Asiana Airlines Flight 214: A Pilot’s Perspective
slate.com
slate.com
Also in 1985...the crash of a Delta Air Lines L-1011 in Dallas that killed 137.
There's always been a lot of speculation over how IBM gave up an entire industry (the personal computer) to a seemingly insignificant start-up (Microsoft). One theory is that may not have happened if Don Estridge hadn't been killed in that crash. More about him here:
http://en.wikipedia.org/wiki/Philip_Don_Estridge
and here:
http://www.nytimes.com/1985/08/05/us/philip-estridge-dies-in...
Of particular note:
"His most revolutionary move was to make the computer's design specifications public, allowing thousands of young people to write programs for the machine."
We take it for granted now, but before Don Estridge and the IBM PC, "proprietary" was the rule and "open" was the exception. RIP
i was in a car accident with my ENTIRE team one time. minor, but scary.
to quote ... shit happens.
Such an accident prompted changes in the time between large and small planes landing.
Fate seemed to be sealed (or on it's way) much earlier than that (based on my memory, and supported by an obvious link below.)
http://inventors.about.com/od/computersoftware/a/Putting-Mic...
"Bill Gates then talked IBM into letting Microsoft retain the rights, to market MS-DOS separate from the IBM PC project, Gates and Microsoft proceeded to make a fortune from the licensing of MS-DOS"
That was of course way before Estridge got killed.
And Compaq came out in 1982...
http://en.wikipedia.org/wiki/Compaq
"In November 1982 Compaq announced their first product, the Compaq Portable, a portable IBM PC compatible personal computer."
There have been a handful involving regional affiliates, but the majors have been virtually accident-free
Now, I realize that even including those the stats are still fairly good, but it makes the "virtually accident-free" stats of majors a result of spinning off risk to affiliates, which is not something a consumer should care about. It might be a bit of a nit-pick (as it's still a handful), but moving things into different brands to avoid stigma is a common and, in my opinion, unhealthy practice.
=========
"I'm sorry, but it's just wrong to say that. Yes, it may have technically been a ComAir flight that crashed in 2006 in Lexington, killing all 50+ people aboard (aside from the first officer), but those people booked a Delta flight, not a ComAir flight, so why make the distinction? And, yes, it may have been a Colgan flight that crashed in Buffalo in 2009, also killing 50 people, but they booked their flight on Continental. Major airlines ferret out their regional connections to these airlines all the time, and you don't know you're on one unless the flight attendant announces it (or you just happen to know about aviation), so why on Earth is this guy making a distinction?
I'm a fairly frequent flyer on USAir (enough for mid-level status) and I can't tell you how often I book a USAir flight but I'm actually flying Republic or Chautauqua. Yes, air travel is safe, but let's not ignore reality just to make a (false) point. There have been recent and very deadly crashes since 2001."
I think the point is that there was a streak of 12 years with no fatal incidents of a large-size jet.
Lets not forget that 228 people perished when the flight crew of Air France 447 flew the plane straight into the ocean.
I note that checked bags cannot block passengers from escaping an aircraft. Perhaps someone will someday quantify the additional risk airlines forced on passengers when they started charging for every bag.
Perhaps not, but people standing in the aisle reaching to get them, dropped bags people trip over and block the aisle, etc do.
One of my favorites: http://www.askthepilot.com/essaysandstories/the-exploding-to...
It seems he came back to slate.com as a one-time thing, but you can read his archived work at Salon and at www.askthepilot.com. He seems to have a book as well now.
I actually just read it the other day and was pretty interesting (and a quick read)
I don't think this is as big a problem as one makes it out to be and here is why. There are certain things I need when I travel that I can't afford to go without in the case my checked bags don't make it to my destination at the same time as me. Things such as prescription medicine, contacts and my retainer (though not nearly as important as the previous two but still important none the less) are things I always carry on because they are things I can't easily replace if my bags are lost. Then I bring the entertainment, usually a laptop and/or a tablet and books/magazines. All of that stuff would need to be in at least one carry on.
