Will The Result Of The Asiana 214 Investigation Be Just More Of The Same?

As the hearings into last summer’s crash of Asiana 214 at San Francisco International Airport get underway, I can only hope that they will result in a real and meaningful look at the relationship between today’s pilots and their modern aircraft.  I expect though, the result will once again be platitudes like “over reliance on automation” and the obligatory mandate for stricter policy and more procedure. Standard operating procedure (SOP) is essential in airline operations, however, it should be used as a tool and SOP compliance should never be viewed as THE objective in establishing a safe operation.  The system will try to legislate and regulate effective decision-making through narrowly targeted training scenarios, more SOP and increased spending on airport navigation aids.  It will succeed in giving the appearance of making the airline industry safer while actually failing to address the root cause of this type of accident, ineffective threat identification and mitigation. 

In 1996 the FAA Human Factors Team issued a report on the interface between flight crews and modern flight deck automation. It was a result of a 1994 A300 crash in Nagoya as well as 1995 accidents in Cali and at Hartford, CT.   This FAA report is an exhibit in the NTSB Docket for Asiana 214.  The HF Team’s report clearly articulates their recognition that it was essential to look beyond flight crew errors for a deeper level of understanding of the issues.  After reading this report it would appear that almost all of the concerns raised in 1996 were still contributing factors Asiana 214 and UPS 1354 hull loss accidents.  Why, 20 years later, are we still unable to manage human error?

A friend of mine said this reminded him of the scene in the movie, A Few Good Men, where well meaning policy and procedure (Lt. Daniel Kaffee) collide with operational realities (Col. Nathan R. Jessup) in their iconic courtroom scene.

 Jessep (Jack Nicholson): You want answers?    
  Kaffee (Tom Cruise): I think I’m entitled to them.    
  Jessep: You want answers?    
  Kaffee: I want the truth!  
  Jessep: You can’t handle the truth!

What is the “truth” here?  Let me see if I can explain.

There are two fundamental components to aviation, the airplane and the crew.  The advancements in aviation safety have come from improvements to these two components.  The airplane was first.  With the advent of the digital age, avionics technology was able to assist the airplane with a truckload of very reliable hardware programmed with “if-then” software meant to help with crew awareness and workload.  As technology advanced so did the amount and sophistication of these hardware/software devices.  Later in the evolution came improvements to the crew, or human, component.  Crew improvements came from the development and introduction of CRM, Crew Resource Management.  CRM soon became the “poster child” for all progressive flight operations.  Unlike the technological advancements to the airplane, CRM was not universally adopted in a standardized manner and therefore lost much of its value and influence.  Each flight operation developed and trained its own CRM objectives and methods.  CRM became synonymous with teamwork and communication rather than improving the crew effectiveness component of aviation safety.  A member of the 1996 FAA Human Factors Team and the “Godfather” of error management, Dr. Robert L. Helmrich, from the University of Texas, along with James Klinect and John Wilhelm, wrote about this deterioration of CRM in their paper MODELS OF THREAT, ERROR AND CRM INFLIGHT OPERATIONS.

AQP, the Advanced Qualification Program, implemented to improve training for airline crews mandated two, among other, essential elements necessary to align training with line operations. CRM and Advanced Simulation were required.  They were included for very important reasons.  CRM for the very explanation Helmreich et al stated, “CRM is an active process by crewmembers to identify significant threats to an operation, communicate them to the PIC, and to develop, communicate, and carry out a plan to avoid or mitigate each threat.”  Advanced Simulation is essential because it is meant to create a flight deck environment identical to the real line operations.  The intent was to provide crews an opportunity to face realistic scenarios and effectively debrief their experience, not to only perform according to preplanned scripts.  Unfortunately the industry has not embraced the intent of line oriented simulation as described in a manual for debriefing simulator events by Key Dismukes, former Chief Scientist for Aerospace Human Factors in the Human Systems Integration Division at NASA Ames Research Center, with Lori K, McDonnell and Kimberly Jobe from San Jose State University. The first sentence of the introduction states, “How much crews learn in Line Oriented Simulations (LOS) and take back to the line hinges on the effectiveness of the LOS debriefing.”   Most simulator training is still about “what” and very little time is spent learning the “why”.

