NTSB update on Asiana 214

[barit1]

I believe it's worse than that. There are airlines so imbued with nepotism, and cronyism, to the point they do not differentiate between skilled and marginal pilots.

In other words, the social hierarchy overwhelms the technical needs of the flight deck. I then have to wonder about the shop situation.

[safetypee]

400driver, fullforward, Mozella. “Blue side up, airmanship, not OK”; so what should be done?
Blame might be self-satisfying, but it does nothing for future safety; neither will firing all the errant pilots.

More training; how much and for which situations? Many people appear to be bound by hindsight, demanding more training for ‘the last accident’ and attempting to cover every detailed eventuality.

If the industry is as barit1 suggests, then the attitudes above might back everyone into an impossible safety corner – fewer qualified pilots, more training, more cost, more operational restrictions …. more ‘violations’ (erroneous activities defined by requirement).
However, considering the industry at large, it is very safe; aircraft are flown manually and landed safety every day. Look at what goes right; consider the positive role of pilots in providing this safety, what freedoms do they have. If we can provide more of what is right, then there should be less opportunity for what is wrong.

There is significant focus on ‘the last accident’, with gut reaction demanding fixes, but will these fix the future – not entirely. Thus it is essential to understand the widest range of issues in major accidents, learn from them and make small but potentially effective changes in order to maintain the current level of safety. Most of the NTSB’s recommendations are in this category.

[400drvr]

I do not believe I blamed anyone other than stating the obvious.

[barit1]

By no means did I mean to imply the industry as a whole is contaminated; but a review of accident statistics will quickly highlight certain carriers, in certain regions, in which management must be suspect.

BTW, if ferryboat statistics align with airline statistics, for me this is a double red flag.

[Gretchenfrage]

or do you mean a red and blue circle?

[AirRabbit]

safetypee, you make some really good points … i.e., “more training?” … “Ok, how much and what for?” as well as … “understanding the widest range of issues in major accidents; learn; and then, make small but effective changes to correct the recognized errors…” Of course, I can’t speak for the kinds of rules, regulations, authorizations, “do's and don'ts,” traditional and non-traditional aspects, etc. etc. for aviation systems other than those in the US – But, for the US, I DO know and HAVE experienced the full gamut of most of those characteristics. However, that doesn’t change the validity of what you’ve pointed out … I merely want to add the following:

Even as good as the NTSB is at determining the “probable cause” of accidents and investigated incidents, the training recommendations they make either as a result or seemingly to prevent a similar situation in the future – while quite logical, at least most of the time, if an FAA regulation was created for each of the safety recommendations made – the increase in requirements and all the resulting time and cost concerns would be much more than theoretical. Over the recent 20 – 30 years, or so, I have seen a good effort on the parts of all the major players – and by that, I mean individuals representing each … the FAA, the NTSB, several individual airlines, a couple of pilot unions, appropriate airplane manufacturers, several training organizations, etc., who have, on multiple occasions, got together, laid all of the issues on the table, and mutually agreed to work to find logical, realistic, and workable recommendations. Profit margins, ticket sales, advertisement schemes, etc. were all set aside for these discussions.

Within these “working groups” there was, initially surprising, but later quite expected, quite logical, sensible, workable, realistic recommendations that were distilled out of all of the conversations and professional “give ‘n take” that was provided from ALL of the participants. Sounds pretty good … eh? Well, not so fast. As good and as logical as these recommendations were, it was still necessary to get those recommendations through each of the participants’ management structure at home. Even when some potentially productive efforts were put into operation – even if it was only to gather information which was to be later used to refine the rules and regulations, while at the same time provide instructive recommendations, there was the inevitable “head-shed” decision that either blew apart the effort or changed its direction so dramatically that all of the original intent was no only lost but provided substantial logic to go in a completely skewed direction.

I think almost everyone who participated in more than one or two of these efforts eventually came to understand that to see any of the recommendations become an industry wide practice – it would have to be 1) simple to adopt, easy to administer, provide superlative aviators, and add “depth” to the corporate coffers, be they airline or manufacturer, training organization or individual pilot pocket; or it would have to be 2) required by regulation. You may have, but I’ve never seen (and probably will never see) anything that might be even close to having the features of number 1 … and that leaves only number 2.

