Asiana Hava Yollarına Ait bir Boeing 777 uçağı kazası… ANİMASYONLU

HER OLAYDAN OLDUGU GİBİ BUNDAN DA ALACAGIMIZ ÇOK DERS VAR.
1. UÇAKLAR MODERNLEŞTİKÇE DEVAMLI OTOMASYONU KULLANMAMIZ SONUCU; UFAK BİR OTOMASYON PROBLEMİNDE ÇIĞ GİBİ BÜYÜYEN SORUNLAR YUMAGI İÇERİSİNDE KALABİLİYORUZ. ILS Glide Path’in ARIZALI OLMASI SONUCU GÖREREK YAKLAŞMADA YAŞANAN SORUN TAMDA BUNU İSPATLIYOR. NORMAL SÜZÜLÜŞ AÇISININ ALTINA İNİLİYOR, UÇAĞIN ALÇAK KALDIĞI GÖRÜLÜNCE LÖVYE GERİ ÇEKİLEREK UÇAĞIN ALÇALMASI DURDURULMAK İSTENİYOR. BUNU YAPAN PİLOT, GAZ AÇMALI Kİ BU ESNADA DÜŞECEK SÜRATİN DÜŞMESİNİ ENGELLESİN. BUNU OTAMATİK GAZ KOLU YAPACAKMIŞ GİBİ DÜŞÜNÜYOR. YİNE OTOMASYONA BIRAKMA ALIŞKANLIĞI. BU ESNADA ÇARPMAYA 7 SANİYE KALA DİĞER KAPTANDAN İKAZ GELİYOR, ANINDA TEPKİ VERİLSE DURUM NORMALE DÖNECEK. ÇARPMADAN 1.5 SANİYE ÖNCE GAZ AÇMA VE PAS GEÇME İŞLEMİ BAŞLATILIYOR. ANCAK ÇOK GEÇ. UÇAK BURNU 15 derece CİVARINDA YUKARIDA VE UÇAĞIN KUYRUGU DENİZLE PİSTİN BİRLEŞME YERİNE VURUYOR. BİR SANİYE ÖNCE GAZ KOLU İLERİ AÇILSA UÇAK SETE DEĞİL PİST OVERRUN KISMINA TEMAS EDECEK VE KÜÇÜK HASARLA OLAY ATLATILABİLECEKTİ.
2. OTOMASYONA BU KADAR ÇOK ALIŞTIK O HALDE; MÜMKÜN OLDUĞUNCA OTOMASYONU KULLANMALIYIZ. ÖZELLİKLE BÖYLESİ YENİ UÇACAĞIMIZ BİR UÇAK VE MEYDANDA OTOMASYONU DEVAMLI KULLANMALIYIZ. UÇAĞA İYİCE ALIŞTIKTAN SONRA VE İNİLECEK MEYDANI İYİ BİLİYORSAK O ZAMAN MANUEL UÇABİLİRİZ. BUNU YAPARKEN DİĞER PİLOTA DİKKATLİ OLMASINI VE HATALARI ANINDA İKAZ ETMESİNİ SÖYLEMELİYİZ.
28 L PİSTİNİN ILS G/P ARIZASI VARSA GPS ALÇALMASI YAPILABİLİRDİ. KULE AMERİKADA GÖREREK İNİŞ SERBEST DER ANCAK PİLOT YAKLAŞMASINDA ILS, VOR, GPS GİBİ ALETLERDEN YARARLANARAK İNİŞİNİ YAPABİLİR BUNDA BİR ENGEL YOKTUR.
