Ignorance, Incompetence, and Arrogance

Three Good Men

Two good men died last month. From opposite sides of the office, they left us with the same message: it is important to actually know what you are doing. There is another good man who died in 1988.

Robert Ebeling was an engineer at Morton Thiokol, the company that made the solid rocket boosters for the space shuttle. On his way to watch the shuttle launch, he told his daughter, “The Challenger is going to blow up. Everyone’s going to die.”

It was January 28, 1986. I was flying a B-767 (ship number 612, registration C-GAVF) between Toronto and Vancouver. The Captain was S.R. (Rod) MacDonald. I was the First Officer. It was my leg. We heard about the Challenger disaster when we were over Winnipeg, listening to the news on one of the ADF radios. I can still remember how stunned we felt, how sad for our fellow aviators.

Andy Grove was the tough and brilliant manager who founded Intel in 1968 with Gordon Moore and Robert Noyce. In a 2010 article he wrote for Bloomberg Businessweek, he said, “But what kind of a society are we going to have if it consists of highly paid people doing high-value-added work—and masses of unemployed?”

He wrote when we were still reeling from the Great Recession. Even now, six years later, the people in the trenches have not recovered. The “recovery” part of the economy has gone mostly to the top 1%.

But income distribution is only part of the story. In the same article, Andy Grove also said this about exporting jobs to fatten the bottom line: “Not only did we lose an untold number of jobs, we broke the chain of experience that is so important in technological evolution.”

Richard Feynman died at 69, in 1988. He was a Nobel physicist, but he was also one of the great teachers of the last century. A member of the Rogers Commission which investigated the Challenger disaster, he famously squeezed a rubber O-ring in a C-clamp and put it into a glass of ice water. When he removed it and undid the clamp, the O-ring did not spring back – it kept its distorted, squeezed shape.

The shuttle solid rocket boosters were built in sections. The joints were sealed with large O-rings. The shuttle had never been launched at such a low temperature. That’s what Bob Ebeling was thinking about when he talked to his daughter that day. He had spent the previous (week) trying to convince managers at both Morton Thiokol and NASA to postpone the flight.

The other shuttle disaster was Columbia, on February 1, 2003. It disintegrated on re-entry because a few thermal tiles were missing. They had been knocked off during launch. Pilots do a walkaround before every flight. These pilots were not allowed to do a space-walk to inspect the vehicle before re-entry. From safe seats in Houston, managers took control. Seven astronauts paid with their lives. For the curious: William Langewiesche published his Columbia’s Last Flight in the November, 2003 Atlantic Magazine. (William is the son of Wolfgang Langewiesche, who wrote the wonderful how-to-fly book Stick and Rudder in 1944). It is a good read and worth the time.

Andy Grove said, “we broke the chain of experience.” But it is worse than that. We are losing knowledge. In this day of the internet, where we can theoretically teach ourselves anything we want to learn, knowledge is actually disappearing.

As a pilot I study accidents, trying to learn and survive. Recently there has been another tragedy. The Board has not completed its study, but from what I (and many other pilots) know already, the cause(s) were well known to the trade. For me, that is the tragedy of the tragedy. It happened because trade knowledge was not being passed on.

It gets worse yet. In aviation, we are well into to age of robots. Fly-by-wire was introduced into commercial aviation in the Airbus A320 in 1988. Knowledge and skill have been coded with varying degrees of success. The hard-earned legacy of many crashes and many pilots’ lives lies hidden on a chip. Today’s pilots (still critical to survival) may or may not understand the code or (increasingly) their job.


Andy Grove, in the article mentioned above, put it succinctly and with more than his usual tact: Our fundamental economic beliefs, which we have elevated from a conviction based on observation to an unquestioned truism, is that the free market is the best of all economic systems—the freer the better. Our generation has seen the decisive victory of free-market principles over planned economies. So we stick with this belief, largely oblivious to emerging evidence that while free markets beat planned economies, there may be room for a modification that is even better.

Ideology blinds us, making learning – true learning – more vital than ever.

A very old friend – we have known each other since kindergarten – recently took up the subject of learning. He is retiring gradually from the practice of medicine, and he is re-examining the mathematics and science he learned forty-five years ago. Recently he showed me his derivation of the number e. It would be an exaggeration to say that I now understand e, but he has taken me parsecs closer. He himself, through his efforts, now owns the number e in his heart and soul.

This kind of learning is possible in our age, but even with the ubiquitous internet we have not yet figured out how (Although Sugata Mitra is getting warm).

So there is hope. But so far I see more loss than gain. Knowledge is leaking away.

The Cycle We Have to Break

There is a tragedy. We don’t want to assign blame or upset the apple-cart, so we don’t learn from our mistakes. Managers, once again, become arrogant and complacent. Engineers have to feed their families. They keep their mouths shut. When teachers are leaned on, they are already paid so little they are more likely to leave the profession entirely. But not all of them. Some stand up and say what needs to be said. Thank you, Andy Grove. Thank you, Bob Ebeling, And thank you, Richard Feynman.

