Flt 214 Landing Accident at SF Airport

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the FMC is programmed for the ideal world. The airplane is flown in the real world. Things in the real world change at the last minute. It's not the sterile, ideal world in which the airplane was designed...it never is...


At my former aerospace company we said that, "an FMC is programmed for a Synthetic 3-D world, whereas our pilots have to fly in a Real 3-D world."

We can provide all kinds of tools for pilot feedback and reduced crew loads, but takeoffs and landings require a human computer fully aware of his 3-D situation.
 
Originally Posted By: Astro14


You don't understand because you've never been in line operations. I've been trying to get you to understand this: the FMC is programmed for the ideal world. The airplane is flown in the real world. Things in the real world change at the last minute. It's not the sterile, ideal world in which the airplane was designed...it never is...


And you don't understand what I am trying to say. I understand the manual takeoff and landing parts. We are talking about Flt 214 so try to stay on topic please. I am not talking about any landing on any given day with any aircraft. I have been in third seat on many airlines prior to 911, more often on Cathay Pacific, so I do know what you are talking about. I am gettign ready to do Cert3 on the 747-8 and Cert1 on the 787-9 so I will be in the cockpit for several times for flight test before the year end.

If you look at Flt 214 approach profile on the mishap Saturday and the previous several days you will see a different. Why? The FMS would have given the same descent path right down to the airport everyday but the flight profile was totally different on that Saturday. Lets say the ATC gave them a different path on the final approach for some reason, they should still have enough time to make any FMS adjustments. If they were entering data then they should have seen the warning on the MCDU regarding speed and altitude. Why didn't they?

The flight crews are now claiming everything from no response to speed setting to being blinded by bright light above 500ft, etc. The trainer asking for more speed 7 seconds before touch down is little tough for the aircraft to do. Even with your ability I don't think you can pull it off at 7 seconds before impact. The problem started way before that last 7 seconds and this is why I believe the FMS could have save them.
 
Originally Posted By: 757guy
Originally Posted By: azsynthetic
Originally Posted By: 757guy


We have many manuals. There is the Aircraft Operating Manual - Aircraft Specific usually written by the Airplane Manufacturer, but at my airline, the Aircraft Operating Manual is written by Flight Procedure Managers who are line pilots. Each aircraft also has a Cockpit Operating Manual that defines step by step procedures for EICAS warnings, cautions, and advisory messages.
...
I am sorry if I offended you. I'm the pilot - it's my airplane, and I will fly it as safely as I can using automation, or not.


All aircraft operating manuals go back to or reference the Aircraft Operating Manual - Aircraft Specific from the airplane manufacturers or the warranty is voided. This is a fact that you might not know. The Aircraft Operating Manual is written by engineers that might or might not be pilot, and reviewed/approved by flight test engineers and pilots.

You are a commercial pilot and it is not your airplane. You were hired to fly it per the company policy stated in the manuals. Whether you can fly it as safely as you can or not is yet to be determined. No, I am not offended at all because pilots think that they are a rare breed. I have trained many pilots in the Army and some thought that they were the best until they crashed.


You have no idea what your talking about. Look up the definition of Pilot in Command then tell me it's not my airplane: Pilot in command means "the person who has the final authority for the operation and safety of the flight".


And you live in a dream land. Read the link above about the two pilots that missed the airport. They landed the plane safely and are now jobless and doubtful if they will be piloting commercially ever again. The airlines own you and the airplanes, you own nothing. You are just another bus driver with a much higher skill set and making a lot more money (maybe not on the money). Fly according to company policy and within FAA rules or you will be looking at another career if not jail time.

http://www.examiner.com/article/airline-pilot-gets-jail-time-for-flying-drunk
http://news.travel.aol.com/2011/01/24/drunk-delta-pilot-jailed-in-uk/
 
Originally Posted By: Astro14

The article makes the point that I was making in my first post: the psychology. Why don't pilots like to go around? The reasons are complex, and at this point, speculative, but fundamentally, it's the ability to accept the "failure" that's perceived in a go-around...so, with only 3% going around when unstable, how likely was it that a go around would happen with an airline that has a culture that precludes the admission of error? Where "saving face" and the hierarchy of command is so rigid?


You purposely missed an important point about pilot performance in the article.

"It's not that they're making the wrong decision necessarily, it's how they get led down that path," said Rudy Quevedo, director of global programs at the Flight Safety Foundation, which studies aviation accidents. "One of the biggest things that we see is that the pilots don't feel a threat -- they feel they can recover."

"Feeling" can't beat physics and most pilots disagreed until they crashed.
 
