Skills, Training, CRM, Culture... Safety

[TeeVee]

well buddy, here is how just one state statute defines criminal negligence:

"CRIMINAL NEGLIGENCE. A person acts with criminal negligence with respect to a result or to a circumstance which is defined by statute as an offense when he fails to perceive a substantial and unjustifiable risk that the result will occur or that the circumstance exists. The risk must be of such nature and degree that the failure to perceive it constitutes a gross deviation from the standard of care that a reasonable person would observe in the situation."

so given that knowingly allowing the airspeed to decay to below stall speed in a plane full of humans, knowing that such low speed would likely result in a crash coupled with the fact that even cessna pilots know this is a problem, to me = criminal negligence, if they merely said, "screw this, i'm gonna continue."

[3WE]

...1300fpm is unacceptable....

Just be sure to put it in context...800 fpm is about what you need to average for a 3-degree landing and airliner landing speeds.

[3WE]

If these guys had somehow pulled off this landing ( obviously earlier recognition of the situation ) Would anyone have ever heard a word about it ? How often does this go on ? How many times does a crew pull one out of their ass and all agree when they land this will be our secret to the grave ?

How many times?

Failing to watch an instrument, and/or flipping the wrong switch has happened a lot...a whole lot, and many crashes have already been listed.

...and how many times has someone failed to watch an instrument and/or flipped the wrong switch and you do not crash?

...and I haven't heard any word yet on the fatigue factor, nor the preceding 48 hours of these pilots lives.

...those things have also helped instruments to not be watched and wrong switches to be flipped. (Corporate Airlines 5966 has not been listed)

Yeah, sure Gabriel- we can circularly argue till the end of time...yes, a major major screw up here, but it could be insidious too, because this sort of thing happens often, as Craker hints.

[3WE]

...The speed was not stabilized (and had never been during the approach).
The glide slope was not stabilized (as and had never been during the approach)..

Are you 100% sure.

I hate to split hairs, but in the final moments of the landing, there was an 'instant' where they were perfectly on speed and 'perfectly' on the glideslope. Maybe they weren't the exact same time, but it all happened right there over the approach lights...

If the engines had just come up like they had a zillion times before...

[Evan]

Just be sure to put it in context...800 fpm is about what you need to average for a 3-degree landing and airliner landing speeds.

A better context would be that anything greater than -1000fpm on approach is considered an excessive flight parameter deviation and the cue for a missed approach.

[Evan]

Are you 100% sure.

I hate to split hairs, but in the final moments of the landing, there was an 'instant' where they were perfectly on speed and 'perfectly' on the glideslope.

...and sink rate? Don't forget that hair.

[Gabriel]

Are you 100% sure.

How does that goes, that 100% absolute statements are almost 100% always wrong? Better let's wait for the final report.

I hate to split hairs, but in the final moments of the landing, there was an 'instant' where they were perfectly on speed and 'perfectly' on the glideslope. Maybe they weren't the exact same time, but it all happened right there over the approach lights...

Yes, since they crossed from way too high to way too low, and from way too fast to way too slow, they necessarily had to cross through the right slope and right speed at one time.

Not only that, but they might have been exactly at the glide slope and Vref when crossing 500ft.
And that doesn't make it a stabilized approach at all.
[/quote]If the engines had just come up like they had a zillion times before...[/QUOTE]
They would have gotten away with it and saved the crash for a later instance.

The difference between your view and mine, is that you propose that they didn't know what they were doing. My view is that they knew, all except how the AT works. But they knew that they were not stabilized and that they should have gone around.

Anyway, this is my hypothesis for this thread, which was NOT intended to be a second Asiana thread, but about how to deal with some personalities that are not compatible with a professional pilot.

[jt325i]

Failure to speak up?

What about the captain under training who was actually flying the plane? He didn't have to speak up. He had to go around.

And the training captain that was supervising the other guy? He didn't have to "speak up", he had to command a go around. He was the Pilot in Command for a reason. He was in the high side of the cockpit gradient.