Most, if not all, of the airlines I have flown have a limit to how many bags you can carry on. So it isn't like charging for check bags is going to have people start bringing 10 carry ons, it would have them bring the max if they wanted which as far as I know is 2 for most airlines.
So now that checked bags cost money, people bring more and larger carry-on luggage. This additional carry-on luggage:
1. increases boarding times. 2. increases injuries from passengers and flight attendants lifing heavy bags into overhead compartments. 3. increases the amount of crowding on a cabin from under seat carry-ons thus increasing evacuation times.
A couple times gear was delayed, and so the FE team had to wait a day or so for it to arrive, but nothing has ever been stolen.
Nice thing about a Pelican Case - no straps to get tangled up in any baggage sorting gear, and large enough that it doesn't usually get stuck in the corner somewhere.
From a probability perspective, much more likely to get mugged coming out of the airport, or getting hijacked using your equipment in the field - this has happened to our Field Engineers multiple times, but no losses in the airplanes (yet).
You put $100k of equipment in checked luggage, then you probably have some very specific insurance that covers you. If you don't, you are lucky. Most people most of the time do not have anything stolen.
If a baggage handler steals a $3000 camera out of someone's luggage, the airline will totally deny liability.
Here's an article interviewing a former TSA handler who was arrested with more than 80 stolen cameras and other assorted electronics in his home at the time of arrest. http://rt.com/usa/tsa-stealing-from-travelers-358/
Wow, the number of fatalities that year is incomprehensible by today's standards. Yes, this accident has made big news because so few accidents have happened in this decade...but I'd say that today's news cycle has served to amplify just about everything, no matter what their statistical, relative, or absolute significance.
My comment is not about the culpability of the pilots, but the long recognized psychological phenomenon of overestimating risk probabilities due to increased "hearing of" incidents, rare or not, the cause being irrelevant.
Besides, it's incredible such an accident happen when the weather is perfect, there is no wind, it's not at night, the plane is working just fine, and it's just a couple of pilots who don't know what they are doing because they don't know how to land a plan manually since they are used to pressing buttons the whole time and relyong on autopilot. That's what the news is about.
Just like the AF447 crash between Rio and Paris: Pilots incompetence at its best.
There were clear indications from the communication with the air tower that the pilots did not communicate any emergency situation until 1.5 seconds before the crash, and that the co-pilot was apparently silent in the cockpit. Check the Los Angeles times article about that. It's clearly linked to cultural aspects, all over again.
Which is a wild leap no matter which way you cut it.
But I mean, congrats I guess. You were looking for a conclusion and unsurprisingly you found it.
Can't find the link I originally saw that went into this in more detail, but the basic subject is covered here: http://blogs.wsj.com/middleseat/2008/12/04/malcolm-gladwell-...
More on the business side here: http://www.nytimes.com/2002/03/26/business/new-standards-mea...
http://www.pprune.org/rumours-news/518568-asiana-flight-cras...
Don't play the martyr. If you had posted that link as an entirely separate comment and suggested that it was a major factor in the crash, no one would have down voted you, I'm sure. But because of that first comment that was, IMO, a huge jump in both tone and topic from its parent, people probably perceived your subsequent comments as being irrational and motivated by emotion. It was nothing to do with what you were talking about, and everything to do with how you were talking about it.
The main issue I had with the post was that he's claiming this to be the case purely on the notion that the copilot did not speak during the crash. That's severely reaching, and smells a lot like fitting facts to a predetermined conclusion rather than the other way around.
"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 cant 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. Its actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they dont trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they dont 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!"
The whole post : http://www.pprune.org/rumours-news/518568-asiana-flight-cras...
Right.. and this crash only killed 2 people. Perhaps one if the reports of the girl being hit by a rescue vehicle are believed; so what's your point? The real story is just how better aircraft safety has come over the years. This same accident years ago could very well have killed everyone aboard.
Just like the AF447 crash between Rio and Paris: Pilots incompetence at its best.