Originally Posted By: Astro14
E.G. at 6 miles, at 3,000 feet, you get a change in clearance, cleared to fly the ILS to 28L. The FMC had been programmed for 28R. So, what to do? Go heads down and start typing while the airplane is leveled off and heading in the wrong direction? Hoping that the typing is complete, and then the MCP can be adjusted, and then the autopilot and FMC guidance will catch up with the real world? Or fly it while the PM/PNF changes the FMC. Typing will get you so far off parameters that you would never land.


I just did this on the 777 simulator and it took all 5 seconds plus 2 seconds for the MCP change. Why is it taking you so long?

Originally Posted By: Astro14
OR, at 1,000 feet, SFO tower says, "United 285, can you sidestep to 28L?" Now, the FMC is programmed with vertical and lateral guidance to 28R, the ILS (tuned by the FMC) is tuned to 28R...at 90 seconds from touchdown, I can fly the airplane safely, visually, to 28L. But the FMS guidance is useless at that point....it will now start squawking all sorts of warnings about how I am off...because it doesn't yet know that we're cleared to land on a different runway.


If you feel unsafe then TOGA, why risk it? Or maybe you think you can easily recover like the article said? If you "own" the aircraft like some 757 pilot think you are then you should be able to abort and reject the ATC, right? So, who has the power over the aircraft, you or the tower?

I want to make it clear that I don't doubt your flying ability. As a designer of the FMS I do want to know the end user problems with the current FMS system. If you think the FMS is useless on final approach and landing because of a simple flight path modification then I need to fix it.
 
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Oh my Gawd.

All I can say is that I would be proud to fly with Astro14 or 757Guy. And the only thing I have ever flown is a Schweizer 2-33:)
 
Originally Posted By: azsynthetic
Originally Posted By: Astro14

The article makes the point that I was making in my first post: the psychology. Why don't pilots like to go around? The reasons are complex, and at this point, speculative, but fundamentally, it's the ability to accept the "failure" that's perceived in a go-around...so, with only 3% going around when unstable, how likely was it that a go around would happen with an airline that has a culture that precludes the admission of error? Where "saving face" and the hierarchy of command is so rigid?


You purposely missed an important point about pilot performance in the article.

"It's not that they're making the wrong decision necessarily, it's how they get led down that path," said Rudy Quevedo, director of global programs at the Flight Safety Foundation, which studies aviation accidents. "One of the biggest things that we see is that the pilots don't feel a threat -- they feel they can recover."

"Feeling" can't beat physics and most pilots disagreed until they crashed.


I don't "purposely miss" anything...but I don't share the opinions...so, I make the point differently. I've been flying for 27 years now, and have been an instructor for 10 of those years (F-14 and 747-400), so I've spent some time looking at human performance and the man-machine interface...my perspective derives from that experience...

Look, AZsynthetic, I think we're talking past each other.

I recognize that the FMC guidance is useful, generally. I recognize how easy/hard it is to program. You build the tool. I get it.

But I use the tool you've built every day.

And this accident wasn't about the tool. The tool was one of many aspects of a crash that was caused, primarily, by a breakdown in cockpit resource management. The tool, the FMC, was one of many resources in the cockpit that should, or could have, been used. But by itself, the FMC is not as important as the rest of the elements of breakdown in situational awareness, energy management, configuration management, approach path management, instruction, leadership, and probably a few others I've overlooked.

And for the record, my degree was in Astrophysics, so my "feeling" is based on a sound understanding of physics as well as the aerodynamics that I've learned over the years...I do understand how airplanes fly...what makes them work...or not...
 
Okay guys, I posted the write up by "Iron Mike", I am not "Iron Mike". Here is another interesting read by "Tom B".



Subject: Low-down on Korean pilots


After I retired from UAL as a Standards Captain on the B747–400, 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’s 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 don’t 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 simulator 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 (rejected take-off) 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 (2003-2008) 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 (means clear skies and excellent visibility...Clear and visibility OK). 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 normal 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 couldn’t 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 Brown 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 couldn’t 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-141’s 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 can’t 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. It’s actually illegal to own a Cessna-152 and just go learn to fly. Ultra-lights and Powered Hang Gliders are Ok. I guess they don’t trust the people to not start WW III by flying 35 miles north of Inchon into North Korea. But, they don’t 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 at 250’ 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’ 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, it’s 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.

Tom B
 
Originally Posted By: azsynthetic
I just did this on the 777 simulator and it took all 5 seconds plus 2 seconds for the MCP change. Why is it taking you so long?


OK...first, you knew it was coming, we don't...next, you didn't verify against an approach plate, as we're required to when using the FMS guidance...that is why it takes time...finally, when you make an MCP input, it still takes the airplane over 0.3 miles to actually respond...

