yes.


regarding flight directors...I hate the two cue and love the single cue (howard johnson roof), but LOVE NO FLIGHT DIRECTORS THE BEST.

One sim instructor was really into FDs , yelling all the time...so, there was a little button marked: flight director cue/sync.

by pressing this button the flight director would sort of follow me, so I pressed the button and flew it without really looking at it. He loved it. (the instructor)said I was doing great following the flight director.

sheesh.(and this was over 20 years ago).


Then, I'll never forget this, he said: fly the NDB apch to runway 34 left, circle to land (remember those?)16 right.

oh, and do it just the way you would do it on the line.


he wanted me to configure at the NDB go to the MDA and make the pattern and land.


I went in clean and FsST to the NDB, went to the MDA, entered the pattern, slowing on the down wind etc and circling to land.

He said: that's not the way we do it.


I said:: ITS THE WAY WE DO IT ON THE LINE

my sim partner and I laughed and laughed and the sim instructor looked like I had taken away his birthday.


of course now a days we are limited to basic VFR for circling, so really how hard is it?


What we need is to demand the hand flying skills and GOUGE airmanship from the old days and knowledge of the magic.


oh, and has anyone noticed that jane fonda's eye wrinkles look just like the stress wrinkles aft of the wing on a 737? not fonda jane.

[Jazz Hands]

Improvements in automation shouldn't be taken as an excuse to reduce the training of pilots by the same factor. All that does is give a false impression of the safety improvement - the safety level increases but only by virtue of the machines being reliable, when it should be increasing at a greater rate by virtue of the reliable machines being combined with pilots whose training hasn't been reduced as a result of the 'better' automation.

[RAT 5]

To add a small note to this topic: if it is decided by the powers that be, after many years of hand wringing and perhaps a few more high profile easily avoidable crashes, that it is necessary to revert back to basics and reaffirm the need for piloting skills, and to keep them tuned on the line, where will be the old farts to bring this about. In short time the training departments will be full of young bucks who have come up through the current system and who have ingratiated themselves in the SOP inner sanctum. Where will there be the knowledge and skill base to reintroduce these basics? It will be a lost art almost like using a pen to write a letter, read a map or cook a proper meal for 1 from fresh ingredients.

[olasek]

Would anyone like to take a guess if the Korean authorities might disagree with whatever the NTSB has to say, as the Egyptians did after that accident they had?
I will guess that Koreans won't disagree with NTSB. First they don't have a track record of such 'disagreement', second this is not a 'mystery' crash over Atlantic, the crew survived, would be next to impossible to blame unspecified equipment failure.

[awblain]

The Korean airworthiness authorities might well be able to understand more about the nuanced subtleties of culture and practice at Asiana than the NTSB.

However, I would be very surprised if they came to different conclusions about the factual details and causes. Perhaps there'd be a political preference to try to shuffle some responsibility onto ATC, but it's not clear how that would be achieved.

Korea's not Egypt - it's a sophisticated, well-educated state, and doesn't have members of murderous/deranged communities seeking work in cockpits. If anything, the Egyptian protests about that "accident" just cemented the correctness of the NTSB's conclusions.

[AirRabbit]

…if it is decided by the powers that be, after many years of hand wringing and perhaps a few more high profile easily avoidable crashes, that it is necessary to revert back to basics and reaffirm the need for piloting skills, and to keep them tuned on the line, where will be the old farts to bring this about. In short time the training departments will be full of young bucks who have come up through the current system and who have ingratiated themselves in the SOP inner sanctum. Where will there be the knowledge and skill base to reintroduce these basics? It will be a lost art almost like using a pen to write a letter, read a map or cook a proper meal for 1 from fresh ingredients.

Another spot-on comment!. THE only thing that’s not allowing the accident/incident rate to shoot through the roof today, is that, at least for a while, the guys managing the training departments, and for those few larger operators who can afford to do so, actually re-hire retired line pilots back into the training department, are the “old f@rts” you are describing … and they pass along the real necessity to fly the airplane – knowing full well that you may do that physically yourself – or – you may use the autoflight guidance system to manipulate the controls as long as you remember that you’re NOT transferring control of the airplane to the autopilot (!) which is, I’m afraid, what a lot of the “newer” guys actually do. I’ve often told relatively new pilots that if you take out the A/P Engage switch-light cover, and look on the back, it DOES NOT SAY – Pilot Disengage.

[Cool Guys]

A Korean government inititive to improve airline safety:

Airlines to face suspension in case of fatal accident (http://www.koreaherald.com/view.php?ud=20131126000884) (Airlines to face suspsension in case of fatal accident)


An Asiana inititive to improve airline safty:

Asiana Airlines? new safety chief stresses preemptive action (http://www.koreaherald.com/view.php?ud=20131204000989) (Asiana Airlines' new safety chief stresses preemptive action)

[Intruder]

WOW! Asiana must REALLY be serious about changing their corporate culture and reputation, to hire a Japanese guy as VP Safety!

[bubbers44]

An easier flight means a safer flight,” he added.

An easier approach for a pilot means use automation to the runway??????

What does an easier flight mean. In our country it is doing a visual approach. What does it mean for Koreans?

Why, once again, could they feel stressed with a visual approach with no ILS on a clear day?

[HundredPercentPlease]

Why, once again, could they feel stressed with a visual approach with no ILS on a clear day?

Two groups of interlinked problems.

Group 1: Currency and culture


If you never do a certain type of approach, then you become bad at it.
If you are monitored to death with a picky and punitive culture, then you never expose yourself by doing something you are bad at.
Loop the above two round until you can't do it. If you have to do it, you are stressed for two reasons, the punitive culture and the lack of skill.


Group 2: Tech


He reverted to A320 methods: call for FD off to get A/T in speed mode, do nothing with the stick, expect no movement from the thrust levers and you will arrive.
Nothing needs monitoring because the A320 goes "ping" if any of the auto systems fail. No ping, no problem, no need to monitor. A trillion pilots are guilty of this.
Notwithstanding, stuff goes wrong and "oddly" the a/c is not maintaining the path. Everyone in the west knows that if it goes wrong you simply go around. Here he has to wait for the other chap to call the go-around, due to bizarre culture.


What needs fixing?

Stupid flight deck culture and stupid airline punitive monitoring culture.
More manual flying, on the line, of complex airliners.

What won't fix it?

Idiot pilots thinking that throwing these chaps in the bin will do anything other than bury the real problems. Which are closer to home than you may think.

[ATC Watcher]

100%please : superb analysis for me. Kuddos !
I fear your last line is unfortunately what is likely to happen (again)

[HPSOV L]

Insurance actuaries, statistics, economics and increasing airspace requirements dictate that there will be no going back to basics for long haul operators.

The likely outcome off this investigation will be a long overdue warning in the FCOM, followed by improvements to the 777 autothrottle and warnings systems.

[deadcut]

The public already thinks that the aircraft fly themselves with no input from the pilot. What these "pilots" did will dig the hole deeper.

Say hello to single pilot airline operations within the next 10-20 years. I better start retraining now.

If it wasn't for the brilliant work from Boeing and Airbus then Korean, asiana and all those other third world airlines would have been dropping like flies.

[Ultra Glide]

We'll have single pilot airline operations sometime after we get single engine airliners for the very same reason, if you need to have one to get safely back on the ground then you're going to need at least 2 for dispatch.

I think HPSOV L is correct, if the Triple had systems like the Airbus that (a) wake up the throttles no matter what (Alpha Floor) and (b) had a warning that you're on your own with the thrust (like when you pull the throttles to idle on the bus Autothrust disconnects accompanied by a "ding" and an ECAM warning) this accident probably would not have happened.

Boeings most likely will be modified accordingly.

[deadcut]

Ultra Glide

What I meant was the aircraft will fly and do everything by itself and the "pilot" will be there just in case it fails.

[Capn Bloggs]

I 100% agree with 100%Please. :D

[ExSp33db1rd]

What I meant was the aircraft will fly and do everything by itself and the "pilot" will be there just in case it fails. Plus the dog.

( the pilot is there to feed the dog, and the dog is there to ensure that the pilot doesn't touch anything - and you thought it was a joke, didn't you? World's Gone Mad.)

[olasek]

Boeings most likely will be modified accordingly
Not a chance.

[awblain]

In a world run by lawyers, when there is a system that allows supposedly trained and responsible people to effectively commit suicide, and potentially take hundreds of paying customers with them, it seems within the realms of product liability experience to insist that the manufacture takes some action.

Perhaps insist that the machine at the very least asks politely whether suicide is indeed the captain's intent this afternoon (beyond displaying the perilous airspeed and height), or perhaps that the manufacturer takes a hand in checking the competence of the drivers.

It's a sad turn of events, but perhaps lawsuits will affect the situation? Is a plane a car, where the manufacturers are generally shielded, or does the manufacturer potentially face lawsuits from victims?

[porterhouse]

but perhaps lawsuits will affect the situation? They rarely do, Boeing (or Airbus or Cessna or Bombardier...) is sued after practically every such crash. But suing and winning are two completely different things. To prove manufacturer's negligence is very tough - look what happened to recent two well publicized lawsuits against Cirrus - after over 5 years of litigation plaintiffs walked away with ZERO even though one party was actually winning in lower court.

[olasek]

Perhaps insist that the machine at the very least asks politelyThis machine was asking politely - the speed was in amber zone, there was a warning sound associated with this, the pilot was also pulling 80 lbs on the yoke.. even a blind and deaf pilot was being warned!

BTW, never heard about car manufacturers being shielded from lawsuits.

[awblain]

Perhaps not by legislation, but by practice.

Insurance companies seem to go after drivers, and not manufacturers - although there was that relatively recent fuss about Toyota software that seemed to turn out to be due to a mix of badly-secured floor mats and a lack of regard for the switch-off instructions in the manual for a keyless car.

If car accidents happened only once every two years, then I guess that might change.

[porterhouse]

Insurance companies seem to go after drivers, and not manufacturersBecause insurance companies have nothing to gain suing car manufacturer when you caused the accident. :ugh:

But if car design is in question you bet - victims sue.

[Elephant and Castle]

777's must have done many tens of thousands of visual approaches without mishap. It wasn't the airplanes fault, that much is clear.

Political correctnes will not prevent this type of accident happening again. We cannot have pilots that are scared of flying the airplane on a nice clear day. If they are worried/scared is because even they themselves have serious doubts about their ability (or currency). On top of that we cannot have a cultural mindset where a high probability of a crash is preferable to loosing face or speaking out of turn.

A pilot that cannot look out of the window and land an airplane visually on a suitable runway is not a pilot, it does not belong in an airliner. This has to be an absolutely minimum requirement. What would this crew have done if they had to land flaps up? Or gear up? Or in a strong crosswind? Or with unreliable airspeed? Or in many of hundreds of other more demanding scenarios than a visual approach?

The cultural issues are not new and they are well understood, they still need to be addressed. The systems manager versus pilot debate has taken us the wrong path. We have to be pilots AND systems managers. We are droping the pilot bit because it costs money to train and maintain. Accidents cost money too.

[Al Murdoch]

Shall we drop the "has no place in a flight deck" posts? I think we've established that opinion here...

[chuks]

There's always a problem, post-crash, with lawsuits. Part of this is the fact that cases usually go before a jury of non-specialists who may be told stuff that makes any pilot worth his salt roll his eyes, because the jury often buys nonsense.

I particularly remember a case where a light aircraft pilot made what looked like a typical undershoot with CFIT, followed by a post-crash fire. His family found a shyster who put it about that, no, the aircraft had caught fire on short final, that that was the cause of the crash! Of course the aircraft wreckage had been destroyed by fire, so that it was impossible to say that this very unlikely scenario had not played out, and then there was the bereaved family up against the big, rich, aircraft manufacturer, when the jury came down on the side of the family.

I think the judgment was reversed on appeal, but those initial, multi-million dollar settlements often lead to no win-no pay lawsuits by people who really don't have a leg to stand on. Everyone from the company that built the crash aircraft down to the guy who last serviced its toilet end up having to fight off the sharks.

[RAT 5]

Regarding training culture and the use of simulators for RST's etc: I heard a story some years ago and ask for verification.

It was said that there was an airline in the far east where sim checks were conducted by computer. The story went that the check ride was loaded in the sim, you checked in with your ID card and when ready pressed the Go button and followed the program. At the end of the session it printed out a pass/fail and grade. You then checked out and went home.

Is this true or was it April 1st?

[barit1]

chuks:His family found a shyster who put it about that, no, the aircraft had caught fire on short final, that that was the cause of the crash!

I'm a bit surprised at this; fire while airborne leaved a distinctive smoke trail following the airflow. Any decent accredited investigator, acting as a defense witness, would refute the "fire before crash" theory.

[chuks]

What I remember reading was a scenario that went as if the aircraft, a Beechcraft Bonanza, went on fire on short final, distracting the pilot and thus causing the CFIT. Post-crash, the aircraft burnt out completely, leaving nothing to show when the fire had started, whether that was pre- or post-crash.

