July 6, 2013. San Francisco, California. An Asiana Airlines captain flies the plane in for a visual approach, without automated control. The National Transportation Safety Board’s Deborah Hersman says it came in too low and too slow.
“About five seconds later and about three seconds before impact, there is a call for a go-around [aborted landing]. There is a second call for a go-around at 1.5 seconds prior to impact.”
The 777 hits the seawall and crashes, leaving three people dead and 180 injured.
The NTSB says the cockpit recorder for the South Korean jet indicates the crew had problems in the approach. The NTSB says it was the first time the crew had flown together. There was no cockpit discussion about aborting the landing, despite automated announcements of low altitude and despite frantic urgings from the other two pilots to go around seconds before the plane hit the ground. There was no mention of low speed until nine seconds before impact.
History of problems
Sixteen years earlier on Guam, Korean Airlines flight 801 crashed, killing 228 people.
The NTSB accident report indicated problems with the approach. Again, it was the first time the crew had flown together. Again, the report cited no cockpit discussion about a go-around -- even though the first officer urged a go-around six seconds before impact.
Map of Asiana and Korean Air incidents since 1990.
“The Safety Board concludes that the first officer and flight engineer failed to properly monitor and/or challenge the captain’s performance, which was causal to the accident," the NTSB reported. It goes on to say, “Problems associated with subordinate officers challenging a captain are well known.” It also mentions “KAL’s inadequate flight crew training.”
Two years later, another fatal crash involving Korean Air occurs in London. According to the British Aircraft Accident Report, the first officer said nothing about the plane’s unsafe altitude and the captain ignored warnings from the flight engineer, who was 20 years his junior. The investigative team advised the South Koreans to revise training to “accommodate the Korean culture,” which places great weight on seniority and discourages younger people and subordinates from challenging their elders or superiors.
The South Korean government ordered Korean Air to suspend 138 flights a week for 6 months and to concentrate on improving safety and training.
Transport Canada conducted a special safety audit of Korean Air and then issued a notice of suspension to Korean Air. The airline corrected the safety concerns so the suspension never took effect.
The FAA downgraded all of South Korea's airlines from a Category 1 International Safety rating to a Category 2. By the end of the year, South Korea regained its Category 1 status.
At the time, Jim Hall was the chairman of the National Transportation Safety Board, which had investigated the Guam crash.
VOA showed him the similarities between that 1997 crash and the one involving Asiana.
“I think the Asiana crash (investigator) is going to have to look and ask, ‘Was this an unusual situation in which it was just crew error? Or is this an indication that the lessons that were pointed out in the previous accidents still have not been learned and not taken root in the Korean aviation system?’ ” Hall said.
The NTSB and South Korean officials say the captain landing in San Francisco, Lee Kang-kook, was on his first trip to become certified to operate the 777. He has logged more than 9,400 hours of flying, but only 43 on the 777.
The instructor pilot, Captain Lee Jeong-min, was on his first trip as a training captain and was the senior pilot. As a former military pilot, he is three years older. He has more than 12,000 flight hours and 3,200 on the 777. The relief co-pilot is seven years his junior.
Sources who understand Korean culture say many factors establish hierarchy - like age, rank, schools attended, union status and military service. Conformity is encouraged.
A former Asiana pilot who spoke to VOA on condition of anonymity described how seniority can be established at the airline. “The military pilots get super-seniority when they get hired by Asiana," he says. "They get a 10-year career in the service and maybe only get out with 2,000 hours of fly time. In America, most airlines have a seniority system. If your seniority number comes up and you want to bid for a new airplane, you have to pass the proper tests.”
Park Jong-kook is executive director of the South Korean pilots' union.
“It was true that this kind of tradition affected the communication at the cockpit before the crash in Guam happened," says Park. "There was a vertical or military tradition in the past. But, the companies have put forward a lot of effort to improve this kind of tradition.”
Kwon Yong-bok is director general of Aviation Safety Policy at the South Korean transport ministry. He says about 14 percent of the pilots in the country are foreigners, "so Korean culture is changing more globally and universally.”
Ross Aimer, a former United Airlines captain, was brought in to train the Korean Air pilots in 2005 and 2006.
Change hard to come by
“It would take perhaps generations of pilots to eventually change the culture into a Western type of flying culture.”
Captain Vic Hooper retired from Asiana two years ago. He says Korean deference in the cockpit was evident from his very first flight until his last.
“I met the other three pilots, I’m going to fly with one of them, but both the first officers come up to me and they put their hands across their chests, and they bow and shake their hands, which is part of their culture, which is show their subservience to the rank. Because like I said, they respect rank, age, and position.”
No investigator has yet to formally connect cockpit culture to this crash. But Jim Hall hopes what NTSB investigators accomplished in the '90s was not in vain.
“With a decade, it’s not unusual, unfortunately in the accident investigation business, to find that lessons learned are also lessons forgotten as times pass,” he says.
Asiana executives bowed and expressed their sympathy and regret at a news conference the same day as the crash. They are initially paying $10,000 to each survivor, but did not want to be interviewed for this story.
Korean Air refused VOA requests for interviews, although KAL did send a list of all the improvements it made following the crashes in the 1990s. Changes were made to training, flight manuals, safety audits and more. KAL, though, is currently under a special safety review by the South Korean government, after one of its jets overshot a runway on August 6.
Additional reporting by Brandon Goldner in Washington, D.C., and Daniel Schearf in South Korea.
Related video report by Carolyn Presutti: