Aircraft Accidents and the Forgotten Engines

On January 15, 2009, US Air flight 1549, an Airbus A320, took off out of LaGuardia Airport and intercepted a flock of Canadian Geese going in the opposite direction.  Both CFM56-5B4/P engines were FOD’d out, meaning they received Foreign Object Damage and stopped putting out power, or thrust.  The airliner was ditched in the Hudson River.

While I was researching this accident for a class I’m teaching, I came across an AMT Magazine article (Foreign Object Damage, Chandler, 5/15/2009), which reported that the two accident aircraft engines: CFM56-5B4/P series, manufactured by CFM International – a joint effort by General Electric (GE) and Société Nationale d’Étude et de Construction de Moteurs d’Aviation (SNECMA) – were sent to the manufacturer’s Cincinnati facility for a teardown within weeks of the National Transportation Safety Board (NTSB) onsite investigation.  This is normal procedure, because the manufacturer has available to it all the necessary overhaul tooling, specifications, and full access to the design engineers.

The NTSB accomplished their due diligence, e.g. pictures, analysis of bird remains, etc. to the recovered engines before shipping it out for teardown, which is removing components and ducting, exposing the engine’s inaccessible parts for better analysis.  The teardown allows the manufacturer to determine exactly what components failed and the extent of damage incurred.

NTSB report AAR 10/03 has the initial information the NTSB engine/powerplant team found.  It is unclear what information comes from the teardown and what comes from the initial on-site inspection.  There are no references to the Cincinnati facility’s teardown, beyond biological findings.  Furthermore, Search Engine queries cannot find any evidence of a published CFM International report concerning the two accident aircraft engines’ teardown.

This is unusual.  The NTSB is meticulous; they investigate every technical anomaly.  Even general aviation single engine aircraft investigations result in an engine teardown.  When a Cessna 150 has an inflight engine failure or a Beech Bonanza suffers a propeller strike, the engine case is split, the cylinders are checked for scoring; pistons for bearing wear; the crankshaft is inspected for sudden stoppage damage.

However, US Air 1549 was a high-profile accident, its recognition tied directly to both engines, damaged by bird ingestion, that the two engines could not provide adequate power to reach an airport.  How does an investigation of this caliber stop here?  Where are the CFM studies?

Reading through NTSB Report AAR 10/03 can be confusing; facts are cited, but sources are unclear.  The only reference to the teardown comes under Section 1.16 Tests and Research, subsection 1.16.2 Biological Material Sampling and Analysis.  Inside this subsection, the NTSB describes the different samples of biological material procured, e.g. bird tissue, bone and how they damaged the engines’ Outlet Guide Vanes.  Later in this Section the Engine Dual Failure checklist and Airplane Performance Studies are discussed.

In the Analysis Section, subsection 2.1 General, AAR 10/03 states, “Although both engines experienced an almost total loss of thrust after the bird encounter, the flight crew was able to ditch the airplane in the Hudson …”  This statement is ambiguous; ‘Almost’ is imprecise.  Does ‘almost’ mean 1% thrust was available? 5% thrust? 10% thrust?  Does ‘almost’ apply to one or both engines equally?  Does ‘almost’ imply the engines were turning and producing adequate power?  Too much information is left to interpretation.  Furthermore, it contradicts information found later in the report, including conversations captured by the cockpit voice recorder (CVR) transcripts.

As one moves forward through NTSB report AAR 10/03, it is stated that the #2 (right) engine suffered a compressor stall days earlier, but that the stall was corrected in maintenance.  The flight data recorder (FDR) parameters suggest that a compressor stall was not a culprit in the accident, that a compressor stall did not reoccur.  This works because it defuses any speculation that the compressor stall was a possible cause.

In Section 2.2 Engine Analysis, subsection 2.2.2 Identification of Ingested Birds, the report says each engine ingested two Canadian Geese weighing between 7.3 through 9.2 pounds each.  This exceeds the size of bird the engines were certificated to ingest and still provide power to sustain flight.  Why?  What damage would larger birds impose on the Fan?  What Turbine damage?  Would one overwhelm the Burner section?  The report doesn’t say what the consequences would be.  What would CFM do to fix these problems in the future?

