Landing Incident @ SFO

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Only Korean I flew with always called ahead to whoever landed first at UT25 and asked them to grab him a "4 piece" fried chicken from the gas station. He may have also kicked a hole through a door while drunk.

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Error chain:
new PIC, new check pilot
out of their time zone
ILS OTS
unstable approach
(new) 1 flight director on 1 off, don't know about Boeings but very bad in the Bus
everybody in the cockpit sight seeing, no one looking inside

break a link in the chain and we would be talking about something else
 
ATN_Pilot said:
My biggest problem with your attitude is your continual use of the word "negligent." There was no negligent behavior in this crash. There were mistakes. Mistakes that any of us could have made.
Click to expand...

Words have meaning. When we are free to redefine words at will or reject definitions we don't like, effective comminication is compromised.

Intent is not a necessary component of negligence. There are lawyers on this forum that can correct me if I'm wrong but I understand that "due care" is a common legal test for negligence. The Comair crew wasn't merely at fault, they were negligent.

Any pilot can make mistakes in judgement or execution, that is well understood. At a certain point, the threshold of negligence is reached. Often negligence is the result of an accumulation of mistakes. I think it is a rhetorical trick to take a case like Comair, examine each mistake, then claim that because any one of us could have made a component mistake we are just as capable of having the same outcome.

This idea that we can't comment critically and aggressively on the mistakes of others when there are tragic outcomes because we are all capable of making mistakes is a puzzling standard that paralyzes discourse. Instead of just accepting that our mistakes are subject to criticism, it seems some pilots have created a polite fantasy world.

Identifying and criticizing mistakes is not arrogant behavior if you understand that your own mistakes are subject to the same scrutiny, which I do. This idea that criticizing poor piloting is a claim of superior skills by the critic is not a very robust argument.
 
Found this, don't know if posted yet.

After I retired from UAL as a Standards Captain on the –400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it’s a minefield of a work environment ... for them and for us expats.

One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don’t think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all “got it” and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.

We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.

This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce “normal” standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this Asiana crew, it didnt’ compute that you needed to be a 1000’ AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn’t pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.

Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested “Radar Vectors” to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then “Cleared for the approach” and he could have selected “Exit Hold” and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to “Extend the FAF” and he couldn’t understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was “Hold at XYZ.” Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).

This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141’s in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!

The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can’t change 3000 years of culture.

The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It’s actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don’t trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don’t get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!

Finally, I’ll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.

Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250’ after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800’ after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real “flight time” or real experience did he get. Minutes! Of course, on the 777 or 747, it’s the same only they get more inflated logbooks.

So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.
 
Pilot Fighter said:
Words have meaning. When we are free to redefine words at will or reject definitions we don't like, effective comminication is compromised.

Intent is not a necessary component of negligence. There are lawyers on this forum that can correct me if I'm wrong but I understand that "due care" is a common legal test for negligence. The Comair crew wasn't merely at fault, they were negligent.

Any pilot can make mistakes in judgement or execution, that is well understood. At a certain point, the threshold of negligence is reached. Often negligence is the result of an accumulation of mistakes. I think it is a rhetorical trick to take a case like Comair, examine each mistake, then claim that because any one of us could have made a component mistake we are just as capable of having the same outcome.

This idea that we can't comment critically and aggressively on the mistakes of others when there are tragic outcomes because we are all capable of making mistakes is a puzzling standard that paralyzed discourse. Instead of just accepting that our mistakes are subject to criticism, it seems some pilots have created a polite fantasy world.

Identifying and criticizing mistakes is not arrogant behavior if you understand that your own mistakes are subject to the same scrutiny, which I do. This idea that criticizing poor piloting is a claim of superior skills by the critic is not a very robust argument.
Click to expand...

Again, you miss the point. Step out of the "Blame Mentality." Careless, negligence, these are words of blame. To increase safety, we need to focus on trapping threats and mitigating errors.

If we focus on blame, people don't come forward to report vulnerabilities in the system. Maybe there's a contributing factor that everyone at Asiana was aware of, but didn't mention because they would be punished instead of rewarded. If two experienced instructor pilots (PF was a A320 instructor prior to 777) could allow this to happen, there is a systemic problem at Asiana in regards to CRM and cross checking. How else will you discover these weaknesses without a just culture? When speaking up gets you punished or censured, it makes the whole system less safe.

Calling them negligent reinforces the antithesis to just culture, and that's why you're getting pushback from the guys on here with extensive contemporary safety experience.
 