...and a week after this accident everyone was blaming the weird weather that happens at the equator for the crash. The point is that everyone is speculating, even you, that this this accident is the pilot's fault, but more often than not it's found to be a combination of mechanical failure and the pilot not being able to respond to it quickly enough -- which just so happens to be the official cause of AF447 crashing in 2009.
Air disaster investigations typically take a while. Most reach conclusions that are extremely non obvious, nor intuitive. I recommend, for the sake of my own sanity and the rest of the people you inflict your opinion on, that you read the following books:
http://www.amazon.co.uk/Air-Disaster-Vol-Macarthur-Job/dp/18...
http://www.amazon.co.uk/books/dp/1875671196
There is a third volume available as well if you can stick it out, but perhaps you may gain some much needed perspective.
In fact, if you can actually get an airline pilot in a relaxed situation where he's certain you won't rat him out, you'll hear lots of stories about stupid mistakes. The fact that this inevitable human error almost never results in fatalities is a testament to the level of redundancy in air traffic procedures.
As a case in point, I talked to a pilot in one of Europe's major low-price carriers. They had an incident where both pilots literally fell asleep in the cockpit and were intercepted by German jets. Apart from the jet fighter escorts, the passengers never knew anything was off.
This you know how?
My point is, it is premature to rule out aircraft problems.
Life, and all subcomponents of life, is one giant ball of probabilities. Training, preparation, and planning all go towards decreasing the probability of undesirable events, but they do not rule them out entirely.
This includes plane crashes, car crashes, or even scraping your knee.
Professional football players don't play perfectly every game. Olympic athletes still make mistakes despite years of daily training. And you still have major bugs in your codebase - would you describe yourself as incompetent?
Mistakes happen. Accidents happen. So long as we can confidently determine that it is accidental rather than systemic (i.e., incompetence), we learn from it and keep going.
But nevermind all that. Let's hang a sign around their necks, parade them in the streets, let people throw things at them, and then execute them publicly.
I realize that not all the facts are in, and the NTSB full process will take quite some time, but I believe that once all the facts are in, you will find this to be a stunning display of lack of basic airmanship skills.
Why would no one on the ground warn the flight? The altitude transmitted to ATC radar is in hundred foot increments and the high and fast on initial won't trigger an alert, once they pull the power off and try to capture the appropriate vertical profile, ATC radar has no information that anything is wrong, then when they start blowing through the vertical profile, there's not enough resolution to trigger a low altitude alert.
More fundamentally perhaps, it's not ATC's job to fly the plane. ATC keeps planes separated; pilots fly them. On a clear-and-a-million day, and an 11,000 foot runway, the crew couldn't manage a visual approach. There was more than one error, but I think the NTSB findings on probable cause will overhwelminginly find the failures to be in the forward portion of the aircraft, immediately behind the yokes. (It is hard to fathom.)
As you say, a failure like this is not "pilot error" but rather a failure of the aviation system and that is what needs to be corrected for all aviation. The "pilot error" is a symptom of the problem, not the cause.
Same type of plane( yes different type of engines) , same type of issues while landing. I am not suggesting that sfo crash was due to engine failure. I am just suggesting that we all should wait for the investigation to conclude.
You know, there's not a single thing about your comment that's useful.
>Jet engines don't change their output on a dime.
Yeah, I know. That's the reason for the question.
This specific item has been addressed by people who know this stuff. They didn't indicate it was abnormal. How is that not useful?
Who? You're some guy on the Internet. I should take it on faith that you can tell who is knowledgeable and who is a blowhard?
> have commented on it and not said it was anything unusual, so, yes, I'd say it's reasonable.
Again, instead of providing a fact I have to trust the judgment of a person I do not know.
> Jet engines don't change their output on a dime.
It should have been obvious from my question that I know that much about turbines. Do you have any information specific to 777 engines or something comparable?
>Experts commenting on their field of expertise don't count for anything, or what?
They might. It depends who they are. I don't always believe everything I see on television or the Internet. Sometimes I like to know their reasoning.
