July 9, 2013

Could pilot experience be a causal factor in the Asiana Crash?

I arrived at the airport early this morning and logged into a company computer to electronically sign in for the day's trip. Having just completed Boeing 737 school in early May, the computer displayed my current experience on the airplane...38 landings and a total of 130 hours. The same screen pops up every time I sign in for a trip and not only displays my experience, but the experience of the pilot I'm flying with as well.  Over the years, I grew to appreciate the ability to sum up the other half of the cockpit without having to ask. It often put me in the proper mind set and provided a mental reminder to keep a close eye on a relative new guy.

Before I switched airplanes earlier this year, I had become accustomed to being the more experienced of the two pilots in the cockpit. With 13 years and just over 9,000 hours in the right seat of the MD80, most of the captains I flew with had accumulated more total time than me, but few had as much time in type.  Now I'm the new guy. I took a quick look at my logbook this morning and noted that I've logged just under 15,000 hours of flight time, more than 6,000 landings and just under 2,000 instrument approaches since I started flying in 1987. But I'm new on the 737 and my experience level is not unlike that of the pilot at the controls of Asiana 214.

As the crash investigation reportedly begins to focus in on the possibility of pilot error and the experience level of the pilots, I feel as though I'm in a unique position to add some perspective to the idea that experience, or lack thereof, could be considered a contributing factor to the accident.

I've always been annoyed by mainstream media outlets in the early hours following an accident such as this one. Eye witness interviews are laughable, so-called experts weigh in on matters they obviously know little about and news anchors draw meritless conclusions that may seem reasonable on the surface, but don't even begin to make sense.  With that in mind, I will not draw conclusions here. I don't know if there was anything wrong with aircraft. Although weather seems to have been ideal at the time of the accident, I do not know with any certainty that it was not a factor. I was not in the cockpit and at this point, I know little about what was said and done by the crew. No matter how obvious the cause of this accident may seem, all possibilities will be fully investigated by the NTSB.

I was flying the day Asiana 214 crashed. I landed in Los Angeles minutes after the accident and was scheduled to pass through San Francisco twice the next day. I only worked one of those flights.  The second was cancelled as a result of severe flow restrictions caused by the temporary closure of San Francisco's two main runways, 28L and 28R. The flight I worked was an early morning departure from LAX to SFO the day after the accident.  Surprisingly, we managed to leave LA on-time and landed at SFO without significant delay. Even with relatively low clouds in the area that would normally slow the flow of traffic, the airport managed to keep aircraft moving with relative ease. Oddly enough, I was on the arrival frequency with Asiana 2144 while descending into the San Francisco area...I found it odd that they chose to use that flight number...and landed just few minutes after they touched down.

The atmosphere at the airport that morning was somber and eerie. I was struck by the burned out carcass of that beautiful airplane sitting in the grass and the flurry of activity that surrounded it. The airplane had not been moved. The tail section of the airplane, or what was left of it, sat on the runway where it had come to rest less than 24 hours earlier. The meticulous investigation of physical evidence was ongoing and the "all systems normal" operation taking place on runways 19L and 19R felt odd...if not slightly disrespectful in light of lives lost and injuries sustained.

Waiting for takeoff on 19R the day after the accident.
I heard rumors the day of the accident about the pilot's lack of experience at the controls of the Boeing 777, but hadn't seen any official remarks until today. After completing interviews with the crew, the NTSB is now reporting that the pilot at the controls had only accumulated 35 hours of flight time on the 777, had never landed at SFO and was accompanied by what a spokesman from Asiana described as a deputy pilot who was more experienced on the jet and assigned to "assist" the new captain.  In terms more familiar to U.S. pilots, the captain had completed his type rating on the Boeing 777, but was undergoing his Initial Operating Experience (IOE) and was accompanied by a company instructor-pilot who was legally the Pilot In Command (PIC) of the aircraft.  At Asiana, IOE consists of a minimum of 20 flights and 60 hours of flight time.  The accident flight was the instructor pilot's first flight as an IP.

For the record, there were three pilots in the cockpit at the time of the accident. And while the pilot at the controls may not have been experienced at flying the Boeing 777, he was a highly experienced pilot who had logged around 10,000 hours of flight time in other aircraft. He was no novice...and he was accompanied by a pilot specifically trained to teach and watch over newly qualified pilots.  

I shared an experience with you in a post a few weeks ago about a rainy approach to New York LaGuardia that resulted in a go-around.  The go-around occurred through no fault of my own, but due to a heavy rain shower moving over the approach end of the runway as we neared minimums.  (The video below is not of my approach, but is very close to what my go-around looked like.)


We were unable to visually acquire the runway and were forced to go-around for another attempt.  After a quick check of my logbook, I found that I had less time on the 737 at the time of that approach than the pilot of Asiana 214 had on the 777 at the time of the accident.  On that same trip, I flew two other approaches to LGA, the technically complicated Expressway Visual to runway 31 and an ILS approach to runway 22 in gusty winds and rain. The captain was confident in my ability to fly those approaches because he knew I was well trained and had logged many hours and approaches on other jets.  I'm not patting myself on the back...I would say the same thing about nearly every other professional pilot I have ever flown with…and I would say the same thing about the pilot of Asiana 214.

