Landing Incident @ SFO

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PhilosopherPilot said:
Possibly. But the whole point is discovering the underlying issues, and fixing them. And I'm not talking about technology. From what we've learned so far, there appear to be significant culture issues at play here. Of course when the report comes out, we will see for sure.

There was more at play here than stick and rudder skills.
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But they probably would have mitigated all the underlying issues.

Ill take a 300 hour bush pilot flying my 777 over a 1500 hour pilot with a degree in sim wizardry
 
canadian_atc said:
In my profession 60 seconds is an eternity, literally, a hundred things can happen, plans change two-three times when the proverbial turd is hitting the fan, sitting there just watching things go bad for over a minute?? That's got nothing to do with pilot skill, sorry that's just sad to hear.

Only further proves my point.
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Your example is not valid. Imagine on your display you have conflicting information plus a dozen seemingly unrelated alerts or alarms. You have never seen this before nor were you trained to. Resolve it. You have 60 seconds to sort it out. Guess wrong and you die. Still so sure?
 
canadian_atc said:
But they probably would have mitigated all the underlying issues.

Ill take a 300 hour bush pilot flying my 777 over a 1500 hour pilot with a degree in sim wizardry
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And here we are, back at the root of my argument. Humans make mistakes, and no amount of experience and skill can prevent that. Eventually, even the 10,000 hour instructor pilot will ball one up without the proper safeguards and culture in place.
 
Hacker15e said:
Can you expand on that a bit, specifically what you've seen in this discussion that makes you say that?
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There are a few on here who are intent on believing that:

1. This is an isolated incident, and could never happen to them personally.
2. It is because they are bad pilots, or at least weak pilots skill-wise.
3. They must have been negligent.
 
PhilosopherPilot said:
Possibly. But the whole point is discovering the underlying issues, and fixing them. And I'm not talking about technology. From what we've learned so far, there appear to be significant culture issues at play here. Of course when the report comes out, we will see for sure.

There was more at play here than stick and rudder skills.
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That may be the case and we'll see what happens. Personally I'm not convinced of this cultural issue being alluded to.

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Here is more or less what our organization says on the first page of our ops manual regarding just culture: We believe in a Just Culture that doesn't punish people for making honest mistakes. Therefore, our desire is to eliminate systemic errors rather than blame individuals. We strive for an atmosphere of trust in which people feel free to share essential safety-related information. At the same time, we want you to clearly understand where we draw the line between acceptable and unacceptable behavior. To keep the culture truly just, we hold you accountable for willful, illegal or immoral acts.

I think that last statement may be defined elsewhere as "negligent," so that may be where I differ from PhilosopherPilot. I can't remember the exact numbers, but I think for every accident there are something like 30 incidents and 300 ASAP's (as you guys call them, we call them SYE's). Statistically speaking, that's how accidents tend to go. So our organization is pretty demanding of having everyone report stuff in order to truly eliminate systemic errors.
 
RedBaron2000 said:
At the same time, we want you to clearly understand where we draw the line between acceptable and unacceptable behavior. To keep the culture truly just, we hold you accountable for willful, illegal or immoral acts.

I think that last statement may be defined elsewhere as "negligent," so that may be where I differ from PhilosopherPilot. I can't remember the exact numbers, but I think for every accident there are something like 30 incidents and 300 ASAP's (as you guys call them, we call them SYE's). Statistically speaking, that's how accidents tend to go. So our organization is pretty demanding of having everyone report stuff in order to truly eliminate systemic errors.
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"To keep the culture truly just, we hold you accountable for willful, illegal or immoral acts." Okay, let's address that.

Willfull = "Damn the torpedoes, I'm going to fly this mamma jamma into the seawall."

Did they do that, you think?

Illegal = "I'm going to drink these 5 beers and snort this cocaine before I fly."

They didn't drug test, but do you think they were all drunk?

Immoral = Not really relevant to this accident.
 
PhilosopherPilot said:
There are a few on here who are intent on believing that:

1. This is an isolated incident, and could never happen to them personally.
2. It is because they are bad pilots, or at least weak pilots skill-wise.
3. They must have been negligent.
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Do you think there is any possibility that any of those are true?

Obviously item #1 is ridiculous for any pilot to think, so I completely agree with you there, but there is certainly a possibility that #2 and #3 are true. Certainly the post quoting from the KAL sim instructor (if it is to be believed, and obviously I don't have any provenance to prove its authenticity) supports that.

I think the problem is when we start ruling out root causes with no evidence to do so. Although I understand the discussion about "just culture", I don't understand the seemingly associated need to not point the finger at an individual's actions and find that there is a professional weakness in that/those individuals that is the root cause.

Not saying that is the root cause, but I don't get how someone can state that it definitively is not possible for that to be found eventually as the root cause.
 
RedBaron2000 said:
Here is more or less what our organization says on the first page of our ops manual regarding just culture: We believe in a Just Culture that doesn't punish people for making honest mistakes. Therefore, our desire is to eliminate systemic errors rather than blame individuals. We strive for an atmosphere of trust in which people feel free to share essential safety-related information. At the same time, we want you to clearly understand where we draw the line between acceptable and unacceptable behavior. To keep the culture truly just, we hold you accountable for willful, illegal or immoral acts.
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That makes perfect sense to me -- I'm glad to see that explicitly stated in a company's policies. Can anyone say if that is representative of policies/cultures across the 121 community?

In the Air Force flying community, we say "there is a difference between a mistake and a crime," but it is exactly the same mindset.

Unfortunately, there are a lot of times that mistakes are punished as crimes because of differing viewpoints between flying communities regarding where that line between mistake and crime is.
 
Wow. I'm saying I think it would be easy to depend on all the cool stuff that plane has and as a result become a little complacent.