Pilot Fighter said:
Words have meaning. When we are free to redefine words at will or reject definitions we don't like, effective comminication is compromised.

Intent is not a necessary component of negligence. There are lawyers on this forum that can correct me if I'm wrong but I understand that "due care" is a common legal test for negligence. The Comair crew wasn't merely at fault, they were negligent.

Any pilot can make mistakes in judgement or execution, that is well understood. At a certain point, the threshold of negligence is reached. Often negligence is the result of an accumulation of mistakes. I think it is a rhetorical trick to take a case like Comair, examine each mistake, then claim that because any one of us could have made a component mistake we are just as capable of having the same outcome.

This idea that we can't comment critically and aggressively on the mistakes of others when there are tragic outcomes because we are all capable of making mistakes is a puzzling standard that paralyzes discourse. Instead of just accepting that our mistakes are subject to criticism, it seems some pilots have created a polite fantasy world.

Identifying and criticizing mistakes is not arrogant behavior if you understand that your own mistakes are subject to the same scrutiny, which I do. This idea that criticizing poor piloting is a claim of superior skills by the critic is not a very robust argument.
Click to expand...


As PhilosopherPilot has so eloquently stated in several posts now, you don't understand Just Culture. What's worse, you don't seem to care. I hope you don't have anything to do with 121 flying. Your attitude is a serious accident waiting to happen.
 
PhilosopherPilot said:
Again, you miss the point. Step out of the "Blame Mentality." Careless, negligence, these are words of blame. To increase safety, we need to focus on trapping threats and mitigating errors.
Click to expand...

I agree to a great extent. I didn't think that these things were mutually exclusively but concede that simply labeling something as negligent and walking away does not improve safety. Despite my strong feelings about Comair, I welcomed the approach of investigators and policy makers and the subsequent enhancements to safety.

I can see how my comments could lead to assumptions about my attitudes towards safety. I've served on military accident boards and I have faced the scenario where nobody wanted to go any further than concluding pilot error.
 
PhilosopherPilot said:
Again, you miss the point. Step out of the "Blame Mentality." Careless, negligence, these are words of blame. To increase safety, we need to focus on trapping threats and mitigating errors.

If we focus on blame, people don't come forward to report vulnerabilities in the system. Maybe there's a contributing factor that everyone at Asiana was aware of, but didn't mention because they would be punished instead of rewarded. If two experienced instructor pilots (PF was a A320 instructor prior to 777) could allow this to happen, there is a systemic problem at Asiana in regards to CRM and cross checking. How else will you discover these weaknesses without a just culture? When speaking up gets you punished or censured, it makes the whole system less safe.

Calling them negligent reinforces the antithesis to just culture, and that's why you're getting pushback from the guys on here with extensive contemporary safety experience.
Click to expand...

I am very familiar with the "Just Culture" model, as the organization I work for believes very strongly in this. Reporting of safety issues is not only encouraged, it is demanded, as those of us in leadership have been told when the safety management isn't getting enough SYE (Share Your Experience) and other types of safety reports from pilots and mechanics. So I get it, and I believe very strongly in the Just Culture mentality. At the same time, that doesn't mean people don't bear responsibility for their actions, and that doesn't mean there cannot be negligence in accidents and incidents. The organization I work for is very fair, and the safety culture is great, yet there have been pilots in the past who have been fired because of their negligence in accidents. I'm not here to say whether the pilots in the Lexington accident were negligent or not, just that even in a Just Culture, people still bear responsibility for their actions.

In Indonesia many airlines in the past I know fined pilots when they elected to go around. They're trying to change this, but this is a perfect example of what you were talking about. This also gets into shame vs. guilt oriented societies, and what makes individuals point out something they see wrong, whether it's the individual doing something wrong or someone else doing something wrong (West = guilt oriented, East = shame oriented).

In the case of Asiana 214, this may have nothing to do with it. It could be as simple as they thought the A/T was engaged and they all just missed the visual cues and decaying airspeed.
 
ATN_Pilot said:
As PhilosopherPilot has so eloquently stated in several posts now, you don't understand Just Culture. What's worse, you don't seem to care. I hope you don't have anything to do with 121 flying. Your attitude is a serious accident waiting to happen.
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Don't compare yourself to PhilospherPilot, you are no philosopher pilot.

Let's see, because I believe that an accumulation of preventable mistakes can reach the threshold of negligence, my attitude towards safety is compromised?

What makes you think that I'm not capable of both being brutally honest about poor piloting and embracing every opportunity and process to make flying safer?