The ultimate result of this 20 year safety evolution of airplane and crew is the huge bureaucracy called SMS, Safety Management Systems.  SMS has tried to do to the airline industry what digital technology has done for the airplane, program the system with “if-then” software (procedures and policy).  The concept was good.  The goal was to look at risk from an integrated perspective.  Unfortunately, there are so many layers, and competing agendas, that like all big bureaucracies there are lots of people doing lots of things but accomplishing very little.  One of the things that SMS has been able to accomplish is to communicate to crews that “they, meaning the SMS group” are the genesis of threat mitigation strategies.  The problem is that SMS threat mitigation strategies are seldom, if ever, timely or appropriate.  That is because SMS can address overall risk of an organization, but it cannot manage individual threats very well.  Threats, which are generally defined as events or errors that occur beyond the influence of the crew, increase operational complexity, and must be managed to maintain the margins of safety, can only be identified and managed tactically by the crew.  The crew can and should rely heavily on procedural guidance for their threat mitigation strategies, but all the procedural guidance, all the SOP the airline can come up with is worthless if it is not effectively applied.  The bureaucracy has lost sight of the fact the machines can be programmed, humans cannot.  You can teach humans what to think about, but you cannot program humans to think only in “if-then” binary patterns.  Policy and procedure is only as good as the judgment and decision-making used to apply it.

The identification of threats, and their mitigation is the most fundamental of all aircrew responsibilities.  Conventional wisdom, including most flight standards and training managers, has replaced threat management with procedural compliance.  The system (airlines, regulators, etc.) arrogantly and narcissistically assumes it can write a policy or procedure for every condition and then naively thinks that all crew members can and will comply.  Airline managements are reticent to spend money on training that is not FAA mandated or have a corresponding dollar value.  Pilot bulletins and computer-based learning have replaced facilitated workshops where line pilots are allowed to discuss their experiences and relevant operational safety issues.  Chalkboards and instruction from experienced pilots has been replaced with PowerPoint presentations packed with dozens of slides that are just “cut and paste” text and pictures from the flight manual.   Pilot associations have their share of responsibility as well.  They are quick to point out any deficiencies in the system, but at the same time are only interested in looking at human factors as a way to avoid responsibility when mistakes are made.  They need to be willing to look introspectively at human factors in an effort to raise the level of pilot performance, i.e. threat identification and mitigation.  There have been some airline operators with robust TEM programs, however, through budget cuts and/or mergers these programs have been trivialized or abandoned altogether. 

If the airline industry is really serious about making flight operations safer it will increase its efforts to improve crew effectiveness not just pilot performance.  Training and evaluation must be outcome based not just procedure driven.  Crews should be trained and evaluated using the LOSA paradigm.  That paradigm focuses on the values of crew awareness and self-correction where they are actively engaged with the airplane and environment so they can identify and mitigate threats and errors in a timely manner.    These instructors, evaluators and crews encourage and accept peer feedback in an effort to achieve a safe outcome.  There are only three responses to a threat or error; it is not identified, it is identified and not mitigated or it is identified and mitigated.  Two of those responses require luck or things outside the crew to provide a safe outcome.  To ensure a safe operation, isn’t it worth at least as much time and effort to train pilots to identify and mitigate threats and errors as it is to teach procedure?

That outcome-focused approach is in contrast to the still employed, “I know more than you do.” ego centered dynamic utilized by many flight standards organizations. We must get away from the ancient methodology of training and evaluating performance based on procedural compliance and focus on safe outcome.  The equation, Procedure + compliance = safe operation only works in an academic environment.  Intentional and unintentional non-compliance are unavoidable realities.  You might reduce one but you never eliminate the other.

