NTSB update on Asiana 214
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Mr. Snuggles of Sweden calls us back to the subject; with that charming phrase "faceplant" (trouble with ATPL's performing a faceplant is that so many people are sitting behind them)
What is this thread really about? It is neatly sumarised by Piltdown Man, who reminds us that modern jets are designed by westerners to be flown by westerners who speak English. We must not be too squeamish to recognise the problems set up by cultural values not shared. In Russia basic instruments read the other way round, so undertrained pilots on a basic go around thought the 737 instruments were telling them lies..... Korean and Turkish co-pilots saw the airspeed decay, but did not forcefully insist on a go-around....
We cannot say that unassertive junior pilots are exclusively a third world problem. Tenerife was initially blamed on Spanish ATC, but the Dutch Captain ignored the feeble protests of his first officer.
Was it in Indonesia where Adam's fond mother bought an airline for her son, equipping it with the latest shiny new airplanes? For nightmare bedtime reading, look up the story of Adam Air on Wickipedia!
We moan about the FAA and the CAA, but I for one am very glad that somebody is minding the industry in English speaking civilisations.
What is this thread really about? It is neatly sumarised by Piltdown Man, who reminds us that modern jets are designed by westerners to be flown by westerners who speak English. We must not be too squeamish to recognise the problems set up by cultural values not shared. In Russia basic instruments read the other way round, so undertrained pilots on a basic go around thought the 737 instruments were telling them lies..... Korean and Turkish co-pilots saw the airspeed decay, but did not forcefully insist on a go-around....
We cannot say that unassertive junior pilots are exclusively a third world problem. Tenerife was initially blamed on Spanish ATC, but the Dutch Captain ignored the feeble protests of his first officer.
Was it in Indonesia where Adam's fond mother bought an airline for her son, equipping it with the latest shiny new airplanes? For nightmare bedtime reading, look up the story of Adam Air on Wickipedia!
We moan about the FAA and the CAA, but I for one am very glad that somebody is minding the industry in English speaking civilisations.
Good points Mary, but I believe we've also had a UK reg stalling on the approach, fortunately the go round was called early enough to avoid the ground!
In fact IIRC the go round was called at the stickshaker and the aircraft stalled during the go round.
In fact IIRC the go round was called at the stickshaker and the aircraft stalled during the go round.
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modern jets are designed by westerners to be flown by westerners who speak English
Russians use metric system and a different artificial horizon - so we see accidents when they are placed in a Western (Anglo-American) airplane where everything is strange to them (with feet, knots, inches and a reversed artificial horizon). It is known that in an emergency it is often the thing we are taught FIRST that kicks into action. So a Russian pilot facing a difficulty will probably revert to the old Russian logic built airplane.
This does not mean that the Russian pilot is worse. It does not mean that the Western plane is bad. It just means that a Western plane are built for another mindset than the Russian.
In the case of the Asian carriers and their accident rates I am thinking of a radical solution. Maybe you will flame me to death because of it, but here goes...
I believe that there is nothing wrong with Asian (in this context I am referring to Singapore, China, Korea, Taiwan, Indonesia) views on loss of life and airplane accidents. I truly believe that they are just as devastated as anyone. What we do know is that their culture is based on another logic than the Western. Any attempts to eradicate this would not just be immoral (in my belief it is not OK to remove anyone's culture and traditions) but also take a very long time.
The easier way to do this is to honour their culture and design the aircraft systems and CRMs to accommodate for the differences in culture. This would need an open mind from the aircraft manufacturers and a close collaboration with Asian carriers as to what their needs are and how their culture works and how to "work around" the things that have contributed to accidents in the past.
I remember reading about a Korean cargo B747 that nosedived into a field somewhere in the UK. Apparently the Capt's instrument had failed - or if he had vertigo, or both - so he didn't realise their dangerous attitude. But the FO had working instruments and didn't say a single word even though he knew he would die. I find this accident very tragic and indeed, Asiana 214 could have been a disastrous repeat of it.
Now, we Westerners found -our- way for CRM to reduce accidents. I firmly believe that it is easier to successfully adapt CRM to the culture, than to remodel the cultural way of thinking.
But these are just my own thoughts and ponders about this, apparently very sensitive, subject.
Yes, I agree, cultural differences affect what is now referred to as CRM.
