More on Asiana 214

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By Paul Bertorelli , Editorial Director | July 11, 2013

I do it. You do it. We all do it.

As pilots, in the wake of an accident like Asiana 214 last Saturday in San Francisco, we crank up our piety and discipline and decline public comment until the investigators are done. But amongst ourselves, there�s no such restraint and there�s not much in the e-mail I�ve been getting, either, the tone of which is to flat out ask how this crew could have flown such an unstable, off-speed approach. Might as well come right out and say it, even if it will be months before the NTSB puts the puzzle together and learns why the pilots appeared to be so far off acceptable airmanship, much less an A-game. I�ve seen a few unkind student pilot analogies posted and not all of them are from the aviation illiterate masses.

If the current fact pattern is sustained, I�m sure the NTSB will get around to finding out how large looms the human factors aspect of this accident. And at that juncture, a certain d�j� vu settles in; a couple of correspondents think they�ve seen this movie before. One of the things investigators will probably examine is how the flying pilots worked both the automation and the CRM. That may cause the surprise appearance of a large elephant long thought dead: the bad old days of Korean air safety when KAL and related companies had 16 hull losses between 1970 and 1999. Two of the worst were KAL 801 in Guam and KAL 8509, both of which occurred within two years of each other in 1997 and 1999.

In KAL 801, the Captain failed to brief the 747 crew on the approach then followed erroneous glideslope signals, crashing into a hill and killing 228. Investigators determined that a contributing cause was a fundamental aspect of Korean culture in which subordinates don�t question their superiors--filial piety woven into the base societal structure in a way that deifies the left seat occupant. In the west, you'll sometimes hear the term "five-striper" applied to such a situation .�The FO and engineer on 801 failed to question the Captain�s actions and decision-making, the very thing that modern CRM is supposed to prevent.

The circumstances were different for 8509, a 747 freighter, but the outcome was the same.The Captain�s INU/ADI had proven faulty on the inbound flight and wasn�t repaired properly. When the Captain overbanked on a night takeoff from London�s Stansted Airport, the FO rode through the subsequent departure and crash without uttering a word, even though his ADI was functioning normally. That accident proved to be a watershed for KAL, serving as a wakeup call to improve training and CRM in a way that eventually elevated the airline to among the safest in the world. But human perfectibility being what it is, changing a thousand years of culture might not be as easy as that, and I�m sure investigators will consider it during their interviews and CVR analysis.

Some have seen in the 214 accident an eerie echo of another more recent crash: Air France 447 in 2009. In that accident, three crew members mushed a perfectly recoverable aircraft into the ocean because of confusion over instrument and automation indications and a baffling inability to interpret stall indications. Could flight 214�s crew have suffered similar confusion over the arming of but the failure to engage the autothrottles? Did that even matter? Is there a human interface issue with the automation that�s a design flaw or a training lapse in the airline�s program? I�m sure that�s another lead that will have to be pursued in explaining why the approach went so wrong.�

The Asiana crash reminds me of another accident I remembered, but I had to call my friend John Eakin at Air Data Research to pin down the details. It was Continental 1713, which crashed on departure in a raging snow storm from the then-Stapleton Airport in Denver in November, 1987. The investigation revealed that the airline had paired two inexperienced in-type crew members, one with 166 hours, the other with 26 hours. And the relatively green Captain assigned the takeoff to the FO who over rotated on takeoff and lost control of the DC-9.

After 1713, the NTSB recommended�and the FAA adopted�not pairing two low-time crew members on the same flight. I suspect the NTSB will consider if Asiana repeated that mistake. Although both pilots had plenty of total time, the Captain was 43 hours into his IOE and, according to Asiana, the check airman training him was on his first flight as an instructor. Could that, coupled with whatever remnants of Korean culture that persist despite CRM training, have been a factor?

I�m sure that question will come up, too. And given the language and culture barriers, I don�t envy the NTSB figuring it out.