Boeing, the same company who months ago reviewed their 787 batteries and found no reason to ground their planes?
The initial conclusions from the US National Transportation Safety Board is that the engines were functioning normally; i.e. a totally different issue while landing. I doubt a Seoul-San Francisco flight in mid-July was likely to have experienced the same unusually cold temperatures that resulted in the BA038 fuel droplets freezing (over Siberia in January) either
And there is video footage of it happening. Never underestimate the how much excitement there is in news rooms where there is actually video of the news that isn't just people talking.
Yes the news cycle amplifies everything but when they have video the volume goes to 11 (or beyond)!
For example, 2012: * April 20 – Bhoja Air Flight 213, a Boeing 737, crashes near Chaklala airbase, Rawalpindi, Punjab, Pakistan reportedly due to bad weather, killing all of the 127 passengers and crew on board. * May 9 – In the Mount Salak Sukhoi Superjet 100 crash, a Sukhoi Superjet 100 crashes into Mount Salak, Indonesia on an exhibition flight, killing all 45 passengers and crew on board. * June 3 – Dana Air Flight 992, a McDonnell Douglas MD-83 carrying 146 passengers and 7 crew members crashes in a suburb of Lagos, Nigeria on approach to Murtala Muhammed International Airport, killing all on board and an estimated 6 more people on the ground.
Of course, air safety has been greatly improved, but it's not like these larger accidents are unheard of.
In the Air France crash over the Atlantic, the early theories all centered around the loss of airspeed indicators--a mechanical problem. When the flight recorders were finally found (an astounding feat of salvage BTW), it turned out that the airspeed indicators did fail...but then they came back online, and the pilots flew a perfectly good aircraft into the ocean anyway.
So as we look at this SFO crash, the lessons from Air France are mixed. On the one hand it's possible that the early theories of pilot error will be wrong, and it will be some subtle or previously unknown software or hardware error. On the other hand we know that modern highly trained pilots can make enough wrong decisions in a row to crash a sound airplane.
The linked yokes in an Airbus to average their inputs without force feedback, unless one yoke or the other is explicitly disabled. The experienced pilot had no idea that his co-pilot was stalling the plane the entire time.
The depressing part of that transcript is immediately after the co-pilot tells the pilot he's been pulling back on the stick the whole time - the pilot instantly knows it's all over and that he's got a couple seconds to live, and that it was such a stupid error that got them there. It's horrifying.
Under the normal fly-by-wire control law, constant back stick wouldn't stall the aircraft. The computers would stop pitching the aircraft up before it reached the stall angle of attack. But, the system had dropped to Alternate law which is a reversionary measure, in this case caused by the pitot system failing. Under Alternate law, high angle of attack protection is lost and you can pitch up into a stall.
That said, in the AF447 case, the suspicion is that the F/O never even appreciated they were in a stall, irrespective of Alternate law being active.
The only explanation is that sometimes the brain just goes haywire during incredibly intense moments. Like pedal misapplications in cars, when people frantically try to brake but jam the accelerator instead, it never seeming to click in their heads that they're speeding up, ie pressing the wrong pedal.
I don't think the emergency exit was some walk down the isle where a few people stopped to reach under their seats and grab their carry-on to save the inconvenience. From the pictures I saw of the cabin, the seats were torn loose, piled up on top of each other, and there was no 'center isle' left. However, it does seem that the condition of the cabin after the plane came to rest was highly variable depending on where you were sitting.
For all we know, passengers that were seen carrying bags outside the aircraft could have had to throw those bags down the chute to clear the egress. Or maybe they were in a state of panic and shock and were running on autopilot (if only the plane had landed that way).
I do think Patrick is on to something, that the increased level of automation makes it more likely that when the automation isn't there to help that accidents will happen. What I still don't get is flying 30 knots too slow on approach should have been ringing alarms all over the place, including in the tower, and yet no one noticed?