Of course it was far more likely that the pilot simply made a mistake and did a "duck-under" when he went visual, or perhaps never went visual and just hit obstructions off the approach end with the usual post-crash fire, but the jury bought this other theory about the in-flight fire. After all, it could have happened that way, even if that was rather improbable!

My point is that American lawyers go after the guys with the deep pockets, any way they can. You will see a list of defendants as long as your arm, sometimes: all the major suppliers, of the airframe, the engines, the instruments, the seats, the galleys... you name it. That "scatter gun" approach is the way to go if you don't have to worry about being hit for costs if you lose.

[5LY]

Rat 5:


No I don't think so. There are certainly canned sessions where the instructor selects a pre-programmed scenario and runs it. How could a computer know when to stop, start, close or open doors, fix issues that arise, judge CRM issues, play ground, ATC, company, purser etc. Running the sim is pretty hands on, even with a canned session.

[RAT 5]

I agree totally. I wonder if it was more a computerised sim check with no input from the examiner, or SFI if a recurrency, other than as you suggest to do the necessary but not to intervene at all.

[AirRabbit]

That takes me back a couple of decades (at least) to the “old joke” of airliners being destined to have only 1 pilot and 1 dog in the cockpit. The dog is there to keep the pilot from touching anything, and the pilot is there to feed the dog.

[DozyWannabe]

Dozy...
who signed for the aircraft: the check captain or the captain who was being checked?

Put another way, who the hell is in charge of the mission?

You've got your finger right on the point I was trying to make. On paper, it appears to be the latter - and the interviews with both flight crew bear this out. It only becomes apparent when you read Capt. Kim's interview in full that real-world practice in Asiana tends to blur the distinction. He states that previous check Captains tended to be far more hands-on than this one, and - possibly because his mindset was attuned to this - he was unsure whether the more laid-back attitude of this particular check Captain indicated confidence in what he (as PIC) was doing, or whether the CC's attention was wandering (note reference to "double workload").

... am I the only one who is thinking the crew is maybe playing the "culture" card to cover for gross piloting error. Not that they would expect that to completely excuse them, but if the culture card is taken at face value then their crucifictions should become less painful since the "institution" would bare some blame as well.

I must admit that I don't get that impression at all. Both Captains' interviews are unequivocal when it comes to saying Asiana's approach to CRM is good - when asked directly. The discrepancy only becomes apparent when both interviews are read in full - if either or both wanted to complain about the airline's training and culture then they would have said that when directly questioned.

Improvements in automation shouldn't be taken as an excuse to reduce the training of pilots by the same factor...

Completely in agreement - though I'd argue that this was never an explicit intention so much as a side-effect of airline management transitioning from a group of industry specialists to the MBA generation - for whom the quarterly financials are utterly sacrosanct above all other concerns.

Two groups of interlinked problems.

Group 1: Currency and culture


If you never do a certain type of approach, then you become bad at it.
If you are monitored to death with a picky and punitive culture, then you never expose yourself by doing something you are bad at.
Loop the above two round until you can't do it. If you have to do it, you are stressed for two reasons, the punitive culture and the lack of skill.


What needs fixing?

Stupid flight deck culture and stupid airline punitive monitoring culture.
More manual flying, on the line, of complex airliners.

What won't fix it?

Idiot pilots thinking that throwing these chaps in the bin will do anything other than bury the real problems. Which are closer to home than you may think.

I couldn't agree more with this stuff - more power to your elbow, sir! :ok:

However this bit:

Group 2: Tech


He reverted to A320 methods: call for FD off to get A/T in speed mode, do nothing with the stick, expect no movement from the thrust levers and you will arrive.
Nothing needs monitoring because the A320 goes "ping" if any of the auto systems fail. No ping, no problem, no need to monitor. A trillion pilots are guilty of this.
Notwithstanding, stuff goes wrong and "oddly" the a/c is not maintaining the path. Everyone in the west knows that if it goes wrong you simply go around. Here he has to wait for the other chap to call the go-around, due to bizarre culture.


...I'm not so sure about. I'm sure there was a post earlier in the thread from an Airbus pilot stating that the A/THR on the FBW types would not have "woken up" in that situation, and that the behaviour of the T7 autothrottle was more-or-less the same.

For one thing, I'm certain that moving thrust levers are a red herring here. For another, the A320 will not, as you say, "ping" if the apparent command given by the crew is consistent with the situation - contrary to a lot of received opinion, Airbus automatics are no more "intelligent" than those of other types.

As to the third point, the interviews state that Asiana's rule regarding GAs is that they must be *flown* by the Captain and not the FO. Whether GAs can be *called* by the FO is not stated, but the PF in this case was already a Captain upgrading to long-haul from a short/medium haul position - moreover he was an instructing/check Captain on the short-haul types, so even if he reverted to previous behaviour he should have had no trouble ordering or flying a GA.

What is interesting is that this particular check flight seemed to combine a visual approach without ILS backup (apparently a very rare occurrence for Asiana PICs), an airport which was considered "difficult" among Asiana's line pilots and a check Captain whose technique was more hands-off than seems to normally have been the case. For his part, he seems to have been reticent to directly ask the check Captain whether the latter was happy with his handling of the flight - and the check Captain himself, despite noting that the PIC seemed "nervous" (per the interview), did not make any attempt to find out why, or provide encouragement/direction if necessary. Possibly as a result of the seemingly punitive nature of the airline's culture, these factors appear to have added to the stress levels of the PIC.

If I may be permitted to speculate:

The airline was known to have a hard-line approach to excessive descent rates - could this have led to the PIC erring on the side of caution and come in fast and high?
The check Captain (apparently unusually) was content to let the PIC get on with things - did this cause him to avoid corrective action until too late?
The PIC seems to have been concerned enough to take on PNF/PM tasks on final - did this impression of "double workload" in fact cause him to be task-saturated at a critical phase?


To illustrate the point I was making earlier about stress, we know that a pilot considered the best in his airline was so concerned about duty/time regulations that the distraction may have caused him to attempt take-off without permission. We know that a pilot who was highly spoken of by his colleagues became so concerned about wake turbulence that it may have caused him to overcontrol his aircraft to the point of structural damage. We have countless examples of pilots being so concerned about making schedule that they continued with approaches that they shouldn't have.

Therefore, no matter what anyone's experience or view of "culture" may be, the nature of increased stress and its ability to cause even the best pilots to make mistakes that seem incredible at face value must be considered here.

[A Squared]

What I remember reading was a scenario that went as if the aircraft, a Beechcraft Bonanza, went on fire on short final, distracting the pilot and thus causing the CFIT. Post-crash, the aircraft burnt out completely, leaving nothing to show when the fire had started, whether that was pre- or post-crash.

That's about what I recall of that lawsuit. It's been a while but as I recall at the time it was the largest award ever in a GA liability suit. Again, going from memory here, but the award was 107 million dollars against the engine manufacturer, Teledyne Continental, the amount was later reduced on appeal.
And I also remember that the evidence that it was an in flight fire was virtually non-existent.

[porterhouse]

I think the judgment was reversed on appeal, but those initial, multi-million dollar settlements Correct, like the initial win of $17 mln against Cirrus in the Minnesota crash, it was later reversed. But it is all an example how in some cases jury system completely fails when (some) technical/aviation expertise is required.

That "scatter gun" approach is the way to go if you don't have to worry about being hit for costs if you lose. All very true, however sometimes the suing 'loser' is faced with surprising financial liability - Cory Lidle's widow was slapped with $80,000 judgement to repay Cirrus' court fees after losing the battle against them for $50 mln. Her lawyer called it a "double injustice". Of course the $80 K is a relative chump change compared to what was in stake in this trial and what lawyers' fees were.

[Jet Jockey A4]

Just how accurate it is but here it is...

It seems to me there was some misuse of the automation on this aircraft that then put them in a bad situation with no one minding the store.

From another aviation web site...

"During hearings on December 11, National Transportation Safety Board officials described the final approach sequence of Asiana Airlines Flight 214, scannerwhich crashed at San Francisco International Airport on July 6. The Boeing 777 was cleared for a visual approach to Runway 28 Left where, as per a Notam, the glideslope was inactive. The left-seat pilot flying had logged fewer than 45 hours in the 777, while the right-seat instructor had 3,200 hours of time on the widebody. On a 15 mile final approach, the Boeing’s airspeed was at 210 knots as it descended with autopilot and flight-level change (FLCH) engaged. Descent altitude was set at 1,800 feet. The aircraft was high on final approach and switching to vertical speed mode did not help this situation. Final approach reference speed was calculated at 137 knots. On a five-mile final the altitude was reset to 3,000 feet in case of a go-around. At 1,600 feet and 3.5 miles from the runway, the FLCH switch was again activated, which changed the auto-throttle mode. [Boeing does not recommend using FLCH inside the final approach fix—Ed.]. When the FLCH was engaged, the autopilot tried to climb the aircraft to 3,000 feet. The pilot reacted by pulling the thrust to idle and disconnecting the autopilot. This put the autothrottles in hold mode at idle. At 1.4 miles from the runway and at 500 feet above the water the aircraft was still descending. With the thrust at idle, the left-seat pilot began to add backpressure to the control wheel to stop the descent and get back on the visual glideslope from the precision approach path indicator. The airspeed continued to decay–now slowing through 120 knots–although neither pilot mentioned it. Eleven seconds before impact a low-speed alert was heard in the cockpit. At eight seconds from impact and with the aircraft 100 feet above the water, the pilots moved the throttles full forward to initiate a go-around. Four seconds later the stick shaker activated and someone in the cockpit called for a go-around. The action was too late and the main gear and aft fuselage struck the seawall. The lowest recorded airspeed was 103 knots, 34 knots below the calculated safe reference speed."

[DaveReidUK]

During hearings on December 11Available here:

National Transportation Safety Board (http://ntsb.capitolconnection.org/121113/ntsb_archive_flv.htm) (Flash)

or here:

National Transportation Safety Board (http://ntsb.capitolconnection.org/121113/ntsb_archive_wmv.htm) (Windows Media Player)

[Skyjob]

Improper use of automatics...

What I still do not understand, is why they didn't fly a LOC approach or VNAV as only G/S u/s if they were so concerned about a visual approach and its perceived problems.

But having set the Missed Approach Altitude to 3000', every Boeing pilot knows that pressing FLCH will cause the aircraft to climb up, not go down. Basic school boy error, like hitting TOGA instead of A/T disconnect as sometimes seen on another Boeing type due incorrect throttle positioning of the hands. Time and height permitting if can be corrected with visual references: continue, otherwise the best course of action is to continue that climb and try again.

[joema]

why they didn't fly a LOC approach or VNAV as only G/S u/s if they were so concerned about a visual approach and its perceived problems.

This has been asked many times and never explained. The Asiana pilot said he was very stressed over having to hand fly a visual approach w/o ILS glideslope in CAVU conditions. If so he evidently had two options: (1) use the published RNAV/GPS approach or (2) use the FMS VNAV system.

Further unexplained is since the 777 uses back-driven thrust levers and they were not moving -- sitting at the idle detent (where the pilot put them) why the surprise over low thrust?

It's ironic this accident is commonly attributed to "automation dependence", when in fact the pilot did not understand how the automation worked. He wasn't over-dependent on automation which failed, rather he didn't understand the automation, plus failed to use available automation modes, plus couldn't hand fly a visual approach. That was not a good combination.

[PA-28-180]

" Cory Lidle's widow was slapped with $80,000 judgement to repay Cirrus' court fees after losing the battle against them for $50 mln. Her lawyer called it a "double injustice". Of course the $80 K is a relative chump change compared to what was in stake in this trial and what lawyers' fees were. "

....and even though Cirrus 'won'....how much did defending their company ultimately cost them - and the consumers? Because sure as God made little green apples, there ain't ANY company that doesn't pass along costs to US. The sad fact is that most Americans consider the civil 'justice' system to be the same as playing the lottery. Most often, the plaintiff pays NOTHING and the 'lawyers' get paid from whatever judgement is won. Fortunately, some states have begun changing - such as Texas - where, at least in medical malpractice cases - it's now 'loser pays'. Prior to this change, many so called high risk medical practicioners left Texas - obstetricians, anethesiologists, neuro-surgeons, etc. AFTER the change, many have returned and many more have moved to Texas. A little know fact, is that aLOT of medical costs are because of 'defensive medicine' practices, which is just CYA for physicians and hospitals - NOT because it's clinically needed. Unfortunately, as long as the American trial layers association keeps pumping money into political campaigns, it's very unlikely this will change elsewhere anytime soon. :ugh:

[roulishollandais]

It's ironic this accident is commonly attributed to "automation dependence", when in fact the pilot did not understand how theautomation worked. He wasn't over-dependent on automation which failed, rather he didn't understand theautomation, plus failed to use available automation modes, plus couldn't hand fly a visual approachIt is often suggested that older experienced pilots would dislike FBW and automation.But the new generation show that all the pilots need the same level of better FBW design and wide information from manufactors to reverse to handfly as soon as needed (young farts need first to learn handflying basics, in Asia, Europe, Russia,etc.)

