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Pilot of Asiana 214 “Very Concerned” About Landing at SFO

12/13/2013

This story first appeared in the December 13 edition of AirlineRatings.com.

The pilot at the controls of Asiana Flight 214 says he was “very concerned” about landing a Boeing 777 at San Francisco International Airport visually, without aid of a glide-slope indicator. The device helps pilots monitor descent to the runway. The revelation comes in a 139-page Operations Group Factual Report released by the U.S. National Transportation Safety Board in conjunction with a hearing in Washington, DC.

Thirty-five of trainee Captain Lee Kang Kuk’s 9,700 flight hours had been spent flying the Triple-Seven. The aircraft he was piloting late morning July 6, 2013 struck a seawall just short of Runway 28L at San Francisco International Airport. Three of the craft’s 291 passengers died. 199 were taken to hospitals. 11 crewmembers were hurt.

While the official Probable Cause of the accident won’t be known until NTSB publishes its report, investigators are honing in on human factors. Overreliance on technology, culture and communication could have played pivotal roles in this accident.
So might be the operation, and crew understanding of, the Triple-Seven’s auto-throttle feature.

Consider:

– Lee knew the glide-slope indicator was inoperative. But because other pilots were doing visual approaches, the report says “he could not say he could not do” one.

– Lee told investigators he was blinded for a brief moment while on approach. Why no sunglasses? It would have been impolite to don them when flying with his PM, the pilot monitoring his actions.

– Lee didn’t break off the approach and initiate a “go-around” maneuver on his own because “Normally only in our Korean culture the one step higher level the final decision people he did he decide the going around thing. It’s very important thing. As a first officer (co-pilot) or the low level people they dare to think about the going around thing. It’s very hard…The instructor pilot got the authority. Even [if] I am [in] the left [command] seat, this is very hard to explain, that is our culture.”

Information from Flight 214’s cockpit voice recorder shows that 16.7 second before the 777’s tail slams into the tarmac an unidentified voice in the cockpit says, “It’s [the aircraft] low.” 3.9 seconds before impact the cockpit is filled with the rattling sound of a “stick-shaker,” signaling the onset of an aerodynamic stall.

Precisely 2.5 seconds before ground and airplane meet Captain Lee Jungmin, the man monitoring Lee Kang Kuk’s airmanship, says, “Oh # go around.” It is too late.

As the video shows http://www.ntsb.gov/investigations/2013/asiana214/asiana214.html , the 777 hits tail first and then almost cartwheels down the runway. The crash could have been far worse than it was.

Life-saving CRM, or Cockpit Resource Management training, stresses communication, collaboration and individual initiative. Lee Kang Kuk told investigators he had taken CRM training “frequently.” In a post-crash interview, they asked the man in control of Asiana 214 if his airline encouraged junior pilots to “speak up if they felt uncomfortable about something.” Lee Kang Kuk responded “yes.”

Again, NTSB has issued no Probable Cause. In any event, the Safety Board doesn’t assess blame. Its mission is to find fact, and issue recommendations that prevent similar accidents in the future.

It’s safe to say the global airline industry will be paying rapt attention to the lessons learned from Asiana 214.

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