I wonder if a simple and effective thing to do here would be to simply display a velocity vector, either in a HUD on the windscreen itself, or on some kind of video display in the cockpit. Just a symbol on the screen that shows exactly which way the airplane is headed at any given moment. When it's on a runway, that's where you'll touch down if nothing changes. When it's on a seawall before the runway, that's where you're going to crash unless you fix things. Maybe I'm underestimating the difficulty, but it doesn't seem like it would be too hard to construct one based on GPS and a forward-looking camera.
Edit: thinking more about that last suggestion, more recurrent training for visual approaches would probably be a better idea. A normal human has a built-in velocity vector already. You look out the window and find the point on the ground that isn't moving relative to your view. That's the point you're headed toward. This is Aviation 101 stuff, literally one of the first things a pilot ever learns about landing an airplane. High and low comes later: the first thing you pay attention to is whether that non-moving point is, in fact, on the runway where you intend to touch down. (Or, because of the flare, slightly before where you intend to touch down.)
On normal flights you spend hours or days before of being in the mindset to keep your valuables, medicine, money and identification on you (or within sight) at all times. Life will be miserable when you don't have those. A few minutes after landing they would have to collect them, and make sure to not to leave any behind before facing immigration etc.
It is easy to see how in a state of shock, the instinct to what you have been doing and were concerned about kicks in. The cabin crew will shout at passengers to leave their stuff in an effort to overcome this. It should be noted that on this flight there are reports that some of the escape slides opened up inside the plane trapping the flight crew, hence there being fewer available at the beginning of the evacuation.
Shock is a very strange condition. No matter how cool, calm, rational and effective we all think we will be, it isn't a predictor of what we will do.
http://www.theatlantic.com/national/archive/2013/07/professi...
One supposition is that the normal system for correcting low airspeed was temporarily disabled. Key lines from the article I linked:
"The 777 can catch you out with with what is known as the FLCH trap. When you are above the glide slope and need to get down in a hurry Flight Level Change (FLCH) is a useful mode to use."
[...]
"The 777 has autothrottle wake up, i.e. when the aircraft approaches a stall the power comes on automatically to almost full power. This gives pilots great confidence; however, autothrottle wake up is inhibited in FLCH. "
Of course, time will tell, and we're all out of our depth in trying to understand what happened.
The NY Times made a nice graph with it: http://www.nytimes.com/interactive/2013/07/07/us/asiana214-u...
For the less sensationalist view of the crash and analysis, see the AVHerald information [1]
One thing that surprises me is that the same personality trait that crashed 8509, would make them a lousy flight lead as well, not to mention a lousy Squadron CO or Wing CO. If the pilots in the squadron aren't comfortable raising safety issues with their CO, then sooner or later, a crash will happen.
It's not just a foreign issue, poor safety culture lead to the VFMAT-101 crash in San Diego, where 4 people on the ground died[2]. The CO of VR-1 (Fleet Logistics Squadron/VIP transport) got canned for poor command climate [3], which caused a few safety issues, then fudging her NATOPS flight proficiency paperwork. A more "balanced" CO would have realized that flying the checkride, staying fully current would have been easier, and certainly better for safety climate.
IMO(Former pilot): Based on reports, the Pilot Not Flying(PNF/Experienced FO) didn't inform the veteran Captain that he was significantly slow by 500 ft, which could be considered the "waveoff window"[3] for landing a 777 on a runway, even when on a visual approach. Others have pointed out the regulations requiring a go-around for a visual approach are vaguely worded as "when required" without specifying the conditions. Some pilots take that the regulations literally, and believe that a visual approach doesn't require a decision altitude, call-outs or a stabilized approach. It does require to pilots to be safe, and is often required by company Operations Manuals.
[1] http://en.wikipedia.org/wiki/Korean_Air_Cargo_Flight_8509
[2] https://en.wikipedia.org/wiki/2008_San_Diego_F/A-18_crash
[3] http://www.navytimes.com/article/20120916/NEWS/209160317/UAV...