Also, I think that, while everyone here recognizes that a government entity does not have an exclusive capability to generate “bureaucracies,” virtually all corporations that have more than 2 employees have their own version of such a “head-hurting” processes … but NONE of those corporations have that process down to the level of “science” that the government manages to provide 25 hours a day, 9 days a week, and 15 months out of every year! The effort it takes to outline the necessities for having to modify an existing rule is quite major … but it doesn’t hold a candle to what happens to construct, write, review, modify, re-review, and then defend either a “major” overhaul of an existing rule, or, heaven forbid, the initiation of a brand new requirement!

The very notable exception to this point – as would be jumped on by the regulatory managers and some of the management officials of those airlines currently participating in one such “major” effort … in the US it is known – either affectionately or not-so-much (depending on your position) as the “Advanced Qualification Program,” or AQP. This was a working group-developed concept that was originally designed to provide data that did not exist at that time. It was proposed to provide that data, get a “hands-on” working familiarity with some of the then-understood philosophies, and help determine the logic of maintaining those philosophies or of changing them … which would be accomplished in accordance with the data gathered from this effort. It was initially planned to have something like 3 to 4 or 5 airlines entered into this program, and was predicated on a rather sophisticated data gathering process and a really well-laid-out record keeping process. The initial queries were to focus on the logic of continuing to have airline Captains return to the simulator every 6 months for a recurrent proficiency check, while requiring First Officers to return every 12 months for the same kind of check … particularly when there were some local FAA offices that thought that it would be appropriate to allow one recurrent training period each year to substitute for that visit’s proficiency check. That meant that Captains would get 1 course of training and 1 recurrent proficiency check each 12 months – equally spaced.

Unfortunately – that thought process didn’t quite make it through to frontal lobes of some … who, apparently blindly, allowed First Officers to get the same one recurrent course of training each 12 months. If one were to stop talking (and thinking) at that point, it would be fine. But, First Officers were only coming in once each 12 months – now that visit was going to be a training session … not a proficiency check. Of course, some operators and a few regulatory offices recognized this and allowed every other proficiency check for First Officers be satisfied with the course of training in the simulator. But, even then, that allowed F/Os to be checked only once every 2 years. During the first 18 – 24 months of this “data gathering effort” there were several management changes in the FAA – both locally and at the HQ level. At the same time, there was an influx of accidents and incidents that kept aviation – with the emphasis on the airline portion thereof – firmly on the front pages of most of the newspapers and all the local media outlets in the Washington, DC area. Naturally, no one in the FAA – particularly the senior managers – were very happy about having to be questioned by the Department of Transportation officials and the occasional Congressman or Senator – or the local TV, radio, and/or newspaper reporters, and the kind of questioning was quite pointed. Lucky for them the FAA had two on-going programs that were very highly thought of by members of the airline community.

These programs were the National Simulator Evaluation Team (NSET) and the Advanced Qualification Program (AQP). The airlines liked the efforts to clearly define both the technical requirements for simulators and the authorized uses for each such device (as it standardized the quality of the devices, making them more reasonably priced through competition of the manufacturers of simulators) and clearly set out the capabilities such that no one airline was getting more authorized in a simulator, requiring them to use the airplane more frequently – now it was more of a “level playing field.” At the same time, the idea of using the AQP to gather data, was discarded. The authorized training frequency was converted to a permanent factor, and any airline could petition to have its training program approved under the AQP … and doing so for one airplane fleet for a given airline, came with an authorization for all the other airplanes operated by that airline to move to a “single-visit training” function for all their crewmembers – Captains and First Officers.

This meant that, for larger airlines, this authorization immediately reduced their training budget by the cost of one simulator recurrent check or training for each captain they employed every year. If the airline had, say, 8000 crewmembers – 4000 captains and 4000 first officers – what used to be 8000 pilot training sessions for captains (2 per year) and 4000 pilot training sessions for first officers (one per year), for a total of 12,000 training sessions per year – instantly became a total of 8000 training sessions per year (one for each captain and one for each first officer) – which, using the appropriate number of calculators, means that 4000 pilot training sessions could be saved each and every year. THAT could mean a substantial cost savings – authorized by your friendly neighborhood regulator. And there were airlines in the US that had well over 10,000 pilots on their seniority lists … meaning a substantial savings … presto.