I think it is even worse that 2 experienced pilots and a trainer couldnt see until the last few seconds they needed to do a go around. I bet they knew the approach was wrong a lot earlier and simply didnt say or do anything until it was too late thinking they could turn things around and execute the landing.

[Gabriel]

I think it is even worse that 2 experienced pilots and a trainer couldnt see until the last few seconds they needed to do a go around. I bet they knew the approach was wrong a lot earlier and simply didnt say or do anything until it was too late thinking they could turn things around and execute the landing.

Well, that has been exactly my point.

[Dispatch Dog]

Anyway, this is my hypothesis for this thread, which was NOT intended to be a second Asiana thread, but about how to deal with some personalities that are not compatible with a professional pilot...

...That too. If the autothrottle had worked in the way the pilots wrongly expected, this accident probably would not have happened...

...

Assumption!

An insidious and re-occurring circumstance that litters the reports of so many accidents.

In many cases it is not just about personality, competence or culture, but simply a circumstance that every human being finds themselves in at one time.

BD92, where the pilots in agreement shut down the wrong engine:
An experienced professional crew with an excellent performance record. There are too many elements in the processes that led to the mistake, so I'll isolate some pertinent factors:
When they shut down the right engine, many of the symptoms of a failing engine ceased. So the crew made the assumption that they had done the right thing and continued with the dozens of other tasks needed.

In the process of doing so many other things, the action of shutting down the engine was relegated to the back of their mind and they were now facing urgent tasks that occupied them fully.

Only when it was too late, did they realize that they had made a mistake.

In hindsight, we can all judge that action as incompetent or even negligent. We can assess the conversion training as inadequate and we can plug that particular error path can be eliminated by training, changing the instrument display and simply the experience of reading the report and becoming aware that it is an easy mistake to make so guard against it.

But what has been done to prevent the human brain from assuming something that is incorrect?

As we make planes and their systems more complex, augment piloting and systems management with more automation and support warning systems, what are we doing to ability of a human brain to stay in the sharp end of being spatially aware of the status of all these systems as well as the aircraft itself?

My view is that we are unintentionally encouraging pilots to make bigger assumptions and trusting automation too much.

Nor can we have a situation where a pilot has to constantly question everything the aircraft does or every decision he has made too much because this just creates mental clutter and lack of confidence.


BD92 is probably not a great example of the point I'm trying to make and I'm sure there are countless example.

In the case of Asiana 214. A few attempts were made to set the auto-throttle in a mode that satisfied their needs. For whatever reasons, all 3 flight deck crew made the assumption that this had been done and moved on. In hindsight and our analysis, it looks like an explainable mistake to fail to monitor not only that system, but the basic principles of piloting. Yet that system was designed to let the pilot concentrate on many other things.

The investigations into the causes of many accidents in the past have stopped short at the point where blame can be attributed rather than the deeper causal factors of human behaviour. While this has been getting better and much research has been and continues to be done to understand how the brain works, the habit of assumption can only be reduced through thorough training and adherence to procedure with all the associated checklists and compliance tests.

We can also introduce even more warning systems about incorrect setting of AP and AT, or speed decay, etc, but these are merely plasters covering the real issue of human factors and the interface between the machine.

Whatever the solutions to the real root cause (human nature), it will have to apply to the full spectrum of piloting ability, experience, personality and circumstance which includes fatigue, AND not be just another system or procedure remember or manage.

As for the airline "knowing" that these pilots were deficient in their understanding of the systems and procedures... maybe, but as we have seen many times before, the existing check system for pilots doesn't catch them all and can be navigated successfully where bad personality traits and piloting skills can sometimes be hidden from official view. So again, I advocate the use of constant monitoring through a DFR system that is reviewed regularly iso of after a crash or incident.

The laws regarding video surveillance prevent this in some countries, as do union pressures, but if used correctly, would enable airlines to truly know about potentially dangerous levels of behaviour and competence BEFORE we lose lives.