[olasek]

He wasn't over-dependent on automationCan't agree. I would argue this was still the case of rather chronic automation dependency. Who said that you can't be automation dependent while at the same time poorly understand the same automation. He was automation dependent because he blindly believed in the auto-throttle that it will be there to think for him. Failure to cross-check instruments making sure that everything works is also a form of automation dependency.

[Jazz Hands]

I would argue this was still the case of rather chronic automation dependency. Who said that you can't be automation dependent while at the same time poorly understand the same automation.


I think it's essentially the same thing under different names. Not understanding what the automation is doing makes you assume the automation knows what it's doing - therefore, as you say, you become dependent by virtue of not understanding.

[suninmyeyes]

If anyone wonders why 777 pilots' basic hand flying skills are not to a high standard consider the following when manually flying the 777.

1) When you put on power there is no pitch up couple, this is taken out automatically

2) The autothrottle is always engaged and pilots are not allowed to disconnect it. This destroys the basic instinct of taking off or putting on power when levelling off after a climb or descent.

3) If there is an engine failure rudder is applied automatically.

4) Pilots are encouraged to use a flight path vector which makes flying manually a bit easier.

5) There is no pitch change when gear or flap is selected.

6) If you overbank then the automatics chip in and roll the wings back towards level.

7) When you roll into a turn there is no need to apply back elevator pressure.

The only time 777 pilots genuinely hand fly the aircraft is when it is in "Direct Mode". This takes out all the aids mentioned above apart from the autothrottle. However this is only ever practiced in a simulator.

As 777 sectors are typically 8 hours long or more, and are frequently overnight, hand flying in to a busy airport is not recommended. The fatigue factor which the Asiana pilots undoubtedly experienced has not been discussed much and I believe it would have been a significant factor. Although I frequently hand fly the 777 I strenuously avoid it after overnight flights apart from disconnecting the autopilot below 1000 feet and hand flying the remainder of the approach to landing.

In no way am I saying that what happened in SFO was anything other than pilot error, but I am just explaining to those who have not flown a 777 how it has been made relatively easy to hand fly using artificial means, but consequently basic flying skills can be eroded by those same artificial means.

Does anyone remember the SAS DC10 accident at JFK about 1984 when it overran into the water? I seem to remember over reliance on the autothrottle system was cited as a cause.

[BOAC]

The fatigue factor which the Asiana pilots undoubtedly experienced - do you mean fatigue or tiredness? Do you have evidence that they were flying fatigued? That would make their contribution to the accident culpable, at least under European rules..

[flarepilot]

suninmyeyes


are you thinking of the world airways DC10 at Boston? Autothrottles were part of it,even the engine kept running after it went into the water.

here is the report: http://www.airdisaster.com/reports/ntsb/AAR85-06.pdf


while I understand everything you have written about the 777, I also know that if you only take the elevator between floors on a skyscraper (for british folk, THE LIFT on a tall building), then if the elevator fails you will not be in shape to take the stairs.


dear pilots, take the stairs!

[tdracer]

2) The autothrottle is always engaged and pilots are not allowed to disconnect it. This destroys the basic instinct of taking off or putting on power when levelling off after a climb or descent.

Suninmyeys, there is a A/T "DISARM" switch on the forward panel. Flip that switch to 'disarm' and the A/T is taken completely out of the loop. Does your airline prohibit using that switch?

[suninmyeyes]

Suninmyeys, there is a A/T "DISARM" switch on the forward panel. Flip that switch to 'disarm' and the A/T is taken completely out of the loop. Does your airline prohibit using that switch?

Tdracer. That's affirm, we are not allowed to switch it off for practice in the aircraft.

BOAC fair point, tired then.

[misd-agin]

Then that's a COMPANY problem and not an AIRPLANE issue.

IMO you don't become a better pilot on the 777. You retain your previous skill set. IMO putting new airline pilots into long haul fleets will restrict, or even prevent, the development of decent piloting skills.

[joema]

Can't agree. I would argue this was still the case of rather chronic automation dependency

My point was this wasn't a simple case of a whiz-kid "child of the magenta" being unable to hand fly the plane when faced with an outright automation failure.

Rather, he didn't understand the automation behavior. Had he been a stick-and-rudder guru, he could have still crashed by not understanding that.

The A320 pilot at the Habsheim crash was a highly experienced test pilot with excellent hand flying skills. Yet a misunderstanding about automation combined with poor decision making caused a crash.

Likewise, further improving the hand flying skills of the Asiana pilot -- by itself -- might not have prevented the problem if he *still* misunderstood aspects of the automation. This implies the overall problem and solution is broader than automation dependency.

[Lonewolf_50]

joe, this takes one back to a point raised during the prolonged discussion on AF447: how well do you know your aircraft, and how well do you know your aircraft systems and sub systems?

[AirRabbit]

Hello stator vane:

My compliments on one of the most cogent, accurate, and professional posts on this thread. I think your comment …”so that is why I am always right there with knowing what I want it to do and making sure the airplane does what I want” ... should be tattooed on the inside of every pilot’s eyelids – so that is what they see every time they blink!

I posted a comment earlier on this thread where I described a comment I’ve often made to students … but I’m not sure that your version of it isn’t more professional … What I posted says … “I’ve often told relatively new pilots that if you remove the A/P Engage switch-light cover, and look on the back of it, it DOES NOT SAY – Pilot Disengage.

[GobonaStick]

Sounds to me like the similar "automation dependence" on electronic calculators which crept into the classroom.

I found that some classmates were quite adept at bashing calculator keys parrot-fashion and coming up with the right answers, but were stumped if they had to solve the same problem by hand.

In other words, they didn't understand the reason mathematics worked. They didn't know what the calculator was doing, and why - only that it worked, as if by magic.

It's not enough to teach pilots the procedures of accessing modes on aircraft. You have to teach them why you're accessing those modes. And you have to teach them not just how it responds, but why.

[chuks]

I came up the usual "self-improver" way. I did a year flying out of Miami to some rather far-off islands using light twins without autopilots. You wouldn't want to fly into a busy terminal area doing that, so that a lot of the necessary skills for flying the line are not learned, but you certainly do master hand-flying and keeping your scan going.

Years later, I ended up flying a Dornier 328, having to learn modern systems I had only read about. (The 328 has Honeywell Primus 2000 glass, but no autothrottle.) There was a period of "What's it doing now?" but at least that was underpinned by the basic ability to revert to primary cues and fly the aircraft when the automation had been told to do something I did not want it to, such as taking us to the wrong waypoint. or ignoring the localizer because I had not armed APP.

The insidious thing is that hand-flying skills deteriorate if they are not used; I would take any good chance to practice, when the young FOs would groan when they heard that "cavalry charge" warning tone. Of course, later I could watch some of them really struggle in a sim session when one of the first systems to fail was the autopilot; they had obviously poor hand-flying skills. Some had probably never learned to do that very well, having been carried along through one of our infamous FAA-approved training mills, while others had simply not kept that skill up.

When it came to other things such as following a SID or a STAR then they were often superior to me; I was still essentially just a bush pilot in some ways, but which skill was primary? You need both skill sets, of course, but only one, being able to hand-fly without undue effort, is going to keep that thing dependably shiny side up!

A related problem, addressed on other threads, is the way that stall training has been perverted into an exercise in not losing any altitude. If you go in at 5 thousand feet, then you have to come out at that, even if that means sort of mushing along instead of making a very positive nose-down recovery from the stall. Well, usually not even a stall, of course, just the approach to a stall. It's easy to see how a real, full-breaking stall would come as a very nasty shock to someone only used to getting a bit of buffet or the stick shaker, and thinking that's the same as a stall flown to the break.

All of this seems like swaddling the flight crew in fluffy cotton, keeping them well away from the sharp edges implicit in flying any aircraft at the edge of its envelope, whether that's a critically low speed on final, or an upset in turbulence, or a stall, perhaps one encountered in icing at a speed taken to be above stall speed. I think that problem is spread across much of aviation now; I don't think it's specific to the culture of Korea. What happens as trouble approaches, whether good CRM is practiced, that might be culturally specific, but this lack of hand-flying skill is widespread, I think.

[Lonewolf_50]

It's not enough to teach pilots the procedures of accessing modes on aircraft. You have to teach them why you're accessing those modes. And you have to teach them not just how it responds, but why.
Education and training go together. Try telling that to a bean counter in any land.

[flarepilot]

someone said that there were only a couple of options available tothe pilot other than a visual, ie loc or rnav.

other options:

request ILS 28R

I think we have established that 28 right was ok.

Diversions could have been requested too...Oakland INTL , virtually abeam SFO, San Jose, maybe 45 miles away, the former Naval air station, MOFFET Field (now a federal airfield) even closer...all could handle a 777.

So many options.



Imagine a Dark and Stormy night over the pacific, engine quits and MIDWAY ISLAND is the only place open and in range, and further imagine the ILS is OTS.

IF the pilots could retard the thrust levers when the plane started to climb to the Missed apch alt, how could they not know how to advance the thrust levers when the speed got too slow?

And clutched throttles can be pushed forward even if the autothrottle sw is not used.

strength enough to hold 80 lbs of pressure on yoke, but tooo weak to push throttles forward?

[Jazz Hands]

Try telling that to a bean counter in any land


A frequent complaint. But I wonder if anyone's ever tried.

[Lonewolf_50]

Given that I ran into that in the Navy, related to some Air Force Navy joint training syllabi, yes, I have tried and discovered to my horror that some people think one can get a right nut without a left one and still have a complete "package." :mad: With the Navy not profit oriented, I can see where profit oriented enterprises would do the same, and worse, by damning such heresies as cost centers without added profitable value. :mad:

[Island-Flyer]

But I wonder if anyone's ever tried.

I have personally and I have seen other check airmen and instructors do the same at various 121 carriers here in the US. They all have heard the same answer:

"Train to the training program minimum hours, it's what we're budgeted for. If the FAA thought we'd need more to be safe they would require that we increase the hours in the training program."

The FAA when asked about it says:

"We only hold the minimum standard, it's up to the operator to go beyond that."

[flarepilot]

just for the record

the boeing type rating ride I took had a req'mt to demonstrate a visual apch, purely visual by looking out the window

I was given distance to runway and cleared visual apch and used the 3/1 method until vasi/papi insight

but I had to demonstrate it and did...at night

[aterpster]

Jazz Hands:


A frequent complaint. But I wonder if anyone's ever tried. You bet they have, at least indirectly.

I was on the ALPA Safety/Technical Committee when we went to the Vice-President of Training to attempt to get a second recurrent training sim session.

His response, "Negotiate that in your next collecting bargaining agreement. Otherwise it has a snowballs chance in Hell."

[misd-agin]

Can't bitch too much about the lack of training. Company went to a yearly sim schedule back in the late 90's but you could go to a 6 month sim on your own. Unpaid but they'd pay for the hotel. How many guys went? Almost zero.

Last training cycle had a night visual approach to a 7000' runway with no GS, PAPI, or VASI.

[Capn Bloggs]

Last training cycle had a night visual approach to a 7000' runway with no GS, PAPI, or VASI.
Good, someone's got the message...

[ExSp33db1rd]

Engine caught fire on a 707 one night over the Middle East, extinguished and diverted to the only practical airport available, and arrived to find it was now raining and the ILS was u/s. (GPS/INS not yet invented )

Murphy was alive and well.

Ended up doing a manual, visual, NDB approach at night and broke out just above minima - on three.

But then we only had a rudimentary auto-pilot and auto-throttle anyway, so it was really - almost - just another day at the office.

No problem.

[twentyyearstoolate]

Having worked with these guys, I heartily disagree. IMHO they would NOT make good instructors.

There are 3 dead people, numerous severely injured. One flight attendant is paralysed below the waist and another severely burnt with severe facial scarring. No, I'm sorry, if I was scheduled to be trained by them I would refuse!!

[SawMan]

They may have learned something from this mistake but that doesn't make them good candidates for trainers. If something this basic was not trained into them, then all their training which occurred after that point becomes suspect and needs to be checked out too. They can only pass on what they know and until it's all verified as being correct (and rectified if it isn't) then they don't need to be instructing anyone, possibly adding to the wrong.

[fireflybob]

Training the trainers is key.

In the 1960s Boeing were concerned about the accident rate when their shiny jets were being operated by certain companies.

One of the things they instituted was that part of the package of buying a Boeing would be that they would train the training Captains who were going to train the line pilots - this was not optional but mandatory.

There are, of course, many other factors which go to make a safe operation.

[chuks]

I once had to attempt to train a fellow who had made the most spectacular horlicks of a night visual approach, writing off a brand-new aircraft and nearly killing himself and all aboard in what was technically classed a non-survivable accident (the aircraft was pretty much shredded by a relatively fast, flat impact in a field of corn).

It was horribly fascinating to see how the same thought patterns that must have led to the crash were still present afterwards; he had learned nothing at all from his mistakes, plus he was now quite traumatized, so that he was essentially untrainable.