Originally Posted By: azsynthetic
If you feel unsafe then TOGA, why risk it? Or maybe you think you can easily recover like the article said? If you "own" the aircraft like some 757 pilot think you are then you should be able to abort and reject the ATC, right? So, who has the power over the aircraft, you or the tower?


I don't feel unsafe flying a visual approach. Did one today into Houston...CAPT did one today into SAT, with G/S out of service (so, FMC was again, not useful, but the PAPI was)....but on that visual approach, safely flown, I am visual, by definition, flying with only visual reference, and so the FMS is not being used...it isn't needed...and it isn't providing useful information.

I make the decision on whether or not the approach is safe, you knew that, and our SOPs define parameters for stabilized approach, which, if exceeded, require a go-around. I've done that too...most recently on a visual approach into Billings, MT, in which I simply couldn't get the airplane onto stable approach parameters after being cleared for the visual at 18,000'...there wasn't enough drag available to get it down...

Originally Posted By: azsynthetic
I want to make it clear that I don't doubt your flying ability. As a designer of the FMS I do want to know the end user problems with the current FMS system. If you think the FMS is useless on final approach and landing because of a simple flight path modification then I need to fix it.


I don't think we can educate each other over BITOG...we keep talking past each other...and I would prefer not to...I respect your opinion, but I can't impart the "big picture" view of line operations that I've got from actually doing it...how the pilot/crew/machine/weather/ATC/SOP/facilities factors all come together...

I can discuss what I think are the causes of this event...but I can only scratch the surface of how all those factors affect the equation...
 
Quote:
As a designer of the FMS I do want to know the end user problems with the current FMS system. If you think the FMS is useless on final approach and landing because of a simple flight path modification then I need to fix it.


As a recommendation, if your company does not have a multi-disciplinary group for feedback, it should.

Our multi-disciplinary group included the Domain Engineers (experts on each box), Pilots, Human Factors, DERs, and Principle Systems Engineers/Architects.
 
Originally Posted By: Bill in Utah
Sadly another person from the flight died today.

As of now the total is 3.



And confirmation that a fire truck did run over one of the victims. Apparently she was covered in the foam they were spraying.
Hopefully she was already dead when it hit her. They'll know if they find foam in her lungs. Probable story will be "undetermined".
 
Originally Posted By: MolaKule
Quote:
As a designer of the FMS I do want to know the end user problems with the current FMS system. If you think the FMS is useless on final approach and landing because of a simple flight path modification then I need to fix it.


As a recommendation, if your company does not have a multi-disciplinary group for feedback, it should.



There are two constraints to this feedback situation. One: Boeing and other manufacturers dictate to us what they want based on their engineers, FAA and airlines pilots feedback. We cannot deviate from Boeing's SCD. Two: During flight tests, we ran through corner cases that 99.99% of the pilots will never see. Boeing and Airbus test pilots are amazing with what they can do when we tell them these maneuvers. In their opinions, a qualified pilot should be able to do these maneuvers on the fly. But apparently, some can't.

I have weekly meeting with aircraft OEM test pilots and they want everything to be automated. Never once did I hear a "lets make that a manual operation" from anyone. There isn't a complain that I haven't heard at least five times from some pilots. At the end, we tell them to go tell Boeing, Airbus, Embraer, etc. because we can't change it unless they say so.
 
Originally Posted By: Astro14
Originally Posted By: azsynthetic
I just did this on the 777 simulator and it took all 5 seconds plus 2 seconds for the MCP change. Why is it taking you so long?


OK...first, you knew it was coming, we don't...next, you didn't verify against an approach plate, as we're required to when using the FMS guidance...that is why it takes time...finally, when you make an MCP input, it still takes the airplane over 0.3 miles to actually respond...


What???? You mean you didn't get one of the new FAA approved Ipad with the approach plates on it?
 
Originally Posted By: azsynthetic
Originally Posted By: Astro14
Originally Posted By: azsynthetic
I just did this on the 777 simulator and it took all 5 seconds plus 2 seconds for the MCP change. Why is it taking you so long?


OK...first, you knew it was coming, we don't...next, you didn't verify against an approach plate, as we're required to when using the FMS guidance...that is why it takes time...finally, when you make an MCP input, it still takes the airplane over 0.3 miles to actually respond...


What???? You mean you didn't get one of the new FAA approved Ipad with the approach plates on it?


Sigh....

The approach plate is on the Ipad...do you know what I mean by brief and verify an approach?

It takes time to perform those tasks.....

They are required.

This is the point where knowledge of systems is not the same as knowledge of operations...Operations require more than just FMS programming. I can install an approach in the FMC in seconds.