I dunno where you got anything close to "it couldn't happen to me" out of that.

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desertdog71 said:
Wow. I'm saying I think it would be easy to depend on all the cool stuff that plane has and as a result become a little complacent.

I dunno where you got anything close to "it couldn't happen to me" out of that.

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I wasn't talking about you, sir.
 
Hacker15e said:
Do you think there is any possibility that any of those are true?

Obviously item #1 is ridiculous for any pilot to think, so I completely agree with you there, but there is certainly a possibility that #2 and #3 are true. Certainly the post quoting from the KAL sim instructor (if it is to be believed, and obviously I don't have any provenance to prove its authenticity) supports that.

I think the problem is when we start ruling out root causes with no evidence to do so. Although I understand the discussion about "just culture", I don't understand the seemingly associated need to not point the finger at an individual's actions and find that there is a professional weakness in that/those individuals that is the root cause.

Not saying that is the root cause, but I don't get how someone can state that it definitively is not possible for that to be found eventually as the root cause.
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I'm merely speaking from my previous experience in the safety department. There were examples of events that could have been accidents, and the pilots were good pilots. Conscientious pilots who never, ever thought that they would nearly become a statistic. I tend to give the pilot's skills the benefit of the doubt, and look for human factors, merely because in general that's the common thread in the events I've seen before.

This case certainly appears to match, given that there was a check airman in the right seat, and the guy receiving OE had 10,000 hours, and was an instructor on the A320. MAYBE they were just bad pilots, and this accident had been waiting to bite them for the past several thousand hours. Do you think that is likely?

I could be completely wrong, but I tend to think that they were at least average pilots skill-wise, but other factors came into play to bite them this time. Maybe there was a CRM failure? Maybe fatigue was involved? Maybe the autothrottles malfunctioned, and they were fatigued, with a CRM weakness? Who knows? We will learn more once the report comes out. I just doubt it is going to boil down to flying skill.
 
PhilosopherPilot said:
Do you think that is likely?
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Likely, no. Possible, yes.

Thanks for your response -- I largely agree with your point of view, but I also think that it is still possible that there are pilots out there in the major airline world who are not up to certain performance levels and that deficiency is rarely seen -- if ever -- because of how capable and reliable the systems are that have been built up to facilitate air transport as we know it today.

I say this based on my experience flying with reservist USAF pilots who are also major airline pilots. My observation was that they were extremely proficient when the flight went exactly as planned and the aircraft could be flown using FMS and FGS inputs primarily. Unfortunately, I also observed on a frightening number of occasions that when pure hand flying and basic on-the-fly airmanship was required, many of them were below average in ability to execute. As someone mentioned in an earlier post, this was especially acute when it required physically looking out the window!

As I stated earlier, I definitely don't believe this was primarily "talent" problem (obviously they hadn't gotten that far in their flying careers by being total clowns, although I do believe that some of them were just not great pilots to begin with), but an "experience" problem. In other words, they hadn't spent much time recently (several years, perhaps) in flight conditions requiring hand flying or real-time fast-paced 3-dimensional decisionmaking, so that part of their airmanship had atrophied. As we know, most of the different facets of flying are perishable skills, and if they are not practiced they can be lost or significantly degraded over time. The extremely predictable and safe nature of 121 flying (and the lack of anything really abnormal occurring) hadn't required them to step out of that comfortable position and keep those abilities exercised.
 
PhilosopherPilot said:
There are a few on here who are intent on believing that:

1. This is an isolated incident, and could never happen to them personally.
2. It is because they are bad pilots, or at least weak pilots skill-wise.
3. They must have been negligent.
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I was waste deep in this thread and I don't think I saw, even a few, adopting these views.

I think we had a couple of distracting semantic arguments about negligence. Specifically, can you believe that a pattern of errors or mistakes can reach the level where we are comfortable using the word, negligence. I agree with most everything you've said and have found your posts thought-provoking.

3) I don't think this is an example of negligence.

2) I don't think they were bad pilots. Given their level of experience, my first thought was that this airline has some systemic problems. The event and discussion led me to ask, does my team have any similar systemic problems and would I be able to recognize them if they were present.

1) I think the enthusiastic curiosity about this crash suggests a willingness to question whether it could happen to us. We put ourselves in the cockpit of this 777, first as ourselves and then as the Asiana crew. As details were revealed, my thoughts were - Do I know what I think I know about my plane? Are there areas where I'm not proficient (or my crew)? Does my team's CRM help make this outcome less likely?

Statistically, the outcome is rare, an outlier, it is isolated. I think we all identified the elements that weren't rare or isolated. From flying into a new airport to coming in high and hot on a visual. We've all learned something about our equipment...when it didn't function like we thought it would. Other than a passing comment, I don't think anybody wrote it off as an isolated incident without wanting to know more.
 
Well, it's good to know that on final for leg 10 of the day I need to be thinking about how mistakes are inevitable and a just culture will absolve me of mine. All this time I was focused on making sure the gear was down, the speed was appropriate, and other important things associated with not balling up an airplane.
 
PhilosopherPilot said:
MAYBE they were just bad pilots, and this accident had been waiting to bite them for the past several thousand hours. Do you think that is likely?
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Uh, yes. I've flown with guys with 10s of thousands of hours who couldn't find their ass with both hands and a map. Generally, more experience = better pilot, but there are always outliers.
 
jynxyjoe said:
Funny enough... both jtrain609 .

Someone here has to bring the funny.
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This thread has been bringing the funny! 57 pages and nobody has bothered to look up the actual definition of negligence (hint: nobody has given the proper definition yet). This has been like watching a dog chase a car WHILE chasing its tail!
 
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