Since you brought up 121 operations. One reason I'm not in 121 aviation is because of my attitudes towards safety. A couple of months ago, I felt one of our pilots needed work on visual approaches. I had the freedom to schedule a non-revenue training flight that included more than a dozen approaches. I can't do that in 121 jet operations. I don't think 121 operations are willing to expend the resources to operate safely.
 
Seggy said:
From what I recall, it was the needless speculation.
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Unless Doug and the mod team have named you the official JC Ombudsman - and frankly, with the favortism shown you they may have - then who the hell are you to be the sole arbiter of what is "needless speculation", "acceptable speculation", a worthy opinion or an unworthy opinion?
 
Whoa boy. Okay, before THIS thread devolves into another Wacofan, Seggy, ATN_Pilot, and whoever else orgy, let me try to get back on track by saying that I heard this morning that the pilots did, indeed, have A/T engaged, and that they did, apparently, think that the 777 was maintaining its own airspeed. It wasn't until it was probably too late to do anything about it that the pilots noticed. So, we are almost definitely looking at a human factors issue as well as a pretty major goof by any pilot inside the cockpit.

I obviously do not fly 121, but while on approach, how often are you guys glancing down during visual approaches to do a basic flight instrument scan? It seems like SOMEONE should have seen that they were below Vref on the tape and said something.

I'm actually a little surprised that there isn't a more obvious Idiot Light or audible warning to indicate that you've gone below Vref. I mean, with all of the other warnings out there ("Sink Rate" "100" etc.) you'd think there would be one for "Airspeed" or "AOA." Besides the stick shaker, is there no real glaring indication of approaching the critical AOA?
 
I absolutely think there was pressure from Boeing, with the 787 having been offline, to rule out mechanical / engineering causes in this case. At the same time, this seems to be a reasonably clear cut accident. Even so, I've been surprised with the pace of the release of facts and evidence by the NTSB. Like you said, at this rate, seems like the final report will be out by the weekend.


deadstick said:
I thought the question was about the PF and whether there was a negative habit transfer from his last airframe.

This is what I undertand as far as the line-up on the flight deck:
-PF was in the left seat on an IOE flght. He has 10k hrs TT and <40 in type. He had prior experience on the 747 landing at SFO.
-PM/PNF was the CKA in the right seat and evaluating the PF on this IOE trip. He had 12k TT and >3k in the 777.
-The jump seat was occupied by an IRO (IRO #2 was in the cabin)

Possible "cultural" issues:
-PF joined the company before the PM/CKA
-PF graduated from the same university as the PM/CKA, but earlier
-PF was senior to the PM/CKA in age, schooling, and time with the company.

I think the info provided by canadian_atc (#864) is interesting. Whether it was the clutch or AT/FLCH issue, (depending on his last aircraft) I can see him relying on AT to hold airspeed, getting confused/frustrated/fixated with the sink rate, altitude, and airspeed ("Why is this not working?") in those final seconds. The PF's frustration could be from the possible culture issue: PF loses face for not figuring it out and the PM/CKA and IRO could cause the PF to lose face by pointing out the problem to him.

The way things are going, the NTSB will have a final out by the weekend. I'll be very interested to see how this pans out.

On another note: NTSB's flow of information. Does anybody think they are doing this to clear Boeing ASAP because of all the 787 issues? Just curious.
Click to expand...
 
Strange stuff indeed these airplane wrecks.

First thing - some of you don't remember it but in the 70's and 80's it wasn't particularly shocking when an airliner crashed. Bad yes, but "OMG! That is shocking!", no. Today it is almost a shock when a major carrier crashes a plane, at least here in the US. I guess it hit me in watching my daughters reaction to the coverage and how utterly surprised she was that a big airplane could crash - but when you consider the safety record over her 15 year lifespan it isn't really. Just off the top of my head I can recall the PSA mid-air in the 70's, a Pan Am 727 in New Orleans, the Delta 1011 at DFW, American 191 in Chicago, the Air Florida Washington DC crash, and others that had occurred by the time I was her age.

The human errors thing and culture - hard thing to prove in a way but different cultures can be weird - and I'm all for finding out the causes and creating "systems" to fix things. I guess my question is, how much safer can things possibly get? As long as humans are at the controls you are going to have an error once in a while and a plane will crash it seems - and that's about what we have - "once in a great while". While the human is the weakest part of the airplane a lot of times, the flip side is that the human can do amazing things - Sully, Al Haynes, etc - that's the flip side to the human error thing. It seems though that at some point you can't get a whole lot safer and I'm wondering how close things are at this point?
 
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