In subsection 2.2.3.1 Engine Spinner, Fan Blade and Fan Inlet Case Damage, harm to each engine Fan is documented; as reported, “Although the fan blades of both engines showed evidence of bird ingestion and subsequent mechanical damage, as noted, no significant fan blade damage or fractures were found.”  This means both Fans were physically capable of providing thrust; their integrity was intact.  In subsection 2.2.3.2 Engine Core Damage, the report reveals damage to the Low and High Pressure Compressors, Inlet Guide Vanes, Variable Guide Vanes (VGV), which, as reported, is significant.  The core’s damage is enough to prevent sufficient thrust to sustain flight.

Here this reader is confused; this makes little sense.  No matter the size of the bird, for the meat and bone to damage the Compressor Core, the carcasses would have to first pass through the Fan, which, per the previous paragraph, did not incur significant damage (no Fan blades were missing or broken).  The Fan, at takeoff power, is turning at over 5000 rotations per minute.  A bird’s flesh and bone, no matter the size, passing through the Fan, would be reduced to the consistency of a liquid, a thick milk shake and/or an atomized mist; the Fan would be chewing up the meat and hollow bones at an incredible rate.  In addition, the birds strike the engines at close to two hundred miles per hour; at this point they begin the ‘Cuisinart Effect’, reducing the carcasses integrity from solid to liquefied sludge.  Result: if the carcasses did not destroy the Fan, then any subsequent damage had nothing to do with the size of the birds.  Past the Fan, bird size is irrelevant.

So why were the Compressor blades damaged?  Per AAR 10/03, the Compressor Core blades and Guide Vanes were significantly damaged; this is factual information.

NOTE: As air passes through the Compressor, it is compressed to incredible pressures; this is because a gas (air) is compressible.  Liquids and solids, however, are not compressible.  As the carcasses passed through the Compressor, the pureed carcasses resisted compression; pressure feedback damaged the blades.  This raises an important point: If the engines were certified to ‘provide sufficient thrust to sustain flight’ after a bird ingestion, why did both engines fail?  Did they fail?  Were they capable of operating sufficiently and awaiting the command to throttle up?  What did CFM International find out about this?

The CVR shows the bird impact happened at 15:27:07 (15:00 hours, 27 minutes, 7 seconds).  At 15:27:54, the crew attempts to relight an (?) engine; 15:28:25, number one engine comes back up ‘a little bit’; at 15:29:00, an (?) engine relight fails; 15:29:21, something about power on number one followed by 15:29:26, “go ahead, try number one.”  At 15:30:09, “Got no power on either one?  Try the other one,” (are they discussing an engine or a power bus?).  The question here is: At 15:28:25, did they have power on Number One engine and, if so, did it shut down and when?  If they did have sustainable power, why does the NTSB report say there was no power output while simultaneously saying, ‘an almost total loss of thrust’?  Could number one engine have ‘sustained flight’?

Why is a report from CFM International important?  Because no organization understands the limits of the CFM56-5B4/P engine better than the manufacturer.  The NTSB has to be forgiven for not being able to ‘fix’ the issues that caused the accident aircraft’s CFM56-5B4/P engines to fail.  In the investigation of all major accidents, the NTSB is a ‘jack of all trades, master of none’; they cannot adequately discover problems, analyze problems and fix problems better than the engine manufacturer.  And the NTSB cannot adequately document those ‘fixes’ better than the manufacturer.

I have not been able to locate the CFM Industries report.  It would provide information about what needed to be fixed, why the engines failed to sustain power, etc.  If the engines were unable to perform as certificated, what could the crew have done to save the plane?  Was there something they could have done?  And … what if the plane was savable to begin with?  That is why, the CFM International report is so important.

Aircraft Accidents and SPACE Men

Who was Guy Fawkes and why should the aviation community care?  Guido ‘Guy’ Fawkes was a terrorist who was implicated in the Gunpowder Plot of 1605; the intent was to explode a stockpile of gunpowder under the House of Lords, part of England’s Parliament.  He is also the likeness of the mask used in movies, e.g. V for Vendetta; this likeness is also employed extensively today by self-proclaimed insurgents who are too cowardly to show their face.

Normally I don’t go political, but let me just say: People who wear Guy Fawkes masks do not understand who (or what) Guy Fawkes was.  People who wear Che Guevara T-shirts do not understand who (or what) Che Guevara was.  Either they wear these items to ‘look cool’ or they are desperate to feel akin to a ‘revolutionary’.  I think it’s the ‘looks cool’ thing.