Open Letter to Elon Musk

Dear Elon,

Congratulations on trying to land every booster. The lessons learned will be invaluable in space. An congratulations on posting the failures as well as the successes on your site. Thanks for the video, for your observations, and for your humor.
You are right comparing the problem to landing on a carrier. If you would allow a few observations from a pilot, here goes:
As you say, the barge is translating and rotating. The rotation is in three axes: pitch and roll as well as yaw. After touchdown the tail of the booster is effectively fixed to the barge, but the nose (because of the pitch and roll of the barge) must describe an ellipse. Somehow forces must be generated to a) accelerate the nose around the ellipse, and b) counteract gravity (because the long axis of the booster is not parallel to the gravity vector), and c) compensate for the moment of the long axis if there is any translation at touchdown. Forces a, b and c act in the same direction, so the force required can be as large as their sum. The required correcting forces can be a) transmitted through the landing legs, or b) generated by the nose thrusters, or both.
In the video I can’t see the nose thrusters (last time, in the Atlantic, I could), nor do I know their thrust. However, you should be able to calculate the maximum size of the nose ellipse, as well as the maximum lateral velocity at touchdown, with the thrust available from the nose thrusters.
Last time I wrote I also suggested that the nose ellipse be flown prior to touchdown, to minimize these forces at touchdown. Also, a little more time in the vertical deceleration schedule might be advantageous, especially in the last ten meters or so (if the video is in real time).
The carrier landing analogy, then, is interesting but incomplete. The pilot of an F-18 can, for all practical purposes, consider his aircraft (and himself) as one mass acting at their combined center of gravity. The booster – a long shape touching down on its tail – cannot.

I wish you and your ventures well. No – more than that. They are our future.



Open Net Letter to Sir Richard Branson


Dear Sir Richard,

I offer you my heartfelt condolences on your loss: a life, a spacecraft, money, and momentum. The life and the aircraft will be missed. The money and momentum can be made up. But as in every disaster, there is also opportunity.

I have been a pilot for nearly fifty years, and in my trade accidents are fodder: nearly always, there is something vital to be learned. The accumulation of this knowledge is what allows us to hone our skills and make our missions safer.

Spaceship Two awakes powerful echoes from the past. We have been here before and moved on.


The following is fiction. I look to the net for facts: what I find there may or may not be true. Using what I find I make up a story. My hope is to get everyone thinking about the way forward while we wait for the NTSB. Please accept my offering as help, and as hope for the future for this very special project.

Test Flying

One pilot friend has given up test flying. Another still does it and has flown an amazing number of types. His preparation method is simple: know and prioritize the systems. Knowing means finding everything you can and studying, asking questions in a practical way. Prioritizing means asking the question, what is going to kill me first?

Often it is the fuel system. But Spaceship Two’s rocket motor was designed to be simple. Sure, it’s new, and could kill us, but is it first in line?

Look instead at the flight envelope: subsonic atmospheric flight as an airplane or glider. High Q, high G, supersonic flight as a rocket plane. Ballistic flight as a near-spaceship. Re-entry as a badminton bird. Subsonic glide to landing.

Then look at configuration. Airplanes have flap and gear speeds. Maneuvering speeds. Spaceship Two is a chameleon: an airplane/spaceship/shuttlecock. Combine flight envelope and configuration and you have a whole world of limitations.

The Flight

Our pilots have trained in the fixed-base simulator. The clever helmet G sim has added realism to the profile. They are ready for the high G during the acceleration and pullup after rocket ignition. They are confident in their ability to glide to a landing at Mojave after re-entry.

But the real thing is frightening. It is more than training can prepare you for. It is like going over Niagara Falls in a barrel. The discipline required to stay exactly with the aircraft is huge. It is like learning to fly instruments in IMC and turbulence, believing what the panel says and ignoring what the body says. Only it is magnified by several factors of ten.

Pilots know that their IQ is cut in half the moment they strap in, and in half again under fear or stress. They prepare carefully, rehearsing in their heads so the real thing will not freak them out.

Our co-pilot was overwhelmed. Somewhere in his consciousness was a fear of forgetting his tasks. His mind left the present and moved ahead, rehearsing. He knew that at some point he would have to unlock the tail feathers.

The pilot was hanging on to his awareness for dear life. His field of vision had narrowed to a tiny cone centred on the Flight Director. He didn’t see the co-pilot’s hand reaching for the unlock lever. But he hung on to that thread of awareness and understood the ship was breaking up around him. He managed, though injured, to undo his harness and get free of his seat.

Crew Co-ordination

I am reminded strongly of Air Canada 621 in June 1970. Not in the pilots’ behavior: our Spaceship Two pilots were not arguing. They had a good understanding of the ship and her systems.

No, the echo has more to do with the novelty and design of the systems and configuration. The DC-8-63’s spoiler system was an early one, imperfect in its ergonomic design. The line between arming and deploying was not as sharp as, say, the later system on the DC-9, where up was arm (for landing), and up, back, and up was ground spoiler deployment (for a rejected takeoff).

Spaceship Two’s feather system is an excellent mechanical and aerodynamic design. The lock can hold the feathers in the airplane position even at high Q in a high G powered pullup.

But crew co-ordination and Standard Operating Procedures are just as important. Our pilot did not see the co-pilot’s hand reaching for the unlock lever. There was no communication:

Ready for Feather Unlock.”

Our pilot had no opportunity to say:

Negative. Standby.”


Get your $#%* hand off that f#%# lever!

He just saw the result: the breakup of the ship from aerodynamic forces.

Moving On

Let’s go flying again as soon as we can. But designers, remember: it’s not your ass strapped to the machine. It’s the test pilots’. And they have to understand the implications of any action at any point in the flight envelope.

No, you don’t have to design software to limit when the feathers can be deployed. You have to keep the pilots in the loop, not take them out of it.

But communication is all. And respect for each others’ work. Bernard Zeigler designed the Airbus to be “pilot proof” and “un-stallable”. We know what happened there.

Aware of the past, analyzing accidents, we are wiser. We will respect everyone and expect the best from everyone. We will prioritize and rehearse. We will use all available means to communicate and to share information, hopes, and doubts. There will be Standard Operating Procedures. There will be verbal calls followed to the letter to eliminate misunderstanding. And there will be the joy of success.