As a Captain with an Asian airline employing many nationalites, a British co-pilot profusely apologised to me for disembarking and boarding the crew transport before me. I asked him what he meant ? He explained that on his last trip the "Local" Training Captain had torn into him with rage when he left the flight deck before the Captain, asking that if he treated a Training Captain with such disrespect, how did he treat a mere Line Captain ?
In the early days of "monitored approach" trials - whereby the "non-handling" pilot flies the instrument approach down to minima, where the "handling pilot" then takes over and completes a manual landing, a PanAm skipper walked over to us and said " Pan Am has practised monitored approach procedures since the dawn of aviation" Oh! Really ? " Yes, he said, I fly, he monitors " !
In my early days as a Second Officer / Navigator, I was roundly admonished for addressing the co-pilot by his Christian names. " We do NOT use Christian names on the flight deck, MR XXXX " and one of that Captains own colleagues was known for not talking to anyone but his co-pilot, he would order the co-pilot to ask the flight engineer to set take off power, and as Navigator I wasn't allowed to pass any information directly to him, I had to give it to the co-pilot for transmission across the centre pedestal ! - and that was in a British airline with only British crew. North Atlantic Barons we called that generation of Captains, maybe the British Class system was still alive and well in those days.
We are all subject to "culture" !!
As a Captain with an Asian airline employing many nationalites, a British co-pilot profusely apologised to me for disembarking and boarding the crew transport before me. I asked him what he meant ? He explained that on his last trip the "Local" Training Captain had torn into him with rage when he left the flight deck before the Captain, asking that if he treated a Training Captain with such disrespect, how did he treat a mere Line Captain ?
In the early days of "monitored approach" trials - whereby the "non-handling" pilot flies the instrument approach down to minima, where the "handling pilot" then takes over and completes a manual landing, a PanAm skipper walked over to us and said " Pan Am has practised monitored approach procedures since the dawn of aviation" Oh! Really ? " Yes, he said, I fly, he monitors " !
In my early days as a Second Officer / Navigator, I was roundly admonished for addressing the co-pilot by his Christian names. " We do NOT use Christian names on the flight deck, MR XXXX " and one of that Captains own colleagues was known for not talking to anyone but his co-pilot, he would order the co-pilot to ask the flight engineer to set take off power, and as Navigator I wasn't allowed to pass any information directly to him, I had to give it to the co-pilot for transmission across the centre pedestal ! - and that was in a British airline with only British crew. North Atlantic Barons we called that generation of Captains, maybe the British Class system was still alive and well in those days.
We are all subject to "culture" !!
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Exsp33dbird
I see what you are writing. As I recall it, there were at least one spectacular accident in England attributed to, amongst other factors, poor CRM. (Staines Disaster.)
I really hope that the Asians can find -their- way to work around experience gradients in the cockpit. The Anglo-American sphere found its own way. This may not be the only way, though.
I see what you are writing. As I recall it, there were at least one spectacular accident in England attributed to, amongst other factors, poor CRM. (Staines Disaster.)
I really hope that the Asians can find -their- way to work around experience gradients in the cockpit. The Anglo-American sphere found its own way. This may not be the only way, though.
As I recall it, there were at least one spectacular accident in England attributed to, amongst other factors, poor CRM. (Staines Disaster.)
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fireflybob
You are right. There was no mention of CRM during that time. But one of many contributing factors was a hostile work environment, that much can be deduced from the report. Also, some people have shared their first hand knowledge of the workplace circumstances at that period. I'm sure you may be one of those.
But let's not drift from the thread here. There is a thread somewhere about Staines. Let's keep any more Staines discussions there. Sorry about this, mods.
You are right. There was no mention of CRM during that time. But one of many contributing factors was a hostile work environment, that much can be deduced from the report. Also, some people have shared their first hand knowledge of the workplace circumstances at that period. I'm sure you may be one of those.
But let's not drift from the thread here. There is a thread somewhere about Staines. Let's keep any more Staines discussions there. Sorry about this, mods.
