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San Francisco crash highlights cockpit culture flaws

Dec. 12, 2013, Washington, D.C. - The investigation into the crash-landing of an Asiana Airlines flight at San Francisco's airport last summer has highlighted problems with cockpit culture and the trainee pilot's lack of confidence in his ability to safely land the Boeing 777.


December 12, 2013
By The Associated Press

Thousands of pages of investigative documents released during a
National Transportation Safety Board hearing Wednesday revealed that
pilot Lee Kang Kuk harboured fears about landing safely while relying on
manual controls and a visual approach, but he didn't express them to
his fellow crew members because he didn't want to fail his training
mission and embarrass himself.

 

The top official at the NTSB, which is
probing the July 6 crash that killed three people and injured more than
200, said the agency is examining an apparent lack of communication in
the cockpit and signs of confusion among the pilots about the jetliner's
elaborate computer systems.

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Junior officers' reluctance to speak up
has been an issue in past accidents, though industry training has tried
to emphasize that safety should come first.

 

"It's never one thing. It's always
several hazards coming together with a catastrophic result," said Tom
Anthony, director of the aviation safety program at the University of
Southern California. "You can see that the areas of concern to the NTSB
are the effects of automation and also communication in the cockpit —
whether (pilots) are communicating hazards to other crew members."

 

Airlines will be forced to examine
cockpit culture, Anthony said. The U.S. went through that decades ago
and shook off a "captain-as-overlord" mentality, he said, and now some
Asian airlines will have to make sure their training encourages even
junior pilots to speak up about hazards.

 

Asiana officials declined to discuss
cockpit culture or any confusion about the jet's computer controls. But
in a statement they expressed "sorrow for the loss of life and the
injuries sustained in the accident" and said they are "taking the steps
necessary to ensure that such an accident never happens again."

 

Lee, a veteran pilot
undergoing training on the wide-body 777, told investigators he had been
"very concerned" about attempting a visual approach without instrument
landing aids, which were turned off because of runway construction. A
visual approach involves lining up the jet for landing by looking
through the windshield and using other cues, rather than relying on a
radio-based glideslope system that guides the aircraft to the runway at
the proper angle.

 

Lee said he had worried privately before
takeoff about his ability to handle the plane. But he told investigators
he didn't speak up because others had been safely landing at San
Francisco

International Airport under the same conditions. As a result,
he said, "he could not say he could not do the visual approach."

 

Another Asiana pilot who had recently
flown with Lee told investigators he was not sure if he was making
normal progress. That pilot said Lee, who had less than 45 hours in the
777 jet, did not perform well during a trip two days before the accident
and he was "not well organized or prepared," according to the
investigative report.

 

"This pilot should never have taken off,"
said lawyer Ilyas Akbari, whose firm represents 14 of the passengers.
"The fact that the pilot was stressed and nervous is a testament to the
inadequate training he received, and those responsible for his training
and for certifying his competency bear some of the culpability."

 

During its approach, Asiana Flight 214
came in too low and too slow, then clipped a seawall, breaking off part
of its tail. Neither Lee nor an instructor pilot in the cockpit had said
anything when the first officer raised concerns four times about the
plane's rapid descent.

 

NTSB Chairman Deborah Hersman said the
agency has not yet determined the cause of the crash. So far, the
investigation has not found any mechanical problems, although testing is
ongoing, NTSB investigator Bill English said.

 

But documents released Wednesday
catalogued other issues that could have played a role in the crash, such
as a culture of not acknowledging weakness and of deferring to a
higher-ranking colleague.

 

Lee told NTSB
investigators he did not immediately move to abort the landing and
perform a "go-around" because he felt that only the instructor pilot had
the authority to initiate that emergency move.

 

Lee also said he had been blinded during a
critical instant before the botched landing by a piercing light from
outside the aircraft. NTSB investigators repeatedly asked about the
light, but he was unable to pinpoint its origin or how it precisely
affected him.

 

Asked whether he wore sunglasses in the
cockpit, Lee said he did not "because it would have been considered
impolite to wear them when he was flying with his" instructor. The
instructor pilot told investigators he never saw a bright light outside
the aircraft.

 

Recordings from the cockpit show Lee took
the controls about 1,500 feet above San Francisco Bay. Though he was an
experienced pilot with the Korea-based airline, it was his first time
piloting an airliner into San Francisco's airport since 2004, according
the NTSB.

 

The plane's first officer, Bong Don Won,
told NTSB investigators that as the plane started its descent, he
noticed its "sink rate" was too rapid. He said that he said nothing at
that point, but as the plane's altitude dropped below 1,000 feet, he
advised the crew four times about the rapid descent. The cockpit
recorder showed no response from the others, though the first officer
said the pilot deployed the plane's flaps, which appeared to slow the
plane's drop.

 

The crew did not comment again on the
jet's low approach until it reached 200 feet above the ground, according
to a transcript of the cockpit voice recording.

 

Lee conceded to investigators that he was
worried about his unfamiliarity with the 777's autoflight systems. He
admitted he had not studied the systems well and thought the plane's
autothrottle was supposed to prevent the jet from flying below minimum
speed as it neared the runway.

 

NTSB investigators also
raised concerns about the design of the 777's controls, warning that the
plane's protection against stalling does not always automatically
engage.

 

When the plane's autothrottle is placed
in a "hold" mode, as it was during the Asiana flight, it is supposed to
re-engage or "wake up" when the plane slows to its minimum airspeed.

 

Boeing Co.'s chief of flight deck
engineering, Bob Myers, testified that the company designed the
automated system to aid — not replace — the pilot. If there's a
surprise, he said, "we expect them to back off on the automation" and
rely on their basic skills.

 

Boeing evacuation engineer Bruce Wallace
testified that at least one, if not two, of the passengers who died did
not have seat belts on.

 

Wallace also said inflatable rafts
deployed inside the jet, pinning at least one flight attendant in the
wreckage. Engineers had never seen that happen before and were looking
at safety improvements.

 

One of the three fatalities was a teenage
girl from China who survived the crash but become covered in
firefighting foam and got hit by an emergency vehicle on the runway.

 

Documents released Wednesday revealed
that Ye Meng Yuan was struck twice — once by a fire rig spraying foam
and again 11 minutes later by a second truck that was turning around to
fetch water.