Clueless Crews?

July 1, 2014 by Bruce Landsberg

OLYMPUS DIGITAL CAMERAHow much automation is enough? When is the line crossed between having something that’s really useful and doing so much that, like the Wizard of Oz with his hot air balloon, we have no idea how it works? What role does training play?

In the wake of the Asiana accident where the crew flew what appeared to be a perfectly functioning B777 into a seawall, inquiring minds are now wondering if the auto-throttle system was perhaps a bit overdesigned. My only experience with auto-throttles have been in simulators—Gulfstream IV and the Airbus 330. It was pretty easy. Push a mode button here, select a speed there, and then monitor the system for anomalies. “Monitor” is a key word.

The ease of flying a fully automated approach makes you wonder just how hard this could be? In primary instrument training there are roughly five or six instruments to be scanned to keep the localizer and glideslope (or was it glideslop?) somewhere near center scale. It’s a lot of plates to keep spinning simultaneously. When first introduced to the horizontal situation indicator (HSI) and the single-cue flight director, they significantly lowered my estimation of how hard it was to fly bigger aircraft.

One of the NTSB’s Asiana findings was that auto-throttle modes were confusing. Former NTSB Chair Debbie Hersman noted, “This crew was extremely experienced. They had a lot of hours, but they just didn’t have the ability to understand what was happening in the critical few seconds before the crash. It wasn’t just one person in the cockpit that didn’t understand. There were three experienced people in the cockpit that didn’t understand what was going on.” Really? Didn’t have the ability to see that the aircraft was not stabilized early in the approach and failed to take action when slowing below Vref? Hmmm.

I know nothing about the B777 systems which may be complex, but with several hundred thousand (or more) successful automated landings completed over the aircraft’s 20 plus year history, ya gotta wonder just how bad the system design was. Ms. Hersman and I both agree that engineers often overthink and overdesign systems. We diverge somewhat on the statement regarding this crew’s capability. Experience and competence are two different attributes.

The other two airline accidents that bear at least some similarity with somewhat clueless crews are the Colgan Q400 accident in Buffalo and Air France 447, the Airbus 330 that stalled over the South Atlantic. In all cases, a highly automated aircraft wrested control away from the crew. (Shades of Space Odyssey and the HAL 9000 computer… “I’m sorry, Dave. I’m afraid I can’t do that.” )

Lest you think I’m just picking on air carrier pilots, many more GA pilots demonstrate a lack of clue far more frequently. Automation doesn’t seem to trap us often although it’s becoming more prevalent.  It’s more often judgment. Lack of fuel, too much weather, too much wind, too little altitude, not enough runway—you know the list.

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Adrian Gilbert

    This Asiana accident has all the hallmarks of a particular feature of Asian culture: that is, the reluctance of juniors to question the actions – or lack of actions – of their seniors.

    This feature of Asian culture has been noted in many aviation accidents. JAL had a bad run of such accidents in the early days of their jet operations. The B707 landing short of Hanada in Tokyo Bay being typical.

    While on the first foreign B747 Captain course with ANA, we saw the inability of Asian aviators to grasp the meaning of Cockpit Resource Management. The course included a CRM component but it was evident that Japanese aviators had great difficulty accepting the concept. Trans Cockpit Gradient – the different level of authority within the cockpit – is very steep in Asian airlines. Basically, an Asian First Officer is constrained by his culture to the point that he would rather die than criticize his Captain.

    While flying as a Captain for ANA – later for Mandarin and finally for Nippon Cargo – I would always end my pre-take off briefing to the crew with: “if you see anything you don’t like with my flying you must speak up and tell me so.” Often the response was along the lines of: “oh no, Captain, I could never criticize you !.”

    The SIA accident at Taipei – where the crew commenced a take off on a runway clearly marked as unusable and impacted heavy machinery – is another example. There was an experienced Captain riding on the jump seat. Nobody spoke up.

    The China Airlines B747 freighter accident at Stansted – where the Captain persisted on rolling in bank to the point he lost control and crashed the aircraft – is another one. The FO’s and the standby AHI were all serviceable. No attempt was made by the FO to take control.

