October 2, 2022
Op-Ed on Asiana 214 From A 777 Pilot: Human And Cultural Factors – A Tragedy That Should Never Have Happened
Airchive Airlines Airports

Op-Ed on Asiana 214 From A 777 Pilot: Human And Cultural Factors – A Tragedy That Should Never Have Happened

MIAMI —Because we cannot turn back time, there is nothing we can do to save the three fatal victims of  Asian’s Boeing  777-200 ER hull operating Flight 214 from Seoul Incheon airport to San Francisco International. We, as a society,  can and will take the best care of the survivors as long as necessary. And the flight and cabin crew who amongst the survivors, hold the key to the causes of this accident and the evacuation and care for the passengers that ensued. Including actions by crash, fire and rescue equipment, which unfortunately, contributed to the fatal results.

What we can do, however is turn back to the timeline of this accident and learn a few important lessons to avoid similar events in the future. The air transportation industry goal of “zero” accidents, remains as the target, and we are very close to it. The Asiana 214 accident looks certainly like an outlier, an anomaly or an exception to the safety record one expects from an FAR 129, IATA IOSA airline operating in an FAA Category I country.

As the investigation progresses at a frantic pace, thanks to audio-visual and digital data evidence  from flight recorders, the NTSB is intent in providing a probable cause within weeks and final cause in short months. The evidence, data and probable cause leading indicators already shed light to an event driven in large measure by human actions in the cockpit.

The flight deck of a Boeing 777. (Credits: Chris Sloan)
The flight deck of a Boeing 777. (Credits: Chris Sloan)

I have flown, managed and analyzed data for airlines in different regions of the world, including Asia. It is not a secret that cultural traits and lore of groups and society have a way to filter to the cockpit. Thus, what happened in the Asiana 214’s cockpit possibly reflects these cultural trait to an extent in the behavior of this crew. Factors such as ranking, seniority, training-trainee potential “loss of face” in front of an error, are just a few of the elements that the investigation will address, as possible contributing factors to a delayed response to commence a go-around in what is now evident and clear unstable approach and landing attempt. I have personally witnessed a sequence of events in which an Asian First Officer would visibly be aware of an entry error in a flight management computer on a  revenue flight, and instead of pointing it out directly, he tried many indirect ways around it to avoid offending his senior. The error and the hints at it  went unnoticed by the Captain for quite some time, fortunately it was during cruise flight, and eventually the Captain found and corrected the error on his own.

My experience as a former  Boeing B 777 and 747 pilot for a major Asian carrier, Boeing 777 flight data analyst and simulator research and experimental air transportation pilot for different private and public entities gives me enough statistical data to say that in the past, other Asian carriers accidents and incidents have had a strong Cockpit/Crew Resource Management (CRM) issues as contributing and probable causes. This is well known and was addressed in the early part of the 2000s, after a series of high-profile crashes involving particularly some Korean and Taiwanese carriers.  Since then, their aviation operations have garnered much stronger safety records.

The communication loops we heard on  Asiana’s CVR, records of NTSB interviews with the pilots and my own insight and experience yield a fundamental question:

Was Asiana’s 214 accident a bizarre-one off event? Or was it the one flight at the end of a trend of many other “unstable” approaches that in the past managed to get away?

To correct the causes to whichever one of the answers will be in my opinion, a challenging human factors undertaking, in which cultural, attitudinal  and common-sense multi dimensional problem. The fixes for such challenges take time, a lot of it. In a certain way, technical or mechanical problems are easier to fix and predict as machines after all, do not exhibit the “soft” human qualities that can at times miraculously solve the most intricate problems, yet at other times, fail in the face of the most benign routine situation.

Tracking data of last 5 minutes of Asiana Flight 214. (Credits: FlightAware)
Tracking data of last 5 minutes of Asiana Flight 214. (Credits: FlightAware)

Oscar S. Garcia, Chairman is an expert advisor and consultant in the areas of strategy, business and economic development, organizational design and industry forecasting.

(Credits: Author)
(Credits: Author)

His main areas of expertise are Air Transportation, Commercial Space Industry, General & Business Aviation, Aero Marine and Special Mission Aviation.
He is also a well sought after world leading expert in the unique Aero Marine Aviation sector.
He was formerly a pilot with Major Airlines in the US and Asia flying several aircraft including B 777-200/300 and B 747-400.


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