There are those who deal in aviation conspiracies and speculation – two different activities, but, in my opinion, just as damaging.  Am I calling these misguided individuals terrorists?  No, no, no; but I will say they are destructive, especially of the truth, arrogantly erasing the line between fact and fiction.  Terrorists cause damage with intent, while conspiracists cause damage out of ignorance all the while being unaware of the injury they cause.

I call these speculators and conspiracy theorists: SPACE Men, people who find a conspiracy in everything or speculate without the benefit of facts; after all, why let something like the facts get in the way of starting rumors?  I guess this is not politically correct and is certainly cynical, but since in light of recent events, Self-Proclaimed Aviation Conspiracy ‘Experts’ (SPACE) Men are at it again and they are donning a whole new Guy Fawkes mask – Social Media – to cover their tracks.  When is it okay to speculate without the facts?  The short answer would be somewhere between Never and Not Ever.

Look at Malaysia Air MH370 that disappeared over four years ago.  The SPACE men were hard at it – every talking head, aka ‘expert’, who could push their way onto a News set – they speculated where, how and why the plane crashed.  Searchers ran in every direction following up on each theory.  Meanwhile, the victims’ families suffering through this hell, endured a new hope that was quickly dashed.  Half of those ‘crash theories’ were never based in fact, but inexperience and speculation.

Or the 9/11 conspiracies, e.g. Loose Change, (a movie that regularly contradicted itself) divided people more and motivated other ‘experts’, like comedic actor Charlie Sheen, to advise us.  Meanwhile victims’ families suffered the barrage of theories, especially when these Loose Change ‘experts’ crashed their anniversary memorials, hounding the victims’ families with allegations that their family members were not killed by terrorists, but by their own government.  Loose Change ‘experts’ never went to Shanksville, the Pentagon or Ground Zero; they were among the more contemptible conspiracy theorist ‘experts’, but certainly not the only ones.

On Friday, August 10, 2018, a man identified as Richard Russell, a ground service employee, allegedly started, taxied and took off in a Horizon Air (dba Alaska Airlines Regional) Bombardier de Havilland Dash-8-Q400.  I say ‘allegedly’ because, as of this writing, all the facts in the incident’s investigation are not all in, e.g. how or why he commandeered the plane.  Whether he was suicidal or his mental wires were crossed, Richard Russell crashed the Dash-8-Q400, killing himself and destroying the aircraft – that is the only fact we know.

At this point this story must avoid allegation, allow the Federal Bureau of Investigation (FBI), the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB) and the teams of professionals to get to the bottom of what happened and how it happened.  However, SPACE Men decided otherwise.

On social media, less than twenty-four hours after the Horizon Air event concluded, there were calls to discuss the incident, to get the insight of those who like aviation, but are not necessarily professionally involved in aviation.  These brainstorming events would discuss how the aircraft was stolen; what Richard Russell must have been thinking and just put all that combined inexperience to work so that all the rumors that can be fabricated, will be.

My suggestion to these groups was to first allow the facts – all the facts – to come to light before exploring the unprovable.  It is a slippery slope using non-facts to make judgments about another person’s mental state or allowing one’s pride to interfere with common sense when one is not a subject authority; it is a problem both legally and morally.

NOTE: On Monday morning, August 13, 2018, over forty-eight hours after the event concluded, the Aviation Safety Network reported, “The FBI has recovered the flight data recorder and parts of the cockpit voice recorder of the Horizon Air DHC-8 that crashed after being stolen.”  Let’s be clear, the recorders had not been read yet, just recovered.  Facts are, at this point, unknown and unverified.

These ‘insight’ brainstorming – aka Rumor Building – sessions are destructive, on so many levels.  Despite being counter-productive to the truth, Rumor Building is expensive, career-ending, dangerous, unprofessional and a perversion of the facts.

For example, the first rumor to come out from the Richard Russell event was that the aircraft was stolen by an aircraft mechanic (this is the ‘career-ending’ part).  This conclusion-jumping allegation was soon retracted, but not before the media ran with it.  If left unchecked, rumors like this suggest the mechanic workforce as a whole should be painted as ‘unhinged’, that they are all crazy.  Not possible, you say?  Remember Andreas Lubitz and the pilot competency scare in the wake of Germanwings 9525?  Egypt Air 990?  Or FedEx 705?