    To speak up – and, if necessary to take control – when your Captain has ‘lost’ it is clearly what the FO is paid to do. I had to take over control once early in my career while flying as an FO for Cyprus Airways.

    In that part of Europe in those days, altimeters were set to QFE prior to landing so that the altimeters read zero altitude on the ground. Cleared on descent to 1,500 feet QFE, we needed to reset the altimeters. Nicosia airport was at an elevation of 730 ft. In addition, on the HS Trident aircraft that Cyprus Airways operated then, the pilot flying – the Captain in this incident – was required to change a separate altimeter setting for the autopilot. On most aircraft, changing the altimeter setting on the altimeter automatically changes the setting in the autopilot.

    Despite my repeated calls to the Captain to change the barometric setting on the autopilot control panel, he seemed incapable of doing so. As we descended through 1,500 feet above ground level – with the autopilot still referenced to QNH (height above sea level) reading about 2,200 ft – I said ‘I have control’, disconnected the autopilot, leveled off, completed the approach and landed. With QNH still set on the autopilot, the aircraft would have descended to about 770 ft AGL which, with high terrain around the airport, would not have been too good.

    Another Asian B747 freighter ‘incident’ – they got away with this one – was at Anchorage where the crew managed to take off on the taxiway ! The gear left great tracks through the snow bank piled up at the end of the taxiway. The crew then proceeded to fly across the Pacific to Asia as if nothing had happened !

    Modern advances in automation induce complacency. So many tasks are performed by the automation that one of the major problems days is simply keeping awake. On ANA flightdecks it was common to see the Flight Engineer place a little black box on the centre pedestal on reaching top of climb. Attached to the box was a wire. At the end of the wire was a light sensitive diode in a rubber housing. This was pushed over one of the INS amber warning lights. The box – obtained from Radio Shack – contained a battery and a buzzer.

    Approaching a waypoint, the INS amber lights would illuminate. The non-handling pilot confirmed waypoint crossing by noting all three INS units changing to the next leg. The distance and track to the next waypoint needed to be verified and, in those days, a call to Oceanic Control was required giving the time of crossing the waypoint, the altitude and the estimate for crossing the next waypoint.

    But this was evidently an issue with Asian flight crews who would often lapse into a ‘zombie’ like sleep mode on long, night-time, ocean crossings such that they were incapable of seeing the amber INS lights illuminating. The little Radio Shack gizmo was the answer. I was presented with one at my farewell: quite an interesting – or as one might say, ‘illuminating’ – souvenir of Asian aviation.

    Adrian Gilbert
    New Zealand
    17,000 hour ex airline pilot. (over 10,000 hours on B747’s)

  • Bruce Landsberg


    Nicely said and spoken by one who has been there. Showing respect is one thing but deference has been fatal too many times. A well-placed question twice and finally action before things get out of hand is essential.

  • Jay

    Well fantastic. Now that we have thoroughly trashed Asian culture and its authoritarian ways which have been around for thousands of years and will probably still be here long after America is gone, maybe we should compare Asian accidents per hours flown with those of other cultures and then attempt to account for 50 plus years of airline accidents in the USA and detail the causes of those flights.

    While I am concerned that some students might mistake an electronically generated flight path for a raw data localizer or glideslope and allow the autopilot to fly them into the ground, I think it is way off subject to assume that this can’t happen to an American crew just as quickly. Or since everyone is afraid that they might be labeled “Authoritarian” nobody speaks up at all.

    FAR 91.3 still says that the pilot in command ie…(captain) is the final authority and solely responsible for the safety of the flight. And I for one am not ready to replace him with a copilot, a computer hooked up to an autopilot or some ground based drone pilot in the Southwestern U.S. taking turns between Airbuses in Atlanta and Predators in Pakistan.