Yes, there were some requirements that the training program would have to meet some “high-power sounding” metrics, requiring some PhDs to be added to the payroll – at least for the development of the program – but if one were to carefully review just exactly what was required, the “high-power sounds” were … well … over-stated. Next, there was the offer from the regulator that the airline could establish their own standards of performance – regardless of what was indicated in the rules. Additionally, not all tasks contained in the regulations would necessarily have to be conducted during training. The “official sounding” justification for this said …

AQP was established to permit a greater degree of regulatory flexibility in the approval of innovative pilot training programs. Based on a documented analysis of operational requirements, a certificate-holder under AQP may propose to depart from traditional practices with respect to what, how, when, and where training and testing is conducted. This is subject to FAA approval of the specific content of each proposed program. All departures from traditional regulatory requirements are to be documented and based upon an approved continuing data collection process sufficient to establish at least an equivalent level of safety. Because AQP provides a systematic basis for matching technology to training requirements and for approving a training program with content based on relevance to operational performance, an applicant may propose to replace certain requirements of the regulations with an AQP curriculum, subject to FAA approval.

An AQP may also employ substitutes for the practical test requirements. The application to the specific issue of two alternative approaches to any single issue shows how risk based techniques may be used to demonstrate that an alternative methodology achieves a level of safety equivalent to traditional methodology. In order for an airline to “depart from traditional practices with respect to what, how, when, and where training and testing is conducted” that airline must provide “a documented analysis of operational requirements. Once the authorization to “depart” from the “traditional practices” has been issued, the continuation of that authorization will be dependent on “an approved continuing data collection process sufficient to establish at least an equivalent level of safety.” This is further explained by stating that this process must also include a “systematic basis for matching technology to training requirements” as well as the process of “approving a training program with content based on relevance to operational performance.”

A real-world example of substitution of one task for another task – with supposedly an equivalent level of safety - was the authorization for the conduct of recovery from a windshear encounter would replace the necessity for a pilot having to demonstrate satisfactory recovery from either an approach to stall or an aerodynamic stall. Take a moment and re-read that … this says that airline pilots training under AQP would not have to be exposed to recovery from either an approach to stall or an aerodynamic stall. There were other such “authorizations” … but because each training program approval was deemed to be “proprietary,” no one outside of the AQP office that constructed the “approval” and the specific FAA Operations Inspector assigned to that specific airline, would be able to read and understand what that airline was authorized and on what tasks they had to actually be trained and demonstrate proficiency.

After the terrible accident in Buffalo, NY, when this specific authorization was made known to other, more senior managers in FAA Headquarters, the AQP office was notified to “ensure that all AQP-authorized airlines would contain a requirement for training and evaluation in approach-to-stall/stall recognition and recovery.” It might be interesting to find out what other tasks have been “substituted.”

The point for all delving into all of the above is to point out that even when the regulator takes up the task of modifying the rules, someone, someplace, should be held to some level of accountability that the resulting implementation of said-regulation, will have the intended results – and not be left to the potentials that are clearly possible. In this particular case, the cost savings recognized by the airlines involved in AQP tend to make the management officials feel quite positive about complimenting the regulatory officials that allowed such a “modernized” approach to airline training. Those regulatory officials, after finding themselves being complimented for their foresight and courage for allowing a modernized and advanced training program, particularly one yielding the kind of well-trained pilots claimed by those airline management officials, also find themselves being seriously considered for further advancement within the regulatory structure – increasing their income and, at least as importantly, their stature among their superiors, their peers and their subordinates. The epitome of the mutual admiration process … achieved without any direct communication or agreement.

Of course, as all of my posts certainly are, this is simply another of my own, individual opinions. ....right?

[aterpster]

400drvr:

As far as what was doing what when, Auto Thrust Vs Thrust lever position, who cares. I'm normally looking out the window. Keep the same sight picture in the window, again we all know that works to.

What about IAS?

[Petercwelch]

Any pilot

Any pilot who can't successfully land the aircraft they are flying on a clear essentially no wind day on an 11,000 foot runway should not be flying, period!

[400drvr]

Aterpster: What about airspeed?

I learned how to maintain a flyable airspeed when I was a student pilot in 1974. I still remember my instructor saying Pitch Power Trim. Airspeed is like breathing for a pilot, or at least it should be, because if you don't maintain it you may stop breathing, permanently. So I still find looking out the window works for me, and yes the occasional glance at the airspeed tape is always a good idea.

