The National Transportation Safety Board (NTSB) has concluded that the fatal crash of Asiana Airlines Flight 214 on July 6, 2013, in San Francisco was a result of 20 to 30 pilot errors made during the last 14 miles of the approach for landing as well as a general lack of training on the control systems of the jet. The findings, made public on Tuesday, cite the mismanagement of the approach as well as the inadvertent turn-off of an automated system to control speed which, had it remained active, may have helped to prevent the accident altogether. During their meeting in Washington, D.C., the four-member committee also blamed the pilots for not monitoring their speed and for not deciding to abort their landing attempt, which was too low and too slow, until it was too late to do so.
Besides what they believe are the main causes of the crash, in which the plane to hit a seawall before hurtling down the San Francisco runway and leaving a trail of debris and sparks, the NTSB also cited probable pilot fatigue as well as complex automated flight control systems in the plane which were not described adequately in operating manuals. In addition, the captain that day was a trainee who lacked sufficient knowledge to manually land the jet, while the pilot who was in charge of training him did not adequately supervise him.
Great study and concern were given to the throttle system, made by Boeing, that adjusts air speed automatically. The pilots were found to have accidentally shut off the device by not completely deactivating the automated flight systems while they were approaching land. Doing so caused the automatic throttle to set itself to hold, leaving it unable to turn back on to correct the drop in air speed that occurred. Although experts in aviation agree that automated systems have improved flight safety, it has become of utmost importance that those in the cockpit operating the systems fully understand the technology on which they need to rely.
Asiana airline officials vowed last year to completely examine and overhaul safety procedures in addition to developing ways to improve the training and flying skills of its pilots. They are planning to hire safety specialists and consultants to that effect and to also improve the maintenance of their fleet. The government of South Korea is also weighing whether or not to mandate an increase in training and higher penalties in cases where accidents cause casualties.
The NTSB also made over two dozen recommendations to Boeing, Asiana, the FAA, and the city and county of San Francisco, among them that Boeing make changes to its control systems so that the plane would maintain the minimum amount of energy throughout the flight to keep the plane aloft. The panel also asked that Asiana and Boeing work together to make the training manuals easier to read and understand. The recommendations to San Francisco included better training for firefighters who responded, noting that putting out airplane fires requires special training and skills and that the firefighters at the scene had no prior experience working at the airport.
For its part, Boeing states that it does not believe that the evidence supports the finding that the automated control system of the plane contributed to the crash and cited its “extraordinary” safety record. The Asiana Boeing 777 had taken off from Seoul and was attempting to make its landing at the San Francisco International Airport. The crash killed three people and injured 187, of whom 49 suffered serious injuries.
By Jennifer Pfalz