3. UÇUŞ İKİ PİLOTLA YAPILIR. HER İKİ PİLOT BİRBİRİNİ KONTROL ETMEK İÇİN ORADADIR. KISACA KONTROL GÜVENE MANİ DEĞİLDİR. ÖZELLİKLE UÇUŞA YENİ BAŞLAMIŞ EĞİTİMDEKİ BİR PİLOTUN DEVAMLI KONTROLDA TUTULMASI VE HATASININ ANINDA İKAZ EDİLMESİ GEREKİRDİ. DİĞER TARAFTAN UÇAN PİLOT ZATEN DIŞARI BAKIYOR, UÇMAYAN PİLOTUN GÖZÜ SÜREKLİ UÇUŞ ALETLERİNDE OLMAK ZORUNDA ONUN DIŞARI BAKMA GİBİ BİR ALIŞKANLIGI OLMAMALI. 7 saniye ÖNCE SÜRAT İKZI YAPAN KAPTANIN PAS GEÇELİM İKAZI YAPMASI GEREKİRDİ.
5. 10 saat 30 dakika GİBİ UZUN UÇUŞ SONUNDA HEMDE TAM MANUEL OLARAK UÇMAK BÜYÜK BİR RİSKTİR. EĞİTİMDEKİ PİLOT ARKADAŞIMIZ BELKİDE KISA MESAFE UÇAN KÜÇÜK BİR UÇAKTAN GELMİŞTİR. YANİ UZUN UÇMA VE SONUNDA İNİŞ YAPMA GİBİ BİR ALIŞKANLIĞI BİR ANTREMANI DA YOKTUR. DİĞER TARAFTAN İLK OLARAK GİTİĞİ BİR MEYDANA GİTME VE İNİŞ YAPACAK OLMA HEYECANINI YAŞAYAN PİLOT İSTİRAHATINI DA İYİ YAPAMAMIŞTIR. ÖGRETMEN VEYA SORUMLU KAPTAN PİLOTUN BUNU DA DÜŞÜNMESİ GEREKİR.
6. UZUN UÇUŞ YORGUNLUĞU, ŞİRKETLER VE PİLOTLAR BU KONU ÜZERİNDE ÇOK DÜŞÜNMELİ NE YAPILMALI, ETKİSİ NASIL AZALTILIR, DİNLENME SÜRELERİ ÇOK ÖNEMLİ BİR KONU. UÇUŞA GİDEN PİLOT KENDİNİ İYİ İSTİRAHAT ETTİRMELİ, ŞİRKETLER YETERLİ DİNLENME ZAMANI VERMELİDİR.
7. SON YAKLAŞMA STALL VEYA PERDÖVİTESİ ÇOK ÖNEMLİ, BUNUNLA İLGİLİ SİMÜLATÖR EĞİTİMLERİ MUTLAKA YAPILMALI.
BU KAZA BİZE ŞUNU GÖSTERDİ, TIPKI DİĞER HAVACILIK KAZALARI GİBİ GENELLİKLE KAZALARIN NEDENİ ÇOK KÜÇÜKTÜR. BU KAZANIN NEDENİ DE ÇOK KÜÇÜKTÜR. UFACIK BİR MÜDAHALE BU KAZAYI ÖNLEYEBİLİRDİ. EMNİYETLİ UÇUŞLAR DİLERİM.

YORUMLAR İÇİN TEŞEKKÜRLER. ABD’DE 10-15 NM DE ÖNÜNÜZDE UÇAK VARKEN CLEAR TO VISUAL APPROACH AND CLEAR TO LAND TALİMATLARINI DUYABİLİRİZ. NOTAMLARDA ARIZA BELİRTİLMEMİŞSE SİSTEMLER FAALDİR VE ÇALIŞIYOR KABUL EDİLİR. YUKARIDAKİ YAZIMDA ÖZELLİKLE YAPILMASINI TAVSİYE ETTİĞİM GNSS APPROACH’DIR YANİ GENELDE BİZ BUNA GPS APPROACH DİYORUZ. GNSS APPROACH’DA BİLİNDİĞİ GİBİ SİSTEMİN DOĞRULUGU TAMAMEN UÇAK İÇERİSİNDEKİ SİSTEMLERDEN KONTROL EDERİZ. KULE VEYA NOTAMA İHTİYAÇ DUYMADAN BU YAKLAŞMAYI YAPABİLİRİZ. BİZE, ILS KADAR HASSAS VE GÜZEL BİR YAKLAŞMA İMKANI VERİR.