Going by that I would say that this accident crew probably should be used as a warning to others, but not as trainers. By what we can read in the preliminary report they scarcely qualify as pilots: speed control is a basic skill that they appeared completely to lack. Of course, that said, we have to wait for the final report; there might be something missing from what we have been told so far.

[A37575]

But hell, i bet they could now be some of the best instructors ever seen.

Assuming you are serious, and surely you are only joking - then clearly you haven't seen Korean instructors at work.:ugh:

[tdracer]

But hell, i bet they could now be some of the best instructors ever seen.

Years ago, shortly after the Gimli Glider incident, my then lead engineer made the comment that he'd fly anywhere with those pilots. His rational was, they were never going to make that mistake again, and once the emergency started, they performed brilliantly. :ok: (and yes, I know it arguably was not the flight crew's mistake that lead to the fuel exhaustion)

I don't think I would ever make a similar statement about Asiana - while they may never make that exact mistake again, at no time did they display particularly good airmanship. :uhoh: :yuk:

[Desert185]

I once had to attempt to train a fellow who had made the most spectacular horlicks of a night visual approach, writing off a brand-new aircraft and nearly killing himself and all aboard in what was technically classed a non-survivable accident (the aircraft was pretty much shredded by a relatively fast, flat impact in a field of corn).

It was horribly fascinating to see how the same thought patterns that must have led to the crash were still present afterwards; he had learned nothing at all from his mistakes, plus he was now quite traumatized, so that he was essentially untrainable.

Going by that I would say that this accident crew probably should be used as a warning to others, but not as trainers. By what we can read in the preliminary report they scarcely qualify as pilots: speed control is a basic skill that they appeared completely to lack. Of course, that said, we have to wait for the final report; there might be something missing from what we have been told so far.


+1! Amen! :D

[bubbers44]

Please don't make them trainers to return to the US.

[bvcu]

mind you recall the A320 accident in the sub-continent by a pilot trained [and failed] by the manufacturer.

[777fly]

Until the mid 90's the ultimate proof of ability was always the engine out non-precision approach, flown manually in a stiff crosswind, in limiting weather conditions. This was a simulator check, of course, but it was certainly the definitive test of handling skill, instrument scan and situational awareness. A significant percentage could not pass this item at the first attempt. Somewhere along the line it was decreed that exercises of this nature, and even VMC approaches, were best performed on automatics. Situational awareness and basic handling ability seem to have deteriorated ever since.

[averow]

Good points Lonewolf: In my own profession (Anesthesiology/CriticalCare) we have benefitted greatly from automation aids, protocols, etc. But at the end of the day, when things go South we must understand the basics and understand how our machines and profession work: I am a lowly PPL but have learned a lot from these discussions and incidents. One must have a THOROUGH understanding of what makes aviation work and be prepared to respond when Hal lets us down. Thank you !:ok:

[DozyWannabe]

Years ago, shortly after the Gimli Glider incident, my then lead engineer made the comment that he'd fly anywhere with those pilots. His rational was, they were never going to make that mistake again, and once the emergency started, they performed brilliantly.

Loath as I am to take anything away from that crew's achievement, airmanship only got them so far. In that particular case there were two factors that were fortunate - not just a PIC who was a glider/sailplane expert, but also a FO who used to fly out of the Gimli airfield when he was in the military - as a decommissioned airfield it wasn't on their charts. Without the latter factor it wouldn't have mattered how good at handflying they were.

Don't get me wrong - the airmanship and CRM of this Asiana crew left a lot to be desired, but had the Gimli crew been a few thousand miles from known territory then the outcome might have been much less positive.

[RetiredF4]

statir vane
But in my experience, mistakes are the best instructors and equalisers i have personally encountered. Others' mistakes can feed an arrogance and are not quite as revealing as one's own.

And, no, i haven't crashed an airplane. Yet.



Your last sentence makes the difference. To recognize a mistake early enough to prevent the final fate of a mistake and walk away from the scene with new knowledge and dedication is a key factor of any given task. To put it plain and simple, you can learn from a botched approach by comencing a timely go around, there is no need to crash the aircraft and kill people by doing so.

Driving over an pedestrian with your car does not qualify to becoming a driving instructor, and killing a patient will not entitle a doctor to give lessons to medical students.

In view of this accident i can find no indications concerning an ongoing learning process of the crew to the root cause of the accident, not monitoring the basics of flying, airspeed, attitude and altitude. Instead we hear excuses over excuses.

[chuks]

I don't expect others "to concede the point," not on the basis of one post of my own!

I formed an opinion about whether someone who has had an accident might be useful for teaching others how not to have an accident, and I formed that opinion from direct experience, not from a guess. It was a disappointment to discover how stuck in one frame of mind that accident pilot was, how he persisted in dysfunctional, downright dangerous, self-delusional behavior. I thought to myself, "I can teach anyone to fly better than that!" but I failed. Failed doubly, in fact, since he was, for political reasons, allowed to carry on for quite a while longer until he was finally got rid of; my own "down-check" of him was disregarded at the time it was given, since it was embarrassing.

That said, I am sure that my own "incidents" (dents and scratches on various aircraft) have taught me things that have made me a better, because much more humble, teacher of others.

It's just that the fact of having made a real mess of things, as this Asiana crew certainly have done, is not something that automatically denotes value as a teacher. Maybe, maybe not, when my best guess is "probably not." Others may well have a different opinion, particularly since I have had no contact with Koreans in aviation. Koreans, yes, but not in aviation.

[bubbers44]

I think completing a career with no bumps or scratches means you learned from other people's mistakes, not your own. It is not necessary to at 18 wreck your car to learn how to drive safely, even thou most do. Learn how to drive and fly safely looking at what went wrong with others and learn from it.

The Asiana pilots are probably now paranoid of another crash but they aren't better pilots because of it.

[AirRabbit]

I have personally and I have seen other check airmen and instructors do the same at various 121 carriers here in the US. They all have heard the same answer:

"Train to the training program minimum hours, it's what we're budgeted for. If the FAA thought we'd need more to be safe they would require that we increase the hours in the training program."

The FAA when asked about it says:

"We only hold the minimum standard, it's up to the operator to go beyond that."


I was on the ALPA Safety/Technical Committee when we went to the Vice-President of Training to attempt to get a second recurrent training sim session.

His response, "Negotiate that in your next collecting bargaining agreement. Otherwise it has a snowballs chance in Hell."

To me, it’s strange to read these kinds of comments as they are apparently written as a form of resolute agreement with something that is undesirable. Given the above, wouldn’t it make sense for you to figure out what it is that is really needed in the industry – is it really up to the owners and managers, and them alone, to determine if there really IS any merit in going above what the regulator has determined to be “the minimums.” The first question, logically, should be … are these REALLY the minimums … are they REALLY satisfactory? Have I misunderstood the real potential for pilots to successfully “bargain” for something beyond what the regulator has determined to be satisfactory? Why is it that the regulator is right? What would you do differently … and why? What do your representatives think? What are they doing in response to what you think? If whoever is currently representing you really isn’t … maybe it’s time for an adjustment. Do you not know, or could you not find out, or is it possible to determine on your own, what things cost? Could you not find out what it would cost the airline owners and managers to get what you want or need? To me it sounds a lot like the regulator IS listening, but listening only to those who are talking to them - the airline owners and managers – who want to save money. Do you think the regulator will not listen to the folks who actually want and need the training? Of course, the facts would have to be determined, the accuracy of any data should be determined and recognized – what ARE the real costs – what ARE the real benefits – is it possible that there might be adjustments to what is ultimately decided if there were some measure to indicate that such an adjustment could or would be appropriate? Are there any other mitigating steps that could be taken without diminishing what you need out of your initial and recurrent training? After considering all of the above … wouldn’t it make sense for you to argue about it, discuss it, write it, re-write it, argue some more, describe it down to the bitter details (including costs and benefits), and eventually decide what it is that YOU want ... what YOU actually need ... and then approach the regulator and tell them what you guys have determined is the “real” minimum? Is it always (ever?) that "father" (i.e., the regulator) "knows best" ?????

[roulishollandais]

Thank you for that lesson of safe thinking.
The war against pilots unions, and generally unions, is an old political story, lost by pilots whith A320 beginning. Engineers took the power, and refuse today to listen pilots' questions, are these questions about letal stalls or management, aso. Recent PPRuNe's threads show many exemples of that. If you risk to be fired, you accept not only these blackmails, most accept to risk their life... and passengers' life ! Korean pilots of Asiana 214 behaviour and no-communication with heads, in and out of the cockpit, is now worldwide. My thought . But I don't agree to call that "culture", isn't it ?

[DozyWannabe]

The war against pilots unions, and generally unions, is an old political story, lost by pilots whith A320 beginning. Engineers took the power, and refuse today to listen pilots' questions...

On what evidence do you base that assertion?

Aside from the fact that both B and A brand FBW development had pilots involved at all stages, engineers - of all stripes - and pilots are effectively on the same side and always have been.

[bubbers44]

Any airline pilot should know how to do a visual approach with no glideslope.
I have never seen one that couldn't. How did they do that on a clear day? I hope we can do away with these push button pilots so we can go back to where we were.

[DozyWannabe]

Bubs, it's less about not knowing how to perform a visual with no G/S as it seems to be some airlines' policies denying their pilots the opportunity to practice them enough.

[bubbers44]

WHY? They don't care if their pilots can fly a visual approach?

[DozyWannabe]

That I can't answer. But based on the material released, it seems that Asiana's long-haul network doesn't usually fly to airports without ILS, and moreover, the simulator training doesn't include visual approaches other than their home base.

[barit1]

...and even that training does not include glidepath capture from above.

[roulishollandais]

engineers - of all stripes - and pilots are effectively on the same side and always have been.They always have been. But "c'était le bon temps, ça, Monsieur" ! It clearly finished when EADS "forgot" to list Concorde in their responsibility file to the Trade market the 8. Jul 2000, and definitively finished the 25. with Concorde's crash in Gonesse.Certification of "aircrafts" must not need particulary skillful pilots, just pilots being able to land visualy without A/T, AT, AP,and other FBW Systems that regulators themselves don't understand:{ in their armchairs.

[fireflybob]

The attitude to safety and CRM is exemplified by one Company I flew with who introduced some sweeping changes to SOPs which were based more on potential commercial liability rather than flight safety.

At no stage were the experienced pilots in said Company (many of whom who were far more qualified and experienced than those at the top who were changing the rules) consulted and/or asked their opinion about the changes.

The Companies preach the CRM mantra to flight crew and then take an authoritarian approach to instituting changes.

And then we wonder why flight safety is affected?

Any airline pilot should know how to do a visual approach with no glideslope.
I have never seen one that couldn't. How did they do that on a clear day? I hope we can do away with these push button pilots so we can go back to where we were.

bubbers44, quite the most succinct summary of the (sad) situation I have ever read.

[AirRabbit]

Once again, it is apparently necessary to point out that in today’s world, there is an ever increasing philosophy directed toward commercial ventures – which holds that such ventures are launched with only one goal in mind … and then maintained strictly through the satisfaction of one, and usually only one, principle. That goal is to generate “income” while committing to an absolute minimum of “expenditures” … and that principle is to manipulate all impressions of the conduct of the business practices such that when applying anything less than extreme scrutiny, each venture is recognized as being conducted in accordance with all rules, regulations, and agreements, while, at the same time, presenting the business managers in a light of having satisfied the most professional and ethical standards of conduct and being fully committed to the successes of the specific venture, and if pressed, to be able to defend their interest in the advancement and welfare of their employees.

While, of course, it isn’t necessarily true across the board, it is certainly known that in a good many circumstances that have generated sufficiently “good cause” to analyze the business practices of some airlines with something that does, in fact, exceed the typical “less-than-extreme” scrutiny, when someone determined the necessity or logic in doing so, it has been found at least some cases, that the business practices fell far short of what might be considered necessary and appropriate … but such an after-the-fact recognition does little to comfort those involved in the circumstance that generated the scrutiny in the first place.

There are some here who will undoubtedly think that my recommendations are “off the mark” or are a result of “old-timer-thinking.” Well, each is more than welcome to his/her own thought process. I have no particular warm spot in my heart for “labor unions:” despite the fact that I’ve been a member of several and even started one – that, although somewhat changed, is still in existence today – but I also have no animosity toward them either. I have no animosity toward airline owners and managers – as I fully recognize the supreme difficulties that exist in making such ventures profitable in a free flowing, capitalistic world – even those which are ostensibly an “arm” of a specific national government. And, as I’ve said many times on these pages … training one’s own crew members does not result in direct income … it only costs. And the delicacy of the mission of the managers is usually found at the “how-much-is-good-enough” level – and that is applicable to at least the amount of training provided in any specific course; the numbers of repetitions of that training conducted in any given time frame; the cost of the equipment used in such training; the costs of instructors, facilities, transportation, per diem, lodging; AND the loss in revenue due to the individuals not performing the jobs for which they were hired to perform … in the case of flight crew members … flying airplanes in revenue service. Of course, insurance companies have a significant impact on what kinds of, the amounts of, and the recurring amounts of, any training deemed necessary.

