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NTSB update on Asiana 214

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NTSB update on Asiana 214

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Old 5th Jul 2014, 05:49
  #901 (permalink)  
 
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ticking the boxes

Expats in Asiana complete normal induction and examination standards. Citizens have somewhat enhanced pre-information re examination questions and examiner desired answers. My understanding is that there are absolutely no surprises at examinations or during the sim.

Examination and training is done by numbers. No need to think, just get the boxes ticked.

Of course, there is little or no need for CRM in the cockpit. Being Korean is most important, and seniority rules without question. The company is always right, and let us not blow away thousands of years of tradition!

It is no surprise that there is no culturally accepted procedure for less senior PNF to alert PF of developing danger.

Like some ME airlines, there is serious loss of face with a missed approach. In fact a fairly senior Asiana F/O failed to call my high ROD with tailwind at a difficult airfield. I made a missed approach anyway, and he was so disappointed to be associated with it, he complained though the whole missed approach procedure. It was obvious that his nationality and years in the airline needed to be made clear. It did not seem to matter that I was following proven correct procedure for the circumstances to remain safe.

Maybe that same F/O is now a training captain.
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Old 6th Jul 2014, 14:13
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Originally Posted by BOAC
...Now it is more important to be an 'ace' with the buttons...
The problem is the Asiana pilot was *not* an ace with the buttons -- he didn't understand how the autothrottle worked. He wasn't a whiz-kid "child of the magenta" unable to hand fly the plane when faced with an outright automation failure. Nothing failed.

Rather he did not understand the autoflight system or exploit its features. E.g, if uncomfortable with a non-precision approach without glideslope, they could have made a GPS precision approach. This was a published approach, and in fact the FAA urged this usage (after the accident): Foreign airlines urged to use GPS at San Francisco

Total reliance on automation and inability to hand fly an approach in perfect conditions is not good. However if he just used the available automation, it would have landed OK. If you can't hand fly and *also* can't properly use automation, that is a bad combination.

If he was more proficient in hand flying but still did not properly understand the automation, an accident could still happen in other circumstances due to that lack of understanding.
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Old 6th Jul 2014, 16:34
  #903 (permalink)  
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joe - this thread has actually moved on from where you are! That bit is 'done and dusted'.
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Old 6th Jul 2014, 16:37
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If you can't hand fly and *also* can't properly use automation, that is a bad combination.
As far as I'm concerned, you've neatly stated why this accident was just waiting to happen. What failed to stop the chain of events were cultural problems. Unfortunately, those cultural problems changed a "bad combination" into a deadly combination.
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Old 7th Jul 2014, 01:20
  #905 (permalink)  
 
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Centaurus, our conclusions re my training experience differ (#891, 896).
The instructor turned out to be a good guy and a competent operator, although slightly reserved; a good lesson in not judging people on reputation.

Your view suggests that demonstrations precede repetitive and reinforcing training, which although this is a good starting point (effect of controls), training must diverge to in order to generate independent thinking (situation recognition) and the ability to transfer situation/action to similar, but not identical ones.
The demonstration and handling-skill reinforcing was complete – ‘how to land on a paved runway after an engine failure’. The training was in benign situations and followed set procedures – thus ‘success’; the next stage was to recognise situations where success was not assured, where detailed procedures did not apply, and thus alternative action was required. This is typical of military training which is perhaps based on a philosophy of ‘you never fight the war you planned for’.
Whereas a typical commercial aviation approach, with certificated aircraft operating in closely regulated situations, often biases training to ‘expected’ situations – within the scope of cert/reg – a bounded environment. This approach tends to prejudge expected situations, limiting the nature of threats, using predetermined checklists and standard scenarios (SOPs); - the general need is to understand a situation sufficiently to fit it to a procedure.
The problems in the choice of training to improve the ability to understand situations involve cost/effectiveness and the extent required for the anticipated threat – as bounded by cert/reg.

These differences are reflected in other posts; either by assuming specific situations and the need to provide detailed training, or a more flexible approach based on generic situation awareness training, avoiding prejudgment, and having a wide ranging knowledge base. The ideal is no doubt somewhere in between, but views can be biased by recent events.
The unexpected nature (components) of recent accidents has been a fundamental surprise to the industry – the assumptions in certification, regulation, and training were meant to avoid these.
Thus, is the problem a weakness in the process of cert/reg/trng, that the assumptions being made about human performance are optimistic, or that the situations being encountered no longer match expectations. Or perhaps the operational environment is now too complex for a regulated approach which may be overly dependent on human performance.