The Germanwings 9525’s investigation was flawed and unprofessional; it was carried out in the Media, a whole other group of ‘aviation experts’.  Case evidence became corrupted, destroying the credibility of facts.  When the speculation continued, people blamed first officer, Andreas Lubitz’s family, as if the parents were complicit in his actions; as if his siblings sent him on his self-destructive path.  Passion isn’t logical; it doesn’t react from facts; it just reacts – often violently.  All it needs … is a little push.

The news today is chock full of allegations that stand on the theory of ‘Guilty-until-proven-Innocent’; even when proven false, the allegations stick; facts becoming perverted.  Violent radicals come from any walk of life; become pugnacious for any number of minor reasons; seek ‘justice’ against anyone who disagrees with them, e.g. a congressman gets shot while practicing at a ball field; businesses are destroyed for supporting candidates; people are harassed for selling lunch to Immigration agents; a Senator in the Senate Chamber lies to alter an election.  All these things happened … and not because of facts, but because of rumor.  In today’s world, false allegations continually take on lives of their own; even when proven otherwise, false … rumors … persist.

And the radicals who conduct these illegal actions are often hiding behind a mask – just like the Guy Fawkes mask.  When the mask is removed and their images broadcast, (Berkeley, California, August 5, 2018) the thugs are revealed to be … Nobodies; people acting out of emotion – not facts; not leaders, but followers, who become violent because of rumor.  Social Media is the new Guy Fawkes mask; Nobodies stir up dissension and violence from the safety of their Mom’s basement, sometimes not understanding the vicious nature of their audiences.  This is why Rumor Building is wrong; why self-proclaimed ‘experts’, e.g. SPACE Men, are delusional.

Rumors are expensive.  Rumors have a way of getting to our elected officials, who, again, react from passion … and definitely not logic.  Under the banner of ‘representing their constituents’, e.g. SPACE Men, they demand answers to some of the most bizarre questions.  When I worked for the FAA’s Flight Standards Division, we were required to answer dozens of Congressionals: letters written by a Senator’s or Congressman’s staff, demanding answers for their constituents’ concerns.

Topics included: 1 – Why don’t aircraft engine manufacturers use chicken wire over the jet engine inlet to prevent bird ingestion?  Response: Chicken wire clogs and starves the engine.  2 – Why doesn’t the FAA pressure air operators to design/purchase explosion-proof luggage containers that increase payload weight by 300%?  Response: The priority is to design measures to keep explosives from getting on the aircraft to begin with.  Thousands of dollars are spent researching these ‘issues’; inspectors can’t conduct surveillance duties because they have to follow up and respond to trivial Congressionals.

It has been my experience that SPACE Men are irresponsible and arrogant.  They have just enough basic knowledge to be dangerous; their use of aviation buzz words persuades their naïve followers to believe them; they battle facts with emotion, answer questions with misdirection and they suggest Rumor Building is harmless fun, some good old-fashioned brainstorming.  Then when things go south, they don their Guy Fawkes mask, shrug their shoulders and get lost in the crowd, leaving the true professionals to clean up their mess.

Aircraft Accidents and the Slide Rule

The slide rule was invented in 1630 by Reverend William Oughtred, sixteen years after logarithms were first used.  For four hundred and forty years the slide rule was the pocket calculator for math and science applications, completing difficult equations from multiplication to Cube roots to Trigonometry.  My shop teacher taught our class how to use the slide rule in the 1970s, just before it became obsolete by today’s computer standards; some middle school teachers still teach the slide rule, even though computers have tried to replace this irreplaceable technology.

Slide rules are dangerous because they open one’s mind to how things work.  Using a slide rule is like teaching a young boy running across a ½ inch-wide beam about gravity or like teaching a child filled with awe about planes how a wing produces lift; it takes all the magic out of what one takes for granted.

Mister Berman (my shop teacher at Sewanhaka High School) taught us the slide rule for a reason: to teach us how the math works.  He foresaw that the calculator would make our lives simpler by doing the difficult math for us, but it would also conceal from us how to find the answers during a blackout or if the batteries died.  In July 1969, Apollo 11 astronaut Buzz Aldrin used a slide rule to double check the descent math during the landing sequence.  Nine months later, the Apollo 13 crew were forced to shut down all necessary power for a time (blackout); although never out of contact with Mission Control, a slide rule would prove invaluable when the power went out and the batteries died; each of the Apollo 13 astronauts knew how to use a slide rule.  From Mercury to Gemini to Apollo, the space programs were born on the slide rule.

