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.

2 thoughts on “Aircraft Accidents and Lessons Unlearned XVI: Asiana 214”

  1. Another well written article as usual, Stephen. CRM as you know is now a staple of training in two person flight deck operations. However, as evidenced by this accident and at least a few since it in the years following it, aviation still needs to constantly revisit the principles and drill them into pilot heads. This accident in a way reminded me of KAL 801 in Guam (failure to initiate a go-around until it was too late, poor CRM, loss of situation awareness overall). Until air carriers seem to get a better grasp on this, this subject will keep finding it’s way into reports as something that CONTRIBUTED to the accident. The ARFF recommendations in the report had me scratching my head. We’ve talked about this briefly in other times but if the NTSB wanted ARFF to be examined more in detail, they got what they wanted – a year or two after that the DOT IG released an audit on the FAA’s oversight of ARFF. I’m not sure if it’s possible for the Safety Board to do this (they may already and I just don’t know about it, I apologize if they do), but for instances concerning items that could affect safety AFTER accidents release some kind of special safety bulltin. The US Chemical Safety Board does this and it has generally helped the oil and chemical industry greatly.

    1. The whole ARFF direction had me wondering also. It seemed they went off the rails into questionable territory just to … I don’t know, pad the report (???); I don’t know. The CRM issue also has me scratching my head. If you read the CVR transcript nobody in the cockpit acknowledges the one person saying “too low” at 200 feet. It’s like a surprise at thirty feet when somebody says “Oh (expletive) go around”; the sink rate is about ten feet per second. The NTSB likes to put themselves above the FAA, so how did they miss that? The lack of CRM killed this flight. Thanks Jaime.

Leave a Reply

Your email address will not be published. Required fields are marked *