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Culture
Cultures certainly do differ but they also do change and we cannot afford to be PC in acknowledging the fact. I can confirm ExSp33db1rd’s narrated cockpit attitudes of the 60’s (at least). I had to position to SNN for some training details and the first available flight was on a different (but European) airline flying LHR-SNN-JFK. I was on the jump seat and I knew the F/O who had transferred from our company (but it was not, I hasten to add for the benefit of those who may jump to the conclusion that it was to BOAC). The weather was a stiff south westerly at LHR and at SNN. On T/O the F/O slid his seat back and folded his arms. “This is how I am supposed to behave at times like this!” And the same happened at SNN with the Capt literally battling the controls single-handedly like in some ridiculous movie whilst his F/O had to sit mute and inactive. My comment to him was that I thought it was seriously criminal.
Thank goodness those days have gone. Things will change.
I have also flown in the military with Asian pilots. The Command (C-in-C) view was that the Indian and Chinese pilots were neck and neck for first place in ability. There was nothing wrong in their flying. So maybe both A and B should examine their instrument presentation and we should all have a re-think.
Thank goodness those days have gone. Things will change.
I have also flown in the military with Asian pilots. The Command (C-in-C) view was that the Indian and Chinese pilots were neck and neck for first place in ability. There was nothing wrong in their flying. So maybe both A and B should examine their instrument presentation and we should all have a re-think.
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Interesting read, but i beg to differ.
To change aircraft design to adapt for cultural differences is saddling the horse beginning from the tail end. The modern (western) design has proven to be the most suited for civil aviation, with all its controversies (as you may remember, i am inclined to somewhat exclude the AB design here ...... but that's another thread).
Having started aviation with our own western old military heroes at the helm, i experienced the advent of CRM, due to the new awareness that the old ways lead to disaster. It was a pain first, but eventually worked quite well. I am sure it can work just as much for other cultures.
It all depends on the willingness of the regulators and company management.
And that is the problem, not aircraft design. If greed and wrong political or cultural correctness prevail, even a new design must fail.
As much as in the asian and arabic circles a change of culture is difficult, albeit necessary, i am afraid that the new greed and deregulation spectre works to annihilate the achievements we made in our latitudes!
We have to be convincing to the east and vigilant amongst our ranks.
One more thing:
Agreed, but it has to be taught first, and that is criminally neglected in many regions and companies.
To change aircraft design to adapt for cultural differences is saddling the horse beginning from the tail end. The modern (western) design has proven to be the most suited for civil aviation, with all its controversies (as you may remember, i am inclined to somewhat exclude the AB design here ...... but that's another thread).
Having started aviation with our own western old military heroes at the helm, i experienced the advent of CRM, due to the new awareness that the old ways lead to disaster. It was a pain first, but eventually worked quite well. I am sure it can work just as much for other cultures.
It all depends on the willingness of the regulators and company management.
And that is the problem, not aircraft design. If greed and wrong political or cultural correctness prevail, even a new design must fail.
As much as in the asian and arabic circles a change of culture is difficult, albeit necessary, i am afraid that the new greed and deregulation spectre works to annihilate the achievements we made in our latitudes!
We have to be convincing to the east and vigilant amongst our ranks.
One more thing:
It is known that in an emergency it is often the thing we are taught FIRST that kicks into action
It all depends on the willingness of the regulators and company management.
Last year I criticised my local authority...surprise surprise I receive a letter from the Revenue investigation department.
The Trident as did BEA's Tristar had an instrument panel more or less designed for single pilot. The Trident standby instruments were adjacent to the captains knee.
As to the Russian artificial horizon...I always thought it was more logical and less confusing than the western type...but it was more complex to manufacture. The Crossair accident at Rumlang was the result of confusion between the two.
Sadly I was a product of "keep your mouth shut" in my early days. 18 months ago I was given a ride by the owner of a smart single engine aircraft...he decided to put it into his mate's small strip in a vineyard in the south of France. Despite my saying the conditions were dodgy (I had flown a paraglider that morning and knew the area from gliding) he decided to continue...bounced due to tail wind gradient and pushed the stick forward. I didnt get my hand on the stick quickly enough. I could have stopped the accident if I had had my hand on the controls but I had spent 20 years NOT being allowed to do so.
I stopped instructing when I was 60 because I had slowed too much to be safe allowing a student to winch launch or fly with a wing tip feet from a mountain face but I have mates of my age still flying 747s, 737s and 787s.
One, who is back on the Jumbo now, threw the towel in a couple of years ago. Hadj flight returning to the Magreb...line squall..severe Turb..burnt the approach and when he subsequently landed he didn't remember anything that happened. Left the aircraft and caught a flight home after resigning by telephone. Company had to fly another crew in.