Yours sincerely,


Former Captain



Sir Richard, how about – every once in a while – offering a seat on Virgin Galactic to a prominent climate change denier?

The Lost Apprentice

Despite our words of concern for education and training, our workforce is racing toward the cliff of incompetence. Even though innovation and specialization have brought us marvelous new tools, basic skills are vanishing, collateral damage from a squeeze on labour. How? In a word, the apprentice has gone missing.

One company (BMW in South Carolina), experiencing first-hand the dearth of skilled labour, has set up an apprenticeship system. But there is resistance. After all, from skilled labour flows empowered labour and unions. From there a slippery slope leads to socialism and communism. Or so goes political thought.

Yes, we are on a slope, but the destination is not an ‘ism’. It is incompetence.

My trade is flying airplanes, so I’ll stick to what I know. But look around in your own trade or profession and you may see examples of what I’m talking about. Are you passing on your knowledge? Are there barriers to doing so? Will the young people taking up your mantle be able to learn from your mistakes and those of your teachers? Or will they repeat those mistakes? Will they master the new tools that arrive, it seems, every day? Or will they hide behind them, shirking responsibility simply because they are afraid, deep in their gut, that they can’t do the job?

I was lucky. I joined the airline in the right seat of the DC-9 and learned fast. I flew with captains who took their teaching responsibilities seriously. I particularly remember Ike Jones, a great, generous, good-natured Newfoundlander. He was Master to my Apprentice. He taught me and I have never forgotten.

Learn By Doing

Lee Kang Kuk (the Asiana 214 Trainee Captain) was not so lucky. He was an “experienced” pilot, a captain on Airbus aircraft transitioning to the B-777. I put experienced in quotes because although he had thousands of hours of flying, he found the prospect of doing a visual approach “very stressful.” To me this seemed nonsensical until I began to think about it. I thought about the Asiana First Officer who told the investigation he had been flying the A320 for three years and had never landed the airplane manually.

I thought of myself. After retirement from the airline I didn’t fly for 6½ years. I had to get training, pass exams and tests, and retrain myself. This year I have been working with Andrew Boyd, a Class I instructor, trying to get my skills up to where I can get my Class II instructor rating back. It has been a lot of joyful work. But I see even more than I did six months ago that we all learn by doing. Practice, practice, practice. Lee’s airline recommends that its pilots fly their planes manually as little as possible.

Lee didn’t have a chance. He said, “(it is) very difficult to perform a visual approach with a heavy airplane.” Horsefeathers. It is actually harder with a very light airplane. What is difficult (if not impossible) is to fly any maneuver without practice.

History Repeats Itself

Fifty years ago last month an Air Canada DC-8 crashed at Ste.Thérèse, Québec. Last month a Boeing 737 crashed at Kazan, Russia. The DC-8 hit the ground at 55° nose down. The B-737 hit the ground at 75° nose down.

It is unlikely that the young pilots in Russia knew of the DC-8 accident. After all, it happened before they were born. What possible relevance could it have for them?

Well, we know from the evidence so far that they were not prepared for the missed approach they tried to execute. They did make the decision to go around. They did select TOGA (Takeoff/Go Around) mode. The engines did spool up to takeoff thrust. They did retract flap from 30° to 15°.

Then comes the part that is difficult to explain. They disengaged the autopilot but did not fly the airplane.

On its own the B-737, trimmed for approach, will pitch nose-up with both takeoff power and flap retraction. The accident aircraft did just that, achieving 25° nose-up, about 10° higher than the target for this maneuver. Like the DC-8 fifty years before, it was accelerating, at least until it passed the 15° target attitude.

Instrument pilots know that acceleration can produce the sensation of pitching nose-up. That might explain the Ste. Thérèse accident. It surely played an important part at Kazan.

It would have helped if the Russian pilots had been trained to expect the missed approach. Pilots call it being spring-loaded for the Go-Around. It would have helped if they knew of and expected the illusions they were about to experience from the acceleration. But most important by far are the basics, and the foundation of any emergency, indeed of any maneuver, is fly the airplane. Somehow they omitted this crucial step.

How Did We Get Here?

It would be convenient if we could put the finger on one factor, one guilty party. But there are many: deregulation; lazy captains; automation; feeder airlines, merger, and bankruptcy as tools to reduce costs; regulatory impotence. Mark H. Goodrich explores all of these in depth on his website. His unique experience (engineer, pilot, teacher, lawyer, more airplane type ratings than anyone) give him an invaluable perspective. I will summarize from my own experience.

Lazy Captains

In my younger days there were captains who grumbled it was not their duty to teach flying. Their interpretation of the adage Learn, Earn, and Return stopped with the money.


I confess I am a technophile. I love new tools. Flying my Bonanza with its Aspen Primary Flight Display fed by the Garmin GTN650 is a delight. But there are changes. My instrument scan still covers the basic ‘T’, but there are new items in it, and the order is different. From the airplane symbol (attitude) my eye moves an inch to the right to see if there is any pink fuzz on the altitude tape (trend) and an inch and a half down to the aqua diamond (aircraft track). If there is no fuzz and the diamond is on the arrow (desired track), no further action is necessary for the moment. I can look further out, and think for a second or two about other issues.

And here, in front of the MacBook Pro, I can think about the wider implications. How I enjoyed teaching technology on the A320, and how much flying skill I lost in my nine years on the airplane. Yes, I would make sure each of us did an “everything off” visual approach at least once per cycle (trip, 2-4 day sequence of flights). But in the Airbus such an approach is a bit of a parlor trick, chiefly because there is no trim feel.