[400drvr]

VFR and 11000'

Yep, complete agreement.

[CDRW]

AirRabbit

What a gloriously enlightening missive!!

The un-mentionable Middle eastern airline is full of this!

[Mozella]

I wonder if flying skills and democracy are similar in that you can't successfully jam either one down people's throats. Consider Iraq, for example. No matter how much money, blood, and treasure is spent by the U.S. and the rest of the world, forcing a people to embrace democracy when they actually don't much care for the concept is an exercise in frustration at the very least. Dipping one's finger in blue ink to show that you are now a democrat is not the whole story, especially if the opposition cuts that finger from your hand. Certainly the democratic process developed in this way is different from that famous dustup between the colonies and Great Britain in 1776 when the Continental Congress declared independence. Americans didn't have democracy thrust upon them; they fought for it.


Pilots can be trained in ways which are analogous to the democracy example . Many of the world's pilots come from countries with significant aeronautical histories like the U.K., the U.S.A., France, and Germany. If you're from one of those countries, like me, you may have built (and experimented with) model aircraft to one degree or another. Surely all of us have held our hands out the window of a moving car and experimented with angle-of-attack and lift vs. drag long before we know any of these terms, building our personal aeronautical background even if we didn't know it at the time.


Most of us were presented with an opportunity to learn how to fly only after some kind of a struggle. In the old days, kids swept out hangers in return for an impromptu flying lesson. Some scrimped and saved to buy lessons. Some, like me, signed up with a military force which taught us to fly in exchange for serving many years of military service. But what we pilots educated in this way have in common is that we fought and struggled to have the opportunity to learn flying. Training was something we all craved. We took it. We thirsted for it. We thought about it often even when not in a training environment. Our instructors didn't force the secrets of aeronautics on us; we sucked the knowledge out of them. We really wanted to learn to fly and, most of us anyway, wanted it with all our hearts. In that respect, many of us ended up as qualified pilots in a way not unlike like the colonists became Americans; i.e. we battled for it.
As we know, not all pilots get qualified in this way. For example, I lived in Iran for several years trying to train the Imperial Iranian Air Force pilots how to fly the F-14. Nearly every pilot was the son of some influential political or military officer. None of them, not a single one of them, were what I would call good. Although some of them could actually operate a high performance aircraft, even the F-14, they were far from having what you might call "the right stuff". Their understanding was something like a lake a mile wide and an inch deep.



Part of that is because neither the pilots, their culture, nor their country had any real aeronautical background or history. In fact, because they were all wealthy, these pilots didn't have any mechanical background either. Once, when was struggling to explain how the TF-30 igniters worked, I likened them to an automotive spark plug. I invited one of my students to point to a spark plug in his brand new and very expensive BMW. Not only couldn't he do it, he was amazed that anyone would be even interested in knowing such a thing. He actually scoffed. Mechanical work (and the understanding that went with it) was for the lower class.
These Iranians could more-or-less fly as long as everything was going OK, but throw the slightest surprise at them, and the results were totally unpredictable. These men were being trained by forcing knowledge down their throats. They, would rather do anything other than learn how to fly. One senior officer even refused to attend ground school and went water skiing or goat hunting most days instead. This resulted in the operations officer causing over a million dollars damage on the very first Iranian F-14 flight.



These Iranians were weren't interested in flying They were more interested in the prestige associated with being a military pilot. Until their first day at flying school, none of them had ever given a thought to what makes an airplane fly. None of them ever held their hand out the window of a moving car when they were children. That sort of stuff simply wasn't part of their culture or background.


Can a country without any aviation history eager to have its own nationals flying aircraft for their national airline pluck someone out of the population and MAKE them a pilot by jamming flight training down their throat, so to speak? The answer is yes. We all know that. Is there a certain risk associated with this policy? I think so.



What say you?,

[Jet Jockey A4]

@ Mozella...

First of all you forgot Canada in your list of countries with aeronautical background.

Second, I agree with you and your statements that there is a cultural baggage that does help in one becoming a good pilot.

Anyone like you said, can learn to fly an aircraft but not all will become good pilots for various reasons. The same can be said about driving a car or any other motorized vehicle.

