The approach to both runways at San Francisco International Airport (KSFO).

The Failure of Crew Resource Management (CRM) – Part III

Part III: Asiana Airlines Flight 214

This is Part III in a series of blog posts on “The Failure of Crew Resource Management.” Click here to read Part II. 

NB: The following post is adapted from a script for a TED-style video talk that was submitted in Dr. Adam M. Grant’s Management 238: Organizational Behavior course (Fall 2014). Special thanks to Harikrishnan Joy, who was my teammate in research and execution of this project. We conducted an analysis of the Asiana Airlines Flight 214 crash in 2013 through the lens of the Hackman and Ginnett research presented in Part II. In order to paint a picture of what happened in the cockpit on that day, we listened to the tapes stored by the plane’s cockpit voice recorder (CVR). We later found the official NTSB report and CVR transcript and acknowledge several omissions in our own transcript that were picked up in the NTSB’s detailed audio analysis – so please forgive what may at times appear to be a dramatization from the original events.

July 6, 2013. Asiana Airlines Flight 214 is on final approach into San Francisco International Airport. The hot California sun beats down on the Boeing 777’s aluminum exterior. It seems like a pilot’s perfect day – light wind, no precipitation, maximum visibility, no wind shear. At the controls is Captain Lee Kang Guk, a 45-year-old with 9,793 flight hours under his belt and completing his required Initial Operating Experience training. It is Captain Kang Guk’s first time landing the Boeing 777 aircraft at San Francisco International, an airport notorious for its seaside runway requiring an approach pattern over the Bay. It is also his first time flying with the gentleman in the right seat, Captain Lee Jung Min, a 48-year-old Asiana veteran with 12,387 flight hours. As the highest ranking pilot on board, Jung Min has the title of “Pilot in Command,” assuming responsibility for the safety of the 291 passengers and 16 crew on board. Although this senior position would have generally placed him in the left seat of the cockpit, on this flight Captain Jung Min also serves as a “checkride instructor” tasked with evaluating Captain Kang Guk’s performance. Behind both Captains is their subordinate First Officer, Bong Dong-Won, 41 years old, and seated behind the cockpit in the cabin is yet another Captain, Lee Jong-Joo, 52 years old.

As the plane passes through 1,700 feet and three miles out from the airport, Captain Jung Min notes that the airspeed is too high. This leads Captain Kang Guk to disengage the plane’s autopilot and set the engine thrust to idle, which causes the plane’s onboard computers to switch the automatic throttle into a “Hold” setting. Although both pilots expect this, Captain Kang Guk appears to misunderstand this feature of the autothrottle, believing that it would hold the plane’s airspeed at a desired level, when in fact the plane was now responding purely to his controls. As a result, the plane begins to sink below its intended glide slope to the runway. About two miles out from the runway, First Officer Bong Dong-Won alerts both captains to the unusually fast descent, by calling out “Sink Rate, sir”.

No response.

“Sink Rate, sir” he repeats.

No response.

One final time: “Sink Rate.”

No response.

Finally, at around 1.4 miles from the runway, Captain Kang Guk responds to this warning and begins pulling the plane’s nose up – and with the engines still at idle, this action causes the plane to slow even more. At eleven seconds before impact, the airspeed warning in the cockpit begins to ring. Four seconds later, Captain Jung Min appears to take control of the aircraft, pushing the thrust levers up to maximum. Air Traffic Control, noticing the plane’s unusually low altitude, calls out: “Asiana 214, go around.”

It’s too late.

At 11:27am and 50 seconds, Asiana 214 slams into the seawall at the end of the runway. The plane tears apart, making a 330-degree spin before smashing into the ground and catching on fire. Three passengers, Chinese students on their way to summer camp, are killed.

Crew Resource Management, or CRM, is a set of training procedures that focuses on decision making, leadership, and communication between pilots in the cockpit. The CRM concept was developed in response to the United Airlines Flight 173 crash in 1978, where two pilots failed to work effectively together in troubleshooting a mechanical problem. In a 1990 study on pilot interpersonal behavior, Robert Ginnett found “repeated evidence of poor crew work resulting in errors, accidents and incidents…” Following the crash, United Airlines revamped its crew training program, and CRM has since become the global standard for airlines. A 2014 study by Ford, Henderson and O’Hare in the Journal of Safety Research claims that CRM increases safety by reducing communication barriers in the cockpit and decreasing the traditionally hierarchical and authoritarian relationship between senior and junior pilots. This is evidenced by several pilots’ first-hand accounts of various accidents. As Captain Al Haynes (of the UA232 Sioux City incident) states: “…we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced, any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn’t used [CRM], if we had not let everybody put their input in, it’s a cinch we wouldn’t have made it.”

What happened on Asiana 214 is a clear example of the failure of CRM. As pilot in command, Captain Jung Min failed to take any overriding action or make any commanding statement until it was too late. Caught up in an unbiased evaluation of Kang Guk, Jung Min may have been reluctant to intervene. Even more shockingly, both captains neglected the first officer’s repeated warnings. Kang Guk later said that it was “very hard” to make the decision to abort the landing, given the deference shown to superiors in Korean culture. By misinterpreting Jung Min’s silence as a sign of approval from a senior pilot, Kang Guk failed to act decisively even when he felt uncomfortable with the landing. And perhaps there was an element of face-saving – he didn’t want to look weak in the eyes of his superior by heeding a junior’s warnings. Furthermore, First Officer Dong Won may have been reluctant to speak up in the face of two senior pilots. His first two warnings contained the respectful suffix “Sir.” His third warning did not and was more authoritative in nature. Unfortunately, this came too late.

In an interview called “Why Teams Don’t Work”, J. Richard Hackman claims that many teams consistently underperform their potential. From his research, small teams who stay together for a long time perform the best. In the context of flight crews, the NTSB found that 73% of incidents occurred on a crew’s first day of flying together, before having the chance to learn how best to operate as a team. A NASA study found that fatigued crews who had a history of working together actually made about half as many errors as crews composed of rested pilots who had not flown together before. Hackman points out that while crews are cycled in and out due to financial and efficiency constraints, this often comes at the expense of team effectiveness. Decreased communication and less support break down positive team dynamics. Hackman found that the Strategic Air Command, a Cold War nuclear bomb squad, had teams that trained together and performed better than any other flight crew ever studied.

In Hackman’s eyes, there are 5 things for building an effective team. Teams need to have:

1) Realness

2) A Compelling Direction

3) Enabling Structures

4) A Supportive Organization

5) Expert Coaching

In addition, the use of a deviant, such as junior pilots speaking up, helps propel an effective team.

Moving forward, we suggest altering the process by which CRM is implemented. The breakdown of teamwork and communication between pilots can be disastrous. Even with CRM implemented, there have been many examples of improper decisions being made due to factors such as cultural norms. It’s critical for CRM training programs to explicitly acknowledge these teamwork impediments through the lens of previous failures. By using Hackman’s principles, we hope to see safety standards greatly improved and CRM failures reduced.

On Saturday, March 8, 2014, Malaysian Airlines Flight 370 disappeared while flying from Kuala Lumpur to Beijing. Although we do not know yet what happened to the plane, the dynamics in the cockpit that day will certainly be interesting to analyze in this organizational behavior context. Teamwork takes more than simply having a group of people; in the case of airlines and especially crises, a successful team needs to train together, stay together, and deal with the situation together.



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