Landing Incident @ SFO

[tomokc]

I'm not a 121 or 135 guy, but is there a concern that problems occur so infrequently in the real world that the pilot(s) have a delay in responding due to initial disbelief?

"I can't be Vref -30 and below DH one mile from the marker - it must be something else."

I know this isn't what you train for, but does complacency exist when you're out on the line?

 

[jtrain609]

Put one of these in every airline cockpit?

It's already built into the low speed awareness on the tape and the PLI.

 

[wbauman1217]

I've never flown anything bigger than a Navajo, but I've got a theory to throw into the pot:

Let's say the pilot thought he had auto thrust engaged, but it wasn't, so he just pitched for glideslope without realizing his throttles were at idle. That could explain the delayed reaction.. Still not much of an explanation for allowing your speed to get so far below approach speed.

 

[seagull]

I've never flown anything bigger than a Navajo, but I've got a theory to throw into the pot:

Let's say the pilot thought he had auto thrust engaged, but it wasn't, so he just pitched for glideslope without realizing his throttles were at idle. That could explain the delayed reaction.. Still not much of an explanation for allowing your speed to get so far below approach speed.

If that is coupled by focusing on outside-the-aircraft issues and the pilot is expecting that a system that has never failed in his career to work (errant mental model), then it does explain the airspeed getting that slow.

 

[wbauman1217]

If that is coupled by focusing on outside-the-aircraft issues and the pilot is expecting that a system that has never failed in his career to work (errant mental model), then it does explain the airspeed getting that slow.

Maybe auto thrust was inop and they didn't recognize it?

 

[ScorpionStinger]

So from your guys' POV, what is the systemic factor that connects them all?

My perspective, which we've discussed before and diverges from some of you 121 guys, is that this is rooted in a combination of currency/recency/proficiency (as in, long haul international guys not getting many opportunities to get their hands on the yoke and throttles and land very often) and a de-emphasis of hands-on airmanship paired with an emphasis on automation.

The first part, there isn't a whole lot that can be changed systemically to change, and the second part is obviously rooted in some safety and economic factors that drive a lot of 121 policies.

What's the perspective from where you guys sit?

DITO!!!! My ex-girl friend and I were just texting the same thing yesterday! She's not even a pilot and we both came to that conclusion regarding Automation. The focus of our text was on Pilot Error.

First she believed their ethical & cultural background played a bigger role than what is being perceived. She said she remembered reading about Asian Airline's cultural attitudes in the book "OUTLIERS" (where the author discussed a (Korean Air Cargo Flight 8509 crash). She mentioned how Asian cultural attitude in the cockpit has been cited as a cause of many accidents in Asian carriers. They're taught at a young age to respect and obey authority figures, and not speak out.

Although she was right that rarely do Asian FO's rebuttal, challenge, and correct authority figures such as the Captain who has final authority. I've been reading that those cultural attitudes and practices have been diminishing due to better CRM implementation, and initial PPL flight training. They are taught in flight training to not be tools i guess. Thus Asian Carriers, specifically Korean Carriers have greater safety records.

In terms of Pilot Error, we were left with possible crew over dependance on "Automation" as a factor.

We discussed "if" it was the Airspeed Indicator that malfunction both pilots should have caught some warning signs before hand. Also, she mentioned that "someone should have been looking outside & at the instruments".

She is 100% correct. That's coming from someone with 0 aviation experience, and 0 flight hours.

 

[Boris Badenov]

Apparently she's not right. It could happen to anyone and it's the airport's fault for turning off the ILS or maybe the company's fault for failing to check to make sure these multi thousand hour pilots remembered how to land or possibly Korea's fault for apparently having a Crash Culture or something...*inhale*. But it is definitely not the case that these two jokers just screwed up.

 

[seagull]

I wouldn't use Gladwell as an authoritative source, he's a pop sci writer and often wrong, entertaining and thought provoking as his books may be.

 

[ScorpionStinger]

Ruled out the Asian cultural attitude, since both were captains...... Then again maybe not.