Understanding the math is important, not because of power outages and uncharged batteries, but to preserve the ability to do the math; if we don’t understand how we got from A to Z, we sacrifice reasoning; we cannot question; we surrender to another intelligence to do the thinking for us.

Once upon a time, knowing the multiplication tables, from one times one to twelve times twelve and everything in between, were a requirement.  This wasn’t asked of a student, it was expected.  Today students are provided with the multiplication tables attached to the desk – not requested, but expected.  But even this was dumbed down from the students of the 1700s and 1800s, where students at the Elementary school age were expected to do more complicated math problems than long division or multiplication with only a chalkboard to write with.

Reading was the foremost means of entertainment.  No television, i-phones or even radio were available, just firelight and a borrowed book; wealthy members of society actually owned books (plural).  But the point is that information was absorbed by reading the written word, e.g. newspapers, books and published documents.  A video did not play what information you absorbed and audio books did not exist.  We draw closer to the world exemplified in Zager and Evans 1969 song, In the Year 2525, where ‘Everything you think, do or say is in the pill you took today’.

A bit dramatic, possibly cynical?  Perhaps, but think of where we are today in aviation.  Pilots don’t necessarily fly the aircraft anymore; punch a button and the aircraft follows a predefined course; even general aviation aircraft are capable of this.  Manufacturers and air operators are studying the ‘pilot shortage’ problem; the solution is to engineer the pilot out of the cockpit, turn control over to the computers.  Mechanics don’t troubleshoot anymore; they ask the aircraft’s computer, which tells them what to do to resolve the problem.

We are losing the ability to do the math.

No longer do we work through a problem.  We lost track of how to go between A and Z, so accustomed are we to immediate answers, typing (or speaking) the numbers in without bothering about the formula.  Result: a lack of familiarity with the aircraft which can affect how decisions are made and how much time is committed to solving a problem in real time.

Consider Air Midwest 5481, the Beech 1900D that crashed in Charlotte, NC, on January 8, 2003; an airliner that is, for all intents, as close to a general aviation aircraft design as you can get.  Could the pilots’ familiarity with the aircraft have affected how they responded to the emergency?  The aircraft took off with a center-of-gravity too far aft.  In addition, the elevators had been rigged with almost zero nose down authority.  As per the voice recording transcript from National Transportation Safety Board (NTSB) accident report AAR 04/01, from the moment the flight crew realized there was something wrong (they were entering an aerodynamic stall) and tried to push the yokes forward to bring the nose down, about twenty-one precious seconds passed before the crew attempted something else to save the aircraft.

Twenty-one seconds in an emergency is an eternity.

This is, in no way, a criticism of how the flight crew responded; no Monday morning quarterbacking.  However, what they tried by pushing the yokes forward would never have worked.  The yokes’ movements were limited by mechanical stops: metal blocks.  The pilots lacked the physical strength to overcome the metal blocks’ strength; no one alive could have overcome the metal blocks’ strength; two Gold-medal Olympic weightlifters could not have moved the yokes forward.  Both pilots spent twenty-one seconds pushing against an immovable object.

NOTE: There was nothing the aircraft computer could have done to save the flight; not even the most advanced aircraft could have saved the flight.  As we put more and more trust in the computers, this accident was a testament to technology’s limits.  And there are many more testaments in the NTSB accident archives.

But, I digress.  People in the aviation industry must remember this: what doomed Air Midwest 5481 was the loss of twenty-one seconds; the pilots did only what they were capable of doing because both pilots had a limited familiarity of the aircraft’s systems.

The pilots simply could not do the math.

The pilots jumped in the airliner and started the engines; the airliner moved forward.  Push the throttles forward, the airplane went faster.  Pull back on the yokes, the plane went higher.  However, how did the engines work?  When the yokes are pulled back, what occurs to make the elevators go trailing edge up?  Why was the weight distribution in that particular airliner so critical?  Forget the elevators for a second; why did they even depart with the center of gravity so out of limits and why did they not question it?  Why were they incapable doing the math?

A lesson could have been gleaned from the Air Midwest 5481 accident, been part of the recommendations for NTSB accident report AAR 04/01: Require pilots learn basic systems knowledge of the aircraft they fly.  Since many accidents are a result of poor training, a pilot can forego time lost with futile attempts and focus on alternative methods to save the aircraft, at least try.  Learn how to do the math.