An analogy is like trying to kill a fly on a wall – either a wide angle shot-gun hoping to hit everything, or a well-aimed rifle for precision. These are extremes, neither assuring success and thus require compromise, but there are also other parameters – the size of the wall and the robustness of the fly (the environment and threat). The industry needs to consider what adaptations are required for these, and who is best placed to adapt - CEOs, design and certification, regulators, operators, or individuals at the sharp-end?
Everyone within their capability.
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Old 7th Jul 2014, 13:14
  #906 (permalink)  
 
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Originally Posted by OK465
From my first go as an instructor I was strongly advised to assume that the student is always trying to kill you....this training Captain evidently didn't get that advice.
It is easier to believe of a novice than of an experienced pilot, but this point is worth repeating.

Anecdote: on a refresher flight after too much time at a desk, I was being "refreshed" and we knocked most of the rust off of my flying skills.

As the PIC came in for final landing, as we passed abeam ... I casually mentioned that the gear were still up. At the 90 / base position, him having reviewed "landing checks complete," I said with a bit more energy "gear has three up indications" and moved my hand to the gear handle with the intention of lowring it should he have missed my point.

He lowered the gear and all was sweetness and light after that.

Any of us can make a boo boo, no matter the number of hours in our logbook.

Last edited by Lonewolf_50; 7th Jul 2014 at 14:04.
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Old 7th Jul 2014, 16:30
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LW50,

Yep, the Training Captain's overriding purpose for being there was to exercise supervisory discretion to prevent exactly what occurred.

He was the linebacker, the free safety (pun intended) and the goalie....and he dropped the ball....

....regardless of the fromage, the ancillary findings or the excusatory human factors findings. All of which he was put there to deal with (including the fromage).

I get weary of the view that this class of accident somehow provides wonderful opportunities to learn from and improve the system when there is really no novel magic reason to be sought out to 'explain' what absolutely shouldn't have occurred with existing knowledge levels and within the current system. Every accident is not revelationary, some just sad repetition.

And relative to higher experience levels....

On a 727 recurrent training flight with an 'on paper' very experienced ex-airline type, the FE instructor who had flown with him previously as his pilot instructor passed me a folded note that said,

"Roger is capable of surprises."

Training Captains are specifically there to minimize the effect of any such surprises. That is the job, however there's always that bell curve lurking.
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Old 7th Jul 2014, 16:33
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The three most important words I was taught when I did my instructor's course a little while ago were "I have control".
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Old 8th Jul 2014, 12:06
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"The three most important words I was taught when I did my instructor's course a little while ago were "I have control"."

Yah, I saw Captain Al Haynes (United flight 232} in a speech about his ordeal............And he said that he had said about the same thing.

Just after his F/O said that he had no control.
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Old 11th Jul 2014, 20:28
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Originally Posted by OK465
He was the linebacker, the free safety (pun intended) and the goalie....and he dropped the ball....
....regardless of the fromage, the ancillary findings or the excusatory human factors findings. All of which he was put there to deal with (including the fromage).
All right, OK465 – I don’t think I’ve laughed, out loud, for quite as long as after having read your post that included the above quote! Probably for a multitude of reasons, but perhaps the most prevalent, besides the fact that someone actually used the word, is the fact that someone used the word correctly, in both its definition and its normally understood application – and did so twice!

I have long ago recognized your competence with the subject matter normally bantered about on these pages, but I now have a new and most interesting insight into your knowledge of aviation and of linguistics (particularly the background of some specific references) and your propensities to use either or both!

Thanks for the laugh!

Last edited by AirRabbit; 12th Jul 2014 at 21:59. Reason: grammar
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Old 13th Jul 2014, 13:54
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Forgive, please, the repetition:
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance.
...And not one word about the management structure of the airline that permitted three incompetent pilots (regardless of their logbooks) behind that locked door.
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Old 13th Jul 2014, 23:07
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Also how could any pilot knowing his level of incompetence not do anything to correct it? In this case all three of them.
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Old 14th Jul 2014, 01:10
  #913 (permalink)  
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They became passengers around 500 feet, or more.