[Dispatch Dog]

this can easily be construed as criminal negligence. perhaps not what you meant to point out, but i would also argue that the authorities should be charging people criminally in cases like your example. let a jury decide if what they did was simply poor training, poor skills, plain ol lazy-ass, or like you said, "i'm too good to worry about all this BS."

But what does really this do to actually prevent exactly the same thing happening again?

Punitive action often leads to people getting better at hiding things. Do you want to be punished for making a mistake at work when you have been worked too hard, insufficiently trained and been put in circumstances that were out of your control? Not saying this happened in the case of Asiana, but when underlying issues are not dealt with during the normal process of selection, training and testing, in order to prevent mistakes, they have to first be known in one way or another.

As usual, we see a selection of information coming to light after an accident which falls into the "I knew this would happen" category.

Splitting on your workmates is not a reliable method either especially when you know they may be punished, i.e lose their rating, job or career.

Performance monitoring has to be more intrusive when you are talking about minor mistakes turning into huge loss of life. It also has to be handled with higher levels of integrity where pilots are not sacked as a result of mistakes through poor working conditions and/or training.

In the world of increasing commercial pressures, companies do actually make decisions based on the equation of cost/lives. If the associated cost of losing 300 lives is less than the cost of prevention over the same statistical period, sorry, but too often morality does not enter into it.

[TeeVee]

But what does really this do to actually prevent exactly the same thing happening again?

Punitive action often leads to people getting better at hiding things.
In the world of increasing commercial pressures, companies do actually make decisions based on the equation of cost/lives. If the associated cost of losing 300 lives is less than the cost of prevention over the same statistical period, sorry, but too often morality does not enter into it.

it sets an example to others: intentionally break the rules and people die, and you go to jail for a long time. forget about your license and your career. where you're going you won't need one.

you seem to want to coddle these people. we do enuf of that in our society and look where it's gotten us. hit 'em and hit 'em hard. very hard.

as to the hiding things, sure, if you're talking about real criminals. in which case the answer is videorecording of the cockpits and random screening of the video and voice recordings.

on your last point, the fact that it is common enuf for people like us to even discuss it openly is beyond comprehension. once again, this is a DIRECT result of lax enforcement. money is not the answer. jail time is. lots of it.

look, we put pilots in jail if they drink alcohol a certain amount of time before a flight. why should their superiors who consciously make a decision to place the lives of hundreds in danger to save three f*ckin dollars get off the hook? oh, because they are executives? wall street bitches? because they answer to the shareholders? f*ck the shareholders. the people you really have to answer to are the pax. period. end of story. absolutely nothing to discuss.

we have created this insane culture wherein we have "come" to believe that on-time performance actually means something. i fly a lot as part of my work and honestly, don't give a rat's ass about on-time performance. ANY flight that arrives safely was a good flight. risking lives to leave on time? i do not believe there is a jury on the planet that wouldn't convict.

[TeeVee]

and speaking of cost-saving measures, AA 191 was the perfect example. in order to save 200 man-hours AA used an unapproved method for removing/servicing an engine, directly costing 273 people their lives.

result? it cost aa $500,000 in fines. i'm sure that they "learned their lesson."
NOT.

"The field service representative from McDonnell Douglas said the company would "not encourage this procedure due to the element of risk" and had so advised American Airlines." (from the wiki quoting the NTSB report).

criminal negligence = the knowledge that what you are about to do is wrong and carries a great risk or likelihood of serious injury or death.

[guamainiac]

Right TV but the key, the absolute key in your scenario is where they actually say "screw this, I'm going to continue". I don't think you will hear that on the tape.

Regarding AA-191, I doubt you would in reality find a man in that maintenance crew who ever even thought "you know we can kill someone this way but what the fu'k let's do it anyway. Don't wanna' miss the Friday night fights down at the Gin Mill."

And, yes, I have changed out a few J series engines. One thing I toss on the table and open myself up, I knew that aviation mechanics were not for me and after I left the military, the only thing I ever did was change a few Bird Dog wheels. It was a good decision for all of us.

[guamainiac]

The "sink rate for an instant" .. well that sounds like another way of saying a broken clock is right twice a day.