This is NOT an indictment of “automatic systems” – but it IS a caution that pilots MUST be educated, trained, and found to be proficient on how each automatic system performs and how pilots MUST monitor that performance in order to realize the true benefits of such systems. There is ONLY ONE pilot flying at any given time. Engaging the automatics does NOT relievel the pilot flying from those responsibilities – but I’m not at all sure that all training in those areas are anywhere near where they need to be in respect to who is still in control of the airplane.

Additonally, as I’ve repeatedly said, perhaps the single area that is often overlooked – is that of the originally established regulatory minimums. It has been my experience that, despite what some here believe to be true, i.e., that regulators are not guilty of “being ignorant of, or lack an understanding of, airplane systems … while merely sitting in their armchairs.” Each individual regulator I’ve ever known is responsible to his/her superior – and at some point, while moving “up” the chain … there comes an individual that has to answer to someone’s concern about having to defend a requirement for congressional constituents being required to increase a costly function merely to satisfy some “safety concerns” that those constituents believe to be either irrelevant or ineffectual or superfluous. More often than not a reduction in the amount, the quality, or the required frequency or duration originally drafted in a typically developed set of regulatory requirements (which are often developed in concert with a specifically invited representation of airline owners/managers, pilots, pilot unions, training organizations, and other similarly interested parties) results from someone either within the hierarchy of the regulator or the government office responsible for such actions and wind up “caving” because of political pressure from “above” or from someone in the elected representation of the government. I’m not sure if that will ever change … and I have no logical recommendation as to how that might be achieved … but I DO know that the professional development of appropriate minimum standards, minimum content, minimum performance, minimum understanding, minimum equipment capabilities, etc., etc., simply cannot be compromised, and must not allow any compromise, to such professionally developed standards. This is one, but only one, of the reasons that I’ve recommended, on repeated occasions, that those here become involved in any (all, if possible) of the internationally developed efforts currently underway, and others being considered, that focus specifically on the requirements that should be considered minimum – without having to endure some other “bureaucrat” submission to political expediency. I know it won’t happen if we all sit on our hands. It won’t happen if we each wait for the “other” guy to get involved. It won’t happen if we don’t want to be the “squeaky wheel.” The old adage IS, in fact, true … it is the squeaky wheel that gets the most grease, and gets it first. Where are you?

[twochai]

training one’s own crew members does not result in direct income … it only costs.

What nonsense! "If you can't afford safety, just try an accident".

[220mph]

At the risk of grossly oversimplifying a complicated situation, it would seem we need to get away from the current "train to fly the instruments" and get back to "train to fly the aircraft"

Automation is without doubt our friend, but apparently only to a point.

We must perform a risk assessment, do the benefits of automation outweigh the risks? I think that answer is a clear yes - the balance of positives far outweighs the few negative results as here.

Normally a rational risk assessment would say Asiana 214 is an anomaly, certainly necessary to review and consider, but one incident should not outweigh years of safe ops.

But the Asiana failure was so massive and complete - the complete failure to simply fly the aircraft in CAVU conditions and with a full flight deck of allegedly experienced pilots - that the level of the failure was so basic it shocks our belief. And escalates the importance in any risk assessment exponentially.

It seems a conundrum.

Do we require more hand flying, without automatic aids, which may slightly reduce safety in the short term, but likely increase safety in the long term. Do we require a bunch of hand flying time in the sims to try and train out the automation reliance? Do we take away some of the automation altogether - reduce the complexity - in the interests of safety?

Do we FURTHER automate, attempt to "tech" away the problem? Do we require "certification" to fly into major and/or "difficult" airports? Do we require all pilots be trained and certified in a unrelated stand alone program outside the company? Do we require one pilot to wear a hat that says "I'm in charge" so there is no uncertainty?

Some of these are obviously silly. But they reflect the complexity and importance of the issue.

The failure was at the most basic simple level. The solution seems anything but.

It seems to me there absolutely IS a cultural issue. Crew hierarchy and the tendency to train (and/or learn) by rote repetition and memorization. And this must be addressed.

But the automation "trap" seems to transcend that - we are beginning to see indications this fault could affect all of the system. And that would seem to be the bigger elephant in the room.

To me a couple short term changes might be a help in at least identifying weak competency at hand flying, and removing company/culture bias.

What if certification was required to be completed by independent authorized arms length organizations? And what if every certification required a hand flown, no instrument/automation, approach and landing, preferably in the aircraft?

[douglasheld]

What good is adding a new certification?

These people already have ATPLs and type ratings. Something is broken, but documentation/examination/sign-off is not it.

In my unprofessional opinion, the man-machine interface has failed in this instance. That is something more valuable to look into.

[Schnowzer]

At the risk of grossly oversimplifying a complicated situation, it would seem we need to get away from the current "train to fly the instruments" and get back to "train to fly the aircraft"

There in lies the rub, many airlines just teach following FDs. Putting a box on a cross is not training to fly anything! My view is that some airlines make flying an "internal" task flown in the confines of the cockpit, satisfying a computer without any seeming reference to the outside world!

[RAT 5]

I hope we can do away with these push button pilots so we can go back to where we were.

In the hope that the XAA's and the training departments take the initiative in this matter, before more smoking holes, we could be seeing "Back to the Future 3." Let's hope so.

[PAXboy]

bubbers44The Asiana pilots are probably now paranoid of another crash but they aren't better pilots because of it. True. BUT the airline is probably a better airline because of it.

It is oft been said that an airline is at it's safest immediately following a prang. Every other member of staff - in all capacities - is watching out more closely than before.

[CodyBlade]

"WOW! Asiana must REALLY be serious about changing their corporate culture and reputation, to hire a Japanese guy as VP Safety!"

I agree, this is getting serious.

[AirRabbit]

training one’s own crew members does not result in direct income … it only costs.

What nonsense! "If you can't afford safety, just try an accident".

We hear that a lot … but the fact of the matter is simply that if an airline suffers an accident but is adequately insured, and they can even muddy the waters to the extent that it “looks” like they’ve complied with all the “requirements” - OR - if they can show that they've met all the regulatory requirements, there is a better-than-even chance that it will be the INSURANCE COMPANY that picks up the so-called costs – and in some cases, the airline actually makes money(!) … besides, the “absence of cost” is not immediately recognized as “income” no matter what the details happen to be.

220mph – you’ve pretty well outlined the levels (plural) of frustration that most feel when actually looking and, specifically, understanding the problems (again, plural) that we face on a regular basis. The point I’ve been making is that whatever the ultimate solutions are determined to be … unless either the owners/managers of each airline voluntarily go along with those solutions (and you tell me the chances of that happening) …OR … the regulatory authority understands the problems and the issues … and makes the decided-upon solutions part of the minimum, regulatory requirements … those solutions are not likely to be incorporated into very many, if any, airline training programs.

In the hope that the XAA's and the training departments take the initiative in this matter, before more smoking holes, we could be seeing "Back to the Future 3." Let's hope so.
From your lips to God’s ear! … but if I were a betting person … I wouldn’t be putting my money on the “airline training departments” without the swift kick in the posterior that a regulatory requirement would deliver.

[maDJam]

LiveLeak.com - Asiana Airlines Fire Crew did run Ye Meng Yuan over

:mad:

[Jet Jockey A4]

So sad!

I feel terribly bad for all involved in this ground tragedy.

Perhaps in the future some sort of ground markers, like bright flags could be installed near a body whether alive or dead to avoid this situation.

[deSitter]

Just unbelievable incompetence.

Ground markers? How about, let's move this person to a safe area instead of over-reacting and freaking out..

[lurker999]

that's really really poor. no excuses for that at all. there has to be better triage than a 3 sec visual.

no help to the parents, but surely the court case is just a matter of how many $ they get.

[Jet Jockey A4]

Call it what you want but it is still a tragedy for all involved.

I'm sure the two drivers involved feel more than terrible about what happened. It is something they are going to live with for the rest of their lives.

In any case I agree with you that the little girl's body should have been moved out of the way and put in a better and safer location as to avoid this tragedy.

I also think that more care should have been taken in checking her out to see if she was indeed alive.

My comment/suggestion about ground markers was a means to facilitate the location of bodies (whether alive or dead) just in case it was SOP for a Fire department's post crash investigation not unlike a police investigation at a crime scene where nothing is moved.

Hopefully a full review by the SFFD and other agencies will bring about changes to their SOP as to avoid this in the future.

[doyll]

I always try to keep in mind this kind of information is coming for the news media... many of which put a good story and ratings above truth. :=

If, in fact, the the edited video shown in this new broadcast is accurate there are many people people besides the drivers who dropped the ball and will be asking themselves why they didn't check her out, move her, etc. for the rest of their lives.

[maDJam]

agree with doyll that media do inflate the story to get higher ratings- they did mention the fireman had a "50 minute video" and the other camera on the firetruck probably had more- so it's the B-roll (extra footage) that we'd love to see to truly pass judgement on this tragedy.

Also in the new report was a mention of the family we're provided with the footage, so someone in the fire department felt sympathetic enough to give them the video in the first place- food for thought

[Chu Chu]

Other problem with flags is that "bodies" that aren't dead sometimes move . . .

[Tomspur]

This is truly horrendous. If, as doyll mentions what we can see from the footage that we did get to see is accurate, then there are no excuses for this gross incompetence. I was under the impression off the bat that the girl must have been covered in foam, that's why she wasn't seen and run over......

This is truly horrific, either way!

[Big Pistons Forever]

The "gross incompetence" happened on the flight deck when a whole crew conclusively demonstrated they could not get the airplane to the end of the runway without crashing on a CLEAR day !

Responding to a burning crash will by definition be an exercise in chaos management requiring making decisions in a hurry with limited information. Those examining the first responders will have months or years to analyse a situation that the people on scene had to deal with in real time.

At the end of the day faults may be found and hopefully lessons learned whcih will allow other first responders to deal with horror of a major airfield crash.

But there IMO are no lessons to be learned when looking at the actions of the flight crew just a sad manifestation of utter incompetence at the most basic flying skills.

[Tomspur]

I absolutely agree with you but my statement had nothing to do with the actual flight accident even though it is what lead to this travesty playing out in the first place.
If and this is a BIG if we can assume the footage from the helmet cam is an accurate depiction of the events then only gross incompetence caused TWO trucks to drive over this poor girl.

It is a BIG IF, I know

[Not-a_Pilot]

Of course it is tragic. The whole incident was tragic. And while I really feel for the girl's family, it seems inappropriate to immediately want to crucify the rescuers.

The rescuers in any situation put their lives in danger to mitigate the effects of mistakes made by others.

I've never worked as a resucer, but have been caught up in some motor-vehicle incidents that happened right in front of me. The level of chaos when multiple vehicles and casualties are involved is difficult to comprehend until one has experienced it first hand. When you're faced with a burning aircraft and bodies and walking wounded all over the place, the chaos must be exponentially greater.

If there are more than 50 mins of video, what is shown about the incident in the bits that landed on the cutting-room floor?
If the video was released by the family, or someone sympathetic to the family, is it possible that the edited version posted above paints an unfairly critical picture of how the rescuers responded?
Has anyone determined whether or not the injuries the girl sustained in the place crash were survivable?
Does slamming the rescuers with a lawsuit really achieve anything other than making them second-guess themselves in future?
Given the current cost-cutting trend in organisational management, how much will have to be spent on legal fees and insurance that could have been better spent on training?

Just a few thoughts...

[Load Toad]

It is tragic, it was a dangerous and chaotic, evolving, volatile situation - I'm not looking to apportion blame.

However - the reason given for running over the injured girl before was that fire fighting foam was covering her....

Which - wasn't there in the edited video shown.

[KiloMikePapa]

1 The girl was located before she was covered with foam
2 The girl was wrongly assumed to be dead after a 3 sec (!) evaluation
3 The girl was not moved into a safe zone
4 Firefighter command was not informed in time about the girl

Asiana crash video: 'Firefighters saw the 16-year-old girl before she was run over' - Americas - World - The Independent (http://www.independent.co.uk/news/world/americas/asiana-crash-video-firefighters-saw-the-16yearold-girl-before-she-was-run-over-9061476.html)

These firefighters are trained and paid to act professionally as most of us are - did they?

Put yourself in place of the parents/friends/relatives? How would you feel about this?

[barit1]

Doctors take an oath that begins "First, Do no harm..." In this case, a clear risk of harm was identified early on, was it not? :ugh:

[Lonewolf_50]

barit, how can you harm someone who is already dead?
Part of this seems to involve a belief "she's dead" when she wasn't ... and of course, I don't see the point in running over a dead body if one does not have to, different issue altogether ...

[deSitter]

You have to understand the psychology of "first responders" - like it or not, many are drawn to the profession by the prospect of calamity and the excitement of dire emergency. That's probably as it should be. But in modern times, this I think has become pathological. It's directly responsible for the catastrophic loss of life among firefighters on 9/11. And in this case, you have a contingent of folks who mostly are bored senseless because aviation is so safe, and then they are called into action and fail completely. This is a systemic problem across police and firefighting forces everywhere. It needs to be addressed.