Still we continue to allow our youth to ‘not do the math’.  We encourage our youth to substitute figuring out the problem with turning the problem over to the computer.  They are allowed to talk their way out of work, demanding a hand up with no discipline to work it out themselves.

It is time to teach our youth about slide rules; confiscate the calculators and challenge them to work out the math.  If not, the consequences will be more than failing a test, they will fail themselves.

Aircraft Accidents and Lessons Unlearned XVI: Asiana 214

At 11:28 AM, on July 6, 2013, the weather conditions at San Francisco airport in San Francisco, California, included ten miles visibility, six-knot winds out of the west, few clouds and a temperature of eighteen degrees Celsius (sixty-five degrees Fahrenheit).  Despite favorable conditions, Asiana flight 214 impacted the seawall during a visual approach to Runway 28-Left.  The aircraft was destroyed.

Lessons Unlearned articles highlight the warnings our industry tries to make us sit up and take notice of, if we have the wits to pay attention.  In several past Lessons Unlearned articles, it has been established that warnings have been forgotten or trivialized, resulting in a replay of the catastrophic events, sometimes numerous times.  Either the warnings were not recognized for their urgent nature due to the inexperience of the investigator(s); were overlooked in favor of other issues; were missed due to political correctness or were revisited so often that the warnings became redundant.  With Asiana 214, all four reasons seem to apply.

Critical factors on a standard approach are an airliner’s lateral and vertical profiles, the angles dictating the glidepath at which the aircraft descends.  On a visual approach, physical references outside the cockpit windscreen can aid in the landing cycle; indeed, they cannot hurt.  According to the National Transportation Safety Board (NTSB) accident report AAR 14/01, the flight crew mismanaged the airliner’s vertical profile at five miles out from the runway during initial approach; in this case, the B777 was too high.  This made a stabilized approach more difficult, forcing the crew to overcorrect to properly capture the glide slope; meanwhile manageable time and distance to the runway were decreasing.

According to the cockpit voice recorder (CVR) transcript, when the aircraft was at an altitude of 200 feet, flight crewmembers noticed the low airspeed and low path that should have dictated a ‘Go-Around’ (GA), or aborted landing; this concern was not communicated except a comment of: “It’s Low”.  Even when the aircraft dropped to 100 feet of altitude, a GA still was not called for, even though the aircraft was too low (altitude) and too slow (speed) to achieve the conditions to successfully execute a GA.  It was not until three seconds before impact at ten feet of altitude, that a ‘Go-Around’ was called for, too late.

The accident aircraft was a Boeing B777-200ER, one of the most technologically advanced and efficient airliners flying today; four trained and qualified B777 pilots on the flight deck during the approach, yet the aircraft crashed in ideal weather conditions.  So how does this happen?

NTSB accident report AAR 14/01 noted that role confusion and decreased pilot monitoring of the instruments were to blame; also noted was fatigue.  To be truthful, the recommendations demonstrate the NTSB’s unfamiliarity with the air carrier world.  Because of the NTSB’s inexperience, many of the report’s Recommendations are ineffective; they represent wasted opportunities, long overlooked.  Furthermore, twenty-eight Recommendations were made to the Federal Aviation Administration (FAA), Boeing, Asiana Airlines, Aircraft Rescue and Firefighting (ARFF) and even to San Francisco, most of which amount to ineffectual fixes that have nothing to do with the accident; more precisely, what caused the aircraft to crash.

To understand what the true nature of the accident’s root causes were, one must look past unimportant Findings and dismiss useless Recommendations.  For example, the NTSB noted that fatigue played a part in the flying pilots’ inaction.  In the air carrier world, one must understand that these pilots had two advantages not normally found in air carriers where fatigue is an issue.  First is that there were four pilots flying a two-man cockpit airliner.  The reason for this is to prevent fatigue by the flight crews; working on and off this allows two pilots adequate rest during the twelve-hour flight.  The second reason is that pilots flying international flights are at the top of the seniority list; they are not low men, but have the bidding rights to choose to fly these routes.  Can they get fatigued?  Absolutely.  However, if fatigue were an issue, they would have not bid the routes.  Instead they would have bid shorter flight schedules for less pay.

