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KSFO 777 incident


Ed Cesnalis

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Subject: the lowdown on Korean pilots

 

After I retired from UAL as a Standards Captain on the 400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it’s a minefield of a work environment ... for them and for us expats.

 

One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don’t think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG. Many of the new captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all “got it” and continued the takeoff (in accordance with their manuals). The word had gotten out; I figured it was an overall PLUS for the training program.

 

We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.

 

This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce “normal” standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 knot crosswind and the weather CAVU. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this SFO Asiana crew, it didn’t‚ compute that you needed to be a 1000’ AGL at 3 miles and your sink rate should be 600-800 Ft/Min.

 

After 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn’t pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.

 

Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. This captain requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested “Radar Vectors” to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then “cleared for the approach” and he could have selected “Exit Hold” and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Eah time he failed to “extend the FAF” so he couldn’t understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and three missed approaches before he figured out that his active waypoint was “Hold at XYZ.” Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).

 

This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken [to teach third world pilots basic flying]. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141s in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!

 

Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning. so they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM, never-challenge-authority still exists either on the surface or very subtly. You just can’t change 3000 years of culture.

 

The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It’s actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are OK. I guess they don’t trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don’t have the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. It was a shock!

 

Finally, I’ll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.

 

This is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. In accordance with their SOP, he calls for the autopilot to be engaged at 250 feet, just after takeoff. How much actual flight time is that? Not even one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800‚ after the gear was down, flaps extended and on airspeed using the autothrottle. Then he might bring it in to land. Again, how much real “flight time” or real experience did he get. Minutes! Of course, on the 777 or 747, it’ the same only they get more inflated logbooks.

 

So, when I hear that a 10,000 hour Korean Captain was vectored in for a 17-mile final and cleared for a visual approach in CAVU weather, it raises the hair on the back of my neck.

 

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So, when I hear that a 10,000 hour Korean Captain was vectored in for a 17-mile final and cleared for a visual approach in CAVU weather, it raises the hair on the back of my neck.

 

Wow, thanks Eddie, OMG!

 

After reading this I am of the opinion that the west needs to ban Korean airlines until they turn over their training completely to the west. Not only are they children of the magenta "can't hand fly" but they don't know how to fly with the automation turned on either.

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This guy was fired. Does he have an attitude? Maybe. Is it a balanced, verified account? No, it's an anecdote.

 

Look at the list of WWII and Korean War aces. Any Japanese or Chinese there? I wonder if they were on autopilot? How about Vietnamese (or were they all Russians?).

 

God forbid a man depends for his freedom or credibility on what may be printed about him on the internet.

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This guy was fired. Does he have an attitude? Maybe. Is it a balanced, verified account? No, it's an anecdote.

 

Look at the list of WWII and Korean War aces. Any Japanese or Chinese there? I wonder if they were on autopilot? How about Vietnamese (or were they all Russians?).

 

God forbid a man depends for his freedom or credibility on what may be printed about him on the internet.

 

 

Jim,

 

I took the author of the Asiana training story at his word that he was fired for doing the right thing. But, as someone who earns his paycheck in the academic world, I should have considered the source of this account more carefully. Thank you for your reminder that none of us would want the internet to be the sole basis for our reputations.

 

Safe landings everybody...

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Both the cultural CRM issue and the lack of hand flying are pretty well documented from various sources. These issues didn't exist during the wars and some countries like Japan have overcome them. The performance of the 4 pilots support the assertions. They didn't get low, slow and behind the power curve in 1 second, it took time. Someone should have lunged from the back seat and advanced the throttles rather than have ~ 500 lives at risk. Something seems seriously wrong and deserves a look.

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I bet the cultural CRM issue is pretty well assessed through the lenses of Western culture and ideology as we are judging them now.

 

Hey, I have a revolutionary idea! How about a holistic view?

 

http://sunnyday.mit.edu/accidents/safetyscience-single.pdf

 

A New Accident Model for Engineering Safer Systems ∗

Nancy Leveson

Aeronautics and Astronautics Dept., Room 33-313

Massachusetts Institute of Technology

 

"Most accident models view accidents as resulting from a chain or sequence of events. Such

models work well for losses caused by failures of physical components and for relatively simple

systems. But since World War II, the types of systems we are attempting to build and the context

in which they are being built has been changing. This paper argues that these changes are stretching

the limits of current accident models and safety engineering techniques and that new approaches

are needed."

