Asiana airlines crash key learnings-2013-sep

“Spock’s Brain & the Singularity”:
(Asiana flight 214- Key Learnings)
Brian Landberg
September-2013

Note
• This discussion is about a recent, serious accident.
Despite the title, I am not intending to treat this
accident lightly. No intent to disrespect those affected.
• Intention is for organizational and systemic learning.

Overview
0. Prelude
1. What happened
2. Societal Trends
3. Lessons for Quality Assurance/ Supplier
Management

“Spock’s Brain”
• Old Star Trek TV episode
– One of the worst ones?
• Spock’s brain is stolen.
– To control systems on an alien planet; collective intelligence
put into central computer.
– Citizens became stupid over time, since they rely on big
brain to do all the thinking for them.
• McCoy downloads knowledge, operates, reconnects
Spock’s brain.
 Q: What happens if automation makes thinking obsolete?

As for the “singularity”…
we will get to that part shortly.

1. What Happened
July 6, 2013, ~11:26am,
Asiana 214 (Boeing 777-200ER)
arriving to San Francisco (SFO), from Incheon, Korea

Asiana 214 – Accident Simulations
Animation source: Eyewitness Animations
http://www.youtube.com/channel/UCsvKUhNY1Z8b7jEJP59X3Zg
http://www.youtube.com/watch?v=eXCwI6a1DqI&feature=youtu.be
Click to view
animations.

What went wrong?
Landing sequence
• 2 pilots misjudged airspeed, no corrective action until too late (-7s).
• Sink-rate warnings from 3rd pilot in jumpseat not heeded (-54sec).
• Pilots “experienced”, but new on 777.
• Airport runway guidance systems down for construction (pre-notified)
Evacuation
• Evacuation delayed 90sec due to poor pilot judgment.
• Inflatable chutes for evacuation opened inside rather than outside the
plane.
Response/Rescue
• 1 victim had been “rescued” only to be placed in harms way (see p10).

Root Cause Factors
Hypothesis Category Evidence Conclusion
SYS: Airplane Design Failures None (except escape chutes) No
SYS: Airplane Malfunction None (black box, tower data) No
SYS: Airstrip Guidance trouble ILS offline (pre-notified), but not
necessary for good visibility cond.
No
ENV: Weather/Visibility Clear conditions/visibility No
SOP: Unanticipated Problems None revealed No
HE: Miscommunication Not w/ control tower;
Possibly in cockpit (among pilots?)
TBD
HE: Poor Training Slow/no response to flight data Yes
HE: Pilot Fatigue Chief pilots were relieved during
flight and were rested
No
HE: Cockpit Culture Jumpseat pilot warnings of “sinkrate”
not heeded due to age/status?;
Also evacuation delay.
Yes

Additional Tragedy
• A 16-year old girl with Chinese passport was pulled from the aircraft and left near the plane's wing, where
she was run over by an airport crash tender while covered in fire-fighting foam. Autopsy confirmed that
the girl was still alive prior to being run over by a rescue vehicle.
• Rescue driver involved was experienced, but had just returned from an errand to find that emergency
occurred and all colleagues were out at the scene. She drove a truck by herself to the crash site. (Allowed
only for emergency situation).
• “Another firefighter had carried the girl from the back of the plane and left her near the left wing, a
hazardous place as the huge ARFF rigs jockeyed to fight the fire. There was in the area where the victim
was found a blanket of foam that was applied to suppress the fire on the aircraft.” the truck did not have
Forward Looking Infrared (FLIR). Similar system is installed on other trucks. This truck was a reserve truck,
and was not retrofitted, due to rare use in the field(?)
• Videos show victim in a fetal position on the ground before the truck rolled over her -- several firefighters
walk by, perhaps not realizing she needed help.

What went well?
Survival rate
• Few deaths (3 out of 291 passengers, 16 crew on board)
– One analysis: “Lucky”… would have been worse if fuselage had flipped over.
– Attendants ejected from the tail also very lucky!
Cabin Crew and Airport Staff
• Good response from control tower
• Flight attendants acted quickly to initiate and expedite evacuation
• Fast response from airport on-site fire team
• Excellent support to passengers from partner airline UA.
Airplane Equipment
• Airplane structural integrity mostly intact, except for tail zone (direct strike
area), allowing high survival rate.
• Nose/cockpit perfectly intact
• Flight data recorders provided key data to analyze the accident details

Background of Good News
Decreasing trend of airline crashes and fatalities among US airlines.
Only 1 fatal accident involving a U.S. airline in past 6 years: 2009 crash near Buffalo, New York.