[West Coast]

Quick germination process there de sitter. You offer an opinion based on nothing you choose to post, then conclude there's a systemic problem that needs addressing.

Why do we even need the NTSB and other investigative bodies? Send the data to pprune and you'll have an answer in hours.

[deSitter]

This is truly horrendous. If, as doyll mentions what we can see from the footage that we did get to see is accurate, then there are no excuses for this gross incompetence. I was under the impression off the bat that the girl must have been covered in foam, that's why she wasn't seen and run over......


A PPRUNE member here pointed out the actual scenario within days of the crash, by analyzing HD video of the crash scene. He was pretty much ignored. I was excoriated by another member for agreeing with him in perhaps more direct terms. The SFPD made many statements absolving themselves of blame, or putting it into the "mistakes were made" category. It's a trend - cops beat a homeless guy to death or kill an unarmed bystander and are routinely exonerated. "Mistakes were made." If we want mistakes not to be made, then we have to start by being honest. Fewer heroes, more professionals.

[glad rag]

The rescuers in any situation put their lives in danger to mitigate the effects of mistakes made by others.



is that why they are shouting at each other [as evidenced on the video] "if there's any in there, don't go in, there already dead"

Really, who checked??

?

No further comment req'd.

[deSitter]

220mph's analysis

http://www.pprune.org/safety-crm-qa-emergency-response-planning/520419-asiana-crash-investigation-5.html#post8001903

http://www.pprune.org/rumours-news/518568-asiana-flight-crash-san-francisco-118.html#post7951724

[wiggy]

I saw the Carry No News piece on this a few hours back, a bit of a lawyer fest to be honest. I'm sure the first responders were trying to do the best they could.....is the idea that "carp happens, we really will learn from this" an outmoded mindset?

[TheBigD]

I'm sure the NTSB will determine that non-standard American R/T was the culprit.......

[grounded27]

Well none of those four bullet points listed above, unfortunately, lists investigating if gung-ho fire truck drivers ran over and killed survivors from the accident, so I presume that's been airbrushed out.

Sacrifice the few to save the many!

[Piltdown Man]

This Fire Department, like every other, needs as much help as we can can give. One thing they don't need it litigation. This robs the system of cash, drives pathetic managers to hide evidence or force non-collection and will serve no one, except for the filthy lawyers.

[tdracer]

The news report that I saw implied that the video was provided by the victim's family lawyer(s). If true, I'm confident the video has been professionally edited to make the first responders look as bad as humanly possible. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/censored.gif

I have little doubt that the victims family will see little of any resultant settlement, the lions share will go to the lawyers and their minions. :ugh:

[Yankee Whisky]

bamboo

if the pilot allowed the copilot to fly plane too slowly for safety, is it the copilot's fault?

or is it the captain's fault?

so too with any aircraft system...if the pilot allows the autothrottles to maintain speed, but the authothrottles do not maintain speed, who is at fault?

and if the pilot has asked the autothrottles to maintain speed incorrectly, who is at fault?




THERE ARE TWO PILOTS. CROSS CHECKS (DOUBLE AND TRIPPLE) AVERT THINGS GOING OFF THE RAILS !

[bubbers44]

Obviously all three pilots were at fault and none should be absolved of responsibility for properly piloting their aircraft. The FO should have known how to do a visual, the captain should have monitored and the check aiman should have been a check airman, not an observer.

[jimjim1]

@bubbers44
The FO should have known how to do a visual, the captain should have monitored and the check airman should have been a check airman

My memory of reports says that the Trainee Captain was in the left hand seat, the Training Captain was in the RH seat and the FO was in the seat behind.

I have never been much of a pilot but that arrangement was a surprise to me. For some reason I had assumed that the Training Captain would have been behind instructing on Captainy bits with the normal crew at the controls. They can already fly?

Well apparently not;-)

[Capn Bloggs]

Jim Jim, until/unless you can actually do this stuff yourself, I'd go easy on the criticism.

That arrangement is quite normal where I operate.

[belfrybat]

Even if she was dead, would it be acceptable to further mutilate the body by repeatedly running it over? Shouldn't they have placed a marker by her?

[WHBM]

What I can't get my head around is the attitude from those in the posts above from the accident nation, which is unbridled criticism for the aircrew involved, and yet the complete opposite, every justification and platitude imaginable for the fire truck crew.

[Jet Jockey A4]

Although I somewhat agree with you, there is a major difference between the two accidents.

- The pilots have continuous training on how to perform their duties.

- The pilots work in a very controlled environment. They have their airline
behind them to help out on various phases of flight. In other words they
are well supervised or surrounded in their duties.

- The pilots have specific SOPs.

- The pilots should be able to complete a visual approach to an airport with
VFR conditions.

- Not sure the firemen get as much training as pilots.

- Not sure if the SFFD as SOPs.

- Not so sure Firemen are well supervised or surrounded in their duties.

[Cows getting bigger]

Society expects pilots to perform professionally using clearly defined procedures together with their knowledge and experience in order to protect their charges. Failure to do so rightly results in investigation.

Exactly the same applies to the emergency services.

[Jet Jockey A4]

I can agreed with your statement.

[TeachMe]

SOPs may have their validity in a standard situation, such as landing a plane, but are in many ways useless in an accident situation where every accident situation is VERY unique. I do not mean that emergency responders have no plans for potential situations, but that those plans can only help to do things better and not train how to do it perfectly based on having face that exact situation before.

Hypothetical situation based on mental calculations and incomplete knowledge: Would you move one person far away from a burning aircraft for fear of a 10% chance of being run over by a fire truck and thus allow for another person's risk of burning to death on the plane to increase from 10% to 50%?

TME

[ThreeThreeMike]

What I can't get my head around is the attitude from those in the posts above from the accident nation, which is unbridled criticism for the aircrew involved, and yet the complete opposite, every justification and platitude imaginable for the fire truck crew.


WHBM, I have no sympathy for the emergency personnel whatsoever. Their actions are inexcusable.



1 The girl was located before she was covered with foam
2 The girl was wrongly assumed to be dead after a 3 sec (!) evaluation
3 The girl was not moved into a safe zone
4 Firefighter command was not informed in time about the girl

Asiana crash video: 'Firefighters saw the 16-year-old girl before she was run over' - Americas - World - The Independent (http://www.independent.co.uk/news/world/americas/asiana-crash-video-firefighters-saw-the-16yearold-girl-before-she-was-run-over-9061476.html)

These firefighters are trained and paid to act professionally as most of us are - did they?

Put yourself in place of the parents/friends/relatives? How would you feel about this?

From the article linked by KMP:

In light of the new footage being released, this has prompted Ye Meng's parents to file a claim against the city and county of San Francisco, claiming that emergency responders “were grossly negligent” in their work.

The family's attorney detailed the reasons for the claim, saying that the emergency workers had: “failed to move her to a safe location, failed to mark her location; failed to protect her from moving vehicles in the vicinity of the Aircraft where it was known that vehicles would be traveling; failed to alert commanders at the scene; and/or abandoned Ye Meng Yuan in a perilous location.”

I can't argue with anything the attorney stated. It's difficult to understand why the girl was ignored. The firefighters were dealing with an empty aircraft, and they had sufficient equipment to easily extinguish the fire.

Why didn't one of the EMS responders attend to the girl? There weren't overwhelming numbers of significant injuries to other passengers, and it appears there were many EMS personnel on scene.

I would like to know how the coroner determined the girl was still alive when she was run over. I'm assuming she had some visible and significant injuries, and thus when someone checked to see if she was alive they quickly determined she was already dead.

More details about the "three second" assessment would be informative. I have seen more than one body at a fatality accident that didn't take more than three seconds to confirm the person had expired, but in this case there isn't enough detail to comment about that.

[glad rag]

What I can't get my head around is the attitude from those in the posts above from the accident nation, which is unbridled criticism for the aircrew involved, and yet the complete opposite, every justification and platitude imaginable for the fire truck crew.

I didn't want to put it quite so bluntly; having been singled out for abuse and stalking across different threads previously [nice one mods, btw] by the usual 'cousins' and having learnt a painful lesson about ppru as it is today.

Ho-Hum-Tally-Ho!

:)

[bungacengkeh]

WHBM

Join Date: Oct 2002
Location: London UK
Posts: 4,704
What I can't get my head around is the attitude from those in the posts above from the accident nation, which is unbridled criticism for the aircrew involved, and yet the complete opposite, every justification and platitude imaginable for the fire truck crew.


WTH, ppruners at their very best! Is there such a word called hypocrisy or overt " white shadowism "?

[bungacengkeh]

- Not sure the firemen get as much training as pilots.

Belive me, FIREMEN GET MUCH, MUCH MORE TRAINING THAN PILOTS in their respective roles!

[doyll]

Huge difference between flight crew and fire crew.

Flight crew were flying a fully functional plane with no problems except the ones they created by their inability to safely fly and land. Something any pilot with a license should be able to safely do on he day in question.

Fire crew were responding to a crash trying to put out fire and save lives. Has SFPD ever responded to anything similar to this crash?

No defending them. Just trying show a little perspective here.

[bubbers44]

The fire crew wouldn't have even been there if the pilots hadn't totally screwed up an easy visual approach on a clear day. The fire crew didn't put the body in harms way, the pilots did.

[awblain]

The thing to note is that I believe this footage was taken when the trucks were tackling the resurgent fire, after the evacuation was long over.

Did the truck crew know that? Did their chief? Did anyone?

It really doesn't appear to be a case of them arriving at full speed to potentially save hundreds of lives, and getting mixed up with some runners in smoke and chaos, leading to an unfortunate casualty: it looks like a case of driving about gently, with guides on foot, many minutes later.

It also doesn't look like a random city fire truck turning up to help, and being out of its trained comfort zone, since it looks like it had a huge foam monitor on the front.

There's been blood…
Now there will be lawyers…

[lomapaseo]

There's been blood…
Now there will be lawyers…

But they do little to come up with corrective actions that are practical.

[lurker999]

And yet bubbers is prepared to let the SWA pilots off, with a "we all make mistakes". The SWA pilots were very very lucky not to dump their 737 into a ravine due to an error that rivals the magnitude of the asiana pilots error.

And mate. Just becuase someone stuffs up doesn't give carte blanche for everyone else following to just callously disregard human life.

[awblain]

Quite so, Lomapaseo. Making practical improvements isn't really lawyers' role - it's getting piles of cash for their clients. If that motivates the former owners' of the money to make practical and sensible changes, then that's an improvement. Unfortunately, those changes often tend to be impractical and cosmetic - to reduce the future impact of lawyers, rather than accidents.

[PBY]

The SWA pilots made a decision or call it a information error. But they did not display a complete inability to fly an aircraft.

[glendalegoon]

Lurker

you are right the southwest pilots were lucky they didn't fall off into a ravine.

and the asiana pilots were not lucky that they crashed their plane.

maybe it is luck.

But sometimes it is luck. And sometimes it is your priorities in flying.

Long ago someone came up with:

Aviate

Navigate

Communicate


The Asiana crew didn't aviate well.

the southwest crew didn't navigate well.

[Agnostique75]

The inventor of the "competent all-american mistake made in good faith", Bubbers44, in his relentless fight against -foreign- incompetence, remarked that " The fire crew didn't put the body in harms way, the pilots did."

Pushing this logic “ad absurdum”, shouldn’t the parents of this hapless girl be designated as the ultimate culprits? Had they not conceived her… etc…

More seriously, we all recognise that in life-threatening emergency situations, potentially bad things can and do happen. I certainly don’t suggest that rescuers should be systematically thrown under the bus when overlooking certain aspects related to an emergency. But potential shortcomings should be analysed and lessons learned from them.

What I find disturbing in the case of the Asiana crash is the level of denial that has from the start surrounded the performance of the SFO’s fire department. And all the publicly available evidence (witness testimony, CCTV recordings, helmet-mounted camera footage) suggests that that performance was less-than-stellar. This is probably where the real issue lies.

Again, as I pointed out (http://www.pprune.org/safety-crm-qa-emergency-response-planning/520419-asiana-crash-investigation-5.html#post8000549) previously, the first reaction of Chief Joanne Hayes-White was to ban helmet-mounted cameras and take disciplinary action against the Battalion Chief wearing it. The footage recorded by the BC is precisely today a central element of the NTSB’s enquiry and Ms Hayes-White’s reaction amounted to a desire to supress critical evidence, a most unwelcome attitude for any emergency professional.

However, I am certain that under the rather firm and uncompromising leadership of Deborah Hersman, the NTSB will take a long, hard and fair look at the overall performance of the SFO’s fire department. And that’s how it should be.

[glendalegoon]

agnostique 75

bubbers 44 has an on going fight against incompetence, but I would not say it is against foreign incompetence.


San Francisco fire fighters are among the very best in the world. They have a tradition that only is rivaled in America by the Chicago fire department.

IF THIS WERE A FIREFIGHTERS forum instead of a forum for professional pilots you might feel more at home.