YORGUN VE UZUN UÇUŞ SONUNDA BİZLER GENELLİKLE 500 FEET CİVARINDA OTOPİLOTTAN ÇIKARIZ. OTOTRUST DEVREDE İNİŞE DEVAM EDERİZ. HATA YAPMA OLASILIĞINI AZALTMANIN YOLU OTOMASYONLA DEVAM EDERKEN KONTROLE DAHA FAZLA ZAMAN AYIRMAYI SAĞLAMAKTIR. BUNU ÖZELLİKLE BİR ARIZA, ABNORMAL DURUMDA YAPARIZ.
ŞUNU ÖZELLİKLE BELİRTMELİYİM. CRM ÇOK ÖNEMLİ. YANIMIZDAKİ PİLOT ARKADAŞIMIZLA YÜZLERCE DEFA UÇMUŞ OLABİLİRİZ, ÇOK İYİ BİR PİLOT OLDUĞUNU BİLİYORUZDUR. ANCAK HİÇBİR ZAMAN CRM’İ BIRAKMAMALIYIZ. YANİ BİZ KENDİ GÖREVİMİZİ KONTROLU YAPMAYA VE LİMİT DIŞI DURUMLARI ANINDA İKAZ ETMELİYİZ. BU İKAZLARDAN KİMSE ALINMAZ.
BİR BAŞKA HATA UÇMAYANIN KENDİ İŞİNİ YANİ UÇUŞ ALETLERİNİ KONTROL ETME GÖREVİNİ BIRAKIP UÇAN KENDİSİ GİBİ DIŞARIYA BAKMASI VEYA BAŞKA BİRŞEYLE İLGİLENMESİ. BUNU ÖZELLİKLE DÜŞÜK GÖRÜŞTE YAPILAN CAT II – III İNİŞLERDE GÖRÜYORUZ. UÇMAYAN PİLOT TA SİZİNLE BİRLİKTE PİSTİ GÖRMEYE ÇALIŞIYORDUR. BU ESNADA UÇAK KENDİ BAŞINA KALMIŞTIR.
EMNİYETLİ UÇUŞLAR DİLERİM

ENGİN KAPTANIM, YAZILARINIZI BÜYÜK BİR KEYFLE OKUYORUM. ELLERİNİZE SAĞLIK, BİLİMİ TÜRK SİVİL HAVACILIĞINA KAZANDIRMA YOLUNDA ÖNEMLİ BİR GÖREV YAPIYORSUNUZ. EMEKLERİNİZİN BOŞA GİTMEYEĞİNİ BİLMENİZİ İSTERİM.
CAT II-III YAKLAŞMALARINDA UYGULANAN BİR YÖNTEMİ SİZİNLE PAYLAŞMAK İSTERİM. ALÇALMAYI HUNDRED ABOVE İKAZINA KADAR FİRST OFFECER YAPIYOR BURADA CAPTAN DIŞARI BAKIYOR PİSTİ GÖRDÜYSE I HAVE CONTROL DİYEREK VE GAZ KOLUNU TUTARAK KONTROLÜ ALIYOR, FİRST OFFİCER İÇERİ YANİ UÇUŞ ALETLERİNE BAKMAYA VE CALL OUT’ LARA DEVAM EDİYOR.
ŞAYET MİNİMUMDA CAPTAN KONTROLÜ ALMADIYSA YANİ PİST GÖRÜLMEDİYSE FİRST OFFİCER TOGA YAPIP PAS GEÇME İŞLEMİNİ YAPIYOR. YANİ FİRST OFFİCER HİÇ BİR ZAMAN GÖZÜNÜ UÇUŞ ALETLERİNDEN AYIRMIYOR.