Another interesting aspect is the very High Decent Rate. Wonder if the PNF spoke up!

What would you guys do if you were PNF?

Captain PNF: "Hey Captain, add power! Were a bit low now."
Captain PF: "I know, It's alright I'll grease it softly on the runway, it'll float, just watch."

 

[Seggy]

Apparently she's not right. It could happen to anyone and it's the airport's fault for turning off the ILS or maybe the company's fault for failing to check to make sure these multi thousand hour pilots remembered how to land or possibly Korea's fault for apparently having a Crash Culture or something...*inhale*. But it is definitely not the case that these two jokers just screwed up.

If you are really thinking that, you really don't get it.

 

[ScorpionStinger]

I wouldn't use Gladwell as an authoritative source, he's a pop sci writer and often wrong, entertaining and thought provoking as his books may be.

1) Beyond being a pop sci writer, he is correct.
2) He's not the "Source" of the information.
3) See the Red Link I posted, many authoritative sources. Also 44min Video Re-presentation.
4) Again, she is not in Aviation, it's a book she read recently, and the section of the book regarding asian culture, respect for authority figures, not speaking out, etc., came to her mind as a possible cause. Human/Pilot Error.


Below is video reenactment of that Korea Air Cargo 747 crash...Goes into great detail regarding the Asian Culture and flying.

 

[seagull]

It is possible that local cultural values were an issue, but in this case we have a senior training Captain in the right seat, who was also apparently well acquainted with the Captain in the left seat. The power gradient could have gone either way, or been neutral. I would not say it was more relevant than the same issue would be with a U.S. flight crew based on what we know at this point, and absent more information.

 

[Seggy]

seagull, let us not forget the two other pilots on the flight deck......

 

[seagull]

Ruled out the Asian cultural attitude, since both were captains...... Then again maybe not.

Another interesting aspect is the very High Decent Rate. Wonder if the PNF spoke up!

What would you guys do if you were PNF?

Captain PNF: "Hey Captain, add power! Were a bit low now."
Captain PF: "I know, It's alright I'll grease it softly on the runway, it'll float, just watch."

Depends on what the pilot monitoring (PM, not PNF anymore) was doing. He (as reported) was not just PM, he was also a training captain and (most probably if true) actually the legal PIC of the flight. There are any number of other explanations that would fit what we know right now. He could have been trying to talk the the Capt about getting down on profile, perhaps distracted by something else at the moment (looking down to switch a frequency or at a chart), or any number of things. Having spent a few years as a check airman/instructor a similar sized aircraft, I can tell you that it is a busy job. If a crew got into the FLCH autothrottle corner-point where they do not provide any speed protection (and it is a corner point most pilots will never see in their careers), it could be quite a set up in terms of automation bias, expectations, etc.

People want to make this very simple, but the world is actually not as simple as many realize.

 

[seagull]

seagull, let us not forget the two other pilots on the flight deck......

How do you know they were on the flight deck? Even assuming they were, how much time have you spent as a relief pilot? I can tell you that there are quite a few that are not as attentive as they should be. Even as a check airman there were times when I was giving line checks to crews that it was all I could do to keep my eyes open due to lack of sleep, and my experience is far from unique! Watching others fly is very, very, passive, and so it is very easy for the mind to drift away from the task at hand and a real fight to prevent that from happening.

 

[z987k]

After all the hullaballoo, they still haven't done a very good job on the signage out there, just sayin'.


I'm fond of:

"During descent FO confused aircraft call signs the crew responded to a radar vector given to another aircraft. FE picked up something was wrong and said nothing. FO was also not happy but said nothing. AC took up new heading. Despite visual conditions crew did not look out and see that the current heading would not take aircraft to the airfield. Radar picked up 70 degree heading error and corrected. Captain hit FO with the back of his hand for making the error. The incident caused by similar sounding call signs, lack of situational awareness, crew not looking out, crew not speaking up, incorrect radio procedures and implicitly trusting ATC."