 

Lessons from Cali

http://flightsafety.org/fsd/fsd_may-june98.pdf

 

http://sunnyday.mit.edu/accidents/calirep.html

 

Role of software in aircraft accidents

http://sunnyday.mit.edu/accidents/issc01.pdf

 

Anyone think that whether the pilot ate with chopsticks was fundamental to the accident should take a broader perspective of airplane and other accidents.

 

Hint (oh my god) the NTSB and FAA preference to find one culpable party as soon as possible may not be the complete picture and the continuation might be why we still have people who run out of gas, people who stall-spin, people who CFIT, who VMC to IMC and on and on. Is it conceivable that there may be a better way? Another hint - look at how accidents are prevented in industrial plant design. Another example - keeping grain from spoiling (and crusting or bridging) in a bin would halt nearly every single grain bin death in the U.S. immediately. So, do we worry about workers in grain bins or do we worry about keeping the grain in good condition?

BTW, I eat often with chopsticks. I spent a year in Korea, including living on the economy must of the time, and found the Koreans to be independent, opinionated, hard headed and more or less "what you see is what you get" in distinct contrast to the Japanese where a Westerner never knew what they really thought of thought of them.

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Thanks, maybe an admin can fix.

 

The only question remains why was the pilot 50 feet off the water on approach underspeed

 

He wasn't flying 50 feet off the water, look at the graphic.

  • Why didn't someone call for a go-around in a timely manner? The approach was unstable and not aligned from the beginning according to the LCA/checkairman who was the co-pilot.
  • Why is this 10,000 hour captain unable to fly the visual?
  • Why was the crew unable to act?
  • Why the excessive pitch up when they did apply power? It only served to seal their fate by requiring additional power to overcome the induced drag.
  • Where they still relying on automation? ( assuming auto-throttles would maintain airspeed )

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Fast Eddie,

 

What a great post! I have 33 years of teaching in simulators and airplanes and have given foreign students instruction both in the simulator and aircraft. For all you readers out there, Fast Eddie's post was spot on. CRM (crew resource management) in some cultures is just not there. We have been making significant strides here in the USA over the last 30 years, but for the older pilots on this forum, you may remember we had difficulty with that concept as well.

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Just to be clear, that was not my post - I just copied and pasted from a public forum.

 

I've got lots of hours instructing, but have never flown anything bigger than an Aztec.

 

OK, I see the public post comment now - nevertheless thanks for putting it up on the forum - it speaks volumes about this incident.

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The subject title is wrong. The airport is KSFO not KFSO. The 777 'incident' was pilot error, flying too low and too slow. The only question remains why was the pilot 50 feet off the water on approach underspeed... The only guy that can answer that is the pilot. No doubt he is being interrogated fully by the NTSB.

 

You don't know that. The pilots are saying the autothrottles did not respond.

How about we find these guys gulity before we hang them?

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Also why didn't the tower call a go-around? Surely the could see he was well below glideslope.

 

The tower is not going to call a go around because he is busy with many other things, because he is not there, because he does not see what the pilot sees, because if he did the airlines and the public would have his neck - where did you come up with this idea?

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Fast Eddie,

 

What a great post! I have 33 years of teaching in simulators and airplanes and have given foreign students instruction both in the simulator and aircraft. For all you readers out there, Fast Eddie's post was spot on. CRM (crew resource management) in some cultures is just not there. We have been making significant strides here in the USA over the last 30 years, but for the older pilots on this forum, you may remember we had difficulty with that concept as well.

 

And I still say we are all running off at the mouth and implying or infering things that may have no relationship to the actual eventts. Yet, not a one of you readers looked at the Leveson approach, did you? If the culture is wrong, by god our culture has it's own fatal flaws.

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The tower is not going to call a go around because he is busy with many other things, because he is not there, because he does not see what the pilot sees, because if he did the airlines and the public would have his neck - where did you come up with this idea?

 

I guess by the fact I have been told to go around by towers before. I can give you their number if you want to call them and tell them they are doing it wrong.

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Towers tell pilots to go around all the time but the reason they do it on visual approaches is to provide traffic separation.

 

Generally true, but if the tower sees a condition developing that is a danger to a landing aircraft, would they not call the go around? They are just going to watch it burn and say "oh well, I'm not PIC..." ? I bet if I came in at 100ft AGL six miles out on final they'd tell me pretty forcefully to take some corrective action, for example.

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Hi Andy,

 

Unless the plane landing was going to interfere with another aircraft on the ground the controller will never tell a pilot how to land his aircraft. I have been ask a time or two to stay at pattern altitude on my approach to the field instead of flying too low, but once set up in the pattern and making your approach run the controller is out of it.

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