Figure: Asiana Airlines Flight 214 Crash Landing, from "When Pilots Aren't," ProPilot, March 2104.
It seems most of the pilot world is chalking this crash up to pilots relying too much on automation and not getting enough stick time. Perhaps the best in the business, John Nance, flatly blames "the philosophy behind automation uber alles that encourages us to use autoflight systems almost exclusively, keeping pilots around for emergencies only." ("When Pilots Aren't," ProPilot, March 2104.)
I don't think this was an issue of over reliance on automation. Korean Air Lines (later branded Korean Air) and Asiana Airlines have a history of pilots mishandling visual approaches and not fully understanding the automation. See: Mishaps / Korean Airlines. I think the problems can be boiled down to three areas:
- A culture that frowns upon crew resource management: the pilot flying the airplane was senior in rank and stature to both the instructor pilot and copilot who would have been reluctant to speak up. This isn't an Asian thing at all, the Japanese have fully embraced CRM. The Koreans and Russians have not.
- Pilots that don't have a background in flying visual approaches: there are several Asiana and Korean Air Lines mishaps where the pilots could not bring themselves to fly anything but an ILS and made very bad decisions on the way to mishaps because they simply couldn't keep the airplane on a glide path to the runway without an electronic glide slope.
- Pilots who don't understand the finer points of the automation in their aircraft. More about this below.
As of August 2014 the accident investigation's results are still not published. The narrative comes courtesy of an excellent article in Business & Commercial Aviation. A letter from an ex pat instructor, shown below, sheds light on this mishap.
So why do I make a case study about this mishap, one that could have easily been prevented by an airline willing to fire a few pilots and institute some real changes? Because there is a lesson for us all: when you change equipment, operators, or flying environment, you need to be willing to relearn all that you knew before. You need to invite outside critique. In short, you should be very careful to ward off complacency. More about this: Pilot Psychology / Complacency.
Most everything here is from the references shown below. The Ex Pat's opinions are provided on the condition of anonymity. My usual comments are shown in blue.
- Date: 6 July 2013
- Time: 11:28
- Type: Boeing 777-28EER
- Operator: Asiana Airlines
- Registration: HL7742
- Fatalities: 0 of 16 crew, 3 of 291 passengers
- Aircraft Fate: Destroyed
- Phase: Landing
- Airports: (Departure) Seoul-Incheon International Airport (ICN/RKSI), South Korea; San Francisco International Airport, CA (SFO/KSFO), USA
[Lessons Learned — Asiana Flight 214, Business & Commercial Aviation, August 2014]
- Investigators determined the flight was vectored for a visual approach to Runway 28L and intercepted the final approach course about 14 nm from the threshold at an altitude slightly above the desired 3-deg. visual glidepath. (The ILS localizer was available for lateral guidance, but the glideslope was out.)
- "This set the flight crew up for a straight-in visual approach," said the Safety Board. "However, after the flight crew accepted an ATC instruction to maintain 180 kt. to 5 nm from the runway, the flight crew mismanaged the airplane's descent, which resulted in the airplane being well above the 3-deg. glidepath when it reached the 5-nm point."
- The crew's difficulty in managing the airplane's descent continued as the approach progressed. In an attempt to increase the airplane's descent rate and capture the desired glidepath, the pilot flying (PF) selected an autopilot (A/P) mode (flight level change speed [FLCH SPD]) that instead resulted in the autoflight system initiating a climb because the airplane was below the selected altitude.
- The PF disconnected the autopilot and moved the thrust levers to idle, which caused the autothrottle (A/T) to change to the HOLD mode, a mode which the A/T does not control airspeed. The PF then pitched the airplane down and increased the descent rate. No one in the cockpit — the PF, the pilot monitoring (PM) and the observer — noted the change in autothrottle mode to HOLD.
- As the airplane reached 500 ft. above airport elevation, the point at which Asiana's procedures dictated that the approach must be stabilized, the PAPI would have shown the flight crew that the airplane was slightly above the desired glidepath. Also the airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 kt.
- However, the thrust levers were still at idle, and the descent rate was about 1,200 fpm, well above the descent rate of about 700 fpm needed to maintain the desired glidepath. The NTSB said these were two indications that the approach was not stabilized.
- As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath. The decreasing trend in airspeed continued, and at about 200 ft. the pilots became aware of the low airspeed and low glidepath conditions but did not initiate a go-around until the airplane was below 100 ft. At this point, the airplane did not have the performance capability to accomplish a go-around.
[Lessons Learned — Asiana Flight 214, Business & Commercial Aviation, August 2014]
- The NTSB determined that the probable cause of this accident "was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances."
The NTSB recommendations center around better training about autothrottle modes, human factors studies about automation, and adherence to SOPs. In my view all this misses the point. The fact no other operators are having the rash of these types of approach and landing accidents speaks volumes about the pilot culture at Asiana and Korean Air Lines. As the Ex Pat's Opinion makes clear, a fix was attempted but failed.
An Ex Pat's Opinion
Here are some extracts from a U.S. pilot sent to Korea to help correct things, at their request. He spent five years in Korea with both airlines. He found them to be identical, "the only difference was the color of the uniforms and airplanes."
- We ex pat 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.
- 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 didn't compute that you needed to be a 1000' AGL at 3 miles and your sink rate should be 600-800 Ft/Min.
- 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. 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.
I agree with just about everything this ex pat instructor has to say except: "You just can't change 3000 years of culture." The Japanese have similar baggage when it comes to learning and never challenging authority. And yet they don't have the same issues. I grew up in the "this side of the cockpit is mine, that side is ours" era and have witnessed a sea change in attitudes in the U.S. military and civilian aviation communities. Old dogs can learn new tricks.
Lessons Learned - Asiana 214, Richard N. Aarons, Business & Commercial Aviation, August 2014
When Pilots Aren't, John Nance, ProPilot, March 2014.