In the Bonanza I have the best of both worlds. There is no autopilot. You fly it every second you’re airborne, and then some. And the tools I have at hand are better than I had on the Airbus. ForeFlight in my iPad, fed by a tiny GPS and a satellite weather receiver. New capability arrives every few months with a software change. Flying in IMC I no longer have to request permission to leave the ATC frequency, call the FSS, and copy weather with one hand while flying with the other. Instead, my right forefinger taps the iPad over the airport of interest, and the last METAR appears. Another tap brings the forecast or the winds aloft or the airport information. One more tap and the approach I have chosen is drawn over the map in scale. Using two fingers I zoom and pan as I brief for the approach. I am still flying with my left hand.

I love it all. But is it easier than the old way?

Yes and no. In the old days you started with heading and guessed at the track made good. You integrated (looked at change over time) the localizer or VOR needle to see how good your guess was. Now you just glance at the little diamond. That’s a huge improvement. But you have to learn the system, to understand what is going on. The diamond is of no use whatever if you don’t know what it is. And once you do you have to retrain your eye so it knows where to look. So I am solidly with Mark Goodrich when he says that automation requires more pilot training, not less.

Airline Management Strategies

Since deregulation (1978) airline management has focused on reducing costs. Robert Crandall (American Airlines) spoke out against deregulation, but once it was law he led the way, inventing one strategy after another for his airline’s survival. The first of these was hub and spoke. As I young man I flew the DC-9 across Canada on many long, thin, multiple-stop routes. By the time I was captain on the same airplane (1987) hub and spoke had arrived and there were feeder airlines flying turboprops, bringing passengers from the smaller cities into the hubs where the jets flew. This not only made economic sense – it also provided the opportunity to set up a two-tier pay scale and reduce the power of the pilot unions. But there was a casualty: apprenticeship. Young pilots starting out at the feeder had no contact with the old guys (still mostly men, even then) nearing the end of their career. Instead, they flew with captains near their own age whose only concern was getting a job with the main line. Seniority and career trumped teaching and learning. The wisdom of the old farts retired with them.

Then, as Robert Crandall so accurately predicted (in the Senate hearings on Deregulation), the airlines started losing money. There was a frenzy of merger and acquisition, and then bankruptcy. Collateral damage to pilots came in training, salary, and pension.

When I joined the airline training on a new type included two hours at the controls of a real airplane, doing takeoffs and landings. Now a pilot’s first landing on a new type is on a line flight with passengers. That can be interesting. I know because I spent my last eight years as a Line Indoctrination Training Captain. For more about reliance on simulators and airline training in general, see Mark Goodrich’s Simulating Reality and The Training Paradox.

Regulatory Impotence

The FAA recently changed the regulations to require that First Officers on transport aircraft have 1500 hours total time and an Airline Transport Rating. This was largely a response to the Colgan Air crash at Buffalo, NY in February, 2009. There are not enough pilots with these qualifications, and airlines are beginning to cancel flights in the smaller markets such as Grand Forks, ND.

The FAA now requires some Asian airlines to fly GPS approaches instead of visual approaches if the ILS is unserviceable. Note that aircraft “land themselves” only if an ILS is available on the landing runway. Note also that GPS approaches with vertical guidance, although they allow an autopilot to fly the airplane down a glideslope, themselves require training.

So which is better? Apprenticeship, or regulations which say only masters can fly? Training pilots in the fundamentals so they have the confidence they can fly, or regulating the level of automation they must use?


We have come full circle. Laziness interacts with automation, cost cutting with simulator training, loss of apprenticeship with pilot confidence and competence. The emperor has no clothes. But again, why?

The answer, I’m afraid, is simple. We can’t see that the emperor has no clothes because we don’t want to look. Deregulation opened airline financial decisions to the market, which means you and I, the bargain-seeking traveler, push prices down to where flight operations can no longer be safely undertaken. It has taken a generation, but that is where we have arrived.

A Canadian Multi-Crew Licence?

Canada’s Flight Training Reputation

Trying to keep Canadian flight training competitive is a laudable goal. We have a well-deserved reputation for competence, earned the hard way by flying in our terrible weather around our huge unpopulated country with plenty of pressure to get there (sooner or later) because it’s often the only way to get there.

Much training business has come to our shores because of this reputation. The way to keep it coming is to maintain and bolster our good reputation in these trying times.

Loss of Control Accidents

In the last decade the character of airline tragedies has changed completely. Modern aircraft are so reliable that engine and system failures are rare. Aircraft and crew are designed and trained to deal with these failures if they occur. What we are seeing instead are crew failures.

These have come to be called loss of control accidents. The well-known examples are AF447, Colgan Air at Buffalo, and now Asiana 214 at San Francisco. There are many more, including, most recently, Southwest at LaGuardia. These accidents were all caused by crew action (or inaction).

(That includes, by the way, AF447 and Colgan, in which icing played a peripheral role. Flying into known icing is something for which the crew is responsible.)

These accidents all have something in common: pilot incompetence.

I know that sounds harsh, but it must be said. It is an accurate statement. The pilots in these cases may have known their airplane fairly well. They may have memorized their company’s operating manual and their Standard Operating Procedures. But in all cases they did not understand some of the basics of flying an airplane. Colgan and AF447 fell into the ground or sea with the wing stalled, not flying, because the pilots pulled back on the control column and held the back pressure despite warnings and stick shakers. The Asiana crew pulled back to stretch their glide, even though they were far gone on the back side of the drag curve, within a few knots of the stall.

What is missing in these cases is basic flying training. The causes are legion and still being debated, but the fix is simple. In order to get a license, especially a license to fly a large airplane with many paying passengers aboard, a pilot must demonstrate the ability to take off, fly, and land an airplane while keeping it within its safe envelope. He must, in other words, demonstrate competence.