One of my hobbies is to teach people how to drive their usually expensive cars on a race track in high performance driving schools so that they can learn how to drive properly and understand the physics behind driving. Let me tell you that not all of them will ever "get it".

I also believe one of the ingredients required to be a good pilot is "common sense". Some people just don't have it and will allow themselves to get deeper in trouble when someone with common sense will back off prior to getting in trouble.

[John Marsh]

Mozella:

An interesting and worrying picture you paint. What about fear?

Fear of failing the course, sure; but more importantly, fear of dying. Doesn't that sharpen the appetite for training?

I suggest that a small degree of fear, or at least wariness, is healthy and useful in all aircrew and pax. As the latter, I need to pay attention to the safety demonstration. Flight crew who are continually wary of unexpected events can seek to prepare for them.

Has the advent of highly-reliable cockpit automation served to annul fear?

[RAT 5]

Fear of failing the course, sure; but more importantly, fear of dying. Doesn't that sharpen the appetite for training?

Culture is a very real thing. It can a help or hinderance, and knowing which and how to use it is what good leaders should be all about. Sadly not always the case. The story told is not unreal.

Certain people are very good a academic studies and will work harder than I to succeed. Others are better at the physical and will never give up. All are where they want to be. Put someone in the wrong place for the wrong reason and when the going gets tough they collapse. A cockpit is not the place to be when that happens.

[barit1]

Common highway accident of natives in the sandbox is encountering speed bumps (Norteamericanos call them 4 by 4s) at 150 clicks on what had once been a clear road. This frequently removes the undercarriage, and leaves the rest of the Jag, Mercedes, etc. tumbling end over end, spilling contents all over the desert. Happens with enough frequency that it's evidently a cultural thing.

[safetypee]

AirRabbit, #869 “… right?” Yes, as far as I follow the points, and these seem to have a distinctly US/FAA cultural approach. However, the safety scenario remains the same, where expert groups seek detailed solutions by examining a very small data set (accidents / incidents), where there are many unknowns and great supposition, with an objective of further regulative constraint ... there is no action, no change.

In order to improve or just maintain the industry’s high level of safety we have to find alternative methods to complement the existing initiatives. There are several eminent views ranging from ‘high reliability’ and ‘resilience’ to a simple change in thinking in ‘Safety1 and Safety 2’.
But all of the ideas involve the need to change the way in which we think about safety.

The blocks in our safety thinking are not solely due to national culture; professional culture also involves group beliefs etc, and all of these depend on the overall operational environment. Thus ‘cultural’ aspects seen in one county could easily appear in another country, or in a professional group under a different guise, more so as the safety environment continually changes. The harder we try to be safe, the greater the process complexity, the greater the pressure to be safe, the harder we try ...; a cycle which frustratingly appears to be active, but actually makes little or no progress.
The safer we appear to be, the less we feel we need to know, to do, to think of.

[deefer dog]

Didn't have time to read all of above (so it's been probably stated already), but too many times I've seen pilots trying to correct something "slightly unusual" by sole use of the autopilot when a quick disconnect would achieve the goal far quicker....presumably something desirable while conducting an approach.

In my day the main route of progression was by old fashioned "hands on" hour building. Now it seems that fewer hours are a requirement for trainee FO's, and of these most are spent pushing buttons and monitoring computer screens.

Is it any wonder therefore that the culprits don't have the confidence to hand fly when the need arises, and God forbid, how would they ever manage without a flight director?

[RAT 5]

...too many times I've seen pilots trying to correct something "slightly unusual" by sole use of the autopilot when a quick disconnect would achieve the goal far quicker....presumably something desirable while conducting an approach.

'Children of the magenta line' should be compulsory viewing for all new pilots and all instructors: come to think of it, ALL pilots, even the older ones.

[BRE]

JetJockey A4: "One of my hobbies is to teach people how to drive their usually expensive cars on a race track in high performance driving schools so that they can learn how to drive properly and understand the physics behind driving. Let me tell you that not all of them will ever "get it"."

Do those who have never driven anything besides an automatic transmission ever get it? Do those who have never tested out the limits on a car without ABS, ESP and no or a very direct power steering ever get it?


Turnin back to aviation: does it take have done hundreds of visual landings on a single engine propeller plane to be able to be confident about doing visuals in a heavy jetliner?