In the end, its going to be pilot error.
"In cruise, nobody has a hand on the throttle anyway."
That's absolutely right!
By doing so, most of us get what I call a paralised hand.
It's there all right, but we don't feel anything with it.
I can tell you a nice story about that.
During CATII/III approaches the Sabena B737 SOP calles for the F/O (who's always the PF) to have his hand on the throttles, fingers ready at the TOGA in case of a go around. Since your hand is on the throttles you should be able to feel all movements and spot any abnormalities right away, isn't it? At least that's what someone claimed here on this forum (and what I used to think as well...)
During my first sim recurrent I ran into an instructor who liked to show us just how much we really notice what our hand feels when it is on those thottles.
This is what he did during the biannual low visibility approach revision session. (Low vis approaches mean we always have both A/P and A/T on for the approach, although legally you can do it without A/T)
The plane was nearing the FAF with Gear down, F15, speed 170kts and so the captain (always PNF) asked for the latest RVR (legally required for the approach ban) while I was flying through the A/P and A/T.
RVR was just about right, so we continued the approach, and shortly before the marker we selected F25 and a slower speed (140kts) on the glareshield.
All came out nicely and the A/T put our throttles in idle to give us the lower speed.
The captain then did his airswitching (to avoid bleeding air from our engines reducing our go-around performances) and started going over the landing checklist.
At that moment the instructor failed our A/T.
The plane approached the set speed of 140kts so I called for F30 then F40 and Vtarget.
The plane was decelerating and I had my hand on the throttles (with the failed A/T which none of us noticed although it was failed for 20 sec now)
The landing checklist was completed and the plane neared the Vtgt at around 500AGL.
However, unlike usual, the A/T did not bring up the throttles to keep vtarget. Instead we kept on decelerating quite fast!
None of us noticed anything weird about our thrustsetting nor about the speed and it was only at vtgt-15 kts that I spotted our speed was way too low. A go-around was initiated but stickshaker was encountered anyway, because I tried to start the go-around by clicking the TOGA buttons, not realising the A/T had failed!
A manual go-around was flown and we got out of this safely, but I must say that I didn't step out of that simuator happy that evening.
Stickshaker at less then 200 AGL in IMC is not good for your health!
Here's an interesting email I got today from my coworker who spent several years as a Boeing simulator instructor training Asiana and KAL pilots.
After I retired from UAL as a Standards Captain on the –400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it’s a minefield of a work environment ... for them and for us expats.
One of the first things I learned was that the pilots kept a web-site and reported on every training session. I don’t think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all “got it” and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.
We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-2008) we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.
This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce “normal” standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts ... with good reason. Like this Asiana crew, it didnt’ compute that you needed to be a 1000’ AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldn’t pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain Brown was.
Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested “Radar Vectors” to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then “Cleared for the approach” and he could have selected “Exit Hold” and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to “Extend the FAF” and he couldn’t understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was “Hold at XYZ.” Every time he punched LNAV, it would try to go back to the IAF ... just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).
This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141’s in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!
The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can’t change 3000 years of culture.
The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. It’s actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don’t trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don’t get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!
Finally, I’ll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.
Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged at 250’ after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800’ after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real “flight time” or real experience did he get. Minutes! Of course, on the 777 or 747, it’s the same only they get more inflated logbooks.
So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.
And here's the report filed by the relief pilot in the United B747 that was nearly part of this whole tragedy.
On July 6, 2013 at approximately 1827Z I was the 747-400 relief F/O on flt 885, ID326/06 SFO-KIX. I was a witness to the Asiana Flt 214 accident. We had taxied to hold short of runway 28L at SFO on taxiway F, and were waiting to rectify a HAZMAT cargo issue as well as our final weights before we could run our before takeoff checklist and depart. As we waited on taxiway F heading East, just prior to the perpendicular holding area, all three pilots took notice of the Asiana 777 on short final. I noticed the aircraft looked low on glidepath and had a very high deck angle compared to what seemed "normal". I then noticed at the apparent descent rate and closure to the runway environment the aircraft looked as though it was going to impact the approach lights mounted on piers in the SF Bay. The aircraft made a fairly drastic looking pull up in the last few feet and it appeared and sounded as if they had applied maximum thrust. However the descent path they were on continued and the thrust applied didn't appear to come soon enough to prevent impact. The tail cone and empennage of the 777 impacted the bulkhead seawall and departed the airplane and the main landing gear sheared off instantly. This created a long debris field along the arrival end of 28L, mostly along the right side of 28L. We saw the fuselage, largely intact, slide down the runway and out of view of our cockpit. We heard much confusion and quick instructions from SFO Tower and a few moments later heard an aircraft go around over the runway 28 complex. We realized within a few moments that we were apparently unharmed so I got on the PA and instructed everyone to remain seated and that we were safe.
We all acknowledged if we had been located between Runways 28R and 28L on taxiway F we would have likely suffered damage to the right side aft section of our aircraft from the 777.
Approximately two minutes later I was looking out the left side cockpit windows and noticed movement on the right side of Runway 28L. Two survivors were stumbling but moving abeam the Runway "28L" marking on the North side of the runway. I saw one survivor stand up, walk a few feet, then appear to squat down. The other appeared to be a woman and was walking, then fell off to her side and remained on the ground until rescue personnel arrived. The Captain was on the radio and I told him to tell tower what I had seen, but I ended up taking the microphone instead of relaying through him. I told SFO tower that there appeared to be survivors on the right side of the runway and they needed to send assistance immediately. It seemed to take a very long time for vehicles and assistance to arrive for these victims. The survivors I saw were approximately 1000-1500' away from the fuselage and had apparently been ejected from the fuselage.
We made numerous PAs to the passengers telling them any information we had, which we acknowledged was going to change rapidly, and I left the cockpit to check on the flight attendants and the overall mood of the passengers, as I was the third pilot and not in a control seat. A couple of our flight attendants were shaken up but ALL were doing an outstanding and extremely professional job of handling the passenger's needs and providing calm comfort to them. One of the flight attendants contacted unaccompanied minors' parents to ensure them their children were safe and would be taken care of by our crew. Their demeanor and professionalism during this horrific event was noteworthy. I went to each cabin and spoke to the passengers asking if everyone was OK and if they needed any assistance, and gave them information personally, to include telling them what I saw from the cockpit. I also provided encouragement that we would be OK, we'd tell them everything we learn and to please relax and be patient and expect this is going to be a long wait. The passenger mood was concerned but generally calm. A few individuals were emotional as nearly every passenger on the left side of the aircraft saw the fuselage and debris field going over 100 knots past our aircraft only 300' away. By this point everyone had looked out the windows and could see the smoke plume from the 777. A number of passengers also noticed what I had seen with the survivors out near the end of 28L expressing concern that the rescue effort appeared slow for those individuals that had been separated from the airplane wreckage.
We ultimately had a tug come out and tow us back to the gate, doing a 3 point turn in the hold short area of 28L. We were towed to gate 101 where the passengers deplaned. Captain Jim Abel met us at the aircraft and gave us information he had and asked if we needed any assistance or hotel rooms for the evening. Captain Herlihy and F/O Ishikawa went to hotels and I went to my home an hour away in the East Bay.