BEN DE 13 SENE B737’DE UÇTUM HEP A/T DAN ÇIKIP İNİŞ YAPTIK. AMA AİRBUSTA ÇIKMIYORUZ. ZANNEDERİM SUN EXPRESS A/T DAN ÇIKMIYOR SPEED MODA GEÇİYOR GAZ KOLU ARM DA YAKLAŞIYOR. SÜRAT DÜŞÜNCE A/T DEVREYE GİREREK SÜRATİN DÜŞMESİ ENGELLENİYOR. BUDA BİR YÖNTEM TABİ.
SAYGILAR SELAMLAR EMNİYETLİ UÇUŞLAR DİLERİM.

CRM VE THY KONUSUNDA İÇİNDE YAŞADIĞIM İÇİN ÇOK İYİ GÖZLEMLİYORUM. SÖYLEDİKLERİNİZE KATILIYORUM. 15 SENE ÖNCEYLE MUKAYESE EDİNCE ÇOK MESAFE KATEDİLDİ. ARTIK İKİNCİ PİLOT VEYA KAPTAN İZLEME İKAZ VE MÜDAHALE KONULARINDA DAHA CESUR DAVRANIYORLAR. BU DOĞRU. BUNA ŞİRKETİN SERİ OLARAK BÜYÜMESİ DE KATKI SAĞLADI. SÜREKLİ YENİ BİRİLERİYLE UÇMANIN VERDİĞİ TEDİRĞİNLİK SONUCU DİKKAT ETME MECBURİYETİ HİSSEDİLMEYE BAŞLANDI. BU TABİ HEM KAPTAN HEM FİRST OFİCER İÇİN GEÇERLİ. DİĞER BİR NEDEN KONU EĞİTİMLERDE UÇUŞ OKULLARINDA DA İŞLENMEYE BAŞLANDI. AYRICA YURT DIŞI EĞİTİMİN VE YABANCI KAPTANLARIN DA CRM’E KATKISI UNUTULMAMALI.
CRM İÇİN EN TEMEL KONU TABİ Kİ BİLGİ, AKSİ HALDE CAHİL CESARETİNİ TARTIŞIRIZ. BU BİZİ ESKİSİNDEN DAHA KÖTÜ NOKTALARA GETİRİR. YAPILAN BİR UYGULAMAYI BİLMEYEN VEYA KRİTİK BİR NOKTADA YANLIŞ BİR BİLGİ İLE SENİ PROBLEME SOKACAK BİR CALL OUT HİÇ OLMASIN DAHA İYİ.
NTSB AÇIKLAMALARINI BEN DE İZLİYORUM. BİR HANFENDİ OLAYIN İLK DAKİKASINDAN İTİBAREN ELDE EDİLEN NET TEKNİK BİLGİLERİ YORUMSUZ VE SONUCU KİMİ ZORA SOKABİLİR ENDİŞESİ OLMADA AÇIKLIYOR. GEREK ABD GEREKSE KORE DEVLET MAKAMLARI VEYA ŞİRKET MEYDAN GİBİ OTORİTELER HİÇ YORUM YAPMIYORLAR. NTSB’ Yİ YALANLAMA AŞAĞILAMA GİBİ BİR AÇIKLAMA DUYMUYORUZ.
KONU UZMANINA BIRAKILMIŞ NTSB’DE İŞİNİ İYİ BİLİYOR. DÜRÜSTCE OLAYI YÖNETİYOR.
AİR ASİANA OLAYI ÇÖZÜLMESİ YÖNÜYLE ZOR BİR OLAY OLMADIĞINDAN YÖNETİLMESİ KOLAY. KARMAŞIK OLAYLARDA NTSB’DE OLAYI BU KADAR KISA ZAMANDA VE NET OLARAK AÇIKLAYAMIYOR.