Similar Historical Cases
• 2008, crash landing of a (777) plane British Airways flight 38 landed short of
runway at Heathrow Airport , London. (no deaths, mechanical failure, ice in fuel).
– Only other recent 777 accident; 1100+ airplanes flying, 18yrs since first flights.
• 2009 Air France 447 (Airbus 330) crashed over Atlantic Ocean after Autopilot
failed and pilots reacted incorrectly. Brazil to Paris route. All 220 passengers &
crew died.
• 1993 Air France (747-400) to Tahiti landed long and crashed. Human error due to
improper usage of Autothrottle control was central factor. Many procedural and
technological improvements were made.
• 1968, Japan Airlines plane bound for SFO had problem similar to Asiana 214's. The
crew guided it through a properly stabilised approach—but "landed" two miles
short of the runway, right in San Francisco Bay. The circumstances were worse than
in the Asiana case—bad weather, and cloud ceiling of only 300 feet. The outcome
was better, in that no one was killed. ( ‘Famous’ in aviation lore for the "Asoh
defense," explanation by captain Kohei Asoh: “As you Americans say, I f*ked up.”)

1. Automation (and singularity)
2. Cutting Corners
3. Organizational Bias
Social Challenges:
Quality & Safety in 21st Century

1. Automation (avoinics example)
• Autothrottle - presetting of speed/thrust (cf. car “cruise control”)
• Flight director – altitude guidance display vs. trajectory plan
• ILS - landing guidance (from airstrip)
• GPS - precise control tower guidance, not stair-step descent.
“Pilots sometimes "abdicate too much
responsibility to automated systems."
(2011 FAA study, data/info from 9000+
flights).
“A typical mistake was not recognizing
that either the autopilot or the auto-
throttle – which controls power to the
engines – had disconnected. “

Airline Cockpit Automation (Avionics)
Function Commercial
Adoption
747
(1970~90s)
777
(1995~)
787
(2011~)
Autopilot/AFS 1930 Yes Yes Yes
Flight recorder (black box) 1965 Yes Yes Yes
Autothrottle/ FMS 1980s? Primitive Yes Yes
“Glass Cockpit”
LCD monitor
1970s Primitive Yes Yes
Head-up display (HUD) 2011 No No Yes
Auto-landing with
HUD+GPS
2011 No No Yes
Airstrip ILS 1970s Yes Yes Yes
Airstrip GPS WAAS /LPV 2003 No Yes Yes
Ground-proximity warning
system (EGPWS)/TAWS
1990s Primitive Yes Yes
Collision Avoidance (TCAS) 1993 No Yes? Yes

What is the
Matrix Singularity ?
“Within thirty years, we will have the technological means to create superhuman
intelligence. Shortly after, the human era will be ended.” --Vernor Vinge, 1993
Boeing 787
Cockpit image
(simulator).

The Singularity (technological)
Examples in recent news:
• Deep Blue (chess)
• IBM Watson (Jeopardy champion)
• Self-driving cars (Google)
• Global-Hawk Drones (US military)
• Autopilot landing systems (Boeing 787)
•  Baxter
Definition: The point at which artificial
intelligence
surpasses human intelligence. Human’s will
not be able to keep pace with exponential
technology change.
Computers/robots go from helping to
commanding. They may replace humans in
every respect, except creative arts, human-
centric services.

“2nd Half of the Chess Board”
1st half:
We understand this;
(in fact we have
achieved it.)
2nd half:
We probably do not understand the implications…
Haswell transistor
Count: 1.6G (109)
~50yrs, counted in secs.
This is 1019 ….
30x more than age of
the universe in secs…
“We won’t experience 100 years of progress in the 21st century—it will be more like
20,000 years of progress (at today’s rate)...” –Ray Kurzweil

How can we avoid losing Spock’s brain
despite increasing automation?

– Rapid Growth (new equipment, new workers)
• E.g. SE Asia airline industry growing rapidly
– Global Competition (short-term thinking)
• E.g. Training, outsourced maintenance, crew fatigue from multiple flights…
• LCC airlines, pressure for reducing “gate turn-around”
2. Cutting Corners on Quality/Safety
[Asiana] about 0.5 percent of SFO’s 600 daily landings. Its go-around total, however, is well
above that… One such aborted landing happened July 19, just days after SFO reopened the
runway where Flight 214 crashed. The Asiana jet pulled out of its landing just 14 seconds
from touchdown. (source link)

How to maintain a balance between
economics and quality/safety?

