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NTSB Blames Pilots and a Series of Conditions — Including Over-Reliance on Automation, Lack of Situational Awareness

Tue June 24 2014 7:02 pm
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The National Transportation Safety Board held a hearing to determine the cause of the 2013 Asiana Flight 214 plane crash, and Acting Chairman Christpher Hart explained some of the issues discovered.

The NTSB held a hearing regarding the Asiana Airlines Flight 214 crash that occurred last summer on Saturday, July 6, 2013. A Boeing 777-200ER aircraft crashed on final approach into SFO. Of the 307 people aboard, two passengers died at the crash scene. One 16-year-old girl was run over by a San Francisco Fire Department airport crash tender as it was being re-positioned to fight the fire, and a third female child victim died in a hospital intensive care unit several days later. A total of 181 other passengers were injured — including 12 critically injured.

The crew had been cleared for a visual approach and they were hand-flying the aircraft,” according to then NTSB Chairman Deborah Hersman.”During the approach there were statements made in the cockpit first about being above the glide path, then about being on the glide path, then later reporting about being below the glide path. All of these statements were made as they were on the approach to San Francisco. Three seconds before the crash, someone in the cockpit called for the plane to abort the landing, or ‘go around’. Then 1.5 seconds before impact, a different crew member again called for a ‘go around'”. None of the statements in the cockpit were aired over the radio.

Next, the main landing gear of the aircraft hit the seawall just before the runway, as the crew attempted to fly around for a second landing attempt.

A lot of issues lined up simultaneously to cause the accident …

The pilot was new.

The pilot instructor was new.

The crew members were tired.

The crew had issues with understanding the automation of the aircraft.

These issues — isolated — would probably have had innocuous results, but with all of them lines up in a single instant, the casualty was the result.

Regarding the accidental striking of the victim on the ground, Acting Chairman of the NTSB Christopher Hart said firefighters should not have to be preoccupied with the decision of whether a scene is a crime investigation scene, where firefighters would have limited access to a scene, or whether a scene is a rescue scene, where firefighters would have full access to the scene. Hart reported that firefighters did not have adequate guidance, and did not have adequate training regarding this issue.

Two of the inflatable chutes expanded into the aircraft cabin instead of outside. The first chute, which blocked the forward right exit, nearly suffocated a flight attendant, was deflated by a pilot with a fire axe from the cockpit.

The second chute expanded toward the center of the aircraft near the fire. The chute also trapped a flight attendant until a co-pilot deflated it by piercing it with a dinner knife.

San Francisco Fire Department Fire Chief Joanne Hayes-White ordered that the department’s 2009 ban on video recording devices be extended to include any devices mounted on helmets that record emergencies. It was the recorded video from a helmet-cam that resulted in inquiries regarding the death of the 16-year-old female victim that was struck by the airport crash tender.

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