[Agnostique75]

Glendalegoon,

I’m certain that Bubbers44 is able to take as much as he gives and as far as his –not so- rampant xenophobia and his relative indulgence for US "mishaps" are concerned, his track record speaks volumes.

But let’s not get distracted. Together with the performance –or lack thereof- of the flight crew, already much discussed on this forum, the NTSB will also review the performance of the SFO’s fire department. And this seems to be difficult to accept for some members.

Your praise of the “ San Francisco fire fighters (that) are among the very best in the world (and who) have a tradition that only is rivaled (sic) in America by the Chicago fire department” would indeed be most welcome on a firefighters forum, although I believe that many non-San Francisco based American emergency professionals would take issue with such a statement.

But my point is elsewhere. First, the distinction between crew performance and rescue-related performance is only normal. Let me try to explain: If, dead drunk, I smash my car in a tree, this should not constitute an excuse for my garage to repair it poorly.

As I have said over and over again, mistakes happen. What is puzzling is the attitude off the SFO’s fire department Chief. Denial, sanctions taken against a subordinate who –most certainly inadvertently- documented potential shortcomings, a ban on useful forensic tools used by law enforcement professionals around the world, all this smacks more of a desire to cover up an unpleasant reality rather than facing it, analysing it and drawing lessons for the future. And this should be a legitimate concern for all those involved in aviation, crews and passengers alike.

I am convinced the NTSB is not biased against the SOF’s FD and we could may be discuss this issue again once its report is out. And while I would not rule out a tar and feather episode, I will agree with you that this won’t take anything away from the dedication of individual emergency professionals in San Francisco, the US or anywhere else in the world.

At the same time, I hope that you are also prepared to accept that a degree of positive criticism might be part of this report.

[sb_sfo]

You talk about the traditions of SFFD and Chicago FD- I assume you are referencing the Great Chicago Fire of 1871 and SF earthquake of 1906. What do these historical incidents over 100 years old have to do with ARFF in 2013?

You familiar with a water cannon salute? I watched a SFO FD water cannon unit fire foam during a salute in 2012. That doesn't mean that all SFO FD water cannon drivers are incompetent, just that at any one time, someone can fcuk up.

In any case, the command of SFO FD ought to be the issue.

[glendalegoon]

The SF AIRPORT FD/ARFF crews made a mistake while responding to an emergency.

The crew of Asiana made a mistake while conducting the most basic kind of landing.

Asiana had all the time its fuel allowed to make a good landing.

ARFF at SFO had minutes to attempt to help those in trouble.

YES, ARFF/SFO made a huge mistake.

AS to traditions. Being a native born SF I can assure you that we are reminded every year during the ceremonial painting of the golden fire hydrant. And if you don't know what this means, you can look it up yourself.


Sadly, the traditions of ARFF/SF FD fell short.


Even sadder the traditions at Asiana never existed in the first place, at least with regard to the most basic type of landing there is.

[Passenger 389]

From reviewing the documents NTSB has disclosed so far, the teen in question almost certainly: (1) was not wearing her seat belt,(2) was violently ejected from the rear of the plane,(3) was fatally injured before any fire crews reached the scene (although her heart may not yet have ceased beating), and (4) was unconscious and thankfully unaware of the additional injuries inflicted by the fire truck(s).That doesn't excuse errors made during the response, or erase the family's loss, but let's be wary of buying into the "she survived the crash, only to be killed by the fire crew" tale being hyped by certain media (and personal injury lawyers). In all probability the young lady was already near death and would not have survived regardless of what the fire crew did (or did not do).

[awblain]

I had assumed that she'd been assisted out of aircraft and had then been forgotten/abandoned and subsequently run over. If she flew there outside the aircraft, then having made her way forward of the wing, it does imply that her outlook was rather bleaker.

Given the damage to the rear of the aircraft, it's also not completely impossible that she could still have been ejected while wearing a seatbelt. And... being foolishly unsecured in no way justifies a death sentence… do we see a cabin crew as lax as the flight crew?

I have a great deal of sympathy for the general rescue firefighter's position, traveling to the accident at 80mph in a 60 ton truck. They stand with the ability to potentially save hundreds of lives on the very rare occasion they are called, and never see a real live event in training. With time of the essence, road accidents sometimes occur on the way to regular city fires too.

[bubbers44]

I notice the people that post most of the negative views are mostly foreign. The rescue team went out to save lives after an airliner crashed for no reason other than they lacked basic flying skills. US pilots can't be certified to fly until they show basic airmanship skills like doing a visual approach by looking out the window. Why do they have such a problem doing the same in some cases?

[Centaurus]

Why do they have such a problem doing the same in some cases?

Simple answer. It stems right from the time these pilots do their first session in an airline simulator where the total accent is on using the automatic pilot and associated AFDS. Watch most simulator sessions. One of the first actions is to turn on the flight director. It is a good bet the vast majority of pilots first actions after raising the landing gear after take off is to engage the automatics. They were taught in the simulator this is the way to fly an airliner. Same with approach and landing. The last action before touch-down is to dis-engage the automatic pilot.

The above may sound like too much of a generalisation. But it is very close to the truth. This inevitably leads to the situation where hand flying is avoided like the plague. The Boeing 777 Asian crash at SFO is the tip of the iceberg. As a Boeing test pilot once told a colleague about the 787 design. He said "The Boeing 787 was designed on the basis it will be flown by incompetent pilots. Hence the numerous automatic protection systems in place".

[bubbers44]

Centaurus, yes, I thought that might be the reason. Thanks. It is slowly creeping into our US training also for the new hires. Management wants low cost pilots with minimum training costs.

[jugofpropwash]

I think the question most are missing is - how did she end up there in the first place? Given the positioning in front of the wing (and that the other ejected passengers and crew were to the rear of the craft) it seems unlikely she was thrown there in the crash. Presumably the autopsy might shed some light on whether or not she could have escaped down the slide on her own. The third possibility is that someone brought her out and left her there, apparently alone. If that's the case, I suspect the individual is keeping their mouth shut for fear of being sued.

[bubbers44]

Once again the blame shifts to the person, other passenger or crew member who got her out of a crashed plane, and away from who crashed a perfectly good airplane short of a perfectly good runway in ideal weather conditions.

[Passenger 389]

Jugofpropwash,

There appear to have been two occasions when a person could have been ejected from the cabin. One was the initial impact, when the tail section separated and at least two passengers were ejected (and perhaps one or more flight attendants--that detail isn't important for purposes of this particular discussion).

The second occasion was the pirouette or whatever the proper term is for the rotation just before the plane reached its final position (a rotation so extreme some onlookers perceived it as a cartwheel).

The young lady in question probably was ejected during the latter event (although the process of being ejected from the plane could have begun earlier).

It is the most likely explanation for why she was found laying motionless in the dirt by the plane instead of being found near the beginning of the runway (as were some others) or inside the plane.

The description of her injuries and other information in the documents released by the NTSB lend support to that hypothesis.

[givemewings]

On the note of "lax cabin crew" once they have passed through the cabin to sit for landing if the passenger decides to remove their seatbelt there is nothing the cabin crew can do.

I fly on widebodies and I can tell you that on every flight the avalanche of seatbelts unbuckling as the wheels hit is ridiculous. It would not surprise me in the slightest IF it comes out that some people undid their belts shortly after the crew conducted the landing checks. I'll never understand the aversion to something that isn't at all uncomfortable but hey..

This trend is also way more prevalent in some cultures over others in my years of observation.

[Passenger 389]

The three passengers who died include:

"Passenger 42A": This 15 year old was ejected just after the initial impact. She was designated as Passenger 42A, the seat assigned to her. She was seated either in Seat 42A (the belt was found unbuckled) or Seat 42B (that belt was found still buckled). She died six days after the crash.

"Passenger 41B": She was designated Passenger 41B, the seat assigned to her, but had switched seats and was in Seat 41D during the crash landing. "Passenger 41B," seated in Seat 41D, was ejected just after the initial impact and found fatally injured near the beginning of the runway. The belt for Seat 41D was found undamaged and unbuckled.

Several members of the group of Chinese students reported that some group members did not have a seat belt fastened at landing. Passenger 41D (who had switched seats and was in Seat 41B, told investigators she could not see if "Passenger 41B"'s seat belt was fastened because "41B" was covered by a blanket as they were approaching to land.

"Passenger 41E": This is the 16-year old found laying near the plane. Passenger 41G, seated near Seat 41E, told investigators Passenger 41E's seat belt was not buckled during the landing attempt (and 41E's seat belt was found unbuckled and undamaged afterwards).

Passenger 41D (seated in 41B) observed that Seats 41D and 41E were empty after the impact. Passenger 41G also noticed Seats 41D and 41E were empty. All three members of the group seated nearby who were questioned believed the three passengers who died (including Passenger 41E) were ejected from the plane before it came to a halt.

There was extensive damage to seats 41D and 41E. Among other things, the lower portion of the seat backs were broken.

All the foregoing seems consistent with the occupant of Seats 41D and 41E having been ejected from the plane (whether at the initial impact, as with 41D, or during the final violent rotation, with 41E), and not having deplaned via a slide or been helped or carried off the plane.

There is more, including medical and other information, but I'll leave it there. I am not a pilot or engineer, and am relying on documents and video released by the NTSB plus a healthy dose of experience (including attending to people following some fatal accidents) and having done my share of factfinding. I posted this only because some (including the media) seemed to be rushing to assumptions that in my view did not appear warranted, at least based on the information available.

Others better qualified to evaluate the evidence released so far, or privy to additional information, may have a different opinion. And how Passenger 41E came to be in the dirt by the plane does not detract from the need for better training, procedures, and equipment at SFO and elsewhere.

[WHBM]

.... crashed a perfectly good airplane short of a perfectly good runway .....
Such a perfectly good runway that its ILS had been out of action for five weeks, on this main landing runway of a supposedly major international airport, and was apparently intended to be so for the rest of the summer.

[fatbus]

So you need an ILS to land in VMC! Are you a child of the magenta line?

[WhatsaLizad?]

Such a perfectly good runway that its ILS had been out of action for five weeks, on this main landing runway of a supposedly major international airport, and was apparently intended to be so for the rest of the summer.

Their mistake was assuming that major international airline pilots would be using that perfectly good runway, and not supposedly major international airline pilots.

[FlexibleResponse]

Part 2 (why it is likely she was ejected from the moving aircraft)

Passenger 389. Very good post...thank you.

[glendalegoon]

WHBM:


Could you land a plane on a runway without an operating ILS? I mean when you report the airport in sight in VMC 17 miles out? Simple question, yes or no?

I am assuming you are a pilot. Please correct me if I'm wrong.

[WHBM]

The answer is of course yes to both, right back to that First Solo long ago and far away. Just like you.

However, that's not to say that we should therefore now just throw away aids like ILS on the basis that they're somehow not needed. Should the pax not fasten their seatbelts either, on the basis that the crew ought to know how to pull off a greaser ?

In other administrations it would be completely unacceptable for the main landing runway at an international airport to have the ILS out for that number of hours, let alone weeks. SFO has plenty of other runways which could have been cycled into use, and there are plenty of international contractors who could have repositioned that ILS in a small fraction of the time this particular project was taking. I trust the NTSB report will also cover why rearranging the ILS was proceeding at such a snails' pace.

[Desert185]

WHBM

Do we always have an ILS for the weak pilots, or do we always have proficient pilots regardless of ILS availability? There are some runways in the system that just don't have ILS, like PANC's 25R, nor is an ILS necessary for the VMC conditions under which the landing is accomplished. There are days in the profession that require one to be a pilot and not a driver.

I know what my choice would be.

[Jet Jockey A4]

First, I agree with Agnostique75's position of the SFFD on the way things were conducted at the crash scene that day and the way its Chief reacted afterwards.

I think an in depth review either internally and/or from an external agency like the NTSB is required of this accident on the SFFD’s procedures and of its Chief. I believe her reactions and actions after the crash smell some sort of cover up to protect the department.

It doesn’t matter whether the girl actually died from the actual truck running over her or as passenger 389 mentioned (in his posts # 457-464 and 466), she might have been nearly dead with just her heart beating from the actual impact after being ejected from the aircraft. An investigation into the conduct of the SFFD is required. BTW, passenger 389... Excellent posts!

Second, I also agree with bubbers44's position... This accident should have never happened in the first place and most if not all the blame goes to the two pilots flying the aircraft in the final phase of the flight.

If the captain (getting his line indoc) cannot fly a simple visual approach on a clear VFR day, then he has no business being in a cockpit of an airliner or perhaps any aircraft.

Then there is the training/check pilot's role in this crash that needs to be addressed too. How and why did he let this "visual approach" deteriorate to the point where they crashed a perfectly working B777 on a clear VFR day into the seawall? Obviously he did not do his job.

Third, I think it's time for WHBM and others like him to get off their high horses. Those who would like to blame KSFO airport authorities and their controllers for this crash are absurd.

So what if we have a major international airport that's going through major construction and some of its landing aids are not available. One of the inconvenience of this work is they have a NOTAM out that indicates the G/S to the runway will be out of service for several months during the construction... BIG DEAL!