I can program the FMS. It's easy, it's quick. So what? My kid can start my car. It's easy, it's quick. That doesn't make my kid ready to drive the car, and it doesn't mean that he's ready to drive the car in rush hour traffic on the highway.

To actually fly the approach, to ensure that the crew is performing effectively as a crew, and to comply with FAA policy, company policy and best practices in safety, that approach must be verified and briefed with the crew so that the human performance results in a safe, and effective operation. That's the operational context, that's the operational environment.

That human performance; everyone clear on assigned tasks, roles, responsibilities and operating parameters for the maneuver that is about to be executed is where this crew failed. There is a great deal more to that performance than just programming the FMC...the FMC is one of many small tasks within a larger set of small and large tasks to deliver the safe operation of an airliner in a complex environment at a demanding airport.
 
Quote:
There are two constraints to this feedback situation. One: Boeing and other manufacturers dictate to us what they want based on their engineers, FAA and airlines pilots feedback. We cannot deviate from Boeing's SCD. Two: During flight tests, we ran through corner cases that 99.99% of the pilots will never see. Boeing and Airbus test pilots are amazing with what they can do when we tell them these maneuvers. In their opinions, a qualified pilot should be able to do these maneuvers on the fly. But apparently, some can't.


Understood, but there is usually a process defined in an Aerospace or Avionic's company for making changes.

Here is a basic, typical process for example :

a. during flight deck operations testing of system, company pilot says he would like higher resolution of xyz indication,
b. change is noted and Proposed Change Document (CR) is submitted to pilot's company, or pilot's company makes request through CR,
c. if proposed change is within scope of contract, a schedule is submitted outlining Requirements Document change and ETC,
d. Systems Engineer modifies Requirements Document to reflect change and pilot's company signs off on Requirements Document change
e. Domain is notified to make software change(s)
f. Domain tests software and hardware,
g. System Engineer tests integrated system to verify change,
h. Pilot's company is notified and new software package is sent to pilot's company for testing,
i. pilot's company flight tests and signs off on change and Change Request is closed.

In other words, this is a consensus process whereby there are no mavericks making changes in isolation.

in some cases, the pilot's company will deem the change not feasible or not necessary and ask the CR be closed without further action.
 
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Originally Posted By: azsynthetic
Originally Posted By: Astro14

The article makes the point that I was making in my first post: the psychology. Why don't pilots like to go around? The reasons are complex, and at this point, speculative...
You purposely missed an important point about pilot performance in the article.


Italics added...

It's been interesting, and educational, to read the exchanges here, going back & forth. While 757Guy & Astro14 have been replying from their own considerable experience in the left seat, AZS you appear to 'fly a desk', in a very controlled environment, not to mention possibly work in a rather hostile one, given by your choice of words and examples.

I don't think nor believe that Astro purposely missed anything. You're implying intent 'to purposely miss' where it appears none existed. In other words, you're being argumentive & getting personal. I started this thread to open a discussion into what happened, not to get personal and combative. If you're unable to do that, why don't you back away from the keyboard?

I recall many flying stories from my A&P uncle, who frequently commented how important it is to FLY THE AIRPLANE, and continue to do so especially when problems arise. In the air, airplanes, like time, don't stand still.

757 posted an interesting video, which I watched, emphasizing this point and these two pilots points: FLY THE AIRPLANE.

On another point you (completely) missed 757's perspective and point of 'owning the airplane' as evidenced by posting a link to a low-level, wheels-up, flyby in a newly received 777, by a Hong-Kong based firm, whose senior pilot was obviously flying with his other stick...not to mention his boss and senior management on board who obviously didn't approve. LOL, eh? Yea right. Not to that pilot. He was fired for it. I don't think for a minute 757's point of 'owning the airplane' means he has the right to pull such a stunt.

I appreciate your posts from your perspective of FMC system design and your contributions to the discussion. However, let's keep the discussion out of the weeds & the ditch.

Finally, a common thread, if oppositional one here, is high-touch vs. high-tech. Man vs. Machine. Analog vs. Digital. Are we too dependant on high-tech cockpits? Are basic skills being lost, ignored or never learned as "Tom B" talked about from his experience?

I too would be very comfortable with either 757 or Astro in the left seat, flying into SFO, in the 'slam dunk', with a last minute change of runway from ATC, in marginal weather. Then again, maybe I already have...
 
Originally Posted By: sleddriver
I don't think for a minute 757's point of 'owning the airplane' means he has the right to pull such a stunt.


Apparently those pilots did so someone must have thought they own the plane. Bottom line is the airlines pilots own nothing and he has to fly according to company policy and within FAA rules. {removed insult towards other member}
 
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