THIS IS most certainly NOT ...

[Michael Grove]

 THE first incidence of its kind -

  the tragic accident at San Francisco Airport over the week-end is yet

  another consequence of the consequences of the complex systems

  which I have oft referred to elsewhere.

As the Daily Telegraph reported - "Lee Kang-kuk, whose anglicised name was released

for the first time on Monday and differed slightly from earlier usage, was the second most

junior pilot of four on board the Asiana Airlines aircraft and had 43 hours experience

flying the long-range jet, the airline said on Monday. 

The plane's crew tried to abort the

descent less than two seconds before

it hit a seawall on the landing approach

to the airport, bounced along the tarmac

and burst into flames.

It was Lee's first attempt to land a 777

at San Francisco, although he had flown 

there 29 times previously on different

types of aircraft, said South Korean 

transport ministry official Choi Seung-youn. Earlier, the ministry said he had accumulated 

a total of 9,793 flying hours, including his 43 at the controls of the 777."

... and therein lies the problem - that the computer control systems of these modern

aircraft have become so complex and sophisticated - that the pilots flying them, whether

experienced on type or not, have often never been appropriately trained to actually cope 

with the kind of situations which arise with the ultimate failure of the ever more complex 

fly-by-wire processes - which are responsible for keeping these aircraft on auto-pilot.

IT IS this airline-training system failure, coupled with a lack of comprehension of the

consequences of consequences of manufacturing systems failures, as well as the lack of

strict accordance to maintenance procedures and increasing difficulty on the part of 

pilots to satisfactorily complete their pre-flight aircraft inspections, that is collectively

putting pressure on airlines to cut corners because of the world wide acceptance, on 

behalf of the flying public, that low-cost flying IS the order of the day.

Several Indonesia airlines have already been banned by the European Union from flying

into European airspace for the reasons that I have described above. Just consider the fact

that weather forecasting has become very hit and miss in recent times because the

forecasters are using systems based on out-dated computer models which cannot yet

keep up with the rate of change of global weather systems - god forbid that this should

ever become the case for taking a flight from Heathrow to San Francisco.

When NASA put over 20 airline flight crews through an exercise to simulate an

emergency engine failure during flight, they were amazed by the variety of

performances they saw, from good communications to almost complete mayhem.

It's clear that effective communication in the cockpit is vital, yet the researchers

have found that those skills are often barely adequate or even non existent.

The psychologists at NASA are discovering that anything that prevents a flight crew

from working like a well oiled team is potentially dangerous and one of the most

disruptive influences is a pilot's personality. Many of them are simply not fitted

for commercial cockpits at all. 

 

As Factman commented on June 27 8:42pm to the FT Qantas engine failure issue -

.

Culture & behaviours: at the root of every major incident. No matter how many

systems & processes you have in place, they'll never save you or your business if the 

safety culture & behaviours are weak. If your safety culture & behaviours are strong, 

they'll prevail however sloppy the systems & processes are.

. 

 

[Michael Grove]

The National Transportation Safety Board determines 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. Contributing to

the accident were; (1) the complexities of the autothrottle and autopilot flight director systems

that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which

increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and

coordination regarding the use of the autothrottle and autopilot flight director systems; (3)

the pilot flying’s inadequate training on the planning and executing of visual approaches; (4)

the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight

crew fatigue which likely degraded their performance.