The point is that they are not supposed to adversely effect safety and cockpit environment. It takes real leadership to encourage co-pilots/subborinates to raise operational issues in an appropriate way.
Some reports indicate KLM Capt. van Zanten wasn't as overbearing as the official report said, but he still would have been somewhat intimidating due to his status, and the fact is that he had opportunity to take 15 seconds to confirm with the tower, and/or Pan Am 747, after the co-pilot pulled the throttles back. He didn't confirm, and a crash occurred.
One very senior test pilot I know, commented that if a crew chief DID NOT ground abort them (usually before taxiing) because of a safety issue, or at least discuss the problem, and let them fly anyway, then the crew chief would be history. It would be considered dereliction of duty, and heading towards Article 15 Non-Judicial Punishment.
Needless to say, it is not that uncommon for this senior pilot to ground abort, and the crew chiefs do their job.
http://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1455 is an example of an experienced crew making unstable approach and landed high, then overran the runway and crashed. 500 ft for Southwest pilots to be "in the slot" or go around.
That's not true http://www.npr.org/blogs/thetwo-way/2013/07/08/200086858/asi... We already know that the captain in training was flying. We also already know that a cockpit with 4 experienced pilots let the airspeed fall below vref for 30 seconds before doing anything.
Really good article!
When Boeing designed the 787, the composite construction allowed for larger windows. I wonder if it allows for larger emergency exit openings too.
The interest I have in stories like this are, how many are preventable by having systems that can override a pilot and is there and preference to doing such?
Now, would you prefer that system overriding the pilot, or the other way around? Humans can think outside the box. Software is the box.
And take the n-root of the total based on the number of quality checks every minimal part of that software has been through before even being tried on a real plane, not considering the ones before it went into service.
Seriously, you really think the software for an airliner is written in Ruby+Javascript and the developers use a cloud-based bug tracking app? I work on systems used in public trasportation that are NOT safety-critical and the number of tests, checks and counterchecks they have to go through before being approved for service is soul crushing.
I'm pretty sure that the total count of in the bug database of any airline software currently in service basically amounts to zero.
No. The point was to reflect on the nature of software and complexity.
I doubt if bug counts are near zero.
EDIT: And undiscovered bugs are definitely not zero.
> I'm pretty sure that the total count of in the bug database of any airline software currently in service basically amounts to zero.
The military, NASA, and a bunch of other critical organizations really wish that what you were saying was true. http://en.wikipedia.org/wiki/List_of_software_bugs
There's been quite a few software bugs in certified aviation software. One in the control system for ABS brakes caused a runway overrun, another in the Airbus fly by wire system caused an in flight upset with multiple head and spinal injuries.
Best to read the whole sentence before dishing out inaccurate sarcasm.
Armchair experts tallyho!
and this was not exactly a minor crash, it broke the spines of several passengers for chrissakes. the evacuation was top notch, even if the rescuers rolled over one of the victims. and a lot of luck, if that plane had turned on its head during the stumbling phase, the evacuation wouldn't have gone so fast.
He is an amateur pilot.
First of all I haven't read or seen any speculation that wasn't qualified as being mere speculation. Second, this is the first instance of reading someone minimizing the accident because of the excellent safety record.
Is it too obvious to say that the safety record comes from not minimizing accidents as flukes? The rigorous/tedious checklists, innovations like removing oxygen from near empty fuel tanks so they're less likely to explode, and flight attendant training for quick exits come from experience and the enormous amounts of attention directed at every past failure.
Such advances come from a combination of the expertise of people with domain knowledge and people outside of the domain having high standards. In 1985, described as an example of a terrible year for air travel, one still could have put the safety record in perspective with other hazards. Surely it was far more dangerous to travel by car. It is easy to imagine pilots and engineers of 1985 wishing that outsiders who knew less than them would just shut up and let them do their jobs without unnecessary distractions. It's even easy to imagine arguments about the meddling not only being costly, but even a dangerous distraction.
