Asiana 214 – A Failure of Standardized Procedures?

TwoZeroWest's Adventures in Light ^ | July 14, 2013 | Bruce Croft

[EveningStar]

Asiana 214 – A Failure of Standardized Procedures?

By Bruce Croft – www.twozerowest.com

In her final on-site briefing NTSB chairman Deborah Hersman added what are in my view two final but highly significant pieces of factual information contributing to the investigation into the cause of the crash of Asiana 214. We learned that there was conversation about being above, then on, and then below the glidepath for the approach – in that order, and we also learned that there was no mention of the aircraft’s speed until a little less than nine seconds prior to impact.  What these facts taken together show is that the crew’s monitoring of the approach was incomplete and therefore substandard in the airline industry - a theme that once again points directly to the core of the probable cause of the crash.

Standardization – A Key Goal of Any Airline

To understand why it was incomplete we must first understand what the complete picture looks like and that means understanding how airline standardization works.  In multiple pilot operations the crew’s actions are guided by a set of standardized procedures prescribed by their company that ensure that all the required steps are taken to operate their aircraft safely and properly. Standardization involves much more than just the checklists that are used.  Indeed standardization describes and articulates how a manufacturer’s operating procedures and an airline’s corporate philosophy and practices are blended to create the safest possible air transportation product. Achieving high levels of effective standardization is thus one of the most important and sought after goals in all of airline aviation.

[EveningStar]

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[EveningStar]

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[dalereed]

That NTSB person isn't capable of babysitting a 2 year old!

Her statements on TV are totally bazaar.

The closest her knowledge of airlines or airplanes is that you have to buy a ticket to get on one!

[Taxman]

Typical Obongo Bozo appointee?

[expat2]

It seems to me that there is some truth in this discussion of the failure of the others in the cockpit, but the pilot should be able to fly the approach without help from the others. In other words, their monitoring of his efforts is valuable and a very desirable back-up, but the pilot doing the flying has all the info needed displayed right in front of him: air-speed, sink-rate, and either his position relative to the ILS 'center' or, as in this case, his position visually relative to the runway and the horizon in a visual approach. He is constantly scanning these different read-outs.
So, the monitoring is only back-up, and there were two mistakes: the main one was a poor execution of the approach, and the failure of others to draw attention to the inadequacies was only secondary.

[rlmorel]

"...In 1992, she received B.A. degrees in Political Science and International Studies from Virginia Tech, and an M.S. in Conflict Analysis and Resolution from George Mason University...She began her government career on the staff of West Virginia Congressman Bob Wise as an unpaid intern during the summer of her sophomore year at Virginia Tech.[5] She rose from intern to office manager and then to senior legislative aide. While working for Wise, Hersman dealt with a series of coal train derailments near Point Pleasant, West Virginia. In 1999 she left Wise’s office to join the staff of the Senate Committee on Commerce, Science and Transportation..."

She is a career bureaucrat, the kind governments at the local, state and federal levels are filled with. I admit that I don't know her from a hole in the wall, but I tend to be suspicious of people with degrees in political science and conflict resolution.

That said, my dad was a political science major (From Holy Cross, with the Jesuits, no less) but I temper that with the fact he was a commissioned officer in the Navy at the age of 19. That is a different type of education.

[CodeToad]

The FAA has loaded itself with non technical idiots. She is a bimbo if there ever was one.

[hattend]

If there is not currently any “standardization” how do they know he screwed up the approach? (other than the crash, obviously)

[Seaplaner]

Typical Obongo Bozo appointee?

I think a Dubya appointee who stayed.

That said, there is nothing online that suggests that Ms. Hersman has so much as taken a flying lesson (or even seen the movie Airplane).

.

[USNBandit]

When she talks she betrays her complete lack of aviation background. We could put any talking head in there. It is a disservice to the entire industry and the fling public.

the fact that they got 30 kts slow makes me think they thought they were on auto throttles. The NTSB lady said the dat recorders show multiple auto throttle modes while on final, which leads on to wonder if they had a series of finger fires, or whether they ever knew what mode they were in. It appears they didn't have any plan for shooting the visual and they got into big trouble without any of the four pilots figuring out. I would like to think on an American airplane the pilot not flying would take the controls if the plane got 5 kts slow without a proper response from the pilot flying.

[rlmorel]

You might find this interesting:

http://www.freerepublic.com/focus/f-bloggers/3041469/posts

(I suspect you have already seen it) I have to admit, I found it completely fascinating. Having no experience, I always had this fantasy that professional pilots all over the world, especially in countries with advanced economies) would have a reasonable degree of expertise, but this view illustrates that even a country like South Korea could be problematic due to cultural issues.

Never woulda thunk it, but I now concede it is possible. Having no experience in international commercial aviation except as a customer, how would I know?

[zipper]

The mistakes made by this crew in crashing a perfectly good airplane boggle the mind, so much so that it’s nearly impossible for them to screw up SO MANY items without the inevitability of a systemic cockpit culture deficiency involving every crew member at Asiana.