Commercial Reasoning

Canada’s proposed Multi-Crew Licence has this as its rationale: Canadian flight training operators providing commercial training to foreign candidates are unable to compete with foreign operators and risk losing a segment of their industry (my emphasis).

Under various names, the Multi-Crew Licence has had a role in most loss of control accidents.

On the face of it this license seems reasonable. There is always a Captain who has a real license to supervise the others with lesser licenses. But on closer inspection what we are really saying is that a pilot who cannot legally take a friend for a ride can occupy a cockpit seat while the captain is back in First Class (AF447, and the Korean Air flight shot down over the Kamchatka Peninsula). We speak of Crew Concept and Crew Resource Management, but if the only pilot who understands the basics is not on the flight deck, these concepts are moot.

Commercial pressures have brought us, step by innocent-seeming step, to where we are today. Each step seems reasonable, at least at the time. We now routinely fly two-engine airplanes on twelve hour overwater legs. Back in the 1970’s that was unthinkable and illegal. In those days airplanes didn’t land themselves. Now they can, under the right conditions, and some operations manuals even specify autolands as the normal procedure. Pilots who comply are soon incompetent, unable to land the airplane by hand. But in San Francisco last month the glidepath transmitters were shut down on both runway 28’s. Indeed, they had been off since June 1. Manual landings were the only way at KSFO.

The Multi-Crew Licence seems like a logical next step in response to today’s commercial pressures. In reality, it is the next step toward complete incompetence on all flight decks.

Public Assumptions

Airlines have done an excellent job marketing a service that whisks you to another continent at half the speed the sun moves. Even with today’s oil prices, ticket prices are (in today’s dollars) a fraction of what they were in the 1960’s. This is the new normal. Flights are uneventful. Pilots are bus drivers. Airplanes land themselves, don’t they?

An airplane crashes at San Francisco. There must have been something wrong with the engines. Or perhaps the autothrust? A nosegear collapses on landing at LaGuardia? Obviously a mechanical malfunction.

Marketing has succeeded in making aviation seem safe. But even though airplanes have changed since the 1930’s, flying is still a dangerous adventure. The safe arrival of even today’s incredible airplanes still depends on the good judgment of pilots.

We don’t want to think about that, because pilots are people and can make mistakes. But we’ll have to start thinking about it, and acknowledging it, or the crashes will continue.

Feeders, Discount Airlines, and the Elimination of Apprenticeship

Flying is an apprenticeship trade. Like any job worth doing, it takes dedication and a lifetime of learning. I have 45 years and 19,000 hours of experience and I am just beginning to understand how little I know. But I have survived so far and I am very serious about continuing to survive. Dying by your own hand at the controls of an airplane is an absolute no-no for a pilot.

I was lucky. I have had (and still have) many fine teachers. When I was a young airline pilot most captains still took their teaching responsibilities seriously. Today’s young pilot is not assured of the same. Pressure on unions and pilot salaries is being applied by business methods: spawning and dividing feeders and discount airlines foremost among them. The goal is to lower costs, but the (perhaps unintentional) byproduct is the interruption of the contact between old and young pilots and the teaching and learning that allows. (I believe that lowering wages also directly reduces respect for the job and the job satisfaction of the worker, but that is an argument for another time.) The FAA’s response to the Colgan Air crash was to raise the experience requirement for First Officers to 1500 hours, even though it was the captain who was flying and who stalled the airplane and even though the airline had given insufficient training to both pilots on icing and how their aircraft handles ice. I have always understood that pilots are paid to be responsible. I am bemused by today’s response to accidents, where band-aids are liberally applied to wounds which obviously require surgery.


Introducing a Multi-Crew Licence in Canada would be just another band-aid papering over the serious issues facing aviation today. Don’t do it!

Losing Competence Part V: Asiana 214 and the Loss of Control Accidents

Automation and Hubris

Bernard Ziegler designed the Airbus to be pilot-proof. He is a good pilot, and he noticed that many pilots are less skilled than himself. In the interest of safety, he designed an airplane that could not be stalled. But it has been known for thousands of years that hubris is followed by nemesis, that Pride goeth before destruction, and an haughty spirit before a fall. (Proverbs, 16:18)

Hubris is arrogance before the gods. The goddess Nemesis alone can see the fine line between doing the best work you can and believing that your work is somehow superior. Cross the line and she is ruthless, finding your fatal flaw and using it to bring you down.

AF 447 was the fall of the hero. Pilot carelessness led the airplane into a line of thunderstorms. Supercooled water drops overwhelmed the pitot heaters, temporarily removing all three sources of airspeed information. The autopilot dropped off. The flight control computers switched from Normal to Alternate Law. The airplane can be stalled in Alternate Law.

Human or robot, there is always a fatal flaw.

How can we work with imperfection?

Don’t Bow Down

Mankind, when confronted with the complicated or the divine, tends to bow down in worship. This can be hazardous in aviation.

The new automation – glass cockpit, fly by wire, IRS and GPS – together bring a change at least as momentous as going from props to jets in the 1960’s. The aircraft is now such a capable pilot on her own that she almost seems real. We called the Airbus Fifi. Rather than bowing down, we found it was much better to treat her like a person. Dare to know her and maintain a relationship.

In her early days, frustrated pilots would exclaim, “What the #$%* is it doing now?” On a go-around at KLGA the map display would disappear, the airplane sailing off the edge of the world because it had passed the last waypoint in the flight plan. Or on a miss from a visual approach at KMIA the power would suddenly go to idle. Finger trouble with the Autothrust. She was trying to maintain go-around speed.

