NTSB: Mismanaged approach, airspeed, misunderstanding of complex avionics led to Asiana flight 214 crash

WASHINGTON, 24 June 2014. National Transportation Safety Board (NTSB) officials in the U.S. have determined that Asiana Airlines flight 214 crashed when the airplane descended below the visual glidepath due to several factors, including: the flight crew's mismanagement of the approach and inadequate monitoring of airspeed, as well as autothrottle and autopilot flight director system complexities and the crew's misunderstanding of those systems.

Jun 24th, 2014
Asiana NTSB
Asiana NTSB

WASHINGTON, 24 June 2014. National Transportation Safety Board (NTSB) officials in the U.S. have determined that Asiana Airlines flight 214 crashed when the airplane descended below the visual glidepath due to several factors, including: the flight crew's mismanagement of the approach and inadequate monitoring of airspeed, as well as autothrottle and autopilot flight director system complexities and the crew's misunderstanding of those systems.

"In this accident, the flight crew over-relied on automated systems without fully understanding how they interacted," says NTSB Acting Chairman Christopher A. Hart. "Automation has made aviation safer. But even in highly automated aircraft, the human must be the boss."

On 6 July 2013 at roughly 11:28 a.m. (PDT), the Boeing 777 was on approach to runway 28L at San Francisco International Airport in San Francisco, Calif., when it struck the seawall at the end of the runway. Three of the 291 passengers died; 40 passengers, eight of the 12 flight attendants, and one of the four flight crewmembers received serious injuries. The other 248 passengers, four flight attendants, and three flight crewmembers received minor injuries or were not injured.

The impact forces and a postcrash fire destroyed the airplane.

The NTSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath as it neared the runway. In response to the excessive altitude, the captain selected an inappropriate autopilot mode and took other actions that, unbeknownst to him, resulted in the autothrottle no longer controlling airspeed.

As the airplane descended below the desired glidepath, the crew did not notice the decreasing airspeed nor did they respond to the unstable approach. The flight crew began a go-around maneuver when the airplane was below 100 feet, but it was too late and the airplane struck the seawall.

"Today, good piloting includes being on the lookout for surprises in how the automation works, and taking control when needed," Hart adds. "Good design means not only maximizing reliability, but also minimizing surprises and uncertainties."

The NTSB made recommendations to the Federal Aviation Administration (FAA), Asiana Airlines, The Boeing Company, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco as a result of the accident investigation. These recommendations address the safety issues identified in the investigation, including the need for reinforced adherence to Asiana flight crew standard operating procedures, more opportunities for manual flying for Asiana pilots, a context-dependent low energy alerting system, and both certification design review and enhanced training on the Boeing 777 autoflight system. The recommendations also address the need for improved emergency communications, and staffing requirements and training for aircraft rescue and firefighting personnel.

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