Every time there is an accident involving the crash of an aircraft with no mechanical deficiencies the focus of correction is to improve the system, or blame the crew.  Writing more policy and procedure does not ensure a more effective crew.  Flying pre-briefed scenarios in the simulator is valuable training, but still does not address the most pernicious component of any crew, ineffective threat identification and mitigation. Before the crash of Asiana 214, there have been other infamous crashes of perfectly good airplanes like the Boeing 757 at Cali, Columbia.  Why can’t we do better?  Imagine if these flights had used even the most basic TEM approach.  Approaching SFO the Asiana crew could have asked themselves, “With the ILS and the VASI out of service what are going to be our challenges flying this visual approach and how should we address them?”  Before starting their descent into Cali the crew of American 965 could have articulated something like, “It’s dark and there are a lot of high mountains on our route, we had better be sure of our flight path on the descent.”  Both crews were supplied with plenty of procedure to address their conditions, however in both cases, it was not simply an over reliance on automation, rather ineffective or absent threat identification and mitigation.  SOP is an invaluable tool in flight operations, but when crews are taught that SOP compliance is in itself, by definition, a safe operation then human error will determine the outcome.  In the absence of active TEM training and practice the only alternative crews have is to rely on things outside themselves like automation and procedure.  We know how that works out.

You Know It Don’t Come Easy

Technological advancement, particularly in aeronautics, is not easy.  This fall, as we remembered the passing of President Kennedy, his speech proposing the landing of Americans on the moon was played often.  "We choose to go to the moon in this decade and to do these other things not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills,…”

This fall also marks the 60^th anniversary of the introduction of the F-100 Super Sabre into the United States Air Force. Like the Boeing 787 Dreamliner, the F-100 pushed the boundaries of conventional technology.  The F-100 Super Sabre was the first operational aircraft to be designed for and capable of supersonic speed in level flight.  The pioneering technology necessary to accomplish this, from aerodynamics to propulsion, was no less dramatic than that of the Dreamliner.

Unlike the Boeing 787, propulsion requirements for the F-100 to achieve its intended supersonic capability could not be satisfied by current turbojet technology.  Therefore, a new turbojet engine design was needed.  The progeny of that effort was the Pratt and Whitney J-57 (JT-3).  The engine design was so revolutionary that the 1952 Collier Trophy was awarded for the J57.  Fitted with recently developed afterburner technology, the J57 met the expectations for the F-100 design objectives.  That engine proved to be integral to the success of not only the F-100, but other famous aircraft as well.  The legacy of many iconic airplanes like the F-101, F-102, U-2, F-8, B-52, B-57, Boeing 707 and Douglas DC-8 was created in no small part because of the J57.

North American Aviation Chief Test Pilot, George Welch (pictured above), flew the first production F-100A on October 29,1953.  On a second flight that day, USAF test pilot Lt. Col “Pete” Everest Jr. set a world speed record of 755.149 over the Southern California desert near the Salton Sea.  This was the last speed record established at low altitude. Welch had also flown the YF-100A prototype the previous May 25 on its maiden flight that included speeds above Mach 1.0.  Welch was no stranger to either first or supersonic flights.  He piloted the North American Aviation F-86 on its first flight October 1, 1947. Also, although not officially recorded and in a dive, Welch exceeded the Mach 1 in an F-86 just days before Chuck Yeager exceeded the sound barrier in level flight in his “Glamorous Glennis” Bell X-1A.

Welch’s career is less widely known than Yeager’s, but his story is equally interesting.  On the morning of Sunday December 7, 1941, after an all night party, Lt’s George Welch and Kenneth Taylor were intending on going for a swim at their auxiliary base Haleiwa Field about 10 miles from the Wheeler Field at Pearl Harbor when the Japanese attack began.  On their own initiative the pilots drove to the aux field where Welch had called ahead to have two P-40s readied for takeoff.  The two pilots took off without orders and engaged the attackers.  Their actions are highlighted in many war movies about Pearl Harbor, including the 1970 film, Tora Tora Tora.  Welch recorded 4 kills that day and, as well as Taylor, received the Distinguished Flying Cross for his heroism.

