I worked as an air traffic controller, and spent my last ten years in the Bay Area. There were times when the weather made a mess of things, but for most of the time, the weather was just incredibly benign: sunny, with calm winds. It was a nice place to be, at least for the weather.
All arrivals to Bay Area airports are sequenced by the radar controllers at NCT (Northern California TRACON, near Sacramento), and these controllers have always taken advantage of this fair weather to allow (and even encourage) commercial flights to fly Visual Approaches. Visual Approaches reduce workload, both for ATC and for the flight crews. So, with the recent fatal crash of Asiana 214, and with some context about past Korean accidents, there is a growing discussion suggesting that ATC’s assignment of a Visual Approach to Asiana 214 may have actually contributed to the accident. In other words, although we should always be able to rely on pilots to safely ‘hand-fly’ visual approaches (vs. flying by instruments, such as using ILS approaches), it is possible that cultural factors may have conspired with the Visual Approach to produce the Asiana 214 crash.
When Asiana 214 crashed on a sunny, calm Saturday afternoon, it was a miracle that so few perished. This accident would have been far worse, if the stall had begun just seconds earlier, or if the collision energy had not been absorbed in breaking off the tail and landing gear. On this day, while losses to some are infinite (as always), the losses were far lower than in the one accident most similar to this: the 1997 crash of Korean Air 801, in Guam. When Korean Air 801 crashed atop Nimitz Hill,* five miles from the intended runway at Guam, the force of impact and post-crash fire killed 228 passengers, leaving only nine survivors.
In both accidents:
- the glideslope was out of service (so the flightcrew had no electronic system for controlling their vertical descent),
- there were substantial fatigue issues (the Guam accident was at 1:42AM local time while the SFO accident was at the end of a flight of more than ten hours),
- and both accidents appear to have been products of a culture where less senior pilots were afraid to challenge the authority of more senior pilots.
And, one other key similarity, the most critical to my own experiences as an ATC whistleblower: in both accidents, controllers failed to notice an observable problem, thus passed on an opportunity to do their job well and act to ‘save’ the emerging accident.
After the KAL801 accident in Guam, a major push was made to ensure airline pilots were speaking up about problems — challenging more senior pilots when necessary. The ‘Crew Resource Management’ (CRM) program was broadly trained, including variations in the ATC work environment. Fifteen years later, in the post-crash analysis of Asiana 214, there has been much discussion about whether CRM training worked. Here are a few comments, mostly by professional pilots, gleaned from the internet. The first three are from pprune.org; the last two are from slate.com:
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One pilot was evidently concerned that too many comments were harping on the ‘Asian pilot’ concept, as if pilot ethnicity mattered. Of course, there is no value in racist comments; this is about flying, and flying safety can be seriously degraded by the failure of a pilot to take full command of the situation. The tragedy at Guam, KAL801 in 1997, was a huge lesson learned about the need for Crew Resource Management (CRM) on the flight deck. And, as this pilot points out, KAL801 was THE example more than any that was cited to justify an extensive program of CRM training. Here is the comment:
“…just by way of an observation which may explain some of the “background noise” here, how many people here attended a CRM course in the past ten years and were not told, “Korean airlines had a problem, a few years ago, but that was fixed by CRM training”, or words to that effect? That’s why people keep harping on it, even if it’s irrelevant in this case. The actual, unspoken, issue, is “How effective was the CRM training that I, and others, underwent?”
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Another pilot, commenting on lack of real stick time by some Asian commercial pilots:
“…actually pilots from Asia very frequently progress from company owned Cessna 172’s to whatever twin and then immediately into big jets, all in the space of 6-12 months. East Asian airlines have some very different ideas when it comes to training progression in my opinion. A lot of these pilots have comparatively little stick and rudder flying experience…”
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Here’s a lengthy but very insightful account by a retired airline pilot, who followed up his airline career by providing contract instruction to help rebuild the Korean commercial pilots, into a culture focused on CRM. He touches on how that same culture can work against safety, by culling out the whistleblowers. In other words, those expat instructors who feel compelled to speak up for safety, will sometimes roll against the flow and fail a pilot the culture wants to protect. When that happens, the retribution follows:
“…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, to right seat, to 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 expat instructors.
“One of the first things I learned was that the pilots kept a website where they 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 and many of the 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 been partially successful and still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified expat 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 how to successfully shoot a visual approach with a 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts … and with good reason. Like this Asiana crew, it didn’t compute that you needed to be at 1000’ AGL at 3 miles, and your sink rate should be 600-800 ft/min. Well, after 5 years of instructing, 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. Eventually, I 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. That failed crew was given another check, passed, and continued to fly while talking about how unfair Captain so-and-so 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 a 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He 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. Of course, he failed to “Extend the FAF” and he couldn’t understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and 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 a 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. 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-141’s 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!
“The 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 and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it 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 get 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. What 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.
“Actually, 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. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250’ after takeoff. How much actual flight time is that? Hardly 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 (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’s 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 CAVOK weather, it raises the hair on the back of my neck.
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Here is a commentary by professional pilot Patrick Smith, who is highly critical of all the uninformed commentary. He is also a regular aviation columnist at Slate.com:
“Lastly, we’re hearing murmurs already about the fact that Asiana Airlines hails from South Korea, a country with a checkered past when it comes to air safety. Let’s nip this storyline in the bud. In the 1980s and 1990s, that country’s largest carrier, Korean Air, suffered a spate of fatal accidents, culminating with the crash of Flight 801 in Guam in 1997. The airline was faulted for poor training standards and a rigid, authoritarian cockpit culture. The carrier was ostracized by many in the global aviation community, including its airline code-share partners. But South Korean aviation is very different today, following a systemic and very expensive overhaul of the nation’s civil aviation system. A 2008 assessment by ICAO, the civil aviation branch of the United Nations, ranked South Korea’s aviation safety standards, including its pilot training standards, as nothing less than the highest in the world, beating out more than 100 other countries. As they should be, South Koreans are immensely proud of this turnaround, and Asiana Airlines, the nation’s No. 2 carrier, had maintained an impeccable record of both customer satisfaction and safety. Whatever happened on final approach into SFO, I highly doubt that it was anything related to the culture of South Korean air safety in 2013.”
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And, as a last item, a response to the Patrick Smith article, referencing a South Korean aviation whistleblower who was jailed for speaking up:
“You said in your post that ICAO has cleared Koean Air’s training standard as the highest in the world. But I am going to have to disagree with you on that for the following reason.
“From 2006 to 2009, a former local pilot for Korean Air had been campaigning to ICAO that Korean Air uses unqualified pilots, despite sending a mountain of evidence to the organization, the ICAO had chosen not to follow through with any of it and had even actively blocked the activist from entering the building. The local pilot/activist was subsequently jailed in South Korea for whistleblowing, and had fled to Canada as a refugee.
“The ICAO was spoiled by Korea’s dirty money, and gave out a sick stench….”
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UPDATE: — An article in the Christian Science Monitor, titled: Asiana Flight 214: Was the pilot training program to blame? Reviews some of the history related to the Guam accident in 1997, and includes comments from contractors with experience training Korean pilots. One of the quotes puzzles over how the loss of speed went unnoticed for more than a minute: “I can’t understand why qualified and experienced pilots wouldn’t look at their speed for that long. That’s like you driving down the freeway and not looking out your front windshield for two full minutes.”