I have watched my performance go slowly down hill since I was in my 40s...yes experience made up for it and I was certainly safer at 50 than at 20 but at 60, tired, in the middle of the night and being kicked about in turbulence I shouldn't be flying a commercial aircraft. Which leads us back to the first line...line flying over 60 IMHO is wrong and the regulators should not condone it.
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Gretchenfrage.
You are right in one thing. Aircraft aerodynamic and physical design should obviously not be altered.
But the interface between the aircraft and the pilots could very well be. Give those Russians what they are used to in terms of artificial horizons etc. It is comparably easy to replace a module in the cockpit, not so easy to replace human lives lost (blind pew gave one really good example in this regard).
CRM is another tool for aircraft safety that could easily be altered to accommodate for cultural differences. Give Asian FOs the tools to communicate to the Capt without loss of face but still within their social limits. Only the Asian carriers would know how to implement this, but I am sure they too want to reduce aircraft losses.
You are right in one thing. Aircraft aerodynamic and physical design should obviously not be altered.
But the interface between the aircraft and the pilots could very well be. Give those Russians what they are used to in terms of artificial horizons etc. It is comparably easy to replace a module in the cockpit, not so easy to replace human lives lost (blind pew gave one really good example in this regard).
CRM is another tool for aircraft safety that could easily be altered to accommodate for cultural differences. Give Asian FOs the tools to communicate to the Capt without loss of face but still within their social limits. Only the Asian carriers would know how to implement this, but I am sure they too want to reduce aircraft losses.
Last edited by MrSnuggles; 8th Mar 2014 at 20:30. Reason: removed " like the Malaysian 370 we are just learning about" because that is irrelevant
[......but I am sure they too want to reduce aircraft losses like the Malaysian 370 we are just learning about. ]
Big jump there ? "Cultural issues" ? Aircraft not even found yet. Possible of course, as is anything else at the moment.
Am reminded of the 747 that was rolled into the sea within around 50 secs of being airborne. Was assumed that the pilots' AH had stuck in a slight right bank as he captured the outbound course, so he applied progressively more left bank to level the wings, until at around 110 deg.bank he suggested that his AH had failed, at which point the co-pilot agreed that his had failed as well i.e. it was correctly indicating 110 bank ! Had he only just noticed, and also ignored a descent in excess of anything reasonable - when they should have been climbing and not yet cleaned up, and an increase in airspeed of unreasonable proportions ?
One has to ask what he had been doing, and not saying, prior to this point, had he not been properly "monitoring" or was he too culturally bound to not question his Lord and Master.
There is some suggestion that there might have been terrorist activity in the Malaysian mystery, but they would have been made to take their shoes and belts off before boarding, so we can discount that !
Big jump there ? "Cultural issues" ? Aircraft not even found yet. Possible of course, as is anything else at the moment.
Am reminded of the 747 that was rolled into the sea within around 50 secs of being airborne. Was assumed that the pilots' AH had stuck in a slight right bank as he captured the outbound course, so he applied progressively more left bank to level the wings, until at around 110 deg.bank he suggested that his AH had failed, at which point the co-pilot agreed that his had failed as well i.e. it was correctly indicating 110 bank ! Had he only just noticed, and also ignored a descent in excess of anything reasonable - when they should have been climbing and not yet cleaned up, and an increase in airspeed of unreasonable proportions ?
One has to ask what he had been doing, and not saying, prior to this point, had he not been properly "monitoring" or was he too culturally bound to not question his Lord and Master.
There is some suggestion that there might have been terrorist activity in the Malaysian mystery, but they would have been made to take their shoes and belts off before boarding, so we can discount that !
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I would have thought that with today's glass cockpits you could have pretty well any instrument paradigm you wanted at the flick of a switch if the manufacturer's could only be bothered to program it.
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Air New Zealand has no plans to ground its Boeing 777s
Is the fourth paragraph accurate? "Three passengers died with the accident attributed to pilot error."
Is the fourth paragraph accurate? "Three passengers died with the accident attributed to pilot error."
you could have pretty well any instrument paradigm you wanted at the flick of a switch if the manufacturer's could only be bothered to program it.
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Air New Zealand has no plans to ground its Boeing 777s
Is the fourth paragraph accurate? "Three passengers died with the accident attributed to pilot error."