Unfortunately, George Welch lost his life October 12, 1954 on a test flight of the F-100.  While performing one of the final evaluations of the Super Sabre’s design, a maximum load high-speed pull up maneuver, the aircraft became uncontrollable and was lost.  The 36-year-old Welch was able to eject, however, the injuries he sustained in the accident were fatal. Stability issues were reported by all of the pilots that had test flown the F-100A.  Most troublesome were poor longitudinal stability in high-speed flight as well as poor low-speed handling characteristics.  The low-speed qualities of the F-100 would prove to be fatal for many pilots who failed to acknowledge it’s unique handling characteristics.  The high-speed instability would be solved, but would require all new high speed jet fighters to respect a phenomenon that cost George Welch his life, inertial roll coupling.

Prior to the F-100, fighter aircraft were neither heavy nor fast enough to experience inertial coupling.  Inertial coupling, simply explained is where the inertia of a longer heavier fuselage overpowers the aerodynamic forces of the wings and tail. It became problematic with the introduction of the supersonic F-100 with its long heavy fuselage versus its relatively narrow wingspan.   The inertial coupling problems were eventually overcome, but not before six fatal crashes and a grounding of the aircraft in October of 1954.  Modifications to the F-100 were made that included increasing the size of the vertical tail, adding a yaw dampener as well as increasing the wingspan. The low speed characteristics of the F-100 remained troublesome for its entire history.

Although the F-100's low speed performance benefitted greatly from the aerodynamically controlled slats introduced on the F 86, they allowed for higher angles of attack that also had distinct disadvantages.  Also, the F-100 had large conventional ailerons that were responsible for the Super Sabre’s legendary adverse yaw.  When the aircraft was turned the aileron on the “up wing” or the outside of the turn would deflect downward into the relative wind.  This aileron’s deflection would create drag and induce a yawing motion away from the turn.  This tendency was greatly exaggerated at low airspeed with high angles of attack.  If the yawing were not corrected with rudder, the plane would eventually roll over in the opposite direction of the turn.  If this happened in the landing pattern or close to the ground both the pane and pilot were often lost.

Also, through the use of the aircraft's automatic slats the F-100 was capable of a very tight turning radius that was useful in air-to-air combat. This ability to achieve high angles of attack also had disadvantages.  The airplane’s unique aerodynamic characteristics caused the airplane to experience large amounts of induced drag from the F-100s wings.  The 45-degree wing sweep also contributed the center of lift to moving forward at high angles of attack and causing a pitch up.  During air combat maneuvers this pitch up would cause the airplane to slow dramatically and lose energy quickly.  The J57 did not have enough thrust to overcome this substantial induced drag. Although the F-100 could turn tighter than its opponent, the energy deficit would leave the pilot vulnerable to a faster enemy plane.  Even more pernicious were the consequences from the enormous induced drag in the landing pattern or maneuvering close to the ground.  The F-100 wing could fly without stalling at a speed low enough to create more drag than the J57 could overcome.  This flight regime is described as the area of reverse command. Pilots refer to it as being “behind the power curve”.  It is the condition of the aircraft filmed doing the infamous “Sabre Dance”.  The engine could not provide enough thrust, even in afterburner, to overcome the induced drag and allow the pilot to “fly” out of his situation.

 

In spite of its initial difficulties, “the Hun” became an essential part of the UASF inventory as a potent tactical air support fighter. The F-100 D and F were fitted with the latest weapon systems for testing as well deployment.  The two-seat F-100F was used for the "Misty" fast FAC (forward air controller) missions.  The "F" was also called upon to introduce the successful “Wild Weasel” concept for destroying surface to air (SAM) batteries in North Viet Nam. F-105 and F-4 aircraft used this successful tactic until radar homing missiles were finally deployed against the SAMs.  The F-100 flew more operational sorties than any other aircraft in Viet Nam. 

