The mismatch

This first appeared as a Comment in Flight International 1 July

The 6 July 2013 Asiana accident at San Francisco was subjected to particularly public scrutiny from the start, when the National Transportation Safety Board’s then-chairman Deborah Hersman provided a series of press briefings on the investigation’s progress.
It was indeed a high profile crash, happening as it did on US soil and being the first Boeing 777 accident in which there had ever been any fatalities. Filmed by aviation watchers at the airport, the aircraft was seen on public media across the world cartwheeling tailless across the airfield and bursting into flames. It was truly remarkable that only two people in the aircraft died.
The NTSB’s verdict is simple but multi-layered: the cause was pilot error, but there were many contributory factors. The Board cited pilot error because this approach in excellent visibility at a major world airport should have posed no problem even for mediocre pilots. But the crew failed to fly their perfectly serviceable aircraft safely, and failed completely to monitor the performance of the automatic systems they were using.
It is an indictment of the industry to be able to say – as we do without any hesitation – that this was an accident waiting to happen. Not because of the aircraft alone, not because of the crew alone, but because the industry has still not prepared modern pilots to fly modern aircraft using modern automated systems.
The precursors for this event are many, but the ­closest parallel is the February 2009 Turkish Airlines 737-800 accident near Amsterdam Schiphol, where the aircraft stalled on short final approach and crashed ­fatally. The industry knows what it should be doing about this mismatch between pilots and aircraft, and is even preparing to do it, but the necessary change in most countries and most airlines is still distant.
The NTSB report castigates almost all aspects of ­Asiana’s training, but not the out-of-date regulatory system that almost guarantees its mediocrity. The most specific training indictment was Asiana’s failure to train the pilots – and even their instructors – to understand their automated systems, not just to use them. Finally, it hits Boeing for the complexity of some of its flight management system modes. Complexity makes them difficult to comprehend and non-intuitive in action.
Modern aeroplanes have improved safety immeasurably in the last 25 years, but when failures happen nowadays it is increasingly because of a pilot/aircraft mismatch that can be fixed, but only if the industry takes it seriously.


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