Some hysteria, and definitely a lot of lawsuits, aided in the prioritization of problems for people who had the expertise to come up with solutions to minimize fatalities in the future. Outside, unwelcome pressure also disrupts the status quo which, by definition, is part of every failure.
I imagine anyone who has domain specific expertise has at least at some time been incredibly annoyed to have to deal with and attempt to manage the reactions of nonexperts while they're in the midst of solving a problem immediately at hand. And yet, such a reaction is cowardly, and enormously unproductive in the long term.
I'm not sure if I am beating a dead horse over an obvious point, or not making the point very well at all, but I think it is really important to avoid the pitfalls of only talking to experts, or peers, or people within your established hierarchy of influence when attempting to address failures. This article, made me recall students of nuclear physics on Reddit talking about Fukishima, who couldn't decide whether it was irrelevant because it was an older reactor design, or whether it was irrelevant because it occurred after an earthquake and tsunami that were more severe than the models forecast as possible, or whether nuclear disasters in general are irrelevant because their understanding of worst case was the not-that-bad-all-things-considered case of what was only achieved through heroics of people at Chernobyl.
What made the point for me personally was reading about failures at NASA. I highly recommend the long "Columbia's Last Flight" by William Langewiesche in The Atlantic[1] as it had a great influence on me when it came out in 2003, and helped me learn to value input from people without specialty knowledge. Even when special expertise defines who is most likely to develop fixes, the big picture view sometimes only afforded to outsiders is important, or sometimes just enough disruption so different voices within the system are heard.
In the case of NASA, things were humming along for the entire edifice because it had worked before when they squelched concerns by small groups within the enormous operation. As a result, when it failed, it was the system itself that failed, and it would have been reckless to trust that system to determine what went wrong. Perhaps even more famously, with Challenger, Richard Feynman was the gadfly in that investigation, and later had plenty to say about the ability of entire cultures to encourage mistakes specifically as a result of their desire to build in-group consensus.
So, I think the air travel industry deserves an enormous amount of respect for its excellent safety record, and that the shortage of voices trying minimize this failure suggests that they will accurately determine what went wrong. The value of this column is as an example to the rest of us, not in the air flight industry, of what not to do, and what attitudes stand in the way of improvement and finding solutions.
[1] http://www.theatlantic.com/magazine/archive/2003/11/columbia...
Otherwise, I agree with your comment, and that it is great that the airline industry has focused so intently on removing every single failure mode they spot.
Yes! This is not unlike having a child solve the problem of the 18-wheeler stuck underneath a too-short overpass. Have outsiders review the data, the situation, suggest possible causes and solutions. This extends to so many venues, IMHO, beyond accidents like the Challenger/Feynman, Chernobyl, Fukishima and Asiana Flight 214. Some of the most successful and impressive businesspeople I have know are those that discuss their work with outsiders openly, and really listen to what the outsiders have to say.
yep, that is implicit in the lack of an official and conclusive report. But I have spent 10 minutes reading the article waiting for something interesting, and he just says nothing apart from wait for the official info, dont speculate. which is the default mindset of many. but yes, there might be a whole lot of other people who needs to read this carefully ;)
Case in point: I was reading something recently (can't remember what) where the author pointed out that many people still believe Richard Jewell [1] to be the Atlanta bomber.
These airports are fixed. We can easily set up transmitters around them to allow the plane to triangulate its position to less than an inch. Even excluding the tragedy of the loss of human life, you would think the lost of a multi-billion dollar airplane even once every decade would push people to automate the most dangerous part of flying (landing) to machines.
Hence, pilots must fly a certain number of manual and auto landings in a quarter to stay legal.
I'd suppose that given a pilot with low experience on that aircraft and relatively good conditions, this was considered a good opportunity to get a visual approach and landing under his belt. That presumes a lot, of course.
Presently, the numbers favour accepting human error.
http://www.pprune.org/rumours-news/518568-asiana-flight-cras...
To me, listing all the past tragedies to make the point that this one doesn't deserve the public attention is at the very least inconsiderate if not offensive.