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Home > Air Safety > Not saying ‘No’ to the Boss has serious implication
Not saying ‘No’ to the Boss has serious implication
Aviation - Air Safety
Thursday, 26 December 2013 16:25


Saying No to Your Boss (Travel 3Sixty – Image: Inmagine)
 
Captain Lim,

Merry Christmas to you

I took the interest to listen to the 8.5 hours Asiana 214 investigative hearing that was conducted on 11th Dec 2013

Being a non-aviator, I captured the following few points of interest to me. I would like to request you to confirm these points, that by improving and enhancing these points in future, it will help to reduce human factors related air accident.

1. Cockpit automation design and technical training provided to pilot and instructor

1.1 Auto-throttle's hold status during flight elevation change seemed not well understood by pilots/instructor

1.2 Mode confusion from cockpit automation seems a big issue to pilots

1.3 About 50% of visual display not scanned by pilot crews, due to data overload during high workload situation (e.g. establishing stabilised approach landing when certain landing guidance system is out of service)

2. Response from Asiana accident pilot crews to 3 and 4 alerts situation arisen from Airspeed Low Alert seemed to take too long.

3. Currently no effective evaluation of CRM in actual flight operation.

4. Long haul pilots, despite accumulating long flying hours, may lack manual flying experience in exceptional situation; and perhaps should be certified by including also the # times of take-off/landing and transition from different airplane type and maker.

5. The 2013 Flight Path Management System to further minimise human factors in air accident/incident.

Lim SJ

Hi Lim SJ,

I do agree with the NTSB observations on most of the issues. My interest is on the No 3 point - the CRM issue.

As I have mentioned in my previous answers to you, “cultural issues may be a contributory factor in the accident and these effect will still be there for quite a while before it goes away.”

No 3 states that “Currently, no effective evaluation of CRM in actual flight operation.” This is not to say that CRM was not being practised, rather that it was more difficult to practise on some ex-military or very senior pilots.

In this beginning and prior to 1990’s, safety records in Korean airlines were not very satisfactory. As a result, Western advisers were brought in to overhaul the civil aviation system. Amongst the other safety training, CRM was introduced. By 2008, ICAO was very pleased with the safety records achieved. They thought that they have solved the cultural issues of the past. Or so it seems.

At the NTSB findings, it was revealed that the junior first officer who was sitting in the cockpit jump seat did not voice out that the senior captain should go around as generally practised in an unsafe approach (see my article in Travel 3Sixty magazine “Saying No to your Bosshere.)

The first officer was aware that the Boeing 777 was in clear danger of crashing but refrained from challenging the more senior pilots flying the plane. He told the investigators “That is very hard to explain… That is our culture.”

PS. If you like what you read, more stories are found in my book LIFE IN THE SKIES (Preview here) and you can purchase a copy here . To check for any latest updates or postings, you can follow my Twitter at @CaptKHLim 


Boeing 777 Crash at SFO Full Animation

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root causes
Thank you Capt Lim.
I agree CRM and intervene by junior crew in timely manner is critically crucial in preventing accident.

Likewise preventing confusion of flight automation operation amongst different airplane maker and model helped to solve root cause too.

I look forward to NTSB final report to recommend a change in the auto throttle issue that resulted in Low Speed Alert.

Regards,
Lim SJ
Lim SJ , 03 Jan, 2014

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