Is the fourth paragraph accurate? "Three passengers died with the accident attributed to pilot error."
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Asiana says Boeing 777's warning system inadequate in SFO crash
In the news today regarding the Asiana crash last summer--Asiana is blaming Boeing and Air Traffic Control for the accident, in addition to their crew allowing the airspeed to decay.
Asiana Airlines admitted in regulatory filings released Monday that its Flight 214 was flying too slow in a crash last July at San Francisco International Airport, but said inadequate aircraft automation and warning systems contributed to the disaster in which three passengers died.
The airline's explanation of how its pilots landed a state of the art airliner short of the runway on a clear, sunny day is contained in documents released Monday by the National Transportation Safety Board.
While its pilots "did not insure minimum safe airspeed during final approach," the "highly trained and experienced" flight crew was beset by problems that "would have been difficult to predict." Asiana said in the documents.
It cited "inconsistencies in the aircraft's automation logic" that led to a surprise disabling of minimum airspeed "without warning to the flight crew."
Also, it said, a low airspeed alerting system "did not provide adequate time for recovery."
Finally, "air traffic control instructions and procedures led to an excessive pilot workload during the final approach."
"Asiana has flown into SFO uneventfully for over 20 years," the airline wrote in its submission to the NTSB. It said that "Asiana crews have successfully accomplished high-energy, visual approaches to the airport numerous times. The series of events that led to the accident, involving an advanced technology aircraft flown by a highly trained and experienced flight crew, would have been difficult to predict given the qualifications of the pilots and Asiana's premier flight safety program."
Asiana says Boeing 777's warning system inadequate in SFO crash - San Jose Mercury News
Asiana Airlines admitted in regulatory filings released Monday that its Flight 214 was flying too slow in a crash last July at San Francisco International Airport, but said inadequate aircraft automation and warning systems contributed to the disaster in which three passengers died.
The airline's explanation of how its pilots landed a state of the art airliner short of the runway on a clear, sunny day is contained in documents released Monday by the National Transportation Safety Board.
While its pilots "did not insure minimum safe airspeed during final approach," the "highly trained and experienced" flight crew was beset by problems that "would have been difficult to predict." Asiana said in the documents.
It cited "inconsistencies in the aircraft's automation logic" that led to a surprise disabling of minimum airspeed "without warning to the flight crew."
Also, it said, a low airspeed alerting system "did not provide adequate time for recovery."
Finally, "air traffic control instructions and procedures led to an excessive pilot workload during the final approach."
"Asiana has flown into SFO uneventfully for over 20 years," the airline wrote in its submission to the NTSB. It said that "Asiana crews have successfully accomplished high-energy, visual approaches to the airport numerous times. The series of events that led to the accident, involving an advanced technology aircraft flown by a highly trained and experienced flight crew, would have been difficult to predict given the qualifications of the pilots and Asiana's premier flight safety program."
Asiana says Boeing 777's warning system inadequate in SFO crash - San Jose Mercury News
Last edited by Feathered; 31st Mar 2014 at 19:47.
Blah, blah, blah...
It must be already April fool's day somewhere on the planet.
The aircraft has been flying for how long without a crew crashing it?
Just because their pilots were incompetent in flying and monitoring the aircraft's systems doesn't mean it is a bad design.
Sure while we are at it might as well bring in SFO's ATC system into the act to deflect the blame off Asiana and their pilots.
Pretty sad situation.
It must be already April fool's day somewhere on the planet.
The aircraft has been flying for how long without a crew crashing it?
Just because their pilots were incompetent in flying and monitoring the aircraft's systems doesn't mean it is a bad design.
Sure while we are at it might as well bring in SFO's ATC system into the act to deflect the blame off Asiana and their pilots.
Pretty sad situation.
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"Well they would say that, wouldn't they?" Mandy Rice-Davies.
Owing to them not making it safely to 21 years, they need to make this submission to the NTSB.
Other airlines have avoided being out in this awkward situation for longer. Are we to assume that there's only so much total luck available, and that the more you need, the sooner you run out?
"Asiana has flown into SFO uneventfully for over 20 years," the airline wrote in its submission to the NTSB.
Other airlines have avoided being out in this awkward situation for longer. Are we to assume that there's only so much total luck available, and that the more you need, the sooner you run out?