BİZİM DE İYİ BİR EKİBİMİZ VARDIR İNŞALLAH. BU EKİP DÜNYADA MEYDANA GELEN HER OLAYI HEM İNCELİYOR HEMDE YORUMLUYORDUR VE BÖYLECE ANTREMANLARINI YAPIYORLARDIR DUYGUSUNU VE UMUDUNU TAŞIMAK İSTİYORUM.
ÇÜNKÜ İSPARTA KAZASI VE SONUCU BANA BU UMUDU VERMİYOR. YENİLENDİKLERİNİ KABUL ETMEK İSTİYORUM.
BUNUN BELİRTİSİ OLARAK DA GENEL TÜRK HAVA SAHASINDAKİ UÇUŞLAR VE RİSKLİ ALANLARI BELİRLEMELERİNİ BUNUNLA İLGİLİ ŞİRKETLERLE İŞBİRLİĞİ İÇERİSİNDE YAKIN ÇALIŞMA YAPTIKLARINI ÜMİT ETMEK VE GÖRMEK İSTİYORUM.
EMNİYETLİ UÇUŞLAR DİLERİM.

Mic Dundee from pprune wrote:Low-down on Korean pilots, (From a friend).
After I retired from UAL as a Standards Captain on the -400, I got a job as a simulator instructor working for Alteon (a Boeing subsidiary) at Asiana. When I first got there, I was shocked and surprised by the lack of basic piloting skills shown by most of the pilots. It is not a normal situation with normal progression from new hire, right seat, left seat taking a decade or two. One big difference is that ex-Military pilots are given super-seniority and progress to the left seat much faster. Compared to the US, they also upgrade fairly rapidly because of the phenomenal growth by all Asian air carriers. By the way, after about six months at Asiana, I was moved over to KAL and found them to be identical. The only difference was the color of the uniforms and airplanes. I worked in Korea for 5 long years and although I found most of the people to be very pleasant, it is a minefield of a work environment … for them and for us expats.
One of the first things I learned was that the pilots kept a web-site and reported on every training session. I dont think this was officially sanctioned by the company, but after one or two simulator periods, a database was building on me (and everyone else) that told them exactly how I ran the sessions, what to expect on checks, and what to look out for. For example; I used to open an aft cargo door at 100 knots to get them to initiate an RTO and I would brief them on it during the briefing. This was on the B-737 NG and many of the captains were coming off the 777 or B744 and they were used to the Master Caution System being inhibited at 80 kts. Well, for the first few days after I started that, EVERYONE rejected the takeoff. Then, all of a sudden they all got it; and continued the takeoff (in accordance with their manuals). The word had gotten out. I figured it was an overall PLUS for the training program.
We expat instructors were forced upon them after the amount of fatal accidents (most of the them totally avoidable) over a decade began to be noticed by the outside world. They were basically given an ultimatum by the FAA, Transport Canada, and the EU to totally rebuild and rethink their training program or face being banned from the skies all over the world. They hired Boeing and Airbus to staff the training centers. KAL has one center and Asiana has another. When I was there (2003-200 we had about 60 expats conducting training KAL and about 40 at Asiana. Most instructors were from the USA, Canada, Australia, or New Zealand with a few stuffed in from Europe and Asia. Boeing also operated training centers in Singapore and China so they did hire some instructors from there.
This solution has only been partially successful but still faces ingrained resistance from the Koreans. I lost track of the number of highly qualified instructors I worked with who were fired because they tried to enforce normal standards of performance. By normal standards, I would include being able to master basic tasks like successfully shoot a visual approach with 10 kt crosswind and the weather CAVOK. I am not kidding when I tell you that requiring them to shoot a visual approach struck fear in their hearts … with good reason. Like this Asiana crew, it didnt compute that you needed to be a 1000 AGL at 3 miles and your sink rate should be 600-800 Ft/Min. But, after 5 years, they finally nailed me. I still had to sign my name to their training and sometimes if I just couldnt pass someone on a check, I had no choice but to fail them. I usually busted about 3-5 crews a year and the resistance against me built. I finally failed an extremely incompetent crew and it turned out he was the a high-ranking captain who was the Chief Line Check pilot on the fleet I was teaching on. I found out on my next monthly trip home that KAL was not going to renew my Visa. The crew I failed was given another check and continued a fly while talking about how unfair Captain so-and-so was.
