Some accidents stick with us, just refusing to go away. Or maybe some accidents stick with us because we keep finding new ways to learn from them. One of these impactful events that seems to have unusually high resonance is Asiana 214, the Boeing 777 that crashed on landing at SFO during visual flight conditions, killing 3 and seriously injuring dozens more. The accident report summarized the cause of the crash as a result of:
“…the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were; (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training, which increased the likelihood of mode error; (2) the flight crew’s nonstandard communication and coordination regarding the use of the autothrottle and autopilot flight director systems; (3) the pilot flying’s inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot’s inadequate supervision of the pilot flying; and (5) flight crew fatigue which likely degraded their performance..”
By my count, there are at least 10 major issues identified in the above statement, each deserving of many hours worth of analysis and discussion by contemporary flight crews. We continue to use this space as a forum for ideas that have broad implications for our industry, but do so in small servings in order that, like too much information on the flight deck, our readers don’t get overwhelmed and can act on the suggestions immediately and directly in their line of work.
This accident report is extremely useful in assessing the myriad distractions that flight crews—experienced and inexperienced—face every time they operate advanced aircraft in 21st-century airspace. As a company focused on the “human side” of the human-machine relationship, we concentrate our work on fine-tuning the operator through knowledge and tools that make accidents like the one described above less likely, even unlikely. On the 6th of July, 2013, the crew of Asiana 214 was unable to manage distractions, failing to push unimportant information aside in favor of that which was most important to preserving the integrity of the aircraft’s flight path. To understand each of the many distractions in play, you might want to read the full report, or some of the official commentary written since (see the link below). Whether you choose to research this accident on your own or not, the insight of one of our generation’s most respected brain scientists, Daniel Goleman, describes in one phrase how our own performance can be degraded when we fail to manage distractions effectively:
“…the likelihood of the right idea connecting with the right memory within the right context—and all that coming into the spotlight of attention—diminishes drastically when we are either hyper-focused or too gripped by an overload of distractions to notice the insight.”
Aviation as a profession is known by many to be comprised of professionals who are uniquely well practiced at focusing the right amount of attention at just the right time in support of safe operations. The pace at which distractions have and will continue to enter flight operations long ago outpaced the human operator’s ability to manage them without a conscious effort, or better yet, a refined strategy. This space, in recent months, has brought just that kind of knowledge to the forefront. Maybe it would be a wise investment of just a few minutes to consider a self-inventory of how well your own habits stack up against those of the best among us when it comes to managing distraction.
Think about it.
Until our next post, fly safe, and always, fly first.
6/24/2014 9:00 AM
NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of June 24, 2014
“Focus: The Hidden Driver of Excellence” by Daniel Goleman. HarperCollins, 2013.