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, theres no such restraint and theres not much in the e-mail Ive 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. Ive 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, Im 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 dj vu settles in; a couple of correspondents think theyve 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 dont 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 Captains 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 Captains INU/ADI had proven faulty on the inbound flight and wasnt repaired properly. When the Captain overbanked on a night takeoff from Londons 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 Im 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 214s 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 thats a design flaw or a training lapse in the airlines program? Im sure thats 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?
Im sure that question will come up, too. And given the language and culture barriers, I dont envy the NTSB figuring it out.