 Numerous models of the F-100 Super Sabre were flown by the air forces of Turkey, France, Denmark and Taiwan.  Air National Guard pilots flew the last USAF F-100 operational sortie in November 1979.  During the 25 years the F-100 Super Sabre was in the USAF inventory, all who flew it, including the USAF Thunderbirds, admired as well as respected this remarkable airplane.  I feel very lucky to be in a small group of pilots that have had the priveldge to fly both the Super Sabre and the Dreamliner.

“You’ve got to pay your dues if you want to sing the blues

‘Cause you know it don’t come easy”

                                                            Richard Starkey

Do Pilots Rely On Automation Enough?

By now everyone in the commercial aviation world knows about the Boeing 747 Dreamlifter landing at the wrong airport in Kansas.  This aircraft is modified to fly large sections of the 787 Dreamliner to facilities where portions of the manufacturing process are performed.  This modified aircraft does, however, have the standard FMS flight guidance systems of a typical B747-400.  There were no injuries to the cargo or crew outside of embarrassment.  Embarrassment is that feeling we get when we have remorse for our actions.   The more public the mistake the more the embarrassment.  Usually there is the obligatory “I’ll never do that again.”

It is ironic that in the midst of an industry wide discussion about commercial pilots’ deterioration of manual flying skills we have an incident that could have been prevented by less manual flying.  It is very hard to fly an instrument approach to the wrong airport.  Landing on the wrong runway maybe, but not the wrong airport.  There were many clues inside the cockpit that could or would have shown the pilots they were not where they thought they were.  Sadly, many pilots crashed in the early days of instrument flying because they did not use or believe the information that was available to them.

This is the lesson that we should all learn from this crew’s embarrassment, “We are all capable of landing at the wrong airport.”  It is not because we are bad pilots.  It is not because we are too reliant on automation.  It is not because we do not have enough information to verify our position.  It is not because the ground proximity warning system is inadequate.  It is not because we have insufficient procedural guidance.  It is because we lack identification with those pilots who have made these mistakes before.  We think we are better than that.  The biggest threat we all face in aviation is the feeling that it won’t happen to us.

Buy In

My last post was meant to initiate a discussion about the priority of standard operating procedure in airline operations.  Is it important?   Why or why not was the type of comment I hoped readers would articulate?  Unfortunately, there were few comments pro or con.  Therefore, I am going to try to argue both sides of this issue.  Those of you that know me understand my appreciation of the “one liner”.  So, considering the fact that I am going to have to conduct the debate by myself, here’s a great one.

 “I may be a schizophrenic, but at least we have each other.”

I have shared my objective for this blog before. It is to initiate a dialog between airman and aviation related professionals to discuss what we do as well as how and why we do it.  Aviation is a very unique activity and therefore requires active participation over a considerable time period to make introspective and vulnerable comments on related complex issues.  It is very easy for management or simulator/instructor pilots to be critical and judgmental of the line pilot. It is not an arrogant critique; I have been there myself.  The judgment does come, however, from a lack of identification with the everyday challenges that are line flying.

Many companies espouse the primary importance of a safe operation, but out of the other side of their mouths preach efficiency.  They have endless charts depicting data that shows where the pilots can be more efficient.  There are detailed presentations showing the company’s operational performance compared with the competition.  When it comes to a safe operation, however, the strategy is simply procedural compliance.  Unfortunately, it’s not that easy.

This reminds me of the young petroleum engineer who asked his mentor, “How can I be successful in the oil business?”  The seasoned “oil man” replied, “It’s easy, get up early, work hard, find oil.”