But the answers are right in front of you on the FMA. (Flight Mode Annunciator, at the top of the Primary Flight Display) We began speaking for her, calling out any change in the FMA, so we all knew what she was doing, or thought she was doing.

And yes, most of the time she was a damn good pilot. Just as we are. Exactly the same, including the occasional lapse. Which is why there is more than one pilot aboard. And which is why the human pilot should never bow down and never step aside. Know her (the automation, Fifi, the airplane) as well as you can. Always monitor her as you would a human pilot and call out anything unusual. And if she’s not doing what she is supposed to, take over. For those interested in pursuing the subject, there is an excellent video, Children of Magenta, of a lecture by an American Airlines training captain. The take-away is the same: if she’s not doing what you want, take over and fly by hand. You don’t have time to figure out what you did wrong with the automation.

Crew Concept – and Not Just Humans

Moving from props to jets, pilots were introduced to many new concepts: mach tuck, dutch roll, deep stall, etc. Perhaps the most important were the long, shallow drag curve and the slow spool-up time of the engines.

Moving into the fly-by-wire era, we have to accept that the airplane (her automation) is part of the crew. Philosophically, it is perhaps a stretch, but in the real world of the cockpit it is a game changer and a life saver. As soon as you accept that the airplane is part of the crew – not a superior or inferior, but an equal – everything starts to make sense. She sounds the cricket as the autopilot drops off. In Alternate Law she says Stall, Stall as the panicked pilot pulls back on the sidestick.

But if you’re on approach below 1000 feet (critical phase of flight) and the descent rate is 1300 feet per minute and the airspeed is below Vapp then someone isn’t doing what needs to be done. (Without a glideslope the airplane will not understand that something is wrong.) The software doesn’t care if the airplane crashes. She is a good pilot but she has absolutely no self-preservation instinct, no will to live. Human pilots have, or they have no place on the flight deck.

Losing Competence Part IV: Asiana 214 and the Loss of Control Accidents

The Drag Curve

Why did I say, yesterday, that saying pull back was exactly the wrong thing to do?


This is a drag curve. Every airplane has one. This looks like the drag curve of a small airplane, say a C-172. The curve for the B-777 is the same, except stretched out in the speed axis, like this:

During descent a jet’s engines are at idle. Descending at perhaps 320 knots, it is near the right-hand end of the curve. Because of the 250-knot speed limit below 10,000 feet, at about 12,000 feet the pilot will pull back on the control column and hold the nose a little higher, slowing the rate of descent and trading kinetic energy (speed) into potential energy (reducing the rate of descent). As he does so he is moving left on the speed axis, toward the low point of the drag curve. Notice that drag is reducing as he slows. This means the rate of descent will decrease.

As he slows further for approach, he moves toward the low point of the curve. As you can see, in a jet the curve at this point is pretty flat, so the transition from one side of the curve to the other is a subtle one, covering, let’s say, from 170 knots to 220 knots. In this range the pilot can pull back, raise the nose, and slow down without much affecting the rate of descent. Subtle though it is, this low point on the curve, the minimum drag speed, is extremely important.

Why? Because as he slows further for final approach, say to 137 knots, he is on what pilots call the back side of the drag curve. (You will more often hear back side of the power curve, but it is the same thing.) Everything changes on the back side of the drag curve. Slower speed requires more power, not less. If you don’t add power, pulling back increases the descent rate. Pilots know that to stretch a glide, you (counterintuitively) have to push, not pull.

In a jet Vapp (final approach speed) is quite a way up the left side of the curve. You can see that as you slow, the drag increases, causing you to slow further. The airplane is “speed unstable”, which means that a small change in speed from turbulence or control input becomes a larger change if left to itself. What the pilot has to do is “catch” the speed as he approaches Vapp by adding power. The pilots of Asiana 214 forgot this step, and continued to slide up the left side of the curve.

There is an old pilot saying: Pull back, you go up. Pull back more, you go down. Now you are closer to understanding why, but you may ask, What happens when you get to the end, where the curve stops? To answer, we have to look at the lift curve.

Instead of drag and speed, we are now graphing lift against Angle Of Attack (AOA, or alpha). (In 1G flight there is an equivalence between AOA and speed, so it’s OK to think of the AOA axis as speed, except in this graph slow is on the right, with larger angles of attack.)

AOA is the angle at which the air meets the wing. What pulling back on the stick or the control column really does is increase the angle of attack. So if the pilot needs to increase lift, he pulls back, moving along the curve to the right. But the wing only “flies” in a narrow range of AOA, from 1 degree or less up to about 16 degrees. Above that the airflow starts to detach from the upper surface of the wing and the wing rapidly loses efficiency. That is called the stall. Now the wing is more like a board. It is still pushing air around, but not nearly as much air. The wing is stalled.

You can see in the graph that as you move to the right, increasing angle of attack, lift increases in a straight line and then suddenly goes over the top like a roller coaster track. Indeed, that’s just what it feels like when an aircraft stalls. Now as you pull back more lift decreases, and the bottom drops out. That’s what happened to Air France 447. When the autopilot kicked off the pilot panicked and pulled. For a brief period they went up. The pilot kept pulling, and for four minutes the aircraft fell, at angles of attack well above the stall, until it hit the sea.

So that’s why the drag curve ends on the left-hand side. The end of the curve is the stall. Asiana 214 was almost there, and that’s why the stick shaker went off. They weren’t stalled yet, but they were within a whisker. They were sitting on top of the roller coaster. And when they pitched up even further in that last second before impact (you can see it clearly the YouTube Video and in this re-enactment) it did nothing to change their flight path. All it did was lower the tail and landing gear.