Yes, I expect a deletion for gross redundancy.
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Old 18th Jul 2014, 23:31
  #914 (permalink)  
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NTSB Final Report Released

Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California, July 6, 2013 (PDF)
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Old 18th Jul 2014, 23:33
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Well, I don’t often jump into a position of “waxing philosophic” … but there are times when I fall victim to just exactly that. So, with apologies to all who may believe it necessary to be apologetic ...

I’ve never been one for deliberately kicking dirt on someone else’s ethnicity, nationality, religious beliefs, their occupational “position” or rank, or even their preferences in food and/or beverage … but all the respectful attitudes and the politeness that may govern verbal or physical responses to whatever someone else does, does not do, says, or does not say … are way down on my priority list when it comes to staying alive! It would, I would think, be appropriate for someone to review not only the training program content, but also review and understand how the provisions of such a program are conducted and how assurance is achieved that the students going through that program actually demonstrate their competency. If there is any potential for students to be provided “cheat sheets” or be provided “foot stompers” during the training, on which those students could then depend to achieve a “passing” score, someone should exercise the discretion to disallow that to continue.

And, of course, if the actual pilot training includes a dependence on subtle hints, or small control inputs on dual-control airplanes, intended to prevent an otherwise lackluster performance by any student pilot – at any point in that pilot’s career – we should all recognize that someone simply HAS to point out that this attitude is a huge disservice to that pilot … and may be paving the way, or greasing the skids, for that pilot to wind up being the first one to the accident scene. THAT isn’t helping that pilot, nor the passengers and crew who might be serving with that pilot when he (or she) gets into one of those situations where his (or her) training had to be supplemented with hints, or gouges, or cheat sheets. In the real world, there won’t be anyone who can, or will, provide those factors.

Before anyone rolls their eyes too much … I fully understand the hierarchy that is entrenched in some societies … but even there, it is very likely that someone understands when and where acknowledging and conforming to that hierarchy is appropriate, and where adherence to such hierarchy is potentially disastrous. Any organization that, for whatever reason, denies the logic of such understanding, should not be authorized to engage in activities where such adherence could result in those disastrous consequences.

Yes, yes, I know the arguments against such a statement. I am fully aware of the cultural aspects that are more seriously ingrained in the psychological makeup of some persons. And, I am fully aware of the challenges that present themselves were this position to be attempted to be applied and enforced. But, I think that the simple knowledge that these propensities exist should be reason enough for concerned professionals to combine their energies to come up with a solution … or at least a stop-gap process or method to mitigate the kinds of tragedies that have been seen, and are apparently (at least in my limited scope) on the increase.

No … I am certainly not saying that whatever can be done would be easily accomplished. But, rather than stand around the smoking hole, kicking dirt with the toes of our shoes, and lamenting what has happened, yet again … certainly the amount of knowledgeable, committed, and innovative professionals we have in this business should be able to come up with a “plan” on how to educate pilots … of all backgrounds, cultural differences, religious and other differing beliefs … that competency simply MUST be achieved and simply because one grew up the son of the village chief, or for that matter, the daughter of that chief, doesn’t necessarily mean that individual will assimilate the necessary skill sets AND, I think, most critically, understand whether or not he (or she) has the necessary understanding to know if he (or she) really does have a mastery of those skills.

Landing the airplane, each time, every time, regardless of the winds, rain, runway conditions, etc. is not always the best of decisions – sometimes (not all the time … but certainly some of the time) a decision to “go around” is the very best professionally determined decision that could be made … and no one should ever feel any less professional for recognizing when the circumstances are either beyond their capabilities, or at least questionable. The professional participants in aviation should pool their collective understandings and make sure that this philosophy becomes the bedrock on which ALL pilot training and evaluation must rest …and no, I don’t have a recommendation right now about how to do that … but someone might … and others may reach that point … but only IF they try!

Before anyone jumps down my throat for speaking this way … I’m not saying that “us smarter folks” should go in and “lay down the law” to those “lesser smarter folks.” But I think a mutual participation in determining the causes of such inattentive or speculative accidents should be the topic of multicultural discussions that address the reasons and the solutions. Those who have been … and I’ll say “victimized” … by their belief systems, will be able to understand and accept the logical corrective attitudes ONLY IF they are integrally involved in determining the causes and the potential solutions.

They have to recognize the validity and OWN the responsibility for coming to the conclusions that are the correct conclusions. Perhaps one of the ways in which such an understanding might be achieved may be through a sports analogy – and by that I mean critically pointing out how a specific person – whether basketball, hockey, soccer (football, to some), or almost any other sport that can point to some clearly good players. If you talk to those players, they’ll likely be the first to point out that it is their teammates that allow them to “look” like the hero. Of course they are quite good – maybe none better – but I think each one would easily point to their teammates as those who are regularly instrumental in achieving the success they each enjoy …and they are invariably correct.

