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The Business Forum Journal

 

Lessons Learned: Asiana Airlines 777 Crash


By David J. Gardner

 

Making the complex simple is something I do for my clients. You see, I want to leave my clients self-sufficient after my work is done. If things are too complex, not well understood, and not sustainable, the outcome of my work is either dependency on me or confusion. Dependency on me or confusion that lingers after I am gone means I have not lived up to my own expectations when I accepted an assignment nor has my client received the value I believe they should have.

Pilot error caused the July 2013 crash of an Asiana Airlines Boeing 777 that hit the seawall just prior to landing at San Francisco International Airport resulting in the deaths of 3 teenage passengers (who were not wearing their seat belts at the time of the crash and whose bodies were thrown onto the tarmac) and injured 187 other passengers. Here is what news reports offered:

"In this instance, the pilots over relied on systems they did not understand and flew the aircraft too low and slow, colliding with a seawall at the end of the runway," said Christopher Hart, acting director of the National Transportation Safety Board, during a long-awaited hearing into the cause of the July 6 catastrophe.

Flight 214 was inbound to San Francisco on a clear day from Seoul, South Korea, with an experienced pilot being trained to fly the 777, and his instructor sitting next to him. As the aircraft passed over the San Mateo Bridge, about 5 miles from the runway, the pilot executed a series of commands that caused it to lose speed rapidly, a problem the pilot discovered too late to execute a go-around for another try at landing.

What caused the confusion in the cockpit has been a key issue of concern, with much of the focus on the technology that has been added to airlines in recent decades to assist pilots.

Asiana has said the accident probably was caused by its flight crew's failure to monitor and maintain safe airspeed during the landing and that a contributing factor was the crew's "failure to execute a timely go-around" as required by company procedures. But the airline also faulted the Boeing 777's complex automation controls for contributing to the accident, claiming "inconsistencies in the aircraft's automation logic" led the crew to believe that the airplane was maintaining a safe airspeed. It added that warnings from the aircraft that something was wrong were "inadequate."

This is horrifying. The fact that the pilot, co-pilot and training pilot did not have a sound understanding of the automated systems that assist them in flying a Boeing 777 is malpractice. Did the passengers and crew understand this when they boarded the plane?  Or, did they assume the pilots were experts? How could the training not take the complexity out of the sophisticated systems such that it was simple for the pilots to understand?

The Boeing 777 is, based on its track record, one of the safest aircraft ever designed and manufactured. As of May 2014, over 1,200 have been manufactured. It was first placed in service in July 1995. The Asiana Airlines crash at San Francisco was the first ever for the Boeing 777 wide-body aircraft. The second incident is Malaysia Airline Flight 370 which disappeared after leaving Kuala Lumpur.

Other airlines and their flight crews seem to be able to manage the 777 well and understand the “complexity” associated with the Boeing 777 flight systems. Why did Asiana pilots have confusion? It seems to me people did not speak up about issues they encountered during their training and re-qualification. If there was confusion amongst Asiana pilots, the airline should have spoken up before an incident occurred, not after the fact. Why did not their flight crews refuse to fly the 777 aircraft if they had discomfort?  The flying public has to expect pilots to be completely comfortable with the aircraft they fly.

As a former Top Gun Navy pilot who launched his plane from aircraft carriers related to me a day after the accident, “Anyone who is unable to land an airplane on a 12,000 ft runway that is not moving on a beautiful visual flight rules day (VFR) needs to find another line of work!”

There is tremendous value in simplifying the complex.  To do anything less creates ambiguity and confusion — and good things seldom flow from these states.


David J. Gardner is a Fellow of The Business Forum Institute and held senior management positions in Product Development, Manufacturing, Sales, Marketing, Customer Service and Product Management.  He joined Tandem Computers in 1979 where he was responsible for Corporate Documentation Standards for Tandem's highly configurable and expandable computer systems. In 1983, he designed and implemented a Configuration Guide for Dialogic Systems instituting a process that greatly simplified a complex, modular product such that the field sales organization and international OEM customers could easily define their order requirements. This methodology satisfied the product definition needs of sales, marketing, engineering, manufacturing, customer service and finance. David founded his consulting practice in 1991.  He is a graduate of San Jose State University (BA) and Santa Clara University (MBA). David is a member of the Society for the Advancement of Consulting (SAC) and has been Board Approved in the Area of Configurable Product & Services Strategy and Implementation. In 2010, he was inducted in the Million Dollar Consultant® Hall of Fame.  Out of over 1,000 consultants who have completed Alan Weiss’s mentoring program, only 26 have been inducted into the Hall of Fame.

Note:-- Dave Gardner can be reached on Twitter and you can check out his video describing why he is in business.


Visit the Authors Web Site  ~  http://www.gardnerandassoc.com

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