Wings Magazine

Pilot mismanagement cause of Flight 214 crash: NTSB

June 25, 2014, Washington, D.C. - Mismanagement by the pilots of Asiana Flight 214, including confusion over whether one of the airliner's key controls was maintaining airspeed, caused the plane to crash while landing in San Francisco last year, the National Transportation Safety Board concluded Tuesday.

June 25, 2014  By The Associated Press

But the board also took the unusual step of faulting the complexity
of the Boeing 777's autothrottle, as well as materials provided by the
aircraft maker that fail to make clear under what conditions the
automated system doesn't automatically maintain speed, saying they
contributed to the accident.


The 777 has been in service 18 years and is one of the
world's most popular wide-bodied airliners, especially for international
travel. Until last year's accident, it had not been involved in a
single fatal crash.



The board's acting chairman, Chris Hart,
warned that the accident underscores a problem that has long troubled
aviation regulators around the globe — that increasingly complicated
automated aircraft controls designed to improve safety are also creating
new opportunities for error.


The Asiana flight crew "over-relied on automated systems that they did not fully understand," Hart said.


"In their efforts to
compensate for the unreliability of human performance, the designers of
automated control systems have unwittingly created opportunities for new
error types that can be even more serious than those they were seeking
to avoid," he said.


The South Korea-based airline's pilot training also was faulted.


Boeing immediately rejected the notion
that the 777s automated systems contributed to the accident, pointing to
the aircraft's safety record.


"The 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," the company said in
a statement. "The evidence collected during this investigation
demonstrates that all of the airplane's systems performed as designed."


The board didn't say that the
autothrottle failed to perform as designed. But rather that its design,
under certain circumstances, could lead to confusion as to whether it
was controlling speed or in an inactive state.


The safety board "did the
right thing," said Ilyas Akbari, a Los Angeles attorney representing 16
of Flight 214's passengers. "It took courage to call out Boeing because
it's an American manufacturer" and one of the nation's largest employers
and exporters.


But most of the fault lies with Asiana and its pilots, Akbari said.


Investigators said the flight's three
veteran pilots made 20 to 30 different errors, some minor and others
significant, during the landing approach on July 6, 2013.


Among the errors were that pilots didn't
follow company procedures on calling out notifications about the plane's
altitude, speed and actions they were taking during the landing
approach. They also weren't closely monitoring the plane's airspeed — a
fundamental of flying. Instead, they assumed the autothrottle was
maintaining the required speed for a safe landing.


But the captain flying the plane, Lee
Kang Kuk, 45, who was new to the 777, inadvertently deactivated the
autothrottle, putting it into a hold mode. A training captain who was
sitting next to Kuk in the right seat didn't notice the error, and then
compounded it by turning off only one of two other key systems for
managing the flight.


Both systems are supposed to be on or off, but not
one on and one off.


A third pilot riding in the jump seat noticed the plane was descending too fast but didn't speak up right away.


The plane, with 307 people on board, was
too low and too slow as it neared the runway. Its tail struck a seawall
and was ripped off. The rest of plane went spinning and sliding down the


Despite the violence of the crash, only
three people were killed. Two were Chinese teens seated in the back, who
weren't wearing their seatbelts and were thrown from the plane.
Investigators said if they had been wearing the belts they would most
likely have survived.


A third teen was hit on the head by one
of the plane's doors but survived the crash. She was killed when, lying
unconscious, she was run over by two rescue vehicles in the chaos
afterward. Nearly 200 people were injured.


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