NTSB update on Asiana 214
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Not to put too fine a point on it:
Almost. It was an Aeronca Champion, now preserved at the Armstrong Museum in Wapakoneta, OH. (Emphasis is on syllables 1 & 4)
I do recall reading that the first man on the moon first learned to fly in a piper cub...
Last edited by barit1; 12th Dec 2013 at 22:46.
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Lee Kang Kuk has an awesome name - even better than the prank name from TV. "Kuk" is a very rude word in Swedish. Very.
Lee Kang-kook
Lee Kang-kook, Pilot Of Crashed Plane, Was Making His Maiden Flight To San Francisco (VIDEO/PHOTOS)
Lee Kang-gook
Pilot in deadly crash had no experience landing 777 in San Francisco - CNN.com
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Yes Individual (airlines) training departments should enforce those standards. But today this is still utopia land we all agree....
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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.
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:
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.
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):
And finally, as promised, returning to Capt. Lee:
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!
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.
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."
...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
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.
Document 12 Other Pertinent Forms and Reports - 6120.1 Filing Date September 16, 2013 11 page(s) of Image (PDF or TIFF) 0 Photos
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.
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.
...
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.
Originally Posted by Accident flight check Captain (PNF)
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.
...
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.
Originally Posted by Accident flight PF
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”.
...
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”.
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!
Last edited by DozyWannabe; 13th Dec 2013 at 01:23.
Modest Hand Flying and Visual Approach Screening Proposal
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
You can even give him a 5000' tow
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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.
The new way of teaching automation first as we can see is not working very well.
@ dozywannabe
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.
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.
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.
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.
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There was no discussion of building a constant descent profile for guidance on the PFD.
That should have been covered in training ad nauseum!
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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?
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?
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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.
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.
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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.”
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.”
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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
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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...
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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?
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?