KAL went through a shakeup years ago with two crashes that both pointed to a huge problem with cockpit culture. They hired native English-speaking Captains of many nationalities to hurriedly change the cockpit culture that led to these accidents. Today they are much better, though many in the industry still can’t stop calling Korean Air “Collision Air”.

Any major airline has a “stabilized approach” requirement,, which, among other things require the airplane to be fully configured, close to on speed, established close to on glidepath, with checklists fully complete before landing, at a relatively low altitude on final. This altitude (depends on which company) may be 500 feet in good weather or 1000 feet in bad weather, or some similar requirement.

The callouts mostly come from a computerized voice, at 500 feet, then again at 50, 40, 30, 20, and 10 feet on the radar altimeter. Callouts from a monitoring crewmember in visual conditions might include challenge/responses on the checklist and (in visual conditions) “stable” or “not stable[reason]” at a predetermined altitude. Afterwards visual approach callouts might be every few seconds or immediately if by exception, i.e., “400 feet, 5 knots slow” etc.

In this case, the marginally type-rated Captain, Sum Ting Wong, was NEVER stable, and approaching the approach-end rocks was 80 feet low and 31 knots slow. His incompetent, unassertive monitoring first officer/instructor, Wi Tu Lo, never called “unstable, go around” at the gate altitude (likely 500 feet), and the monitoring relief first officer Ho Lee Fuk was derelict in his duties too. The fourth pilot, Bang Ding Ow, was snoozing in first class.

[zipper]

with checklists fully complete before landing

That should have been "before landing checklists fully completed"

[Taxman]

In 1995, I interviewed the Chief of Staff for a job on the House Subcommittee for Aviation (at the time, the subcommitte oversaw FAA, and wrote rules and regs, etc.), etc.

He was a WDC critter, GW law school grad, who had never worked in either the aviation community nor private industry.

It was a pleasant interview, but did not cover much about aviation issues.

At the end, he asked me if I had any questions. I did.

“How many Members are licensed pilots?” Ans. “0”

“How many Staffers are licensed pilots?” Ans. “0”

I asked several other pertinent questions relative to the aviation experience of Members and Staff, and in each case, the answer was negative.

I figured that because of my background and experience (MBA, Retired Navy Captain aviator, former USN Maintenance Officer, Safety Officer, 6500 accident FRee hours, etc. etc.), I was a shoo-in for the job.

After all, they needed AT LEAST one person on the committee with some REAL knowledge of airplanes and airspace, didn’t they?

Not so!

I don’t know who they hired, but he did not have one lick of aviation experience.

My take-away FRom that interview experience (and one other committee job I interviewed for and was qualified for) is that the Congress and, by extension, the Fed in general, does not hire people with highly developed job skills. Nor do they hire folks with highly developed BS detectors (that would be me).

They prefer young, wet behind the ears folks who can be “trained” in the “proper” way of doing things.

Which gets us back to the lady with no aviation experience?

[B4Ranch]

When I saw the airspeed variation during the approach my first conclusion was that the pilot was ill or drugged. At no time was the glidepath acceptable to me or I would presume any other American pilot.

[Seaplaner]

very interesting

(and very telling)

Thanks muchly, Capt Taxman, for the detailed reply.

.

[Taxman]

You are most welcome.

Nothing in the intervening years has demonstrated to me that the situation has changed.

Go wander the halls of Congress sometime, and see for yourself. Place is full of wet behind the ears kid staffers dealing with high powered lobbyists, who, themselves were probably at one point wet behind the ears staffers.

It is a very incestuous revolving door situation.

Staff people can and do make very important decisions and policy for their CongressCritter, and they are their gatekeepers.

There are some CongressCritters who recognize the value of outside the Evil Beltway advice, but damn few!

[Taxman]

Most certainly a multiple breakdown in pilot scan coupled with a cultural reticence to speak up. The word is that the pilot flying the approach was the senior man in the cockpit.

The VREF speed is calculated for a purpose! Deviations, autothrottle or no, is a BIG NO! NO!

[Psalm 73]

"The FAA has loaded itself with non technical idiots."

Sadly, the same can also be said for most aircraft companies (mine included) - it's all about the college degree and pedigree - technical competence or actual aircraft experience is secondary (if not alltogether irrelevant).

[CodeToad]

“Sadly, the same can also be said for most aircraft companies (mine included) - it’s all about the college degree and pedigree - technical competence or actual aircraft experience is secondary (if not alltogether irrelevant).
“

I came from Boeing. The MBA/PMP crowd has taken over the management of that company and is sinking it. They have gotten rid of most of the engineers and aviation experts from middle to upper management. They circled the wagons in defense of their lack of skills, meaning, they refuse to hire anyone into management that is not an MBA/PMP and anyone with an engineering or aviation degree or background is shunned. It is why they have Bain in there trying to save the company from eventual failure. Boeing has been taking steps to saturate that group with their replacements, dislodging the MBA/PMP crowd, adding layers of management to break the cronyism bonds, and hopefully save the company before more air disasters sink it for good.