Reviewing the Findings on the final moments of the flight suggest a lack of crew resource management training (CRM-T), i.e. poor communications among the flying pilot, the monitoring pilot and the two reserve pilots.  NTSB report AAR 14/01 only references CRM five times in the entire report and never in regards to the Asiana 214 flight crew’s actions.  Even more so, the two other pilots on the flight deck, the two reserve pilots who were observing, made no correction statements.  CRM-T does not recognize dictatorial authority; it allows the first officer to speak on the same level as the captain.  This open communication prevents bad decisions from going unchallenged and, thus, lead to an accident.  United Airlines was the one of the first major airlines to incorporate CRM-T for its pilots back in the early 1980s.  Before this, the captain’s word was paramount.  In many instances, his decisions went unchallenged, whether by respect for the captain’s superior skill or fear of the captain’s authority.

Example One: On January 13, 1982, Air Florida flight 90, a B737 crashed into the Potomac River outside Washington, DC.  Analysis of the CVR and flight data recorder (FDR) left no doubt that the accident could have been prevented had the first officer insisted on the captain taking heed of the engine gauges and that the aircraft should have returned to the gate to be deiced again.  The wings were fouled with heavy wet snow which disrupted airflow over the wings and the engine sensors were giving false indications of correct takeoff thrust, instead of true readings of inadequate thrust.

Example Two: On April 15, 1999, Korean Air Cargo flight 6316, a McDonnell Douglas MD-11, crashed in Shanghai shortly after takeoff.  There was confusion between the captain and the first officer amounting to the reported altitude being read in meters as opposed to feet.  The captain, thinking the aircraft was too high, nosed the airliner over to bleed off altitude.  Again, the CVR and FDR showed that the airliner became uncontrollable in the steep dive before impacting the ground.  Simple communication could have prevented this accident.

Over sixty-five major aircraft accidents have been attributed to, in some degree, poor CRM-T since the Air Florida flight 90 accident.  It is not absurd for the lack of CRM-T to play a role in safety issues; in fact, it is more likely today than back in the 1980s.  The lack of proper technical training and confidence played a large part in the Colgan 3407 accident’s miscommunications.  I have witnessed firsthand the animosity airline mergers cause inside the cockpit, where a pilot from one merging airline refuses to sit next to, work with or talk to a pilot from the other airline.  These are examples of what CRM-T cannot account for, the Human Element, e.g. pride, arrogance, resistance to change, control issues, etc.

An important reason these CRM-T issues continued to happen after four decades is that accident reports, such as AAR 14/01, do not call out when the failure to use CRM-T is not mentioned as a Probable Cause.  CRM-T is not even listed in NTSB report AAR 14/01’s Findings, even though more than one pilot mentioned in a post-accident interview that they noticed the low speed and low path condition at 200 feet, but did not say anything.  More importantly, these same pilots stayed silent and allowed the altitude to degrade to below 100 feet to the point it was too late to initiate a ‘Go-Around’.  How do qualified pilots watch and remain silent as an airliner is in danger of crashing?

Furthermore, the NTSB did not satisfactorily examine, through interviews with Asiana’s surviving flight crew members and other pilots at Asiana’s Korean headquarters, what role Culture played in the accident and what type of culture existed at Asiana.  Did Asiana’s culture cause communication problems between Asiana’s captains and first officers to exist?  How do Asiana’s relief pilots, instructor pilots and at-the-control pilots communicate when conditions deteriorate before their eyes?

Most egregious is the attention NTSB report AAR 14/01 takes away from the accident’s root cause, only to spread it to other parties that had less to do with the accident and more to do with the aftermath.  Are the two Recommendations to Boeing going to increase safety or are they a distraction?  The B777 began its career in 1994; the instrumentation and Autothrottle modes had been used on thousands of flights in the twenty years before Asiana 214; other models of aircraft flown by Boeing, Airbus and McDonnell Douglas before 1994 have incorporated the same instrumentation … and now this is suddenly a problem?  Why are there four Recommendations for ARFF?  They had nothing to do with the accident, which is what the report is about.  If the NTSB felt that ARFF required further looking into, generate a different report focusing on ARFF and keep it out of the accident report.  It is a distraction.

A missed opportunity to fix an accident’s root cause is the true tragedy, where history has to be repeated before the problems can be corrected.  Asiana 214 was such a tragedy.  Hopefully the FAA and other organizations can correct the problems so obviously overlooked with Asiana 214.