• Departure from Meritocracy, ‘Qualitocracy’
– Cultural norms
• Deference to age, position/rank
– Economic interests
• Please the backers/investors/lobbyists
3. Organizational Bias
http://www.sfgate.com/default/article/S-F-plane-crash-pilot-says-he-was-briefly-blinded-4658043.php
“The crew ordered the passengers to remain seated once the plane came to a stop,
delaying the evacuation for 90 seconds… Pilots were consulting with flight control. An
announcement was made over the intercom telling passengers to "stay in your seats."

How can we ensure
org. culture of quality & safety?

3. Lessons for Quality Assurance

Lessons – Human Error Avoidance
1. Checklist (SOP) is key to ensure right actions.
– Error types: Forgetting vs. Complacency (Have right
knowledge & apply it correctly)
– Read-Do vs. Do-Check checklists
– Normal vs. Emergency response checksheets
2. Flexible thinking & emergency response training
– SOP, but also empowered decision making for
dealing with problems.
– Frontline ready to make decisions, rather than
wait for orders from overwhelmed leaders.
3. Communication within a team
– Checking for omissions, conflicts
– Checklist contains “pause points” for team review
– Communication tasks, as well as to-do items

Checklist Manifesto: Human Error
Knowledge Exists Unknown Notes
1. Knowledge Applied Best result n/a -
2. Not Applied Ineptitude Ignorance
Ignorance – we can never fully
eliminate all unknowns;
Ineptitude – preventable.
2a. Forgot to
apply
Memory lapse
(unintentional)
n/a
Distracted/overwhelmed by
complex or rushed situation.
2b. Misjudged or
overconfident
Complacency
(skipping steps
intentionally)
“Never been a problem
before”; Underestimation of
risks/consequences.
2c. Alignment
failure
Miscommunication
No cross-check, or
lack of trust, etc.
Checklists should include
“pause points” (before, during,
after critical actions/changes).
A checksheet may prevent all 3 types of ineptitude : forgetting, complacency, and
miscommunication. It can provide verification as well as discipline and cross-checks.
Though seemingly boring and simple, checklists can be extremely effective.

Lessons - Auditing
• Specific excursion drills
– “Let’s say we have an excursion on SLI#x; show me your
RFC, containment area, lot hold in db, etc.
– “Show me data and charts on all metrology for SLI#y”
• Communications for improvement
(‘Who watches the watchmen?’)
– DRB signoff responsible?
– PM handoff confirmation?
– Internal audits records?
– Trainers and SV are re-certified?

Lessons – Business Continuity Plans
• “Expect the best; Plan for the Worst” – Zig Ziglar
– Emergency response systems
– Training and drills
– Backup systems
– Early warning indicators
– Learning from near-misses and minor incidents
Planning with awareness/consideration for:
• Failures of automation,
• Pressures of market/economics,
• Organizational bias

Conclusion
• “It would be illogical to assume
that all conditions remain stable.”
–Mr. Spock (Star Trek TV series)

Additional References
• http://abclocal.go.com/kgo/gallery?section=news/local/peninsula&id=9164096&photo=1&pid=91
85603 (photos)
• http://www.patmarlins.com/Asiana.pdf (more photos)
• http://en.wikipedia.org/wiki/Asiana_214 (Wikipedia link)
• https://www.youtube.com/watch?v=eXCwI6a1DqI (animations)
• http://www.cbsnews.com/8301-201_162-57593510/teenage-girl-killed-in-asiana-crash-was-hit-
by-fire-truck-s.f-police-say/ (overall news summary)
• http://abclocal.go.com/kgo/story?section=news/local/peninsula&id=9185603 (Additional tragic
death)
• http://www.forbes.com/sites/brighammccown/2013/07/07/asiana-214-crashes-at-san-francisco-
what-happened/ (analysis of cockpit errors)