Line Operational Safety Audits, LOSA, demonstrates the vulnerability of safe operations to intentional or unintentional non-compliance with SOP.  Error avoidance is always desired, however, error management achieves the same goal and is the essential link between procedure and safe operation.  Threat and Error Management IS bridge between procedure and safe operations.

Safety and efficiency are competing priorities, however, not mutually exclusive goals.  You can be safe and efficient at the same time, but not without vision, resources, mentoring and experience.  The job of the professional airman, specifically that of the airline pilot, has never been more challenging.  The machine and the environment have never been more complicated or crowded with threats.  A set of best practices is invaluable for airline flight crews.  Navigating this “mine field” takes absolute and complete focus by the crew.  Every other group the crew interfaces with has their own agenda.  Gate, ramp, mx, ATC as well as the customer all have their minds focused on an “on time” operation while at the same time assuming a safe operation.  The crew cannot “assume” a safe operation.  They are the “keeper of the flame”.  They must not lose sight of the primary goal, a SAFE OPERATION, in pursuit of procedural compliance.  Delayed flights, lost bags, misconnected passengers, mx delays are all unfortunate situations, but all can be overcome.  An aircraft incident or accident cannot be erased.  Safe Operations is all about prevention.   A replay is not an option.  If threats and errors are not managed the outcome is not assured.   If the outcome is unsatisfactory, there can be no “do overs”.

Standard Operating Procedure, SOP, is recognized as the best way to ensure a safe operation, however, it is not that simple.  Getting flight crews to be highly compliant with SOP is not easy.  Crews are not defiant, but they are generally not committed either.  By “not committed“, I mean they don’t understand why the procedure is in place and why it is crucial to a safe operation.  The rationale is obvious to the one who wrote the procedure, but not necessarily to the line pilot.  The line pilot is faced with literately hundreds of competing dynamic threats on each flight, therefore the rationale for a procedure is very important.  Prioritization, or “workload management” as it is referred to, is the line pilot’s world.  If absolute procedural compliance were really practiced, airlines would rarely operate on time.  Some procedures or regulations are written simply for the sake of liability.  When things go wrong, the excuse “We told them not to do that”, allows plausible deniability for those upstream in the organization.  Very rarely, if ever, do crews that understand the justification for a procedure blatantly disregard it.

Let me emphatically restate my position, Standard Operating Procedure, SOP, is the best way to pursue a safe operation.  However, it is not that simple.  To get a high level of compliance it requires “buy in”.  “Buy in” is the understanding and the internalization of the rationale for a procedure.  When airline flying was less complex the “buy in” was much easier.  Nowadays the environment is far too complex for the procedural rationale to be self evident or assumed.  For “buy in”, airline operators must be able to articulate the answers to the following 7 questions for every procedure.  Not every line pilot will ask these questions, but when one does it must be answered satisfactorily.  Many procedural justifications are self-evident many are not.  Either way, every instructor/management pilot must be supplied with and understand the answers to these questions so that they may educate the line pilots and earn “buy in”.

• What is the threat that the procedure is designed to mitigate or manage?
• What is the justification for the procedure? What does the data say?
• Does the procedure conflict with any other policy or procedure? 
• How does the procedure specifically manage or mitigate the threat?
• Is there a potential for undesired consequences from the mitigation strategy?  (Additional threats)
• What is the strategy to prevent these undesired consequences?
• How is the procedure trained?

If these questions can be answered and communicated effectively to the line pilots and there is still intentional non-compliance the airline needs to reevaluate their hiring criteria.  Once airlines have committed to hire pilots that understand and value a safe operation, the company’s operational leadership owns the responsibility for “buy in” to SOP. 

I will continue the discussion of “buy in” in a future post, but to quote Simon Sinek, the author of START WITH WHY, “there are only two ways to motivate people.  You can either manipulate them or inspire them.”

Are airline pilots so unsophisticated that they must be manipulated with a carrot and/or a stick to achieve the goal of a safe operation?