Last edited by AirRabbit; 20th Jul 2014 at 04:54.
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Old 26th Jul 2014, 15:55
  #916 (permalink)  
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Some extracts from this article, looking at the final report: Asiana Airlines flight 214 crash caused by Boeing planes being 'overly complicated' - Americas - World - The Independent

I have added amphasis to the points I found most interesting.


Acting chairman Chris Hart said that, between them, the three veteran pilots were found to have committed between 20 and 30 errors in their final approach to San Francisco International – varying from minor to highly significant.
Perhaps the most serious came from the 45-year-old captain Lee Kang Kuk, who was new to the 777. Kuk inadvertently prevented the plane’s “autothrottle” system from maintaining speed on approach for landing.
US investigators called on the manufacturer to make changes to the increasingly complicated automated controls which, they claimed, pilots no longer “fully understand”.
Hart said the accident underscores a problem that has long troubled aviation regulators around the world – that complicated automated aircraft controls, designed to improve safety, are creating new opportunities for human error.


The Asiana flight crew “over-relied on automated systems that they did not fully understand,” Hart said.
It is interesting that he says "has long troubled aviation regulators around the world" no mention of the numerous flight crew who have been shouting about this.
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Old 26th Jul 2014, 17:43
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I believe that if we continue to insist that, as an industry, we should be “depending on technology” to get every group of incompletely or incompetently trained pilots, some of whom, apparently, at least at times, place “cast hierarchy” above competency (which has apparently resulted in serious incidents or accidents), we are going to continue to see, and perhaps see an increase in, the occurrences of this kind of “what the @#$% were they thinking” questioning … after the fact. I was under the impression quite some time ago, that we humans finally admitted that technology certainly aids, but does not, cannot, replace human thinking and the application of human recognition and logic. Sometimes I am convinced that we have, perhaps conveniently, forgotten the fact that these so-called “automatic” systems do not think and they do not plan … they do not predict or anticipate the future … they ONLY compare the specific existing status against what a human has set as a very specific and limited scope of a desired outcome. The result is then that these automatic systems attempt to use the range of pre-set (i.e., programmed) capabilities to achieve what was set by that human ... regardless of what happens during the interim.

Of course, these systems perform these comparisons and executions at a rate that is beyond (sometimes well beyond) the range of human capability … but these “systems” do not understand (are not capable of understanding) the ultimate goal of that particular flight crew member. And before anyone becomes offended or thinks I am being insensitive, let me add that I am not advocating the elimination of “cast hierarchy” in those instances where it is tradition or an issue of national pride … far from it … BUT … we MUST recognize that personal belief preferences are not always conducive to the safe and productive operation of at least some technology advancements – particularly in those cases where mismanagement, or incomplete or inaccurate management of those systems can lead to kinds of tragedies we have witnessed recently – and they seem to be occurring at an increasing rate.

However, because it is not likely that an international aviation regulation would be effective in eliminating such “hierarchical cast preferences,” it may be that such a position may have a much better chance of being accomplished through the airplane or airplane system manufacturers. This would require something like these manufacturers refusing to stand behind the equipment they provide when the practice of any such “hierarchical cast preferences” result in the overdependence on such systems and cause, or contribute to, accidents or incidents like those we’ve seen recently. Will this work? Maybe. However, such an action should clearly bring these concerns to the attention of those cultures that embody such “class recognition and/or reverence” that has been seen to raise its presence in airplane cockpits - at least, at times, resulting in tragic consequences.
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Old 27th Jul 2014, 19:39
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US investigators called on the manufacturer to make changes to the increasingly complicated automated controls which, they claimed, pilots no longer “fully understand”.
This is not going to happen. 99.99% of pilots understand it very well. Also changing design right now would probably confuse things even more and cause more harm than good.
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Old 27th Jul 2014, 19:40
  #919 (permalink)  
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porterh - adding low speed protection to FLCH would surely confuse no-one of average intelligence?
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Old 27th Jul 2014, 19:47
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BOAC - we have been through this countless times, nothing more than "average intelligence" is required to understand current logic, also there were arguments presented why actually it is more logical they way it is. Let's not start another futile running in circles discussion.
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