  • Mark H Goodrich

    It’s all too easy to pick on “culture” – it introduces prejudice and allows Americans to engage in one of their favorite and factually unsupportable rationalizations, broadly described as “American Exceptionalism”. As one who has held instruction certificates for 50 years and taught worldwide in everything from Taylor E2 Cubs to most of the airline transport types manufactured by Airbus, Boeing, Lockheed and Douglas over the past five decades (in the airplanes and in their respective simulators), I can say on the basis of experience that to so-called “Asian Culture” exists worldwide (including in the USA). Before CLR/CRM, it was widespread in US Carriers, It has become less of a problem in the USA and Europe, but still exists, as can be readily seen from accidents such as the AAL crash at Little Rock, and the myriad incidents that occur every month in the USA, many of which do not become accidents more as a result of luck than any other factor.

    The common problem that Bruce has identified is a failure to adequately train on the systems and airplanes. The airline corporatocracy and the regulators worldwide (including most notably the FAA and EASA) have engaged in an implied conspiracy within the deregulated environment to make training a sham. To create the illusion that training is taking place, press releases are issued, politicians expound and regulators develop new acronyms to describe what they are doing to prevent some issue “from ever occurring again”. A minor modification is then implanted within the existing training syllabi and footprints, so as to avoid any increase in training expense or change to the time required. We used to say that the specter of an accident was an inherent incentive to train, but the new world of corporations vs. consumer interests has eradicated most of the negative aspects associated with a crash. Regulators and so-called “independent” accident investigation agencies are themselves politically driven to avoid the harshest facts when damage to their respective corporations (read, political contributors and employers) might result.

    Like so many things in this Age of the Corporation, the incredible economic and (therefore) political power of corporations trumps regulatory effectiveness, corporate responsibility and the public safety interest.

    Those interested can read my more extensive thoughts on these issues within aviation white papers published on my web-site at – specifically those entitled “The Automation Paradox” and “The Training Paradox”.

    Mark H Goodrich
    Reno, NV

  • Bruce Landsberg

    Seems like it always comes down to economics. Had I understood that better in college, might have paid a bit more attention. The Colgan accident in Buffalo had sins of omission in training as the crew never had much exposure to the stall characteristics or the prevention systems on the Q-400. Extra sim time is money – not much – but in the eyes of some – not worth it.

    In GA, too often people rush through transition when a bit more time with both hardware and software would yield big dividends but time is money isn’t it?

  • http://AOPA Jim Borger

    I have a great deal of flying time in different Asian countries with Asian co-pilots. In their culture the Captain is never wrong and anything that goes wrong is the fault of the co-pilot because he didn’t think of a way to let the captain know he was wrong in such a way as not to embarrass him, to the point of letting him crash.

    What I see happening today is the young people coming into our profession are taught to use all the automation and little emphasis is put on flying without all the bells and whistles. We older pilots started without all that stuff and don’t 100% trust it so we pay closer attention when George is flying while the younger folks push the proper buttons and don’t monitor what the aircraft is really doing, assuming it is doing what they told it to do.

  • Mitch Velickovich

    in 1966 Richard Bach wrote this in his Book BIPLANE….Ttill applies today!

    “For even in an airplane we see too often imperfectly. With advancing invention, with cockpits closed and navigation instruments and radio and new electronics, the problem of flying has become something to be solved more and more within an arm’s distance of the pilot. Drifting off course? A needle shows it, points the error, and all the pilot must do to see it is to look within a three-inch face of glass. Concerned about weather ahead? Dial a frequency on the radio, call a meteorologist and ask expert advice. Airplane slowing in the air, approaching a stall? A red light flashes on the instrument panel, a warning horn blares. We look outside to the sky only when we have time to enjoy the view, and if we don’t want to be bothered with the view, we needn’t look outside from takeoff till touchdown. It is this kind of flight over which the manufacturers of flight simulators can boast, “Impossible to tell our trainer from flight itself!” And so it is. Those who define flight as a series of hours spent in attention to the moving gages of an instrument panel cannot tell the difference”
    All Excerpts From
    Bach, Richard. “Biplane.” .

  • Jim

    The accidents happened after the autopilot has been shut off. Modern pilots exist in a world that lies in the middle. Airliners have such a high level of automation that it is difficult to maintain adequate stick and rudder skills. The industry needs to advance to being fully automated then these kinds of accidents will cease. In both the SFO and Buffalo crashes the pilots transitioned from planes that had a higher level of auto throttle. Take that away and they loose control of airspeed.