Now you know why.

Next: Why aren’t pilots better trained and more experienced?

Losing Competence Part III: Asiana 214 and the Loss of Control Accidents

Today’s News

NTSB Chairwoman Deborah Hersman continues to impress. Quoted today in the San Francisco Chronicle, she says: “What I’m telling you is that from 500 feet to 100 feet, there is no mention of speed.” That’s on page A10. On page A12 there are two articles, Do pilots have adequate skills? by airline pilot James F. Atkinson, and When will FAA require alerts? by lawyer Robert A. Clifford. (I am not including links to these articles because you would have to be a Chronicle subscriber to read them.)

Atkinson rightly addresses basic flying skills and airmanship, pointing out that today’s automated systems actually undermine skills. Clifford calls for mandatory low airspeed alerts, missing the point that this would make the pilots even dumber. (It is worth analyzing the terrific save by the captain of the Quantas A380 that had the uncontained engine failure. There was so much damage and so many (hundreds) of ECAM alerts that he finally said, Stop ECAM. Lets go backwards and just see what we’ve got left. That critical decision was the key to saving the airplane.)

Analysis of the Last Minute

At 1000 feet, 54 seconds before impact, someone says, Sink Rate. The throttles are at idle. The training captain tells the trainee, who is flying the airplane, to pull back. This is exactly the wrong thing to do. We will explore why that is so in greater detail in another post, but for now we’ll say that they were at idle, on the back side of the drag curve, so total drag is increasing with angle of attack. As any pilot knows (see Stick and Rudder, 1944), instead of correcting the sink rate, pulling back on the control column actually increases the rate of descent and causes the speed to decay faster and faster.

At 200 feet, 18 seconds before impact, the training captain realizes they are too slow and moves to engage the autothrottle. After saying pull back he does nothing for 36 seconds while the airplane descends at over 1300 feet per minute. The target for any approach is 700 feet per minute. The engines are still at idle. They are well below approach speed.

Could they have done a missed approach that point? I will leave that for formal analysis, and point out only that these aircraft are designed to be able to do a baulked landing from any point before touchdown, but only if the engines are already spooled up and the speed is at approach speed, about 1.3 times the stall speed.

Ten seconds later, it was already game over. Perhaps the autothrottle had been armed, but most likely it had not actually been engaged, so thrust lever movement happened only now, at about 100 feet and 8 seconds before impact. And it will be another 5-7 seconds before the engines develop any useful power. So we see the slowest speed at 3 seconds before impact, at perhaps 40 feet above the water. This is where the passengers behind the wings see the plumes of water as the engines start to spool up. Meanwhile the stick shaker is going, indicating impending stall. Despite pulling back and belatedly adding power, they are still descending at 750 feet per minute, by my calculations. This is the first time anyone in the cockpit calls for a go-around. Of course it is too late. Way too late.

What the training captain should have done, back at 1000 feet and 54 seconds, is push the power up. Manually. With the thrust levers. The problem is that he would probably not been able to stabilize the approach from the idle thrust, slow (148 knots) and 1300 feet per minute sink rate descent. It would have been a neat parlor trick if he could have put on go-around thrust, pushed to counter the nose-up moment of the added thrust and bring the speed back up to bug (the approach speed), and then quickly brought the power back to approach power and held the speed. At 1000 feet he had room to fart around a bit, at least in theory. But airline Standard Operating Procedures (SOP’s), his own airline’s included, say that the approach must be stabilized by 1000 feet and remain stabilized, or else a go-around shall be performed.

So what the training captain really should have done is to say:

I have control.


That’s it. That’s the last time the training captain, the Pilot in Command, had any say in the matter. That’s when the pilots, the crew, gave up having any influence over the outcome.

It is sad, but true. It must be said. The pilots were incompetent.

Next: aerodynamics they should have understood . . .

Losing Competence Part II: Asiana 214 and the Loss of Control Accidents

News and Public Relations

Deborah Hersman, The NTSB’s Chairwoman, has taken some flak in the last few days. But from my perspective, she is one of the few in responsible positions who are looking good.

First a minor annoyance: on Saturday and Sunday news outlets kept repeating a young witness’s observation that Asiana 214 came in “low and fast.” Many immediately available facts, including where the aircraft came to rest, made it a slam dunk that the aircraft was, instead, flying way too slowly.

Then on Monday the Korean Government announced they would be “inspecting all Korean B-777’s”. On Tuesday and Wednesday various pilot unions called for Ms. Hersman’s head, saying presumptions of pilot error were speculative and premature.

Please. I am used to the power players grandstanding their interests, but this is amateur hour. There is only so much ignorance out there.

The Last Thirty Seconds

Now let’s get back to what we know. The cockpit cleared the breakwater nicely. The main landing gear and the tail did not. The speed at impact was 106 knots, within a knot or two of the stall speed. (The approach speed should have been 137 kt.) One and a half seconds before impact, engine power increased. Passengers in seats just behind the wing could see spumes of water being thrown up. At four seconds before impact the stick shaker operated, signifying an impending stall. At seven seconds someone is heard on the voice recorder calling for an increase in speed. In his interview the training captain said he went to push the throttles forward but the trainee already had. (Notice at least 5 1/2 seconds elapse between advancing the throttles and the increase in power. Seven seconds spool-up from idle is typical for a fanjet engine.) At 500 feet altitude the training captain became aware that they were too low (the PAPI lights were red over red) and he asks the trainee to pull back. The training captain also notices they are not aligned with the runway. Ms. Hersman says at that point they knew they were low and they were making lateral corrections to line up on the centerline of the runway.