Asiana 214 – Accident Details
• Boeing 777-200ER (first fatal accident in this airplane type)
• RC is determined to be human error by the pilot. (Not mechanical or weather related)
• Pilot experienced (though not for flying a 777). Co-pilot was experienced instructor but did not catch the error.
• The instrument landing system's ground-based guidance on runway 28L was out of service, as scheduled & pre-notified.
• Autothrottle was set for the correct reference speed, but until the runway's precision approach path indicator (PAPI) showed
them significantly below the glide path, the pilots were unaware the autothrottle was failing to maintain that speed.
• Approach at 103 knots, vs. 137 knots airspeed target; If even 1~2 knots below, co-pilot should provide warning, quick correction.
• Both pilots at the controls had ample rest before they left South Korea and during flight, they were relieved by the backup crew
• 3 pilots + 1 First officer said “they were relying on the 777's automated devices for speed control during final descent”
• NTSB investigators that he had called out "sink rate" to call attention to the rate at which the plane was descending during the
final approach. This "sink rate" warning was repeated several times during the last minute of the descent
• Autothrottle control was found to be in the "armed" position during documentation of cockpit levers and switches, differing from
both the "on" and "off" positions.The main pilot’s flight director was deactivated whereas the instructor pilot's was activated.
• Final 2.5 minutes, from flight data recorder, multiple autopilot modes and multiple autothrottle modes activated
• Evacuation delayed for 90sec, as pilot thought they should wait for further instruction from control tower.
• Upon evacuation, 2 of the inflatable chutes expanded into the cabin rather than outwards. The first chute, which blocked the
forward right exit, nearly suffocated a flight attendant and was deflated by a pilot with a fire axe from the cockpit

Some Background Trends
1) Increasing automation of the operator’s (pilot’s) tasks… As a matter of course, we increasingly rely upon the technology to do complex
tasks. Automation is graduating from “robotic” (supplementary) to “artificial intelligence” (command) functions. It makes emergency
response (and emergency planning) all the more important when those systems fail.
http://blog.sfgate.com/stew/2013/07/11/animation-re-creates-saturdays-sfo-crash/
“Asiana’s number of aborted landings, or “go-arounds,” is six to eight times greater than would be expected given the airline’s total number of
flights into SFO.”
“The pilot at the controls of Flight 214 had never flown a Boeing 777 into SFO before and was being supervised by a trainer pilot, federal
investigators say.”
2) Growing pains of new companies and industries (especially in Asia nowadays). Organizational experience and pilot experience cannot
simply be acquired like buying a new fleet of planes. http://blog.sfgate.com/matierandross/2013/07/28/sfo-worries-over-asianas-landing-
record/
3) Cutting corners on safety…economic strain of competition, conflicting with safety requirements (notable in transport industry for long
hours of work to meet a schedule or deadline… and many accidents occurring at hours of greatest fatigue.)
http://www.pbs.org/newshour/bb/nation/july-dec13/plane2_07-08.html
The Safety Board has looked at fatigue for decades. It's been on our most wanted list of transportation safety improvements many times. This
was a transpacific flight, more than 10 hours. We have got actually two crews on this flight. One is a relief crew, because as you look at flight
and duty time and you look at fatigue, it is a concern.
http://www.theatlantic.com/technology/archive/2013/07/today-in-asiana-214-news/278068/
Slow reactions and obvious misperception, with degraded awareness, imply fatigue.
A: failing to correct for the low approach angle
B: failing to notice the slow airspeed (137 kt normal, about 105 knots actual) - Normally the pilot continually checks the airspeed. Failing to
glance repeatedly at this indicates degraded attention, vigilance, and perception. There was not a cockpit call for more speed until 7 seconds
before hitting the seawall.
4) Organizational bias …departure from meritocracy, in favor of respect to those with higher age/experience, or those with powerful political
connections, etc. Includes a relative departure from proven safety culture in favor of certain culturally accepted norms (like waiting for
instructions from a superior, even during an emergency! …referring to the pilots delayed decision)
http://www.sfgate.com/default/article/S-F-plane-crash-pilot-says-he-was-briefly-blinded-4658043.php
“Hersman said the crew ordered the passengers to remain seated once the plane came to a stop, delaying the evacuation for 90 seconds. A
flight attendant had initially asked the pilots whether she should begin an evacuation, but Hersman said she was told not to, as the pilots were
apparently still consulting with flight control. An announcement was then made over the intercom telling passengers to "stay in your seats."

ILS – Instrument Landing System;
VASI - Visual Approach Slope Indicator
Visual descent guidance information during the approach to a runway. These lights are
visible from 3-5 miles during the day and up to 20 miles or more at night.

Asiana airlines crash key learnings-2013-sep

More Related Content

What's hot (20)

Viewers also liked (20)

Similar to Asiana airlines crash key learnings-2013-sep (18)

Recently uploaded (20)

Asiana airlines crash key learnings-2013-sep