The point is that the experience level of the Asiana pilot makes for interesting "Breaking News" headlines and may very well be one of many links in the chain of events that led to this accident, but I do not believe it was, in and of itself, a causal factor.  Every pilot has been the new guy at some point in his career.  Every airline pilot has taken off and landed in the real airplane with actual passengers on board for the first time and I am not familiar with a single instance where that flight resulted in an accident.  

At this point of the investigation, based on my experience as a pilot and the unusually candid press releases from NTSB Chairman Debbie Hersman, I can’t help forming my own conclusions, but it is incredibly important to remember that the investigation is far from over. The NTSB will thoroughly examine what remains of the airplane and they will analyze the contents of the digital flight data recorder and its 1,400 parameters.  They will comb through the two hour long cockpit voice recorder with U.S. and Korean teams listening not only to what was said by and among the crew, but noises, call-outs and warnings issued from the aircraft itself. According to the NTSB, this aircraft was also equipped with a separate recording device similar to the FDR known as a Quick Access Recorder (QAR) that recorded additional aircraft parameters. The NTSB investigation team will be assisted by the FBI in a "precision station documentation" using GPS mapping to mark the exact location of debris.  They will make note of cockpit switch and lever positions and they have already begun the interview process with flight crew members as they attempt to determine what the pilots were thinking, seeing and perceiving about the progress of the approach.  At this point we do not know enough to jump to conclusions.

The Air Line Pilots Association, a union representing more than 50,000 pilots at 33 American and Canadian airlines, says the NTSB is releasing incomplete, out-of-context information that could lead to unfair characterizations of Asiana's pilots.  "Without the full body of facts surrounding a catastrophic event, partial or incomplete information can lead to erroneous conclusions and, in turn, skew the perception of individuals' behavior. This could then lead to misguided assessments of the crew's intentions and actions," the union said in a statement.

According to Hersman, the NTSB is representing passengers and trying to be transparent.

The Facts

The NTSB held a press conference laying out details of the events leading to the crash. Based on the flight data and cockpit voice recorders, which the agency said contained "good" data on the crash. Here's what we know:

Crew Experience - Pilot Flying

Hired by Asiana in 1994
9,700 hours total flight time
5,000 hours as PIC
Type ratings: A320, B737, B747, B777
A320 Captain from 2005-2013
Ground School Instructor: A320
Simulator Instructor: A320

Crew Experience - Check-Airman/Instructor Pilot

13,000 hours total flight time
3,000 hours on B777
10,000 hours as PIC
Korean Air Force - 10 years
Accident trip was first trip as an Instructor Pilot

Relief First Officer - Sitting on jumpseat

4,600 hours total flight time
900-1000 hours in B777
Korean Air force - F-5, F-16
5-6 trips to SFO as monitoring pilot



Speed and Altitude - From the Flight Data Recorder

1,600 feet / 82 seconds from impact - Auto Pilot turned off

1,400 feet / 73 seconds from impact - Airspeed 170 knots

1,000 feet / 54 seconds from impact - Airspeed 149 knots

500 feet / 34 seconds from impact - Airspeed 134 knots

200 feet / 16 seconds from impact - Airspeed 108 knots

125 feet / 8 seconds from impact - Throttles move forward, Airspeed 112 knots

3 seconds from impact - Engines at 50% and increasing

Impact - Airspeed 106 knots

Target airspeed for the approach - 137 knots.  This is the speed the desired as the aircraft crossed the approach end of the runway.

In interviews with the crew, the instructor pilot said that the crew had initially set the automated system to a safe approach speed of 137 knots.  But at 200 feet from the ground, "he recognized that the auto-throttles were not maintaining speed."  The NTSB has confirmed that the auto-throttle switch was in the "armed" position.



Cockpit Switch Positions

Captain's Flight Director was turned off.

Auto-Throttle switch was armed.

All three fire handles were pulled - both engines and APU.

Flaps were set to 30 degrees - consistent with landing configuration.

Speed brake lever was down.



Early approach — everything seems normal.

According to NTSB Chairman Deborah Hersman, there was no indication from the crew that anything was out of the ordinary as the plane began its approach. The pilots reported the runway in sight and were cleared for a "visual approach." The weather was favorable for such a maneuver. The glide slope indicator was offline for the runway in use. That piece of equipment is one tool available to pilots to determine vertical guidance as they approach to land.

Notice to Airman warning of unusable glide path indications.


Seven seconds from impact — a call to increase speed.

Flight 214 was well below normal approach speed.  According to the NTSB, the plane was "significantly" below the target speed of 137 kts. with the engines at idle thrust. Most airlines require the airplane to be on speed, on glide path, properly configured for landing with stabilized thrust by 1,000 during flight through instrument weather conditions and 500 feet during visual conditions as experienced on this approach. While the agency didn't specify exactly how much more slowly the flight was going, NTSB Chairman Deborah Hersman noted that "we’re not talking about a few knots.” The plane then began to accelerate, just over 7 seconds before impact.