Any of you Boeing glass-cockpit guys will know what I mean when I describe these events. I gave them a VOR approach with an 15 mile arc from the IAF. By the way, KAL dictated the profiles for all sessions and we just administered them. He requested two turns in holding at the IAF to get set up for the approach. When he finally got his nerve up, he requested Radar Vectors to final. He could have just said he was ready for the approach and I would have cleared him to the IAF and then Cleared for the approach and he could have selected Exit Hold and been on his way. He was already in LNAV/VNAV PATH. So, I gave him vectors to final with a 30 degree intercept. Of course, he failed to Extend the FAF and he couldnt understand why it would not intercept the LNAV magenta line when he punched LNAV and VNAV. He made three approaches and missed approaches before he figured out that his active waypoint was Hold at XYZ. Every time he punched LNAV, it would try to go back to the IAF … just like it was supposed to do. Since it was a check, I was not allowed (by their own rules) to offer him any help. That was just one of about half dozen major errors I documented in his UNSAT paperwork. He also failed to put in ANY aileron on takeoff with a 30-knot direct crosswind (again, the weather was dictated by KAL).
This Asiana SFO accident makes me sick and while I am surprised there are not more, I expect that there will be many more of the same type accidents in the future unless some drastic steps are taken. They are already required to hire a certain percentage of expats to try to ingrain more flying expertise in them, but more likely, they will eventually be fired too. One of the best trainees I ever had was a Korean/American (he grew up and went to school in the USA) who flew C-141s in the USAF. When he got out, he moved back to Korea and got hired by KAL. I met him when I gave him some training and a check on the B-737 and of course, he breezed through the training. I give him annual PCs for a few years and he was always a good pilot. Then, he got involved with trying to start a pilots union and when they tired to enforce some sort of duty rigs on international flights, he was fired after being arrested and JAILED!
The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues. Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just cant change 3000 years of culture.
The other thing that I think plays an important role is the fact that there is virtually NO civil aircraft flying in Korea. Its actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they dont trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they dont get the kids who grew up flying (and thinking for themselves) and hanging around airports. They do recruit some kids from college and send then to the US or Australia and get them their tickets. Generally, I had better experience with them than with the ex-Military pilots. This was a surprise to me as I spent years as a Naval Aviator flying fighters after getting my private in light airplanes. I would get experienced F-4, F-5, F-15, and F-16 pilots who were actually terrible pilots if they had to hand fly the airplane. What a shock!
Finally, I’ll get off my box and talk about the total flight hours they claim. I do accept that there are a few talented and free-thinking pilots that I met and trained in Korea. Some are still in contact and I consider them friends. They were a joy! But, they were few and far between and certainly not the norm.
Actually, this is a worldwide problem involving automation and the auto-flight concept. Take one of these new first officers that got his ratings in the US or Australia and came to KAL or Asiana with 225 flight hours. After takeoff, in accordance with their SOP, he calls for the autopilot to be engaged after takeoff. How much actual flight time is that? Hardly one minute. Then he might fly for hours on the autopilot and finally disengage it (MAYBE?) below 800 ft after the gear was down, flaps extended and on airspeed (autothrottle). Then he might bring it in to land. Again, how much real flight time or real experience did he get. Minutes! Of course, on the 777 or 747, its the same only they get more inflated logbooks.
So, when I hear that a 10,000 hour Korean captain was vectored in for a 17-mile final and cleared for a visual approach in CAVOK weather, it raises the hair on the back of my neck.