Comments (7)

The Power Line blog has a letter from a retired UAL Standards Captain on the 747-400 who spent five years in Korea training Asiana and KAL pilots. It's definitely worth a read.

http://www.powerlineblog.com/archives/2013/07/on-crashes-and-pilot-training.php

Posted by: Jay Maynard | July 12, 2013 8:23 AM Report this comment

The hick hack about this accident is sickening, as self-declared senior pilot hat people all across the board rip every little released detail to shreds. Suddenly everyone knows something about how terrible those bad Koreans (insert other foreign country as desired/ needed) operate. The press eats it all, hungry for more sensationalism and gore. Of course it's all to blame on the "foreign" Korean flight-crew, haven't we all known forever that they don't train their pilots to our standards...(we fail to mention that many of those received initial training here in the U.S. and most of those end up holding U.S. certificates, but they fly much better...). Suddenly we even complain about dependency upon electronic flight controls, openly discussing that a 10000 hour long range captain really has little experience "hand-flying" the airplane... DOH! Who would have THUNK? The NTSB dutifully plays press clown and releases every little detail instead of completing its investigation without producing more press bias and misinformation that leads to nothing. God forbid this had been a U.S. airplane with a U.S. crew, our holy regulators would already be cranking the machine for more regulations. To me, (excuse the rant) this accident proves one thing: Accident happen. Mass transportation devices don't happen to plop on the ground with a little bit of dust and smoke, they cause pictures to be remembered. We've had no major accidents in the U.S. of commercial airlines for quite some time, in fact a train-wreck in Canada has killed more people in 10 minutes than have died on American soil in several years, flying commercial airliners. Whats amazing is that "only" two people were killed. Pray its not one of our own jets (equally dependent on auto- this and that's) next, otherwise we may see a regulation asking for minimum 1500 hours but maximum 10.000 hours to warm the sheep skin.

Posted by: Jason Baker | July 12, 2013 9:20 AM Report this comment

I'm not sure that I buy the "cultural propensity for deference" argument in this matter. Our "5-striper" syndrome is an American version of the same thing and an outgrowth of the military background of much of the early airline workforce. CRM helped dispel this immensely, but so did the introduction of female pilots and non-military pilots into the workforce. The pilot technically in command of this flight was the right seater, if I'm not mistaken; that pilot was the instructor for the left-seater, and had over 3000 hours in type. The pilot had essentially zero. This speaks more of the more experienced pilot's level of tolerance and monitoring of the left-seater's performance. In general aviation terms, where does your instructor call out "I've got it" and save your bacon? There were so many opportunities here for proper management of the final glide that were missed that all I can think of is that it was sheer apathy, complacency, and fatigue that were the primary contributors to this one.

Posted by: Shaun Simpkins | July 12, 2013 9:41 AM Report this comment

This blog should be on the home page - there is a lot to learn from this botched approach and others that point towards incomplete and inadequate training everywhere. There should be as much emphasys in hand flying than in automated use of systems. Both need to be up to the same level of competency. Good practice makes better, we can't have the blind leading the blind.

Posted by: Rafael Sierra | July 12, 2013 3:35 PM Report this comment

The copilot was PIC and IP, with 12K hours and 3220 in type. I really doubt that he would have "deferred" to his trainee.

KAL is a completely different airline, and let's not forget that one of those hull losses was when a Soviet pilot shot down KAL 007.

Someone on another site pointed out that Asiana's safety record is comparable to American companies, and that the UAL pilot mentioned in the first comment spent nearly all of his time with KAL, not Asiana.

Let's not start making assumptions based on the nationality of the pilots or the carrier.

Posted by: Keith Wood | July 12, 2013 11:59 PM Report this comment

Another unknown to the culture puzzle ... although the right-seater was both Check Airman and officially the PIC, it is quite possible that within the Company he was junior to the Captain transitioning from the 747 to the 777. (We won't know until the NTSB spews more "facts" to the media.)

In General Aviation it isn't unusual for a "green" CFI to be asked to administer a flight review to a much more experienced aviator. Overcoming the cross-cockpit gradient to be assertive when necessary takes some courage. Imagine if that scenario is backed by a thousand years of cultural protocol as well.

Posted by: Corl Leach | July 13, 2013 12:42 AM Report this comment

Okay, several people have raised the question of the captain working through his IOE being paired with an instructor on his first flight.

I have a question about this, and it's not a rhetorical question -- I really don't know the answer. What other flying would a new instructor pilot be doing? Some sort of recurrent training with experienced captains, or...?

I guess I just don't understand how a new instructor builds experience without working with pilots who are, by definition, also learning.

Posted by: Michael Kobb | July 13, 2013 10:32 PM Report this comment