NTSB Releases Initial Findings On Asiana Crash

As I’m sure all of you remember, back in July an Asiana 777 crashed on final approach into San Francisco Airport, killing three people. The NTSB has released some of their initial findings, and they’re rather troubling. Here are a few quotes from the CNN, SFGate, and Yahoo articles that have been published on the findings:

The pilot “stated it was very difficult to perform a visual approach with a heavy airplane,” according to a safety board summary of an interview with Lee, who did not testify Wednesday. “Asked whether he was concerned about his ability to perform the visual approach, he said, ‘Very concerned, yea.’

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Two former Asiana pilots said in interviews that most of the carriers’s crews were uncomfortable with manual flight maneuvers, according to NTSB documents. The pilots gave a similar account in interviews with Bloomberg News in July.

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But when the student captain was asked whether he had contemplated an aborted landing as the plane descended, Lee Kang Kuk said it was a “very hard” decision to make, given the deference shown in Korean culture.

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He stated the trainee captain was not carefully monitoring, examining or focusing on the operations and he accepted the (instructor’s) advice ‘very lightly’ and was not seriously focused on operating the right way,” the safety board said.

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In the last minute of the flight, Lee and his captain instructor, Lee Jung Min, did not react to several warnings from a third member of the crew, First Officer Bong Dong Won, that the descent was too steep, the safety board said.

The first officer, sitting in a jump seat in the cockpit, told investigators that he noticed the steep descent as the plane dropped below 1,000 feet. Investigators said he “prepared in his mind to recommend something, to advise them, but he did not.”

About 40 seconds before impact, he repeatedly called out, “sink rate,” according to a transcript of the cockpit conversations. There was no apparent response.

In interviews with safety board investigators, Lee Jung Min “stated he heard this callout,” but said the plane was still high in the air and appeared to be descending properly.

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Before the crash, Lee – referred to as a trainee captain – had flown just four round-trip flights on the 777. All originated in South Korea, where Asiana is based.

His instructor on a flight to Narita, Japan, two days before the crash told the safety board that he was “not sure if the trainee captain was making normal progress because the trainee captain did not perform well during the trip,” investigators wrote. “He said that the trainee captain was not well-organized or prepared, that he conducted inadequate briefings, and that he deviated from multiple standard operating procedures.”

Comments

  1. Adam P says

    This is horribly unnerving and reminiscent of the cultural, communication, and training issues Korean Air had in the previous decade which resulted in several high profile crashes. Although I know the Korean and several of the Chinese carriers have very nice premium class products, beautiful hub airports, and great award availability, I’m not certain I would be entirely comfortable flying them.

  2. Andrew B says

    So interesting. I’m not a pilot, so I don’t have any expertise on cockpit operations. But, while calling out “sink rate” may be standard, it seems like it might have been more helpful to recommend a solution — “recommend you increase power,” for example.

    Seems like in addition to “culture” having an effect here, there were some other failures along the way: namely, the trainee’s decision to keep flying despite his own misgivings about his preparedness, and the instructor on the NRT flight’s failure to keep him out of the cockpit after observing his inadequacies.

  3. theBOAT says

    The quotes beg the question – Why bother paying a pilot on any Asiana flight, since none of them really fly the plane and merely just watch & program the flight computers. It’s simply amazing that they would actually say they don’t feel comfortable manually flying the planes.

  4. snic says

    theBOAT, it’s incorrect to say that pilots “merely” program and watch flight computers. That is not an easy task in itself, and it takes years of training and experience to do it right.

    The right reaction to the new Lucky posted is not to denigrate pilots (including Asiana pilots) for being “mere” computer operators, but to wonder why Asiana did not emphasize the most basic airmanship. Landing a plane without “instruments” (actually, landing *always* uses instruments; it’s a question of which ones) in clear visibility is the most basic of piloting skills. Asiana needs to be called to account for letting their pilots fly planes without being adequately trained on such a basic task.

  5. AS says

    I think this is an extremely misleading post.

    First of all, with a headline of “NTSB releases initial findings…” the lack of a link to the actual release is a glaring omission.

    Second of all, the quotes are selected from newspapers looking to drive viewership and sell copies. You have selected a subset of them and left out others, further spinning the story.

    What’s missing in the facts is that there are concerns about the Human/Computer Interface in the 777 (and 787) that caused the pilot to inadvertently set the throttles to idle rather than maintaining the normal approach speed. The fact that 787 pilot manuals apparently have a written warning about the way the autothrottles work suggest that the H/CI is a contributing factor.

    The NTSB will issue a report with the final probable causes of the crash [and they have not done so yet], but anyone who minimizes it to “pilot error” and thinks it’s culture, lack of training, and lack of experience is pushing an agenda not reporting the entirety of the facts.

  6. Dan says

    @AS, be sure to call out CNN, SFGate, and Yahoo News for also not linking to the report. Fair is fair, right?

  7. snic says

    “anyone who minimizes it to “pilot error” and thinks it’s culture, lack of training, and lack of experience is pushing an agenda not reporting the entirety of the facts.”

    I agree that more was likely at play than simply pilot error or inadequate training – there is pretty much always a whole array of distal and proximal causes for any event like this. But from what was posted on SFGate and elsewhere, it is crystal clear that inadequate training was *one of the factors* that contributed, and I do not think that I or anyone else who draws that conclusion from those news stories is necessarily “pushing an agenda.”

    “Drawing a conclusion” is not the same as “pushing an agenda”.

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