The FO just saying "roger" to anything and everything was very very common. Even if roger couldn't possibly be an applicable response. "AMF 123, say airspeed." "AMF 123, roger."

 

[Cherokee_Cruiser]

Hey Derg, I'm still waiting for you to "toss me the keys" of moderation as you claimed you would do. This place has some slime that needs cleaned up.

Are you serious? You are far too emotional on issues to be a fair moderator. Union issues, especially.

You're biased, as is clear by your statement: "this place has some slime that needs cleaned up." Clearly implying you already know the people here (slime) that you will personally target (clean up).

 

[PhilosopherPilot]

Apparently she's not right. It could happen to anyone and it's the airport's fault for turning off the ILS or maybe the company's fault for failing to check to make sure these multi thousand hour pilots remembered how to land or possibly Korea's fault for apparently having a Crash Culture or something...*inhale*. But it is definitely not the case that these two jokers just screwed up.

No one said they didn't make a mistake. But you're dead wrong if you think it couldn't happen to you.

Read up on Just Culture. Because you're human, mistakes are inevitable. They will happen. Some big, some small. The expectation should be that someone notices, and speaks up. We don't yet know if someone noticed, but didn't speak up.

In my experience with FOQA, none of the crews thought they would ever get their aircraft into the situations they did. Most were conscientious, but just were either making the "best" out of a bad situation, or simply didn't realize how bad their situation was. There is always a moment where you become aware of how bad it's getting. Hopefully, it is soon enough to fix it, or go around.

The point of a callout is to snap you out of your goal-driven mindset, and get you to see what the situation is.

 

[Cherokee_Cruiser]

To borrow this from pilot and author Patrick Smith:

Lastly, we're hearing murmurs already about the fact that Asiana Airlines hails from South Korea, a country with a checkered past when it comes to air safety. Let's nip this storyline in the bud. In the 1980s and 1990s, that country's largest carrier, Korean Air, suffered a spate of fatal accidents, culminating with the crash of Flight 801 in Guam in 1997. The airline was faulted for poor training standards and a rigid, authoritarian cockpit culture. The carrier was ostracized by many in the global aviation community, including its airline code-share partners. But South Korean aviation is very different today, following a systemic and very expensive overhaul of the nation's civil aviation system. A 2008 assessment by ICAO, the civil aviation branch of the United Nations, ranked South Korea's aviation safety standards, including its pilot training standards, as nothing less than the highest in the world, beating out more than 100 other countries. As they should be, South Koreans are immensely proud of this turnaround, and Asiana Airlines, the nation's No. 2 carrier, had maintained an impeccable record of both customer satisfaction and safety.
Whatever happened on final approach into SFO, I highly doubt that it was anything related to the culture of South Korean air safety in 2013. Plane crashes are increasingly rare the world over. But they will continue to happen from time to time, and no airline or country is 100 percent immune.


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South Korea of the 80s and 90s is not the South Koera of today 2013. It is far better, far safer, with better CRM than in the 80s and 90s. Would you like to compare air safety in the USA in the 70s, 80s, and 90s compared to today? It is also better and safer. I wouldn't use this as red herring and say OMG! Cabotism! This proves it is dangerous!

 

[Seggy]

How do you know they were on the flight deck?

How do you know they weren't? I will take my assumption.

Even assuming they were, how much time have you spent as a relief pilot? I can tell you that there are quite a few that are not as attentive as they should be.

None, but I have spent a ton of time on the jumpseat and know that I will be pissed tested along with the rest of the crew if something happens.

Even as a check airman there were times when I was giving line checks to crews that it was all I could do to keep my eyes open due to lack of sleep, and my experience is far from unique!

To have TWO additional pilots not alert during final approach? Is that something you think they will likely find here? Or do you think the culture will have more at play?

Watching others fly is very, very, passive, and so it is very easy for the mind to drift away from the task at hand and a real fight to prevent that from happening.

I have talked a lot of former Flight Engineers on the 727 and DC-10 recently and they said it was the best seat in the house as they learned a lot catching the mistakes of others.