Four seconds from impact — the plane is about to stall.

According to the NTSB, the stick shaker activated four seconds before impact. The stick shaker does exactly what it sounds like it does…it shakes the control wheel to warn the pilots of an impending stall.  In airplane terms, a stall relates to the lack of sufficient air flow over the wings, a condition that will cause the loss of lift and result in an aircraft falling out of the sky.  Usually, a pilot would increase speed in response to this warning, and that’s exactly what happened for flight 214. According to the NTSB, throttles responded properly, indicating that “an engine failure or malfunction probably didn't play a role in the crash.”

One and a half seconds from impact — attempt to abort the landing.

At this point, someone in the cockpit called for a "go around," or an aborted landing.  But the call was made too late and the aircraft impacted the seawall.

As of the time of this post, the following video is the most recent release from the NTSB.  More recent briefings are being uploaded to the NTSB YouTube page.


9 comments:

  1. Married to an airline pilot. Extremely well written. Thank you!

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  2. One minor comment, most reports say there were three pilots in the cockpit, not four. The fourth crewmember, one of the cruise pilots, was in the cabin. This is explained in the interviews of Lee Yoon-hye, the purser/cabin manager. Not sure this makes a material difference on the outcome, as it is also widely reported that Korean pilots would be unlikely to speak up even if they did see something out of the ordinary, especially the more junior cruise pilots.

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    1. Thanks Jeremy, I think I was changing that in the post about the time you made this comment. Someone else pointed to that interview as well...I had not seen it. Either way, I don't have an editor and I'm sure I make plenty of grammatical errors. I hope to keep the factual ones to a minimum.

      CRM issues within Korean Air cockpits was a well known issue that was handled years ago. I don't know if is or was a problem at Asiana, but I'm sure the NTSB will investigate.

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  3. Brad,
    I feel a little sorry for the two pilots. They are both conscientious and very, very skilled. Still this accident. I hope they are cleared of any blame and resume flying duties soon. I believe this accident falls in the realm of human factor studies. Wish the third pilot in the cockpit had monitored the speed. Brad, do you think 'automation surprise' has some role in this accident. Would be grateful if you could devote an article on auto-thrust and how it functions or the 'traps' one should be watchful of. I have heard there are various modes -- Idle, Speed and Off. That engaging the auto-throttle is a complex process. You arm it, then engage it. Again I read somewhere that when auto-thrust is engaged in an Airbus aircraft, the thrust levers don't move unlike in Boeing aircraft. Here's an interesting article from Flightglobal:

    http://www.flightglobal.com/news/articles/turkish-737-altimeter-fault-occurred-on-several-flights-prior-to-325753/

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  4. Thanks for the comment Pranesh. I feel the same way about the accident. As we continue to learn more about what happened, it seems more and more like an issue of pilot error, but the auto-throttle is an interesting twist. I may write a post on the subject, the accident has me thinking about a number of other things I may write that are related to what happened in San Francisco.

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  5. Brad,
    Will look forward to your future posts on the Asiana crash. Your writings, quality of research and presentation are always top class. The following para in your post superbly puts things in perspective:

    'We were unable to visually acquire the runway and were forced to go-around for another attempt. After a quick check of my logbook, I found that I had less time on the 737 at the time of that approach than the pilot of Asiana 214 had on the 777 at the time of the accident. On that same trip, I flew two other approaches to LGA, the technically complicated Expressway Visual to runway 31 and an ILS approach to runway 22 in gusty winds and rain. The captain was confident in my ability to fly those approaches because he knew I was well trained and had logged many hours and approaches on other jets. I'm not patting myself on the back...I would say the same thing about nearly every other professional pilot I have ever flown with…and I would say the same thing about the pilot of Asiana 214.'
    Regards

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  6. This is a really excellent post.

    I want to point out something that I saw on CNN yesterday that made a whole lot of sense to me. They played a clip from a CNN interview in 2009 when a book author discussed research done upon countries relating to "respect for authority."

    It was found that Korea was #2 on the list of countries which respect authority/seniority in relation to members of society. The author who was being interviewed related this study to a list of countries with the highest commercial aviation accident cases. In each, Korea was at the top of the list.

    In the late 1990's, Korean Air experienced a number of catastrophic accidents and crashes. It was found upon analyzation that the pilots almost always had a lack of communication. Due to cultural elements, one pilot would frequently withhold information from the other--not wanting to intrude or be disrespectful (calling the senior crew member out). Korean Air ended up making reforms later on, and brought in people with different cultural ideals. This dramatically changed their safety record.

    I'll be curious to see if this type of cultural influence and cockpit culture will play a large role in the Asiana Crash,
    Thanks for the post,
    -Swayne

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  7. It's hard to believe that those pilot with a lot of experience had that accident. Although, I think the problem was the communication and the situation of awareness. They failed to do a normal and basic landing, in vmc conditions and without mechanical issues, from what I've read I think there's the possibility that they had some kind of external pressure,or fatigue, something that could've affected their situaton of awareness, who knows what was on their minds, in the last few year it's been a lot of accidents caused by the lost of the situaton of awareness.

    Regards,
    Marco B.

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