These are the bare facts.

Flight Preparation in Seoul

Now let’s go back twelve hours or so to the pilots’ briefing. The dispatcher has already produced the flight plan with its route as close as possible to the minimum time track. The weather is good over the Pacific and at destination. Most likely they have fuel for a close alternate, such as Sacramento. It looks easy. But somewhere in the data available to the dispatcher and pilots are these two lines:

ISFO 06/005 SFO NAV ILS RWY 28L GP OTS WEF 1306011400-1308222359

ISFO 06/004 SFO NAV ILS RWY 28R GP OTS WEF 1306011400-1308222359

San Francisco airport (KSFO) always lands on runways 28L and 28R unless a winter storm blows through. With today’s light winds and good visibility it is a near certainty that these runways will be in use. But decoding the two lines above (they are called NOTAMS, for Notices To AirMen) we find that the GlidePath (GP) is OuT of Service (OTS) for both runways. The When in EFfect (WEF) is from June 1, 2013 to August 22, 2013 at midnight. This is important because the aircraft cannot fly these approaches on autopilot in the way the pilots are used to.

Here is where we have to move into sensitive territory. (There will be more of these before we’re done.) At the end of the article Terror on Jet, in The New York Times on Monday, July 8, we find these lines:

Some experts said that pilots often have little opportunity to practice landings without the aid of such technology . . .

Still, given that the weather was ideal and the guide lights (PAPI, or Precision Approach Path Indicator) were on, making a visual landing should not have been difficult for most commercial pilots . . .

on a difficulty scale of 1 to 10, this was a 2 or 3 at the most . . .

Pilot Judgment

A pilot’s most important skill is his judgment. (see my Developing Pilot Judgment) He must look at the tasks and maneuvers ahead and ask two questions: Can the airplane do it? and Can I do it?

The former is mostly hard data in the Aircraft Flight Manual Limitations section, but it is also practical knowledge of what the aircraft’s systems can and can’t do and an understanding of the feedback systems that tell the pilot if the job is being done. (A good example is the AutoThrottle).

The latter question is the more important of the two: Can I do it? The only way to answer is through experience, and it is not measured in flight hours.

Training: have I been trained in this maneuver?

Practice: have I practiced it on my own? What were the results?

Recency: have I done one in the last 30 days? 90 days?

When Asiana’s pilots were preparing for the flight in Seoul, the two NOTAM lines about the glidepaths on 28L and 28R should have triggered a dialogue:

We’re going to have to do an everything-off visual approach in KSFO. Has any of us been trained for this? Who has practiced one in the last year? Which of us has done one in the last 30 days? 90 days?”

I’d be willing to bet (I’ll back this up in future installments) that none of the four pilots had flown a visual approach in the last 90 days. In that case, pilots with sound judgment would never have attempted the visual approach to 28L in KSFO. They would have diverted to Sacramento where there were long runways with functioning ILS systems.

Next: what else they did wrong . . .

Losing Competence: Asiana 214 and the “Loss Of Control” Accidents


Asiana 214 is in my dreams. All day her last two minutes of manually controlled flight replay in my head. Searching for a cause does not distress me. The pilots were clearly incompetent. But how did we get to this pretty pass? My overwhelming sense that that’s where we are distresses me greatly.

For the last few years disasters like this one have come to be known as “Loss Of Control” accidents. It’s a catchy label, but it doesn’t get to the heart of the matter. The pilots of these airplanes – I’m thinking of Colgan Air at Buffalo, Air France 447, and Asiana 214, but there are many more – these pilots fundamentally did not understand what was happening, so they were unable to do their jobs.

How has this come about? And how can it be fixed?

At this point I don’t know if this is going to be a blog, a series of blogs, or a book. I know only that I must explain the technical issues, explore the commercial and financial forces as they interact with my trade, and try to map a path through this crisis.

Flying has grown into a huge industry. The era of limitless supplies of hugely keen, military-trained pilots is over. Worldwide, there will be a demand for over 600,000 pilots in the next decade. Where will they come from?

I love flying. Most of my working life has been in airplanes, flying and teaching. I see flying as a living link between the sailors of the past from Magellan to Jack Aubry and the space explorers of the future like Jim Kirk and Jean-Luc Picard.

Sailing, navigating, flying: these have always been apprenticeship trades. You learn the theory, but you also learn the practical, the hands on. You practice. You repeat. You get sharper. Gradually you come to understand what you have to do to stay sharp, to stay competent. (Or, in airline-speak, to maintain your compentency.) Then you pass your knowledge on.

Somehow this process has broken down. There is no single villain, no smoking gun. Instead there are many villains conspiring unwittingly, starting with you and me, airline customers, frequent flyers, looking for a painless flight and, most of all, for a deal.

Training a pilot, says Transport Canada (in the Flight Instructor’s Guide), must be done right the first time. The pilot can’t see his airplane moving through the air, because most of the time air is invisible. Instead he must imagine the air flowing over his wings and through his engines, and imagine the air pushing on his slipping or skidding fuselage and fin. Above all he must imagine the angle the airflow makes meeting his wings and how this critical parameter is related to lift and airspeed. He must viscerally feel the drag curve as he controls this angle, the Angle of Attack, as he slows his airplane for approach and landing. He must understand at all times where he is on that curve and what the consequences are. He must know how to fly.

It is not as easy as 1, 2, 3. It requires work and practice, and most of all it requires imagination.

Pilots don’t call it that, of course. That sounds too much like an artist, an inventor, or a writer. Pilots refer to it as Situational Awareness. It’s what was missing in all of these “Loss of Control” accidents. But why? And how can we fix it?

More to come . . .