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Student Team Explores Major Issues Behind “Pilot Error”

Stephanie Chow and Stephen Yortsos combined research on Asiana Flight 214 and have put themselves squarely in the midst of an aviation industry-wide discussion
November 06, 2014 —
Stephen Yortsos and Stephanie Chow at the ISASI conference in Australia

Pilot error.

That was the official cause listed for the July 2013 crash of Asiana Airlines Flight 214, which occurred when the plane struck the seawall short of the runway at San Francisco International Airport, killing three people and injuring numerous others. The crash was the first involving the highly sophisticated Boeing 777, which was a key factor in drawing the interest of two USC Viterbi students.

Stephanie Chow and Stephen Yortsos, students in the Viterbi school’s industrial and systems engineering program, had both taken the class ISE 370L, “Human Factors in Work Design” with Professor Najm Meshkati and produced term papers on two different aspects of the Asiana crash — Chow addressing cockpit automation and Yortsos discussing cultural factors. On the surface, the content of these two papers might seem completely disparate, but as these two students found out, they’d collectively identified one of the most pressing issues facing aviation today.

The flight was reported to be issue-free until the landing, when part of the airport’s automated landing system became dysfunctional and required an inexperienced pilot to visually guide the plane onto the runway. In addition to flying too low on final approach, the cockpit displayed an airspeed of 103 knots (118 mph), which is well below the target speed of 137 knots (160 mph). When questioned after the accident, the pilot stated that he assumed the plane would maintain a speed of 137 knots.

A post-crash investigation conducted by the National Transportation Safety Board (NTSB) found no mechanical malfunctions by the plane, and at no point did the aircraft send any sort of distress signal. The pilot simply relied on automated systems with which he was clearly uncomfortable.

As one of the world’s preeminent experts in aviation safety, Meshkati instantly realized that his students’ research cut right to the core of a major industry need — a uniform solution for the correct balance of human interaction and machine control. He suggested his students work together and guided them through production of a joint paper titled “Asiana Airlines Flight 214: Investigating Cockpit Automation and Culture Issues in Aviation Safety.”

“I’m incredibly proud of these two students for taking on one of the most vexing problems facing aviation today,” said Meshkati, a professor in the Sonny Astani Department of Civil and Environmental Engineering, Daniel J. Epstein Department of Industrial and Systems Engineering and teaches in the Aviation Safety and Security Program at USC Viterbi. “Their research on this particular issue of human interaction with automation is the first step in producing a systematic solution that will have the power to fundamentally change the industry and could well be the Holy Grail of aviation safety.”

Wreckage of Asiana Flight 214 (Alexander Novarro, via Wikimedia Commons)

Industry response has been incredibly favorable.

Meshkati forwarded a draft of the article to a number of aviation safety luminaries, including the Honorable Christopher A. Hart, acting chairman of the National Transportation Safety Board (NTSB), and the Honorable Robert L. Sumwalt, another NTSB member — both of whom commented, advised and even met with the student team.

Additionally, Geoffrey Thomas, a renowned aviation journalist in Australia who frequently serves as a source for major international aviation stories — most recently appearing on CNN to discuss Malaysia Airlines — cited their paper in his article “Coming Up Short,” which won the award for Best Safety, Training and Simulation story at this year’s Aviation Media Awards in London. The award citation explicitly refers to his work with the University of Southern California.

Per Thomas’ award-winning article:

In 1996 the US Federal Aviation [Administration] (FAA) conducted a comprehensive review of human factors in aviation and identified issues with automation and cultural factors. One of its recommendations was: “The FAA should ensure that research is conducted to characterise cultural effects and provide better methods to adapt design, training, publications, and operational procedures to different cultures. The results of the research should also be used to identify significant vulnerabilities, if any, in existing flightdeck designs, training, or operations, and how those vulnerabilities should be addressed.”

Chow and Yortsos are attacking that research project head-on and in so doing, are drilling into an issue that the greatest minds in aviation have been unable to solve over nearly the last two decades.

“[This paper] is an outstanding piece of work because it makes a very complex subject simple to understand while treating with respect and sensitivity great cultures like that of Korea,” said Thomas. “Assumption is the biggest enemy of aviation, yet the industry has assumed that we have trained out cultural factors. This research is the first step in a long process to re-think this entire question.”

The paper also will be published in Aviation Psychology and Applied Human Factors, the official journal of the European Association for Aviation Psychology and the Australian Aviation Psychology Association (AAvPA). Additionally, the student team was awarded the Rudolf Kapustin Memorial Scholarship, administered by the International Society of Air Safety Investigators (ISASI). As a result, the pair traveled to Adelaide, Australia to present their paper at ISASI’s Annual Seminar.

“Presenting in Australia was a lot of fun,” said Chow. “We spoke on the last day of the conference with the other winners — I think there were six of them — but the best part was getting feedback from the industry experts. Everyone there was coming from a government agency or commercial airline, and a number of the people we talked to were lead investigators on Asiana 214, so there was a lot of value.”

“I was a little nervous going in and presenting in front of the very people whose work we’d spent so much time researching,” said Yortsos. “The experts were all really helpful, though, and gave us a lot of positive feedback, which put me at ease and gave me a good feeling about the work we’d done.”

While both students are focused on their upcoming graduation this spring, their experience with researching Asiana 214 has left an indelible mark, as Chow would like pursue a career in technology consulting, specifically within aerospace and aviation. Yortsos remains a little more open to other possibilities but is quick to acknowledge the power of the connections this process has given him.

“I’m passionate about technology and am open to most anything that may come my way,” he said. “But I do have quite a few good contacts in aviation now, and that’s always a good place to start.”