Asiana Pilots Didn't Understand Automated System: NTSB

The National Transportation Safety Board on Tuesday unanimously voted to approve staff recommendations that the probable cause of the crash of Asiana flight 214 at SFO last July was pilot error.

The board agreed that the flight crew of the Boeing 777 did not appropriately understand the airplane's cockpit automation systems, and did not appropriately respond when the plane started flying too slow and too low to land safely during final approach.

The flight crew of Asiana Airlines Flight 214 “over-relied on automated systems that they did not fully understand," NTSB Acting Chairman Christopher A. Hart said at a public hearing in Washington, D.C.

"As a result, they flew the aircraft too low and too slow and collided with the sea wall at the end of the runway,” Hart added. The Korea-based crew "over-relied on automated systems that they did not fully understand," Hart added.

That was the major conclusion of the NTSB hearing into the July 6, 2013 crash at SFO, which caused the deaths of three teenage girls and injuries to about 180 passengers. Aside from that over-reliance, federal investigators also found that pilot mismanagement, lack of training, confusion regarding technology, and the complexity of the Boeing 777's autothrottle contributed to a "cascade of errors" that day.

In a statement, Asiana Airlines agreed with the findings of the NTSB, writing, in part: "We believe the National Transportation Safety Board (NTSB) has properly recognized the multiple factors that contribued to the accident." The written statement added that Asiana has already implemented the training reccomendations mentioned in the hearing and has hired an outside safety specialist, Akiyoski Yamamura.

However the manufacturer of crashed jet, Boeing, took issue with the NTSB's findings.  In a written statement, a Boeing spokesperson wrote that the company "respectually disagrees with the NTSB's statement that the 777's auto-flight system contributed to this accident". The spokesperson pointed to the track record of the auto-flight system, which "has been used successfully for oer 200 million flight hours" and said that "all of the airplane's systems performed as designed."

The crash was the only fatal passenger airline accident in the U.S. in the last five years.

And the goal of the federal hearing, Hart said, was to answer the question of why the plane crashed "while executing a visual approach on a clear day" and offer recommendations "to prevent similar accidents." A preliminary hearing was held in December, where similar findings were released.

The Boeing 777 carrying 219 passengers was on approach to runway 28L at SFO when it struck the seawall at the end of the runway. The hearing revealed that two of the three girls who died after being ejected from the plane had not been wearing safety belts. One of the girls was the one who had been later run over by a San Francisco fire truck.

While Hart said “automation has unquestionably made aviation safer and more efficient," pilot error and lack of experience led to the fatal crash in this instance. There were no apparent mechanical problems with the plane officials confirmed. The pilot, Captain Lee Kang Kuk, 45, had eight years of experience, but was new to flying the 777.

NBC Bay Area's investigative team first reported in August 2013, that NTSB investigators were focusing on over-reliance on the cockpit automation systems by the three experienced pilots who were in the 777's cockpit at the time of the crash. The investigative team found that the problem is found throughout the industry and has long concerned both the FAA and the NTSB.

Data recovered from the airplane's black boxes after the crash showed that the three pilots in the cockpit did not respond for a full 26 seconds after the plane dropped below the safe speed and safe altitude to land safely.

 #NTSB No evidence any of 3 pilots of #Asiana were aware throttles were in idle as plane went too slow and too low — Stephen Stock (@StephenStockTV) June 24, 2014

Evidence from the black boxes showed the pilots may have incorrectly programmed the computer, setting the plane's altitude higher than it actually was during final approach to land.

The NTSB also addressed the San Francisco Fire Department’s role in the death of one of the victims who was run over by a San Francisco fire truck, but agents mentioned that two of the girls who were killed were not wearing their seat belts when they were ejected from the plane.

The NTSB also found that in two discrete incidents, SF firefighters identified the girl lying on the ground after she was ejected from the plane but before she was run over.  On each occasion, the firefighter identified the girl has deceased and did not further check on her condition. NTSB recommended better victim triage to prevent this from happening in the future.

NTSB's report also faulted the fire department for a lack of training in aircraft rescues for those who were coordinating the resopnse.

"These individuals had no previous experience working at an airport, nor had they been involved in an airport disaster exercise," said Jason Fedok, NTSB investigator.

The fire department said changes have been made in response to the Asiana plane crash at SFO, including mandatory aircraft rescue training for everyone in the department above the rank of lieutenant.

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