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Asiana Flight 214: Five takeaways

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Acting NTSB chairman Christopher Hart said the pilots “over-relied on automated systems that they didn’t fully understand.”

On July 6, 2013, Asiana Airlines Flight 214, a Boeing 777-200ER en route from Seoul Incheon International Airport, came down short of San Francisco International Airport’s runway 28L, hit a sea wall and crashed on landing. There were three fatalities among the 307 passengers and crew aboard. The US National Transportation Safety Board (NTSB) this week held a public hearing to release the findings of its nearly year-long investigation of the accident; here are the key takeaways:

  1. NTSB determined that the primary probable cause of the accident was pilot error, but importantly did not attribute the flight crew’s mistakes to a lack of competency. The pilots’ certification and qualification “were not factors in the accident,” NTSB stated. NTSB member and former airline pilot Robert Sumwalt said, “The errors of the pilots were not because of incompetency.” This is a significant point because much of the international media, in the immediate aftermath of the crash, erroneously tried to paint experienced Asiana pilot Gang-Guk Lee as unqualified to land the aircraft at SFO because he was in the midst of transitioning to the 777. I tried to debunk this at the time and I’m glad NTSB has clearly stated qualification was not an issue. It would be too easy—and dangerous—to explain away the mistakes made by the flight crew in this case as a lack of qualification. For the sake of air safety generally and avoiding a similar accident in the future, it’s important to keep in mind that these were experienced pilots and the errors they made could also be made by other experienced pilots.
  2. The pilots, according to acting NTSB chairman Christopher Hart, “over-relied on automated systems that they didn’t fully understand.” Over-reliance on automation is a problem in cockpits around the world. Asiana 214 emphasizes the need for pilots to remain adept at manually operating aircraft even as modern aircraft are more and more flown by automation. “By encouraging flight crews to manually fly the airplane before the last 1,000 feet of the approach, Asiana Airlines would improve its pilots’ abilities to cope with maneuvering changes commonly experienced at major airports and would allow them to be more proficient in establishing stabilized approaches under demanding conditions,” NTSB said. And a full understanding of the automated systems in each aircraft type is also critical for flight crews. Sumwalt said, “I think this is a case of the pilot thinking the airplane would do something for him that it was not designed to do.” The pilots appeared to think that the 777’s auto-throttles would ensure the aircraft maintained a proper speed no matter what the auto-flight settings were, an assumption that proved to be fatally wrong.
  3. NTSB concluded that “complexities” in the 777’s auto-throttle and autopilot flight director systems were a “contributing” factor in the crash. Boeing disagrees with this conclusion, pointing out that the 777’s “auto-flight system has been used successfully for over 200 million flight hours across several airplane models, and for more than 55 million safe landings.”
  4. NTSB clearly concluded that there were no aircraft structural, engine or system failures that contributed to the crash. The accident occurred because of “the flight crew’s mismanagement of the airplane’s descent during the visual approach, the pilot flying’s unintended deactivation of automatic airspeed control, the flight crew’s inadequate monitoring of airspeed, and the flight crew’s delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances,” NTSB said.
  5. It should not be forgotten that most of the 307 passengers and crew aboard survived the accident with no or minor injuries. This is attributable to substantial advances in aircraft safety over the last couple of decades, including installing fire blocking materials on aircraft that, in this instance, gave passengers and crew critical extra seconds to escape a fiery fuselage. “In years past, [a similar crash] might have resulted in scores or hundreds of fatalities,” Hart said.

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