As I recall there is still a localiser approach with PAPI available to that runway (although with higher minimums). What an airline pilot cannot fly a LOC only approach with the aid of a PAPI to a specified runway?

Then there is also a RNAV/GPS approach to that runway available. Please tell me a crew flying a B777 internationally can fly a GPS type approach?!

And then there is the other simple option to fly the darn aircraft visually with the help of the PAPI for vertical guidance to the runway, something I guess neither pilot could do!

Also, it seems the pilot flying the aircraft didn't understand or was confused by the A/T mode he had selected. Again, whose fault is that? Maybe it’s the airline’s training department's fault, maybe it’s the check pilot in the right seat fault? Or maybe as some of you would have us believe, it’s the airport’s fault?

Bottom line here… it’s the crew’s fault. They couldn’t get a perfectly functioning aircraft down to the runway on a clear VFR day without crashing it.

I’ll go further and say, this crew is extremely lucky only 3 people died on their flight (many were seriously injured). Of course this is a very little consolation to all involved in this tragedy.

[porterhouse]

In other administrations it would be completely unacceptable for the main landing runway at an international airport to have the ILS out
You are wrong, it happens in all kinds of "administrations" around the world.

[Cows getting bigger]

Asiana Airlines Crash Passengers Sue Boeing (http://news.sky.com/story/1197540/asiana-airlines-crash-passengers-sue-boeing)

Passengers suing Boeing. :zzz:

[awblain]

Specious, but potentially lucrative with the right jury.

Then again, with Boeing relatively-recently based in Chicago, and a clear boon to the area, a local jury might be able to see behind the money grubbing to appreciate the reality of the situation.

Given the severity of the impact, and yet the excellent survival rate, perhaps the survivors should be paying Boeing.

[mm43]

The suit says that Boeing knew or should have known its 777 passenger jet did not have inadequate auto-throttle control and low airspeed warning systems, according to the Chicago Tribune newspaper.Looks like there is fair bit of "inadequate" knowledge being demonstrated, even if just by the media.:hmm:

[Jet Jockey A4]

LOL... Of course blame it on Boeing!

[glendalegoon]

WHBM

being a pilot means commanding, commanding the plane, atc, crew, passengers everything.

I would wager money that the NOTAM was in force and available 24 hours prior to takeoff from Korea for the pilot to read.

AND if he was worried about hand flying visual approaches, he could have thought about what to do and do it upon arrival at KSFO.

HE could have requested the ILS 28R and landed on that runway, couldn't he?

BUT he didn't.


WHY?

For whatever reason, a routine approach and landing was screwed up badly.

YOU asked about seatbelts and greasers. The seatbelts are there in case something goes wrong. pilots have landed with flight attendants standing in the aisle (this is a mistake of course) and after landing they remained standing. But sometimes things go wrong and that is what seatbelts are for.

WHBM, by the way, San Francisco has 4 pieces of pavement totaling 8 runways.

Winds favored runway 28L and 28R. Which runways would you offer instead? Would you offer 1L and 1R? Crosswind and an approach you can't imagine unless you've circled off of 28 to 1L and 1R. And if you screwed up that one (much harder than straight in to 28s) you would fall upon a major and very busy freeway (101, the bayshore to you SF folk).

Oh, and you could have landed on 10 L/10R with NO ILS and a tailwind.

Or maybe you could land upon 19L and or 19R. NOw a crosswind but probably the ILS would work as well as 28rights ILS.

But 19R/19L are shorter than the 28's.

So, tell us what to do and, here is the big one, why didn't the pilot command the situation?

And telling the NTSB to report the snail's pace of the ILS on 28L is not the cause of the accident.

Look WHBM, asiana screwed up and killed people. They did it with poor handling of the most basic kind. OH and comparing the screw up of the fire department, that would be like the fire trucks not being able to get out of the fire house in terms of basic skills.

[awblain]

Primarily, I suspect, the concept of "losing face".

I'm sure the NTSB will get to the bottom of it, with appropriate cultural sensitivity.

[WHBM]

For whatever reason, a routine approach and landing was screwed up badly.I never said it wasn't. But we should all know here that many accidents have multiple contributing causes.


He could have requested the ILS 28R and landed on that runway, couldn't he?And I hope the NTSB start by asking why it was not offered. They should know that non-precision approaches have an accident ratio, what, 5 times, 10 times precision ones. There was a runway right alongside with all the right kit facing the right way and available. Why wasn't it offered.

And telling the NTSB to report the snail's pace of the ILS on 28L is not the cause of the accident.Well, it's one of the contributing factors. Which is why I would want them to get right into it. The AAIB here in the UK certainly would in such a circumstance.

Look all. An airport with a known history of people getting low/slow on approach and striking the surface of the Bay decides to put one of its principal approach ILS out of service for the whole summer for some unfathomable reason. Then they don't offer the adjacent parallel runway for landings to a crew 8 hours out of their time zone. Then they have an accident. Then the fire trucks drive over a survivor, and all sorts of excuses are offered why this is not significant. The local TV news stations make ludicrous xenophobic joke reports about it. Pilots from the locality all post that they're such Hot-Shots that this could never happen to them (despite a somewhat similar accident in Alabama shortly afterwards). There's just a whole "couldn't care less" culture evident here.

[glendalegoon]

WHBM: Why wasn't the ILS 28R offered? Because it is considered normal in our business to offer the easiest, most fuel efficent approach. The visual approach. OH and the visual approach is not a non precision approach.

I asked you , WHBM, why didn't the pilot ask for 28R if he could not handle a visual approach?

HE had hours to plan his approach into KSFO.

He could have told ATC he did not have the airport in sight. But he didn't.

IN this country a student pilot can advise ATC he is unfamiliar or a student pilot and he will get extra attention.

The NTSB has also released information that the pilot was holding 80lbs of back pressure on the controls. IS there any reason in NORMAL flying to hold 80lbs of control pressure? (no of course).

At my airline getting below Vref is worthy of a callout by the non flying pilot.

Being over 30 knots below Vref is worthy of much more action.

[bubbers44]

And I hope the NTSB start by asking why it was not offered. They should know that non-precision approaches have an accident ratio, what, 5 times, 10 times precision ones. There was a runway right alongside with all the right kit facing the right way and available. Why wasn't it offered?

They must not have known the Asiana crew was incompetent to do a visual approach on a clear day like everybody else that flies there.

[A Squared]

Y'know, WHBM, it's starting to get pretty old listening you try to hammer the "Americans are bigoted xenophobes" square peg into a round hole. Particularly the way you reaaaaaaaalyy stretch reality to try to support your view.

They should know that non-precision approaches have an accident ratio, what, 5 times, 10 times precision ones.

Right. That wouldn't surprise me one bit. Lets assume that the figures you quote you are 100% accurate. Cool? OK, now that is for Instrument approaches". The relevant statistic for this situation is what is the accident rate for visual approaches in CAVU daylight conditions to runways with precision approach, vs accident rates for visual approaches in CAVU daylight conditions to runways which do not have precision approaches. SO if you have that statistic and can substantiate it, by all meas post it. but posting instrumet approach statistics is completely irrelevant as this was not an instrument approach.

The local TV news stations make ludicrous xenophobic joke reports about it.

Actually, the TV station was unknowingly drawn in by someone else's prank, a prank they didn't catch. Are you ignorant of what really happened or are you intentionally misrepresenting it?



Pilots from the locality all post that they're such Hot-Shots that this could never happen to them (despite a somewhat similar accident in Alabama shortly afterwards). There's just a whole "couldn't care less" culture evident here.

Ahhh yes the same tired old " The Birmingham accident was exactly like the Asiana accident" tripe. Except that it wasn't exactly like it. In fact it wasn't anything like it, not even a little bit. At Birmingham, the crew struck terrain they couldn't see, at night. The Asiana crew, in virtually perfect visual conditions, lost control of their aircraft, failed to hit a runway they could see clearly, and hit water and terrain short of and below the runway, the same runway which could be clearly seen in their windshield. No matter how desperately you want those accidents to be the same, they really are not. Not in any rational analysis. About the only similarities were that they occurred while large airliners were in the landing phase. Similarities end there.

[olasek]

Originally Posted by WHBM
And I hope the NTSB start by asking why it was not offered. Either you are non pilot or you forgot how ATC works. ATC has no way of knowing that a particular crew has some serious deficiencies in their training and can't execute the simplest visual approach, it is incumbent upon the crew to request an approach they are qualified to perform based on the equipment aboard and their competency level.

[Alexander de Meerkat]

Astonishing article on the CNN website -

Pilot concerned about landing Asiana jet before crash - CNN.com (http://edition.cnn.com/2013/12/11/us/ntsb-hearing-asiana-flight-214/index.html)

Apparently the pilot was worried about performing a visual approach - just who you want in charge of a jet airliner!

[porterhouse]

Some are forgetting here that there is a magic simple word a pilot can always utter to a controller: Unable.

[edmundronald]

Presumably if you say "unable" on a "simple" approach, with a check captain next to you, there goes your career. It would be interesting to know whether other crews requested runway changes during this period without ILS.

[bubbers44]

Unfortunately saying you are unable to do a visual on a clear day tells all the other pilots and ATC that your airline training doesn't meet standards but you want to couple up so the automation can fix your incompetence.

Pride would prevent saying unable I would think.

[edmundronald]

Bubbers44

It would be interesting to know whether other crews requested runway changes during this period without ILS. Maybe will to live outweighed pride for some.

[misd-agin]

Almost every a/c flying today can build an FMC glideslope(VTI)('poor man's glideslope')(VTK error) overlay into any airport. Add in a VASI/PAPI and it's basic flying.


Expressing concern about a non-precision approach with visual glide path assistance (VASI/PAPI) shouldn't be an issue, especially on a CAFB day.

[Emma Royds]

If cultural barriers prevented the relief crew member and the trainee to call 'Go Around', then no amount of remedial training can change the culture of a nation.

Expect to see more expats on Korean registered airframes and much to the dismay of the Koreans.

[bubbers44]

Having done hundreds of approaches to 28L never felt I was giving up a will to live to do a simple visual approach with no glide slope. Amazingly we never got low once and always touched down beyond the threshold with no risk of life. No pilot I have ever met has either. Why did you say that?

[glendalegoon]

First off Edmundronald, I would think NO ONE requested an ILS on a day that was so nice. I don't think anyone requested an ILS for weeks during periods of daylight in good wx. Second I would tell any checkairman that I was going to do an ILS if I wanted it and they couldn't not deny my judgement.

bubbers, if I was so worried about pride, I would tell ATC that we had to do an ILS to check some equipment. Yes, its sort of lame but it would work.

Being UNABLE to do a visual approach means you don't have the airport in sight or are unsure in some way.

In no method of teaching flying would I teach someone how to couple an ILS without being sure they couldn't fly a visual approach in broad daylight. They would also have to demonstrate hands off trim in landing configuration on target speed.

I think the mods should lock this and call it a day. IN a year or so we will hear the final reports.

[bubbers44]

I agree. Enough is enough. We all know what happened and the official report will come out eventually.

[WHBM]

I'd be disappointed to have a thread closed just because it has documented inconvenient truths. There are a range of issues and it will be good to see the enquiry address each and every one.

I want to know, if dispatch with an unserviceable ILS on the aircraft is not allowed by the MEL, why is dispatch with the ILS unserviceable on the anticipated landing runway allowed.

Thank you to those who have sent encouraging PMs.

[porterhouse]

why is dispatch with the ILS unserviceable on the anticipated landing runway allowed.
Because it is allowed, you presented yourself here as a pilot but your line of questioning smacks of someone who has little clue. Passenger/cargo aircraft do routinely fly on scheduled trips around the world to airports where no ILS is present, I mean not only a single runway has no ILS but the whole airport never had one, nor there is any other precision approach offered. Try to grasp this concept.

[barit1]

The difference in ILS ground vs. aircraft hardware is pretty evident if you think in terms of a typical airline flight.

On board the aircraft, having no ILS puts you in a sorry state if both primary and alternate airfields are IMC.

But if one runway's ILS is out, there will be a multitude of Plan B's - Either other runways at the destination, or at the declared and undeclared alternates.

[A Squared]

why is dispatch with the ILS unserviceable on the anticipated landing runway allowed.


Seriously???? Are you seriously suggesting that dispatching to an airport with no ILS (operative) should be prohibited?

[West Coast]

You can physically drag the localizer and glide slope shacks to the dump and I can still fly the ILS approach. Why would I cancel a flight for that? I can take a NPA to the airport and turn it into a precision approach if needed.
Makes no sense to tie an inop NAVAID in general terms to dispatch. There are likely exceptions to this, but the mindset shouldn't be to cancel a flight because the ILS is out.

[WHBM]

Because Passenger/cargo aircraft do routinely fly on scheduled trips around the world to airports where no ILS is present, I mean not only a single runway has no ILS but the whole airport never had one, nor there is any other precision approach offered.
I'm aware of all that, of course, and you haven't got the gist of my question. If the ILS had been u/s on this aircraft in Seoul, no go. But why then go when the known landing runway at SFO had none.